McCoy Memorial Nursing Center

In the surveyor’s words

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

• Actual harm, isolatedF689Jul 5, 2024

  Based on interviews, record review, and review of facility policy the facility failed to protect Resident (R)3) from accident hazards in the resident's environment specifically, Certified Nursing Assistant (CNA)1 failed to engage the wheel locks on a shower chair, causing R3 to sustain a fall with major injuries. Findings Include: Review of a facility policy titled, Fall Prevention Program last revised 09/01/23, states, Each resident . will receive care and services in accordance with their individualized level of risk to minimalize the likelihood of falls. Review of R3's Face Sheet revealed R3 was admitted to the facility on [DATE], with diagnoses including but not limited to: Alzheimer's, dementia, and osteoarthritis. […]

• Actual harm, isolatedF580Jan 19, 2022

  Based on record reviews, interviews, and review of the facility policy titled, MD Notification, the facility failed to notify the attending physician of a necrotic decubitus pressure ulcer, acquired in the facility, to ensure orders for treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's failure constituted harm, past non-compliance. Cross Refer: F600, F686, F842 Findings include: The facility admitted R1 on 7/12/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record on 10/12/21 at approximately 12:00 Noon, revealed a Comprehensive Plan of Care which included, a stage 1 pressure ulcer to the left hip that resolved on 7/22/21 and a stage 2 decubitus to the sacrum that resolved on 7/22/21. […]

• Actual harm, isolatedF600Jan 19, 2022

  Based on record reviews, interviews and review of the facility policy titled, Abuse, Neglect and Exploitation, the facility failed to ensure Resident (R)1 received care and services needed to prevent the development of a large necrotic pressure ulcer requiring a hospital stay for 1 of 5 residents reviewed for facility acquired pressure ulcers. The facility's failure constituted harm at past non-compliance. Cross Refer: F580, F686, F842 Findings include: The facility admitted R1 on 7/12/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R1's medical record revealed he weighed 115 pounds (lbs) and was 72 inches tall on admission. […]

• Actual harm, isolatedF686Jan 19, 2022

  Based on record reviews, interviews and review of the facility policy titled, Body Audit Policy, and Pressure Injury Prevention Guidelines, and Pressure Ulcer Surveillance, the facility failed to ensure body audits were completed, and a large necrotic pressure ulcer was prevented and treated prior to requiring hospitalization for elevated temperature and slow responsiveness for Resident (R)1 for 1 of 5 residents reviewed with pressure ulcers. The facility's failure constituted harm, past-noncompliance. […]

• Actual harm, isolatedF842Jan 19, 2022

  Based on record reviews, interviews, and review of the the facility policy titled, Body Audit Policy, and Pressure Ulcer Surveillance, the facility failed to ensure complete and accurate records related to body audits, assessments, measurements and documentation of a pressure ulcer that was described as large and necrotic for Resident (R)1 for 1 of 5 residents reviewed with pressure ulcers. The facility's failure constituted harm, past non-compliance. Findings include: The facility admitted R1 on 7/12/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]