Serenity Estates at Morris

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure a resident was properly secured in their wheelchair while being transported by facility staff in the facility's van. This failure resulted in R2 falling from his wheelchair and sustaining a subdural hematoma (brain bleed) and fracture. This applies to 1 of 3 residents (R2) reviewed for supervision and accidents.

Inspectors wroteBased on interview and record review, the facility failed to administer the laxative suppository as ordered by the physician,This applies to 1 of 3 residents (R2), reviewed for administration of laxative medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to have enough full body lifts to accommodate residents' needs. This applies to 2 of 2 residents (R1 and R3) reviewed for mechanical lifts.

Inspectors wroteBased on interview and record review, the facility failed to administer prescribed medications as ordered. This applies to 1 of 1 resident (R1) reviewed for medications.

Inspectors wroteBased on interview and record review, the facility failed to provide a residents POA (Power of Attorney) notification of end of therapy services. This applies to 1 of 1 resident (R6) reviewed for notification of end of therapy.

Inspectors wroteBased on interview and record review, the facility failed to protect residents right to privacy and confidentiality. This applies to 2 of 2 residents (R7 and R8) reviewed for resident's rights.

Inspectors wroteBased on interview and record review, the facility failed to provide a care plan conference for a resident and their representative. This applies to 1 of 1 resident (R6) reviewed for care planning.

Inspectors wroteBased on observations, interview, and record review, the facility failed to provide safe medication storage and labelling practices for residents receiving prescription and narcotic medications. This applies to 4 residents (R1, R5, R12, and R105) sampled for medication storage and labeling in a sample of 26.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide foods at a palatable temperature acceptable to the residents. This applies to 13 of 13 residents (R3, R7, R23, R27, R31, R35, R48, R73, R105, R107, R111, R118, R123) reviewed for dining in the sample of 26.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pureed consistency foods to residents that have a diet order for the same. This applies to 4 of 4 residents (R21, R39, R80, R129) reviewed for pureed diets in the sample of 26.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow transmission-based precautions for COVID-19 positive residents. The facility also failed to follow standard infection control practices while handling contaminated medical devices. This applies to 6 of 26 residents (R3, R20, R25, R98, R103, R118) reviewed for infection control in the sample of 26.

Inspectors wroteBased on interview and record review, the facility failed to provide dignity to a resident during provisions of care. This applies to 1 of 26 residents (R118) reviewed for dignity in the sample of 26.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services to prevent further contractures for a resident and failed to apply recommended devices to treat a resident's contractures. This applies to 2 of 3 residents (R14 and R15) reviewed for range of motions in the sample of 26.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that recommended fall preventive measures were put in place at all times for residents who were identified as high risk for falls. This applied to 2 of 3 residents (R2, R4) reviewed for falls in the sample of 5.

Inspectors wroteBased on interview and record review, the facility failed to ensure medications were readily available to newly admitted residents. This applies to 2 of 3 residents (R1, R2) reviewed for medications in the sample of 3.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident was safely transferred with a mechanical lift for 1 of 4 residents (R1) reviewed for falls in the sample of 4.

Inspectors wroteBased on interview and record review, the facility failed to provide safe transfer assistance. This applies to 1 resident (R1) of three reviewed for safe transfers. This failure resulted in R1 incurring a acute nondisplaced bimalleolar fracture and a nondisplaced oblique fracture of the distal fibula.

Inspectors wroteBased on interview and record review, the facility failed to employ sufficient staff to carry out the functions of the Food and Nutrition Services, including meal preparation. This applies to all residents that receive oral nutrition and foods prepared in the facility kitchen.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow their menus. This applies to all residents that receive oral nutrition and foods prepared in the facility kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly label/date/store items, remove expired items, sanitize equipment, and wear hair restraints in the facility kitchen. This applies to all residents that receive oral nutrition and foods prepared in the facility kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate fall interventions and a hazard free environment to all residents. This applies to 4 residents (R207, R158, R360 and R261) reviewed for safe environment in a sample of 28.

Inspectors wrote10. R63 is a [AGE] year-old female with mild cognitive impairment as per the Minimum Data Set (MDS) dated [DATE]. On 10/08/24 at 10:35 AM, a half-full 60-gram Nystatin topical powder bottle (used to treat fungal or yeast skin infections) was observed at R63's bedside. 11. R64 is a [AGE] year-old female with cognition intact as per the MDS, dated [DATE]. On 10/08/24 at 10:38 AM, R64 was observed in her bed with a wound cleanser bottle (3/4th of a 16-ounce bottle, used to clean wounds), Hibiclens (3/4th of an 8-ounce bottle, used as an antimicrobial skin cleanser), and Betadine (half of an 8-ounce bottle, used to prevent infection and promote healing in skin wounds, pressure sores, or surgical incisions) at her bedside. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control practices for residents under TBP (Transmission Based Precautions) and during transportation of dirty linen. This applies to 4 of 4 residents (R357, R356, R156, and R158) reviewed for infection control in a sample of 28.

Inspectors wroteBased on interview and record review, the facility failed to order a residents chosen Advanced Directives status of DNR (Do Not Resuscitate). This applies to 1 of 1 resident (R268) reviewed for Advanced Directives in a sample of 28.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide ADL (ADL/Activities of Daily Living) care to dependent residents. This applies to 2 of 2 residents (R307 and R356) reviewed for ADL care in the sample of 28.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure anti-contracture devices and Controlled Ankle Movement (CAM) Boot were applied as ordered. This applies to 2 of 2 residents (R160 and R354) reviewed for assistive devices in a sample of 28.

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep the indwelling catheter bag below the bladder level to prevent potential urinary tract infection (UTI). This applies to 1 of 2 residents (R57) reviewed for catheter care and treatment in a sample of 28. The Findings Includes: R57 is a [AGE] year-old male with severe cognitive impairment, as per the Minimum Data Set (MDS) dated [DATE]. R57 was admitted with an admitting diagnosis including urinary retention. On 10/8/24 at 11:00 AM, R57 was observed in his wheelchair with an indwelling catheter bag hanging behind his wheelchair and above his bladder level, with urine pooling in the catheter tubing. On 10/8/24 at 11:05 AM, V5 (Registered Nurse/RN) stated the therapist might be the one who left the indwelling catheter bag above bladder level. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy on maintaining a Peripherally Inserted Central Catheter (PICC) line. This applies to 1 of 1 resident (R62) reviewed for central line catheter care in a sample of 28. The Findings Includes: R62 is a [AGE] year-old male with cognition intact, as per the Minimum Data Set (MDS) dated [DATE]. R62 was admitted with a diagnosis of Sepsis, Right Lower Limb Cellulitis, and Osteolysis. On 10/08/24 at 10:42 AM, R62 was sitting on his chair with a left upper arm double lumen PICC line, with a dirty reinforced dressing, with no date or label, and was peeling off from the insertion site: On 10/08/24 at 10:42 AM, R62 stated he was not sure the facility had ever changed his PICC line dressing. Reviewing R62's Physician Order Sheet (POS) on 10/8/24 indicates no order to change R62's PICC line. [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain consents for psychotropic/antidepressant medications, and failed to follow pharmacy recommendations. This applies to 2 of 4 residents (R156 and R308) reviewed for unnecessary medications in a sample of 28.

Inspectors wroteBased on interview and record review, the facility failed to produce documentation or evidence of the yearly Performance Improvement Projects (PIP) for falls, identified by the facility as a problem-prone area. This has the potential to affect all 90 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to hold a QAA (Quality Assessment and Assurance) meetings on a quarterly basis, and failed to have the appropriate committee members at QAA meetings. This has the potential to affect all 90 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to safely transfer a resident from her bed to her reclining wheelchair using a mechanical lift, resulting in a fall and skin tear. This applies to 1 of 3 residents (R1) reviewed for mechanical lift use. Findings Include: R1's 12/21/23 nursing note from 7:57 AM showed, Called to resident room by CNA [Certified Nursing Assistant]. Observed resident lying on her right side next to the wall by the foot of her bed, [mechanical lift] sheet partially underneath her. Blood noted by her right lower leg area .resident unable to say what transpired .CNA stated that during transfer [mechanical lift] started to tip over and as she (CNA) reached for the resident to prevent the fall the [mechanical lift] tipped anyway but she was able to break the fall so the resident did not hit the floor with her full body weight . [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow sanitary practices during dish washing, meal prep, and meal service. This has potential to affect all 80 residents that received foods in the facility kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed follow standard infection control practices with regards to hand hygiene and gloving during provisions of incontinence care, and by not donning of personal protective equipment (PPE) when entering an isolation room. In addition, the facility also failed to ensure they have a process to measure or monitor the growth of Legionella and other opportunistic waterborne pathogens in building's water system. This applies to all the 80 residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assist residents identified as needing assistance with personal hygiene and mobility. This applies to 5 of 5 residents (R10, R13, R29, R63 and R75) reviewed for ADLs (activities of daily living) in the sample of 19.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide incontinence care in a manner that would prevent urinary tract infection (UTI). This applies to 4 of the 4 residents (R4, R7, R9, R44) reviewed for incontinence care in the sample of 19.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident's choice of Advanced Directive was correctly reflected on Physician Order Sheet (POS) to inform patient's wishes in case of emergency. This applies to 1 of 1 resident (R53) reviewed for advance directives in the sample of 19.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents identified with heart disease and renal disease were weighed daily as ordered by the physician. This applies to 2 of 19 residents (R18 and R284) reviewed for physician orders in sample of 19.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess and provide supportive device/splint to a resident, to prevent further reduction in ROM (range of motion). This applies to 1 of 3 residents (R13) reviewed for range of motion in the sample of 19.

Inspectors wroteBased on observation, interview, and record review, the facility failed to serve pureed consistency Teriyaki beef tips and rice for the lunch meal. This applies to 2 of 2 residents (R37, R44) reviewed for pureed diets in the sample of 19.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the wheelchair breaks were maintained in working condition. This applies to 3 of 3 residents (R1, R32, R50) reviewed for falls in the sample of 19.