John T Mather Memorial Hosp T C U

In the surveyor’s words

From the most serious findings on record at John T Mather Memorial Hosp T C U, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812May 23, 2025

  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. […]

• No harm, potential for more than minimal, patternF812Oct 5, 2022

  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. […]

• No harm, potential for more than minimal, isolatedF635May 23, 2025

  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. […]

• No harm, potential for more than minimal, isolatedF655May 23, 2025

  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. […]

• No harm, potential for more than minimal, isolatedF695May 23, 2025

  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. […]