Memorial Health Care Center

Based on observation, interview, and record review, the facility failed to provide information to resident's and their representatives on their rights related to filing grievances or concerns for 10 of 42 confidential residents. The facility failed to ensure 10 confidential residents were provided, the Grievance Procedure, information in regards to who the facility grievance officer was, their contact information, how to file an anonymous grievance. This failure could place the residents at risk of unresolved grievances and decreased quality of life. Findings included: Interviews during Resident Council with 10 confidential residents, stated they did not have access to a Grievance form, they did not know they could file a Grievance anonymously, and they had not observed a posting of the Grievance procedure in prominent locations. Record Review of the facility Grievance policy updated April 2017 reflected a copy of the Grievance/complaint procedure should be posted on the resident bulletin board. Observed prominent postings in the lobby of the facility on 8/20/2025 at 11:45am. 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 interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that include measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 4 of 16 residents (Resident #29, Resident #36, Resident #39, and Resident #42) reviewed for care plans. The facility failed to develop a care plan for Resident #29's, Resident #36's, Resident #39's and Resident #42's advanced directives. These failures could place residents at risk of not receiving the care required to meet their individualized needs. Findings included: Resident #29 Record review of the resident face sheet for Resident #29, dated 08/20/25 revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: dysphagia (difficulty swallowing), acute pulmonary edema (difficulty…

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, interviews, and record review, the facility failed to ensure the personal food policy was followed to maintain safe and sanitary storage of residents' food items for 4 of 16 residents rooms reviewed for food safety (room [ROOM NUMBER]A, #16B, #19B, and #21B) in that: The refrigerators located in room [ROOM NUMBER]A, #16B, #19B, and #21B were not being monitored for internal temperature and expiration/used by dates. These failures could place residents at risk for food borne illnesses. Findings include: During an observation on 08/19/2025 at 11:34 AM, Resident room [ROOM NUMBER]B contained a personal refrigerator. The refrigerator contained perishable food items such as a personal Ziplock package of summer sausage (expiration date 8/20/2025), 3 individual containers of Jello pudding, one bag of Doritos chips, two bags of Cheese It crackers, and a Ziplock bag of an unknown, unlabeled/undated food item. The refrigerator also contained numerous cans of unopened soda. During an observation 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 establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 3 residents (Residents #39 and #29) reviewed for infection control.1. CNA A failed to utilize proper hand hygiene between glove changes and failed to change gloves when going from dirty to clean when providing incontinence care and catheter care for Resident #39. 2. CNA A and RN B failed to follow enhanced barrier precautions (EBP) and wear a gown when providing incontinence care and catheter care for Resident #39. 3. CNA C failed to change her gloves when going from dirty to clean when providing incontinence care for Resident #29.These failures could place residents at risk for cross contamination and infection. The findings include: Resident #39 Record review of the resident face sheet for Resident #39,…

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 reviews and interviews the facility failed to develop, implement, and maintain an effective training program for all new and existing staff; individuals providing services under a contractual arrangement; and volunteers, consistent with their expected roles for 6 out of 6 employees (RN F, CNA A, LVN H, CNA G, CNA I, and CNA J) reviewed for required training. The facility failed to ensure staff were properly trained in Fall Prevention, HIV, Restraints, Emergency Procedures and Dementia for 6 of 6 employees (RN F, CNA A, LVN H, CNA G, CNA I, and CNA J) reviewed for training at hire and annually. This failure could place residents at risk of receiving care from individuals who did not have the knowledge and skills to properly provide safety from adverse events or other resident life and health complications.Findings include: Record review of employee records for RN F reflected RN F was hired at the facility on 07/28/2025, and the facility was unable to provide documentation indicating RN F received training, through the facility, on Fall Prevention, HIV, Restraints,…

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 ensure all residents had the right to formulate an advance directive for 2 of 16 residents (Residents #27 and #28) reviewed for advanced directives, in that: Residents #27 and #28 was listed as a DNR (Do Not Resuscitate) but had Out-of-Hospital Do Not Resuscitate (OOH-DNR) forms that were incorrectly filled out or had missing required information. These failures could place residents at risk for not having their end of life wishes honored and their records being incomplete/inaccurate.Findings included: Resident #27 Record review of Resident #27's face sheet, undated, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include dementia (impairments of at least two brain functions), Hypothyroidism (thyroid gland does not produce enough thyroid hormones), and Hypertension (force of the blood against the artery walls is too high). The face sheet also revealed under the advance directive section - DNR-Do 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 interview and record review, the facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week for 10 out of 90 days (01/11/25, 01/12/25, 01/25/25, 01/26/25, 02/08/25, 02/09/25, 02/15/25, 02/16/25, 02/22/25, and 02/23/25) reviewed for RN coverage. The facility failed to ensure they had RN coverage 8 hours a day, 7 days a week for the following weekend days: 01/11/25, 01/12/25, 01/25/25, 01/26/25, 02/08/25, 02/09/25, 02/15/25, 02/16/25, 02/22/25, and 02/23/25 This failure could place residents at risk for inconsistency in care and services.Findings include: Record review of the facility's PBJ Staffing Data Report for the Fiscal Year Quarter 2 2025 (January 1 - March 31) dated 08/15/25 revealed there were no RN hours for the dates 01/11/25, 01/12/25, 01/25/25, 01/26/25, 02/08/25, 02/09/25, 02/15/25, 02/16/25, 02/22/25, and 02/23/25. During an interview on 08/21/25 at 12:11 PM, the Admin stated the DON was hired at the end of 2024 and has worked Monday through Friday 8 am to 5 pm and sometimes more than that. 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 observations, interviews and record review, the facility failed to prepare food in a form to meet individual needs in 1 of 1 kitchen reviewed for dietary services in that: The facility failed to ensure puree meat, puree vegetables, and puree pasta were prepared to a smooth uniform texture. This failure could place residents at risk for choking. Findings include:During an observation on 08/20/2025 at 12:10 PM, the test tray sampled revealed the pureed broccoli had small chunks of broccoli and strings in it and was not a smooth uniform texture. The puree pasta had chunks of dough and was not a smooth uniform texture. During an observation on 08/21/2025 at 11:55 AM, the test tray sampled revealed the pureed pork had small grains of pork and was not a smooth uniform texture. The puree carrots had chunks of carrots and were not a smooth uniform texture. The puree potatoes had chunks of potatoes and were not a smooth uniform texture. During an interview on 08/21/2025 at 12:05 PM, the DM stated she 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.

Based on interview and record review, the facility failed to electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS for 1 of 1 facility reviewed for administration (Fiscal year 2024 for the second quarter January 1, 2024, to March 31, 2024). The facility failed to submit PBJ (Payroll Based Journal) staffing information to CMS for the 2nd quarter of the fiscal year 2024. This failure could place residents at risk for personal needs not being identified and met due to staffing. Findings included: Record review of the CMS PBJ Staffing Data Report (payroll-based staffing), CASPER Report (Certification and Survey Provider Enhanced Report)1705 D FY Quarter 2 2024 (January 1- March 31), dated 07/18/24, indicated the following entry: Failed to Submit Data for the Quarter Triggered .Triggered=No Data Submitted for the Quarter. During an interview on 07/25/24 at 11:15 AM, the DON stated…

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, interview and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible in 2 of 3 common resident baths (Tan and Mauve Halls) in that: The facility failed to ensure chemicals were not stored with resident toiletries and personal items in 2 of 3 common resident baths (Tan and Mauve Halls). These failures could place residents at risk for accident hazards resulting in injuries. The findings include: On 7/24/24 at 9:02 AM an observation was made of the central bath on the Mauve Hall which included rooms 32 through 43. The door to the bath was not locked. There was a spray bottle of Disinfectant Cleaner and Deodorizer on an open shelf next to washcloths and towels. The Virex Plus One Step Disinfectant Cleaner and Deodorizer was labeled, Causes moderate eye irritation. Avoid contact with eyes or clothing. Wash thoroughly with soap and water after handling . The upper cabinets in the bath were locked. One of 2 cabinets had spray bottles of Virex Plus, a spray bottle of pink liquid, and an aerosol…

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 offer, based on a resident's comprehensive assessment, a therapeutic diet when there was a nutritional problem, and the health care provider ordered a therapeutic diet for 3 of 3 residents (Residents #18, 72 and 73) reviewed for nutrition status. The facility failed to provide Residents #18, 72 and 73 with their physician ordered therapeutic diets that included fortified foods for the noon meals on 7/23/24, 7/24/24 and 7/25/24. This failure could place residents at risk for hunger, weight loss and chemical imbalances. The findings included: Resident #18 Record review of the current undated face sheet for male Resident #18 revealed that the resident was admitted to the facility on [DATE] and re-admitted on [DATE]. The resident was [AGE] years old and had diagnoses of moderate protein calorie malnutrition (nutritional deficiency), urinary tract infection, site not specified, (history of) (infection of urinary tract), Constipation,…

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, interviews, and record review, the facility failed to maintain an infection control program designed to provide a safe, comfortable, and sanitary environment to help prevent the development and transmission of diseases for 3 of 4 residents (Residents #3) reviewed for infection control. 1. CNA A failed to utilize proper hand hygiene during incontinence care for Resident # 3. 2. CNA C failed to utilize proper hand hygiene during incontinence care for Resident #172 3. The facility failed to implement enhanced barrier precautions for Resident #18. These failures could place residents at risk for infection and cross contamination. The findings include: Resident #3 Record review of Resident #3's undated face sheet revealed a [AGE] year-old female originally admitted on [DATE]. Resident #3 had medical history of congestive heart failure (compromised blood supply to the body), hypertension (high blood pressure), and generalized anxiety disorder. Record review of Resident #3's quarterly MDS dated…

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 interviews and record reviews the facility failed to ensure the residents had the right to participate in, his or her treatment which included the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred, for 3 of 13 residents (Residents #8, #72, #222) reviewed for resident rights. The facility failed to obtain a signed informed consent based on information of the benefits, risks, and options available for: Residents #8 prior to the administration of Lorazepam and Trazodone; Resident #72 prior to the administration of Trazodone; Resident #222 prior to the administration of Seroquel and Lorazepam. Lorazepam, Trazodone, and Seroquel are psychotropic medications (a psychoactive drug taken to exert an effect on the chemical make-up of the brain and nervous system); This failure could place residents at risk 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 interview and record review, the facility failed to ensure PRN orders for psychotropic drugs are limited to 14 days unless the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, for 2 of 16 residents (Resident #3 and Resident #72) reviewed for unnecessary medications. - The facility failed to ensure Resident #3 had a stop date or duration for PRN alprazolam (a medication used to treat anxiety). - The facility failed to ensure Resident #72 had a stop date or duration for PRN Trazadone (a medication use to treat insomnia). These failures could put residents at risk of possible psychotropic medication side effects, adverse consequences, decreased quality of life, and dependence on unnecessary medications. Findings included: Resident #3 Record review of Resident #3's undated face sheet revealed a [AGE] year-old female originally admitted on [DATE]. Resident #3 had a medical history of congestive heart failure (compromised blood…

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.