John T Mather Memorial Hosp T C U

Based on observations, record review, and interviews conducted during the Recertification survey initiated on 5/21/2025 and completed on 5/23/2025, the facility did not follow proper sanitation practices to prevent the outbreak of foodborne illness and did not store and prepare food in accordance with professional standards for food service safety. This was identified during the Kitchen Task. Specifically, during the kitchen observation on 5/21/2025: 1) Multiple undated, unlabeled, uncovered cooked food, and expired food items were observed in the walk-in refrigerators, walk-in freezer, and dry storage room. 2) Multiple dietary staff did not perform proper hygienic practices including hand washing and hair covering while handling food. 3) There was an unsanitary soiled reach-in refrigerator and a soiled meat slicer. The washed wet cooking pans were nesting on top of each other. 4) Catch buckets with dirty kitchen towels and aprons were placed in the dry storage room adjacent to the stored food items. This is a repeat deficiency. The findings included but were not limited to: 1) 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, and interviews during the Recertification Survey initiated on 5/21/2025 and completed on 5/23/2025, the facility did not ensure that each resident had physician orders for the resident's immediate care at the time the resident was admitted to the facility. This was identified for two (#158 and Resident #151) of two residents reviewed for Limited Range of Motion. Specifically, 1) Resident #158 utilized a lumbar spine orthosis without a Physician's order, and 2) Resident #151 had a diagnosis of left distal radial (arm bone near the wrist) fracture and was wearing a sugar tong splint (a type of splint that stabilizes injuries of the forearm and wrist by preventing forearm rotation and wrist motion) and sling on the left arm. There was no Physician's Order for using the sugar tong splint and sling until 5/22/2025. The findings are: 1) Resident #158 was re-admitted to the facility with diagnoses including Diabetes Mellitus, stroke management, and Back Pain. The resident was…

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, and interviews during the Recertification Survey initiated on 5/21/2025 and completed on 5/23/2025 the facility did not ensure it developed and implemented a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. This was identified for one (Resident #158) of two residents reviewed for Limited Range of Motion. Specifically, Resident #158 used a lumbar spinal orthotic device due to a lumbar vertebra (spine) fracture; however, the device was not included in the baseline care plan and there was no physician's order for the device. The finding is: The facility's policy titled Interdisciplinary Care Plan, dated 3/2025, documented all residents requiring a stay in the facility will have an Interdisciplinary Plan of Care upon admission. The purpose is to develop a plan of care, treatment, and services individualized and appropriate to the resident's…

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 on observations, record review, and interviews during the Recertification Survey initiated on 5/21/2025 and completed on 5/23/2025, the facility did not ensure that each resident who needs respiratory care is provided such care consistent with professional standards of practice and the comprehensive person-centered care plan. This was identified for one (Resident #154) of one resident reviewed for Respiratory Care. Specifically, during observation, an unlabeled nebulizer mask was not covered and was hung on the wall-mounted oxygen flowmeter with the oxygen tubing still connected to the nebulizer mask in Resident #154's room. The finding is: The facility's policy and procedure titled Equipment Processing and Circuit Change Intervals last revised in July 2021 documented that each resident's nebulizer setup will be discarded and replaced every seven days by Respiratory Therapists. The date of the equipment change and the therapist's initials will be written on the plastic treatment bag. After each treatment, nebulizers will be emptied and put back into the labeled plastic bag…

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 observations, record review, and interviews during the Recertification Survey initiated on 5/21/2025 and completed on 5/23/2025 the facility did not ensure it established and maintained an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. This was identified for one (Resident #158) of six residents observed during the medication pass. Specifically, during the medication administration observation for Resident #158, Registered Nurse #2 brought the medication cart into the resident's room for medication administration. Registered Nurse #2 then dropped an individual blister-packed medication (one pill in an individual blister pack) onto the floor. While wearing gloves, the nurse picked up the blister-packed medication and popped the tablet out of the blister pack into a souffle cup already containing other medication tablets. The nurse then discarded the medications that were in the souffle cup. The nurse did not…

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 on record review and staff interviews during the Recertification Survey initiated on 5/21/2025 and completed on 5/23/2025, the facility did not ensure that it designated one or more individual(s) as the Infection Preventionist(s) (IP)(s) who are responsible for the facility's Infection Prevention Control Program (IPCP) and the Infection Preventionist must have completed specialized training in infection prevention and control beyond initial professional training or education prior to assuming the role. Specifically, the facility's designated Infection Preventionist did not have documented evidence of specialized training in infection prevention and control beyond the initial professional training or education prior to assuming the role. Finding is: The facility's policy for Infection Prevention and Control did not include qualifications/training requirements beyond the initial professional training or education for the facility's Infection Control Officer/Preventionist. A review of the Director of Infection Prevention (the designated Infection Preventionist) personnel 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.

Based on observations, record review, and interviews conducted during a Recertification Survey initiated on 6/17/2024 and completed on 6/20/2024, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. This was identified during the Kitchen observation conducted on 6/17/2024. Specifically, the walk-in refrigerator for produce and dairy was observed holding a rack of eight trays of cooked chicken breast and three pans of gravy sauce. The trays of cooked chicken breast were uncovered and undated and the gravy sauce was unlabeled and undated. A rack containing uncooked and undated bacon strips was observed. The bacon strips were taken out of their original package and prepped onto 15 baking sheets. The walk-in refrigerator for meat was observed with two racks containing trays of various uncovered food items including but not limited to pizza, pasta, and chickpeas. The finding is: The facility's policy titled Nutrition and Food Services Guidelines last reviewed on 3/18/2021 documented that…

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 on record review and interviews conducted during a Recertification Survey initiated on 6/17/2024 and completed on 6/20/2024, the facility did not ensure that their policy regarding the use and storage of foods brought to residents by family and other visitors included to ensure facility staff assists the resident in accessing and consuming the food if the resident is not able to do so on their own. Specifically, the facility policy did not include guidance to facility staff regarding assisting the resident in accessing, handling (reheating), and consuming the food brought in from outside by the family members and other visitors if the resident is not able to do so on their own. The finding is: The facility's policy titled, Nutrition and Food Services Guidelines last reviewed on 3/18/2021 documented that patients who desire to have food brought in from outside should be permitted to do so. Food should be labeled with the patient's name and date when placed in the pantry refrigerator and discarded after 72 hours. The policy did not specify how the facility staff would assist 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.

Based on observation, record review, and staff interviews during the Recertification Survey, initiated on 6/17/2024 and completed on 6/20/2024, the facility did not ensure it maintained an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections for one (Resident #58) of seven resident observed during the medication administration. Specifically, Resident #58 had a physician's order for a tuberculin skin test (a screening diagnostic test for Tuberculosis). When Registered Nurse #1 offered the test to the resident on 6/18/2024, the resident refused. There was no documented evidence that Registered Nurse #1 reported the refusal to the Physician. The finding is: The facility's policy titled Tuberculosis Control Strategy Plan, dated 2/20/2024, documented it is the policy of the facility to minimize patient and healthcare personnel risk for exposure to pathogens that can cause disease and/or infection. The intent of this policy is to identify patients with Tuberculosis, describe measures to prevent…

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 on observation, record review, and staff interviews during the Recertification Survey initiated on 10/3/2022 and completed on 10/5/2022, the facility did not ensure proper sanitation practices were maintained in the main kitchen area to prevent the outbreak of foodborne illness. Specifically, during the initial tour of the main Hospital kitchen, the light fixtures near the kitchen exhaust fan were observed with a buildup of grease and dirt. The finding is: During the initial tour of the main Hospital kitchen area on 10/03/2022 at 11:39 AM, three light fixtures were observed with a buildup of grease and dirt near the kitchen exhaust fan. The Food Service Director (FSD) was interviewed on 10/3/2022 at 11:40 AM and stated the fixtures should not have a build-up of grease and dust and will be cleaned promptly. The FSD stated that the exhaust liner is cleaned every 2 months. The liner was last cleaned in August 2022 and the service company should have cleaned the light fixtures at that time. The Administrator was interviewed on 10/6/2022 at 12:15 PM and stated that the kitchen is…

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.