Morning Star Post Acute

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure a safe environment and adequate supervision for one of three sampled residents (Resident 1) when Resident 1 exited the facility unsupervised through the main entrance door, where the door alarm failed to sound an audible alert and staff did not conduct the required fifteen-minute checks. This failure resulted in Resident 1 who was cognitively impaired and has insulin dependent diabetes (IDDM-a chronic condition where the pancreas makes little or no insulin, the hormone which allows sugar to enter cells to produce energy) eloping from the facility and roaming city streets for approximately three hours and eight minutes (between the hours of 3:55 p.m. [...]

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to prepare and store food in accordance with professional standards for food safety for all residents who consumed meals prepared in the kitchen when a of five-pound bag of chicken with a used by date of 2/16/26 was stored in the refrigerator available for residents use. This failure placed residents at potential risk to develop gastrointestinal illness (illness that affects the digestive system [GI tact] which runs from mouth to anus) which could result in serious health conditions. During a concurrent observation and interview on 2/17/26 at 8:22 a.m. during initial tour in the kitchen with Dietary Service Manager (DSM), in the refrigerator there was a bag of chicken with prep date of 2/14/26 and used by date of 2/16/26. The DSM stated, It [chicken] was supposed to be used yesterday [2/16/26]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure garbage was stored and disposed of in a manner that prevented unsanitary conditions for all the residents in the facility when two of three outdoor dumpsters were observed with the lids open and overflowing. This failure placed residents at potential risk for exposure to pest, offensive odors, and contamination of food or medications which could compromised residents health, safety, and the overall sanitary environment of the facility. During a concurrent observation and interview on 2/18/26 at 8:15 a.m. with Dietary Service Manager (DSM), the facility's dumpster located behind the building was observed with two of the lids in the open position. One dumpster contained overflowing garbage in a plastic bag, which prevented the lid from closing securely. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a comprehensive, person-centered care plan (a plan that provides direction for individualized care of the resident) was developed and implemented to meet the identified needs for two of 10 sampled residents (Residents' 5 and 10) when: 1. Resident 5's change in condition on 2/14/26, when the resident complained of a cough and subsequently received new physician orders, including cough medication, steroids (medicine used to reduce swelling and inflammation), antibiotics (medicine used to treat infections caused by bacteria [germs]) and diagnostic testing. This failure had the potential to result in inconsistent care, lack of staff awareness regarding Resident 5's change in condition and failure to monitor the effectiveness of interventions, which could have led to a decline in Resident 5's respiratory status. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to meet professional standards of practice for three of 10 sampled residents (Resident 12, 49 and 29 ) when:1. Resident 12 was administered 2.5 LPM (liter per minute-a unit of measurement for the flow rate of oxygen) of oxygen therapy (a colorless, tasteless gas essential to living organisms) without a physician's order. This failure resulted in Resident 12 receiving oxygen therapy without a physician's order which had the potential to result in shortness of breath, oxygen toxicity (lung damage that happens from breathing in too much extra oxygen therapy), and serious medical conditions.2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to safely and securely label and store medications ready for residents use when:1. The medication room contained four expired Fexofenadine Hydrochloride (medication used to treat allergy symptoms) 180 milligrams (mg-a unit of measurement for medication) tablet bottles, one expired Dextromethorphan HBr 20 mg Guaifenesin 400 mg (medication used to treat cough and chest congestion symptoms) bottle and two expired 8.5 fluid ounce Vashe wound solution (skin cleanser used for debriding and irrigating wounds) bottles. This failure placed residents at potential risk to receive ineffective or unsafe medications and wound care solutions, which could lead to delayed wound healing, worsening of underlying medical conditions or preventable hospitalization.2. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure an effective infection prevention and control program was maintained for two of 15 sampled residents when:1. The facility did not ensure Resident 5 was tested for COVID-19 (Coronavirus is an infectious respiratory disease) in accordance with the facilities policy and procedure titled COVID-19, after Resident 5 developed a cough. This failure had the potential to delay identification of communicable diseases and increase the risk of transmission to other residents and staff within the facility.2. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure a complete and accurate informed consent was obtained prior to the administration of psychotherapeutic medication (prescription drugs designed to manage mental and emotional disorders by altering the brain's chemical makeup and nervous system) for one of five sampled residents (Resident 3) when Resident 3, who was her own representative party (RP-a person designated to received updates of resident's care and make decisions), did not sign an informed consent and was administered clonazepam (psychotherapeutic medication used to manage anxiety disorders) 0.5 milligrams (mg- a unit of measurement for medication dosage). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure its policy on against medical advice (AMA-patient chooses to leave before the doctor recommended discharge) was followed for one of three sampled residents (Resident 57) when Resident 57 left the facility AMA on 2/6/26, and there was no documentation the medical doctor (MD) and administrator (ADM) were notified. This failure had the potential to place Resident 57 at risk of health complications, including worsening of her condition. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Minimum Data Set Assessment (MDS-assessment of physical and psychological functions and needs) accurately reflected resident's health and functional status for one of five sampled residents (Resident 58) when Resident 58's Infection of the foot in Section M (Skin Condition) was inaccurately coded in the MDS assessment dated [DATE]. This failure had the potential to result in Resident 58's care needs not met and the potential for adverse reaction to not be monitored. During a concurrent observation and interview on 2/17/26 at 10:48 a.m. during initial tour in Resident 58's room, Resident 58 was observed lying in bed with facial grimacing stating he has pain on his right foot. [...]

Inspectors wroteBased on observation during the survey period of 2/17/26 through 2/20/26, the facility failed to ensure each bedroom accommodated no more than four residents in 3 of 16 rooms (rooms [ROOM NUMBER]). This failure had the potential for residents to not have reasonable privacy or adequate space.

Inspectors wroteBased on interview and record review, the facility failed to recognize and appropriately act on the clinical change in condition for one of three residents, (Resident 1), when: Nursing staff did not notify the physician on 9/12/25 for abnormal blood lab results. Nursing staff did not notify the physician on 9/13/25 for Resident 1's low blood pressure of 91/55 millimeters of mercury (mmHg- unit of measurement), (normal BP 120/80), elevated heart rate (HR) 116 beats per minute (bpm), (normal range 60-100 bpm). [...]

Inspectors wroteBased on interview and record review, the facility failed to provide services which met professional standards of practice for two of the five sampled residents (Resident 1, and Resident 5) when Resident 1 and Resident 5's medications were not available, and the license nurse did not notify the physician the medications were not administered. This failure had the potential risk for Resident 1 and Resident 5 to experience worsening of existing health conditions and delayed medical response. During a record review on 8/7/25 at 11:47 a.m. with the Licensed Vocational Nurse (LVN) at the nurses' station, Resident 1's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 8/7/25 was reviewed. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow professional standards practice and the facility's policy and procedure for one of four sampled residents (Resident 1) when Resident 1 was not administered medications as ordered by the physician on 5/23/25. This failure had the potential for Resident 1 to experienced worsening chronic conditions, health deterioration, re-hospitalization and or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen according to facility policy and procedures and the FDA (Food and Drug Administration-is a government agency responsible for protecting the public health) Food Code when: 1. There was brown, grey, and black debris observed in several areas in the kitchen, including one ventilator fan in the milk refrigerator, two vents above the dishwasher area, one vent in front of the milk refrigerator and one vent in front of the food warming table. 2. There was black and brown debris found on the cabinet shelves next to the stored clean bowls. 3. There was brown debris on every shelf inside of one food cart. 4. There was brown debris on top of the toaster and brown particles found inside the toaster. 5. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective infection prevention and control program for 54 of 54 sampled residents when: 1. The facility's Water Management Program (WMP) was not implemented since 4/8/22 to reduce the risk of Legionella (waterborne bacteria which can cause life threatening pneumonia - a lung infection) and other waterborne pathogens (germs that cause disease) in accordance with the facility's WMP. This failure placed the residents at risk for cross contamination (when harmful bacteria accidentally move from one food item to another), infection and had the potential for not identifying the risk of waterborne illnesses such as Legionella. 2. Resident 13 and Resident 30's oxygen nasal cannula (a small thin flexible tube with two prongs that fit into the nostrils and connects to an oxygen source) was on the floor. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were treated with dignity and respect for nine of 13 sampled residents (Residents' 2, 4, 6, 9, 14, 21, 26, 29, 31, 34, and 106) when: 1. Licensed Vocational Nurse (LVN) 1 checked Resident 106's blood sugar level (BS-amount of sugar in the blood) without closing the privacy curtain or the door. 2. LVN 3 checked Resident 34's blood pressure (B/P-measures the pressure of circulating blood against the walls of blood vessels [channels that carry throughout the body]) and did not provide privacy. 3. LVN 3 administered medications to Residents' 2, 4, 6, 9, 21, 26, 29, 31, and 34 without closing the privacy curtain. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services on acquiring, receiving, dispensing, and administering of all drugs to meet the needs of 54 residents residing in the facility when the contracted pharmacist did not check the expiration date of the lorazepam (medication used to treat anxiety and seizure- [a burst of uncontrolled electrical activity in the brain]) medication stored in the emergency kit (E-kit-contains medications provided to residents during emergency situations). This failure placed residents at potential risk for taking expired medications which could lead to serious consequences including reduced effectiveness in treating resident's condition in an event of an emergency and potential adverse reaction.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored and labeled in accordance with the facility's Administering Medications, Discontinued Medications, and Storage of Medications policy and procedure when: 1. Treatment cart was left unlocked and unsupervised in front of the nursing station. This failure had the potential for residents and staff to access medicated ointments inside the cart and used which could lead to serious health condition. 2. Resident 14's two inhalers (a device used to give medications in the form of a spray that is breathed in through the mouth) did not have an open date or expiration date on the medication. 3. Resident 14's nasal spray (a devised used to give medications in the form of spray through the nose) did not have an on date or expiration date on the medication. 4. [...]

Inspectors wroteBased on observation and staff interview during the survey period from 12/3/24 through 12/10/24, the facility failed to ensure each bedroom accommodated no more than four residents in (room [ROOM NUMBER], room [ROOM NUMBER] and room [ROOM NUMBER]).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure call light was within reach for three of 14 sampled (Residents' 104, 19 and 30) when: 1. Resident 104's call light was under his bed and not within his reach. 2. Resident 19 and Resident 30's call lights were on the floor and not within their reach. This failures resulted in the potential harm of Resident 19, Resident 30 and Resident 104 to not be able to call for assistance by using the call light in the event of an emergency.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide services which met the professional standards of practice of care for one of 13 sampled residents (Resident 14) when Licensed Vocational Nurse (LVN) 2 allowed Resident 14 to self-administer her two inhaler (a device used to give medications in the form of a spray that is breathed in through the mouth) not following their own policy and procedure of self-administration of medication. This failure had the potential for Resident 14 to not received the correct medication dose as ordered by the physician.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents who were unable to carry out activities of daily living (ADLs-routine tasks/activities a person perform daily to care for themselves) were provided assistance to maintain personal hygiene and grooming for one of seven sampled residents (Resident 22) when Resident 22's fingernails were long, jagged, with dark colored particles under the nails and his mouth and in between her teeth had food particles. These failures resulted in Resident 22's poor personal hygiene and had the potential to result in serious health condition.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure dietary staff were able to carry out the functions of food and nutrition services safely and effectively when: 1. [NAME] 2 was unable to properly calibrate the thermometer. This failure had the potential to cause foodborne illness for 50 out of 51 sampled residents who received foods from the kitchen. 2. [NAME] 2 did not follow manufacturer's guideline time length for testing the red bucket Quaternary (Quat) sanitizer (sanitizing solution used for sanitizing food contact surfaces). This failure had the potential to cause foodborne illness for 50 out of 51 sampled residents who received foods from the kitchen. 3. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain a sanitary environment, prepare, and served food in accordance with professional standards for food service safety when: 1. The 3-compartment sink did not have an air gap (is vertical space between the end of a pipe and the top of a nearby sink that prevents the backflow of contaminated water). 2. [NAME] debris was observed on the wall next to the milk refrigerator, cook freezer, above the steam table, door frame of the dry storage door and a black fan located next to clean water pitchers. 3. Milk refrigerator and produce refrigerator shelves had chipped paint. 4. Two floor holes observed underneath the ice machine. 5. The inside of two microwaves, one located by the hand wash station and the other next to the three-compartment sink had brown sticky substance. 6. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement and maintain an effective infection prevention and control program to prevent the transmission of infections when: 1. Licensed Vocational Nurse (LVN) 1 did not perform hand hygiene during medication administration to Resident 51. 2. The clean linen room door was left open to the hallway, and the room was unoccupied. 3. The linen cart located in the east hallway containing clean gowns was left open and a crumpled paper tissue was left on the bottom shelf of the cart. 4. The north shower room had washcloth hanging on the soap holder and the handheld shower head was left on the floor. These deficient practices placed residents at risk for cross-contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect).

Inspectors wroteBased on interview and record review the facility failed to provide written notification before a room change for three of 53 sampled residents (Resident 31, Resident 27, and Resident 307) when the residents were moved to another room without a written notification including the reason for the move provided to residents and responsible representative (an individual chosen to act on behalf of the resident in order to support the resident in decision-making; access medical, social or other personal information of the resident; manage financial matters; or receive notifications). This failure violated the right of Resident 31, Resident 27, and Resident 307 to receive a written notice explaining the reason for the move before the room changed.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for three of 53 sampled residents (Resident 27, Resident 8, and Resident 6) when: 1. Resident 27 and Resident 8 did not have a comprehensive care plan for atrial fibrillation (a-fib- an abnormal heartbeat which reduces the heart's ability to pump properly and increases risk of blood clots) and the use of anticoagulation medication (medication that helps prevent blood clot formation). These failures placed Resident 27 and Resident 8 at risk for signs and symptoms of a-fib and bleeding complications from the used of anticoagulant to go unmonitored. 2. Resident 6's weight loss care plan intervention for weekly weights were not done. This failure placed Resident 6 at risk for delayed identification, reporting, and timely management for weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the nutritional needs for four of four sampled residents (Residents 1, 18, 34, and 309) was met for lunch on 11/7/23 when the meal was not plated in accordance with menu guidance for purred diet portion size for purred meat. This failure had the potential to result in under nutrition further compromising the medical status of Residents 1, 18, 34, and 309 who received pureed meat from the kitchen.

Inspectors wroteBased on observation interview and record review, the facility failed to ensure food was prepared in a form designed to meet individual needs for six of six residents (Resident 33, Resident 45, Resident 1, Resident 18, Resident 34, and Resident 309) when: 1. [NAME] 2 served Resident 33 and Resident 45 a regular textured Brussels sprouts for lunch instead of the physician ordered mechanical soft diet (a diet with food texture of chopped and ground designed for residents who have trouble chewing and swallowing). 2. [NAME] 1 served Resident 1, Resident 18, Resident 34, and Resident 309 chunks of chicken for lunch instead of the physician ordered puree diet (a diet with food texture of soft pudding-like consistency). These failures placed Residents at risk for aspiration (accidentally inhaling food or liquid into the lungs) and choking.

Inspectors wroteBased on observation and interview, during the survey period of 11/6/23 through 11/9/23, the facility failed to ensure each bedroom accommodated no more than four residents in three of 16 rooms (rooms 11, 12 and 14). This failure had the potential for residents to not have reasonable privacy or adequate space.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe, functional, and sanitary environment for (19 of 51 residents (1, 2, 4, 6, 7, 8, 10, 18, 24, 25, 29, 31, 32, 34, 36, 38, 46, 51, and 307) when: 1. Two resident shower rooms had black residue on the tile floors and walls, gaps in between the tiles and the call light pull cords had pink and black substance. 2. Oscillating (rotating) fan with a plastic packaging wrapped at the end of the electrical cord was plugged into a four-socket wall and the plastic packaging was touching the outlet. 3. The shower room in the north hallway had darkened areas on the tile grout. These failure placed residents in a unsanitary environment which could lead to potential health problems and created a fire hazard.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program to ensure the facility remained free of pests when two winged bugs were found in a resident's shower. This failure had the potential for bacteria to spread from flies which could cause illness in a medically vulnerable population of residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure services provided meet professional standards of practice for one of three sampled residents (Resident 6) when Resident 6's Physician order for weekly weights was not done on 7/17/23, 7/24/23, 8/7/23, 8/14/23, 8/21/23, 9/4/23, 9/11/23, 9/18/23, 9/25/23, 10/9/23, 10/16/23, and 10/23/23. This failure resulted in Resident 6 unmonitored weight loss. During a concurrent observation and interview on 11/7/23 at 11:57 a.m. with Resident 6 at the bedside, Resident 6 was lying in bed with the noon meal tray in front of her. Resident 6 took a bite of pasta and stated she likes to eat steak and thought she was in her grandparents' home. During an interview on 11/8/23 at 9:15 a.m. with Resident 6 at Resident 6's bedside. Resident 6 stated her appetite was not good, and she preferred liquid foods for breakfast. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor the effectiveness of nutrition interventions and recommend interventions to maintain acceptable parameters of nutritional status for one of three sampled Residents (Resident 6), during which time weight loss continued. These failures resulted in Resident 6 experiencing an unhealthy, unplanned, and undesired severe weight loss of 33 pounds (lb) or 15 percent in six months and a 54 lb weight loss of 22.5 percent in eight months, which placed Resident 6 at risk for further health status decline.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pain management services consistent with professional standards of practice for one of 53 residents (Resident 2) when Resident 2 was making loud noise and yell during nighttime and was assess for pain by the License Vocational Nurses (LVNs) using the numerical pain scale (a pain assessment tool in which the resident picks or draw a circle around the number that best describes their pain, 0 no pain, 1-3 mild pain, 4-6 moderate pain, and 7-10 severe pain) which was the wrong pain assessment tool because Resident 2's had severe cognitive impairment. This failure resulted in Resident 2's experienced of pain not accurately assess and manage which could have resulted for Resident 2's increased in making loud noise and yelling during nighttime.

Inspectors wroteBased on interview and record review, the facility failed to ensure the policy and procedure for dialysis (procedure to remove wastes and excess fluids from the body) was followed and professional standards of quality were met when one of three sampled residents (Resident 307) did not have documentation of completed post-dialysis weight assessments on multiple dates. This failure placed Resident 307 at risk for delayed identification, reporting, and management of complications from dialysis.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure expired medications were discarded and not available for use when a stool softener was stored and available for use in one of one medication cart. This failure had the potential to result in the administration of expired medication that may have lost their potency and may be ineffective.

Inspectors wroteBased on observation, interview and record review, the facility failed to dispose of garbage under sanitary condition when the facility's trash dumpster was left uncovered and overfilled. This failure had the potential to attract rodents, insects, and flies which could place residents at risk for cross contamination (the process by which bacteria are unintentionally transferred from one substance or object with harmful effect) and foodborne illness (illnesses cause from ingestion contaminated food).

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a comprehensive care plan for three of five sampled residents (Resident 1, Resident 2, and Resident 3) when: 1. Resident 2 did not a have a comprehensive care plan implemented for the used of supplemental oxygen (is the use of oxygen as a medical treatment for patients who have low oxygen in their blood and need more oxygen) with interventions which included replacing the nasal cannula (a lightweight tube placed in the nostrils used to deliver supplemental oxygen to patients) weekly and properly storing the nasal cannula inside a storage bag when not in use. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective infection prevention and control program for three of five sampled resident (Resident 1, Resident 2, and Resident 3) when: 1. Resident 2' nasal cannula (a lightweight tube placed in the nostrils used to deliver supplemental oxygen to patients) was on the floor without a date per physician order and not stored inside a bag. 2. Residents 1 and Resident 3's nebulizer mask (a face mask used to deliver aerosol medications for breathing treatments) was placed on top of the nightstand without a date and not stored inside a bag. [...]