Morrisons Cove Home

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 that nursing services met professional standards of quality by not following hospital discharge orders and dietary recommendations for one resident. The resident was cognitively impaired, required extensive assistance with care, was incontinent, received insulin, and had multiple diagnoses including ESBL UTI, bacteremia, diabetes, hypertension, atrial fibrillation, orthostatic hypotension, and Alzheimer’s dementia. Discharge instructions from the Veterans Affairs Medical Center directed continuation of Insulin Aspart per sliding scale before meals and at bedtime, Metoprolol Succinate 12.5 mg daily with specific hold parameters, Levofloxacin 750 mg every 48 hours with the final dose due on a specified date to complete a one-week course, and a consistent carbohydrate diet. Physician’s orders on admission and subsequent days did not consistently reflect these discharge instructions. Initial insulin orders included Insulin Aspart per sliding scale before breakfast and at bedtime, plus fixed one-unit doses before lunch and dinner, which were then discontinued the next day because they did not match the hospital discharge orders. After this discontinuation, there was no documented evidence on the MAR that the resident’s blood sugars were monitored for several days until a new order for Insulin Lispro per sliding scale was written. For Metoprolol, the resident was initially ordered Metoprolol Tartrate 12.5 mg daily with hold parameters, and later, after a cardiology visit, Metoprolol Succinate ER 12.5 mg daily with the same hold parameters was ordered; however, the clinical record contained no documentation that blood pressure and heart rate were checked as ordered prior to administration. The facility also did not follow the antibiotic and diet instructions as specified. The discharge instructions required Levofloxacin 750 mg every 48 hours with the last dose due on a specific later date, but the physician’s order at the facility directed only a single 750 mg dose, which was administered earlier than the hospital’s indicated final dose date, and there was no evidence that the last scheduled dose per discharge instructions was given. Regarding diet, the hospital discharge instructions called for a consistent carbohydrate diet, but the physician’s orders and dietary documentation showed the resident was placed on a cardiac/heart healthy diet instead. The dietitian later recommended changing to a consistent carbohydrate diet and adding Glucerna supplements, and subsequent notes documented ongoing recommendations and physician agreement to liberalize the diet; however, the resident’s diet order remained cardiac/heart healthy until it was finally changed to a consistent carbohydrate diet at a later date. The DON confirmed that the insulin, metoprolol, levofloxacin, and diet were not ordered per hospital discharge instructions, that ordered BP and HR checks prior to metoprolol administration were not documented, and that the diet was not changed as recommended by the dietitian.

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 inform the resident and/or resident representative in advance of the risks and benefits of psychotropic medication use and the treatment alternatives prior to initiating medication for two residents. The facility policy dated January 27, 2026 stated that before starting or increasing a psychotropic medication, the resident, family, and/or resident representative must be informed of the benefits, risks, and alternatives, including black box warnings for antipsychotic medications, in advance of the initiation or increase. Resident 6 had an admission MDS dated January 15, 2026 showing the resident was cognitively intact, received antianxiety and antidepression medications, and had diagnoses including dementia. Physician orders dated February 5, 2026 included Ativan 0.5 mg every 6 hours as needed. There was no documented evidence in the clinical record that the resident or resident representative was informed in advance of the risks and benefits and treatment alternatives before the Ativan was started. Resident 10 had a quarterly MDS dated February 1, 2026 showing cognitive impairment, use of an antipsychotic, antianxiety, and antidepressant medication, and diagnoses including anxiety and depression. Physician orders dated May 14, 2025 and May 28, 2025 included trazodone 12.5 mg twice daily and then 25 mg twice daily. There was no documented evidence that the resident or resident representative was informed in advance of the risks and benefits and treatment alternatives before trazodone was started or increased. The DON confirmed the lack of documentation for both residents.

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 medications and treatments were provided as ordered by the physician for three residents. For one resident with a diagnosis of osteomyelitis and a quarterly MDS showing cognitive intactness and need for assistance with daily care, the physician ordered 1 gram of Vancomycin intravenously twice daily. Review of the MAR for December 2025 showed no documented evidence that the Vancomycin was administered on multiple ordered dates, and the DON confirmed that the doses were not given. For another resident, the physician ordered a two-step PPD process, including administration of the second step 14 days after the first step was read, but the MAR showed only the first step was administered and read, with no documented evidence that the second step was given. For a third resident with cognitive impairment, heart failure, and partial assistance needs, the physician ordered bilateral lower-extremity compression pumps 60 minutes daily at 60 mmHG. Review of the TAR showed multiple dates with no documented evidence that the compression pumps were applied, and the DON confirmed that the treatments were not documented as having been provided.

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 follow physician's orders for the care and maintenance of an IV catheter for one resident receiving IV antibiotics. Resident 5 was cognitively intact, required assistance with daily care needs, and had a diagnosis of osteomyelitis. Physician's orders included 1 gram of Vancomycin IV twice daily for osteomyelitis, and later orders included placement of a PICC or midline catheter for blood draws and medication administration. The facility's policy stated that peripheral IV catheters were to be flushed before each infusion to assess patency and function and after each infusion to clear the catheter lumen, using the push-pause technique with normal saline. Review of Resident 5's MARs for November and December 2025 showed no documented evidence that the midline catheter was flushed before and after antibiotic administration. The DON confirmed during interview that there was no documented evidence that the midline catheter was flushed before and after the antibiotic was given.

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

Safe, appropriate dialysis care/services were not provided for a resident with end-stage renal disease who received dialysis on Monday, Wednesday, and Friday. The resident’s annual MDS assessment indicated the resident was understood and could understand, and the care plan documented the dialysis schedule. Review of the clinical record found no documented evidence of routine collaboration of care or communication between the LTC facility and the dialysis center when the resident received dialysis services, and no documented evidence of a contract with US Renal, the dialysis facility. The DON confirmed in interview that there was no documented evidence of communication between the dialysis facility and the facility because the facility does not send any paperwork back, and that the facility did not have a contract with the dialysis 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 provide written notice regarding emergency transfers to the hospital to the Office of the State Long-Term Care Ombudsman, as well as to the residents and/or their responsible parties. This deficiency was identified for five residents during the review. The lack of documentation of these notices was confirmed through clinical record reviews and staff interviews. Resident 1, who was cognitively intact, experienced chest pain on two occasions and requested to be sent to the hospital. Despite being admitted with congestive heart failure, there was no documented evidence that the required written notices were provided. Similarly, Resident 29, who was sometimes understood, was transferred to the hospital following a fall and was later admitted for altered mental status, but again, no written notices were documented. Resident 35, who was sometimes understood, was transferred to the hospital for a CT scan and admitted for an acute head injury with bleeding, yet no written notices were provided. Resident 54, who was severely cognitively impaired, experienced falls and changes in condition leading to hospital transfers, but lacked documented notices. Lastly, Resident 59, who was moderately cognitively impaired, was transferred to the hospital following a fall and subsequent admission, with no evidence of written notices being provided.

Plan Of Correction

The facility cannot retroactively correct this deficiency. Residents discharged via emergency transfer have the potential to be affected by this deficient practice. The facility is initiating a notice of discharge or transfer policy. This will include notifying residents or their responsible parties in writing about the reason for the emergency transfer. Nursing staff will receive mandatory training by the Director of Nursing or designee on the new policy, and the Social Services department will oversee the process to ensure compliance. The social services director will resume monthly notification to the Office of Long-term Care Ombudsman. All transfers and discharges will be audited by the administrator for 4 weeks. Audits will be reviewed by the Quality Assurance Performance Improvement committee for results, areas of improvement and/or continued auditing.

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 care plans were updated to reflect changes in resident care needs for four residents. Resident 8, who has dementia, mistakenly used Calmoseptine on her dentures instead of denture cream. Despite a new intervention to remove creams from the bedside, the care plan was not updated, and Calmoseptine was still found in the resident's bathroom. Resident 26, who was on an anticoagulant, had her medication discontinued, but her care plan was not updated to reflect this change. Resident 53, who has a catheter due to neuromuscular dysfunction of the bladder, had a treatment for a skin tear that was discontinued, yet the care plan still indicated ongoing treatment. Resident 66, who is at risk for falls, experienced a fall from a high bed, and the immediate intervention was to remove the bed remote from reach. However, the care plan was not updated to include this intervention. Interviews with the Director of Nursing confirmed that the care plans for these residents were not updated as required.

Plan Of Correction

The facility corrected the care plans for residents R8, R26, R53, and R66 immediately when notified of the errors. No other care plan errors affecting other residents have been identified. All licensed staff will be re-educated on the care plan policy. The Director of Nursing or designee will review five care plans weekly for four weeks and then five care plans monthly for three months.

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 provide a clean and homelike environment for two residents, as observed during a survey. Resident 53, who is severely cognitively impaired and requires assistance with daily care needs, was found to have a room with damaged drywall behind the bed. The area measured approximately seven inches long by ten inches wide, with multiple scratches, gouges, and nicks, and the paint was peeling off. The Maintenance Director confirmed that the condition of the drywall was not homelike and required repair and painting. Similarly, Resident 61, who is cognitively intact and also requires assistance with daily care needs, was found to have a room with damaged drywall. The area behind the bed measured approximately three inches wide by five feet long, with multiple scratches, gouges, and nicks, exposing the brown layer of drywall and peeling paint. A Nurse Aide indicated that the damage might have resulted from the removal of padding previously installed for safety. The Maintenance Director confirmed the need for repair and painting to restore a homelike environment.

Plan Of Correction

The wall repairs for both R53 and R61 have been completed. A house-wide audit will be conducted to identify other residents' rooms in need of repair. A new process referred to as Room Rounds will be initiated to ensure the repairs needed are identified quickly. The Nursing Home Administrator or designee will audit 5 rooms a week times 4 weeks. Audits will be reviewed by the Quality Assurance Performance Improvement committee for results, areas for improvement and/or continued auditing.

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 provide a written notice of its bed-hold policy to a resident and/or the resident's representative at the time of transfer to a hospital. This deficiency was identified during a review of clinical records and staff interviews. Specifically, a nursing note dated March 16, 2024, documented that a resident was transferred to the hospital due to a change in condition. However, there was no documented evidence that the resident or their representative received written information about the facility's bed-hold policy at the time of transfer. An interview with the Director of Nursing on January 24, 2025, confirmed the absence of such documentation.

Plan Of Correction

The facility cannot retroactively correct this deficiency. A house-wide audit will be conducted to ensure the bed hold policies were reviewed with resident or resident representatives. All licensed staff will be educated on the updated Bed Hold policy with emphasis on including the policy at the time of transfer and leave. The Nursing Home Administrator or designee will audit all transfers and therapeutic leaves for 4 weeks. Also, the administrator will audit 3 months of the monthly reports to the Office of the State Long-Term Care Ombudsman. Audits will be reviewed by the Quality Assurance Performance Improvement committee for results, areas for improvement and/or continued auditing.

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 a safe environment for a resident with dementia, who was at risk for falls due to gait and balance issues. Despite being educated by staff on the importance of using the call bell for assistance, the resident continued to self-ambulate. On one occasion, the resident fell while attempting to self-transfer to the bathroom, and there were no new interventions implemented to prevent such incidents prior to the fall. Additionally, the resident mistakenly used Calmoseptine on her dentures instead of denture cream, indicating a lack of supervision and proper management of personal care items. Although a new intervention was suggested to remove bedside creams, this was not documented in the care plan, and the Calmoseptine remained accessible in the resident's bathroom. Interviews with staff confirmed these oversights, highlighting a failure to adequately address the resident's safety and care needs.

Plan Of Correction

The facility cannot retroactively correct the fall interventions but has corrected the care plan for resident R8. A year to date audit of incidents reports will be conducted to confirm suggested interventions have been initiated. All nursing staff, including agency staff and new hires will be educated on the facility care plan policy and procedures. Administrative nursing staff will be educated on the accidents and incident process. The 24-hour clinical nursing report will be reviewed by Director of Nursing or designee, daily for 2 weeks followed by random audits for 2 weeks. Five accidents and incident reports will be reviewed weekly times 4 to confirm interventions are in place. Audits will be reviewed by the Quality Assurance Performance Improvement committee for results, areas for improvement and/or continued auditing.

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 care and maintenance of intravenous (IV) catheters for a resident, as evidenced by the lack of adherence to physician's orders and facility policy. Specifically, the facility did not follow the physician's orders for flushing the IV catheter with normal saline every shift for a resident receiving Meropenem for a urinary tract infection. The Medication Administration Records (MARs) showed no documentation of the required saline flushes on specific shifts, and there was no evidence that the IV catheter was flushed before and after the administration of Meropenem, as required by the facility's policy. Additionally, there was no documented evidence that the resident's physician was contacted for orders regarding the care and maintenance of the IV catheter from the time the orders were discontinued until the catheter was removed. The Director of Nursing confirmed these deficiencies, indicating a failure to ensure that physician's orders were followed and that the facility's policy for IV catheter care was adhered to, resulting in a lapse in the standard of care provided to the resident.

Plan Of Correction

A medication error form will be initiated for the staff who failed to administer the normal saline flush as ordered by the physician/policy. Any resident ordered a normal saline flush is at risk for this deficiency. All licensed nursing staff will be re-educated on the intravenous medication administration policy. The Director of Nursing or designee will conduct audits on all intravenous medication and flushes weekly times 4 weeks. Audits will be reviewed by the Quality Assurance Performance Improvement committee for results, areas of improvement and/or continued auditing.

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 with a diagnosis of Post Traumatic Stress Disorder (PTSD) received trauma-informed care to identify and mitigate potential triggers. Resident 62, who was cognitively intact and had a history of trauma from being a war veteran and a motor vehicle accident, was not assessed for specific triggers that could re-traumatize him. Despite having a care plan indicating a potential for mood problems related to PTSD, there was no documented evidence of a trauma history assessment for this resident. This deficiency was confirmed during an interview with the Nursing Home Administrator.

Plan Of Correction

An assessment has been conducted for resident R62 with triggers identified. A house wide audit has been done for all residents with a Post Traumatic Stress Disorder diagnosis. All identified residents will have an assessment completed to identify triggers and interventions. Nursing and social services will be educated on a newly created Trauma Informed care policy. The Nursing Home Administrator or designee will audit new resident diagnoses and new admissions for diagnoses of post-traumatic stress for 4 weeks. Audits will be reviewed by the Quality Assurance Performance Improvement committee for results, areas for improvement and/or continued auditing.

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 accountability for controlled medications for one resident. The facility's policy required staff to document the administration details of controlled substances, including the time, day, amount administered, and remaining quantity. However, for one resident, there was no documented evidence in the clinical records, including the Medication Administration Record (MAR), that doses of Ativan, a controlled medication, were administered on specific dates and times, despite being signed out. The resident involved had a diagnosis that included depression and required assistance with all care needs. Physician's orders indicated the resident was to receive Ativan as needed for restlessness and anxiety. Despite the orders, the controlled drug records showed discrepancies, with doses signed out but not documented as administered. The Director of Nursing confirmed the lack of documentation for the administration of these doses.

Plan Of Correction

Immediate education was provided to the licensed staff who failed to indicate on the medication administration record that an as needed medication was given. A whole house audit will be conducted to confirm narcotics that have been signed out are initialed on the medication administration record. All licensed staff will be re-educated on the facility's controlled substance policy. The Director of Nursing or designee will audit 5 narcotic sheets a week for 4 weeks. Audits will be reviewed by the Quality Assurance Performance Improvement committee for results, areas for improvement and/or continued auditing.

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's Quality Assurance Performance Improvement (QAPI) committee failed to address recurring deficiencies effectively, as evidenced by the results of a survey ending January 24, 2025. The survey identified repeated deficiencies related to the revision of care plans and pharmacy procedures, services, and records. These deficiencies were previously cited in a survey ending January 4, 2024, where the facility had developed plans of correction that included quality assurance systems to maintain compliance with nursing home regulations. Specifically, the facility's plan of correction for a deficiency regarding the failure to update residents' care plans included completing audits and reporting the results to the QAPI committee. However, the current survey revealed that the QAPI committee did not successfully implement this plan, as evidenced by the citation under F657. Similarly, the plan of correction for deficiencies in pharmacy procedures, services, and records involved audits and QAPI committee reviews, but the current survey, cited under F755, showed that these measures were not effectively implemented.

Plan Of Correction

No specific residents and/or staff were affected by these deficiencies. Currently, the core team of the Quality Assurance and Performance Improvement committee meets weekly and will work with a consultant to ensure focus on reoccurring issues. The Nursing Home Administrator and/or designee will retrain the members of the Quality Assurance and Improvement Committee on its responsibility for maintaining compliance with previously cited deficiencies. The Nursing Home Administrator and/or designee will audit open plan of corrections weekly x 4 then monthly x 2 or until substantial compliance is accomplished. Findings will be reviewed at the monthly facility Quality Assurance and Performance Improvement meeting.

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 hand hygiene during wound care for one resident, identified as Resident 53. The facility's policy required staff to perform hand hygiene when transitioning from dirty to clean tasks during wound care. Resident 53, who was severely cognitively impaired and receiving hospice care, had a Stage 4 pressure ulcer. Physician's orders specified a detailed wound care procedure, including washing around the wound with antibacterial soap, cleansing with acetic acid solution, and applying specific dressings. During an observation of wound care, an LPN washed her hands and donned gloves before starting the procedure. However, after completing the wound care, she did not remove her gloves and wash her hands before adjusting the resident's pillow, protective heel boots, and bed controls, which was a violation of the facility's hand hygiene policy. The LPN confirmed in an interview that she did not perform hand hygiene after the wound care and before providing additional care to the resident. The Director of Nursing also confirmed that the LPN should have removed her gloves and washed her hands before moving to a clean task.

Plan Of Correction

Re-education including a return demonstration has been provided to the employee. All licensed staff will be re-educated on wound care with an emphasis on handwashing. The Director of Nursing or designee will complete 5 random auditing weekly times 4. Audits will be reviewed by the Quality Assurance Performance Improvement committee for results, areas for improvement and/or continued auditing.

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 was found to be deficient in having a written policy for trauma-informed care. This deficiency was identified through record reviews and staff interviews. A quarterly Minimum Data Set (MDS) assessment for a resident, dated December 5, 2024, indicated that the resident was cognitively intact and had a diagnosis of Post Traumatic Stress Disorder (PTSD). The resident's care plan, dated September 11, 2024, noted a potential for mood problems related to PTSD. However, during an interview with the Nursing Home Administrator on January 22, 2025, it was confirmed that the facility lacked a policy regarding trauma-based assessments, which is necessary to address the resident's needs effectively.

Plan Of Correction

An assessment has been conducted for resident R62 with triggers identified. A house wide audit has been done for all residents with a Post Traumatic Stress Disorder diagnosis. All identified residents will have an assessment completed to identify triggers and interventions. Nursing and social services will be educated on a newly created Trauma Informed care policy. The Nursing Home Administrator will audit new resident diagnoses and new admissions for diagnoses of post-traumatic stress for 4 weeks. Audits will be reviewed by the Quality Assurance Performance Improvement committee for results, areas for improvement and/or continued auditing.

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 notify the physician about an incident involving a resident who ingested perfume. The facility's policy requires that any incident with the potential to cause bodily harm be reported immediately to the nursing supervisor and the physician. However, in this case, the physician was not informed. The incident involved a cognitively impaired resident with vascular dementia and behavioral disturbances, who required extensive assistance for daily care. The resident was at the nurse's station, grabbed a bottle of perfume, and placed it to her lips. The nurse intervened, noting a tiny drop on the resident's lips and presumed a small amount was ingested. The nurse assessed the resident, finding no signs of distress such as gagging, nausea, or vomiting, and the resident's vital signs were normal. An attempt was made to contact the resident's guardian, but there was no answer, and a message was left. Despite these actions, there was no documented evidence that the physician was notified about the ingestion. The Director of Nursing confirmed that the physician should have been informed, indicating a lapse in following the facility's notification procedures.