Memorial Healthcare Center

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF908Mar 4, 2022

  Based on observation, interview, and record review, the facility failed to maintain backflow protection resulting in the potential of contamination of the domestic water supply, affecting all residents and staff in the facility. Findings Include: On 3/2/22 at 1:17 PM, a submerged inlet (a water supply source that is below the flood level rim of a sink), located in the trough sink of the dish machine drain board, was observed to not be provided with a backflow protection device to prevent the backflow or backpressure of contaminated liquids into the potable water supply. Furthermore, the water supply line providing water to the trough submerged inlet continued on to another submerged inlet at the waste disposal. Both submerged inlets were not provided with a vacuum breaker. […]

• No harm, potential for more than minimal, patternF689Mar 4, 2022

  Based on observation, interview, and record review, the facility failed to properly monitor and maintain safe water temperatures, resulting in the potential for scalding, affecting all 18 residents in the facility. Findings include: On 3/3/22 at 1:00 PM, the bathroom hand sink water temperature, of Room 572, was measured using a Thermapen digital thermometer and found to be at 131.4 degrees Fahrenheit. No point of use mixing valve was observed at the hand sink. On 3/3/22 at 1:03 PM, the bathroom hand sink water temperature, of Room 574, was measured using a Thermapen digital thermometer and found to be at 130.2 degrees Fahrenheit. […]

• No harm, potential for more than minimal, isolatedF641Jan 14, 2026

  Based on observation, interview, and record review, the facility failed to accurately complete a Minimum Data Set (MDS) assessment for 1 (Resident #12) of 8 reviewed for MDS assessments, resulting in the potential for inaccurate care plans and unmet care needs.Resident #12Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R12 was an [AGE] year old female originally admitted to the facility on [DATE], with diagnoses that included dementia. The above MDS reflected R12 had a Brief Interview for Mental Status (BIMS) score was 2/15 indicating severe cognitive impairment and was dependent on staff for all activities of daily living.During an observation and interview on 1/13/26 at 11:10 a.m. R12 was sitting in chair in room with family at bedside. […]

• No harm, potential for more than minimal, isolatedF692Feb 15, 2023

  Based on observation, interview, and record review, the facility failed to ensure physician orders for a therapeutic diet were routinely followed for one (Resident #19) of two residents reviewed for nutrition resulting in the potential for adverse consequences including coughing, choking, and aspiration (process of food, liquid, or other material entering a person's airway or lungs instead of being swallowed). Findings include: Resident # 19 (R19) initially admitted to facility 11/11/22 with 2/2/23 facility readmission with diagnoses including hematemesis, aspiration pneumonia due to gastric secretions, esophagitis, and severe protein-calorie malnutrition. […]

• No harm, potential for more than minimal, isolatedF908Feb 15, 2023

  Based on observation, interview, and record review, the facility failed to properly install backflow protection devices, in two locations in the kitchen, resulting in the potential contamination of the domestic water supply. Findings include: On 2/13/23 at 9:30 AM, during an inspection of the kitchen, the atmospheric vacuum breaker (AVB) (a device commonly used in plumbing to prevent the backflow of contaminated liquids into the domestic water supply), at the waste disposal near the three-compartment sink, was observed to be plumbed in a position that makes the AVB functionally irrelevant. […]