Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Serenity Estates At Morris during CMS and state inspections, most recent first.
A resident with multiple neurologic and GI diagnoses returned from an ED visit with constipation and urinary retention and had an order for glycerin rectal suppositories once daily for 3 days. The eMAR showed the suppository was not given on two ordered days because it was unavailable at the facility, and only one dose was documented as administered; the DON confirmed the full ordered course was not given.
Insufficient Full Body Mechanical Lifts for Resident Transfers: Two residents who were dependent on full body lifts for transfers were affected when the facility had only one working lift available at times. One resident with hemiplegia, CVA, DM, OA, and cognitive communication deficit reported being unable to get out of bed or return to bed for extended periods, while another resident with polyneuropathy, anemia, DM, MDD, HTN, OA, and disc degeneration reported being told she could not lie down because no lift was available and had to eat dinner in her wheelchair. Staff confirmed the facility had only two lifts total, with one sometimes unavailable due to charging, being on another unit, or being in maintenance.
A resident with multiple diagnoses, including CVA-related hemiplegia, diabetes, and cognitive communication deficit, had an order for Xanax 0.25 mg at bedtime. The MAR showed the medication was not available on three occasions, and RNs documented the missed doses without contacting the MD, NP, or pharmacy or obtaining the medication from emergency stock. The DON stated she was unaware the resident had missed three doses and that benzodiazepines should not be stopped abruptly.
A resident with Alzheimer’s disease and multiple comorbidities, who identified her daughter as her POA and decision-making partner, reported not knowing why her therapy ended and not recalling any notice of termination. Record review showed that while a NOMNC/SNFABN was signed by the resident for the end of Part A skilled therapy, there was no documentation that her POA was notified, and no NOMNC or ABN was issued or documented for the end of Part B therapy. The Social Services Director confirmed that no NOMNC was sent to the POA and that the resident’s Alzheimer’s diagnosis was not taken into account, despite facility policy requiring issuance of NOMNC/ABN to the resident or representative whenever Medicare-covered services end.
A CNA recorded and posted a collage of videos of two residents on a personal social media account without any written consent, showing one resident in a gown being lifted with a mechanical lift, performing personal hygiene in the bathroom, sitting in a wheelchair organizing personal items, and engaging in ball activities, as well as an “In Loving Memory” card with that resident’s birth and death dates and funeral home name. The other resident was also depicted participating in ball activities. One resident had a signed audio, video, and photographic release form from the POA specifically prohibiting release of the resident’s name or photograph outside the facility without written authorization, and the other resident had no consent on file. The DON and Activity Director acknowledged that no consents had been obtained and that staff were not allowed to post residents on personal social media, contrary to the facility’s social media policy prohibiting unauthorized photographs or recordings of residents or their private space.
A resident with multiple complex conditions, including hemiplegia, dementia, diabetes, and communication deficits, reported that neither she nor her POA had ever attended a care plan meeting since admission. The Social Services Director acknowledged that care plan conferences had not been conducted as required and could not produce any documentation of a conference for this resident, and the Administrator confirmed there was no record of such a meeting, despite facility policy requiring interdisciplinary, person-centered care plan conferences with the resident and representative at least every 90 days or with significant change.
Multiple residents reported receiving cold meals, both in their rooms and in the dining area. Staff observations confirmed that hot food was not consistently maintained at appropriate temperatures during plating and delivery, with temperature checks showing some items below the standard for palatability. The facility lacked both adequate equipment and a policy to ensure food was served at an appetizing temperature.
Unsafe medication labeling and narcotic storage practices were found for multiple residents. A resident with COPD received Trelegy Ellipta without a pharmacy label even though a labeled inhaler was available, and several narcotic cards for residents had opened pockets re-taped with paper tape in the locked narcotic box. The DON stated unlabeled meds should not be administered and that unused narcotics should be discarded with two nurses rather than returned to the card.
Pureed diet foods were prepared with improper texture for several residents ordered pureed diets or pureed meat. A cook blended Italian beef and 3-bean salad for service, but both items still contained visible coarse particles and bean pieces, and the dietary manager agreed they needed further pureeing. The dietitian stated pureed foods should be smooth with no lumps or chewing required, and facility records showed multiple residents were ordered pureed diets.
Failure to follow TBP for COVID-19 positive residents and unsafe handling of contaminated sharps were observed. Residents with COVID-19 were seen in common areas and rooms without the required PPE, staff entered isolation rooms without eye protection, visitors were not properly informed of PPE requirements, and an RN handled used lancets with ungloved hands during blood glucose checks before disposing of them and continuing med pass.
A resident who was cognitively intact and dependent on staff for showering was left alone and undressed in the shower room by a CNA, who left to assist another resident and returned about 15 minutes later to find the resident shivering and cold. Facility leadership confirmed that residents should not be left alone or naked during shower care.
Failure to provide ROM support and apply ordered splints: Two residents with stroke-related hemiplegia and contractures did not receive the ordered ROM, restorative support, or brace/splint assistance documented in therapy records. One resident’s left hand remained fisted without prior OT involvement or a resting hand orthosis, while the other resident had left hand and elbow contractures but was not receiving the recommended hand and elbow braces, and CNAs reported they had not been directed or educated to assist with the devices.
Two residents with a history of repeated falls, dementia, and poor safety awareness were observed multiple times without the required non-skid mats on their wheelchair seats, despite care plans specifying this intervention. Staff interviews confirmed the non-skid mats were not consistently used, and facility records showed multiple falls for both residents over several months.
Two cognitively intact residents with complex medical conditions did not receive their prescribed medications in a timely manner after admission due to delays in order entry, lack of staff access to medication storage, and missed opportunities to request STAT pharmacy deliveries. Staff did not follow facility policies for obtaining unavailable medications or notifying physicians about the delays, resulting in missed doses of critical medications.
A resident with dementia and high fall risk was improperly transferred using a mechanical lift, resulting in a fall and head injury. The CNAs involved failed to secure the lift sling properly, causing the resident's wheelchair to tip backward. The facility's policy on safe transfers was not followed, leading to the incident.
A resident with a history of aphasia and hemiplegia suffered fractures due to improper transfer assistance. A new CNA performed a one-person pivot transfer, contrary to the care plan requiring a two-person assist with a mechanical lift. The resident was initially assessed with no injuries but later confirmed to have fractures after expressing pain. Facility staff confirmed the CNA did not follow the safe transfer policy.
The facility failed to maintain sufficient dietary staff, impacting meal preparation for all residents. The Dietary Manager reported staffing shortages, leading to meal schedule changes and mismatches with the menu, affecting residents' meal choices. The facility's staffing schedule showed numerous days with insufficient staff, falling short of the required levels to meet residents' needs.
The facility failed to follow its established menus due to staffing shortages, leading to meal substitutions not aligned with policy. A resident expressed dissatisfaction with the inconsistency, and the Dietary Manager admitted to altering meals because of insufficient staff, which is not permitted by the facility's policy.
The facility failed to maintain proper food safety and sanitation practices, including improper labeling and dating of food items, inadequate sanitization of kitchen equipment, and lack of hair restraints by staff in the kitchen. These deficiencies were observed during meal preparation and storage inspections, posing potential cross-contamination and foodborne illness risks.
The facility failed to implement adequate fall prevention measures for several residents, leading to multiple incidents. A resident on anticoagulants fell out of bed without fall mats in place, another with cognitive impairment had her bed left in a high position against care plan instructions, and a third resident at high fall risk had only one fall mat instead of two. Additionally, exposed metal bed frames posed injury risks, indicating systemic issues in fall prevention and safety measures.
A long-term care facility failed to properly label, store, and dispose of medications, leading to potential safety risks for residents. Insulin pens were found without proper labeling, and controlled substances were improperly stored. Expired medical supplies were not disposed of, and medications were found at residents' bedsides without proper orders or safety assessments. The facility's policies on medication storage and controlled substance accountability were not adhered to, posing a risk of medication errors and potential harm to residents.
The facility failed to follow infection control practices for residents under TBP and during the transportation of dirty linen. A resident with C. difficile was visited by a family member and an occupational therapist without proper PPE or hand hygiene. Another resident under EBP for MRSA had a CNA enter without a gown due to lack of supplies, and the urinary catheter bag was mishandled. Additionally, CNAs failed to change gloves or perform hand hygiene during incontinent care and transported soiled linen improperly.
A facility failed to implement a resident's chosen DNR status, despite it being documented in the POA paperwork and confirmed by family members. The resident, with multiple diagnoses including dementia, had made the DNR decision prior to cognitive changes. The facility lacked a physician's order for the DNR, and the resident was assumed to be a full code, contrary to the facility's policy on communicating code status.
The facility failed to provide adequate ADL care to two residents, resulting in deficiencies in personal hygiene and toileting assistance. One resident was observed with a crusted substance on her eyelid over several days, indicating her face had not been washed. Another resident was not properly assisted with wiping or handwashing after toileting. The facility's policy requires necessary services for residents unable to perform ADLs.
The facility failed to apply assistive devices as ordered for two residents. One resident with Parkinsonism and dementia did not have the prescribed hand rolls to prevent contractures, and staff used makeshift solutions due to the absence of a restorative program. Another resident with a leg fracture had a CAM boot that was not worn as ordered, with staff misunderstanding the requirement for it to be on at all times except during specific activities.
A resident with severe cognitive impairment and urinary retention was found with an indwelling catheter bag positioned above bladder level, risking a UTI. A nurse indicated the bag might have been left in this position by a therapist, and both the RN and DON confirmed the risk of UTI from improper positioning. Facility policy requires catheter bags to be below bladder level.
A resident with a PICC line was found with a dirty, peeling dressing lacking a date or label, and there was no physician order or documentation for regular dressing changes. The facility's policy requires weekly dressing changes to prevent infection, but this was not followed, as confirmed by the RN and DON.
The facility failed to obtain consents for psychotropic medications for two residents and did not follow pharmacy recommendations. One resident was administered Clonazepam and Mirtazapine without consents, while another received Escitalopram and Olanzapine without consents and had a delayed AIMS test. The facility's policy on medication management and monitoring was not followed.
The facility failed to document their yearly Performance Improvement Projects (PIP) for falls, identified as a problem-prone area. During a QAPI/QAA task, the Administrator and ADON could not provide records of QAPI/QAA meetings or data on interventions for the fall PIP. The ADON had interventions in mind but had not documented them, affecting all 90 residents.
The facility did not conduct QAA meetings quarterly and lacked required members, including the Medical Director, in recent sessions. The last official meeting was in June 2024, and subsequent sessions were introductory, not formal QAA meetings.
Failure to Administer Ordered Glycerin Suppository
Penalty
Summary
The facility failed to administer a physician-ordered glycerin rectal suppository for constipation as prescribed for one resident with multiple diagnoses, including hemiplegia and hemiparesis following cerebral infarction, cerebral infarction due to thrombosis of the right middle cerebral artery, diverticulosis of the large intestine without perforation or abscess, and need for assistance with personal care. After returning to the facility from an ED visit with family, the resident was documented as having constipation and urinary retention, and the ED nurse reported that a suppository had been given with an order to continue glycerin 2-gram rectal suppositories for the next 3 days. The physician order was for one suppository rectally once daily for constipation for 3 days. The medication administration record showed the resident did not receive the suppository on two of the ordered days because it was not available at the facility and was being ordered from the pharmacy. The eMAR showed the resident received only one dose at the facility, and there was no evidence that the remaining two ordered doses were administered. The DON reviewed the order and acknowledged that the resident did not receive the full ordered doses because the medication was not available on April 25 and 26, 2026, and confirmed there was no evidence of the additional doses needed to complete the 3-day order. The facility policy stated medications are to be administered as ordered by the physician.
Insufficient Full Body Mechanical Lifts for Resident Transfers
Penalty
Summary
The facility failed to have enough full body mechanical lifts available to meet residents’ transfer and positioning needs for 2 of 2 residents reviewed for mechanical lifts. One resident, admitted with diagnoses including hemiplegia and hemiparesis affecting the left non-dominant side, cerebral infarction, diabetes, osteoarthritis, muscle weakness, cognitive communication deficit, and need for assistance with personal care, was wheelchair dependent and required a full body lift with two staff for transfers. The resident stated the facility had only one working full body mechanical lift and that when ready to get out of bed or return to bed, a lift was not available, causing the resident to remain in bed or in the wheelchair for extended periods. A second resident, admitted with diagnoses including polyneuropathy, megaloblastic anemias, diabetes, major depressive disorder, hypertension, osteoarthritis, and intervertebral disc degeneration, was also dependent on staff for transfers and used a full body mechanical lift. The resident stated staff told her she could not lie down because no mechanical lift was available and that she had to eat dinner in the wheelchair instead of in bed. Staff confirmed that the facility had only two full body mechanical lifts total, one electric and one manual, that both were on another unit at times, and that residents sometimes could not get out of bed or lie down because lifts were not available. The administrator stated one lift was in the maintenance office due to safety concerns and that all units were sharing the lifts.
Medication Not Administered as Ordered
Penalty
Summary
The facility failed to administer a prescribed medication as ordered for one resident who was admitted with multiple diagnoses including hemiplegia and hemiparesis affecting the left non-dominant side, cerebral infarction, diabetes, osteoarthritis, muscle weakness, cognitive communication deficit, and need for assistance with personal care. The resident had an active order for Alprazolam (Xanax) 0.25 mg at bedtime, and the MAR for April 2026 showed it as a scheduled medication. The MAR also showed that on three dates, the medication was coded as not available, with nurse initials entered in those boxes. During interviews, the Psych NP stated the pharmacy had informed her that nurses could obtain Xanax from the convenience box/emergency medications until the shipment arrived. An RN stated she signed the MAR that the Xanax was not available but did not call the doctor, NP, or pharmacy, and another RN stated she also signed that the medication was not available, did not call the pharmacy, and did not obtain the Xanax from emergency supply. The DON stated she was unaware the resident had missed three doses, that nurses had not informed her, and that the resident should not have missed three doses because the pharmacy and providers should have been called; she also stated benzodiazepines should not be stopped abruptly.
Failure to Notify Resident’s POA of End of Medicare-Covered Therapy Services
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s Power of Attorney (POA) of the end of Medicare-covered therapy services, as required by facility policy. The resident had multiple diagnoses including hemiplegia and hemiparesis, muscle disorders, difficulty in walking, cognitive communication deficit, diabetes, Alzheimer’s disease, visual disturbance, depression, hearing loss, and dementia. The resident reported that her daughter was her POA, that she used to receive therapy, and that she did not know why it ended. She stated she did not remember receiving or signing a letter stating therapy would be ending and that, had she received such a letter, she would have given it to her daughter, with whom she makes decisions. The resident’s Power of Attorney for Health Care document identified her daughter as POA and authorized the agent to make decisions starting immediately and continuing after the resident was no longer able to make them herself. Record review showed that a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN/NOMNC) was issued and signed by the resident in mid-December for the end of Part A skilled therapy services, but there was no documentation that the POA was notified of the last covered day of skilled services. The Social Services Director stated she issued a NOMNC to the resident when skilled therapy ended in December but did not issue a NOMNC when Part B therapy ended in March and did not send any NOMNC to the resident’s POA. She acknowledged she did not take into consideration the resident’s Alzheimer’s diagnosis. The EMR contained no documentation of a NOMNC or other notification to the resident or POA for the end of Part B therapy with last covered dates in late February and early March. The facility’s Advance Beneficiary Notices Policy required that a NOMNC be issued to the resident or representative whenever Medicare-covered services are ending, and specified the use of the appropriate CMS forms for Part A and Part B services, but the facility was unable to provide evidence that these requirements were met for the resident’s POA at the end of therapy services.
Unauthorized Social Media Posting of Residents Without Consent
Penalty
Summary
The facility failed to protect residents’ rights to privacy and confidentiality when a CNA recorded and posted multiple videos of two residents on a personal social media account without consent. One resident, R7, who had central cord syndrome of the cervical spinal cord, CHF, quadriplegia, anxiety, major depressive disorder, and benign prostatic hyperplasia, was shown in a TikTok video collage wearing a gown and being lifted by a mechanical lift, in the washroom performing personal hygiene, in his room in a wheelchair organizing personal items, and engaging in ball activities. Another clip showed a resident in a gown holding a rosary and a death notice with a picture of a female, and the final clip displayed an “In Loving Memory” card with R7’s date of birth, date of death, and the funeral home name. The video ended with the social media site name and the CNA’s username. The Administrator confirmed that the residents in the video were R7 and R8, that the CNA had been employed at the facility until shortly before the survey, and that no permission had been obtained from R7, R8, or R7’s family to take or post any videos or pictures. Record review showed that R7’s Audio, Video and Photographic Release Form, signed by his POA, specifically directed the facility not to use his name or photograph within the facility in certain circumstances and not to release his name or photograph outside the facility without specific written authorization. Progress notes documented that R7 was on hospice care, nearing end of life, and later expired, with subsequent removal by a funeral home. R8’s EMR contained no written consents for photography, video recording, or social media posting, and the facility was unable to provide any audio, video, or photographic consent for R8. The DON stated that sharing resident videos was wrong and violated the facility’s social media policy and HIPAA, and the Activity Director stated she had never obtained written consents for R7 or R8 and that employees were not allowed to post residents on personal social media. The facility’s Social Media Use Policy prohibited taking, keeping, or distributing unauthorized photographs or recordings of residents or their private space without written consent and barred transmitting resident-related images that could violate privacy or confidentiality, which was not followed in this case.
Failure to Conduct and Document Required Care Plan Conference
Penalty
Summary
The deficiency involves the facility’s failure to conduct and document a care plan conference for a resident and their representative as required by facility policy. The resident was admitted with multiple significant diagnoses, including hemiplegia and hemiparesis, muscle disorders, difficulty walking, cognitive communication deficit, diabetes, Alzheimer’s disease, unspecified visual disturbance, depression, hearing loss, and dementia, according to the face sheet. During an interview, the resident reported that neither she nor her POA had attended a care plan meeting since admission. Review of the resident’s EMR showed no evidence that a care plan conference had been conducted. The Social Services Director acknowledged that care plan conferences had not been done as they should have been and stated that if a care plan conference had been held for this resident, it would have been documented in progress notes, but she was unable to provide such documentation. The Administrator also confirmed that there was no documented record of a care plan conference for this resident and stated that care plan conferences should occur at least every 90 days or with a significant change. The facility’s Comprehensive Care Plans Policy requires development and implementation of a comprehensive, person-centered care plan with measurable objectives and timeframes, prepared by an interdisciplinary team that includes the resident and resident representative to the extent practicable. Despite this policy, the facility could not provide any documentation that a care plan conference with the resident or her POA had been conducted.
Failure to Serve Meals at Palatable Temperatures
Penalty
Summary
The facility failed to provide food at a palatable and acceptable temperature for residents, as evidenced by multiple resident interviews and direct observation. Thirteen residents reported that their meals were served cold, both in their rooms and in the dining room. Residents described the food as 'not really hot,' 'ice cold,' and 'not very edible.' During meal service, it was observed that hot food items were plated under a heating lamp, covered with metal lids, and transported on trays using a free-standing cart covered by a plastic liner. Only one insulated enclosed cart was available for a specific unit, and the facility did not use heating pellets for each plate. Temperature checks conducted by the Dietary Manager after the last meal tray was served showed that the Italian roast beef sandwich was at 104.5°F and potato wedges at 134.9°F, while the standard for palatability was stated by the facility dietitian to be between 110-120°F. The facility lacked a policy regarding the palatability of food, and staff confirmed the absence of necessary equipment to maintain appropriate food temperatures during delivery. These actions and inactions resulted in residents consistently receiving meals at temperatures below acceptable standards.
Unsafe Medication Labeling and Narcotic Storage
Penalty
Summary
The facility failed to provide safe medication storage and labeling practices for residents receiving prescription and narcotic medications. For R1, who was admitted with diagnoses including COPD with acute exacerbation, acute kidney failure, and hypertensive heart disease with heart failure, the POS dated November 14, 2025 included an active order for Trelegy Ellipta inhalation aerosol powder. On December 16, 2025, a nurse administered Trelegy Ellipta to R1 even though the inhaler had no pharmacy label. The nurse stated the medication was probably brought in by R1 on admission, and also stated that R1 had an unopened labeled Trelegy Ellipta sent by the facility pharmacy, but staff had been administering the unlabeled inhaler. The DON later stated the unlabeled inhaler had been brought from another hospital, that it was not safe to administer medications without the facility pharmacy label, and that the medication should not have been given to R1. The facility also had narcotic medication cards in the locked narcotic box that had been opened and re-taped with paper tape. R105 had a Dipen/Atrop tablet 2.5 mg card with two pockets opened and re-taped, R12 had a tramadol HCL 50 mg card with two pockets opened and re-taped, and R5 had an alprazolam 0.5 mg card with one pocket opened and re-taped. Nurses stated that opened and unused narcotic medications are supposed to be discarded with two nurses and should not be returned to the narcotic card. The DON stated the facility should have had two nurses witness and dispose of unused narcotic medications appropriately and that nurses should not have returned unused narcotic medication by applying paper tape to seal the medication cards.
Pureed Diet Foods Served With Improper Texture
Penalty
Summary
The facility failed to provide pureed consistency foods for residents with diet orders for pureed diets or pureed meat. During observation of lunch meal preparation, a cook prepared pureed Italian beef for four residents by placing an unmeasured amount of ground Italian beef, including charred portions, into a blender with beef broth and thickener. After blending, the product still contained coarse particles, charred bits, and hardened pieces of meat when tasted, and the dietary manager agreed it needed to be pureed more. The cook also prepared pureed 3-bean salad for service, but the mixture contained visible pieces of beans floating in it and was determined not safe to serve; the dietary manager again agreed it needed further pureeing. The dietitian stated that pureed food should be smooth with no texture, like mashed potatoes, with no lumps or chewing required. She also stated she would revise the menu to exclude 3-bean salad from the pureed consistency menu because kidney beans would be difficult to puree. Facility records showed that R39, R80, and R129 were on pureed diets, and R21 was on a pureed meat diet. The facility’s pureed food preparation policy and pureed meat protocol described pureed foods as smooth, applesauce-like or smooth mashed potato consistency, and the recipe for pureed Italian beef instructed that it be processed until fine in consistency.
Failure to Follow COVID-19 Isolation and Safe Handling of Contaminated Devices
Penalty
Summary
The facility failed to follow transmission-based precautions for residents with COVID-19 and failed to follow standard infection control practices while handling contaminated medical devices. The report identified this failure in 6 of 26 residents reviewed for infection control, including residents who were COVID-19 positive and residents who were being cared for in the same common areas and rooms without the required precautions being followed. On December 15 and 16, 2025, residents known to be COVID-19 positive were observed in common areas and rooms without the PPE required by the posted precautions. R20 and R98 were sitting in the common area without PPE while R20 was coughing at a table with other residents nearby. Staff members entered the area wearing only surgical masks, and unmasked residents were present at nearby tables. On another observation, unmasked R20 was in the common area and staff applied surgical masks to residents there. The ADON/IP stated that residents with COVID-19 should wear an N95 mask or at least a surgical mask, and that staff should wear a gown and PPE. The facility’s records showed R20 and R98 were on contact and droplet isolation for COVID-19, with care plans requiring transmission-based precautions. The report also documented that staff did not consistently wear eye protection when entering rooms of COVID-19 positive residents. R3 and R118 were both COVID-19 positive and had signs on their doors indicating contact and droplet precautions, including eye protection. During intermittent observations on December 15, 16, and 17, 2025, multiple staff members entered their rooms to provide direct care without eye protection. Visitors were also observed in the facility and in R118’s room wearing only surgical masks, and one visitor stated no one had told them they needed gown, gloves, N95 mask, and eye protection before entering the room of a COVID-positive resident. In addition, when R35 tested positive, the room initially had no isolation sign or PPE cart outside, the roommate remained in the room, and staff were observed entering with incomplete PPE while the infection prevention nurse stated the roommate had tested negative the night before and that staff in the hallway only needed surgical masks. The facility also failed to follow standard infection control practices during blood glucose testing. While performing a finger stick on R103, the nurse placed the used lancet on a paper towel, removed a glove, picked up the contaminated lancet with an ungloved hand, and later reached into a trash bag to retrieve it before disposing of it in the sharps container. During blood glucose testing for R25, the same nurse removed a glove and picked up the used lancet without gloves before disposing of it. The nurse then performed hand hygiene and continued medication pass. The facility’s hand hygiene policy was cited in the report as applicable to all staff.
Resident Left Unattended and Undressed During Shower
Penalty
Summary
A resident with diagnoses including intervertebral disc disorder with radiculopathy, acute respiratory failure with hypoxia, generalized muscle weakness, chronic pain, and dizziness, who was cognitively intact and dependent on staff for showering, reported being left alone and naked in the shower room by a CNA. The resident stated that the CNA turned on the water and left to attend to another resident in a different shower room, returning approximately 15 minutes later to find the resident shivering and cold, unable to wash himself. Facility leadership confirmed that residents should not be left alone or naked in the shower room during care.
Failure to Provide ROM Support and Apply Ordered Splints
Penalty
Summary
The facility failed to provide services to prevent further contractures for one resident and failed to apply recommended devices to treat another resident’s contractures. For the first resident, the record showed a history of stroke-related diagnoses, including hemiplegia and hemiparesis, dysphagia, and ataxia following cerebral infarction. The resident was moderately cognitively impaired and had impairment on one side in range of motion. During observation, the resident’s left arm was flaccid and the left hand was closed in a fist, and the resident stated he could not open it, did not receive therapy, and staff did not do range of motion exercises with him for the left arm and hand. Staff interviews confirmed the resident had not been receiving the expected support. A CNA stated she had never seen the resident with any device on the left hand during the past ten months. The Director of Therapy stated the resident had been seen by PT in December 2024 and July 2025, but OT had not previously been requested. The OT stated the resident had neuromuscular palsy from the stroke, that the flexor muscles were shrinking, and that if the condition was not assessed it would worsen and develop into a flexor contracture. OT recommended a wrist-hand orthosis for the left wrist, hand, and digits, and the OT evaluation included a left hand WHO to prevent contracture. The DON stated the facility did not have a restorative program and was just about to start one. For the second resident, the record showed diagnoses including hemiplegia and hemiparesis following cerebral infarction, weakness, epilepsy, chronic pain, and fusion of the spine. OT documentation showed therapy was initiated to address a left upper arm flexion contracture, with goals to improve skin integrity, hygiene, joint alignment, and prevent contracture. OT recommended an elbow extension orthosis and a resting hand orthosis, and the discharge summary stated a restorative ROM program and splint and brace program were established, including passive ROM to the left shoulder, elbow, wrist, and digits. However, when observed, the resident had a closed left-hand contracture and a left elbow contracture, and no splint, brace, or other device was on the left arm or hand. The resident stated she had braces but no one put them on because staff could not open her hand enough, and she reported that no one had put on her elbow brace for months. Multiple CNAs stated they did not assist with the splints or braces and had not been educated or directed to do so. The Director of Rehab stated the resident should have been wearing both the hand brace and arm brace daily after OT discharge, that staff had been trained on how to apply the splint, and that staff were aware she needed the brace. The DON stated the CNAs were responsible for the point-of-care tasks related to brace placement, but the resident had no restorative program, no task or order for placing or assisting with the resting-hand brace, and no care plan for the left arm or left-hand contractures.
Failure to Implement Fall Prevention Measures for High-Risk Residents
Penalty
Summary
The facility failed to implement recommended fall prevention measures for residents identified as high risk for falls. Two residents with multiple medical diagnoses, including repeated falls, unsteadiness, lack of coordination, and dementia, were observed multiple times without the required non-skid mats on their wheelchair seats, despite care plans specifying this intervention. Observations on several occasions showed these residents sitting in their wheelchairs or being assisted by staff without the non-skid mats in place. Staff interviews confirmed that the non-skid mats were not consistently used, and one CNA stated she had never seen a non-skid mat on one resident's wheelchair. The facility's fall incident log documented multiple falls for both residents over a period of several months. The care plans for both residents, which were updated following these incidents, included the use of non-skid mats as a specific intervention to address their high risk for falls due to poor safety awareness, dementia, and other medical conditions. Despite these documented interventions, direct observations and staff interviews revealed that the non-skid mats were not in use at the times observed, indicating a failure to follow the established fall prevention measures for these high-risk residents.
Failure to Provide Timely Medications to Newly Admitted Residents
Penalty
Summary
The facility failed to ensure that medications were readily available to newly admitted residents, resulting in delays in medication administration for two residents. One resident, who was cognitively intact and had multiple diagnoses including COPD, depression, and chronic respiratory failure, was admitted after the pharmacy's medication order cut-off time. The assigned LPN did not have access to the medication storage and was unaware of the process to obtain medications after hours or request a STAT delivery. As a result, the resident did not receive several scheduled medications on the evening of admission and the following morning, with documentation showing that medications were not delivered until the afternoon of the next day. Another cognitively intact resident with complex medical conditions such as diabetes, congestive heart failure, and stage 4 kidney disease also experienced delays in receiving medications. The resident's medication orders were not entered into the computer until the evening of the day after admission, and medications were not administered until the following day. The resident missed multiple doses of oral medications and insulin, and family members had to retrieve medications from the previous care setting due to the delay. There was no documentation that physicians were notified about the delays in medication administration. Facility policies required immediate action when medications were unavailable, including notifying the physician and obtaining alternative orders or emergency deliveries. However, staff did not follow these procedures, and there was a lack of communication and timely action to ensure that newly admitted residents received their prescribed medications as ordered.
Unsafe Transfer Leads to Resident Fall
Penalty
Summary
The facility failed to ensure the safe transfer of a resident using a mechanical lift, resulting in an accident. The resident, who has a history of dementia, weakness, Meniere's disease, and hearing loss, was identified as high risk for falls. The care plan specified the use of a mechanical lift with two staff members for transfers. During a transfer from a wheelchair to a bed, the resident's wheelchair was lifted along with the resident, causing the wheelchair to tip backward and the resident to fall, hitting his head on the floor. The incident occurred because the mechanical lift sling was not securely attached to the metal hook, and the staff were focused on the issue with the wheelchair rather than ensuring all hooks and slings were properly secured. The incident was witnessed by two CNAs who were conducting the transfer. One CNA was operating the lift controls while the other was positioned on the side of the resident, leaving no one behind the wheelchair to prevent it from tipping. The resident's wife, who was not present during the incident, reported finding the resident on the floor with a bruise on his head. The resident was sent to the hospital and diagnosed with a scalp hematoma before being discharged back to the facility. The facility's policy on safe resident handling and transfers was not adhered to, as it requires ensuring all slings are securely placed and the resident is positioned safely during transfers.
Failure to Provide Safe Transfer Assistance
Penalty
Summary
The facility failed to provide safe transfer assistance for a resident, resulting in an acute nondisplaced bimalleolar fracture and a nondisplaced oblique fracture of the distal fibula. The resident, who has a medical history of aphasia, hemiplegia, and hemiparesis following a cerebral infarction, was being transferred from an electric wheelchair to a bed via a pivot transfer when the incident occurred. The transfer was conducted by a CNA who was new to the facility and performed the transfer alone, despite the resident's care plan indicating that a two-person assist with a mechanical lift was required. The resident was lowered to the ground after becoming weak during the transfer, and subsequent assessments initially did not reveal any obvious injuries. The resident later expressed pain in the right lower extremity and was sent to the emergency room, where initial evaluations did not indicate fractures. However, continued pain led to further X-rays, which confirmed the fractures. Interviews with facility staff, including the Director of Nursing and a Licensed Practical Nurse, revealed that the CNA was not familiar with the facility's procedures and did not seek assistance for the transfer, which was against the facility's policy for safe resident handling and transfers. The policy clearly states that two staff members must be utilized when transferring residents with a mechanical lift.
Insufficient Dietary Staffing Affects Meal Preparation
Penalty
Summary
The facility failed to employ sufficient staff to carry out the functions of the Food and Nutrition Services, impacting meal preparation for all residents receiving oral nutrition. The Dietary Manager, identified as V9, reported that the facility was short-staffed, with only two staff members, including herself and the cook, available on certain days. This staffing shortage led to changes in the meal schedule, such as switching meals between days and serving meals that did not match the menu, which affected the residents' ability to choose their meals. For instance, a resident, R205, expressed dissatisfaction with receiving meals that did not match the menu, such as being served tuna salad on white bread instead of toast. The facility's staffing issues have persisted for at least two months, with the Dietary Manager having to adjust meal plans and even the facility's Administrator assisting in the kitchen due to insufficient staff. The facility's staffing schedule highlighted numerous days with insufficient staff, totaling 33 out of 111 days. The facility's assessment tool indicated a need for a specific number of dietary staff to meet residents' needs, but the current staffing levels fell short of these requirements. The Dietary Manager emphasized the importance of feeding residents on time and the challenges posed by the lack of staff, which sometimes led to meal substitutions and disruptions for the residents.
Failure to Follow Menu Due to Staffing Shortages
Penalty
Summary
The facility failed to adhere to its established menus, which are required to meet the nutritional needs of residents, as observed during a survey. The Dietary Manager, identified as V9, admitted to altering the menu due to insufficient staffing levels. On a specific Monday, the planned meal of chicken enchiladas was replaced with pulled pork, pasta salad, and pea salad because the preparation time for enchiladas was too long for the available staff, which consisted of only two people instead of the required five. This substitution was not in line with the facility's policy, which does not allow for menu changes due to staffing issues. Additionally, a resident expressed dissatisfaction with the meal changes, stating that meals often did not match the menu, which affected their sense of choice. Further observations revealed that on another day, the lunch served did not match the menu, with chicken enchiladas being served instead of the planned Hawaiian Pork Sliders. The Dietary Manager acknowledged that meal substitutions had occurred on other occasions due to staffing shortages, and even the facility's Administrator had to assist in the kitchen. The facility's policy on menu substitutions only allows for changes when a product is unavailable or for special requests, not for staffing shortages. This inconsistency in meal service highlights the facility's failure to follow its own menu policies, impacting the residents' dining experience.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to proper food safety and sanitation practices in the kitchen, affecting all residents who receive oral nutrition. During a lunch service, a cook was observed placing a thermometer probe on a visibly dirty serving table and then using it to check the temperature of food without sanitizing it. The cook also dropped a lid on the kitchen floor and continued to use the same oven mitts to handle food trays, and later dropped a thermometer on the floor, cleaning only the probe but not the digital display, which then touched food. These actions were identified as potential cross-contamination risks. Additionally, the facility did not ensure proper labeling and dating of food items in storage. Several items in the walk-in refrigerator, freezer, and dry storage were found without labels or dates, including diced chicken, egg products, yogurt, grape salad, ice cream cake, cookies, baking powder, and powdered sugar. Some items were also found to be expired, such as pie crusts and baking powder. The Dietary Manager acknowledged that all food items should be labeled and dated to ensure safety and prevent foodborne illness. The facility also failed to enforce the use of hair restraints in the kitchen. Two CNAs entered the kitchen during meal preparation without wearing hairnets, posing a risk of physical contamination of food by hair. The Dietary Manager confirmed that all staff entering the kitchen should wear hair restraints to prevent contamination. The facility's policies on labeling, dating, and hair restraints were not followed, contributing to the deficiencies observed.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to provide appropriate fall interventions and maintain a hazard-free environment for several residents, leading to multiple incidents. One resident, admitted with a history of falls and on anticoagulants, was found on the floor with a head injury and skin tear after rolling out of bed. Despite being at high risk for falls, the resident did not have fall mats in place, which were part of the prescribed interventions. The staff admitted to forgetting to replace the fall mat, and the resident had experienced multiple falls since admission. Another resident with severe cognitive impairment and a history of falls was observed with her bed in a high position, contrary to her care plan that required the bed to be in a low position at night. The resident expressed confusion about her bed preference, and staff inconsistently managed the bed height, leaving it high even after providing care. The Director of Nursing was initially unaware of the resident's fall interventions, indicating a lack of communication and adherence to care plans. A third resident, with a history of repeated falls and a subdural hematoma, was found with only one fall mat beside her bed, despite being at high risk for falls. Staff acknowledged that two fall mats should be in place if the bed is not against a wall, but this was not implemented. Additionally, another resident's bed had exposed metal frames, posing a risk of injury, which the Assistant Director of Nursing confirmed should not occur. These findings highlight a systemic issue in the facility's fall prevention and environmental safety measures.
Medication Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to properly label, store, and dispose of medications, leading to potential safety risks for residents. Several insulin pens were found without proper labeling, including opened and expired pens that were not discarded, as observed with residents R269, R155, R254, R206, and R60. Additionally, controlled substances such as clonazepam and hydrocodone were improperly stored, with some blister packs taped, which could lead to contamination. The medication room refrigerator was not maintained properly, with excess ice buildup and missing temperature logs, indicating a lack of oversight in medication storage conditions. Expired medical supplies were found in the medication room, including catheterization trays and IV administration set tubing, which were not disposed of despite being past their expiration dates. This oversight was acknowledged by the LPN, who was unaware that medical supplies had expiration dates. Furthermore, medications were found at residents' bedsides without proper orders or safety assessments, as seen with residents R357, R359, R63, R64, and R304. These medications included nasal sprays, creams, and wound cleansers, which were accessible to residents without supervision or proper documentation. The facility's policies on medication storage and controlled substance accountability were not adhered to, as evidenced by the lack of proper labeling, storage, and disposal of medications. The Director of Nursing and other staff members were unable to provide clear answers or demonstrate knowledge of the facility's expectations regarding medication management. This lack of compliance with established protocols poses a risk of medication errors and potential harm to residents, as medications were not securely stored or properly monitored.
Infection Control Lapses in PPE Use and Linen Handling
Penalty
Summary
The facility failed to adhere to infection control practices for residents under Transmission Based Precautions (TBP) and during the transportation of dirty linen. This deficiency was observed in four residents who were part of a sample of 28. For instance, a resident diagnosed with enterocolitis due to Clostridium difficile was placed under contact isolation. However, a family member and an occupational therapist entered the resident's room without wearing the required personal protective equipment (PPE) and did not follow proper hand hygiene protocols. The family member was not instructed on the necessary precautions, and the occupational therapist used alcohol-based hand sanitizer instead of washing hands with soap and water, which is ineffective against C. difficile. Another resident with a Foley catheter and wounds was under Enhanced Barrier Precautions (EBP) due to the risk of Methicillin Resistant Staphylococcus Aureus (MRSA). Despite this, a certified nurse assistant (CNA) entered the resident's room without a gown because the isolation bin was not stocked with gowns. The CNA handled the urinary catheter bag, which was improperly placed on the ground, without wearing the appropriate PPE. The Director of Nursing (DON) and other staff members acknowledged the need for proper PPE and hand hygiene but failed to ensure compliance. Additionally, there were lapses in the handling and transportation of soiled linen. A CNA performed incontinent care on a resident without changing gloves or performing hand hygiene afterward. The CNA also transported soiled briefs and linen to the soiled utility room without placing them in a garbage bag. Another incident involved a CNA who did not change gloves or wash hands during the process of changing a resident's wet brief and pants. These actions were contrary to the facility's policies on handling soiled linen and hand hygiene, which require proper disposal and hand hygiene to prevent the spread of infection.
Failure to Implement Resident's DNR Status
Penalty
Summary
The facility failed to honor a resident's right to have their chosen Advanced Directives status of Do Not Resuscitate (DNR) implemented. This deficiency was identified for one resident, who was admitted with multiple diagnoses including encephalopathy, frontotemporal neurocognitive disorder, convulsions, type 2 diabetes, hypertension, anxiety, and dementia. The resident's family members confirmed that the resident had made the decision for a DNR status prior to experiencing cognitive changes, and this was documented in the Power of Attorney (POA) paperwork provided to the facility. However, the facility did not have a physician's order for the resident's DNR status, and the Director of Nursing stated that without a POLST or physician's DNR order, the resident is assumed to be a full code. The Assistant Director of Nursing acknowledged that physician orders are required for code status on admission and that the resident's code status, as part of the POA, should have been followed. Despite the POA forms being scanned into the Electronic Medical Record, the physician orders did not contain directives regarding the resident's resuscitation status. The facility's policy on Communication of Code Status emphasizes the importance of adhering to residents' rights to formulate Advanced Directives and implementing procedures to communicate a resident's code status to necessary individuals, which was not followed in this case.
Deficiencies in ADL Care for Two Residents
Penalty
Summary
The facility failed to provide adequate ADL care to two residents, resulting in deficiencies in personal hygiene and toileting assistance. One resident, who was admitted with multiple diagnoses including a fracture, anxiety, and cognitive impairment, required substantial assistance with personal hygiene. Despite this, the resident was observed over several days with a crusted substance on her eyelid, indicating that her face had not been washed. The CNAs responsible for her care admitted to not washing her face, and the Director of Nursing acknowledged that ADLs should be performed daily, with a visual assessment to determine residents' needs. Another resident, diagnosed with Parkinson's disease and other conditions, was dependent on staff for toileting hygiene. During an observation, a CNA assisted the resident with toileting but failed to wipe the resident after a bowel movement or offer handwashing. The CNA later acknowledged the importance of assisting residents with wiping and handwashing. The Director of Nursing confirmed that CNAs are expected to ensure residents' hygiene is maintained and to encourage handwashing to prevent contamination. The facility's policy states that residents unable to perform ADLs should receive necessary services to maintain hygiene.
Failure to Apply Assistive Devices as Ordered
Penalty
Summary
The facility failed to ensure the proper application of anti-contracture devices and a Controlled Ankle Movement (CAM) Boot as ordered for two residents. Resident R160, diagnosed with Parkinsonism, weakness, and dementia, had a physician's order for hand rolls to reduce the risk of contractures. However, observations over several days showed that R160's right hand was consistently in a fist form without the prescribed splint. Interviews with staff revealed that there was no restorative program in place, and makeshift solutions like rolled-up washcloths were used instead of the ordered hand rolls. Resident R354, admitted with a displaced bimalleolar fracture and other mobility issues, had a physician's order for a CAM boot to be worn at all times except during range of motion exercises and bathing. Despite this, the CAM boot was observed off while the resident was in bed, contrary to the physician's order. Interviews with CNAs and the Occupational Therapist indicated a misunderstanding of the order, with staff believing the boot was only necessary when the resident was in a chair. The Director of Nursing confirmed that the boot should be on at all times, except during specific activities as per the order.
Improper Catheter Positioning Risking UTI
Penalty
Summary
The facility failed to maintain proper catheter care for a resident, leading to a potential risk of urinary tract infection (UTI). A male resident with severe cognitive impairment and a diagnosis of urinary retention was observed with an indwelling catheter bag positioned above the bladder level while seated in a wheelchair. This improper positioning caused urine to pool in the catheter tubing. A registered nurse acknowledged that the catheter bag might have been left in this position by a therapist and confirmed that such positioning could lead to a UTI. The Director of Nursing also stated that the catheter bag should be kept below the bladder level to prevent potential UTIs. The facility's policy on indwelling catheter use and removal specifies that the catheter should be secured to facilitate urine flow, prevent kinks, and be positioned below the bladder level.
Failure to Maintain PICC Line Dressing
Penalty
Summary
The facility failed to adhere to its policy on maintaining a Peripherally Inserted Central Catheter (PICC) line for a resident, identified as R62, who was part of a sample of 28 residents reviewed for central line catheter care. R62, a male resident with intact cognition, was admitted with diagnoses including Sepsis, Right Lower Limb Cellulitis, and Osteolysis. On observation, R62 was found with a left upper arm double lumen PICC line that had a dirty, peeling dressing with no date or label. The resident expressed uncertainty about whether the facility had ever changed his PICC line dressing. Further investigation revealed that there was no physician order to change R62's PICC line dressing, and the Medication Administration Record (MAR) lacked documentation of weekly dressing changes. The Registered Nurse (V5) confirmed the absence of an order and documentation for dressing changes. The Director of Nursing (V2) stated that PICC line dressings should be changed weekly and as needed, with proper dating and labeling to prevent central line-associated bloodstream infections (CLABSI). The facility's policy, reviewed and revised shortly before the incident, mandates weekly dressing changes or as needed to minimize infection risks, with physician orders specifying dressing type and change frequency.
Failure to Obtain Consents and Follow Pharmacy Recommendations for Psychotropic Medications
Penalty
Summary
The facility failed to obtain consents for psychotropic and antidepressant medications for two residents, R156 and R308, and did not follow pharmacy recommendations. R308, who had multiple diagnoses including major depressive disorder and anxiety, was administered Clonazepam and Mirtazapine without signed consents or documented verbal consents in the electronic medical record. The facility's administrator and director of nursing acknowledged the absence of consents and highlighted the potential risks of administering psychotropic medications without them. Additionally, the facility's policy required that residents and their representatives be educated on the risks and benefits of psychotropic drug use, which was not adhered to in these cases. For R156, who had diagnoses including Alzheimer's Disease and unspecified psychosis, the facility did not have medication consents for Escitalopram and Olanzapine. Furthermore, the facility failed to complete the AIMS test as recommended by the pharmacist until the survey was conducted. The assistant director of nursing confirmed that the AIMS test should have been completed within a day of the pharmacy's recommendation. These oversights indicate a failure to comply with the facility's policy on psychotropic medication management and monitoring.
Lack of Documentation for Falls PIP
Penalty
Summary
The facility failed to provide documentation or evidence of their yearly Performance Improvement Projects (PIP) for falls, which they had identified as a problem-prone area. This deficiency was discovered during a QAPI/QAA task conducted with the surveyor, where the Administrator and Assistant Director of Nursing (ADON) were unable to locate any records of QAPI/QAA meetings or information regarding the facility's PIP. Additionally, there was no tracking or trending data available to demonstrate which interventions were implemented to address the fall PIP or their effectiveness in reducing falls within the facility. The facility's QAPI Feedback policy outlines the importance of collecting feedback from staff, residents, and family members to conduct structured investigations and analyses of problems affecting quality of care, quality of life, and resident safety. However, the lack of documentation and data collection indicates a failure to adhere to this policy. The ADON mentioned having interventions in mind but had not documented them, as she had only recently taken over the QAPI responsibilities. This lack of documentation and systematic data collection potentially affects all 90 residents residing in the facility.
Failure to Conduct Quarterly QAA Meetings with Required Members
Penalty
Summary
The facility failed to hold Quality Assessment and Assurance (QAA) meetings on a quarterly basis and did not have the appropriate committee members present at these meetings. During an interview and record review, it was revealed that the Medical Director did not participate in the last QAPI meeting since the Assistant Director of Nursing (ADON) took over two weeks prior. The Administrator provided sign-in sheets for the QAA meetings, with the last meeting held in June 2024. The ADON provided two sign-in sheets dated September 26, 2024, and October 3, 2024, which were not QAA meetings but rather introductory sessions on QAPI for staff. These sign-in sheets did not include the Medical Director's attendance. According to the facility's policy, the QAA committee should include the Director of Nursing and the Medical Director or their designee and meet at least quarterly.
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What surveyors actually found near you
We read the 160 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Morris
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Arcadia Care Morris | 0.9 mi | ★★★★★ | 5 | 0 |
| Goldwater Care Marseilles | 14.2 mi | ★★★★★ | 12 | 0 |
| Aperion Care Wilmington | 16.8 mi | ★★★★★ | 11 | 0 |
| Alden Estates Of Shorewood | 17.1 mi | ★★★★★ | 6 | 0 |
| Alden Courts Of Shorewood | 17.1 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.