Morningside Manor

Inspectors wroteBased on interviews and record reviews, the facility failed to have evidence that all alleged violations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated to prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation was in progress for 1 of 2 residents (Resident #1) reviewed for neglect. The facility failed to ensure the previous Executive Director A followed the facility's Abuse Prevention Program policy, when she did not complete an investigation of neglect that involved Resident #1 and did not submit a 3613A Provider Investigation Report to HHSC. This failure could place residents at risk of not being provided with services to meet their needs or prevent them from being neglected.

Inspectors wroteBased on interview and record review, the facility failed to assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every three months for 1 of 4 (Resident #4) residents reviewed for MDS assessments. The facility failed to complete Resident #4's Quarterly MDS Assessment within three months of their most recent comprehensive assessment. This failure could lead to residents not receiving necessary, complete, or correct care due to lack of current information for their care plans.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's right to participate in the development and implementation of his or her person-centered plan of care, including but not limited to: The right to participate in the planning process, including the right to identify individuals or roles to be included in the planning process, the right to request meetings and the right to request revisions to the person-centered plan of care. The right to participate in establishing the with the resident and the resident's representative for 3 of 5 residents (Resident #8, Resident #48, and Resident #69) reviewed for Comprehensive Care Plans in that: The facility failed to ensure Resident #8, Resident#48, and Resident #69 or the resident's representative were invited to participate in the residents' care plan meeting. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident had a right to secure and confidential personal and medical records for 6 (Residents #7, #9, #45, #61, #69, & #74) of 7 residents reviewed for privacy and confidentiality The facility failed to ensure the privacy and confidentiality of resident's clinical records that were not left on top of a treatment cart face up in the hallway unattended from 11:30 AM to 11:57 AM, for Resident #7, #9, #45, #61, #69, & #74 on 08/7/25. This deficient practice could place residents at-risk of loss of dignity due to lack of privacy and confidentiality.

Inspectors wroteBased on interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 1 (Resident #8) of 5 residents reviewed for quality of care. 1. The facility failed to accurately assess Resident #8's bowel and bladder status. 2. The facility failed to accurately access Resident #8's ability to voice her bowel and bladder needs. These failures could place resident with having inaccurate care plans and inappropriate identification of care needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure enteral feeding physician orders were followed for 1 (Resident #12) of 7 resident reviewed for enteral tube feeding, in that: The facility failed to assess, obtain physician order, care plan, and obtain consent for Resident #12 to self-administer her bolus feedings via the g-tube two times a day. This failure could place residents with G-tubes at risk of needs not met and a decline in resident's health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 3 of 9 reviewed for pharmaceutical services, in that: LVN A administered the expired insulin to Resident #4, Resident #22, and Resident #74. This failure could result in residents not receiving an accurate dose of medication as well as not being maintained at their best therapeutic level.

Inspectors wroteBased on observation, interview, and record review, the facility failed to label drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 5 medication carts in that: Two insulin pens were not labeled with an open date in Unit 5 nurse med cart. Two insulin pens were expired in Unit 5 nurse med cart. These failures could result in residents not receiving an accurate dose of medication as well as not being maintained at their best therapeutic level.

Inspectors wroteBased on observation, interview and record review, the facility must properly dispose of garbage and rubbish in accordance with current state laws for dumpster 1 of 2 reviewed for garbage disposal. The facility failed to ensure the doors on dumpster 1 were secured. This failure could place residents at risk of contracting disease by attracting pest and disease carrying rodents.

Inspectors wroteBased on interviews and record reviews the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 16 residents (Resident #1) reviewed for care plans. The facility failed to develop a person-centered care plan with interventions to address Resident #1's use of anti-coagulant medication, bed rails, and walker. This failure could have placed residents at risk of not having their needs identified and met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #45) of 7 residents reviewed for infection control. The facility failed to follow EBP (Enhanced Barrier Precautions) procedures for Resident #45 when the wound treatment team failed to wear PPE while providing wound care to Resident #45 on 08/07/25. This failure affected residents by placing them at an increased and unnecessary risk of exposure to communicable diseases and infections.

Inspectors wroteBased on observations, interviews and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights and 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. The comprehensive care plan must describe the following -The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 6 of 16 (#6 , #3, #38, #56, #57, #120) in that: 1. Resident #6 received honey consistency liquids instead of nectar thick liquids. 2. Resident #3 did not have her 1/4 bed [NAME] in her care plan. 2. Resident #38 did not have her indwelling catheter in her care plan. 3. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure there were no more than 14 hours between a substantial evening meal and breakfast the following day, except when a nourishing snack was served at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal span for 3 of 9 residents (confidential residents in group) reviewed for frequency of meals. The facility failed to ensure residents were offered snacks at bedtimes as required due to mealtimes being more than 14 hours apart. This failure could affect all residents who received meals served from the facility's only kitchen by placing residents at risk for, unplanned weight loss, and side effects from medication given without food, and diminished quality of life.

Inspectors wroteBased on observations, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. 1. There were approximately 5 boxes that appeared to be less than 18 inches from the ceiling, in the walk-in fridge. 2. There was a chocolate pie that was not fully covered in the walk-in fridge. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure residents received services in the facility with reasonable accommodation of resident needs and preferences for 1 of 8 residents (Resident #54) reviewed for call lights. Resident #54 was placed in her room without access to her call light. On 06/05/2024 CNA P assisted Resident #54 in her wheelchair to her room and placed her out of reach of her call light. This failure could place residents at risk for harm by not having the ability to call for assistance.

Inspectors wroteBased on interviews and record reviews the facility failed to immediately consult with the resident's physician when there was a need to alter treatment significantly for 1 of 8 residents (Resident #6) reviewed for notification. On 03/23/24, LVN A and LVN C failed to notify the Medical Doctor 3 out of 7 neuro checks were not being done for 12 hours. Resident #6 was hospitalized on [DATE] and returned 03/27/24 with new diagnoses to include: cerebral infarction (a type of stroke caused by impaired blood flow to the brain), hemiplegia (weakness of one entire side of the body) and hemiparesis (complete paralysis of one side of the body) following cerebral infarction affecting right dominant side , ataxia (a loss of muscle coordination), and slurred speech . An IJ was identified on 06/07/2024. The IJ template was provided to the facility on [DATE] at 09:00 PM. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure residents had the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay, for 1 of 8 residents (Resident #54) reviewed for their right to voice grievances to the facility. CNA P failed to report and document Resident #54's complaint she was left without a call light, left unattended, and received rushed care. This failure could place residents at risk for harm by not having their grievances addressed.

Inspectors wroteBased on interviews and record reviews the facility failed to immediately consult with the resident's physician when there was a need to alter treatment significantly for 1 of 8 residents (Resident #6) reviewed for notification. The facility failed to ensure Resident # 6 was assessed as ordered for neuro-checks every 4 hours x 3 days. Resident # 6 was sent to hospital and returned to the facility on [DATE] with new diagnoses to include: cerebral infarction and hemiparesis following cerebral infarction affecting right dominant side, and slurred speech. An Immediate Jeopardy was identified on 6/29/2024 . The IJ template was provided to the facility on 6/29/2024 . [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each Resident, for 1 of 7 residents (Resident #170) reviewed for pharmacy services. LVN U dispensed Resident #170's medications (11 pills) and stored them in a small pill cup in the medication cart with the intention of administering the medications at a later time and continued to dispense and administer medications for other residents. This failure could place residents at risk for harm by medication administration errors.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure a therapeutic diet was prescribed by the attending physician for 1 of 8 residents (Resident #6) reviewed for food and nutrition services. The facility failed to ensure Resident #6 had a physician's order for a pureed diet with nectar thickened liquids. The resident was prescribed a pureed diet with thin liquids and was provided a pureed diet with nectar thickened liquids. This deficient practice could place residents who are provided a modified texture diet at risk poor intake, and weight loss and diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 2 of 17 (Residents #25 and #57) residents in that: 1. Resident #25 did not have an order or care plan for diabetic shoes in her record. 2. Resident #57 did not have an order or care plan for diabetic shoes in her record. This failure could result in assessments not being completed as ordered could result in residents' not receiving the necessary care resulting in a decline in health and or death. This could affect all resident with assistive devices and could result in no orders for resident care.

Inspectors wroteBased on observations, interviews and record review the facility faield to ensure resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely for for 3 of 21 (Room#243, Room#237 and room [ROOM NUMBER]) resident rooms during initial rounds in that: 1. room [ROOM NUMBER]'s bathroom, the shower chair had black substance on the back side of the nylon mesh used to hold up body in place and at the bottom side of shower chair. 2. room [ROOM NUMBER]'s bathroom shower curtain had black substance on it. 3. room [ROOM NUMBER]'s bathroom shower curtain had brown substance on it. This could affect residents and place residents at risk for infections.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure a medication error rate below 5% for 2 of 8 Residents (Residents #25 and #36) reviewed for medication administration errors, in that: The Facility staff administered 28 medications of which 7 were administered to Residents #25 and # 36, 1 to 1.5 hours after they were scheduled, which resulted in a 27% medication error rate. This failure could place residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions.

Inspectors wroteBased on observations, interview and record review revealed the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchens in that: 1. Ice machine had a pink film across the lip of the ice shoot. 2. Low temperature dishwasher temperature for wash cycle was 114 degrees Fahrenheit and 115 degrees Fahrenheit. should have been 120 degrees Fahrenheit. 3. The Dish machine log was not completed. 4. Dietary aid _G_ was at dish machine and had several jewelry on, such as rings and bracelets. This failure could place residents at risk of cross contamination Ns food borne illness.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Minimum Data Set (MDS) was electronically completed and transmitted to the CMS System within 14 days after completion for 1 of 70 (Resident #53) residents reviewed for MDS transmittal in that: Resident #53's 5-day MDS assessment dated [DATE] and discharge MDS assessment dated [DATE] was not submitted as of 4/21/2023. This deficient practice could place residents at risk of not having their assessments transmitted timely.

Inspectors wroteBased on interviews and record reviews the facility failed to maintain medical records on each resident that are complete, accurately documented, readily accessible, and systematically organized, for 1 of 8 Residents (Resident #19) reviewed for complete and accurate medical records, in that: Resident #19 medical record was missing 7 of 16 weekly Skin Assessments since 1/01/2023. This deficient practice could affect residents whose records were maintained by the facility and place them at risk for errors or delays in care and treatment.