CMS Inspection Results for MATTHEWS MEMORIAL HEALTH CARE

The Center for Medicare & Medcaid Services (CMS) contracts with each state to conduct inspections once every 9-15 months to assure that certified facilities meet the minimum Medicare and Medicaid quality and performance standards.

• 03/20/2009 Health Survey for MATTHEWS MEMORIAL HEALTH CARE

Administration
Deficiency	Scope	Level of Harm
Have a detailed, written plan for disasters and emergencies.	Widespread	Minimal harm or potential for actual harm
Environmental
Deficiency	Scope	Level of Harm
Put firmly secured handrails on each side of hallways.	Pattern	Minimal harm or potential for actual harm
Provide needed housekeeping and maintenance.	Isolated	Minimal harm or potential for actual harm
Nutrition and Dietary
Deficiency	Scope	Level of Harm
Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
Pharmacy Service
Deficiency	Scope	Level of Harm
1) Make sure that residents who take drugs are not given too many doses or for too long; 2) make sure that the use of drugs is carefully watched; or 3) stop or change drugs that cause unwanted effects.	Pattern	Minimal harm or potential for actual harm
Resident Assessment
Deficiency	Scope	Level of Harm
Make a complete assessment that covers all questions for areas that are listed in official regulations.	Isolated	Minimal harm or potential for actual harm
Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured.	Isolated	Minimal harm or potential for actual harm
Resident Rights
Deficiency	Scope	Level of Harm
Immediately tell the resident, doctor, and a family member if: the resident is injured, there is a major change in resident's physical/mental health, there is a need to alter treatment significantly, or the resident must be transferred or discharged.	Isolated	Minimal harm or potential for actual harm
Keep each resident's personal and medical records private and confidential.	Isolated	Minimal harm or potential for actual harm

 

• 03/17/2009 Fire Safety Survey for MATTHEWS MEMORIAL HEALTH CARE

Automatic Sprinkler Systems
Deficiency	Scope	Level of Harm
automatic sprinkler systems that have been maintained in working order.	Isolated	Minimal harm or potential for actual harm
Medical Gases and Anesthetizing Areas
Deficiency	Scope	Level of Harm
no-smoking signs where oxygen is used.	Isolated	Minimal harm or potential for actual harm
Miscellaneous
Deficiency	Scope	Level of Harm
fire safety features required by current fire safety codes.	Pattern	Minimal harm or potential for actual harm
Smoking Regulations
Deficiency	Scope	Level of Harm
posted No-smoking signs in areas where smoking is not permitted or did not provide ashtrays where smoking was allowed.	Widespread	Minimal harm or potential for actual harm

 

• 01/10/2008 Health Survey for MATTHEWS MEMORIAL HEALTH CARE

Administration
Deficiency	Scope	Level of Harm
1) Review the work of each nurse aide every year; or 2) give regular training for the nurse aides.	Isolated	Minimal harm or potential for actual harm
Environmental
Deficiency	Scope	Level of Harm
Move, clean and store sheets, towels and other linens in a way that prevents the spread of infection.	Pattern	Minimal harm or potential for actual harm
Nutrition and Dietary
Deficiency	Scope	Level of Harm
Make sure that residents are well nourished.	Pattern	Minimal harm or potential for actual harm
Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
Quality Care
Deficiency	Scope	Level of Harm
Give professional services that follow each resident's written care plan.	Pattern	Minimal harm or potential for actual harm
Use a registered nurse at least 8 hours a day, 7 days a week.	Isolated	Minimal harm or potential for actual harm
Resident Assessment
Deficiency	Scope	Level of Harm
1) Develop a complete care plan within 7 days of each resident's admission; 2) prepare a care plan with the care team, including the primary nurse, doctor, resident or resident's family or representative; or 3) check and update the care plan.	Pattern	Minimal harm or potential for actual harm
Resident Rights
Deficiency	Scope	Level of Harm
Try to resolve each resident's complaints quickly.	Pattern	Minimal harm or potential for actual harm

 

• 01/07/2008 Fire Safety Survey for MATTHEWS MEMORIAL HEALTH CARE

Fire Alarm Systems
Deficiency	Scope	Level of Harm
a fire alarm system that can be heard throughout the facility.	Isolated	Minimal harm or potential for actual harm

 

• 02/08/2007 Health Survey for MATTHEWS MEMORIAL HEALTH CARE

Administration
Deficiency	Scope	Level of Harm
Make sure that nurse aides show they have the skills to be able to care for residents.	Isolated	Minimal harm or potential for actual harm
Environmental
Deficiency	Scope	Level of Harm
Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
Mistreatment
Deficiency	Scope	Level of Harm
1) Hire only people who have no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.	Isolated	Minimal harm or potential for actual harm
Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property.	Isolated	Minimal harm or potential for actual harm
Nutrition and Dietary
Deficiency	Scope	Level of Harm
Hire enough skilled workers to carry out dietary service.	Pattern	Potential for minimal harm
Store, cook, and give out food in a safe and clean way.	Pattern	Potential for minimal harm
Quality Care
Deficiency	Scope	Level of Harm
Give professional services that follow each resident's written care plan.	Isolated	Minimal harm or potential for actual harm
Resident Assessment
Deficiency	Scope	Level of Harm
Make sure all assessments are accurate, coordinated by an RN, done by the right professional, and are signed by the person completing them.	Isolated	Minimal harm or potential for actual harm
Resident Rights
Deficiency	Scope	Level of Harm
Let residents give themselves their drugs if they are able.	Isolated	Minimal harm or potential for actual harm

 

• 02/08/2007 Fire Safety Survey for MATTHEWS MEMORIAL HEALTH CARE

Corridor Walls and Doors
Deficiency	Scope	Level of Harm
corridors that are separated from common areas by walls constructed to limit the passage of smoke.	Isolated	Minimal harm or potential for actual harm
Electrical
Deficiency	Scope	Level of Harm
weekly inspections and monthly testing of generators.	Widespread	Potential for minimal harm
Exits and Egress
Deficiency	Scope	Level of Harm
exits that are accessible at all times.	Isolated	Minimal harm or potential for actual harm
Fire Alarm Systems
Deficiency	Scope	Level of Harm
properly maintained smoke detectors.	Isolated	Minimal harm or potential for actual harm