Morton Plant Rehabilitation Center

Inspectors wroteBased on observation interview and policy review, the facility failed to ensure federal staff posting dates were accurate for two (02/03/25 and 02/04/25) of four days of survey.

Inspectors wroteBased on record review, interview, and review of the facility's policy titled Pre-admission Screening for Mental Disorders (MD)/Intellectual Disability (ID) Patients, the facility failed to ensure Level I Preadmission Screening and Resident Review (PASARRs) were accurate upon admission for three Residents (#27, #75, and #297) of six residents sampled for PASARRs.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure posting of cautionary and safety signs indicating the use of oxygen in resident rooms for eight residents (#298, #33, #4, #56, #80, #81, #147 and #148) out of ten residents reviewed for oxygen use.

Inspectors wroteBased on observation record review and interview the facility failed to ensure the medication error rate was less than 5.00%. Thirty-seven medication administration opportunities were observed, and 15 errors were identified for three residents (#56, #43, and #45) of six residents observed. These errors constituted a 40.54% medication error rate.

Inspectors wroteBased on observation record review and interview the facility failed to assess and obtain physician orders for a skin injury for one (#7) of one resident sampled for non-pressure related skin conditions, failed to remove a topical pain patch per documentation for one (#149) of two residents observed during medication administration receiving topical patches, and failed to obtain blood pressure measurement for one (#20) of one observed resident receiving anti-hypotensive medication per physician ordered parameters.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure behavioral monitoring related to psychotropic medications was performed for three residents (#19, #26, and #183) of five residents reviewed for unnecessary medications.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to 1) Ensure one of one kitchen dish washing machine was running effectively during one of four days observed on (12/19/2022); and 2) Ensure three of three walk in/reach in freezers with food items inside, were free from heavy ice and frost build up during two of four days observed (12/19/2022, and 12/21/2022).

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure it had an effective pest control program during four of four days observed (12/19/2022, 12/20/2022, 12/21/2022, and 12/22/2022). It was observed the kitchen and first floor main hallways near resident rooms 121 - 134 had many small knat-like insects flying around.

Inspectors wroteBased on observations, interviews, and record review the facility failed to maintain confidentiality of personal health information (PHI) for two residents (#52 and #282) out of 25 residents sampled.

Inspectors wroteBased on record reviews, and interviews, the facility failed to ensure the discharge Minimum Data Set (MDS) assessment was completed within the Resident Assessment Instrument (RAI) manual within the required timeframe for one resident (#54) out of 25 residents sampled for accuracy of assessments.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure services were provided to meet professional standards related to 1) a failure to assess skin conditions for one resident (#233), and 2) a failure to obtain oxygen orders for one resident (#283) out of 25 resident sampled.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to ensure one resident (#27), who required Eating supervision, 1) was supervised timely by staff out of twenty-five sampled residents, and 2) failed to ensure the resident received eating utensils in a manner where they could be reached during three (12/19/22 and 12/20/22) of four meals observed.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure the medication error rate was less than 5.00%. Twenty-five medication administration opportunities were observed, and two errors were identified for two residents (#25, #7) of five residents observed. These errors constituted an 8.0 % medication error rate. Findings Included: On 12/21/2022 a 9:18 a.m. medication observation was conducted alongside Staff L, Registered Nurse (RN). She prepared and administered the following medications to Resident #25 Gas relief 80 mg one tablet, Miralax 17 gram, Lorazepam 0.125 mg, Aspirin enteric coated 81 mg, Docusate 100 mg, Fluoxetine 10 mg, Lasix 40 mg, Metformin 500 mg, Spironolactone 100 mg, Lovastatin 40 mg, and Flonase. [...]

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure a staff member (M) used sanitary practices to prevent cross contamination when taking food temperatures and failed to perform hand hygiene in one of one kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure prevention of further potential abuse or mistreatment while an investigation was in process for one resident (#241) out of two sampled residents. The facility failed to ensure that the alleged perpetrator, a facility employee, remained under suspension until completion of the investigation, and failed to identify that they were in fact working in the facility and providing care to other residents while the investigation was on-going.

Inspectors wroteBased on record review and interviews the facility failed to ensure that the Preadmission Screening and Resident Review (PASRR) was completed accurately related to requirement for Level II PASRR evaluation for one resident (#55) out of two sampled residents. Resident #55 was newly admitted to the facility, had a diagnosis of a serious mental disorder as defined in 42 CFR §483.102(b)(1), and was not a provisional admission.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that the necessary services required for eating to maintain good nutrition were provided in a timely manner for one resident (#230) for three of three meals observed for two of two days out of four sampled residents.

Inspectors wroteBased on record review, interviews, and policy review the facility did not ensure PRN (as needed) psychotropic medication had a stop or renewal date after fourteen days, for two residents (#1 and #5) of five residents reviewed.