Average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Morrow Manor Nursing Center during CMS and state inspections, most recent first.
A resident who required substantial assistance with bathing was left alone in the shower room after staff were told she could shower by herself. She slipped, fell, and was found on the floor with the shower chair tipped over her and the water still running. She reported right shoulder pain, and imaging showed an acute proximal right humerus fracture. The investigation noted the wet, slippery shower floor, lack of instruction on the emergency cord, and conflicting staff directions about leaving the resident unattended.
Unsanitary food handling occurred during lunch meal service when a cook used the same serving spoon for two vegetable pans, continued using visibly soiled tongs after they fell into sauced chicken, and handled bread for two residents on finger food diets with soiled gloves. The cook changed gloves without washing hands, used the microwave, and returned to the serving line without handwashing or changing gloves. The cook confirmed the observations, and the facility policy required handwashing after handling soiled utensils or unsanitary surfaces and before donning gloves.
A resident's funds were not dispersed to their representative within the required timeframe following the resident's death. Staff involved were unaware of the policy timeframe, and the facility did not provide evidence that the funds were refunded within thirty days as required by policy.
A resident with Alzheimer's disease and severely impaired cognition was prescribed Sertraline for mood and Depakote for Alzheimer's disease without documentation supporting appropriate diagnoses for either medication. The medical record lacked evidence that the physician was aware Depakote was not indicated for dementia, and the facility's own materials noted Depakote use for agitation in Alzheimer's disease was off-label and not FDA-approved. The DON and ADON confirmed the diagnosis for Sertraline had been updated later, but it had not been documented as appropriate before then.
PASRR screening for mental disorders or ID was not completed timely for a resident with dementia, bipolar disorder, anxiety, delusional disorders, and hallucinations. The resident had severely impaired cognition on MDS review, and the only PASRR in the record was completed before admission. A clerical worker said she only completed PASRRs when told there was a significant change in condition and was unaware it was required on admission.
Care plans did not reflect specific ADL needs for two residents. One resident with COPD, AFib, DM2, a femur fracture, and moderate cognitive impairment required help with bathing, hygiene, dressing, toileting, incontinent products, and oxygen administration, but the care plan had no ADL or oxygen focus. Another resident with malnutrition, a humerus fracture, schizoaffective disorder, schizophrenia, chronic pain, and intact cognition required substantial/maximal assistance with bathing, but the care plan did not specify the level of ADL assistance needed.
A resident with multiple chronic conditions repeatedly refused several ordered meds, but staff did not document education about the refusals, did not ask why the resident was refusing, and did not notify the MD. Two other residents had hospice-related deficiencies: one had hospice services without hospice orders or a detailed care plan, and another was admitted from the hospital with hospice and NPO instructions that were not reflected in current orders. The record also showed missing skilled assessment documentation and incomplete vital sign monitoring during the first days after admission.
Pressure ulcer not timely assessed or documented. A resident with dementia, DM2, and severe cognitive impairment developed a right buttock pressure ulcer/deep tissue injury, but the record lacked timely documentation of the wound onset, measurements, and notification of the MD and family. The skin observation form incorrectly showed intact skin, and survey observation found the dressing removed with no ordered barrier cream or dressing in place.
Failure to Post Oxygen Signage: A resident with COPD, emphysema, and other chronic conditions was ordered oxygen via NC at 1 to 4 LPM, but repeated observations found no oxygen warning sign posted outside the room. An RN confirmed the missing sign, and the resident was later observed resting in bed wearing a nasal cannula. Facility policy required an oxygen-in-use sign outside the doorway.
A medication error rate of 10.71% was identified after surveyors observed an RN crush metoprolol, open omeprazole and gabapentin, place all three in one cup, and administer them together via a resident’s G-tube without an active order to combine them. The resident had cancer of the oropharynx and HTN, and both the RN and DON confirmed no order existed to give the meds together; facility policy required meds via gastric tube to be given one at a time or as ordered.
Failure to Supervise Resident During Shower
Penalty
Summary
The facility failed to provide adequate supervision to a resident who required substantial to maximal assistance with bathing. The resident had an admission diagnosis history that included severe protein-calorie malnutrition, COPD, hypertension, schizoaffective disorder, schizophrenia, chronic pain syndrome, personality disorder, and a high fall risk assessment. Her MDS documented that she was alert and oriented and needed substantial/maximal assistance with bathing, and her care plan included staff presence in the shower and bath to provide assistance. On 03/19/25, the resident was left unattended in the shower room after staff were told she could shower by herself. While in the shower, she slid and fell to the floor. Staff found her lying unclothed on her right side with the shower chair tipped over her and the shower still running. She reported pain to her right shoulder, and assessment showed her right shoulder was lower than the left with decreased range of motion and pain. An X-ray later showed an acute comminuted fracture through the greater tuberosity of the proximal right humerus, and CT confirmed a fracture without dislocation. The investigation and witness statements documented that CNA #161 had been told by CNA #135 that the resident could be left alone in the shower room, despite the resident’s need for assistance. The root cause analysis identified that the resident was unattended, the shower floor was wet and slippery, the shower seat bench was smooth, and the resident had not been instructed to use the emergency cord. The facility’s records also noted that the resident was not listed as a fall risk in the shower process at the time of the incident, and the fall resulted in a fracture.
Unsanitary Food Handling During Meal Service
Penalty
Summary
Food was not served in a sanitary manner during lunch meal service, affecting the 27 residents who consumed food from the kitchen. During observation, Dietary Staff #137 was seen using the same serving spoon for two different pans of vegetables, one containing peas and the other a capri mix of broccoli, cauliflower, and carrots. The tongs used to serve chicken covered in sauce fell into the container and became visibly soiled, but the cook continued using them and soiled her gloves. She then used those soiled gloves to reach into a bread bag and touch bread while preparing a sandwich for Resident #17, who was on a finger food diet. The cook changed gloves without washing her hands, continued using the soiled tongs, used the microwave, and then returned to the serving line without washing her hands or changing gloves to prepare a sandwich for Resident #16, also on a finger food diet. The cook confirmed the observations during interview, and the facility policy on handwashing stated employees should wash hands after handling soiled equipment or utensils, after contact with unsanitary surfaces, and before putting on disposable gloves.
Failure to Timely Disperse Resident Funds After Death
Penalty
Summary
The facility failed to ensure that a deceased resident's funds were dispersed to the resident's representative within the required timeframe. Review of the closed medical record showed the resident had been admitted and subsequently passed away. Interviews with the Business Office Manager and Corporate Accounts Receivable revealed that although a check was eventually issued for the resident's funds, both staff members were unaware of the specific timeframe for dispersing funds after a resident's death. The facility's policy requires that all funds be refunded to a resident's representative within thirty days of discharge, but there was no evidence that this was done in a timely manner for this resident. The deficiency was identified during a complaint investigation and affected one resident out of those reviewed for dispersed funds.
Unnecessary Psychotropic Medications Without Supporting Diagnoses
Penalty
Summary
The facility failed to ensure Resident #7 had appropriate diagnoses for prescribed psychotropic medications. Resident #7 was admitted with diagnoses including Alzheimer's disease, dementia, hereditary and idiopathic neuropathy, and gastro-esophageal reflux disease without esophagitis. Her MDS assessment showed severely impaired cognition and that she received an antipsychotic, antidepressant, antibiotic, and anticonvulsant medication. Her plan of care identified anticonvulsant therapy related to mood, with interventions for monitoring side effects and obtaining labs as ordered. Physician orders included Sertraline 50 mg daily for mood and Depakote 125 mg twice daily for Alzheimer's disease. The medical record contained no documentation showing the physician was aware Depakote was not indicated for dementia or why it was appropriate for the resident. The facility provided an article stating Depakote use for agitation in Alzheimer's disease was off-label and not FDA-approved, and that research showed it was not an effective treatment of behaviors in dementia. Review of Depakote prescribing information showed it was indicated for seizures, migraine prophylaxis, and manic episodes associated with bipolar disorder. The DON stated the pharmacist reviewed the article with the physician when Depakote was prescribed, but this was not documented. The ADON later verified Sertraline had been updated to major depressive disorder, but prior to that there was no diagnosis documented to support its use for mood.
Delayed PASRR Screening
Penalty
Summary
PASRR screening for mental disorders or intellectual disabilities was not completed timely for one resident. Resident #11 was admitted on 02/01/23 and had diagnoses including unspecified dementia with agitation, bipolar disorder, generalized anxiety disorder, delusional disorders, and hallucinations. The resident's quarterly MDS 3.0 assessment showed severely impaired cognition. Review of the medical record on 08/18/25 showed the only PASRR on file had been completed on 04/04/22, before the resident's admission to the facility. During interview, the clerical worker stated she completed PASRRs when told a resident had a significant change in condition and was unaware that a PASRR was to be completed upon admission.
Care plans did not reflect specific ADL needs
Penalty
Summary
The facility failed to ensure care plans reflected specific ADL needs for two residents reviewed for care planning. For Resident #6, the medical record showed an admission date of 7/29/25 and diagnoses including tachycardia, COPD, unspecified fracture of the right femur, emphysema, unspecified atrial fibrillation, type 2 diabetes mellitus with hyperglycemia, and hypertension. The most recent MDS 3.0 assessment showed moderate cognitive impairment and that the resident required assistance with bathing, hygiene, dressing, toileting, and use of incontinent products. The care plan did not include a focus for ADLs or oxygen administration, and the ADON confirmed there was no care plan focus for those needs. For Resident #4, the medical record showed an admission date of 02/14/25 and diagnoses including severe protein-calorie malnutrition, nondisplaced fracture of the surgical neck of the right humerus, schizoaffective disorder, schizophrenia, chronic pain syndrome, and personality disorder. The quarterly MDS 3.0 assessment showed intact cognition and that the resident required substantial/maximal assistance with bathing. The care plan dated 03/24/25 identified an ADL self-care performance deficit related to bathing, hygiene, toileting, and dressing, with interventions including therapy as ordered and teaching/encouraging the resident to request assistance to toilet and showers twice a week per preference, but it did not address the specific level of assistance the resident required with ADLs. The ADON verified the care plan did not specify the level of assistance needed.
Medication Refusals and Hospice Order Deficiencies
Penalty
Summary
The facility failed to educate a resident about medication refusals and failed to notify the physician of those refusals. The resident had an admission diagnosis history that included diabetes mellitus, obstructive and reflux uropathy, venous insufficiency, major depressive disorder, unspecified psychosis, chronic pain syndrome, chronic systolic heart failure, and chronic respiratory failure with hypoxia. The resident’s record showed intact cognition on the comprehensive MDS and multiple physician orders for medications including aspirin, ezetimibe, Entresto, Eliquis, folic acid, Lasix, Wegovy, vitamin D, and metoprolol. The MAR documented repeated refusals of several ordered medications over multiple days, including aspirin, ezetimibe, folic acid, Lasix, vitamin D, Wegovy, Eliquis, and metoprolol. Review of progress notes from 07/01/25 through 08/18/25 showed no evidence that the resident was educated about the risks of refusing medications. There was also no evidence that staff asked the resident why he was refusing the medications, and there was no documentation that the physician was notified of the refusals. During interview, the resident stated he believed he was only supposed to receive three medications and did not know why the facility continued to provide more. The facility also failed to have hospice orders and detailed hospice care plans in place for two residents. One resident with Alzheimer’s disease, dementia, GERD, dysphagia, depression, and anxiety had a hospice consult and hospice services began, but the care plan did not address how to contact hospice or identify the admitting diagnosis for hospice services, and the ADON verified there were no hospice orders. Another resident admitted from the hospital with malignant neoplasm of overlapping sites of the oropharynx, post-laminectomy syndrome, hypertension, and chronic fatigue was to be admitted on hospice and NPO, but the current physician orders did not include hospice or NPO. The record also showed skilled assessments from the first several days after admission did not contain daily vital signs, and the resident’s vital signs were only documented once on the admission day and once several days later. The DON and ADON both verified the lack of twice-daily vital signs during the first three days of admission and confirmed the absence of active hospice and NPO orders.
Pressure ulcer not timely assessed or documented
Penalty
Summary
Resident #11, who had diagnoses including unspecified dementia with agitation, type 2 diabetes mellitus, bipolar disorder, generalized anxiety disorder, delusional disorders, and hallucinations, was identified as severely cognitively impaired and at risk for skin breakdown. Her care plan included daily skin checks, incontinence care, pressure reduction measures, and referral to physician orders for current treatment. However, review of the record showed no documentation in progress notes from 08/05/25 through 08/13/25 of a skin impairment, no measurements of a skin impairment, and no documentation that the physician or family were notified of a new skin issue. A skin observation on 08/14/25 incorrectly documented that her skin was intact. The wound nurse practitioner documented a pressure ulcer to the resident’s right buttock described as unstageable or a deep tissue injury, measuring 4 cm by 6 cm, with deep purple non-blanchable tissue surrounding an open wound. The note stated the wound onset date may have been different from the assessment date, and treatment orders were entered for cleansing, collagen, moisture barrier cream, and a dry dressing daily and as needed, with a low air loss mattress recommended. During survey observation, the dressing was removed and a small area to the buttocks was seen, with the ADON stating she was unsure what the area was and that it may have been moisture associated skin damage; she also verified there was no dressing or calmospetine lotion in place at that time. The ADON further confirmed there was no documentation of when the wound started or whether the family and physician had been notified, and that the 08/14/25 skin observation form was incorrect.
Failure to Post Oxygen Signage
Penalty
Summary
The facility failed to ensure oxygen signage was used for a resident receiving oxygen therapy. Resident #6 was admitted on 07/29/25 with diagnoses including tachycardia, COPD, unspecified fracture of the right femur, history of pulmonary embolism, hypertensive heart disease without heart failure, emphysema, type 2 diabetes mellitus with hyperglycemia, and hypertension. The MDS 3.0 assessment showed moderate cognitive impairment, and the resident required assistance with bathing, hygiene, and dressing. Current physician orders for August 2025 included oxygen via nasal cannula at 1 to 4 LPM. During observations on 08/18/2025 at 9:24 AM, 11:43 AM, and 2:55 PM, no oxygen warning sign was noted on the resident’s door. RN #103 confirmed at 2:57 PM that there was no oxygen warning sign on the door. On 08/19/2025 at 2:57 PM, the resident was observed resting in bed wearing a nasal cannula, and continued observation showed no oxygen signage posted outside the room. The facility policy titled Oxygen Administration, dated April 2008, stated that an oxygen in use sign was to be placed outside the resident’s doorway.
Medication Administration Error Rate Exceeded Allowed Threshold
Penalty
Summary
The facility failed to ensure the medication error rate did not exceed five percent. Surveyors found three medication errors out of 28 opportunities for error, resulting in a 10.71% error rate. This affected one resident who was observed during medication administration. The resident had an admission date of 08/15/25 and diagnoses that included cancer of the oropharynx and hypertension. The most recent MDS assessment indicated cognition was still in progress, and the resident required assistance with bathing, hygiene, and dressing. During observation of medication administration, an RN crushed metoprolol, opened an omeprazole capsule, and opened a gabapentin capsule, placing all three medications into the same medication cup. The RN then administered the combined medications through the resident’s G-tube after checking placement by listening for air. Review of the resident’s physician orders showed no active order to combine crushed medications and administer them together via the G-tube. The RN stated that an active order was required to combine medications and that if no active order existed, medications were to be given separately. The DON also confirmed there were no active orders to combine the medications, and the facility policy stated medications through a gastric tube were to be administered one at a time or as ordered.
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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.
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Nursing homes near Chesterville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bennington Glen Nursing & Rehabilitation Center | 10.1 mi | ★★★★★ | 15 | 0 |
| Woodside Village Care Center | 10.2 mi | ★★★★★ | 0 | 0 |
| Country Meadow Rehabilitation And Nursing Center | 10.7 mi | ★★★★★ | 0 | 0 |
| Centerburg Pointe | 11.8 mi | ★★★★★ | 6 | 0 |
| Centerburg Respiratory & Specialty Rehab Ctr | 11.9 mi | — | 0 | 0 |
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