Memorial City Nursing and Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, patternF656Sep 23, 2024

  Based on observations, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident medical, nursing, mental, and psychosocial needs for 1 (Resident #1) of 3 residents reviewed for care plans in that: The facility failed to ensure Resident #1 bed was in the lowest position per care plan while he was in the bed. The facility failed to update falls and interventions for Resident #1's care plan after his last 3 falls. This failure placed facility residents who were fall risk at risk of serious harm and injury. An Immediate Jeopardy (IJ) was identified on 9/18/2024. […]

• Immediate jeopardy, patternF689Sep 23, 2024

  Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 4 residents (Resident #1) reviewed for free of accidents, hazards, supervision, and devices., in that: The facility failed to ensure precautionary interventions in place Resident #1, while he was prescribed an anticoagulant, who was a known fall risk that resulted in falls with injuries to the head and hospitalization . An IJ was identified on 9/17/2024. The IJ template was provided to the AIT and DON on 9/17/2024 at 5:06 p.m. While the IJ was removed on 9/20/2021 at 12:31 p.m., with the ADMIN and DON. […]

• Immediate jeopardy, isolatedF695May 19, 2024

  Based on interviews and record review, the facility failed to ensure residents requiring respiratory care, consistent with professional standards of practice for 1 (CR#1) of 5 residents reviewed for quality of care. The facility failed to provide immediate care to CR#1 when she experienced respiratory distress on [DATE]. After the resident was observed gurgling with emesis by LVN A, the NP was notified; monitoring nor interventions were initiated. When observed by the NP, CR #1 was unresponsive and oxygen saturation dropped to 60%. 911 was called and arrived at 12pm. During the course of hospitalization , CR #1 was declared brain dead and expired on [DATE] after atifical support was removed. […]

• Actual harm, isolatedF600Apr 28, 2026

  Based on interview, and record review, the facility failed to ensure resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 13 residents (Resident #21) reviewed for abuse. The facility failed to ensure Resident #21 remained free from abuse when LVN A removed the resident's property (cell phone) as a way to restrict the resident's communication (preventing calls to 911). These failures could place residents at risk of an unsafe environment and unprotected from mistreatment. The findings included: Record review of Resident #21's face sheet dated 04/23/2026 reflected a [AGE] year-old female who was admitted to the facility on [DATE]. […]

• Actual harm, isolatedF697Apr 28, 2026

  Based on interviews, and record reviews, the facility failed to ensure that pain management was provided to Resident #21's who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. The facility failed to monitor and address Resident #21's pain on 03/04/2026 from 3:00 a.m. to 11:00 a.m., when Resident #21 pressed her call light, cried out in pain, called 911 twice, and pulled the fire alarm requesting to go to the hospital. This failure had the potential to place residents at risk for delayed treatment, pain, and actual harm. The findings included: Record review of Resident #21's face sheet dated 04/23/2026 reflected a [AGE] year-old female who was admitted to the facility on [DATE]. […]