Memorial Heights Nursing Center

In the surveyor’s words

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

• Actual harm, isolatedF600Jan 17, 2024

  Based on observation, record review, and interview, the facility failed to ensure a resident was free from abuse for one (#3) of five residents sampled for abuse. On 08/31/23 Res #3 informed the charge nurse that they were struck by CNA #3. CNA acknowledged they had slapped Res #3. The facility was in past noncompliance after having put the final measures in place to correct the deficiency on 09/05/24. The administrator identified 58 residents who resided in the facility. Findings: Res #3 had diagnoses which included major depression disorder, anxiety disorder, and cerebrovascular disease. A state reportable incident form, dated 08/31/23, documented that at 7:03 a.m. the resident informed the charge nurse they had been struck by a staff member. […]

• No harm, potential for more than minimal, widespreadF812Apr 15, 2026

  Based on observation, record review, and interview, the facility failed to ensure:a. proper final cooking temperatures were monitored to check the internal temperature was safe for consumption prior to placing on the steam table for holding before meal service; andb. a log was maintained to reflect the monitoring of final cooking temperatures and holding temperatures for 1 meal service observed. The compliance officer identified 86 residents resided in the facility.Findings:A Position Description Dietary Service Manager, read in part, Assures correct procedures in preparation of food and inspects quality, temperature, and appearance of food prior to serving.On 04/14/26 at 10:32 a.m., an observation was made of peas cooking on the stove, roast beef was in the oven, rolls were rising on the… […]

• No harm, potential for more than minimal, widespreadF925Jun 12, 2025

  Based on observation, record review, and interview, the facility failed to ensure an effective pest management program was maintained during daily observations.The administrator identified 78 residents resided in the facility.Findings:1. On 06/08/25 at 4:03 p.m., rodent feces were observed in room [ROOM NUMBER]B's bedside dresser middle drawer. On 06/08/25 at 4:50 p.m., the door in dining room going out behind the facility was observed to have had gaps at the top and along the bottom of the door large enough for flies and rodents to access the facility. Mouse droppings were observed along the wall in the dining room near the back door and flies were all over the facility landing on the glass, residents sitting nearby, and the staff. […]

• No harm, potential for more than minimal, widespreadF636Dec 1, 2022

  Based on record review and interview, the facility failed to ensure comprehensive assessments were completed within 14 days of admission on five (#19, 28, 36, 101, and #108) of 15 residents reviewed for comprehensive assessments. The Resident Census and Conditions of Residents, dated 11/29/22, documented a census of 56 residents. Findings: An undated policy, Resident Assessment Instrument Process (RAI/MDS), did not contain documentation regarding the timeline for completion of comprehensive resident assessments. Res #19 was admitted on [DATE]. A comprehensive assessment due on 10/01/22 was not completed. Res #28 was admitted on [DATE]. A comprehensive assessment due on 09/08/22 was completed late on 09/29/22. Res #36 was admitted on [DATE]. […]

• No harm, potential for more than minimal, widespreadF638Dec 1, 2022

  Based on record review and interview, the facility failed to ensure quarterly assessments were completed every three months for six (#7, 32, 36, 38, 39 and #96) of 15 residents reviewed for quarterly assessments. The Resident Census and Conditions of Residents, dated 11/29/22, documented a census of 56 residents. Findings: An undated policy, Resident Assessment Instrument Process (RAI/MDS), did not contain documentation regarding the timeline for completion of quarterly resident assessments. Res #7 was admitted on [DATE]. A quarterly assessment dated [DATE] was not completed. Res #32 was admitted on [DATE]. A quarterly assessment dated [DATE] was not completed. Res #36 was admitted on [DATE]. A quarterly assessment dated [DATE] was not completed. Res #38 was admitted on [DATE]. […]