Morningside Health Services

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a safe and sanitary manner. This practice had the potential to affect more than 4 of the 30 residents residing in the facility. Staff did not complete proper hand hygiene prior to donning/doffing gloves, while preparing and serving food, and during dish washing.

Inspectors wroteBased on staff and resident representative interview and record review, the facility did not maintain privacy of medication and healthcare information for 1 resident (R) (R41) of 15 sampled residents. R39 was discharged home with a blister pack of R41's medication.

Inspectors wroteBased on staff and resident representative interview and record review, the facility did not ensure a bed-hold and transfer/discharge notice and/or a discharge summary was provided for 3 residents (R) (R24, R1, and R39) of 4 sampled residents. R24 was transferred to the Emergency Department (ED) on 1/18/26 and 2/6/26. Neither R24 or 24's representative were provided with a bed-hold or transfer/discharge notice. R1 was transferred to the hospital on [DATE]. Neither R1 or R1's representative were provided with a bed-hold or transfer/discharge notice. R39 was not provided with an accurate discharge summary. R39 discharged home on [DATE] with a blister pack of R41's medication which was accidentally administered to R39.

Inspectors wroteBased on staff interview and record review, the facility did not ensure Minimum Data Set (MDS) assessments were accurate for 2 residents (R) (R8 and R6) of 15 sampled residents. R8 had diagnoses including anxiety disorder and delusional disorder. R8's MDS assessment, dated 1/21/26, indicated R8 did not have a mental illness. R6 had diagnoses including post-traumatic stress disorder (PTSD), bipolar disorder, major depressive disorder, and schizoaffective disorder. R6's MDS assessment, dated 11/20/25, indicated R6 did not have a mental illness.

Inspectors wroteBased on staff interview and record review, the facility did not ensure Pre-admission Screening and Resident Review (PASRR) requirements were met for 1 resident (R) (R24) of 5 sampled residents. R24 had diagnoses including anxiety disorder and major depressive disorder. The facility did not ensure R24's PASRR Level I Screen was completed timely or accurately.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure nail care was provided for 1 resident (R) (R23) of 15 sampled residents. R23 was not provided nail care on a regular basis.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure the accurate and safe administration of medication for 1 resident (R) (R13) of 15 sampled residents. Containers of Mentholatum Original Ointment (decongestant, analgesic ointment), Biofreeze (pain relieving gel), and Equate Vaporizing Rub (cough suppressant, topical analgesic) were observed on R13's bedside table. The medications did not contain pharmacy labels and only one of the medications had a physician's order. In addition, R13 did not have a self-administration of medication assessment that indicated R13 could safely and accurately self-administer medication and/or store medication at the bedside.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a Power of Attorney for Healthcare (POAHC) was notified regarding an allegation of abuse for 1 resident (R) (R2) of 3 sampled residents. On 11/23/24, Certified Nursing Assistant (CNA)-D reported that CNA-D witnessed CNA-C be aggressive and use vulgar language during cares for R2 on 11/19/24. The facility did not notify R2's POAHC of the alleged abuse.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure all drugs and biological were stored and disposed of in accordance with the facility's policy. This had the potential to affect more than 4 of the 26 residents residing in the facility. On [DATE], a medication cart was left unlocked and unattended. On [DATE], an expired bottle of ProSource (a protein supplement) was observed in the medication cart.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure nutritional needs were met for 5 residents (R) (R5, R12, R15, R14 and R6) of 5 residents who had orders for carbohydrate-controlled diets. Staff did not follow physician-ordered carbohydrate-controlled diets for R5, R12, R15, R14, and R6 when they served full servings of dessert during the 10/7/24 lunch meal and did not offer diet desserts or half-servings as indicated.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for 6 residents (R) (R5, R1, R22, R18, R20, and R24) of 6 sampled residents. R5 was on enhanced barrier precautions (EBP). On 10/7/24, Certified Nursing Assistant (CNA)-C and CNA-D did not wear gowns during high-contact care for R5. In addition, RN-E did not cleanse hands between glove changes or wear a gown during wound care for R5. R1 was on EBP. On 10/7/24, Registered Nurse (RN)-E exited R1's room before removing personal protective equipment (PPE). RN-E removed RN-E's gown and gloves in the hallway, disposed of the PPE in the medication cart garbage, and performed hand hygiene at the medication cart. [...]

Inspectors wroteBased on staff interview and record review, the facility did not ensure 2 Certified Nursing Assistants (CNAs) (CNA-G, and CNA-H) of 18 CNAs reviewed had a valid Certified Nursing Assistant certification. This practice had the potential to affect multiple residents in the facility. CNA-G and CNA-H did not have active nurse aide certification and were not on the Wisconsin Nurse Aide Registry.

Inspectors wroteBased on staff and resident interview, and record review, the facility did not investigate, resolve, and record resolution of a grievance for 1 Resident (R) (R17) of 2 residents reviewed for grievances. The facility did not thoroughly document and investigate a grievance expressed by R17.

Inspectors wroteBased on staff interview and record review, the facility did not implement its policy and procedure to prohibit abuse, neglect and mistreatment of residents for 1 staff (Registered Nurse (RN)-E) of 8 staff reviewed during the caregiver program compliance check. The facility did not ensure an out-of-state background check was completed for RN-E.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a written notification of transfer, including the reason for the transfer, location of the transfer, appeal rights, and contact information for the State Long-Term Care Ombudsman was provided for 3 Residents (R) (R14, R7, and R20) of 3 residents reviewed for hospitalization. R14 was transferred to the hospital on 4/21/23 and was not provided a written transfer notice. R7 was transferred to the hospital on 6/26/23 and was not provided a written transfer notice. R20 was transferred to the hospital on 7/10/23 and 7/14/23. R20 was not provided a written transfer notice for either transfer.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 3 Residents (R) (R14, R7, and R20) of 3 sampled residents reviewed for hospitalization received written information of the duration of the bed hold policy, the reserve bed payment and the right to return to the facility. R14 was transferred to the hospital on 4/21/23 and did not receive a written bed hold notice. R7 was transferred to the hospital on 6/26/23 and did not receive a written bed hold notice. R20 was transferred to the hospital on 7/10/23 and 7/14/23. R20 did not receive a written bed hold notice for either transfer.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure 1 Resident (R) (R11) of 4 residents observed during medication administration was free of a medication error. Licensed Practical Nurse (LPN)-C administered 50 milligrams (mg) of Metoprolol Succinate Extended Release (ER) (blood pressure reducing medication) to R11 prior to obtaining R11's pulse.