Malley Transitional Care Center

In the surveyor’s words

From the most serious findings on record at Malley Transitional Care Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF880Jul 28, 2021

  Based on interviews and record review, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection. Specifically, the facility failed to ensure the water management plan for legionella was effective by including the maintenance director in the process for completing the water management plan and providing him documentation that a water management plan existed. Furthermore, the facility failed to ensure the monitoring of control measures were conducted such as disinfectant flushes and testing (which were identified in the water management plan) were conducted weekly or at all. […]

• Immediate jeopardy, patternF689Mar 30, 2023

  Based on observations, interviews, and record review, the facility failed to ensure the residents' environment remained as free of accident hazards as possible. This was evidenced by hazardous hot water temperatures in resident care areas on two of three units. Water temperatures in resident rooms and two shower rooms exceeded safe temperatures, creating the likelihood for serious harm/injuries if the situation was not corrected immediately. Findings include: I. Immediate jeopardy A. Situation for immediate jeopardy Excessively high water temperatures were discovered in several resident rooms. […]

• Actual harm, isolatedF689May 14, 2026

  Based on observations, record review and interviews, the facility failed to ensure one (#4) of three residents reviewed for accidents out of 18 sample residents remained as free from accidents and hazards as possible.Resident #4, who had diagnoses of multiple sclerosis (a progressive neurological condition), polyneuropathy (a disease featuring weakness, numbness and burning pain) and anxiety disorder (an intense, excessive and persistent worry and fear about everyday situations), was admitted to the facility on [DATE]. Resident #4 was dependent on staff for transfers utilizing a Hoyer lift (mechanical lift).On 4/7/26 staff were transferring Resident #4 using the smaller Hoyer lift. According to the resident's weight, the resident required the larger Hoyer lift. […]

• Actual harm, isolatedF689Sep 7, 2023

  Based on record review and interviews, the facility failed to ensure one (#2) of three residents reviewed for accidents remained free from accidents. On 7/7/23 Resident #2 sustained an arm fracture during a transfer by one certified nurse aide (CNA) using a sit to stand lift. Prior to the transfer, Resident #2 was not evaluated and was not deemed safe or appropriate for the use of sit to stand lift. The incident during transfer was not clearly communicated to the nurse and head to toe assessment was not completed. As a result, the resident's arm fracture went unnoticed for the next 48 hours. The next day on 7/8/23 the resident refused to be transferred with a sit to stand lift and stayed in bed more than usual. […]

• Actual harm, isolatedF760Mar 30, 2023

  Based on record review and interviews, the facility failed to prevent a significant medication error for one (#85) resident of eight residents reviewed for medication errors out of 47 sample residents. The facility failed to ensure medications were labeled according to the physician's orders to prevent significant medication errors for Resident #85. On 1/6/23, the facility administered 65 mg of Methadone instead of 15 mg ordered on 12/2/22. After the incorrect dose was administered, the resident required Narcan (to treat narcotic overdose) to be administered and was sent to the emergency room . The medication error caused the resident to be upset; he rocked in his wheelchair, hyperventilated, yelled and cursed at staff. Findings include: I. […]