McCall Rehabilitation and Care Center

Based on record review and observation it was determined the facility failed to ensure a qualified individual was employed with the knowledge and skill set to carry out the function of food and nutrition services. This deficient practice created the potential to affect 35 residents who consumed food prepared by the facility. This placed residents at risk for undetected weight loss and adverse health outcomes when the facility did not employ a qualified individual to meet all resident nutritional needs. Findings include: The facility's Quality Assurance and Performance Improvement (QAPI) meeting minutes, dated January 2025, documented under dietary services, the facility had a goal to enroll the Dietary Manager (DM) into a dietary manager certification training by the next quarter. The facility's QAPI meeting minutes dated April 2025, included confirmation of enrollment to the dietary manager certification training. On 7/23/25 at 10:43 AM, the DM stated she is not a Certified Dietary Manager. She stated she was currently enrolled in a training program and had 11 months left before…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Number of residents sampled:Number of residents cited:SDP= GenesisUniverse= Facility wide Concerns with Food and Nutrition Services regarding kitchen sanitation. Based on observation, staff interview, and Food Code review, it was determined the facility failed to ensure the kitchen equipment was maintained in sanitary condition and food was handled in a safe and sanitary manner. These deficient practices created the potential to affect 35 residents who consumed food prepared by the facility. This placed residents at risk for potential food contamination and adverse health outcomes, including food-borne illness. Findings include: The FDA Food Code Section 4-601.11 (C) Cleaning of Equipment and Utensils, documented nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, food residue, and other debris. 1. On 7/23/25 at 10:59 AM, during a kitchen inspection a black kitchen aid mixer was observed sitting on a counter with white encrustations. On 7/23/25 at 11:05 AM, the DM stated the mixer was not in sanitary condition. 2. On 7/23/25 at 11:05 AM, a kitchen…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, policy review, and staff interviews, it was determined the facility failed to ensure neurological assessments were performed after unwitnessed falls and/or incidents involving a potential head injury, and medications were administered consistent with physician orders. This was true for 5 of 5 residents (#5, #19, #21, #22, and #27) reviewed for falls, and 1 of 8 residents (Resident #7) reviewed for medication administration. These failures created the potential for harm should residents experience undetected changes in neurological status and adverse effects from medications that were administered contrary to physician orders. Findings include: The facility's policy for Neurological Evaluation, revised May 2007, documented the following: * All incidents involving head trauma result in a comprehensive neurological assessment for a minimum of 72 hours. * A neurological assessment flowsheet was used for all residents who sustained head trauma due to falls or other incidents. *…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, it was determined the facility failed to ensure the resident or the resident's representative received information and assistance to exercise their right to formulate an Advance Directive. This was true for 1 of 4 residents (Resident #15) reviewed for an Advance Directive. The deficient practice created the potential for harm should resident's wishes regarding end of life or emergent care not be honored when they were incapacitated. Findings include: Resident #15 was admitted to the facility on [DATE], with multiple diagnoses including vascular dementia and cognitive communication deficit. Resident #15's record did not contain an Advance Directive or documentation the facility provided Resident #15 or Resident #15's representative information on an Advance Directive, and offered assistance to develop an Advance Directive if desired. On 7/23/19 at 3:48 PM, the admission Coordinator reviewed Resident #15's record and said it did not include an Advance Directive. The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, it was determined the facility failed to ensure a resident's representative was notified in a timely manner of a resident's significant change in condition which required hospitalization. This was true for 1 of 4 residents (Resident #30) reviewed for notification of changes. This placed the resident at risk of inappropriate care and treatment due to lack of advocacy and involvement by their representative. Findings include: Resident #30 was admitted to the facility on [DATE], with multiple diagnoses including dementia with behaviors. A Nurse's Progress Note, dated 5/20/19 at 5:24 PM, documented Resident #30 was attempting to exit the building. The facility staff were attempting to redirect him and Resident #30 became physically and verbally abusive to a staff member. The police, Emergency Medical Services (EMS), and the physician were notified of the behaviors and Resident #30 was sent to the ER (emergency room) for an evaluation. Resident #30 was admitted to the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, it was determined the facility failed to ensure a resident's code status was documented on their baseline care plan. This was true for 1 of 2 residents (Resident #130) reviewed for baseline care plans. This failure created the potential for harm should a residents' wishes not be followed regarding their code status due to lack of information on the baseline care plan. Findings include: Resident #130 was admitted to the facility on [DATE], with multiple diagnoses including cognitive communication deficit, history of stroke, and left bundle branch block (a delay or blockage in the electrical impulse traveling through the heart). Resident #130's physician orders documented Do Not Resuscitate (DNR), dated 7/17/19. Resident #130's Preferred Intensity of Care form documented she was a DNR, and it was signed by her representative on 7/16/19. Resident #130's Initial Care Plan, dated 7/16/19, did not include documentation regarding her code status. On 7/25/19 at 2:50 PM, the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, policy review, and resident, resident family member, and staff interview, it was determined the facility failed to ensure care plans were revised and updated as care needs changed. This was true for 1 of 13 residents (Resident #13) whose care plans were reviewed. This failure created the potential for harm if cares and/or services were provided based on inaccurate information on the care plan. Findings include: The facility's policy for Comprehensive Person-Centered Care Planning, revised [DATE], documented each resident's care plan was reviewed and/or revised by the Interdisciplinary Team (IDT) after each assessment. Resident #13 was admitted to the facility on [DATE], with multiple diagnoses including cerebrovascular disease (a medical condition that affects blood vessels of the brain), aphasia (the loss of ability to understand or express speech), and cognitive communication deficit. Resident #13's care plan documented she was not to be resuscitated, Do Not Resuscitate…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review, and resident and staff interview, it was determined the facility failed to provide showers and communication assistance as needed. This was true for 2 of 12 residents (#13 and #18) whose activities of daily living were reviewed. This failure placed the residents at risk of psychosocial distress related to embarrassment and/or isolation from not receiving showers and not being able to communicate. Findings include: 1. The facility's policy for Restorative Care, revised 11/2017, documented objectives for providing direct nursing care services that maintained optimum physical and mental health for the resident and meet all his medical treatment needs, and Participate in the retraining of the resident in self-care activities. Residents would be evaluated on their ability to carry out activities of daily living (ADLs), including the ability to understand speech and talk. Resident #13 was admitted to the facility on [DATE], with multiple diagnoses including cerebrovascular…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interview and record review, it was determined the facility failed to ensure residents received restorative services through the restorative nursing program as needed. This was true for 2 of 2 residents (#9 and #13) reviewed for the restorative nursing program. This failure created the potential for residents to experience a decline in Range of Motion (ROM). Findings include: 1. Resident #9 was admitted to the facility on [DATE], with multiple diagnoses including age related physical disability, osteoarthritis, muscle wasting, and atrophy (a breakdown of tissues). A quarterly MDS assessment, dated 5/13/19, documented Resident #9 was to receive active ROM and walking therapy through the restorative nursing program. Resident #9's care plan, revised on 5/9/19, documented the restorative program was to provide active ROM exercises 5-6 times a week for 15 minutes. Resident #9's care plan, revised 6/26/19, documented the restorative program was also to provide walking assistance 5-6 times a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.