Ms Care Center of Morton

Inspectors wroteBased on interviews, observations, record review, review of the facility's investigation, and facility policies review, the facility failed to develop and implement adequate supervision and individualized interventions to prevent an avoidable accident after identifying Resident #1's pattern of sitting at the facility's exit door with his hand on the door handle and documenting that he should not go outside unassisted. As a result, Resident #1 exited the facility without staff knowledge or supervision for approximately three (3) minutes on July 11, 2026. This deficient practice affected one (1) of three (3) residents reviewed for elopement risk. Resident #1.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to honor a resident's right to refuse fingerstick blood glucose checks and use a Continuous Glucose Monitor (CGM) device for blood glucose monitoring for one (1) of (19) sampled residents (Resident #16).

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure a resident's right to a safe, clean, comfortable, and homelike environment for one (1) of (19) sampled residents (Resident #70) when the facility failed to repair a leaky faucet in the resident's room.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure a resident was free from unnecessary chemical restraints related to psychotropic medications when the facility failed to attempt or document a Gradual Dose Reduction (GDR) for a resident receiving antipsychotic and antidepressant medications initiated on 5/20/25 for one (1) of five (5) residents reviewed for unnecessary medications. (Resident #79).

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure the comprehensive care plan was revised when residents experienced multiple falls and failed to ensure care plan interventions were dated to reflect new or revised individualized interventions for two (2) of (19) residents reviewed for care plans. (Resident #1 and Resident #3).

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure services were provided in accordance with professional standards of practice when the facility failed to obtain a physician order for the use of a Continuous Glucose Monitor (CGM), failed to ensure a consistent and clinically directed method was used to obtain blood glucose readings, and failed to ensure accurate and complete documentation of blood glucose results for one (1) of (19) sampled residents. (Resident #16)

Inspectors wroteBased on interview, record review, and facility policy review, the facility's consultant pharmacist failed to ensure monthly medication regimen reviews (MMRs) identified and reported medication-related irregularities regarding insulin administration and documentation (Resident #16), failed to identify and report the absence of a Gradual Dose Reduction (GDR) for a resident receiving psychotropic medications (Resident #79), and failed to provide resident-specific documentation of MMRs to demonstrate which residents were reviewed for two (2) of (19) sampled residents.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to prevent significant medication errors when nursing staff administered insulin outside of physician-ordered parameters for one (1) of (19) sampled residents (Resident #16).

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to store, prepare, and serve food in accordance with professional standards for food safety, when the facility failed to repackage, label, and date opened food items, failed to discard expired and deteriorated food items, and failed to store food according to manufacturer's instructions for one (1) of two (2) kitchen observationsFindings include:A review of the facility's policy, Food Procurement, Store/Prepare/Serve - Sanitary (revised 9/2022), revealed, .The facility will.d. Store, prepare, distribute and serve food in accordance with professional standards for food service safety. A record review of the facility's Inservice Report, dated 8/5/25, revealed dietary staff received training regarding food preparation practices for food safety. [...]

Inspectors wroteBased on interviews, record review, facility policy review, and facility investigation review, the facility failed to protect the residents' right to be free from sexual abuse by another resident for two (2) of four (4) sampled residents. Resident #2 and Resident #3On 12/17/25 at 11:26 AM, Resident #1 (male) inappropriately touched the breast of Resident #2 (female) in the day room. After staff were notified, Resident #1 was taken to his room and left unsupervised. At approximately 11:32 AM, Resident #1 was assisted back to the day room by a staff member who was unaware of the incident. On 12/17/25 at 11:49 AM, Resident #1 inappropriately touched the breast of Resident #3 (female). [...]

Inspectors wroteBased on interviews, record review, facility policy review, and facility investigation review, the facility failed to develop and implement a comprehensive care plan related to sexually inappropriate behaviors for one (1) of four (4) sampled residents. Resident #1On 12/17/25 at 11:26 AM, Resident #1 (male) inappropriately touched the breast of Resident #2 (female) in the day room. After staff were notified, Resident #1 was taken to his room and left unsupervised. At approximately 11:32 AM, Resident #1 was assisted back to the day room by a staff member who was unaware of the incident. On 12/17/25 at 11:49 AM, Resident #1 inappropriately touched the breast of Resident #3 (female). [...]

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to ensure a medication was secured in a locked storage area and available to only authorized personnel when a medication was left at a resident's bedside for one (1) of three (3) sampled residents.

Inspectors wroteBased on observation, interviews, record review and facility policy review, the facility failed to honor residents' rights for self-determination by not allowing residents to go outside together for two (2) of 22 sampled residents. Residents #13 and #14. Findings Include: A review of the facility's policy titled Resident Rights Policy, revised 09/2022, revealed: .Facility will ensure that the resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. The facility will treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of their quality of life, recognizing each resident's individuality . Resident #13: [...]

Inspectors wroteBased on interviews, record reviews, and facility policy review, the facility failed to ensure that a resident who did not have an advance directive received information or assistance in formulating an advance directive for one (1) of twenty-two (22) residents reviewed for advance directives. Resident #7. Findings Include: A record review of the admission Record for Resident #7, revealed an admission date of 10/09/21 with diagnoses including Dysphagia, Dementia, and Alzheimer's Disease. A record review of Resident #7's admission Agreement Checklist dated 10/9/21, revealed that the resident does not have a Power of Attorney (POA) and that the checklist does not indicate acknowledgment of an Advance Directive. During an interview on 10/15/24 at 11:54 AM, Resident #7's Resident Representative (RR) stated that he has not established a Power of Attorney. [...]

Inspectors wroteBased on record reviews, interviews, and facility policy review, the facility failed to complete a Minimum Data Set (MDS) discharge assessments accurately for one (1) of twenty-two (22) residents reviewed for assessments. Resident #109. Findings Include: A review of the facility's policy titled Resident Assessment Instrument (RAI) Policy (undated) revealed, It is the policy of the facility that the RAI will be done as follows: According to the guideline specified by: .Division of Medicaid . A record review of Resident #109's Face Sheet revealed an admission date of 07/01/24 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Hypertensive Chronic Kidney Disease, and Hypertensive Heart Disease with Heart Failure. [...]

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to implement a care plan intervention regarding changing oxygen (O2) tubing for one (1) of twenty-two (22) sampled residents. Resident #76. Findings Include: A review of the facility's policy titled Comprehensive Resident-Centered Care Plans (undated) revealed, . It is the policy of this facility to provide services based on the following requirements .Development/Implement Comprehensive Care Plan. The facility will develop and implement a comprehensive person-centered care plan for each resident consistent with the resident's rights and that includes measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs identified in the comprehensive assessment. A review of the facility ' s policy titled Oxygen Policy (undated) revealed, . [...]

Inspectors wroteBased on observations, interviews, record reviews, and facility policy review, the facility failed to follow standards of practice for respiratory care regarding dating and changing oxygen tubing weekly and storing it in a plastic bag when not in use for one (1) of two (2) residents observed for respiratory care. Resident #76. Findings Include: A review of the facility's policy titled Oxygen Policy, (undated) revealed, . It is the policy of this facility that oxygen will be utilized as follows: . With the specific physician orders . Date the tubing . A record review of Resident #76's admission Record revealed that the facility admitted the resident on 01/18/23. The resident had diagnoses that included Chronic Diastolic (Congestive) Heart Failure and Chronic Obstructive Pulmonary Disease (COPD) with (Acute) Exacerbation. [...]

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to ensure residents received meals that were palatable and served at an appetizing temperature for three (3) of ten (10) residents observed for dining. Resident #63, Resident #85, and Resident #90. Findings Include: A review of the facility's policy titled Meal Service, dated 12/23, revealed: .Food will be delivered promptly to ensure safe, palatable, and high-quality food served at the appropriate temperature .Procedure .6. Food will be served at palatable temperatures (hot food hot and cold food cold) as discerned by the patients/residents and customary practice . Resident #63: During an interview on 10/15/24 at 11:42 AM, Resident #63 stated that he was not pleased with the meals, describing them as hit or miss and noting that only one (1) out of (10) meals were good. [...]

Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility failed to handle linens in a manner to prevent the possible spread of infection (Resident #12) and failed to wear appropriate Personal Protective Equipment (PPE) during administration of a bolus feeding for a resident that required Enhanced Barrier Precautions (EBP) (Resident #56) for two (2) of 22 sampled residents.

Inspectors wroteBased on record review, staff interview, and policy review the facility failed to implement care plan interventions related to Activities of Daily Living (ADL) care for one (1) of three (3) residents reviewed for care plans. Resident #1. Based on the facility's implementation of corrective actions completed by 2/8/24, the SA determined this to be Past non-compliance (PNC) as of 2/8/24, prior to the SA's entrance into the facility on 3/19/24. Findings Include: Record review of the facility's policy, Develop/Implement Comprehensive Care Plan, revised September 2022, revealed, The facility will 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 the resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment . [...]

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to prevent a fall during Activities of Daily Living (ADL) care for one (1) of three (3) sampled residents. Resident #1. Based on the facility's implementation of corrective actions completed by 2/8/24, the SA determined this to be Past non-compliance (PNC) as of 2/8/24, prior to the SA's entrance into the facility on 3/19/24. Findings Include: Record review of the facility's Fall Management Policy, updated 01/23/23, revealed, .shall strive to maintain an environment that promotes resident safety. Resident assessment and monitoring will help in managing the occurrence of falls . Record review of a handwritten statement signed by CNA #1, dated 2/3/24 at 3:00 PM revealed, Was wiping Resident down and got sheet wet so want to change sheet. [...]

Inspectors wroteBased on staff interviews, record review, and facility policy review, the facility failed to provide written notification of a transfer/discharge to a resident, the Resident Representative (RR), and the Office of the State Long-Term Care Ombudsman, when a resident was transferred to a local acute hospital for one (1) of six (6) residents reviewed. (Resident #89)

Inspectors wroteBased on staff interview, record review and facility policy review, the facility failed to implement the comprehensive care plan related to a resident's bed side rails for one (1) of 26 care plans reviewed.

Inspectors wroteBased on observations, resident and staff interviews, record review and facility policy review, the facility failed to attempt the use of alternatives to bedrails prior to the installation of bedrails for six (6) of twenty-one residents reviewed. (Residents #8, #11, #12, #40, #50, and #55)

Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to prevent the possible spread of an infection by staff not disinfecting a mechanical lift (shared equipment) between resident use for one (1) of four (4) days of survey. Findings Include: Record review of the facility's policy, Infection Control, revised 9/2022, revealed, .The facility has developed and implemented written policies and procedures for the provision of infection prevention and control .These .policies and procedures include .Routine cleaning and disinfection of resident care equipment including equipment shared among residents . An observation on 3/21/23 at 2:00 PM, revealed Certified Nurse Aide (CNA) #1 walked out of Resident #58's room with a mechanical lift and immediately took the lift into Resident #31's room. [...]