Morningside Nursing And Rehabilitation Center

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident received insulin lispro in accordance with the physician’s orders and facility policy. The resident had diagnoses including hypertension, diabetes mellitus, and a seizure disorder, and the Minimum Data Set documented moderately impaired cognition and daily insulin injections. The physician’s orders for insulin lispro instructed staff to administer the medication before meals and to notify the MD if blood sugar was greater than 400 mg/dL, but the orders did not include a specific hold parameter for low blood sugar. The MAR showed insulin lispro was not administered on 33 of 72 opportunities from 04/01/2026 through 04/24/2026. At the times doses were omitted, blood glucose readings ranged from 64 mg/dL to 202 mg/dL. The record review found code 4 entries indicating vitals outside of parameter for 11 administration opportunities, but there was no documented evidence that the resident’s blood sugar was less than 60 mg/dL or greater than 300 mg/dL at any insulin lispro administration time during that period. There was also no documented evidence that the physician was notified about any blood sugar level out of parameter or any concern to withhold insulin lispro. During interviews, an RN stated the resident’s rapid-acting insulin was given before meals and that insulin lispro was withheld if blood glucose was less than 140 mg/dL to prevent hypoglycemic episodes, despite acknowledging the order did not include hold parameters. The RN also stated they were not informed that the overnight dose was not being carried out by the night shift nurse. The nursing supervisor stated the resident was to receive insulin lispro with glucose monitoring before meals and that day shift nurses would withhold if blood glucose was below 70 mg/dL, but they were not aware the medication had been omitted multiple times without consulting the MD. The MD stated they could not recall being told that insulin lispro was withheld, and the DON stated they were recently made aware of the concern related to the resident’s insulin management.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Resident #157, who was admitted with diagnoses including hypertension, diabetes mellitus, and seizure disorder and had moderately impaired cognition, did not receive Insulin Lispro before meals as ordered. The physician's orders directed four units, then eight units, then four units subcutaneously before meals, with notification of the medical doctor only if blood sugar was greater than 400 mg/dL. The resident stated during the Resident Council Meeting that they are diabetic and receive insulin, but their blood sugar was not checked the day before prior to meals. The Medication Administration Record showed that the 6:30 AM Insulin Lispro dose was not administered on 21 of 24 opportunities from 04/01/2026 through 04/24/2026. Nurse notes documented 15 of those omitted doses as not given because breakfast was not ready, and 3 additional omitted doses had no documented rationale. There was no documented evidence that a physician was notified for a hold order or that Insulin Lispro was administered prior to the breakfast meal. The DON stated the facility was recently made aware of concerns related to the resident's insulin management and an omitted insulin incident.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility did not ensure resident self-determination by supporting bathing preferences and providing showers twice weekly as required. The deficiency involved two residents who were reviewed for choices and bathing care. The facility policy stated each resident is to have a minimum of two baths or showers each week, with unit nurses responsible for monitoring showers, interviewing residents about refusals, and making adjustments or referrals when needed. One resident had diagnoses including end stage renal disease, hemiplegia, and cataract, and was documented as cognitively intact and partially dependent for bathing. The resident stated they went to dialysis on Mondays, Wednesdays, and Fridays and were too tired for showers on dialysis days, and said they had told staff they wanted shower days changed to Tuesdays and Saturdays instead of Wednesdays and Saturdays. The resident also stated they were not offered showers on Saturday and that staff appeared to prefer bed baths because showers required more work, including use of a Hoyer lift. The care plan documented partial/moderate assistance with bathing but did not document the resident’s bathing preferences. The resident’s shower schedule remained on Wednesdays and Saturdays, and the documentation reviewed showed repeated bed baths, refusals, and instances where no shower was provided, with no documented nursing notes, behavioral notes, or episodic forms reflecting refusals for March and April 2026. The second resident had diagnoses including end stage renal disease, hyperlipidemia, and diabetes mellitus, and was documented as cognitively intact and dependent on staff for showering. The resident stated they were not receiving showers according to the biweekly schedule. The bathing instruction record showed a shower schedule of Tuesdays and Fridays, but the bathing documentation reviewed showed no documented showers during the review period and instead showed bed baths on multiple dates, with one date showing no bath or shower provided. Nursing notes did not show documented evidence that the resident received or refused showers. Staff interviews reflected inconsistent awareness of the resident’s shower schedule and refusals, and multiple staff stated they were not aware of the resident’s shower concerns or that the resident had refused showers, despite other staff reporting that the resident had said the scheduled shower days conflicted with dialysis and that they preferred different days.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a person-centered comprehensive care plan was developed and implemented to address a resident’s hearing impairment. Resident #170 had diagnoses including anemia, hypertension, and asthma/chronic lung disease, and the annual MDS documented intact cognition with assistance needed for multiple activities of daily living. The facility record contained no documented evidence of Speech Language Pathology or Audiology services for the resident, and there was no comprehensive care plan in the electronic medical record for the resident’s hearing impairment or hearing aids. Resident #170 told staff that they had trouble hearing, needed the television turned up very high to hear, had hearing aids that were lost, and had reported the missing hearing aids to staff without receiving replacements. A physician order dated 01/06/2026 included an ENT consult for decreased hearing, and a medical progress note dated 04/15/2026 documented acute inability to hear in the right ear with an ENT consult ordered. The resident was later seen by the consultant, and earwax was removed from the ears. Staff interviews showed that the hearing problem was known to multiple staff members, but no comprehensive care plan had been initiated. A CNA stated the resident had difficulty hearing during care and had long complained about hearing well. An RN stated the resident repeatedly complained that hearing aids were missing, but the RN did not know the resident had hearing aids and could not explain why no care plan was started. The supervisor RN, ADON, and DON each acknowledged that the resident should have had a care plan for the hearing problem, and the DON stated the care plan should have been initiated immediately when the resident complained of hearing problems.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to ensure adequate supervision and proper care planning to prevent accidents for a resident with severely impaired cognition and a high fall risk. The resident had diagnoses including malignant neoplasm of the prostate, anemia, non-Alzheimer’s dementia, and depression, and was assessed as high risk for falls. The facility’s fall prevention and visual check policies required identification of fall risk, interdisciplinary care planning with specific strategies for fall prevention, and scheduled room checks (hourly on day/evening shifts and every 30 minutes on night shift). The CNA Kardex for this resident called for supervision/oversight at least once every hour. Despite these policies and assessments, the resident’s care plan did not document supervision interventions or monitoring frequencies related to fall prevention until after a fall in early January. Between late November and early January, the resident experienced five separate fall events. On each occasion, the resident was found on the floor in or near their room or ambulating in the hallway and lowering themself to the floor. The accident reports consistently documented that there were no visible injuries, though the resident intermittently complained of pain and underwent multiple diagnostic imaging studies, which showed osteopenia, scoliosis, spondylosis, and degenerative changes but no fractures. After each fall, the facility’s internal documentation referenced plans such as reminding the resident to ask for assistance, using the call bell, keeping the bed in the lowest position, and maintaining half-hour visual checks through purposeful rounding. However, review of the resident’s care plan and monitoring logs showed that these supervision and monitoring interventions (hourly or half-hourly checks) were not actually reflected in the written care plan during the period when the falls occurred. Interviews with staff and the resident’s emergency contact further demonstrated the lack of documented, individualized supervision in the care plan despite repeated falls. The emergency contact reported multiple complaints to facility staff about the recurring falls and the absence of updated instructions in the care plan, stating they received no clear explanation for the incidents and believed the facility was unable to provide adequate supervision. CNAs and RNs stated that the resident was considered high risk for falls, was monitored hourly or more frequently, and was sometimes kept in the day room or observed more often when restless, but they acknowledged that increased monitoring (e.g., every 30 minutes or more frequently) was not specifically ordered or documented. Nursing supervisors and the DON confirmed that although the resident was on hourly monitoring during day and evening shifts and half-hour monitoring at night, these monitoring frequencies and supervision interventions were not implemented in or reflected by the resident’s care plan until after the last documented fall, resulting in a failure to ensure that the resident received adequate, care-planned supervision to prevent accidents.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that residents had the right to obtain a written decision regarding their grievances, as evidenced by the case of a resident whose Health Care Proxy repeatedly requested written results for filed grievances but did not receive them. The facility's policy, dated 11/17/2017, required that residents or their representatives be notified of their right to obtain a written decision regarding grievances. Despite this policy, the Health Care Proxy of a resident with severely impaired cognition, as identified in the Minimum Data Set dated 03/18/2024, requested written confirmation of grievance outcomes on multiple occasions via email to the Facility Administrator. These grievances included issues such as the resident being found wet and soiled, concerns about an unlicensed social worker diagnosing medical conditions, and inaccurate comments made by the Administrator during a care plan meeting. The Director of Social Service, who was responsible for investigating grievances, stated that they provided verbal outcomes but did not provide written results. The Facility Administrator confirmed that the Social Service and Interdisciplinary Team were responsible for providing grievance results to residents or their representatives. Despite setting up meetings for the Health Care Proxy to review grievance copies in person, the meetings were either not attended or attended late by the Health Care Proxy, and no written responses were mailed as requested. The facility's failure to provide written grievance decisions as requested by the Health Care Proxy constitutes a deficiency in adhering to the residents' rights as outlined in the facility's grievance policy.

Plan Of Correction

Plan of Correction: Approved April 11, 2025 I. Immediate Corrections Grievances provided Resident #1's Emergency Contact. Written documentation was provided per request, and the concerns were addressed in alignment with the facility's Grievances Policy. Follow-up communications were also conducted to ensure the complainant was informed of the outcome and resolution. II. Identification of Other Residents A full-house grievance audit was conducted. This review confirmed that all grievances submitted during the specified period were fully investigated, resolved, and appropriately closed out. Interviews with residents and/or their emergency contacts confirmed satisfaction with the resolutions. Documentation was provided to those who requested it, demonstrating transparency and adherence to grievance protocol. III. Systemic Changes The Facility Grievance Policy was reviewed, and no revisions were necessary. Upon review, it was determined that the policy remains comprehensive, current, and in full compliance with 42 CFR §483.10(j). Nevertheless, as a proactive measure, all facility Social Workers were re-educated on the policy to reinforce expectations regarding grievance documentation, resolution timelines, and communication with residents and families. IV. QA Monitoring The Director of Social Work or designee will conduct a weekly audit for 4 weeks then a monthly audit for an additional two months to ensure that all grievances are completed in the appropriate time frame and if a copy of the grievance is requested it will be provided. Audit results will be presented to the QAPI committee during the quarterly meetings. The QAPI committee will review the findings and determine if any further corrective action or policy enhancement is warranted. Person Responsible: Director of Social Services

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure the residents' right to be free from physical abuse by nursing home staff, as evidenced by an incident involving a resident with severe cognitive impairment. The resident, diagnosed with Vascular Dementia, Psychotic Disorder with Delusions, and Major Depressive Disorder, approached an Admission Clerk with raised arms. In response, the Admission Clerk pushed the resident, causing them to fall backward and hit their head on a desk. This incident was captured on video surveillance, and the resident was subsequently transferred to the hospital for evaluation. The facility's policy on reporting and investigating resident abuse, neglect, and mistreatment was not adhered to in this case. The policy aims to provide a safe environment and protect residents from abuse. Despite the resident's known history of aggressive behavior, the staff involved did not follow the proper protocol for handling such situations. The Admission Clerk's reaction was deemed inappropriate, as staff are instructed to back away, call for help, and not retaliate when faced with aggressive behavior from residents. Interviews with various staff members, including Certified Nursing Assistants, a Licensed Practical Nurse, and the Registered Nurse Supervisor, revealed that the incident was not handled according to the facility's guidelines. The staff acknowledged that the Admission Clerk's actions were not acceptable and that the proper response should have been to shield from the aggressor and call for assistance. The facility's investigation concluded that the Admission Clerk violated the policy, leading to their termination.

Plan Of Correction

Plan of Correction: Approved January 3, 2025 I. Immediate Corrections - Resident #1 was thoroughly assessed following the incident and promptly transferred to the hospital emergency room. After a complete evaluation, the resident returned to the facility with no injuries. - Admission Clerk #1 was immediately suspended pending a comprehensive investigation. Upon the conclusion of the investigation, the staff member was terminated in accordance with facility policy and standards. - The incident was reported to NYSDOH on 10/25/2024 at 15:00, complaint number NY 641. - All facility staff were educated on abuse prevention. II. Identification of Other Residents - No other residents were identified to have complaints regarding staff treatment. - Social worker followed up with the residents of the unit to provide emotional and psychosocial support. The residents stated that they were not fearful of any additional incident. - The comprehensive care plans of all residents were checked to ensure there was a plan in place to prevent abuse, and specific interventions that were resident centered. All care plans were found in compliance with the protection of our residents. A copy of resident care plan is available in the EMR. III. Systemic Changes - The facility’s policy and procedure titled Abuse Prevention was reviewed and found appropriate. - All clinical and non-clinical staff (All RNs, LPNs, C.N.A.s, Admissions Staff, Recreation Staff, Housekeeping Staff, Engineering Staff, Administrative Staff, Social Service Staff, Rehabilitation Staff, and Dietary Staff) were re-educated by the Nurse Educator/Designee on the policy/procedure. These sessions reinforced the processes and responsibilities outlined in the Abuse Prevention policy to ensure consistent implementation across all departments. The attendance sheet will be kept on file for validation. - The facility will continue to provide education upon hire, annually and as needed on the Policy and Procedure on abuse, neglect, and mistreatment. - Staff hourly observational rounds of all residents will continue. IV. QA Monitoring - An audit tool was developed to ensure that no abuse, neglect, or mistreatment occurred. - The Audit tool will concentrate on resident complaints about staff treatment. - Audits of 5 residents will be performed by Social Services weekly x 4 weeks, then monthly for 2 months. - Any negative findings have immediate corrective action taken and reported immediately to the Administrator. - Results of the audits will be reported monthly and reviewed by the QAPI committee. Continuation, modification, or discontinuation of audits will be based on QAPI committee’s recommendations. Person Responsible: Director of Social Services

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that food was prepared, distributed, and served in accordance with professional standards for food service safety. During the survey, it was observed that the dishwashing machine did not maintain the appropriate temperatures for washing and rinsing dishes, as required by the facility's policy. The wash and rinse temperatures were consistently below the minimum required levels, and the Director of the Dietary Department was unaware of this issue until it was pointed out during the survey. Despite contacting the vendor for repairs, the facility continued to use the dishwashing machine without meeting the necessary temperature standards. Additionally, dietary staff did not adhere to proper hygiene and safety protocols. The Dietary Supervisor was observed with hair not fully covered and wearing inappropriate clothing while handling food. Similarly, a Dietary Aide failed to check and record the temperatures of all food items before serving, did not clean the thermometer between uses, and did not maintain proper hand hygiene. These actions were contrary to the facility's policies, which require staff to ensure food is at the correct temperature before serving and to maintain cleanliness and hygiene standards. Furthermore, the facility did not comply with its policy regarding food storage in the pantry refrigerator. Unlabeled and undated food items were found, including a ham sandwich and containers of coffee creamers and vegetable spreads without expiration dates. The facility's policy mandates that all food in the pantry refrigerator be labeled with the preparation date and resident's name and discarded after 48 hours. The failure to adhere to these standards was acknowledged by the Director of Nursing and Registered Nurse present during the survey.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure proper disposal of garbage and refuse, as observed during a recertification survey. The garbage disposal area was found with a large dumpster overflowing with various types of waste, including cardboard, plastics, metal, papers, wood, and trash bags hanging over the edge. The dumpster was uncovered, contrary to the facility's policy that requires garbage to be contained in covered receptacles. Dietary Aide #2 was seen adding garbage to the open dumpster, explaining that the regular dumpster had been replaced temporarily due to repairs, and the replacement did not have a cover. The Director of Housekeeping confirmed that the regular dumpster was removed for repairs and acknowledged the lack of a cover for the temporary dumpster. The Director of Dietary Department was unaware of the change from a compactor to a dumpster and stated that they ensure garbage leaving the kitchen is in covered bins. The facility Administrator also stated that garbage should be in covered receptacles but mentioned that the vendor indicated no covering was needed if garbage bags were closed. This situation led to the deficiency as the facility did not adhere to its policy for proper garbage disposal.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain proper infection control practices during wound care and medication administration, as observed during a recertification survey. Specifically, Enhanced Barrier Precautions were not adhered to during wound care for a resident with a pressure ulcer. A Registered Nurse did not wear a gown during the dressing change, contrary to the facility's policy and the CMS memo requiring gown and glove use for residents with wounds or indwelling medical devices. Additionally, there was no signage indicating the need for Enhanced Barrier Precautions at the resident's room. The facility's Infection Preventionist and Director of Nursing acknowledged that Enhanced Barrier Precautions should have been implemented for residents with indwelling medical devices and wounds as of the beginning of April 2024. However, they had not yet fully implemented these precautions, as they were still in the process of educating staff. The Infection Preventionist admitted to not being aware of the immediate need for implementation, and the Director of Nursing confirmed that they had identified residents who required these precautions but had not yet completed staff training. Furthermore, during medication administration, a Registered Nurse failed to sanitize a blood pressure cuff between uses on two different residents. The facility's policy requires disinfection of equipment between uses, but the nurse admitted to forgetting to clean the cuff. The Registered Nurse Educator confirmed that nurses are trained to sanitize equipment and are periodically monitored to ensure compliance. Despite this training, the lapse in protocol was observed, indicating a deficiency in adherence to infection control procedures.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident was treated with respect and dignity, as evidenced by the persistent strong odor of urine in the resident's room. The resident, who was moderately cognitively impaired and required supervision for toileting and hygiene, was observed multiple times with a strong urine odor in their room. Despite being continent of urine and bowel, the resident's room consistently smelled of urine, and their underwear was observed hanging in the bathroom. The facility's policy on dignity, which was last revised in November 2016, was not adhered to, as the resident's environment did not promote a dignified existence. Interviews with staff revealed that the resident washed their underwear in the sink and hung it in the room, which was believed to contribute to the odor. The CNA and LPN both noted that the resident was continent but occasionally incontinent of urine, and the urine smell was attributed to the resident's underwear. The housekeeper suggested that the odor might be coming from the mattress, which had been changed multiple times. The Director of Nursing was unaware of the issue, indicating a lack of communication within the facility regarding the resident's living conditions.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident who was unable to perform activities of daily living received appropriate grooming services. This deficiency was identified during a recertification review, where it was observed that a resident had long, untrimmed fingernails with black matter underneath. The resident, who required maximum assistance from two persons for personal hygiene due to conditions such as Cerebrovascular Accident, Hemiplegia, and Arthritis, reported not recalling the last time their fingernails were trimmed. Interviews with staff revealed inconsistencies in the care provided to the resident. A Certified Nursing Assistant (CNA) assigned to the resident stated they had not worked with the resident in about two weeks, while another CNA, a floater, admitted to using hand sanitizer instead of washing the resident's hands before meals. The Registered Nurse Supervisor confirmed that the resident's hands and nails had not been maintained according to the facility's protocol, which required cleaning hands before meals and trimming nails weekly. The Director of Nursing emphasized the facility's commitment to fostering safe independence in activities of daily living, yet the observations and interviews indicated a lapse in adhering to these standards.