Morrow Memorial Home

Inspectors wroteBased on observation, interview and record review, the facility did not prepare, distribute, and serve food in a manner that prevents foodborne illness. This has the potential to affect all to 65 residents. The dry storage area and kitchen cooler contained multiple open food items not labeled with open or use-by dates. Personal beverage stored in kitchen cooler. Culinary Aide (CA) C was not wearing hair restraint on facial hair while assisting with meal service in kitchen.

Inspectors wroteBased on observations, interview and record review, the facility did not treat each resident with respect and dignity and care for each resident in a manner that promotes their quality of life. Resident (R) R44 was not provided privacy of the window shade being closed during cares when lying in bed not fully clothed. This occurred for 1 of 17 sampled residents (R44). This is evidenced by: R44 was admitted to the facility on [DATE]. R44's current diagnoses include chronic obstructive pulmonary disease, chronic kidney disease, Parkinsonism, reduced mobility, major depressive disorder, and anxiety. Minimum data set (MDS) assessment dated [DATE] documents R44 has a Brief Interview for Mental Status (BIMS) score of 2/15, meaning R44 has severe cognitive impairment. [...]

Inspectors wroteThe facility did not establish and 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 of 2 residents (R) R41, observed during personal cares. CNA did not perform hand hygiene before resident contact.

Inspectors wroteBased on interview and record review, the facility did not promptly notify and consult with a resident's physician when there was deterioration in a resident's clinical condition. This occurred for 1 of 2 residents (R39) reviewed for physician notification and consultation. R39 presented with new symptoms of cardio-respiratory complications in addition to a significant weight gain. Staff did not immediately notify R39's provider of this occurrence resulting in R39 being admitted to the hospital 4/30 - 5/4/23, one week after the start of these symptoms, with a diagnosis of heart failure and atrial fibrillation with RVR (rapid ventricular rate).

Inspectors wroteBased on observation and interviews, the facility did not ensure residents (R) were treated with dignity and respect and cared for in a manner to enhance their quality of life during dining. This occurred for 4 (R4, R1, R6 and R40) out of 60 residents.

Inspectors wroteBased on observation, interview and record review, the facility did not provide care consistent with professional standards to prevent development of a pressure injury and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable for one of one resident reviewed for pressure injuries (R40). R40 developed an unavoidable stage 3 pressure injury while at the facility. Observations of poor infection control occurred during wound care.

Inspectors wroteBased on observation, interview and record reviews, the facility failed to adequately assess and treat pain and provide necessary care and services to attain or maintain the highest practicable physical wellbeing for 1 (R40) of 1 resident reviewed for pain. R40 had verbal (moaning, crying out) and non-verbal expressions of pain during wound care. Staff continued to perform the wound care treatment without doing an adequate pain assessment and waiting for the pain medication to be effective.

Inspectors wroteBased on interview and record review, the facility did not ensure 1 of 3 residents (R) R5's drug regime was free from unnecessary medication use without adequate indications for use for an antibiotic.

Inspectors wroteBased on random observation, interview and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and help to prevent the development and transmission of communicable diseases and infections for 2 residents (R) (R60 and R21) Example 1 Facility policy titled, Hand Hygiene, reviewed 07/2023, The following is a list of some situations that require hand hygiene: .Before and after wearing gloves . On 03/26/24 at 6:49 AM, Surveyor observed Certified Nursing Assistant (CNA) C, provide incontinence care for R60. CNA C conducted hand hygiene and donned a pair of clean gloves, removed incontinent product, provided incontinence care and proceeded to do the following: [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure foods were stored at safe ranges to prevent spoilage by not consistently checking refrigerator and freezer temperatures in accordance with professional standards for food service safety. This has the potential to affect all 60 residents in the facility.

Inspectors wroteBased on observation, interview and record review, the facility did not maintain an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections. The facility did not ensure all staff sanitized mechanical lifts between use with multiple residents. This had the potential to effect 12 residents, who require transfers with a mechanical lift, out of 19 residents residing on the north wing of the second floor. The facility did not ensure all staff handled soiled linens properly. Four staff were observed holding soiled linens against uniforms when carrying to dirty linen bins in hallway. This has the potential to affect all 19 residents on the north wing of the second floor

Inspectors wroteBased on record review and interview, the facility did not submit Minimum Data Set (MDS) data to Centers for Medicare and Medicaid Services (CMS) within the required timeframe for 1 Resident (R) of 18 Residents reviewed. (R7) R7 was discharged from the facility on 10/06/22. As of 02/14/23 the discharge MDS was not completed or submitted to CMS.

Inspectors wroteBased on interview and record review, the facility did not ensure Minimum Data Set (MDS) assessments accurately reflected resident's current status for 3 residents (R) of 17 reviewed. (R42, R21, R39) *R42 was listed as a female on the admission and quarterly MDS assessments. R42 was listed as a male on the most recent MDS assessment. This created two residents in the CMS system. *R21's most recent MDS assessment listed a fall with major injury. R21 did not have a fall with major injury since previous MDS assessment. *R39's MDS assessments documented R39 had a Urinary Tract Infection (UTI) in the past 30 days prior to the assessment. R39 did not have a UTI in the past 30 days prior to the assessment.