Community Memorial Health Center

In the surveyor’s words

From the most serious findings on record at Community Memorial Health Center, in the surveyor’s own words.

• Immediate jeopardy, patternF610Jul 8, 2024

  Based on clinical record review, facility investigation review, staff interviews, and facility policy review the facility failed to conduct a thorough investigation of an allegation of abuse. On 4/3/24, the nurse learned of a Certified Nurse Aide (CNA) slapping Resident #1 on the leg. After learning of this allegation of abuse, the facility allowed the CNA to finish working the scheduled night shift and to continue to work unattended behind closed doors with other residents. This failure resulted in residents living at the facility to be exposed to the potential of abuse therefore causing an Immediate Jeopardy to the health, safety, and security of the resident. […]

• Immediate jeopardy, isolatedF689Mar 1, 2021

  Based on observation, record review, facility policy and staff interviews the facility failed to ensure each resident received adequate supervision to prevent elopement for 1 of 10 residents identified by the facility with wanderguards, (Resident #1). Resident#1 exited the facility unsupervised and the facility failed to properly respond to an activated door alarm which resulted in immediate jeopardy to resident health and safety. The facility reported a census of 67 residents. Findings include: Resident #1 had a Quarterly Minimum Data Set (MDS) assessment dated [DATE], that documented a [DIAGNOSES REDACTED]. Resident #1 scored 5 of 15 on a BIMS (brief interview for mental status) test which indicated severely impaired cognition. […]

• Actual harm, isolatedF684Aug 22, 2023

  Based on record review, and staff interview, the facility failed to provide adequate assessment and timely intervention for 1 of 4 residents reviewed (Resident #1). On 4/15/23 at 2:50 a.m. Resident #1's alarm sounded and as staff responded they heard a thud and found resident laying on the floor on his right side. Facility staff failed to complete a thorough assessment which included range of motion (ROM) and failed to initiate neurologic checks following the unwitnessed fall. Additionally, the staff failed to complete a follow up assessment following the fall when pain was noticed during transfer with weight bearing. At 6:38 a.m. resident was assessed for ongoing right leg pain. […]

• Actual harm, isolatedF684Aug 2, 2022

  Based on record review and staff interview, the facility failed to provide adequate assessment and timely intervention for a change in condition for 2 of 2 resident's reviewed (Resident #104, and #3). Resident #104 fell and sustained a head injury and fracture of the C1 vertebrae (neck) on [DATE]. On [DATE] the resident had pain documented on the Treatment Administration Record (TAR) with no documentation interventions were implemented to relieve the pain. The resident also had a change of condition with his oxygen (O2) saturation (sat) dropping to 52% (normal above 90%) and respirations 30 (normal ,d+[DATE]) and labored around 9:30 a.m. The facility failed to assess the resident's lung sounds related to the change. On [DATE] at 1:45 a.m. […]

• Actual harm, isolatedF689Aug 2, 2022

  Based on observation, record review and staff interview, the facility failed to assure a resident had the identified interventions in place to prevent a fall with a major injury for 1 of 6 residents reviewed (Resident #104). Resident #104 had an intervention for a bed alarm to alert staff to his getting up. On 12/31/21 the resident sustained a fall in his room with no alarm. The resident sustained a head injury requiring sutures and C1 (neck) fracture. The facility reported a census of 55 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #104 scored 2 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. […]