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 July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ms Care Center Of Morton during CMS and state inspections, most recent first.
Failure to honor a resident's right to refuse fingerstick blood glucose checks and use a CGM for monitoring. A resident with Type 2 DM and moderately impaired cognition repeatedly stated that fingersticks hurt and that he did not like them, while his daughter and RR reported staff kept doing fingersticks even after providing the CGM and posting signage. An LPN continued the fingerstick despite the resident's refusal, and the DON confirmed the facility had agreed to use the CGM if supplies were provided.
Leaky Faucet Not Repaired in Resident Room: A resident with COPD and intact cognition had a leaking sink in her room that remained unrepaired after she had previously reported it. The Maintenance Director confirmed the work order was overdue, and the Administrator acknowledged the repair request had not been completed; the resident reported the dripping water interrupted her sleep.
A resident with dementia and moderately impaired cognition was receiving quetiapine for hallucinations and sertraline for depression, but the facility did not attempt or document a GDR for the psychotropic medications. The MDS noted no GDR had been documented as clinically contraindicated, and interviews with the DON, pharmacy consultant, NP, attending physician, and Administrator confirmed the GDR was missed.
Care plans were not revised after repeated falls for two residents with fall risk. One resident had chronic kidney disease and moderately impaired cognition, and another had a history of falling with intact cognition. Although both care plans listed a safety focus and multiple fall events, the intervention dates did not match the falls and did not show updated or newly implemented interventions, which RN and DON confirmed.
A resident with Type 2 DM and moderately impaired cognition had an insulin order tied to blood glucose checks, but staff used both a facility glucometer and a CGM without a physician order for the CGM. MAR review showed multiple missing BG readings, inconsistent code entries, and absent progress notes across several months, while staff interviews confirmed confusion about whether the CGM or glucometer should be used and awareness gaps in documentation practices.
Consultant pharmacist monthly MMRs failed to identify and report medication irregularities for a resident receiving insulin, including missing BG documentation, inconsistent MAR entries, and insulin administration records that did not align with the order. The pharmacist also failed to identify the absence of a GDR for a resident receiving psychotropic meds, and the pharmacy reports did not include resident-specific findings or show which residents were reviewed. The DON confirmed no GDR documentation existed and that she had not received a pharmacist recommendation.
Insulin was administered outside physician-ordered parameters for a resident with Type 2 DM and moderately impaired cognition. MAR review showed multiple doses of NovoLog given when BG readings were below the ordered threshold, and one dose given at a lower-than-ordered amount for a higher BG reading, with no documentation or clarification in the record. An LPN stated she had not paid attention to the MAR codes, and the DON confirmed the doses did not match the order and were medication errors.
Improper food storage and labeling were observed in the dietary department when frozen pizza was left unlabeled and undated, opened meat and egg items were resealed without proper dating, and an open container of imitation bacon bits was stored without labeling. Surveyors also found expired buttermilk, deteriorated celery, lettuce that was opened and dated after its best-by date, and soy sauce stored in dry storage despite instructions to refrigerate after opening.
A male resident with a history of sexually inappropriate behaviors was not placed under supervision or subject to care plan interventions, despite prior incidents. This led to two female residents with severe cognitive impairment being inappropriately touched in the day room on separate occasions. Staff failed to communicate the initial incident, resulting in the resident being left unsupervised and able to reoffend before one-to-one observation was implemented.
A facility failed to update and implement a care plan for a resident with a history of sexually inappropriate behaviors, despite documented incidents and psychiatric evaluation indicating severe cognitive impairment and poor judgment. The resident was left unsupervised after an initial incident and subsequently inappropriately touched two other cognitively impaired residents in the day room. Staff interviews confirmed the care plan was not updated until after these incidents occurred.
A resident with a history of skin conditions had a prescribed face cream left at their bedside by an LPN, contrary to facility policy. The resident used the cream unsupervised, leading to facial irritation. The medication was initially prescribed for Actinic Keratosis but was discontinued early due to the adverse reaction. The facility's policy prohibits leaving medications at the bedside without a physician's order and assessment of the resident's capability for self-administration.
Two residents, a married couple, were not allowed to go outside together due to a past incident where one tried to assist the other to prevent a fall. Despite being cognitively intact and expressing a strong desire to spend time outdoors together, they were consistently denied this opportunity by staff. Interviews revealed a lack of awareness and communication among staff regarding the restriction, highlighting a failure to uphold the facility's policy on resident rights.
A facility failed to ensure a resident without an advance directive received assistance in formulating one. The resident, diagnosed with Dysphagia, Dementia, and Alzheimer's Disease, lacked a Power of Attorney and an Advance Directive. Despite providing a booklet on Advance Directives to the resident's representative, there was no documentation confirming acknowledgment of this information.
A facility failed to accurately complete an MDS discharge assessment for a resident with COPD, Hypertensive Chronic Kidney Disease, and Hypertensive Heart Disease with Heart Failure. The resident was discharged to home, but the MDS was incorrectly coded as a hospital stay. Interviews revealed the error was due to incorrect coding by an MDS nurse.
A resident with chronic heart failure and COPD did not have their oxygen tubing changed weekly as required by their care plan. Observations revealed the tubing was not dated, and staff confirmed the oversight. The care plan and physician's orders specified weekly changes, which were not followed, leading to a deficiency.
A facility failed to follow its standards of practice for respiratory care by not dating or properly storing oxygen tubing for a resident with COPD and heart failure. Observations showed the tubing was not dated or stored in a plastic bag when not in use, contrary to facility policy. Interviews with staff confirmed the expectation to change, date, and store tubing weekly, which was not adhered to in this case.
The facility failed to provide meals that were palatable and at an appetizing temperature for three residents. Complaints included food being cold, bland, and lacking seasoning. Observations confirmed that food temperatures were below desired levels. The dietary staff faced challenges due to inadequate training and the use of an open cart system, which contributed to the cooling of food before reaching residents.
The facility failed to prevent potential infection spread by improperly handling linens and not adhering to PPE protocols. A CNA placed dirty linens on the floor, and an LPN did not wear a gown while administering a PEG tube feeding, despite EBP requirements. These actions were confirmed by facility staff, including the DON and Infection Preventionist.
Failure to Honor Resident Preference for CGM Use Instead of Fingersticks
Penalty
Summary
The facility failed to honor a resident's right to refuse fingerstick blood glucose checks and to use a Continuous Glucose Monitor (CGM) for blood glucose monitoring. Resident #16 was admitted with Type 2 Diabetes Mellitus and had a BIMS score of 8, indicating moderately impaired cognition. The resident had a physician's order for sliding scale insulin twice daily and blood glucose checks before lunch and supper. The resident reported that he did not like having his fingers poked and said it hurt, and his daughter and resident representative reported that staff continued to perform fingersticks even after they provided the CGM device and supplies and placed signage in the room directing staff to use the CGM reader instead of fingersticks. During observation, the CGM sensor was seen on the resident's left upper arm and the reader was on the overbed table, but an LPN stated she was not aware the resident had a CGM and had been using the facility glucometer. When the resident again stated he did not like fingersticks, the LPN continued to perform the fingerstick blood glucose check. Another LPN reported awareness of the CGM and the signage but was unsure whether there was a physician order for the device. The DON confirmed the facility had agreed to use the CGM if supplies were provided, but she was not aware of the signage and had not followed up with staff or the daughter regarding its use. The DON and Administrator stated staff are expected to honor and respect resident rights and preferences.
Leaky Faucet Not Repaired in Resident Room
Penalty
Summary
The facility failed to ensure a resident's right to a safe, clean, comfortable, and homelike environment when a leaky faucet in the resident's room was not repaired. The facility's maintenance policy stated that plumbing fixtures were to be maintained in good working order and that maintenance personnel were responsible for establishing priorities for repair service. The resident involved was admitted with COPD and had a BIMS score of 15, indicating cognitive intactness. During observation, the sink in the resident's room was found leaking water, and the resident reported that she had previously reported the problem but it had not been repaired. She stated she had been told the sink would be fixed but could not recall when the request was made. The Maintenance Director confirmed the work order had been submitted and acknowledged the repair was overdue, explaining that the repair required addressing the valves before replacing the faucet. The resident later reported that the dripping water interrupted her sleep, and the Administrator acknowledged that the repair request had not been completed and that only a temporary repair had been attempted previously.
Failure to Document GDR for Psychotropic Medications
Penalty
Summary
The facility failed to ensure a resident was free from unnecessary chemical restraints related to psychotropic medications when it did not attempt or document a gradual dose reduction (GDR) for a resident receiving antipsychotic and antidepressant medications. Resident #79 was admitted with a diagnosis including dementia and had physician orders for quetiapine 25 mg at bedtime for hallucinations and sertraline 200 mg daily for depression. The resident’s quarterly MDS showed a BIMS score of 12, indicating moderately impaired cognition, and documented that no GDR had been documented by a physician as clinically contraindicated. Record review showed the medications were administered as ordered, but there was no documentation of any GDR in the medical record. The facility policy stated residents on psychotropic medications should receive GDRs unless clinically contraindicated, with attempts in two separate quarters during the first year after initiation. During interviews, the DON, pharmacy consultant, NP, attending physician, and Administrator all acknowledged that no GDR had been completed for the resident, and the DON stated she had assumed medication reviews without changes were considered a GDR.
Care Plans Not Revised After Repeated Falls
Penalty
Summary
The facility failed to ensure the comprehensive care plan was revised when residents experienced multiple falls and failed to ensure care plan interventions were dated to reflect new or revised individualized interventions for two residents reviewed for care plans. The facility policy, Develop/Implement Comprehensive Care Plan, stated that a comprehensive person-centered care plan would be developed and implemented for each resident. Record review showed one resident was admitted with chronic kidney disease and had a BIMS score of 11, indicating moderately impaired cognition, while another resident was initially admitted in 2022, readmitted in 12/2025, had a history of falling, and had a BIMS score of 15, indicating intact cognition. For both residents, the care plan included a safety focus identifying them as high risk for falls and listed multiple fall dates, but the intervention dates did not align with the dates of the falls. The record also showed repeated falls for one resident on 12/5/25, 12/7/25, and 1/21/26, and for the other resident on 10/24/25, 10/29/25, 11/22/25, 1/22/26, and 2/7/26. RN #1 and the DON both confirmed that care plans should be updated after a fall and that interventions should be dated to reflect when they were initiated, but after review they confirmed the care plans did not include updated or newly implemented interventions following the repeated falls.
Inconsistent Blood Glucose Monitoring and Missing Documentation
Penalty
Summary
The facility failed to ensure services were provided in accordance with professional standards of practice for a resident with Type 2 diabetes mellitus who was admitted on 1/12/26 and had a BIMS score of 8, indicating moderately impaired cognition. The resident had an order for NovoLog insulin to be given before lunch and supper based on blood glucose results, but there was no physician order identified for the use of a Continuous Glucose Monitor (CGM), even though a CGM sensor was observed on the resident’s left upper arm and a reader was present in the room. The resident reported not liking fingersticks, and a sign in the room instructed staff to use the Freestyle Libre 3 reader to check blood sugar. Record review showed inconsistent and incomplete blood glucose monitoring and documentation on the MAR across January, February, and March 2026. Multiple entries reflected no blood glucose reading documented with codes such as 4, 5, 9, or 13, and several of the entries coded as “other/see progress note” or “hold/see progress note” had no corresponding progress note. In other instances, blood glucose values were documented with insulin administered, but no supporting progress note was present. The MAR also showed entries where no blood glucose reading was recorded and code 13 was used to indicate no insulin required. During observations and interviews, one LPN stated she had always obtained blood glucose readings using the facility glucometer and was not aware the resident had a CGM device, while another LPN stated she knew the resident had a CGM and believed staff were using it instead of the facility glucometer. The resident representative reported providing the CGM device and supplies after admission and placing the sign in the room because staff continued to obtain fingerstick readings. The DON reported she was not aware of missing blood glucose documentation or irregularities, and the NP stated she had not been notified of concerns and relied on accurate and complete documentation to make clinical decisions.
Consultant Pharmacist Failed to Identify Medication Irregularities and GDR Absence
Penalty
Summary
The consultant pharmacist failed to complete monthly medication regimen reviews that identified and reported medication-related irregularities for a resident receiving insulin. Resident #16 was admitted with Type 2 diabetes mellitus and had physician orders for NovoLog insulin based on blood glucose readings before lunch and supper. Review of the MARs for January and February 2026 showed multiple instances of missing blood glucose documentation, codes entered without corresponding progress notes, and insulin administration documentation that did not consistently match the recorded information. These irregularities were not identified or reported in the consultant pharmacist’s monthly medication regimen reviews for January or February 2026. The consultant pharmacist also failed to identify and report the absence of a Gradual Dose Reduction for Resident #79, who was admitted with dementia and was receiving psychotropic medications including quetiapine and sertraline. The quarterly MDS documented that the resident received antipsychotic and antidepressant medications and that no GDR had been documented as clinically contraindicated. The medical record contained no documentation of a GDR, and the DON confirmed there was no GDR documentation and that she had not received any recommendation from the consultant pharmacist regarding a GDR. In addition, the facility did not have resident-specific documentation to show which residents were reviewed during the monthly pharmacy reviews for two sampled residents. The January and February 2026 pharmacy reports stated the consultant pharmacist reviewed numerous charts and discussed medications and doses with staff, but they did not identify individual residents reviewed or include resident-specific findings or recommendations for Residents #16 and #79. During interview, the consultant pharmacist stated he conducts monthly reviews and provides reports, but he does not always review MARs and was not aware of the medication errors or irregularities for Resident #16. The DON and Administrator stated they expected the consultant pharmacist to identify and communicate medication irregularities and recommendations during monthly reviews.
Insulin Given Outside Ordered Parameters
Penalty
Summary
The facility failed to prevent significant medication errors when nursing staff administered insulin outside of the physician-ordered parameters for Resident #16, who was admitted with Type 2 Diabetes Mellitus and had a BIMS score of 8 indicating moderately impaired cognition. The physician ordered NovoLog insulin to be given twice daily for hyperglycemia only when blood glucose was greater than 200, with 5 units for readings over 200, 10 units for readings over 300, and to hold the dose if blood glucose was less than 200. Review of the MARs for January, February, and March 2026 showed multiple instances where insulin was administered outside those parameters, including 5 units given when blood glucose readings were 145, 162, 144, 186, and 161, and 10 units given when the reading was 247, as well as 5 units given when the reading was 180. There was no corresponding documentation or clarification in the medical record for these administrations. During interview, an LPN stated she tries to record blood glucose results right away and had not paid attention to the MAR codes or that there were no BG results recorded. The DON later confirmed the documented blood glucose readings and insulin dosages did not align with physician orders and would be considered medication errors, and stated she had not been notified of these errors.
Improper Food Storage and Labeling in Dietary Department
Penalty
Summary
The facility failed to store, prepare, and serve food in accordance with professional standards for food safety. During a kitchen observation, frozen sliced pizza was found in the freezer without being repackaged, labeled, or dated. Two opened bags of Mexican beef taco meat were opened, used, and resealed with rubber bands without labeling or dating, and a bag of shredded lettuce labeled “Best if Used by March 2, 2026” was observed opened and dated March 16, 2026, although the Dietary Manager stated it had been received approximately two weeks earlier. A bag of celery was observed deteriorated and breaking down inside the packaging, and four half gallons of buttermilk were present with expiration dates of March 4 and March 12. Additional food storage concerns were observed in the refrigerator and dry storage areas. Two partially used bags of chopped boiled eggs were resealed with rubber bands, and the Dietary Department confirmed eggs are not shipped in that manner and acknowledged improper storage. One open container of imitation bacon bits was stored in the refrigerator without labeling or dating. One bottle of Kikkoman Reduced Sodium Soy Sauce had been opened and stored on a shelf in the dry goods room despite manufacturer instructions requiring refrigeration after opening. The Dietary Manager stated staff putting away deliveries were responsible for checking expiration dates, and the Administrator stated she expected dietary staff to properly package, store, and date all food items in accordance with facility policy.
Failure to Protect Residents from Sexual Abuse Due to Lack of Supervision and Communication
Penalty
Summary
The facility failed to protect residents from sexual abuse by not implementing immediate supervision or restrictions for a male resident with a known history of sexually inappropriate behaviors. Despite prior incidents of sexual comments and inappropriate conduct toward staff, no care plan interventions or increased supervision were put in place before the resident inappropriately touched two female residents in the day room. The first incident occurred when the male resident touched the breast of a female resident, which was witnessed by a janitor who separated the residents and notified an LPN. After the initial incident, the LPN escorted the male resident to his room but left him unsupervised while reporting the event to the DON. During this time, another CNA, unaware of the incident, assisted the male resident back to the day room, where he subsequently inappropriately touched the breast of a second female resident. Staff interviews confirmed that there was a lack of communication regarding the initial incident, and the male resident was not placed on one-to-one supervision until after the second incident occurred. The male resident involved had a history of cognitive impairment, poor judgment, and previous sexually inappropriate verbal behaviors, as documented in his medical and psychiatric records. Both female residents who were touched also had severe cognitive impairments. The facility's failure to implement protective supervision and communicate the risk to all staff resulted in two residents experiencing non-consensual sexual contact and placed other vulnerable residents at risk.
Removal Plan
- Hold QA meeting to review Abuse Policy and Care plan policies with all disciplines.
- Start 1-1 observation by DON and ADON when an incident is reported. Assign this to the scheduled Certified Nursing Assistant (CNA).
- Conduct in-services on Abuse and Identifying Sexual Abuse and Capacity to Consent by Staff Development Nurse and the Administrator. Train all staff that if staff witnesses abuse, the one who perpetrates or initiates abusive behavior cannot remain in contact with other residents. Take them with you to a supervisor or another employee must remain with them until a decision is made as to what needs to be done. Do not allow staff to work until in-serviced.
- Discipline and educate LPN #1 on 1-1 supervision when there is an abuse allegation.
- Educate CNA #1 on proper undergarment placement for Resident #2.
- Update Care Plans for all Residents involved and review all residents with behaviors and their care plans.
- Conduct body audits on Resident #2 and Resident #3.
- Initiate hourly checks on Resident #2 and Resident #3.
- Send referrals to multiple Geri-psych units and other facilities for Resident #1.
- Assign 1-1 observation of Resident #1 to the scheduled Certified Nursing Assistant (CNA). Use Post Event Hourly Monitoring Form.
- Review Care Plans on Residents with behaviors weekly for 4 weeks, monthly for 3 months, and then quarterly. Social Services Director and Care Plan Nurse will be responsible for reviewing and addressing in QA.
Failure to Develop and Implement Care Plan for Sexually Inappropriate Behaviors
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan addressing sexually inappropriate behaviors for a resident with a known history of such behaviors. Despite documented incidents of sexually inappropriate comments and actions, including a prior event where the resident asked to see a staff member's breasts and a psychiatric evaluation noting sexually impulsive behavior, the care plan was not updated to include individualized interventions, monitoring instructions, or staff guidance. The resident's cognitive status was severely impaired, as indicated by a Brief Interview for Mental Status score of 6 and psychiatric notes describing poor judgment, impaired decision-making, and confusion. On the day of the incident, the resident inappropriately touched the breasts of two female residents in the day room. After the first incident was witnessed by a staff member, the resident was taken to his room but left unsupervised. Another staff member, unaware of the incident, assisted the resident back to the day room, where a second incident occurred. Both female residents involved had severe cognitive impairment and required staff assessment for mental status. The facility had prior knowledge of the resident's sexually inappropriate behaviors but did not implement immediate supervision or restrictions to protect other residents. Interviews with facility staff confirmed that the care plan was not updated until after the incidents occurred, despite escalating behaviors and psychiatric recommendations. The lack of timely and effective care planning and supervision resulted in two residents experiencing non-consensual sexual contact and placed other vulnerable residents at risk.
Removal Plan
- Hold QA meeting to review Abuse Policy and Care plan policies with all disciplines.
- Start 1-1 observation by DON and ADON when an incident is reported, assigned to the scheduled Certified Nursing Assistant (CNA).
- Conduct in-services on Abuse, Identifying Sexual Abuse, and Capacity to Consent by Staff Development Nurse and Administrator. Train all staff that if staff witnesses abuse, the perpetrator or initiator cannot remain in contact with other residents and must be taken to a supervisor or another employee must remain with them until a decision is made. Do not allow staff to work until in-serviced.
- Discipline and educate LPN on 1-1 supervision when there is an abuse allegation.
- Educate CNA on proper undergarment placement for Resident.
- Update Care Plans for all Residents involved and review all residents with behaviors and their care plans.
- Conduct body audits on Residents.
- Initiate hourly checks on Residents.
- Send referrals to multiple Geri-psych units and other facilities for Resident.
- Assign 1-1 observation of Resident to the scheduled Certified Nursing Assistant (CNA) and use Post Event Hourly Monitoring Form.
- Review Care Plans on Residents with behaviors weekly for 4 weeks, monthly for 3 months, and then quarterly. Social Services Director and Care Plan Nurse will be responsible for reviewing and addressing in QA.
Medication Mismanagement at Resident's Bedside
Penalty
Summary
The facility failed to ensure that medications were secured and only accessible to authorized personnel, as evidenced by an incident involving a resident who had a medication left at their bedside. The resident confirmed that a nurse left a prescribed face cream at their bedside, which they used frequently, leading to irritation instead of healing. The resident's daughter was upset about the situation, and the dermatologist was also displeased upon learning that the medication was left unsecured. The resident had been prescribed Fluorouracil 5% topical cream for Actinic Keratosis, to be applied twice daily. However, the order was discontinued early due to the irritation caused by the unsupervised use of the cream. A new order for Triamcinolone Lotion was issued to address the irritation. The LPN involved admitted to leaving the cream at the resident's bedside due to the resident's insistence, and the situation was reported to the previous Director of Nursing. The resident had a history of Type 2 Diabetes Mellitus with Hyperglycemia, Neoplasm of Uncertain Behavior of Skin, Actinic Keratosis, and Rosacea. A mental status assessment indicated moderate impairment. The facility's policy clearly stated that medications should not be left at the bedside unless there is a physician's order and the resident is deemed capable of self-administration, which was not the case here.
Failure to Honor Residents' Right to Self-Determination
Penalty
Summary
The facility failed to honor residents' rights for self-determination by not allowing two residents, who are a married couple, to go outside together. Both residents were cognitively intact and expressed a strong desire to spend time together outdoors. Resident #13, who was independent in activities of daily living, and Resident #14, who used a wheelchair and required staff assistance for transfers, were not permitted to be outside together due to a past incident where Resident #13 attempted to assist Resident #14 to prevent her from falling. Despite their requests to staff, they were consistently denied the opportunity to go outside together, which was important to them given their limited time together due to their respective medical appointments. Interviews with facility staff revealed a lack of awareness and communication regarding the restriction placed on the couple. A CNA in training and an LPN confirmed the restriction, while the Social Services staff and the Administrator were unaware of the issue. The Director of Nursing emphasized the expectation that staff respect residents' rights, but the inconsistency in staff, particularly with the use of agency staff and different personnel on weekends, may have contributed to the oversight. The facility's policy on resident rights emphasizes the importance of self-determination and access to services, which was not upheld in this case.
Failure to Assist Resident in Formulating Advance Directive
Penalty
Summary
The facility failed to ensure that a resident without an advance directive received the necessary information or assistance to formulate one. Resident #7, who was admitted with diagnoses including Dysphagia, Dementia, and Alzheimer's Disease, did not have a Power of Attorney or an Advance Directive. The Admission Agreement Checklist for the resident, dated 10/9/21, indicated the absence of a Power of Attorney and did not acknowledge an Advance Directive. Interviews with the resident's representative and facility staff, including the Administrator and the Director of Nursing, confirmed that there was no documentation of an Advance Directive Acknowledgment Form or Power of Attorney in the resident's records. Although a booklet on Advance Directives was provided to the resident's representative upon admission, there was no documentation to confirm the acknowledgment of this information.
Inaccurate MDS Discharge Assessment
Penalty
Summary
The facility failed to accurately complete a Minimum Data Set (MDS) discharge assessment for one resident, leading to a deficiency. The resident, who had been admitted with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Hypertensive Chronic Kidney Disease, and Hypertensive Heart Disease with Heart Failure, was discharged on August 8, 2024. The discharge MDS was incorrectly coded as a short-term general hospital stay, despite documentation indicating the resident was to be followed up at home by a home health service and left the facility under the care of family. Interviews with the Registered Nurse/MDS Coordinator and an MDS nurse revealed that the error was due to incorrect coding by the MDS nurse, who acknowledged the mistake and stated that the discharge should have been coded as the resident going home.
Failure to Implement Oxygen Tubing Change as per Care Plan
Penalty
Summary
The facility failed to implement a care plan intervention for a resident requiring oxygen therapy. The care plan, which started on March 22, 2023, specified that the resident's oxygen tubing should be changed and the filter washed every week on Friday. However, during an observation on October 15, 2024, it was noted that the oxygen tubing was not dated, indicating it had not been changed as per the care plan. The resident, who has chronic diastolic heart failure and COPD with acute exacerbation, confirmed the need to wear oxygen at all times. Further observations and interviews with facility staff, including a registered nurse and the MDS/Care Plan Coordinator, confirmed the oversight. The RN acknowledged that the tubing was not dated and should have been changed weekly. The MDS/Care Plan Coordinator and the Director of Nursing both emphasized the importance of following the care plan to ensure proper care. The resident's medical records, including a physician's order dated August 27, 2024, reiterated the requirement to change the oxygen tubing weekly, which was not adhered to, leading to the deficiency.
Failure to Follow Respiratory Care Standards
Penalty
Summary
The facility failed to adhere to its standards of practice for respiratory care concerning the management of oxygen tubing for a resident. The resident, who was admitted with diagnoses including Chronic Diastolic Heart Failure and COPD with Acute Exacerbation, was observed receiving oxygen therapy. However, the oxygen tubing was not dated as required by the facility's policy, which mandates weekly changes and dating of the tubing. Observations revealed that the tubing was not stored in a plastic bag when not in use, increasing the risk of contamination. Interviews with nursing staff, including an RN and an LPN, confirmed that the oxygen tubing should be changed weekly, dated, and stored in a plastic bag when not in use. The Director of Nursing also stated that staff are expected to follow these procedures. Despite these expectations, the tubing for the resident was not managed according to the facility's policy, as it was neither dated nor properly stored, indicating a lapse in following the established standards of practice for respiratory care.
Deficiency in Meal Quality and Temperature
Penalty
Summary
The facility failed to ensure that meals were palatable and served at an appetizing temperature for three residents. Resident #63 reported dissatisfaction with the meals, describing them as often cold and lacking flavor. He noted that his meals, including breakfast and lunch, were lukewarm and bland. Resident #85 expressed that the food was either too salty or tasteless, leading her to skip meals due to the lack of seasoning. Resident #90 also complained about the food being bland, cold, and unappetizing, resulting in her family bringing meals from outside. Observations confirmed that food temperatures were below the desired levels, with test trays showing lukewarm temperatures and bland taste. The facility's dietary staff faced challenges in maintaining food quality and temperature. During interviews, it was revealed that the kitchen staff were not adequately trained, with one staff member still learning cooking techniques and another not certified. The use of an open cart system for meal delivery contributed to the cooling of food before reaching residents. Additionally, the loss of recipes due to a previous roof leak led to limited seasoning options, with only salt and pepper being used. The Director of Nursing acknowledged residents' complaints about the food's taste and temperature, and the Administrator was informed of the issues.
Infection Control Deficiencies in Linen Handling and PPE Usage
Penalty
Summary
The facility failed to handle linens properly and did not adhere to the required Personal Protective Equipment (PPE) protocols, leading to potential infection control issues. During an observation, a Certified Nurse Aide (CNA) placed dirty linens and a soiled brief directly on the floor after providing incontinence care to a resident. This action was confirmed by the CNA, a Licensed Practical Nurse (LPN), a Registered Nurse (RN) who is the Infection Preventionist, and the Director of Nursing (DON), all of whom acknowledged that placing dirty linens on the floor could contribute to the spread of infection. The resident involved had been admitted with a diagnosis of Type 2 Diabetes Mellitus. In another instance, a Licensed Practical Nurse (LPN) administered a bolus feeding to a resident with a Percutaneous Endoscopic Gastrostomy (PEG) tube without wearing the required gown, despite signage indicating the need for Enhanced Barrier Precautions (EBP), which include both gloves and a gown. The LPN stated she was instructed that gloves were sufficient, although the facility's policy and the signage on the resident's door required both gloves and a gown. This was confirmed by the RN and the DON, who reiterated the expectation for staff to follow the facility's EBP policies. The resident had been admitted with diagnoses related to a gastrostomy and had a physician's order for EBP due to the feeding tube.
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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 Morton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Community Place | 20.8 mi | ★★★★★ | 1 | 0 |
| Brandon Court | 22.6 mi | ★★★★★ | 1 | 0 |
| Brandon Community Care Center | 22.8 mi | ★★★★★ | 2 | 0 |
| Wisteria Gardens | 23.6 mi | ★★★★★ | 3 | 0 |
| Ms Care Center Of Raleigh | 24.8 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.