Above 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 Morningside Manor during CMS and state inspections, most recent first.
A resident with multiple comorbidities and severe cognitive impairment reported to hospital staff that she felt staff at the facility might be neglecting her due to differing political views, leading the facility’s former Executive Director to self-report the allegation to HHSC. Despite email communications indicating that an investigation report was being prepared and a request from HHSC’s Complaint and Incident division to submit that report, neither HHSC’s TULIP system nor the facility’s records contained a 3613A Provider Investigation Report or other complete written investigation. The current ED and DON could only locate emails, in-services, and resident safety surveys, and an encrypted email that could not be opened, demonstrating that the facility did not maintain evidence of a thorough investigation or timely written report as required by its Abuse Prevention Program policy.
A resident with spinal stenosis, diabetes, anemia, and hypertension had an annual MDS completed showing no cognitive impairment, but no subsequent MDS was submitted within the required quarterly timeframe. The MDS LVN, who relied on the EHR-generated schedule, acknowledged missing the quarterly MDS that was due, while the DON confirmed the due date and could not explain the omission. The Executive Director, who reported weekly MDS audits, verified that the next assessment should have been completed but was not, contrary to facility policy requiring quarterly MDS completion within 92 days of the prior comprehensive assessment.
The facility failed to maintain comprehensive care plans for several residents, leading to discrepancies in prescribed care. A resident with dysphagia received incorrect liquid consistency, risking aspiration. Other residents lacked documentation for necessary assistive devices and interventions, such as bed rails and catheter care. These omissions highlight significant oversights in ensuring accurate and updated care plans.
The facility failed to ensure no more than 14 hours between the evening meal and breakfast unless a bedtime snack was provided, affecting three out of nine residents reviewed. Staff interviews revealed that snacks were not routinely offered, and residents were unaware of available options. Snacks were only provided upon request, and the Director of Culinary Services confirmed that only a dialysis snack list was maintained.
The facility failed to store and cover food properly in the kitchen, with boxes stored less than 18 inches from the ceiling and uncovered chocolate pies in the walk-in refrigerator. The CDM acknowledged these issues, which violated the facility's food storage policy.
A resident was left without access to a call light after being assisted to her room by a CNA, leading to her loudly calling for help. The resident, who had impaired vision and hearing, was positioned away from her call light, which was not within reach. The DON confirmed that call lights should be accessible to residents, in line with CMS regulations.
A resident with a history of stroke returned to the facility with new diagnoses requiring neuro checks every four hours. The facility failed to perform three out of seven required checks and did not notify the physician, despite worsening symptoms. The family declined checks while the resident was asleep, and staff did not report the missed assessments, leading to a deficiency finding.
A resident with a history of major depressive disorder and other conditions was unable to report grievances effectively due to a failure by the facility staff. The resident was found calling out for assistance with her call light out of reach, and her complaints about being left unattended and receiving rushed care were not documented or reported by the CNA. The facility's grievance policy was not followed, as the Administrator was unaware of the resident's grievance, indicating a failure to ensure residents could voice grievances without fear of reprisal.
A facility failed to conduct ordered neuro-checks for a resident with a history of stroke, due to the resident being asleep and family refusal. The nursing staff did not notify the physician or nurse practitioner of these missed assessments, assuming the family was aware of the potential consequences. The resident was later sent to the hospital with a diagnosis of cerebral infarction and hemiparesis. This deficiency was identified as an Immediate Jeopardy, which was later removed, but the facility remained out of compliance.
A facility failed to ensure proper pharmaceutical services when an LVN dispensed and stored a resident's medications in a pill cup for later administration, instead of disposing and re-dispensing them when the resident became available. The resident, with conditions such as hypertension and diabetes, was prescribed multiple medications to be administered daily. This action was against the facility's policy, which mandates that medications be stored in their original packaging.
A resident with dysphagia was provided nectar thickened liquids without a physician's order, contrary to the prescribed pureed diet with thin liquids. The family was responsible for thickening the liquids, as the kitchen did not prepare them to the required consistency. This practice did not align with the facility's policy, resulting in a deficiency.
Two residents with diabetes did not have orders or care plans for diabetic shoes in their records, despite assessments indicating a need. The facility failed to document or communicate the provision of diabetic shoes, leading to a lack of awareness among staff about the delivery and necessity of these assistive devices.
Failure to Complete and Submit Required Investigation Report for Alleged Neglect
Penalty
Summary
The deficiency involves the facility’s failure to ensure that an allegation of neglect involving Resident #1 was thoroughly investigated and reported to HHSC as required by the facility’s Abuse Prevention Program policy. Resident #1 was an elderly female with diabetes, anemia, vascular dementia, cerebral infarction, and hypertension, with documented short- and long-term memory problems and severely impaired cognitive skills for daily decision-making. Her care plan noted altered mood and behavior, including being easily annoyed, making racist and false accusations, refusing psychiatric services, and refusing certain staff based on political views, with an intervention to allow her to verbalize emotions and validate her feelings. The incident began when a hospital case manager informed the facility’s Marketing Liaison that Resident #1 had expressed uncertainty about returning to the facility because she felt staff might be neglecting her due to differing political views. This concern was relayed to the then-Executive Director (Executive Director A), who self-reported the allegation to HHSC as Intake #1028885. During a later interview, Resident #1 stated that staff were not listening to her, but when asked for clarification, she focused on missing television channels and did not provide specific examples, individuals, or further details about neglect. The DON reported that the hospital also filed a complaint involving Resident #1 that was investigated by the survey team, and that Executive Director A had asked an HHSC surveyor whether an investigation report was needed for Intake #1028885. Record review showed that no 3613A Provider Investigation Report for Intake #1028885 was found in TULIP, and facility staff, including the current Executive Director (Executive Director B) and the DON, were unable to locate a completed investigation report in the facility’s records. Emails showed that Executive Director A told an HHSC surveyor she was working on the investigation report and later asked if she should proceed with submitting it after being told by the survey team that a 5-day investigation was not required, while also receiving a request from the HHSC Complaint and Incident division to submit the investigation. An encrypted email from HHSC to Executive Director A and an encrypted email from Executive Director A to HHSC were identified, but the facility did not have the password and could not access any attached report. The facility’s Abuse Prevention Program policy required that an investigation be initiated and a written report of the investigation be sent to HHSC no later than the fifth calendar day after the oral report, but there was no evidence that a complete written investigation report for this allegation was submitted or maintained by the facility.
Overdue Quarterly MDS Assessment for One Resident
Penalty
Summary
The facility failed to complete a required quarterly MDS assessment within the mandated three-month timeframe for one resident. The resident was an adult female admitted with diagnoses including spinal stenosis, diabetes, anemia, and hypertension. Her most recent comprehensive/annual MDS assessment was completed on 12/04/2025 and showed no cognitive impairment, with a BIMS score of 14/15. Review of the electronic health record under the MDS tab showed no subsequent MDS assessment had been submitted after 12/04/2025, and the next quarterly MDS assessment, with an ARD due by 03/06/2026, was 22 days overdue at the time of review. In interviews, the MDS LVN stated he relied on the electronic health record schedule to complete residents’ MDS assessments and acknowledged that the quarterly MDS for this resident, due on 03/06/2026, had been missed. The DON confirmed that the MDS LVN was responsible for completing MDS assessments and that she reviewed them for accuracy, and she verified that the last MDS was the annual assessment on 12/04/2025 with the next one due in March 2026, but could not explain why it was not completed. The Executive Director stated that resident MDS assessments were audited weekly and, upon reviewing the record, confirmed that the annual MDS was completed on 12/04/2025 and that the next assessment should have been completed in March 2026. The facility’s policy on MDS 3.0 Completion, dated 2025, specified that quarterly assessments must be completed using an ARD no more than 92 days from the most recent prior quarterly or comprehensive assessment, which was not followed in this case.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for several residents, leading to deficiencies in meeting their medical, nursing, and psychosocial needs. Resident #6, who has a history of dementia, traumatic brain injury, and dysphagia, was given nectar thick liquids instead of the prescribed honey consistency liquids, as per the doctor's order. This discrepancy in the care plan could potentially lead to serious health risks, such as aspiration pneumonia, as noted by the speech therapist. The care plan for Resident #6 had not been updated since 2021, despite a change in dietary requirements in 2022. Resident #3, who suffers from polyneuropathy, heart failure, and dementia, did not have her 1/4 bed rails included in her care plan, despite a physician's order for their use to assist with bed mobility. Similarly, Resident #38, who has an indwelling catheter due to urine retention, did not have any interventions related to the catheter documented in her care plan. The Director of Nursing acknowledged the absence of these interventions, which are crucial for the resident's care and monitoring. Additionally, Residents #57 and #120, both of whom require 1/4 bed rails for assistance, did not have these devices included in their care plans. Resident #56, who has a history of alcoholic cirrhosis and major depressive disorder, did not have his dentures mentioned in his care plan, despite ongoing dental treatment. The facility's failure to update and maintain accurate care plans for these residents indicates a significant oversight in ensuring that all necessary interventions and assistive devices are documented and communicated to the care staff.
Failure to Provide Timely Snacks Between Meals
Penalty
Summary
The facility failed to ensure that there were no more than 14 hours between the evening meal and breakfast the following day, unless a nourishing snack was provided at bedtime, which could extend the time to 16 hours if agreed upon by a resident group. This deficiency was identified for three out of nine residents reviewed for meal frequency. The facility did not offer bedtime snacks as required, leading to extended periods between meals, which could potentially affect all residents by increasing the risk of unplanned weight loss, medication side effects, and diminished quality of life. Interviews with staff and residents revealed that residents were not made aware of available snack options, and snacks were not routinely offered. Staff members indicated that snacks were available in the nursing station refrigerator, but they were only provided if residents specifically requested them. The Director of Culinary Services confirmed that only a dialysis snack list was maintained, and no other snacks were distributed from the kitchen. The facility's policies and procedures indicated that nursing staff should offer bedtime snacks, but this was not consistently practiced.
Food Storage and Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in their kitchen, as observed during a survey. Specifically, there were approximately five cardboard boxes filled with various food products stored less than 18 inches from the ceiling in the walk-in refrigerator. Additionally, two chocolate pies were found not fully covered, with their pie crusts exposed. These observations were made during an initial tour of the kitchen with the Certified Dietary Manager (CDM), who acknowledged that the boxes should not be stored so close to the ceiling and that the pies would need to be discarded as they could not be served. The CDM was unable to identify who was responsible for these storage issues, despite staff being trained on proper food storage practices. The facility's policy on food storage, revised in February 2024, mandates that all food and supplies be stored to prevent contamination, with items stored 6 inches above the floor and 18 inches below sprinklers.
Failure to Provide Call Light Access
Penalty
Summary
The facility failed to ensure that a resident received services with reasonable accommodation of their needs and preferences, specifically regarding access to a call light. On June 5, 2024, a CNA assisted a resident in a wheelchair to her room and placed her out of reach of her call light, which was approximately three feet away on her bed. The resident, who had moderate hearing difficulty, impaired vision, and was dependent on assistance for daily activities, was observed loudly calling out for attention as she was unable to reach her call light. The resident expressed frustration, stating that staff rushed through care and left her without the ability to call for assistance. During an interview, the CNA admitted to positioning the resident away from her bedside due to the resident's preference but did not attempt to place the call light within reach. The Director of Nursing (DON) confirmed that call lights should be within reach of residents, except in certain situations like activities or when residents can self-ambulate. The facility's policy adheres to CMS regulations, which require that the call system be within reach and usable by residents. The deficiency was identified as a failure to accommodate the resident's needs and preferences, as outlined in the CMS's State Operations Manual.
Failure to Notify Physician of Missed Neurological Checks
Penalty
Summary
The facility failed to immediately consult with a resident's physician when there was a significant need to alter treatment. This deficiency was identified for a resident who was hospitalized and returned with new diagnoses, including cerebral infarction, hemiplegia, hemiparesis, ataxia, and slurred speech. The resident's medical orders required neurological checks every four hours for three days, with instructions to notify the nurse practitioner of any deficits. However, the facility did not perform three out of seven required neuro checks over a 12-hour period and failed to notify the medical doctor about these missed assessments. Interviews and record reviews revealed that the resident's family had declined neuro checks while the resident was asleep, and the facility staff did not contact the nurse practitioner to report the missed checks. The resident's condition worsened, with increased speech slurring and balance issues, leading to hospitalization with a new diagnosis of cerebrovascular accident. The nurse practitioner and medical director were not informed of the missed neurological assessments until much later, which was against the facility's policy requiring notification of the attending physician in cases of treatment refusal or significant changes in condition. The facility's policy, revised in April 2009, mandates that the nurse supervisor or charge nurse notify the resident's attending physician or on-call physician when there is a refusal of treatment or medications. Despite this policy, the facility did not adhere to the required notification procedures, resulting in a deficiency that was identified during the survey. The immediate jeopardy was recognized due to the failure to follow medical orders and notify the appropriate medical personnel, which could have potentially led to harm for the resident.
Removal Plan
- Verify that current orders are being followed as prescribed by physician/NP.
- All licensed nurses will be in-serviced regarding the need to notify physician/NP of any refusals that keep us from following orders prescribed.
- Physicians/NP partners will be notified to provide team with more concise orders and to consider the nurse's feedback regarding specific resident's characteristics or preferences when deciding a plan of action.
- The DON/Designee will review 24-hour report daily for change of condition UDA including neurological checks for any refusals and review for medical provider notification.
- All residents have the potential to be affected by this alleged deficit practice. At risk resident will be identified by reviewing 24 hr. report, changes of condition assessment and neurological checks.
- Weekly the DON and/or designee will pull all orders from the EHR for any refusals and review for physician and/or NP notification. The administrator will meet with DON weekly to audit and verify this review has been completed.
- Reports to the QAPI committee regarding the reviews will be discussed with the team on an ongoing basis.
- A corporate designee will audit compliance with orders weekly until stable and monthly for the next six months, quarterly thereafter if stable and report findings to the governing body.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to ensure that residents could voice grievances without fear of discrimination or reprisal, as evidenced by the case of a resident who was unable to report her complaints effectively. The resident, who had a history of major depressive disorder, glaucoma, and atherosclerosis, was observed calling out for assistance because her call light was out of reach. Despite her attempts to communicate her grievances about being left unattended and receiving rushed care, her complaints were not documented or reported by the CNA responsible for her care. The resident's care plan indicated a potential communication problem due to a hearing deficit, and it was noted that she should have her call light within reach to ensure a safe environment. However, during an observation, the resident was found in her wheelchair with the call light placed on her bed, approximately three feet away, making it inaccessible. The CNA admitted to positioning the resident away from her bedside due to the resident's preference but failed to ensure the call light was within reach, which led to the resident's frustration and vocal complaints. Interviews with the Director of Nursing and the Administrator revealed that the staff should assist residents with grievance reports, but the Administrator was unaware of the resident's grievance. The facility's grievance policy emphasized the right of residents to voice grievances without discrimination or reprisal and required prompt efforts to resolve them. However, the lack of documentation and reporting of the resident's complaints indicated a failure to adhere to this policy, potentially placing residents at risk by not addressing their grievances.
Failure to Conduct Ordered Neuro-Checks and Notify Physician
Penalty
Summary
The facility failed to immediately consult with a resident's physician when there was a need to significantly alter treatment. This deficiency was identified for one of the eight residents reviewed for notification. The resident in question was admitted with diagnoses including dysphagia following a cerebral infarction and dementia. Upon returning to the facility from the hospital, the resident had new diagnoses, including cerebral infarction, hemiplegia, hemiparesis affecting the right dominant side, ataxia, and slurred speech. Despite these conditions, the facility did not perform neuro-checks as ordered every four hours for three days. The nursing staff failed to conduct the required neuro-checks due to the resident being asleep and family refusal. There was no documentation of the physician or nurse practitioner being notified of these missed assessments. Interviews with the nursing staff revealed that they did not explain the potential consequences of not performing the neuro-checks to the family, assuming the family was already aware due to the resident's history of strokes. The nurses did not attempt to reassess the resident until the next scheduled interval, and there was no communication with the medical provider about the refusals. The resident was eventually sent to the hospital and diagnosed with cerebral infarction and hemiparesis. The failure to perform the ordered assessments and notify the medical provider of refusals could have resulted in the resident not receiving necessary care, potentially leading to a decline in health. This deficiency was identified as an Immediate Jeopardy, which was later removed, but the facility remained out of compliance due to the need to monitor and evaluate the effectiveness of corrective actions.
Removal Plan
- Verify that all assessments were being followed as ordered by physician/NP.
- All licensed nurses will be in-serviced regarding the need to notify physician/NP immediately of any refusals that keep us from following physician ordered assessments. Licensed Nurses on vacation, leave, or unavailable will be trained prior to their next scheduled shift. A Licensed Nurse roster is being utilized to track the Licensed Nurses who have responded and have been in-serviced. The identified Licensed Nurses who were unavailable will attempt to be reached by phone call, text message, and email by the DON/Designee. The DON/Designee will work with the scheduler and audit daily to ensure any Licensed Nurse will not be scheduled until the necessary in-service has occurred.
- The DON/Designee will review 24-hour report daily for change of condition UDA including neurological checks for any refusals and review for medical provider notification. The Weekend Nurse Manager/Designee will review any refusals and contact the DON/Designee immediately if a resident has a refusal to ensure the medical provider has been notified. Audits will be completed daily, weekly, monthly, and periodically thereafter.
- All residents have the potential to be affected by this alleged deficient practice. At risk residents will be identified by reviewing 24-hour report, changes of condition assessment and neurological checks.
- Weekly the DON and/or designee will pull all orders from the EHR for any refusals and review for physician and/or NP notification. The administrator will meet with the DON weekly to audit and verify this review has been completed.
- Reports to the QAPI committee regarding the reviews will be discussed with the team on an ongoing basis.
- A corporate designee will audit compliance with orders weekly until stable and monthly, quarterly thereafter if stable and report findings to the governing body.
Failure in Medication Dispensing and Administration
Penalty
Summary
The facility failed to provide pharmaceutical services that ensure the accurate dispensing and administering of medications for a resident. LVN U dispensed 11 pills for a resident and stored them in a small pill cup in the medication cart with the intention of administering them later. This occurred because the resident was unavailable at the time, being in the shower. Instead of disposing of the medications and re-dispensing them when the resident became available, LVN U continued to dispense and administer medications for other residents. The resident involved was a male with diagnoses including hypertension, diabetes type II, and hyperlipidemia, and was assessed with no cognitive impairment. The medications prescribed for daily administration at 8:00 AM included Amlodipine, Aspirin, Fish oil, Lisinopril, Multivitamin, Sertraline, Vitamin C, Donepezil, Gabapentin, Hydralazine, and Sennosides-Docusate Sodium. The facility's policy requires that drugs and biologicals be stored in their original packaging and not transferred between containers by nursing staff, which was not adhered to in this instance.
Failure to Ensure Physician-Ordered Therapeutic Diet
Penalty
Summary
The facility failed to ensure that a therapeutic diet was prescribed by the attending physician for a resident with dysphagia following a cerebral infarction. The resident was admitted with diagnoses including dysphagia and mild protein-calorie malnutrition. The physician's orders indicated a pureed diet with thin liquids, but the resident was provided with nectar thickened liquids instead. This discrepancy was not supported by a physician's order, and the family was responsible for thickening the liquids, which was not in accordance with the facility's policy. Interviews with staff and family members revealed that the kitchen did not thicken liquids to nectar consistency due to concerns about the liquids becoming too thick by the time they reached the resident. Instead, thickening packets were provided for the nursing staff to use at the time of serving. The facility's policy required that thickened liquids be available as specified in the physician's orders, but this was not followed, leading to a deficiency in the care provided to the resident.
Lack of Documentation for Diabetic Shoes
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, specifically regarding the provision of diabetic shoes for two residents. Resident #25, who was admitted with a diagnosis of Diabetes Mellitus, did not have an order or care plan for diabetic shoes in her medical record, despite having a history of poor circulation. Similarly, Resident #57, who also had a diagnosis of Diabetes Mellitus and a history of pre-ulcerative callus, lacked an order or care plan for diabetic shoes in her record. Both residents expressed concerns about not receiving their diabetic shoes, which they had been expecting for several weeks. The deficiency was further highlighted by the lack of communication and documentation within the facility. The Social Worker arranged for a company to provide free diabetic shoes to residents with diabetes, but this was not communicated to the Director of Nursing (DON) or the Administrator (ADM). The shoe company representative confirmed that they had assessed residents and obtained physician orders, but these were not reflected in the facility's records. The ADM and DON were unaware of the delivery of diabetic shoes and acknowledged the absence of a policy regarding diabetic shoes or durable medical equipment (DME) for residents.
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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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| Golden Estates Rehabilitation Center | 0.8 mi | ★★★★★ | 12 | 0 |
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| The Lev At San Antonio | 2.2 mi | ★★★★★ | 30 | 0 |
| Oak Park Nursing And Rehabilitation Center | 2.4 mi | ★★★★★ | 25 | 0 |
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