Morningside Center

Inspectors wroteBased on interview and record review, the facility failed to ensure the Do Not Resuscitate Order's (DNR, medical order that instructs the health care provider not to do resuscitative measures if a person's heart stops) for Resident #29, Resident #13 and Resident #21 were correct when the Durable Power of Attorney's (DPOA) a legal document that authorizes a designee to manage financial or medical affairs if the person became incapacitated, name was printed on the DNR instead of the name of the resident on Resident #29's DNR, and when the facility failed to ensure that two residents (Resident #13 and Resident #21) had physician letters of incapacitation prior to the Power of Attorney designee making decisions for him/her. This affected three of 14 sampled residents (Resident #29, Resident #13 and Resident #21). The facility census was 56. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure resident assessments were completed accurately for two of 14 sampled residents (Resident #1 and Resident #7) when the facility failed to accurately document a diagnosis of Resident #1 and failed to accurately document a Urinary Tract Infection (UTI) for Resident #7. The facility census was 56. The facility did not provide a resident assessment or Minimum Data Set (MDS) policy. MDS is a federally mandated assessment completed by facility staff in accordance with specified formats and timelines in conducting comprehensive assessments as part of an ongoing process through which the facility identifies preferences and goals of care, functional and health status, strengths and needs. 1. [...]

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. When facility staff did not address UTI (urinary tract infection) with antibiotic usage for two residents (Resident #25 and Resident #14), did not address use of anticoagulant medication or therapeutic activities for one resident (Resident #52) and when dementia care had not been cared planned for one resident (Resident #29 & Resident #52). This affected four of the 14 sampled residents. The facility census was 56. [...]

Inspectors wroteBased on observation, interview and record review the facility failed ensure professional standards of quality of care and all services are provided according to accepted standards of clinical practice when licensed nursing staff administered medications without verification of the order prior to administration for two residents (Resident #1 and Resident #34) and when not maintaining proper nursing techniques and infection control measures for the removal and insertion of an indwelling urinary catheter for two residents (Resident #25 and Resident #5). The affected four residents out of the 14 sampled residents. The facility census was 56. Review of the facility's undated Catheter Insertion and Removal Policy showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dependent residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene when staff failed to provide complete perineal care for Residents #13, #5, #7, #50 after an incontinence episode. This affected four of 14 sampled residents. The facility census was 56. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that two residents (Resident #5 & #25) who had urinary catheter (a tube inserted into the bladder to drain urine from the body), received appropriate treatment and services to prevent urinary tract infections when the facility failed to provide proper catheter care management. The affected two of the sampled 14 residents. The facility census was 56Review of the facility's undated Catheter Insertion and Removal Policy showed: -To remove catheter: put on disposable gloves, attach syringe to balloon port of catheter and aspirate entire amount of sterile water in balloon; -Pinch catheter and withdraw gently and slowly; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff administered medications with an error rate of less than five percent (5%). When staff failed to verify a physician's order prior to the administration of insulin and narcotic medications resulting in two errors out of 25 opportunities for error, which resulted in an error rate of 8%. This affected two of the 14 sampled residents, (Resident #1 and #34). The facility census was 56. Review of the facility's policy titled, Medication administration-general guidelines, revised 8/16, showed: [...]

Inspectors wroteBased on observation and interview the facility failed to ensure that two residents (Resident #1, and Resident # 34) were free from significant medication errors when RN B failed to verify an insulin and narcotic order prior to the administration of both, placing both residents at risk for negative outcome to their health and safety. This affected two residents out of 25 possibilities for a significant medication order. The facility census was 56. The facility was unable to provide any policy regarding a significant medication error. 1. Review of Resident #1's admission baseline care plan showed the resident was alert and oriented with cognition intact and a recent re-admission to the facility. The resident was an insulin dependent diabetic and took insulin with all meals. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure staff provided care in a manner to prevent infection or the possibility of infection when the facility staff failed to maintain sterile precautions when placing a urinary catheter (a tube placed in the bladder to drain urine) for one Residents (Residents #5) out of the 14 sampled residents, and additionally when dietary staff failed to wash hands when serving water on 300 hall without performing hand hygiene between dirty and clean tasks. The facility census was 56. Review of the facility's undated Catheter Insertion and Removal Policy showed: -After donning sterile gloves, use one hand to expose urinary meatus, with the other hand, cleanse resident using one stroke downward and discarding cleanser, repeat the same procedure with other side of meatus; [...]

Inspectors wroteBased on interview and record review, the facility failed to protect one resident's (Resident #2) right to be free from physical abuse when Resident #1 slapped Resident #2 on the cheek. The facility census was 52. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to assure staff treated residents in a manner that maintained their dignity when staff failed to respond to call lights in a timely manner which affected six of the 13 sampled residents, (Resident #15, #47, #45, #1, #27 and #53. The facility census was 52. Review of the facility's policy titled, Residents Call System, revised September 2022, showed: - Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized work station; - Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor; - Calls for assistance are answered as soon as possible, but no later than five minutes; - Urgent requests for assistance are addressed immediately. [...]

Inspectors wroteBased on interviews and record review, the facility failed to follow up with resident's grievances regarding quality of life and resident care or then they did not provide a rationale or response to resident council. This had the potential to affect all the residents at the facility. The facility census was 52. Review of the facility's Grievance Policy, dated 1/1/24 showed: -All grievances would be handled promptly and according to federal regulations; -Provide a written response to the complaint, including: a summary of findings, actions taken or planned to resolve the grievance; -Conduct follow-up with the complainant to ensure satisfaction with the resolution; -All staff will receive training on residents' grievance rights and this policy during orientation and annually thereafter. Review of resident council minutes dated 9/24/24, 10/29/24, and 12/31/24 showed: [...]

Inspectors wroteBased on interviews and record review, the facility failed to obtain a physician's order for code status for four residents (Residents #26, #22, #51, and #16) out of the 13 sampled residents. The facility census was 52. A policy and procedure regarding the provisions of basic life support was requested, but not provided. The physician services policy, date 8/2024., shows once a resident is admitted to the facility, orders for the resident's immediate care and needs can by provided by a physician, physician assistant, nurse practitioner, or clinical nurse specialist. 1. Review of Resident #26's face sheet showed: -readmission on [DATE]; -Diagnoses: Dementia, heart disease, arthritis, fracture of right leg; -Code Status -Do Not Resuscitate (No life saving measures); -Assistance with all activities of daily living. [...]

Inspectors wroteBased on interview and record review the facility failed for follow infection control guidelines when they allowed four volunteers #1, #2, #3, and #4 to be around and provide services in the facility for residents before completing any TB skin testing. This had the potential to affect all residents. The facility census was 52. Review of the facility's undated TB (Tuberculosis) skin test., showed: -The purpose of a TB skin test is to determine if a resident or employee has been exposed to tuberculosis. -TB test will be done on all new employee at the time of hire and three weeks later. -The policy does not address TB skin testing for volunteers. Record Review of Volunteer #1., showed: - Hire date 4/24/24 -Completed criminal background checks 5/1/25 -Start date 5/1/25 -No TB skin testing was completed. Record Review of Volunteer #2., showed: [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to develop and implement a comprehensive person-centered care plan for one of 13 sampled residents, when they did not care plan the dialysis needs for Resident #106. The facility census was 52. Review of the facility's Care Plan policy, date 8/2024., showed: A comprehensive, person centered care plan that includes measurable objectives and timetables to meet the resident's physical, physical, psychosocial and functional needs is developed and implemented for each resident. 1. Review of Resident #106's face sheet showed and admission date of 1/10/25. Review of the resident's baseline care plan, dated 1/10/25, showed: - The resident was slightly confused; - History of falls prior to admission; - Required assistance of one staff for bed mobility, transfers, walking, toileting, and showers; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to complete a discharge summary for one of 13 sampled residents (Resident #55) and additionally failed to follow their own discharge planning policy. The facility census was 52. Review of the facility's Discharge Planning Policy, effective 1/11/24, showed, - The facility is committed to ensuring that all residents experience a person-centered, safe, and coordinated discharge process. Discharge planning will prioritize residents' needs, preferences, and post-discharge care requirements while adhering to regulatory standards. -Administrator is to ensure the necessary resources and staff training for effective discharge planning. - The Social Service Designee will: 1) Initiate discharge planning upon admission and update the plan throughout the residents' stay. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure communication between the facility staff and dialysis (a medical procedure that removes waste products and excess fluid from the blood when the kidneys are no longer able to function properly) center followed standards of practice, when staff failed to document an assessment before and after dialysis. This affected one of the 13 sampled residents (Resident #106). The facility census was 52. Review of the facility's policy titled, Peritoneal Dialysis (a treatment for kidney failure that uses the lining of the abdomen to filter blood) (Continuous Ambulatory), revised October 2010, showed: - All dialysis procedures are administered outside of the facility under a contracted dialysis facility. 1. Review of Resident #106's face sheet showed: - admission date: 1/10/25. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain the kitchen in a sanitary manner, failed to ensure food items were properly labeled and dated, failed to enter temperatures on the temperature logs and failed to ensure the walk in freezer did not have ice buildup. These all have the potential to affect all residents residing in the facility. The facility census was 55. The facility did not provide any policies. Record review of the walk in freezer temperature log showed: - No entries in the morning on 5/1, 5/7, 5/10, 5/13, 5/14, 5/19, 5/20, 5/21, 5/24, 5/25, 5/26, 5/27, 5/28 and no entries in the evening on 5/1, 5/6, 5/21, 5/29. Review of the produce/dessert refrigerator temperature log showed: - No entries in the morning on 5/1, 5/11, 5/15, 5/20, 5/21, 5/24, 5/29 and no entries in the evening on 5/1, 5/5, 5/6, 5/18, 5/21 and 5/29. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered plan of care consistent with the resident rights that include measurable objectives and timeframe to meet the resident's needs. This affected four sampled residents (Residents#4, #23, #29 and #33) The facility census was 55. The facility did not provide a policy regarding care planning. 1. Review of Resident #29's quarterly Minimum Data Set (MDS, a federally mandated assessment completed by staff), dated 3/31/23, showed: -The resident makes self understood and understands others. -Score of 3 on the Brief Interview for Mental Status (BIMS, a structured evaluation aimed at evaluating aspects of cognition in elderly patients). The score of 3 indicates severely impaired cognition. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to assess three residents (Resident's #4, #29, and #33) for entrapment and did not complete side rail assessments at least yearly. The facility census was 55. Review of the facilty's undated Physical Restraint policy showed: -Purpose: To prevent the resident from injuring himself or others; To improve the resident's mobility and independent functions; To treat the resident's medical symptoms. -Physical restraints are defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. -Equipment includes side rails (bed rails). Procedure: 1: Assess resident's need for restraint use. 2: Obtain informed consent for restraint use. 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff administered medications with a medication error rate of less than 5%. Facility staff made three medication errors out of 26 opportunities for error, resulting in a medication error rate of 11.54%. This affected two residents sampled for medication administration (Residents #17 and #28). The facility census was 55. Review of the facility's Medications Policy, dated 5/25/22, showed: - Medications are administered in accordance with prescriber's orders; - Prior to administering the medicine the individual checks the label three times to verify: o Right resident; o Right medication; o Right dosage; o Right time o Right route; o Expiration date. 1. Review of Resident #17's physician order sheet (POS), dated June 2023, showed: - Start date: [...]

Inspectors wroteBased on record review and interview, the facility failed to maintain quarterly quality assessment committee meetings with the required members. The facility census was 55. Review of the facility's undated Quality Assurance and Performance Improvement (QAPI) policy showed: - The Governing Body and QAA Committee of the nursing center develop a culture that involves leadership-seeking input from nursing center staff, residents, their family's and other stakeholders. - The Governing Body is responsible for the development and implementation of the QAPI program. The Governing Body is responsible for: 1. Identifying and prioritizing problems based on performance indicator data. 2. Incorporating resident and staff input that reflects organizational processes, functions, and services provided to residents. 3. [...]