Deficiencies (last 3 years)
Deficiencies (over 3 years)
26.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
651% worse than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Routine
Deficiencies: 4
Date: Nov 14, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, medication storage and labeling, clinical record accuracy, infection prevention and control, and facility maintenance.
Findings
The facility was found deficient in maintaining a safe, clean, and homelike environment, proper medication storage and labeling, complete and accurate clinical records, and infection prevention practices. Specific issues included non-functional doors in resident rooms, unsafe patio door entry, unsecured medications at bedside, incomplete nursing admission assessment, and improper storage of nebulizer equipment.
Deficiencies (4)
Failed to provide a functional accessible bathroom door and bedroom door to Resident #1; broken/torn rubber baseboards, holes in the wall, and broken/missing tiles in Resident #2's room; entry/exit door to patio not functioning properly with a gap between ramp and threshold.
Failed to ensure drugs and biologicals were labeled and stored in locked compartments; medications found at bedside for Residents #1, #4, #6, and #7.
Failed to maintain clinical records accurately; nursing admission assessment for Resident #5 was not documented.
Failed to maintain an infection prevention and control program; Resident #4's nebulizer mask and tubing were not stored properly, risking infection.
Report Facts
Residents affected: 2
Residents affected: 4
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN B | Registered Nurse | Named in medication administration and infection control findings |
| CNA A | Certified Nursing Assistant | Provided observations related to resident room conditions and door issues |
| Maintenance Director | Provided information on maintenance issues and repair priorities | |
| Administrator | Administrator and Registered Nurse | Provided statements on facility policies, deficiencies, and expectations |
Inspection Report
Routine
Deficiencies: 12
Date: Jun 11, 2025
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, infection control, assessment accuracy, care planning, respiratory care, food safety, pest control, and staff competency.
Findings
The facility was found deficient in multiple areas including failure to ensure resident privacy during care, inaccurate resident assessments, incomplete care plans, inadequate tracheostomy care, improper infection control practices, unsafe food storage and handling, ineffective pest control, and failure to maintain staff competency in certain nursing skills.
Deficiencies (12)
Failed to ensure residents have a right to personal privacy during wound care; privacy curtain was not closed.
Failed to ensure assessment accurately reflected resident's tobacco use.
Failed to refer resident for level II resident review following new diagnosis of schizoaffective disorder-bipolar type.
Failed to develop and implement comprehensive person-centered care plans addressing all triggered care areas for multiple residents.
Failed to revise comprehensive care plan to reflect resident's refusal to have weight taken.
Failed to provide tracheostomy care and suctioning according to professional standards; sterile field was broken during care.
Failed to ensure nurses demonstrated competency in tracheostomy care.
Failed to store clean cups properly to allow for air-drying and failed to store mop and broom in a sanitary manner.
Failed to enact a policy regarding use and storage of foods brought to residents by family and visitors; food in resident's refrigerator was not labeled or dated.
Failed to dispose of garbage and refuse properly; dumpster missing drain plug.
Failed to maintain an infection prevention and control program; staff failed to change gloves or sanitize hands appropriately during care.
Failed to have an ongoing and effective pest control program; presence of gnats in resident rooms.
Report Facts
Residents reviewed: 20
Residents reviewed for infection control: 6
Residents affected: 1
Residents affected: 3
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Named in privacy and infection control deficiencies related to Resident #71 | |
| LVN C | Named in infection control deficiency related to Resident #10 and tracheostomy care for Resident #76 | |
| RN B | Registered Nurse | Named in tracheostomy care and competency deficiencies for Resident #76 |
| CNA D | Certified Nursing Assistant | Named in infection control deficiency related to Resident #71 |
| DON | Director of Nursing | Interviewed regarding privacy, infection control, care planning, and tracheostomy care deficiencies |
| MDS Nurse G | MDS Nurse | Interviewed regarding care plan deficiencies |
| RN E | Registered Nurse | Interviewed regarding Resident #75's tobacco use |
| CNA F | Certified Nursing Assistant | Interviewed regarding pest control and weighing Resident #11 |
| Maintenance Director | Interviewed regarding dumpster drain plug | |
| Maintenance Supervisor | Interviewed regarding pest control program | |
| DM | Dietary Manager | Interviewed regarding kitchen sanitation deficiencies |
Inspection Report
Routine
Deficiencies: 12
Date: Jun 11, 2025
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements including resident privacy, accurate assessments, care planning, infection control, respiratory care, food safety, pest control, and staff competency.
Findings
The facility was found deficient in multiple areas including failure to ensure resident privacy during care, inaccurate resident assessments, incomplete and untimely comprehensive care plans, improper infection control practices, inadequate tracheostomy care, unsafe food storage and handling, improper garbage disposal, and ineffective pest control program.
Deficiencies (12)
Failed to ensure residents have a right to personal privacy during wound care for Resident #71.
Failed to ensure accurate assessment reflecting Resident #75's tobacco use.
Failed to refer Resident #75 for level II resident review following new diagnosis of schizoaffective disorder-bipolar type.
Failed to develop and implement comprehensive person-centered care plans for Residents #52, #75, and #80.
Failed to revise Resident #11's comprehensive care plan to reflect refusal to have weight taken.
Failed to provide tracheostomy care and suctioning according to professional standards for Resident #76.
Failed to demonstrate competency in tracheostomy care by RN B.
Failed to store clean cups properly to allow for air-drying and failed to store mop and broom in a sanitary manner.
Failed to enact a policy regarding use and storage of foods brought to residents by family and visitors; food in Resident #5's refrigerator was not labeled or dated.
Failed to dispose of garbage and refuse properly; Dumpster #1 lacked a drain plug.
Failed to maintain an infection prevention and control program; staff failed to change gloves and sanitize hands appropriately during care for Residents #10 and #71.
Failed to have an ongoing and effective pest control program to eradicate gnats in the facility.
Report Facts
Residents reviewed for assessments: 20
Residents reviewed for infection control: 6
Residents reviewed for competent staff: 6
Residents affected by privacy deficiency: 1
Residents affected by assessment deficiency: 1
Residents affected by care plan deficiency: 3
Residents affected by tracheostomy care deficiency: 1
Residents affected by food storage deficiency: 1
Residents affected by pest control deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Named in privacy and infection control deficiencies for Resident #71 |
| LVN C | Licensed Vocational Nurse | Named in infection control and tracheostomy care deficiencies for Resident #10 and #76 |
| RN B | Registered Nurse | Named in tracheostomy care and competency deficiencies for Resident #76 |
| CNA D | Certified Nursing Assistant | Named in infection control deficiency for Resident #71 |
| MDS Nurse G | MDS Nurse | Named in care plan deficiencies for Residents #52, #75, #80, and #11 |
| DON | Director of Nursing | Provided multiple interviews confirming deficiencies and staff training |
| DM | Dietary Manager | Named in food service deficiencies |
| Maintenance Director | Maintenance Director | Named in garbage disposal and pest control deficiencies |
| Maintenance Supervisor | Maintenance Supervisor | Named in pest control deficiency |
| RN E | Registered Nurse | Interviewed regarding Resident #75's tobacco use |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 16, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding discrepancies in medication reconciliation and incomplete medical records for residents.
Complaint Details
The complaint investigation revealed discrepancies in the medication reconciliation log for Hydromorphone involving RN E, RN D, and LVN F, with RN E falsifying medication records and subsequently terminated. For Resident #1, the facility failed to obtain and document physician orders for supplemental oxygen and CPAP/BiPAP, despite verbal orders and documented use.
Findings
The facility failed to ensure accurate medication reconciliation for controlled substances, specifically Hydromorphone for Resident #2, resulting in discrepancies and potential medication errors. Additionally, the facility failed to maintain complete and accurate medical records for Resident #1, who was administered supplemental oxygen and CPAP/BiPAP without physician orders.
Deficiencies (2)
Failed to ensure drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled for Resident #2, with discrepancies in Hydromorphone medication reconciliation log.
Failed to maintain resident medical records that were complete and accurately documented for Resident #1, including administration of supplemental oxygen and CPAP/BiPAP without physician's orders.
Report Facts
Medication discrepancy volume: 18
Hydromorphone doses undocumented: 8
Hydromorphone doses signed but undocumented: 10
Oxygen saturation: 79
Oxygen flow rate: 2
Oxygen flow rate: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN E | Registered Nurse | Named in medication discrepancy and falsification of Hydromorphone reconciliation log |
| RN D | Registered Nurse | Involved in narcotic count and reporting medication discrepancies |
| LVN F | Licensed Vocational Nurse | Involved in medication administration and refusal to falsify medication log |
| Administrator | Conducted investigation, reported findings, and terminated RN E | |
| RN C | Registered Nurse | Documented nursing progress notes regarding Resident #1's oxygen status |
| RN B | Registered Nurse | Documented nursing progress notes and verified oxygen orders for Resident #1 |
| LVN A | Licensed Vocational Nurse | Described process for obtaining physician orders and noted oversight in Resident #1's oxygen orders |
| DON | Director of Nursing | Discussed transcription failures of verbal orders for Resident #1 |
Inspection Report
Routine
Deficiencies: 2
Date: Jan 24, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulatory requirements related to resident safety, communication systems, and environmental conditions.
Findings
The facility failed to ensure an operating call light system in one resident's room, which could place residents at risk of not being able to call for staff assistance. Additionally, the facility failed to maintain safe, functional, and comfortable environmental conditions due to inoperable overhead lighting and heating in resident shower rooms.
Deficiencies (2)
Failed to ensure an operating call light system in Resident #1's room.
Failed to provide a safe, functional, sanitary, and comfortable environment due to inoperable overhead light and heater in resident shower rooms.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident #1 | Reported not being aware that the call light was not working. | |
| Maintenance Director | Interviewed regarding call light malfunction and environmental issues; stated he was not made aware of malfunctions and would repair them immediately. | |
| LVN-B | Licensed Vocational Nurse | Interviewed and stated unawareness of call light malfunction and emphasized the necessity of a working call light system for resident care. |
| Assistant Director of Nurses | ADON-A | Interviewed regarding environmental deficiencies; stated unawareness of inoperable light and heater in resident shower rooms. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Sep 8, 2024
Visit Reason
The inspection was conducted due to a complaint investigation triggered by the elopement of a cognitively impaired resident from the facility on 09/01/2024, and failure to post survey results in an accessible location.
Complaint Details
The complaint investigation was triggered by the elopement of Resident #1, a cognitively impaired male with dementia, on 09/01/2024. The resident left the facility unsupervised through an unknown door and was found at a local hospital early the next morning. The facility was cited for Immediate Jeopardy due to inadequate supervision and failure to secure doors properly. The Immediate Jeopardy was identified on 09/05/2024 and removed on 09/08/2024 after corrective actions were implemented.
Findings
The facility failed to post survey results in a readily accessible place for residents and visitors, and failed to provide adequate supervision to prevent elopement of a cognitively impaired resident, resulting in an Immediate Jeopardy (IJ) situation. The resident eloped on 09/01/2024 and was found at a hospital hours later. The facility implemented a plan of removal including staff education, door alarms installation, and enhanced monitoring.
Deficiencies (2)
Failure to post survey results in a place readily accessible to residents, family members, and legal representatives.
Failure to ensure a cognitively impaired resident had adequate supervision to prevent elopement, resulting in Immediate Jeopardy.
Report Facts
Residents reviewed for elopement risk: 96
Residents newly identified at risk for elopement: 38
Number of exterior or exit doors: 14
Residents allowed to sign out without supervision: 23
Number of new door alarms installed: 14
Number of facility employees: 106
Number of staff trained on elopement and related policies: 111
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Provided progress notes and was involved in the incident of Resident #1's elopement. |
| MA D | Medical Assistant | Provided medications to Resident #1 and reported resident missing. |
| CNA C | Certified Nursing Assistant | Worked on the day of elopement and did not recall seeing Resident #1 or hearing door alarms. |
| CNA E | Certified Nursing Assistant | Worked on the day of elopement, observed untouched lunch tray, and reported resident missing. |
| CNA F | Certified Nursing Assistant | Worked on the day of elopement and participated in search efforts. |
| DON | Director of Nursing | Interviewed regarding facility policies, supervision, and elopement incident. |
| ADMIN | Administrator | Interviewed regarding facility policies, camera access, and incident investigation. |
| RECPST | Receptionist | Interviewed regarding door monitoring and survey results binder location. |
| Maint Dir | Maintenance Director | Interviewed regarding door alarms and facility door security. |
Inspection Report
Deficiencies: 1
Date: Aug 9, 2024
Visit Reason
The inspection was conducted to assess compliance with food safety standards in the facility kitchen, specifically focusing on proper storage, preparation, distribution, and serving of food under sanitary conditions.
Findings
The facility failed to ensure that all employees wore hair nets in the kitchen, which could place residents at risk for cross contamination. Observations and interviews confirmed that a CNA entered the kitchen without a hair net despite training and facility policy requiring hair nets for sanitary reasons.
Deficiencies (1)
CNA A failed to put on a hair net before entering the facility kitchen, risking cross contamination of residents' food.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Named in deficiency for entering kitchen without hair net | |
| Dietary Manager | Interviewed regarding hair net policy and training | |
| Dietary Aide A | Observed asking CNA A to leave kitchen for not wearing hair net | |
| DON | Director of Nursing | Interviewed about staff education and expectations on hair net use |
Inspection Report
Routine
Census: 104
Deficiencies: 1
Date: Jul 18, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with posting daily nurse staffing information, including actual hours worked by licensed nursing staff and certified nurse aides per shift, and to ensure this information was accessible in a prominent place.
Findings
The facility failed to post daily staffing information broken down by shift and in a prominent place on two of three days observed (07/15/2024 and 07/16/2024). The staffing information was posted as total numbers for a 24-hour period without shift breakdown and the detailed shift schedule was posted in a less accessible location. This failure could risk residents, families, and visitors not having access to staffing data.
Deficiencies (1)
Failed to post daily nurse staffing information broken down by shift and in a prominent place on two of three days observed.
Report Facts
Current census: 104
RN coverage: 3
LPN/LVN coverage: 6
CMA coverage: 6
CNA coverage: 18
RN coverage: 2
LPN/LVN coverage: 8
CMA coverage: 6
CNA coverage: 18
CNA 7A-3P names listed: 7
LVNs 7A-7P names listed: 3
CMAs 2P-10P names listed: 3
CNAs 3P-11P names listed: 5
LVNs 7P-7A names listed: 2
RN 7P-7A names listed: 1
CNAs 11P-7A names listed: 3
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 2, 2024
Visit Reason
The inspection was conducted due to a complaint alleging failure to timely report suspected abuse involving Resident #1, specifically that staff did not report an allegation of abuse immediately as required.
Complaint Details
The complaint investigation involved allegations that CNA B and CNA C failed to report suspected sexual abuse of Resident #1 in a timely manner. Interviews revealed delays in reporting, lack of immediate notification to charge nurse or administrator, and uncertainty about reporting procedures. Resident #1 denied abuse and showed no signs of trauma. Police did not pursue formal investigation or SANE exam authorization.
Findings
The facility failed to ensure that alleged abuse was reported immediately, with CNA B and CNA C not reporting suspected abuse on 05/31/2024. Investigations found no physical signs of abuse on Resident #1, who denied any mistreatment. The police declined to file a formal report or authorize a SANE exam. The facility had policies and training on abuse reporting, but staff failed to report timely due to uncertainty and lack of knowledge.
Deficiencies (1)
Failure to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Report Facts
Residents Affected: 1
Date of survey completed: Jun 2, 2024
Date of alleged abuse: May 31, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA B | Certified Nursing Assistant | Named in failure to report suspected abuse for Resident #1 |
| CNA C | Certified Nursing Assistant | Named in failure to report suspected abuse for Resident #1 |
| CMA D | Certified Medication Aide | Named in allegation of abuse but denied accusations |
| LVN A | Licensed Vocational Nurse | Conducted assessment of Resident #1 after abuse allegation |
| Administrator | Facility Administrator and Abuse Coordinator involved in investigation and reporting | |
| DON | Director of Nursing | Conducted head-to-toe assessment and involved in investigation |
| SANE Nurse | Sexual Assault Nurse Examiner | Conducted exam of Resident #1 at hospital and reported no evidence of trauma |
Inspection Report
Complaint Investigation
Deficiencies: 11
Date: Apr 26, 2024
Visit Reason
The inspection was conducted based on complaints and concerns regarding resident care, safety, and regulatory compliance at Memorial Medical Nursing Center.
Complaint Details
The investigation was complaint-driven, focusing on allegations of inadequate care planning, unsafe environment, infection control issues, and policy noncompliance.
Findings
The facility was found deficient in multiple areas including failure to involve residents and families in care planning, incomplete and inaccurate care plans, failure to perform ordered skin assessments, unsafe resident environment with unsecured hazardous items, inadequate respiratory care, food safety violations, infection control lapses, pest control issues, and failure to enforce smoking policies.
Deficiencies (11)
Failed to ensure residents and/or representatives participated in development and implementation of person-centered care plans for 4 of 8 residents.
Failed to develop and implement comprehensive person-centered care plans addressing all resident needs for 3 of 30 residents.
Failed to develop, implement, and revise comprehensive person-centered care plans including measurable objectives and timeframes for 2 of 33 residents.
Resident #20 did not receive ordered weekly skin assessments between 2/23/2024 and 4/22/2024.
Residents #68 and #87 had unsafe possession of cigarettes, lighters, and scissors; unsecured bathing supplies including razors were found in unlocked storage and shower rooms.
Failed to store, prepare, distribute, and serve food in accordance with professional standards including unlabeled/undated food items, malfunctioning ice cream freezer, dirty kitchen vent, and dietary aide not wearing hair restraint.
Failed to provide safe and appropriate respiratory care for 4 residents including lack of orders for oxygen device management and failure to change oxygen humidifier bottles when empty.
Failed to maintain safe and sanitary storage of residents' food items in personal refrigerators for 2 residents with unlabeled and undated food.
Sharps container in Resident #2's room was overfilled, risking puncture injuries.
Facility failed to maintain an effective pest control program; numerous flies observed in resident room and dining room.
Facility failed to establish and enforce smoking policies; residents observed smoking with cigarettes and lighters in their rooms contrary to policy.
Report Facts
Residents reviewed for care plans: 33
Residents affected by care plan deficiencies: 8
Residents affected by skin assessment deficiency: 1
Residents affected by unsafe environment: 2
Residents affected by respiratory care deficiencies: 4
Residents affected by food storage deficiencies: 2
Residents affected by infection control deficiency: 1
Residents affected by pest control deficiency: 1
Residents observed smoking with cigarettes and lighters in rooms: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| ADON F | Assistant Director of Nursing | Described initiation of care plan conferences and responsibilities. |
| SW | Social Worker | Maintains care plan conference schedule and attendee records. |
| ADM | Administrator | Provided information on care plan conference frequency and improvements. |
| DON | Director of Nursing | Discussed care plan meetings, skin assessments, and infection control oversight. |
| MDS Coordinator L | MDS/Care Plan Coordinator | Confirmed deficiencies in care plans for Residents #46, #53, and #85. |
| LVN C | Licensed Vocational Nurse | Performed weekly skin assessments and blood sugar checks; discussed documentation. |
| LVN H | Licensed Vocational Nurse | Performed weekly skin assessments. |
| LVN I | Licensed Vocational Nurse | Performed weekly skin assessments. |
| LVN J | Licensed Vocational Nurse | Performed weekly skin assessments. |
| DA D | Dietary Aide | Observed not wearing hair restraint in kitchen. |
| CNA B | Certified Nursing Assistant | Confirmed unlabeled and undated food in resident refrigerators. |
| Administrator | Confirmed presence of cigarettes and lighters in resident areas and discussed smoking policies. | |
| Dietary Manager | Discussed food labeling, kitchen sanitation, and hair restraint importance. | |
| Maintenance Director | Discussed ice cream freezer and kitchen vent maintenance. | |
| LVN A | Licensed Vocational Nurse | Responsible for changing oxygen tubing and humidifier bottles. |
| LVN C | Licensed Vocational Nurse | Discussed sharps disposal and blood sugar checks. |
| COTA N | Certified Occupational Therapy Assistant | Confirmed Resident #87's possession of cigarettes, lighter, and scissors. |
| Marketer | Confirmed presence of flies in dining room and replaced food items. |
Inspection Report
Complaint Investigation
Deficiencies: 11
Date: Apr 26, 2024
Visit Reason
The inspection was conducted due to complaints regarding failure to involve residents and/or their representatives in care plan meetings, incomplete and inadequate care plans, failure to provide ordered treatments, unsafe resident environment, improper respiratory care, food safety violations, infection control issues, pest control deficiencies, and smoking policy violations.
Complaint Details
The investigation was complaint-driven focusing on issues related to care planning, treatment provision, resident safety, respiratory care, food safety, infection control, pest control, and smoking policies.
Findings
The facility failed to ensure resident participation in care plan development, failed to develop and implement comprehensive care plans, did not provide ordered weekly skin assessments, allowed unsafe resident environment hazards, failed to provide appropriate respiratory care, had food safety and sanitation violations, failed to maintain infection control with overfilled sharps containers, had pest control issues with flies present, and failed to enforce smoking policies regarding possession of cigarettes and lighters.
Deficiencies (11)
Failure to involve residents and/or their representatives in care plan meetings for 4 of 8 residents reviewed.
Failure to develop and implement comprehensive person-centered care plans for 3 of 30 residents reviewed.
Failure to develop, implement, and revise comprehensive care plans including insulin administration for 2 of 33 residents reviewed.
Resident #20 did not receive ordered weekly skin assessments between 2/23/2024 and 4/22/2024.
Residents #68 and #87 had access to cigarettes, lighters, and sharp objects in unsafe ways; unlocked storage rooms contained razors.
Failure to ensure respiratory care orders were followed and oxygen humidifier bottles were changed for 4 residents reviewed.
Food safety violations including unlabeled and undated food items, malfunctioning ice cream freezer, dirty kitchen vent, and dietary aide not wearing hair restraint.
Failure to maintain safe and sanitary storage of residents' food items in personal refrigerators for 2 residents reviewed.
Overfilled sharps container in Resident #2's room posing risk of injury and infection.
Presence of numerous flies in resident room and dining room indicating ineffective pest control.
Residents #43, #198, and #199 observed smoking with cigarettes and lighters in their rooms contrary to facility policy.
Report Facts
Residents reviewed for care plans: 33
Residents affected by care plan deficiencies: 8
Residents affected by skin assessment deficiency: 1
Residents affected by respiratory care deficiency: 4
Residents affected by unsafe environment: 2
Residents affected by food storage deficiency: 2
Residents affected by infection control deficiency: 1
Residents observed smoking with cigarettes and lighters in rooms: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| ADON F | Assistant Director of Nursing | Stated care plan conferences were initiated and held twice a week; responsible for care plan conference participation. |
| SW | Social Worker | Maintains care plan conference schedule and attendees; holds biweekly care plan conferences. |
| ADM | Administrator | Provided information on care plan conference frequency and documentation. |
| DON | Director of Nursing | Oversaw care plan meetings and compliance improvements; responsible for infection control. |
| MDS Coordinator L | MDS/Care Plan Coordinator | Confirmed deficiencies in care plans for Residents #46, #53, and #85. |
| LVN C | Licensed Vocational Nurse | Performed weekly skin assessments; unable to recall training on documentation; involved in Resident #20's care. |
| LVN H | Licensed Vocational Nurse | Performed weekly skin assessments on Resident #20. |
| LVN I | Licensed Vocational Nurse | Performed weekly skin assessments on Resident #20. |
| LVN J | Licensed Vocational Nurse | Performed weekly skin assessments on Resident #20. |
| ADON G | Assistant Director of Nursing/Treatment Nurse | Responsible for skin and wound treatments; acknowledged gaps in weekly skin assessment checks. |
| CNA B | Certified Nursing Assistant | Confirmed presence of unlabeled and undated food in resident refrigerators. |
| Dietary Manager | Dietary Manager | Reported on food labeling, kitchen sanitation, and hair restraint compliance. |
| Maintenance Director | Maintenance Director | Unaware of ice cream freezer malfunction and dirty kitchen vent. |
| LVN A | Licensed Vocational Nurse | Responsible for changing oxygen tubing and humidifier bottles; acknowledged missed changes. |
| LVN C | Licensed Vocational Nurse | Could not dispose of sharps due to overfilled container; reported central supply responsible for replacement. |
| Administrator | Administrator | Confirmed unsafe possession of cigarettes and lighters by residents; confirmed unsecured sharp objects. |
| Marketer | Marketer | Confirmed presence of flies on resident food and drink. |
| COTA N | Certified Occupational Therapy Assistant | Confirmed Resident #87 had cigarettes, lighter, and scissors in wheelchair pocket. |
Inspection Report
Routine
Deficiencies: 4
Date: Feb 16, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, safety, medication administration, and infection control.
Findings
The facility was found deficient in providing timely incontinent care to residents, ensuring bed rails were properly installed and transferred during room changes, administering medications as ordered and on time for multiple residents, and maintaining an effective infection prevention and control program during a COVID outbreak.
Deficiencies (4)
Failure to provide timely incontinent care to residents #7 and #10, resulting in discomfort and potential skin breakdown.
Failure to ensure bed rails were present and properly installed for Resident #1, resulting in a fall with serious injury and subsequent death.
Failure to administer medications as ordered and on time for 19 residents, risking therapeutic failure and adverse health outcomes.
Failure to maintain an infection prevention and control program during a COVID outbreak, including lack of signage and staff not wearing masks.
Report Facts
Residents reviewed for pharmacy services: 19
Residents affected by bed rail deficiency: 1
Residents affected by incontinent care deficiency: 2
Residents affected by infection control deficiency: 1
Residents with beds that had side rails installed: 57
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA T | Named in incontinent care deficiency for Residents #7 and #10 | |
| LVN U | Named in incontinent care deficiency for Resident #7 | |
| CNA W | Named in incontinent care deficiency for Resident #10 | |
| LVN B | Agency nurse | Named in bed rail deficiency for Resident #1 fall incident |
| CNA C | Named in bed rail deficiency for Resident #1 fall incident | |
| SW | Social Worker | Named in infection control deficiency for not wearing mask during COVID outbreak |
| RN X | Named in infection control deficiency for not wearing mask during COVID outbreak | |
| LPN B | Named in infection control deficiency for not wearing mask during COVID outbreak | |
| Agency LPN Z | Named in infection control deficiency for not wearing mask during COVID outbreak | |
| Administrator | Named in infection control deficiency and bed rail deficiency response | |
| Clinical Corporate Resource | Named in bed rail deficiency response and monitoring | |
| Medical Director | Named in bed rail deficiency response and monitoring | |
| DOR | Director of Nursing | Named in bed rail deficiency response and monitoring |
Inspection Report
Routine
Deficiencies: 4
Date: Feb 16, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, medication administration, and infection control.
Findings
The facility was found deficient in providing timely incontinent care to residents, ensuring bed rails were properly installed after room changes leading to a resident fall with serious injury and death, medication administration delays and omissions for multiple residents, and failure to maintain infection control practices during a COVID outbreak including lack of signage and improper PPE use by staff.
Deficiencies (4)
Failure to provide timely incontinent care to residents #7 and #10, resulting in discomfort and potential skin breakdown.
Failure to ensure bed rails were installed on resident #1's bed after room transfer, resulting in a fall with major injuries and subsequent death.
Failure to provide pharmaceutical services ensuring accurate medication administration for 19 residents, including late or missed doses.
Failure to maintain infection prevention and control program during COVID outbreak, including lack of signage and staff not wearing masks properly.
Report Facts
Residents affected by medication deficiencies: 19
Residents affected by incontinent care deficiencies: 2
Residents affected by bed rail deficiency: 1
Residents affected by infection control deficiency: 1
Residents with beds having side rails: 57
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA T | Certified Nursing Assistant | Named in incontinent care deficiency for Residents #7 and #10 |
| LVN U | Licensed Vocational Nurse | Named in incontinent care deficiency for Resident #7 |
| LVN B | Licensed Vocational Nurse | Named in bed rail deficiency related to Resident #1 fall |
| CNA C | Certified Nursing Assistant | Named in bed rail deficiency related to Resident #1 fall |
| SW | Social Worker | Named in infection control deficiency for not wearing mask |
| RN X | Registered Nurse | Named in infection control deficiency for not wearing mask |
| Agency LPN Z | Licensed Practical Nurse | Named in infection control deficiency for not wearing mask |
| Administrator | Facility Administrator | Named in infection control deficiency and bed rail deficiency response |
| Clinical Corporate Resource | Corporate Clinical Resource | Named in bed rail deficiency response and monitoring |
| Medical Director | Medical Director | Named in bed rail deficiency response and monitoring |
| DOR | Director of Rehabilitation | Named in bed rail deficiency response and monitoring |
Inspection Report
Routine
Deficiencies: 5
Date: Jan 25, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to abuse prevention, care planning, administration, wound care documentation, and infection control at Memorial Medical Nursing Center.
Findings
The facility failed to implement adequate policies and procedures to prevent abuse, neglected to develop comprehensive care plans for residents with wounds, lacked proper oversight and policies for nursing students, failed to document wound care consistently, and did not ensure proper infection control practices during wound care.
Deficiencies (5)
Failed to implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation for agency staff by not completing an Employee Misconduct Registry search.
Failed to develop and implement a comprehensive person-centered care plan with measurable objectives and time frames for residents with multiple wounds.
Failed to administer the facility in a manner that enabled effective use of resources by not developing a written policy for nursing students and failing to supervise nursing students and their instructor.
Failed to maintain clinical records in accordance with accepted professional standards by missing wound care documentation on the Treatment Administration Record (TAR) for multiple dates for residents.
Failed to maintain an infection prevention and control program by not ensuring proper hand hygiene and infection control principles during wound care performed by nursing students and instructor.
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 2
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Student D | Vocational Nursing Student | Named in infection control and wound care findings for improper hand hygiene and wound care technique |
| Administrator | Interviewed regarding policies, oversight of agency staff and nursing students | |
| HR Director | Interviewed regarding background checks and EMR searches for agency staff | |
| MDS Coordinator | Interviewed regarding care plan updates | |
| DON | Director of Nursing | Interviewed regarding care plan responsibilities and nursing student supervision |
| Wound Care Nurse | Interviewed regarding wound care procedures and supervision of nursing students | |
| Infection Preventionist | ADON | Interviewed regarding infection control expectations and wound care observations |
| Nursing School Instructor | RN | Observed and interviewed regarding wound care training and supervision of students |
| LVN C | Licensed Vocational Nurse | Interviewed regarding wound care documentation and performance |
Inspection Report
Routine
Deficiencies: 7
Date: Mar 10, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments, care planning, activities of daily living, respiratory care, pacemaker management, and environmental standards in a nursing facility.
Findings
The facility failed to ensure accurate resident assessments, comprehensive care plans, proper assistance with activities of daily living, appropriate respiratory care, and adequate pacemaker management. Additionally, the facility did not meet room size requirements for multiple resident rooms on the South hall.
Deficiencies (7)
Failed to ensure assessments accurately reflected resident's status, specifically missing teeth not coded in admission assessment for Resident #8.
Failed to refer Level II residents with serious mental disorders for resident review upon significant change of condition for Resident #9.
Failed to develop and implement comprehensive person-centered care plans with measurable objectives for 5 residents, including failure to address pain medication, missing teeth, rehabilitation services, independent behavior, and G-tube placement.
Failed to ensure Resident #8 was assisted with feeding during lunch meal, risking decline in physical condition.
Failed to provide treatment and care according to orders and resident preferences for 3 residents with pacemakers, including incomplete care plans and lack of daily pacemaker checks.
Failed to provide safe and appropriate respiratory care for Resident #14, who did not receive oxygen at prescribed 3 liters/min for at least 3 days.
Failed to ensure resident bedrooms met minimum square footage requirements for 8 of 12 rooms on South hall, with rooms measuring less than 80 square feet per resident.
Report Facts
Room size: 63
Room size: 63
Room size: 61
Room size: 64
Room size: 62
Room size: 60
Room size: 54
Room size: 64
BIMS score: 0
BIMS score: 11
BIMS score: 10
BIMS score: 8
BIMS score: 10
BIMS score: 14
BIMS score: Resident #80 no BIMS score documented
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Coordinator | Confirmed failure to code missing teeth for Resident #8 and failure to refer Resident #9 for PASSAR services; responsible for care plans and acknowledged omissions | |
| LVN B | Licensed Vocational Nurse | Observed feeding Resident #8 and stated CNA C should have stayed to assist |
| CNA C | Certified Nursing Assistant | Fed Resident #8 but left to assist another resident without notifying LVN B |
| DON | Director of Nursing | Confirmed care plan omissions and feeding assistance requirements |
| ADON | Assistant Director of Nursing | Confirmed oxygen order requirements for Resident #14 |
| LVN A | Licensed Vocational Nurse | Observed Resident #14 receiving oxygen at 2.5 L/min instead of ordered 3 L/min |
| ADM | Administrator | Discussed room size waiver and lack of policy on room square footage |
| MS | Maintenance Supervisor | Provided room measurements and confirmed rooms on waiver were occupied |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Feb 15, 2023
Visit Reason
The inspection was conducted as a routine annual survey of Memorial Medical Nursing Center to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
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