Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Memorial Health Care Center during CMS and state inspections, most recent first.
Grievance Information Not Provided to Residents: The facility failed to provide 10 of 42 confidential residents with access to grievance forms or information on how to file grievances, including anonymous complaints. During Resident Council interviews, residents stated they had not seen the grievance procedure posted in prominent locations and did not know how to submit a grievance anonymously. The ADM stated she was the grievance officer, but there were no resident grievance forms available and no procedure for anonymous submission.
Missing DNR Care Plans for Four Residents: The facility failed to include DNR status in the comprehensive care plans for four residents whose records and physician orders all showed DNR code status. The DON said this was an oversight and stated she was being trained as she went, while the Admin said the DON was responsible for ensuring code status was care planned. The facility policy required comprehensive, person-centered care plans with measurable objectives and timeframes for each resident.
Unmonitored Resident Refrigerators With Undated and Expired Foods: Surveyors found multiple residents' personal refrigerators containing perishable foods, sauces, and restaurant leftovers that were unlabeled, undated, or past use-by dates. CNA and DON interviews confirmed there was no routine system to check refrigerator temps or remove expired items, and the ADM stated residents were generally responsible for cleaning out their own food despite the facility's policy requiring labeling and timely discard of perishable items.
Staff failed to follow infection control practices during incontinence and catheter care for two residents. A CNA and RN did not wear gowns for EBP while providing care to a resident with an indwelling Foley catheter, and the CNA did not perform hand hygiene or change gloves when moving between dirty and clean tasks. In a separate observation, another CNA placed a clean brief without changing gloves after cleansing a resident during incontinence care. The DON and Admin stated staff were expected to perform hand hygiene between glove changes and change gloves when moving from dirty to clean.
Staff training program was not maintained for required topics, including fall prevention, HIV, restraints, emergency procedures, and dementia management. Record review showed 6 of 6 employees lacked documentation of facility-provided training at hire and annually, including an RN, LVNs, and CNAs. HR and the ADM stated no live training system was in place, the facility had not followed up enough on training, and staff were expected to complete training through CEUs.
Incomplete DNR Documentation for Two Residents: Two residents with severely impaired cognition had DNR status listed on their face sheets, but their OOH-DNR forms were incomplete. One resident’s form lacked physician and resident/guardian signatures and required physician identifiers, while the other resident’s form lacked the physician printed name and license number. Both residents also had no code status order in the physician order summary and no code status care plan.
RN coverage was not provided for at least 8 consecutive hours per day on multiple weekend days. PBJ staffing records showed no RN hours on several weekends, and the Admin stated the DON worked weekdays only while the facility lacked an RN for weekend coverage during January and February, with weekend RN coverage not beginning until March. The facility policy required RN services at least 8 hours every 24 hours, 7 days a week.
Pureed foods were not prepared to a smooth, uniform texture for a resident on a puree diet. Observations of test trays showed pureed broccoli, pasta, pork, carrots, and potatoes with chunks, strings, or grains instead of a baby food consistency. The DM, DON, and ADM stated pureed foods should be smooth and without chunks, and the facility's Puree Diet guidance stated the diet is for patients with chewing and swallowing problems.
The facility failed to submit complete and accurate PBJ staffing data to CMS for the second quarter of fiscal year 2024. The MDS nurse, responsible for the submission, did not ensure the data was submitted, and both the DON and ADM were unaware of the failure. The facility's policy requires quarterly submissions, but this was not adhered to, leading to the deficiency.
The facility failed to maintain a safe environment in two common resident baths by improperly storing chemicals with resident toiletries, posing accident hazards. Observations showed unlocked doors and chemicals like Virex Plus stored next to personal items. Interviews with CNAs revealed inadequate training on chemical storage, and even locked cabinets had gaps allowing potential leakage. The DON and Administrator acknowledged the issue, highlighting a lapse in following safety protocols.
The facility failed to provide physician-ordered therapeutic diets to three residents, including fortified foods necessary for their nutritional needs. A resident with moderate protein-calorie malnutrition did not receive fortified foods during meals, leading to weight loss. Another resident, underweight with a history of alcohol abuse, did not receive prescribed supplements like bananas and chocolate ice cream, affecting her potassium levels. A third resident, at risk for pressure ulcers, did not receive her ordered fortified soup. Communication issues between nursing and dietary departments contributed to these deficiencies.
A facility failed to maintain proper infection control practices, as CNAs did not perform hand hygiene between glove changes during incontinence care for two residents. Additionally, enhanced barrier precautions were not implemented for a resident with an indwelling catheter, lacking signage and PPE. Staff interviews revealed insufficient training and awareness of infection control protocols.
The facility failed to obtain informed consent for psychotropic medications for three residents, including those with cognitive impairments and insomnia. Medications such as Lorazepam, Trazodone, and Seroquel were administered without signed consents, indicating a lack of communication about the risks and benefits. Interviews with the DON and ADM revealed that the oversight was attributed to human error, with staff responsible for obtaining consents on the same day as the medication order.
The facility failed to limit PRN orders for psychotropic medications to 14 days for two residents. One resident received alprazolam for anxiety without a stop date, and another received trazodone for insomnia without a stop date. The medications were administered regularly, and the facility's policy on medication utilization was not followed, as the PRN orders lacked clear indications and were not re-evaluated.
Grievance Information Not Provided to Residents
Penalty
Summary
The facility failed to provide 10 of 42 confidential residents with information about their rights related to filing grievances or concerns. During Resident Council interviews, 10 confidential residents stated they did not have access to a grievance form, did not know they could file a grievance anonymously, and had not seen a posting of the grievance procedure in prominent locations. Record review of the facility grievance policy, updated April 2017, showed that a copy of the grievance/complaint procedure should be posted on the resident bulletin board. However, when prominent postings in the lobby were observed, the postings did not include instructions regarding the grievance procedure. Grievance forms were not available to residents in the facility, and there was no access to submit a grievance anonymously. During interview, the ADM stated she was the grievance officer and was responsible for reviewing grievances and assigning them to department heads. The ADM stated there were currently no grievance forms for residents to complete, staff completed a grievance form if a resident had a complaint, and there was no procedure for residents to submit grievances anonymously. The ADM also stated the facility had a responsibility to resolve grievances immediately with final resolution completed within 24 hours, and that completed grievance forms were kept in a notebook.
Missing DNR Care Plans for Four Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans with measurable objectives and timeframes for 4 of 16 residents reviewed: Resident #29, Resident #36, Resident #39, and Resident #42. Record review showed each of these residents had a physician order for DNR status and each face sheet listed advanced directives as DNR, but their current care plans did not include a specific care plan for advanced directives. Resident #29 was admitted and readmitted with diagnoses including dysphagia, acute pulmonary edema, and pneumonia; Resident #36 had unspecified dementia, generalized anxiety disorder, and benign prostatic hyperplasia; Resident #39 had quadriplegia, pain, and dysphagia; and Resident #42 had GERD, depression, and hypothyroidism. During interview, the DON stated she was responsible for ensuring the resident's code status was in the comprehensive care plan and said the missing care plans were an oversight. The DON also stated she was being trained "as I go." The Admin stated the DON was responsible for ensuring a resident's code status was in the care plan and said the DON had not been provided specific training for code status in the care plan because she did not think about it. The facility policy titled, Care Plans, Comprehensive Person-Centered, stated that a comprehensive, person-centered care plan is developed and implemented for each resident and includes services furnished to meet the resident's needs, including services not provided due to the resident exercising rights such as refusal of treatment.
Unmonitored Resident Refrigerators With Undated and Expired Foods
Penalty
Summary
The facility failed to ensure its policy for foods brought in by family and visitors was followed for residents with personal refrigerators in multiple rooms. During observations, surveyors found perishable and nonperishable food items stored in resident refrigerators that were unlabeled, undated, or past the listed expiration/use-by date, including summer sausage, yogurt, lunch meat, sauces, jelly, brownies, grapes, hot dogs, queso, pastries, and restaurant to-go containers. In several rooms, the refrigerators also contained numerous unopened beverages and other food items without clear dating or labeling. The observations showed that the same concerns remained over multiple days, with expired or undated items still present in the refrigerators when rechecked. In one room, an expired package of summer sausage and an unlabeled food item remained in the refrigerator on later observation. In another room, undated sauce containers and a to-go container from Rosa's Cafe were still present on later observation. In a third room, undated yogurt, cake, lunch meat, and another unknown food item were observed, and some of those items remained in the refrigerator on a later check. Interviews with CNA E, the DON, and the ADM confirmed there was no current system or policy in place for monitoring residents' personal refrigerators, checking temperatures, or routinely discarding expired food. Staff stated residents were generally responsible for cleaning out their own refrigerators, and there was no log or assigned task to verify when refrigerators had last been cleaned or whether they were at an adequate temperature. The ADM stated the facility had a policy for food brought in by family and visitors, which required perishable foods to be labeled with the resident's name, item, and use-by date, and required nursing staff to discard perishable foods on or before the use-by date.
Infection Control Failures During Incontinence and Catheter Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for 2 of 3 residents reviewed for infection control. During observation of incontinence care and catheter care for one resident with quadriplegia, dysphagia, pain, and an indwelling Foley catheter, CNA A and RN B did not wear gowns while providing care, even though the resident had an order for Foley catheter care twice daily and the care plan identified risk for UTI. CNA A washed her hands and put on gloves, but during the care she removed gloves and did not perform hand hygiene before putting on clean gloves again. She also continued care with the same gloves while moving between dirty and clean tasks, including cleansing the groin, wiping the buttocks, placing a clean brief and pad, and later cleansing the catheter and repositioning the resident. During the same observation, CNA A and RN B assisted with the resident’s incontinence and catheter care without using the gown required for enhanced barrier precautions. CNA A stated she had asked the DON about gown use and was told wrong or became confused, and she acknowledged she should have changed gloves and performed hand hygiene before placing the clean brief and after cleaning the catheter. RN B stated she should have worn a gown while helping with the care and said she was nervous and confused. The DON later stated staff should wear a gown and gloves when changing the resident’s brief or providing catheter care and that the facility had been confused about the enhanced barrier precautions. For a second resident who was always incontinent of bowel, CNA C performed incontinence care and washed her hands before donning gloves, but after cleansing the groin and buttocks she removed the dirty brief and placed a clean brief under the resident without changing gloves. CNA C then secured the brief and removed her gloves. CNA C stated she had been trained to change gloves and perform hand hygiene when going from dirty to clean during incontinence care and said she realized she had made a mistake because she was nervous. The DON and the Admin both stated staff were expected to perform hand hygiene between glove changes and to change gloves when moving from dirty to clean during resident care.
Staff Training Program Not Maintained
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for all new and existing staff members, including individuals providing services under contractual arrangement and volunteers, consistent with their expected roles. Record review and interviews showed that 6 of 6 employees reviewed were not documented as having received required facility training in Fall Prevention, HIV, Restraints, Emergency Procedures, and Dementia at hire and annually. The employees reviewed were RN F, CNA A, LVN H, CNA G, CNA I, and CNA J. Employee record review showed RN F, hired on 07/28/2025, had no documentation of facility training for Fall Prevention, HIV, Restraints, Emergency Procedures, or Dementia. CNA A, hired on 05/27/2025, also had no documentation of those trainings. LVN H, hired on 02/17/2025, CNA G, hired on 07/21/2025, CNA I, hired on 01/17/2018, and CNA J, hired on 11/05/2024, likewise had no documentation showing they received the required training through the facility. During interviews, HR stated the hospital CCO was supposed to pick up a training system for the facility, but nothing was in place and live at that time. HR stated the hospital would provide training through orientation and the facility was responsible for ensuring staff completed required training, and that the ADM was responsible for ensuring staff completed trainings. The ADM stated she had asked for a training program but had not received approval yet, that RN B had been hired to help with infection control training and had only started the prior week, and that staff were responsible for completing training through their CEUs. The ADM also stated the facility had not followed up enough on employee training and identified a potential negative outcome as staff not being able to react appropriately with dementia and behaviors due to lack of training.
Incomplete DNR Documentation for Two Residents
Penalty
Summary
The facility failed to ensure that two residents had properly completed advance directive documentation for their Do Not Resuscitate status. Resident #27, an elderly female admitted with dementia, hypothyroidism, and hypertension, had a quarterly MDS showing a BIMS of 6, indicating severely impaired cognition. Her face sheet listed DNR under advance directives, but her physician order summary contained no code status order, her care plan had no DNR care plan, and her Out of Hospital Do Not Resuscitate form was incomplete, with no physician signature, printed name, or license number, and no resident or guardian signature on the acknowledgement section. Resident #28, an elderly female admitted with hypertension, gastro-esophageal reflux, altered mental status, and anemia, had a quarterly MDS showing a BIMS of 0, indicating severely impaired cognition. Her face sheet also listed DNR, but her physician order summary contained no code status order, her care plan had no code status care plan, and her Out of Hospital Do Not Resuscitate form was missing the physician printed name and license number in the physician statement section. During interview, the ADM stated the OOH DNR was not valid if not filled out correctly, that Social Services was responsible for ensuring accuracy, and that the facility did not have a system in place to monitor OOH DNR forms for accuracy.
RN Coverage Not Provided on Required Weekend Days
Penalty
Summary
The facility failed to use the services of an RN for at least eight consecutive hours a day, seven days a week on 10 of 90 days reviewed for RN coverage. Record review of the facility’s PBJ Staffing Data Report for Fiscal Year Quarter 2 2025 showed no RN hours on 01/11/25, 01/12/25, 01/25/25, 01/26/25, 02/08/25, 02/09/25, 02/15/25, 02/16/25, 02/22/25, and 02/23/25. The report identified these as weekend days when the facility did not have RN coverage for the required 8 hours per day. During interview, the Admin stated the DON was hired at the end of 2024 and worked Monday through Friday from 8:00 AM to 5:00 PM and sometimes longer, but did not clock in because the DON was salaried. The Admin stated the facility did not have an RN to cover weekends during January and February 2025, and that weekend RN coverage began in March 2025. The Admin also stated the facility had difficulty hiring an RN for weekend coverage and that the Nurse Practitioner lived nearby and could respond quickly if needed. The facility policy titled, Departmental Supervision, Nursing, stated the nursing services department shall be under the direct supervision of an RN or LPN/LVN at all times and that an RN provides services at least eight consecutive hours every 24 hours, seven days a week.
Pureed Foods Served With Chunks and Uneven Texture
Penalty
Summary
The facility failed to prepare puree meat, puree vegetables, and puree pasta in a smooth, uniform texture to meet individual dietary needs. During an observation on 08/20/2025 at 12:10 PM, the test tray showed pureed broccoli with small chunks and strings, and pureed pasta with chunks of dough, both not smooth and uniform. During an observation on 08/21/2025 at 11:55 AM, the test tray showed pureed pork with small grains, pureed carrots with chunks, and pureed potatoes with chunks, all not smooth and uniform. During interviews, the DM stated she was responsible for puree food items served to residents and was not certain which dietary staff completed the puree task on 08/20/2025 or 08/21/2025. She stated she would ensure all pureed food items were pureed herself to a consistent, smooth texture before being served and that all food served to nursing facility residents was prepared at the connected hospital. The DON stated dietary staff were responsible for preparing and serving pureed foods and that pureed foods should be a soft, baby food consistency without chunks. The ADM stated the DM and dietary staff were responsible for ensuring puree foods were served adequately and that pureed form should be smooth with no chunks. Record review of the facility's Puree Diet document stated the diet is soft in texture and mechanically nonirritating and is used for patients who have problems chewing and swallowing.
Failure to Submit PBJ Staffing Data
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS for the second quarter of fiscal year 2024. This deficiency was identified during a review of the CMS PBJ Staffing Data Report, which indicated that no data was submitted for the quarter. Interviews with facility staff revealed that the MDS nurse was responsible for the PBJ data submission but did not ensure the data was submitted. The Director of Nursing (DON) and the Administrator (ADM) were unaware of the failure to submit the data and did not monitor the process to ensure compliance. The MDS nurse, who had been trained on PBJ data submission three years prior, was unable to explain why the data was not submitted. The ADM, who was new to the facility, also did not know why the data was not submitted and was not aware of the potential risks to residents due to this failure. The facility's policy on reporting direct-care staffing information, revised in August 2022, requires that staffing information be submitted quarterly, no later than 45 days after the end of the reporting quarter. However, this policy was not followed, resulting in the deficiency.
Improper Chemical Storage in Resident Baths
Penalty
Summary
The facility failed to ensure that the resident environment was free from accident hazards in two of the three common resident baths, specifically in the Tan and Mauve Halls. Chemicals were improperly stored with resident toiletries and personal items, posing a risk of exposure to hazardous substances. Observations revealed that the doors to these baths were not locked, and chemicals such as Virex Plus Disinfectant Cleaner and Deodorizer were stored on open shelves next to washcloths, towels, and other personal care items. Interviews with CNAs revealed a lack of awareness and training regarding the proper storage of chemicals. CNA A, who had recently returned to the facility, was unaware of the policy against storing chemicals above toiletries and with resident items. Similarly, CNA C acknowledged that chemicals should be locked up but was not informed about the risks of storing them above resident items. The DON confirmed that staff had been trained on chemical storage, but the training did not emphasize the importance of not storing chemicals above resident items. Further observations indicated that even when chemicals were stored in locked cabinets, they were placed on shelves with gaps that could allow leakage onto resident items below. The DON and Administrator both acknowledged the issue, with the DON stating that she was ultimately responsible for ensuring safe chemical storage. The facility's policy and in-service documentation indicated that staff were expected to keep hazardous items out of reach and ensure safe storage, but these protocols were not consistently followed, leading to the identified deficiencies.
Failure to Provide Therapeutic Diets
Penalty
Summary
The facility failed to provide physician-ordered therapeutic diets to three residents, which included fortified foods necessary for their nutritional needs. Resident #18, who had moderate protein-calorie malnutrition, was observed not receiving fortified foods during meals on multiple occasions. Despite having a diet order for fortified foods with all meals, the resident's meal trays did not reflect this requirement, and there was no specific care plan addressing his nutritional needs. The resident experienced a weight loss of 3.71% in one month, indicating a failure to maintain his nutritional status. Resident #72, who had a history of alcohol abuse and was underweight, was also not provided with her prescribed fortified diet, which included specific supplements like bananas and chocolate ice cream. Observations revealed that she did not receive these items during meals, and her tray card did not indicate a fortified diet. The resident's potassium levels were low, and the lack of high-potassium foods like bananas could exacerbate this condition. The dietary staff failed to ensure the resident received her therapeutic diet, which was crucial for her weight maintenance and overall health. Resident #73, who had a history of obsessive-compulsive disorder and was at risk for pressure ulcers, did not receive her ordered fortified soup with lunch. Despite having a diet order for fortified soup, observations showed that her meals did not include this item. The dietary manager admitted to communication issues between the nursing and dietary departments, which led to the oversight of therapeutic diet orders. The lack of proper communication and monitoring systems contributed to the residents not receiving their prescribed diets, potentially impacting their health and nutritional status.
Infection Control Deficiencies in Hand Hygiene and Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by improper hand hygiene practices and lack of enhanced barrier precautions. During incontinence care for a resident with moderate cognitive impairment and urinary incontinence, a CNA did not wash hands between glove changes, potentially risking cross-contamination. Similarly, another CNA failed to change gloves and perform hand hygiene before handling a clean brief for a resident with occasional incontinence, despite being aware of the correct procedures. Additionally, the facility did not implement enhanced barrier precautions for a resident with an indwelling catheter, as there were no precautionary signs or personal protective equipment (PPE) available outside the resident's room. This oversight was noted during observations, and staff interviews revealed a lack of awareness and training regarding the application of enhanced barrier precautions for residents with indwelling medical devices. Interviews with staff, including CNAs and the Director of Nursing (DON), highlighted gaps in training and understanding of infection control protocols. The DON, who also serves as the infection preventionist, acknowledged the importance of hand hygiene and enhanced barrier precautions but admitted that training might not have been comprehensive or recent enough. The facility's policies on hand hygiene and enhanced barrier precautions were not consistently followed, contributing to the deficiencies observed.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents were fully informed and understood their health status, care, and treatments, specifically regarding the administration of psychotropic medications. This deficiency was identified for three residents who did not have signed informed consents for medications such as Lorazepam, Trazodone, and Seroquel. The absence of these consents meant that the residents or their responsible parties were not informed of the risks, benefits, and alternatives to the prescribed medications. Resident #8, a female with diagnoses including hypertension, anxiety disorder, insomnia, and Alzheimer's disease, was administered Lorazepam and Trazodone without a signed consent. Similarly, Resident #72, who had a history of insomnia, Alzheimer's disease, and other conditions, was given Trazodone without consent. Resident #222, with severe cognitive impairment and a history of heart disease and insomnia, was administered Seroquel and Lorazepam without a complete consent form, as it lacked the necessary signatures and indications of agreement. Interviews with the Director of Nursing (DON) and the Administrator (ADM) revealed that the responsibility for obtaining consents lay with the nursing staff, who were expected to complete them on the same day the medication order was received. However, due to human error, these consents were either missing or incomplete. The DON and ADM acknowledged the oversight but minimized the potential impact, viewing it primarily as a paperwork issue, despite the risk of administering medications without proper consent.
Failure to Limit PRN Orders for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that PRN orders for psychotropic drugs were limited to 14 days unless extended by the attending physician or prescribing practitioner. This deficiency was identified for two residents who were reviewed for unnecessary medications. Resident #3 was prescribed alprazolam, a medication used to treat anxiety, without a stop date or duration for its PRN use. Similarly, Resident #72 was prescribed trazodone, a medication used to treat insomnia, also without a stop date or duration for its PRN use. Resident #3, a female with a history of congestive heart failure, hypertension, and generalized anxiety disorder, was receiving alprazolam PRN regularly over several months without a specified end date. Despite regular administration, the medication was not scheduled, and the consultant pharmacist's reviews did not provide any recommendations regarding the alprazolam. The Director of Nursing (DON) acknowledged the oversight and indicated that the medication should have been scheduled. Resident #72, a female with a history of insomnia, Alzheimer's disease, and other health issues, was receiving trazodone PRN without a specified end date. The medication was administered regularly, and there was a period when the order was on hold, but it remained active without a stop date. The DON admitted that the PRN order was overlooked and that the staff did not want to change the resident's routine. The facility's policy on medication utilization and prescribing was not adhered to, as the PRN orders lacked clear indications and were not periodically re-evaluated.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Seminole
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Shinnery Oaks Community | 19.2 mi | ★★★★★ | 2 | 0 |
| Permian Residential Care Center | 27.4 mi | ★★★★★ | 8 | 0 |
| Desert Springs Health Care Llc | 27.9 mi | ★★★★★ | 12 | 0 |
| White Sands Healthcare | 30.4 mi | ★★★★★ | 14 | 2 |
| Brownfield Rehabilitation And Care Center | 38.7 mi | ★★★★★ | 0 | 0 |
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