Calhoun County Medical Care Facility

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings Include:On 4/22/26 at 9:42 AM, observation of the main ice scoop holder found the bottom with white and brown crusted debris. An interview with Dietary Manager (DM) J found that it should get cleaned weekly. When asked why the inside bottom was roughed up, DM J stated they replaced the scoop and the old one had some rough edges, we will replace it. On 4/22/26 at 9:43 AM, observation of the underside of the tabletop mixer found some white accumulation of debris in the crevices of the under arm of the unit. On 4/22/26 at starting at 10:20 AM, observation of the [NAME] Court kitchen found the air gap for the ice machine had fallen below the overflow rim of the drain and was no longer creating a physical gap between the plumbing. An interview with DM J found that maintenance…

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, interview, and record review, the facility failed to have an active and ongoing plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP), resulting in the potential for increased risk of respiratory infection among all residents in the facility.Findings include: On 4/22/26 at 1:24 PM, an interview with Facilities Operations Manager (FOM) K, regarding the facilities Water Management Plan, found that housekeeping staff flush the domestic water lines in the soiled utility rooms that are not used regularly. When asked if there were other rooms, or fixtures, that needed to be regularly flushed, FOM K stated that they typically don't have empty resident rooms for long and there were no other fixtures that would need flushing. When asked if the facility was performing any testing for disinfection or legionella, FOM K stated that they were not performing any sampling of the water. On 4/22/26 at 1:24 PM, observation of the [NAME] Ridge spa room found 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 During a tour of the kitchen, at 10:35 AM on 2/18/25, an interview with CDM K found that the facility does not regularly test their sanitizer buckets. When asked about the availability of test strips, it was found that the only test strips available had manufacture expiration date of [DATE]. Further review found that the test strips were for bleach based sanitizer and the facility uses quaternary ammonium. According to the 2022 FDA Food Code section 4-302.14 Sanitizing Solutions, Testing Devices. A test kit or other device that accurately measures the concentration in MG/L of SANITIZING solutions shall be provided. During an evaluation of the kitchen, at 11:00 AM on 2/18/25, an interview with CDM K found that the large floor mixer is used approximately five times per week. At this time, the mixer was observed to have dried, white, food debris on the grated splash guard and the mixer was not in use. During an evaluation of the kitchen, at 11:10 AM on 2/18/25, the meat slicer was observed to have an accumulation…

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, interview, and record review, the facility failed to have an active and ongoing plan for reducing the risk of Legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in water borne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among any or all the residents in the facility. Findings include: During an interview with Facilities Operations Manager (FOM) M, starting at 10:23 AM on 2/20/25, it was found that the facility does not currently have any routine testing on the facilities water supply. When asked if there was a team that oversaw the Water Management Program (WMP), FOM M stated she was unsure of a team. When asked what facility established control limits were in place in order to decrease the risk of Legionella and OPPP from growing a spreading in the facility, FOM M was unsure and stated she was slightly newer to the position and had not had…

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.

Based observation, interview, and record review the facility failed to ensure proper storage of medication in three of three medication carts and one medication room of three reviewed for medication storage. Findings include: During an observation and interview on 2/20/25 at 7:57 a.m., Registered Nurse (RN) T opened the Maple Grove Medication cart. RN T verified three opened undated eye drops including xalatin, cosopt, and alphagan. RN T reported should be dated when opened and reported some staff document items open date in binder on medication cart and verified was not documented. During an observation on 2/20/25 at 8:51 AM, Licensed Practical Nurse (LPN) U opened the [NAME] Court Medication cart. LPN U verified open undated eye drop prednisolone Acetate Ophthalmic Suspension 1 % and was unsure when it had been opened. During an interview on 2/21/25 at about 3:30 PM, Director of Nursing(DON) B reported would expect multidose medications including eye drops to be dated when opened and staff to follow, Medication with Shortened Expiration dates, guide placed in medication cart…

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 interview and record review the facility failed to perform a Minimum Data Set (MDS) significant change in condition assessment for one of 19 residents (Resident #87) resulting in the potential for care needs to be unmet. Findings Included: Per the facility census R87 was admitted to the facility on [DATE]. Review of a, Supportive Care Goals Worksheet document dated 1/21/2025, revealed 87's family consented for R87 to have no measures to sustain life, a do not resuscitate (DNR) order, no hospitalization, no routine testing, no routine weights, only essential medication and vital signs were to be given. At the bottom of the form under Supportive Care it was revealed that 87's authorized decision maker signed the form on 1/21/2025 stating that consent was given for Supportive Care, and to provide treatments to promote quality of life and comfort, rather that achieve improvement in health for R87. The Nurse Practitioner signed the form on 1/21/2025, and the Physician signed the form on 1/24/2025. Review of…

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, interview, and record review the facility failed to ensure three out of 19 residents (Resident 26, 57, and 87) received care and services that met their care needs resulting in the potential for unmet care needs. Findings Included: Resident #87 (R87): Per the facility census R87 was admitted to the facility on [DATE]. During the entrance conference on 2/18/2025 at 10:04 AM Administrator A stated that the facility did not offer outside contracted Hospice services, but did offer services provided by the facility to residents. Review of the facility, Supportive Care Protocol policy dated 12/20/2022 and revised on 5/10/2023, revealed that the facility provided, .comfort, dignity, and support, as residents enter the last stages of their life. The policy revealed, This will allow the resident to focus their goals of care to support how they (the resident) choose to live rather than try to cure or aggressively treat their chronic health conditions. Further review of the policy revealed under…

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, interview and record review, the facility failed to ensure proper storage, cleaning and labeling of oxygen/respiratory equipment for two Resident (R57 and R61), of four residents reviewed for oxygen and respiratory care, resulting in the likelihood for cross contamination, respiratory illnesses/disease. Findings include: Resident #57(R57) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R57 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included acute and chronic respiratory failure, congestive heart failure(CHF), chronic obstructive pulmonary disease, history of lung cancer with lung removal, diabetes mellitus, history pneumonia, anxiety and depression. The MDS reflected R57 had a BIM (assessment tool) score of 15 which indicated her ability to make daily decisions was cognitively intact, and she required set up dressing, hygiene; supervision with bathing and toileting; and partial/moderate assist with transfers. During an…

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, interview, and record review the facility failed to insure that one resident (R57) was free from significant medications errors out of one resident reviewed for significant medication errors resulting in the potential for adverse physical reactions/outcomes to residents. Findings Included: Resident #57 (R57) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R57 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included acute and chronic respiratory failure, congestive heart failure(CHF), chronic obstructive pulmonary disease, history of lung cancer with lung removal, diabetes mellitus, history pneumonia, anxiety and depression. The MDS reflected R57 had a BIM (assessment tool) score of 15 which indicated her ability to make daily decisions was cognitively intact, and she required set up dressing, hygiene; supervision with bathing and toileting; and partial/moderate assist with transfers. During an observation and interview on…

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, interview, and record review, the facility failed to develop and/or implement a comprehensive care plan for 1 (Resident #25) of 19 residents reviewed, resulting in the potential for unmet care needs. Findings include: Review of the medical record revealed that Resident #25 (R25) was admitted to facility 11/1/2018 with diagnoses including hypertensive heart disease with heart failure and personal history of other venous thrombosis and embolism. Review of the Minimum Date Set (MDS) with an Assessment Reference Date (ARD) of 12/4/23 revealed that R25 had a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 15 (cognitively intact). Review of an active Activities of Daily Living Care Plan reflected that R25 required extensive assist of 1 with upper and lower body dressing and was dependent for footwear placement. In an observation and interview on 2/25/24 at 1:44 PM, R25 was observed sitting in room, in high back wheelchair, with back of chair reclined slightly and…

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, interview, and record review, the facility failed to provide restorative services for two of two residents reviewed for limited mobility (Resident #17 & #40), resulting in unmet needs and goals. Findings include: Resident #40 (R40) On 2/25/24 at approximately 12:50 PM R40 was observed seated in a wheelchair at a table eating lunch. R40 held a fork in her right hand that was arthritic and appeared to be struggling with picking up food with her fork. On 2/26/24 at 12:44 PM R40 was observed eating lunch using a spoon; she was able to grip and control the spoon more easily when compared to a fork. R40's Minimum Data Set (MDS) assessment with assessment reference date of 12/06/23 revealed she was admitted to the facility on [DATE]; had a Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener, score of 10 (08-12 Moderate Cognitive Impairment). The same MDS assessment indicated R40 did not have deficits in functional range of motion (ROM), in her upper and lower…

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.