Morningside Nursing and Rehabilitation Center

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. This was identified for one (1) resident (Resident #157) during Resident Council Meeting. Specifically, Resident #157's meal-time insulin order did not include specific hypoglycemia parameters; however, licensed nursing staff withheld scheduled meal-time insulin doses as ordered on multiple occasions despite parameters outlined by facility policy, without notifying or consulting the physician, and without documenting a clinical rationale.

Inspectors wroteBased on record review and interviews, the facility did not ensure that residents are free of significant medication errors. This was identified for one (1) resident (Resident #157) during Resident Council Meeting. Specifically, Resident #157 did not receive Insulin Lispro (a fast-acting meal-time insulin) prior to meals in accordance with the physician's order. Furthermore, the omission of several doses and the failure to notify the medical doctor potentiated increased risk of hypoglycemic episodes.

Inspectors wroteBased on observation, record review, and interviews, the facility did not ensure that it promoted and facilitated resident self-determination by supporting resident choice. Specifically, residents were not provided with showers twice a week per their bathing preference. This was evident for two (2) of three (3) residents (Resident #10 and Resident #108) reviewed for Choices out of a total of 38 sampled residents.

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to ensure that a person-centered comprehensive care plan was developed and implemented to address the residents' medical, physical, mental, and psychosocial needs. Specifically, a comprehensive care plan for a resident's hearing impairments was not developed and implemented. This was evident for one (1) resident (Resident #170) reviewed for Vision/Hearing out of a total of 38 sampled residents.

Inspectors wroteBased on observation, record review, and interviews during an abbreviated survey (2704295), the facility did not ensure that each resident received adequate supervision to prevent accidents. This was evident for one (1) out of three (3) residents (Resident #1) sampled for accidents. Resident #1 had severely impaired cognition, was assessed as high risk for falls, and had history of multiple falls. Specifically, Resident #1 experienced recurring falls on five occasions between 11/21/2025 and 01/05/2026. Despite these incidents, preventative supervision of Resident #1 was not documented in the care plan until after the fall on 01/05/2026 at 1:50 AM. There were no injuries noted in Resident #1's medical record because of the falls.

Inspectors wroteBased on observation, interview, and record review conducted during the Abbreviated Survey (NY00337289), the facility failed to ensure residents had the right to obtain a written decision regarding their grievance. This was evident for one (1) of three (3) residents sampled (Resident #1). Specifically, on 11/24/2024, 01/24/2025, 01/28/2025, and 02/27/2025, Resident #1's Health Care Proxy requested written results for the filed grievances. The request was sent on an e-mail to the Administrator. The written results were not provided to Resident #1's Health Care Proxy.

Inspectors wroteBased on observation, record review, and interviews conducted during an Abbreviated Survey (NY00358641), the facility did not ensure the residents' right to be free from physical abuse by nursing home staff. This was evidence for 1 out of 10 residents reviewed (Resident #1). Specifically, on 10/25/2024 at 2:52 PM, in the nursing station as Resident #1 approached admission Clerk #1 with the arms raised to admission Clerk #1's neck area. admission Clerk #1 pushed Resident #1 with both hands and Resident #1 fell backward on the floor and hit their head on the desk behind them. Resident #1 was transferred to the hospital for evaluation and returned to the facility with no new orders.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification survey from 4/7/24 to 4/12/24, the facility did not ensure that food was prepared, distributed, and served food in accordance with professional standards for food service safety. This was evident during observations during the Kitchen facility task. Specifically, 1) the dish washing machine did not maintain appropriate temperatures for washing and rinsing dishes, 2) hair was not covering appropriately by dietary staff preparing and serving meals, 3) the temperatures of food on the steam table was not checked or recorded prior to meals being served and, 4) food in unit pantry was not labeled and dated appropriately.

Inspectors wroteBased on observations and interviews conducted during the Recertification survey from 4/7/24 to 4/12/24, the facility did not ensure that garbage and refuse were disposed of properly. Specifically, the garbage was not properly contained outside of the facility and various types of garbage were observed overflowing from the top of the dumpster. The finding is: The facility policy and procedure titled Proper Disposal of Garbage and Refuse effective date 11/2016 documented that the Food Service Director/Manager will monitor the garbage containers to ensure they are in good condition (no leaks) and with lids and evaluate loading docks, hallways, elevators that are used for both garbage and food transport are kept clean and free of foul odors. On 4/9/24 at 10:37 AM, an observation was made of the garbage disposal area. [...]

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification survey from 04/07/2024 to 04/12/2024, the facility did not ensure that infection control prevention practices and procedures were maintained to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. Specifically. 1) Enhanced Barrier Precautions were not maintained during wound care, and 2) the Registered Nurse failed to sanitize the blood pressure cuff between Resident #27 and #163 during Medication Administration.

Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification Survey from 04/07/2024 to 04/12/2024, the facility did not ensure that the residents were treated with respect and dignity and cared for in a manner and environment that promotes enhancement of their quality of life. This was evident for one (Resident #158) of five residents reviewed for Dignity out of a sample of 38 residents. Specifically, Resident #158 was observed multiple times in their room with a strong urine odor.

Inspectors wroteBased on interviews, observations and record reviews conducted during a recertification review (TD8B11), the facility did not ensure that a resident who is unable to carry out activities of daily living received appropriate services to maintain good grooming. This was evident for 1 (Resident #89) of 10 residents reviewed for Activities of Daily Living out of 38 sampled residents. Specifically, Resident #89 was observed with long, untrimmed fingernails that were imbedded with black matter.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification survey, the facility did not ensure a resident's right to privacy and confidentiality was maintained for 2 (Resident # 48 and Resident # 598) of 39 sampled residents. Specifically, medication blister packs for Resident #48 and Resident #598 were observed on top of a desk in an unlocked room, exposing personal health information.

Inspectors wroteBased on staff interviews and record reviews conducted during the recertification survey, the facility did not ensure that all alleged violations involving abuse were reported within a timely manner to the State Survey Agency. This was evident in 1 (Resident #219) out of 7 residents reviewed. Specifically, the facility did not report an allegation of staff-to-resident physical abuse involving Resident #219 to the New York State Department of Health (NYSDOH) immediately but not later than 2 hours of the alleged violation.

Inspectors wroteBased on record review and interviews conducted during the Recertification survey, the facility did not ensure a resident's Minimum Data Set 3.0 (MDS) assessment was transmitted to the Center for Medicare and Medicaid Services (CMS) within 14 days of completion. This was evident for 1 (Resident #2) of 39 residents reviewed. Specifically, the facility did not transmit a quarterly MDS for Resident #2 within 14 days of completion.

Inspectors wroteBased on record review and interviews conducted during the Recertification and Abbreviated Complaint survey (NY00278436), the facility did not ensure that a resident and/or resident representative (RR) was invited to review the resident's plan of care with the Interdisciplinary Team (IDT). This was evident for 1 (Resident #103) of 39 residents reviewed. Specifically, Resident #103 and their RR were not invited to scheduled quarterly Care Plan Meetings (CPM).

Inspectors wroteBased on observations, record review, and interviews conducted during a Recertification survey, the facility did not ensure that drugs and biologicals were stored in locked compartments. This was evident for for 2 of 39 sampled residents (Resident 348 and #598). Specifically, blister packs of medication for Resident #48 and Resident #598 were observed in an unlocked office two blister packets containing medications were observed on a desk in an unlocked room on the 1st floor in building B.

Inspectors wroteBased on observation, record review, and interview conducted during the Recertification survey, the facility did not ensure that a resident with missing dentures was promptly referred for dental evaluation. This was evident for 1 (Resident #189) of 1 residents reviewed out of a sample of 39 residents. Specifically, Resident #189 reported their dentures were missing for 2 months and they were not evaluated by the dentist.