Ware Memorial Care Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF686Feb 24, 2025

  Based on observation, interview and record review the facility failed to ensure residents receive care consistent with professional standards of practice, to prevent pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and once developed, failed to ensure necessary treatment and services to promote healing for one (Resident #1) of nine residents reviewed for pressure ulcers. The facility failed to: A. Ensure Resident #1 who was admitted to the facility without a pressure ulcer did not develop an unstageable pressure ulcer with eschar (a layer of dead skin tissue that forms over a wound) on her coccyx within two weeks of admission. B. Failed to notify the wound care nurse of the ulcer. C. […]

• Actual harm, isolatedF689Oct 6, 2023

  Based on observation, interview, and record review, the facility failed to ensure that the residents environment remained as free from accident hazards as was possible; and that each resident received adequate supervision to prevent accident hazards for one resident (Resident #1) of 7 residents observed for accident hazards. -CNA A transferred Resident #1 in an unsafe manner resulting in a small skin tear and a large bruise to her left lower leg. This failure could affect all the residents at the facility by placing them at risk for accidents that lead to injuries such as bruising, skin tears, fractures, subdural hematomas, and feeling of isolation. […]

• No harm, potential for more than minimal, widespreadF812Dec 5, 2024

  Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 7 out of 8 resident snack refrigerators located in the residents dining rooms, reviewed for kitchen sanitation. 1. The facility failed to ensure food items were properly stored, labeled, and dated. 2. The facility failed to ensure refrigerators were free of expired foods, non-food items and staff items. 3. The facility failed to ensure cleanliness was maintained in the refrigerators. These failures could place residents who ate food served by the kitchen, and stored food in the resident refrigerators were at risk of food-borne illness. […]

• No harm, potential for more than minimal, widespreadF812Oct 25, 2023

  Based on observation, interview and record review, the facility failed to store, prepare, and serve food under sanitary conditions in 1 of 1 kitchen when they failed to: A. Ensure stored food was properly labeled, dated, and stored. These failures placed all residents who ate food served by the kitchen at risk of food-borne illness. Findings included: An observation of the facility walk-in cooler on 10/23/23 at 8:07AM revealed: 2 watermelons, no date received. 1 Food Service box of head of Romaine lettuce; open to air; no date. 2 8-count packages of pancakes; no label; no date. 1 6-count box of thawed pork tenderloin; no label; no date. 2 boxes, 24-count each, blueberry muffins, no label; no date. 3 thawed briskets; no label; no date. 2 13-ounce bottles of mint flavoring; no date. […]

• No harm, potential for more than minimal, widespreadF812Aug 18, 2022

  Based on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions in 1 of 1 kitchen when they failed to: A. Ensure staff did not use hands when serving food B. Ensure stored food was properly labeled, dated and stored These failures placed all residents who ate food served by the kitchen at risk of cross contamination and food-borne illness. Findings included: An observation of the facility freezer on 8/16/22 at 8:54 AM, revealed: 1 bag of frozen breaded chicken, no label or date, not in original box, open to air 1 bag of frozen potatoes, no label or date, not in original box, open to air In an observation and interview on 8/16/22 at 11:55 AM, Cook A was observed touching kitchen surfaces with gloved hands in the kitchen. […]