Ross Memorial Health Care CTR

In the surveyor’s words

From the most serious findings on record at Ross Memorial Health Care CTR, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF838Jul 2, 2022

  Based on staff interviews and document review, the facility failed to conduct and document a facility-wide assessment to determine what resources were necessary to care for the resident population during day-to-day operations and emergencies. Findings included: A review of a Facility Assessment Tool, dated 2/8/22, revealed it did not include the following: -The facility's resident population, the number of residents, and the facility's resident capacity. -The care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that were present within that population. -The staff competencies that were necessary to provide the level and types of care needed for the resident population. […]

• No harm, potential for more than minimal, widespreadF882Jul 2, 2022

  Based on document review, policy review, and interviews, the facility failed to designate at least one qualified individual as the infection preventionist (IPs) responsible for the facility's infection prevention and control program (IPCP). The failed practice had the potential to affect all residents who resided in the facility. As of 6/28/22, the facility census was 82. Findings included: A review of the facility's policy titled Infection Prevention and Control Manual Interim Policy for Suspected or Confirmed Coronavirus (COVID-19), undated, revealed no information related to the requirement for an IP. A review of the facility's IPCP revealed the facility had not designated at least one qualified individual as the IP. […]

• No harm, potential for more than minimal, widespreadF886Jul 2, 2022

  Based on record review and interviews, the facility failed to perform routine and outbreak COVID-19 testing for all staff and residents as per guidelines from the Centers for Medicare and Medicaid Services (CMS) QSO-20-38-NH. Specifically, the facility failed to: - Identify an outbreak of COVID-9 in the facility after a resident tested positive to ensure broad-based outbreak testing or contact tracing was immediately conducted for residents and staff; and - Perform routine COVID-19 testing per current guidelines when the facility was in a county with a high community transmission rate. This had the potential to affect all staff and residents in the facility. […]

• No harm, potential for more than minimal, widespreadF887Jul 2, 2022

  Based on interviews, document review, and policy review, the facility failed to develop and implement policies and procedures to ensure each resident and staff member was offered the COVID-19 vaccination and provided with education regarding the benefits, risks, and potential side effects associated with the vaccine prior to such offering. Additionally, the facility failed to maintain thorough medical record and personnel documentation reflecting such education and offerings or the vaccination status of each resident and staff member. This had the potential to affect 82 residents and 98 staff. […]

• No harm, potential for more than minimal, patternF584Feb 22, 2024

  Based on observations, staff interviews, and review of the facility policy titled, Safe and Homelike Environment, the facility failed to maintain a safe, clean, comfortable, homelike environment by not making needed repairs in three of five hallways (100 hallway, 400 hallway, and 600 hallway) observed in the facility. There were seven resident rooms needing repair on the 100 hallway (room [ROOM NUMBER], 102, 105, 110, 111, 114, 116, and 118), two resident rooms on the 400 hallway (room [ROOM NUMBER] and 403), and one resident room on the 600 hallway (room [ROOM NUMBER]). […]