Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Morningside Center during CMS and state inspections, most recent first.
Incorrect DNR Documentation and Missing Incapacity Verification: The facility failed to ensure DNR forms were completed correctly for three residents. One resident’s DNR listed the DPOA’s name instead of the resident’s name, and two residents had DNRs signed by DPOAs without letters of incapacitation on file. The residents had significant cognitive impairment and diagnoses including dementia, Parkinson’s disease, atrial fibrillation, and kidney disease.
Inaccurate MDS assessments were found for two residents. One resident’s MDS did not include COPD despite records showing an ER transfer for low O2, SOB, tachycardia, and a later hospital dx of COPD exacerbation and pneumonia, along with orders for antibiotics, mucolytic therapy, cough syrup, and PRN O2 for an URI. Another resident’s MDS did not include a recent UTI despite a UA order followed by Keflex for a positive UA; the care plan noted urinary incontinence and risk for UTI and skin breakdown. The MDS coordinator said dx such as COPD or UTI should be reflected on the MDS after admission, and the DON stated MDS assessments should be accurate and timely.
The facility failed to develop and implement comprehensive, person-centered care plans for several residents with identified needs. Care plans did not address recurrent UTIs and antibiotic use for two residents, Eliquis use and dementia-related psychosocial or activity needs for one resident, and changing functional and skin integrity needs for another resident whose status had declined. The report also described outdated care planning for a resident with major transfer and weight-bearing changes, while another resident’s plan only partially reflected UTI risk and dependence in ADLs.
An RN administered insulin and an opioid to two residents without first verifying the physician orders in the EMR, giving the meds from memory. In separate catheter procedures, staff failed to maintain sterile technique and proper infection control: the RN contaminated the sterile field, cleansed the meatus incorrectly, advanced the catheter with contaminated gloves, and a CNA left the drainage tubing with a dependent loop and the bag on the floor.
Staff failed to provide complete perineal care for dependent residents after incontinence episodes. A resident with cognitive impairment and a UTI was cleaned only on the back side while the front area was left uncleaned, and other residents with severe cognitive impairment were observed with saturated briefs and pants while staff reused disposable wipes, omitted hand hygiene between dirty and clean tasks, and did not provide oral care or hydration during care. The DON stated residents should be checked and changed as needed, with oral care and ADL assistance provided routinely.
Two residents with indwelling urinary catheters received improper catheter care and insertion services. An RN cut the balloon port instead of removing fluid properly, used nonsterile technique during insertion, cleansed the urinary opening in a circular motion rather than front to back, failed to provide peri-care, and allowed catheter tubing to develop a dependent loop with the drainage bag on the floor. For another resident, the RN dropped the sterile tray on the floor, reused it, used contaminated technique while advancing the catheter, and again used circular cleansing and improper balloon-port removal.
Medication Administration Error Rate Exceeded Allowed Threshold: Surveyors found an 8% med error rate, with 2 errors in 25 opportunities. An RN administered lispro insulin to one resident and hydrocodone/APAP to another resident without verifying the physician orders in the EMR, and both medications were given from memory rather than after checking the MAR/eMAR and order details.
Failure to Verify Medication Orders Before Administration: An RN administered insulin to one resident and hydrocodone/APAP to another resident without first verifying the physician orders in the EMR. The insulin-dependent resident was observed receiving Lispro insulin with the computer screen closed, and the cognitively intact resident being treated for pain was given a narcotic from the locked med box based on memory. The RN acknowledged the orders were not verified and stated this was a significant med error; the DON and Administrator said orders were expected to be verified before administration and documented immediately.
Failure to maintain sterile catheter insertion technique and hand hygiene during resident care and food service. A resident with severe cognitive impairment, dependence for all ADLs, and a UTI history had a catheter inserted with multiple breaks in sterile technique, including improper cleansing, contaminated glove use, and a drainage setup with tubing on the floor. Separately, dietary staff passed water and served salads to residents without washing hands or using ABHR between rooms or between residents, including after touching a resident.
A resident with impaired cognition and a history of aggressive behaviors toward staff, including hitting, kicking, and yelling, was not care-planned for aggression toward others despite multiple documented incidents. Another cognitively impaired, wandering resident with socially inappropriate behaviors approached this resident, touching their clothing and wheelchair. Before staff could intervene, the seated resident became angry, yelled for the other to go away, and slapped the wandering resident across the face, causing facial redness. This sequence of events, combined with the lack of care-planned interventions for known aggression, resulted in a failure to protect a resident from physical abuse.
The facility failed to respond to residents' call lights within the required timeframe, affecting several residents' dignity and care. Residents experienced significant delays, with some waiting over an hour for assistance, leading to discomfort and distress. Staff interviews revealed inconsistencies in understanding the expected response times, contributing to the deficiency.
The facility failed to address and follow up on grievances raised by the resident council, affecting all residents' quality of life and care. The grievance policy was not followed, with no documented resolutions or explanations for unresolved issues. The Activity Director lacked training, and the Administrator admitted to not providing documentation to the council, leading to a deficiency in honoring residents' rights.
The facility failed to obtain physician orders for code status for four residents, despite their face sheets indicating specific code statuses. Interviews and record reviews revealed that the care plans and physician orders did not reflect the residents' code statuses, as confirmed by facility staff.
The facility allowed four volunteers to interact with residents without completing TB skin testing, as the policy did not include volunteers in the TB surveillance process. This oversight could potentially affect all 52 residents. The Administrator and DON were unaware of the need for TB checks for volunteers.
A facility failed to include dialysis in a resident's care plan, despite the resident attending dialysis sessions three times a week. The resident, who required assistance with daily activities and had a history of falls, did not have dialysis needs addressed in their baseline care plan. Staff interviews revealed a lack of awareness and communication regarding the resident's dialysis schedule, contributing to the oversight.
A facility failed to complete a discharge summary for a resident, violating its discharge planning policy. The resident, with diagnoses including debility and heart disease, was discharged without a documented recapitulation of their stay or a copy provided to them, despite the policy requiring such documentation.
A facility failed to ensure proper communication and documentation for a resident requiring dialysis. The resident's care plan did not address dialysis needs, and there were no orders for assessments or monitoring of the dialysis site. Staff interviews revealed that vital signs and weight were taken, but no paperwork was exchanged with the dialysis center, indicating a lack of consistent communication and documentation practices.
Incorrect DNR Documentation and Missing Incapacity Verification
Penalty
Summary
The facility failed to ensure that DNR orders were completed correctly for three residents and failed to ensure that two residents had letters of incapacitation before their DPOAs signed DNR forms. Resident #29 had severe cognitive impairment, partial assistance with ADLs, incontinence, and diagnoses including dementia, hypertension, and coronary artery disease. Although the resident’s care plan identified a DNR code status, the DNR form listed the resident’s DPOA name on the line reserved for the resident’s name. The form was signed by the DPOA and later by the physician. The Social Services Director stated the resident’s name should be on the DNR and that the resident should sign if not deemed incapacitated. Resident #13 had moderate cognitive impairment, partial assistance with ADLs, incontinence, and diagnoses including Parkinson’s disease and depression, and Resident #21 had severe cognitive impairment, substantial assistance with ADLs, incontinence, and diagnoses including atrial fibrillation, kidney disease, and dementia. Both residents had DNR code status documented in their care plans, but their DNR forms were signed by their DPOAs without letters of incapacitation in the record. The SSD stated there were no incapacity letters for Residents #13 and #21 and that she should have ensured incapacity verification was on file before the DPOAs signed the DNRs. The DON and Administrator also stated the resident’s name should not have been replaced by the responsible party’s name and that the DNRs for Residents #13 and #21 were not correct.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
Resident assessments were not completed accurately for two sampled residents. For Resident #1, the Quarterly MDS dated 02/03/26 did not select COPD as a diagnosis, even though the record showed orders for azithromycin and Mucinex for an upper respiratory infection, cough syrup and supplemental oxygen as needed, an emergent transfer to the emergency room on 01/13/26 for low blood oxygen levels, shortness of breath, and tachycardia, and a hospital admission on 01/16/26 with diagnoses of COPD exacerbation and pneumonia. The care plan dated 02/25/26 included Enhanced Barrier Precautions for a chronic wound and noted poor safety awareness and confusion, but did not mention supplemental oxygen use or goals and interventions to prevent recurrent URI. For Resident #7, the Quarterly MDS did not select UTI in the last 30 days. The care plan dated 11/12/25 documented urinary incontinence, risk for UTI and skin breakdown, and a goal to detect and treat any UTI promptly. The physician order sheet showed a UA order dated 03/10/26 and then Keflex 500 mg twice daily for 7 days for a UTI after a positive UA result. During interview, the MDS coordinator stated that if a resident was admitted with a diagnosis of COPD or UTI and was on antibiotics, that diagnosis should be reflected on the MDS assessment after admission, and that care plans and MDS assessments were often not updated as quickly as they should be. The DON stated that all MDS assessments should be accurate and completed in a timely manner per CMS requirements.
Incomplete and outdated care plans for UTI, anticoagulant use, dementia, and changing functional status
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes for multiple residents whose assessments identified medical, nursing, and psychosocial needs. The report states that care plans were not updated to address urinary tract infections and antibiotic use for two residents, anticoagulant use and therapeutic activities for one resident, and dementia care for one resident. The facility’s care plan policy required measurable objectives and timetables to address residents’ physical, psychosocial, and functional needs, but the cited care plans did not reflect those identified needs. One resident had cognitive impairment, required assistance with personal care and catheter care, and had diagnoses including prostate disease with urinary symptoms, dementia, and recurring antibiotic use for urinary infections; however, the care plan did not indicate antibiotic use for UTI or a history of UTIs. A family member stated the resident had frequent infections and antibiotic needs related to the catheter and expected those needs to be addressed in the care plan. Another resident had cognitive impairment, dementia-related behaviors, urinary incontinence with UTIs, and a new active UTI with Keflex ordered, but the care plan did not address frequent UTIs, antibiotic use, staff interventions for UTI prevention, or the possibility of an active UTI as a cause of behaviors. A third resident was not cognitively intact, required total assistance, and was prescribed Eliquis 5 mg twice daily to prevent blood clots, yet the care plan did not address the blood thinner or monitoring needs, and it also did not address activity interests or dementia-related psychosocial interventions. The report also noted a resident whose condition had changed from ambulatory and continent to dependent for all care and a mechanical lift transfer, but whose care plan had not been updated to reflect those changes or the skin integrity needs associated with the decline. Another resident’s care plan remained outdated despite changes in transfer status, weight-bearing status, and activity orders, and a separate resident’s care plan identified UTI risk and dependence in ADLs but was not described as fully reflecting the resident’s current needs.
Failure to Verify Medication Orders and Maintain Sterile Catheter Technique
Penalty
Summary
Professional standards of quality of care were not maintained when licensed nursing staff administered medications without first verifying the physician orders in the electronic medical record for two residents. One resident was alert and oriented, cognitively intact, insulin dependent, and had a current order for Lispro insulin with meals. During observation, an RN prepared and administered the insulin from memory with the computer screen closed and the order was not verified before administration or documented at the time it was given. Another resident was cognitively intact and treated for pain, with a current order for Hydrocodone/APAP 10/325 mg four times daily. During observation, the RN removed the narcotic from the locked medication box and administered it without checking the electronic order, and later stated the order should have been verified before giving either medication. Professional standards were also not maintained during indwelling urinary catheter removal and insertion for two residents. One resident had dementia, required assistance with all personal care, and had an order for monthly and as-needed catheter changes. During the catheter change, the RN cut the balloon port with scissors, discarded the catheter, dropped the sterile insertion tray on the floor and placed it back on a clean towel, cleansed the urinary opening in a circular motion rather than the described downward cleansing method, and then attempted to advance the catheter further after the sterile glove became contaminated. The RN also inflated the balloon before immediate urine return was noted. Another resident had severe cognitive impairment, was dependent for all care, and had diagnoses including dementia, pain, and UTI. During catheter insertion, the RN tore the catheter packaging, handed the catheter to a CNA, broke sterile technique by placing hands on the resident’s inner thighs, cleansed the genital area in a circular motion and reused swabs in the kit, and later used contaminated gloves while advancing the catheter and inflating the balloon. The CNA attached the drainage bag and tubing to the bed frame, then lowered the bed so the tubing had a dependent loop and the drainage bag rested directly on the floor. Staff interviews confirmed the expected sterile technique, downward cleansing, perineal care after insertion, and keeping tubing free of dependent loops and the drainage bag off the floor.
Incomplete Perineal Care and Reused Wipes During Incontinence Care
Penalty
Summary
The facility failed to ensure dependent residents received complete perineal care after incontinence episodes. The report states that staff did not clean all areas where urine or feces had touched for multiple residents, and in several observations staff reused disposable wipes during cleansing instead of discarding them after use. The facility’s perineal care policy required wiping from front to back, cleaning all areas touched by urine and feces, and documenting the resident’s tolerance and any refusal of care. For one resident with moderate cognitive impairment, incontinence of bowel and bladder, Parkinson’s disease, depression, and an active UTI treatment course, a nurse aide was observed assisting the resident on the toilet while droplets of yellow liquid were visible on the upper thighs and between the legs. The aide removed the wet brief, cleaned the back, and dressed the resident, but did not offer or attempt to clean the front where urine and/or feces had touched. The resident’s record showed the resident required assistance with toileting and perineal care and was being treated with antibiotics for a UTI at the time. For another resident with severe cognitive impairment, dependence in all ADLs, non-Alzheimer’s dementia, pain, and UTI, staff were observed during evening ADL care wiping the buttocks and coccyx multiple times with the same disposable wipe before discarding it. The resident also had an external catheter stabilizing device that was not properly attached. The DON stated dependent residents should be checked for incontinence and changed every two hours and as needed, and that dependent residents should receive oral care and assistance with ADLs twice daily. A third resident with severe cognitive impairment, incontinence of bowel and bladder, and maximum assistance needs was observed on multiple occasions with saturated briefs and pants. Staff repeatedly reused wipes during incontinence care, including folding and reusing the same wipe several times and, in one instance, tucking used wipes between the resident’s legs. During one observation, staff did not perform hand hygiene or use ABHR between dirty and clean tasks, and no oral care or hydration was provided. A fourth resident with severe cognitive impairment, incontinence, and dependence for toileting, hygiene, and eating was also observed with a saturated brief and pants, with staff wiping the groin area using a folded wipe and not providing a drink or oral care.
Improper catheter care and insertion technique
Penalty
Summary
The facility failed to ensure appropriate catheter care and urinary catheter insertion practices for two residents with indwelling urinary catheters. Both residents had significant cognitive impairment and required extensive assistance with all personal care, including catheter care. One resident had a recent hospitalization for a UTI, a new urinary catheter placed during that admission, and was ordered Macrobid for UTI treatment. The other resident had dementia, prostate disease with ongoing urinary symptoms, and an order for monthly catheter changes and as needed. For one resident, survey observation of catheter removal and reinsertion showed the RN cutting the balloon port with scissors rather than removing fluid through the port, with fluid spilling onto the bed so the amount removed from the balloon could not be determined. During insertion, the RN placed supplies between the resident’s calves, handled sterile items in a manner that broke sterile technique, used circular cleansing motions instead of cleansing away from the urinary opening, and later advanced the catheter further after gloves had been removed and replaced in a contaminated manner. The RN also did not provide peri-care after insertion. The drainage bag was attached to the bed frame, but the tubing developed a dependent loop and the bag was left directly on the floor. For the second resident, observation of catheter removal and insertion showed the RN again cutting the balloon port with scissors and receiving no return of fluid into the collecting container. The insertion tray was dropped on the floor and then placed back on a clean towel. The RN used cleansing swabs in a circular motion rather than cleansing away from the urinary opening, inflated the balloon after insertion, and then attempted to advance the catheter further with a contaminated glove after dropping the leg secure strap on the floor and picking it up. Interviews with staff and the DON confirmed that catheter tubing should be anchored at the insertion site before cleaning and that dependent loops in tubing should not be present, while the RN stated he/she had always cut the balloon port and used circular cleansing motions.
Medication Administration Error Rate Exceeded Allowed Threshold
Penalty
Summary
The facility failed to ensure medication administration error rates remained below 5 percent. Surveyors found 2 errors in 25 opportunities for error, resulting in an 8 percent error rate, affecting 2 of 14 sampled residents. The facility policy required medications to be administered as prescribed, with the medication and dosage schedule on the MAR/eMAR compared with the medication label, and physician orders checked whenever there was any question about dosage or directions. Resident #1 was alert and oriented with intact cognition and was an insulin-dependent diabetic receiving lispro insulin with meals. During observation, an RN prepared and administered lispro insulin while the computer screen was closed, and the physician's order was not verified in the electronic medical record before administration; the insulin was also not documented as given at the time it was observed and was given from memory. Resident #34 was cognitively intact and treated for pain. During observation, an RN removed hydrocodone/APAP 10/325 mg from a locked narcotic box and administered it without checking the electronic medical record to verify whether there had been any changes to the medication order, and the medication was given from memory. The RN stated he/she knew what medications to give but did not verify the physician's orders prior to administering either medication.
Failure to Verify Medication Orders Before Administration
Penalty
Summary
The facility failed to ensure that two residents were free from significant medication errors when RN B administered medications without first verifying the physician orders in the electronic medical record. One resident was alert and oriented, cognitively intact, recently re-admitted, and insulin dependent with orders for Lispro insulin injections with meals. During observation, RN B prepared the insulin at the medication cart with the computer screen closed, dialed the dose to 3 ml, and administered it without verifying the order in the EMR or documenting it at the time it was given. A second resident was cognitively intact and being treated for pain, with an order for Hydrocodone/APAP 10/325 mg, one tablet four times daily. During observation, RN B removed one tablet from the locked narcotic card and administered it without checking the EMR for the current order or any changes, giving the medication from memory. In interview, RN B stated the orders were not verified prior to administration and acknowledged this should always be done and that failing to do so is a significant medication error. The Administrator and DON stated it was the expectation that all physician orders be verified and reviewed prior to administration and documented immediately when given.
Failure to Maintain Sterile Catheter Technique and Hand Hygiene
Penalty
Summary
The facility failed to maintain sterile precautions during urinary catheter insertion for a resident who had severe cognitive impairment, was dependent for all care areas, and had diagnoses including dementia, pain, and UTI. During the observed catheter insertion, the RN tore the catheter packaging, handed the catheter to a CNA, and then broke sterile technique by placing both hands on the resident’s inner thighs. The RN cleansed the genital area with antiseptic swabs in a circular motion and placed used swabs back into the catheter kit packaging instead of discarding them. The RN then inserted the catheter, removed and reapplied a glove with the ungloved hand, used a contaminated sterile-gloved hand to advance the catheter, and used both contaminated gloved hands to fill the balloon. After the catheter was inserted, the CNA attached the drainage bag and tubing to the bed frame and then lowered the bed so that a dependent loop formed in the tubing and the drainage bag lay directly on the floor. An RN stated there should be no dependent loop or coiling in the tubing because it stops urine flow and can lead to infection, and noted the resident was prone to frequent UTIs. The RN who performed the procedure stated he or she was not used to working with the CNA, used a circular motion to cleanse the genitals instead of a downward stroke, and should have provided perineal care after inserting the catheter. The DON stated sterile procedure should be maintained during catheter insertion and catheter care should be provided each shift and as needed for soiling. The facility also failed to ensure hand hygiene during food and water service. A dietary aide passed fresh water on the 300 hall and repeatedly entered resident rooms with clean pitchers and exited with used cups or pitchers without washing hands or using ABHR between rooms. In the dining room, another dietary aide served made-to-order salads to residents without gloves and did not wash hands between residents, including after touching a resident’s back before serving the next salad. The dietary aide stated hands should be washed between residents if touching a non-food service clean surface and between touching residents and serving another resident due to the spread of germs. The Administrator stated staff should wash or sanitize hands after touching a resident when serving meals, and the DON stated staff should use ABHR or wash hands between dirty and clean tasks.
Failure to Protect Resident From Abuse During Resident-to-Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse when one resident slapped another resident on the cheek. The facility’s abuse and neglect policy states that residents have the right to be free from all types of abuse, including physical abuse, and that abusers may include other residents. The resident who committed the slap had an annual MDS showing impaired cognition, dependence on staff for showers, toileting, and transfers, and diagnoses including urinary tract infection, diabetes, and respiratory failure. The resident’s care plan, dated after the incident, later identified that this resident could be a threat to others and could become physically and verbally aggressive, but these interventions were not in place at the time of the event. In the days leading up to the incident, nursing progress notes documented multiple episodes of aggressive behavior by the resident who later slapped another resident. On several dates in December, this resident was noted to be refusing care, hitting, kicking, cursing, yelling at staff, and swinging at them when they approached. Despite these repeated documented behaviors, there were no care-planned interventions for aggressive behaviors toward others in place at the time of the incident. The Assistant Administrator acknowledged that the resident did not have care-planned interventions for aggression because the resident was relatively new and the facility was not aware of the resident’s history, even though the record showed multiple aggressive episodes toward staff prior to the assault. The resident who was slapped had a quarterly MDS indicating impaired cognition, a need for moderate assistance with ADLs such as showering, toileting, and transfers, and diagnoses including dementia, bipolar disorder, and insomnia. This resident’s care plan noted socially inappropriate and disruptive behaviors, including removing clothing in common areas, impaired decision making, and disorganized thinking. On the day of the incident, progress notes and the facility’s self-report documented that the cognitively impaired resident approached the other resident, picked at the resident’s clothing and wheelchair, and touched the resident’s chair and clothes. Before staff could intervene, the seated resident became angry, yelled for the other to go away, and slapped the other resident across the face, causing facial redness. Staff interviews confirmed that the wandering behavior of the victim and the aggressive behavior of the assailant were known, but the assailant’s aggressive behaviors had not been incorporated into the care plan prior to the incident, resulting in a failure to protect the resident from abuse.
Delayed Call Light Responses Compromise Resident Dignity
Penalty
Summary
The facility failed to ensure timely responses to residents' call lights, which compromised the dignity and care of several residents. Observations and interviews revealed that call lights were not answered within the facility's policy timeframe, which states that calls should be answered as soon as possible, but no later than five minutes. In multiple instances, residents experienced significant delays, with some waiting over an hour for assistance. This delay in response was consistent across several residents, affecting their ability to receive timely help with toileting, pain management, and other personal needs. Resident #15, who had moderately impaired cognition and required substantial assistance with daily activities, experienced prolonged waits for call light responses, leading to incontinence and discomfort. The call light logs for this resident showed multiple instances where the response time exceeded the policy's five-minute requirement, with some delays lasting over an hour. This lack of timely response resulted in the resident experiencing cold and wet conditions due to incontinence, which was distressing for them. Other residents, such as Resident #1 and Resident #27, also faced similar issues with delayed call light responses. Resident #1, who had intact cognitive skills but required assistance with showers and experienced MS flare-ups, reported waiting over 20-30 minutes for assistance, which affected their comfort and pain management. Resident #27, who was dependent on staff for all care due to various health conditions, expressed dissatisfaction with the long wait times, which sometimes exceeded an hour. Interviews with staff revealed inconsistencies in their understanding of the expected response times, with some staff believing the policy allowed for longer response times than stated, contributing to the deficiency in care.
Failure to Address Resident Council Grievances
Penalty
Summary
The facility failed to adequately address and follow up on grievances raised by the resident council, which affected the quality of life and care for all residents. The facility's grievance policy mandates prompt handling of grievances, providing written responses, and conducting follow-ups to ensure satisfaction. However, the review of resident council minutes from several months showed no references to prior concerns, no documented resolutions, and no explanations for unresolved issues. Interviews with resident council members revealed that the facility did not follow up on grievances or provide updates on recommendations made by the council. The Activity Director admitted to not receiving formal training on coordinating resident council meetings and was unaware of the process for addressing residents' concerns. The Assistant Administrator stated that concerns were discussed with the administrative team and addressed at quality assurance meetings, but sometimes ongoing issues were not explained to the resident council. The Administrator expected the resident council president to be informed about the status of grievances, but acknowledged that no documentation was provided to the council regarding resolutions. This lack of communication and documentation led to the deficiency in honoring residents' rights to organize and participate in resident/family groups effectively.
Failure to Obtain Physician Orders for Code Status
Penalty
Summary
The facility failed to obtain a physician's order for code status for four residents out of the 13 sampled residents. This deficiency was identified through interviews and record reviews. The facility's policy and procedure regarding the provision of basic life support were requested but not provided. The physician services policy indicates that orders for a resident's immediate care and needs can be provided by a physician, physician assistant, nurse practitioner, or clinical nurse specialist. However, for Residents #26, #22, #51, and #16, there were no physician orders for their code status, despite their face sheets indicating specific code statuses. Resident #26 was readmitted with a diagnosis of dementia, heart disease, arthritis, and a fracture of the right leg, with a code status of Do Not Resuscitate, but this was not reflected in the care plan or physician orders. Resident #22, with a history of stroke and heart disease, was listed as Full Code, but again, there was no physician order. Resident #51, admitted with a fracture and a Stage 4 pressure ulcer, was also listed as Full Code without a corresponding physician order. Similarly, Resident #16, with multiple chronic conditions, was listed as Full Code, but the care plan and physician orders did not reflect this. Interviews with facility staff, including an RN, the DON, and the Administrator, confirmed that there should be a physician order for code status, but it was not present for these residents.
Infection Control Lapse: Volunteers Without TB Testing
Penalty
Summary
The facility failed to adhere to infection control guidelines by allowing four volunteers to interact with residents without completing the necessary TB skin testing. The facility's policy mandates TB testing for new employees but does not address volunteers, leading to a gap in the infection control process. The volunteers began their service without undergoing TB skin tests, which could potentially affect all 52 residents in the facility. During an interview, the Administrator and Director of Nursing admitted they were unaware that TB checks were required for volunteers and had not included them in the TB skin test surveillance process.
Failure to Include Dialysis in Resident's Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident who required dialysis. The resident, who was admitted with a history of falls and slight confusion, required assistance with various activities of daily living. Despite these needs, the baseline care plan did not address the resident's dialysis requirements, which is a critical medical procedure for individuals whose kidneys are not functioning properly. The absence of dialysis in the care plan was confirmed through interviews with the resident, who mentioned attending dialysis sessions three times a week, and various staff members, including the MDS/Care Plan Coordinator, Social Services Designee, Registered Nurse, and Director of Nursing, all acknowledged that dialysis should have been included in the care plan. The deficiency was identified through a review of the resident's records and interviews with the resident and staff. The Physician Order Sheet for the resident did not contain any orders for assessments or vitals related to dialysis, indicating a lack of comprehensive planning for the resident's medical needs. The staff interviews revealed a lack of awareness and communication regarding the resident's dialysis schedule, which contributed to the oversight in the care planning process. This failure to include dialysis in the care plan highlights a significant gap in addressing the resident's medical needs and ensuring their well-being.
Failure to Complete Discharge Summary for Resident
Penalty
Summary
The facility failed to complete a discharge summary for a resident, identified as Resident #55, and did not adhere to its own discharge planning policy. The facility's policy, effective January 11, 2024, outlines a comprehensive discharge planning process that includes initiating discharge planning upon admission, involving residents and their representatives, conducting thorough assessments, and developing a written discharge plan. However, upon review, it was found that there was no recapitulation of Resident #55's stay or evidence that a copy was provided to the resident at discharge. Resident #55's assessment, dated November 5, 2024, indicated that the resident had intact cognitive skills, was independent with eating and oral hygiene, required supervision or standby assistance with certain activities, and needed substantial assistance with bathing. The resident's diagnoses included debility, anxiety disorder, heart disease, and lung disease. Despite these needs, the facility did not document a discharge summary or provide it to the resident, which is a requirement under their discharge planning policy.
Failure in Communication and Documentation for Dialysis Care
Penalty
Summary
The facility failed to ensure proper communication and documentation between its staff and the dialysis center, affecting a resident who required dialysis services. The resident, diagnosed with chronic kidney disease Stage 3 and a history of acute kidney failure, did not have a baseline care plan addressing dialysis needs. The Physician Order Sheet lacked orders for assessments or vitals before and after dialysis, and there were no orders regarding the monitoring of the hemodialysis catheter or fistula care. Progress notes indicated that the resident was transported to and from dialysis without documented assessments or communication with the dialysis center. Interviews with the resident and facility staff revealed that vital signs and weight were taken before and after dialysis, but no paperwork was exchanged between the facility and the dialysis center. The Director of Nursing acknowledged that there should be an order for dialysis and that vital signs and weight should be recorded. However, the facility only sent paperwork and a report with the resident to dialysis once a week, indicating a lack of consistent communication and documentation practices in line with standards of care.
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Illustrative
What surveyors actually found near you
We read the 29 citations issued within 25 miles in the last 12 months — including the 2 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.
Illustrative
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Illustrative
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Nursing homes near Chillicothe
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Grand River Health Care | 0.4 mi | ★★★★★ | 3 | 1 |
| Stonebridge Chillicothe | 0.7 mi | ★★★★★ | 0 | 0 |
| Livingston Manor Care Center | 0.9 mi | ★★★★★ | 3 | 0 |
| Eastview Manor Care Center | 19.9 mi | ★★★★★ | 5 | 0 |
| Sunnyview Nursing Home & Apartments | 19.9 mi | ★★★★★ | 1 | 1 |
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