Morris Nursing Home

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interviews, and facility Enhanced Barrier Precautions (EBP) signage, the facility failed to initiate enhanced barrier precautions as required. This affected one resident (#22) of two residents reviewed for EBP. The facility also failed to ensure the separation of clean and dirty linen. This had the potential to affect all residents in the facility. The facility census was 14.Findings include:1.Review of the medical record revealed Resident #22 was admitted to the facility on [DATE] with diagnoses of orthopedic aftercare for right below the knee amputation, indwelling urinary catheter for neurogenic bladder, hypertension, severe sepsis, and alcohol dependence. Review of the Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #22 had intact cognition and was always continent of bowel and had an indwelling catheter in place for the bladder. Review of physician orders for Resident #22 revealed an order dated 12/17/25 for an indwelling urinary…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the facility failed to ensure resident care conferences occur quarterly with the Interdisciplinary Team and included the resident and/or resident representative. This affected seven residents (#1, #3, #4, #10, #12, #13, #16) out of seven residents reviewed for care conferences. The facility census was 14. Findings include: 1.Record review for Resident #16 revealed this resident was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, dementia, and benign prostatic hyperplasia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed this resident had severe cognitive impairment, required assistance with activities of daily living and was always incontinent of bowel and bladder. Record review for Resident #16 revealed the only care conference held in 2025 was in October. 2. Record review for Resident #3 revealed this resident was admitted to the facility on [DATE] with the following diagnoses: Bipolar Disorder, Chronic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and staff interviews, the facility failed to ensure a performance review for every nurse aide was conducted at least once every twelve months. This affected four (Certified Nurse Aide (CNA) #33, CNA #38, CNA #25, and CNA #40) out of six nurse aides reviewed. The facility census was 14.Findings Include:Record Review of employee files on 12/23/25 at 3:00 P.M revealed CNA #33, CNA #38, CNA #25, and CNA #40 did not have an annual performance evaluation.Interview on 12/24/25 at 8:30 A.M with the Administrator confirmed CNA #33, CNA #38, CNA #25, and CNA #40 did not have an annual performance evaluation.

Based on record review and staff interviews, the facility failed to ensure Nurse aides had at least 12 hours of annual continuing education for four (Certified Nurse Aide (CNA) #33, CNA #38, CNA #25, and CNA #40) out of six nurse aides reviewed. The facility census was 14.Findings Include: Record Review on 12/23/25 at 3:05 P.M revealed CNA #37, CNA #33, CNA #25, CNA #40, and CNA #23 did not have 12 hours of annual continuing education.Interview on 12/24/25 at 8:35 A.M with the Administrator confirmed CNA #37, CNA #33, CNA #25, CNA #40, and CNA #23 did not have 12 hours of annual continuing education.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview, and review facility policy, the facility failed to promote dignity while dining. This affected two (#1 and #13) of two residents reviewed for dignity. The facility census was 14. Findings include:Review of the medical record revealed Resident #1 was admitted to the facility on [DATE]. Diagnoses included cerebral ischemia, major depressive disorder, unspecified psychosis, dementia, and auditory hallucinations. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #1 was severe cognitively impaired and required supervision with eating. Review of the medical record revealed Resident #13 was admitted on [DATE]. Diagnoses included dysphagia oral phase, Alzheimer's disease with late onset, dementia, and depression. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #13 had severe cognitive impairment and required supervision for eating. Observations on 12/23/2025 at 12:27 P.M. revealed Resident #1 and Resident #13…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, review of Notice of Medicare Non-Coverage (NOMNC) letters, and policy review, the facility failed to ensure proper notice was provided to the resident and/or resident representative when the facility was discontinuing Medicare services. This affected one resident (#23) of three residents reviewed for Beneficiary Notification. The facility census was 14.Findings include: Review of the medical record revealed Resident #23 was admitted to the facility on [DATE] with diagnoses of cerebral infarction with left (non-dominant) side hemiplegia and hemiparesis, acute and chronic respiratory failure with hypoxia, aphasia, dysphagia, diabetes mellitus type II, hypertension and atrial fibrillation. Review of the Minimum Data Set (MDS) Significant Change of Status assessment dated [DATE] revealed Resident #23 had severe cognitive impairment, required supervision for eating, maximal assistance for oral and personal hygiene, toileting, bathing and dressing, and was dependent for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of facility self-reported incident and investigation, staff interview and facility policy review, the facility failed to thoroughly investigate an alleged violation. This affected one (#3) of one resident reviewed for abuse. The facility census was 14. Findings include:Record review for Resident #3 revealed an admission to the facility on [DATE]. Diagnoses included bipolar disorder, chronic respiratory failure with hypoxia, and type two diabetes. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 had moderate cognitive impairment. Review of the self-reported incident dated 11/12/25 revealed Resident #3 reported physical abuse by a staff member. Review of the investigation revealed no documentation of assessing any like residents in the facility for abuse from a staff member.Interview on 12/24/25 at 9:10 A.M. with the Administrator confirmed no additional residents were assessed for the investigation.Review of the facility policy titled Abuse…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of facility policy, the facility failed to notify the Ombudsman of a transfer to the hospital and failed to provide the bed hold policy to the resident representative in writing. This affected one (#19) of three residents reviewed for transfers. The facility census was 14. Findings include:Review of the medical record revealed Resident #19 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease with acute exacerbation, dysphagia, transient ischemic attack, generalized anxiety disorder. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the Resident #19 had intact cognition. Review of Resident #19 progress note dated 10/09/25 revealed resident left facility at approximately 11:30 PM via stretcher. There was no evidence the resident or resident representative was provided the bed hold policy in writing or the Ombudsman was notified of the transfer. Interview on 12/23/25 at 10:32 A.M. with the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents were free from significant medication errors. This affected one resident (#12) out of five residents who received insulin. The facility census was 14.Findings include:Review of the medical record revealed Resident #12 was admitted to the facility on [DATE] with diagnoses including type II diabetes mellitus, cerebral Infarction, and morbid obesity.Review of the medication orders revealed Insulin Degludec FlexTouch Subcutaneous Solution Pen-injector 100 UNIT/milliliter (ML), inject 80 units subcutaneously every morning and at bedtime. Review of the December 2025 Medication Administration Record (MAR) for Resident #12 revealed on 12/05/2025, 12/07/2025, 12/11/2025, 12/12/2025, 12/17/2025, and 12/22/2025 the morning dose of Insulin was not documented as being administered. Interview on 12/23/2025 at 1:05 P.M. with the Interim Director of Nursing (DON) confirmed the morning scheduled doses of insulin were not documented as being…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, review of the resident medication list, and policy review, the facility failed to ensure all medications were stored and labeled properly. This had the potential to affected two (#3 and #10) out of 14 residents with medications stored in a medication cart. The facility census was 14. Findings Include: Observation on 12/24/25 at 2:35 P.M with Registered Nurse (RN) #14 revealed in medication cart #1 there were 20 famotidine pills with an expiration date of November 2025. Also, in the medication cart #1 there was one bottle of bisacodyl with an expiration date of July 2025. Interview on 12/24/25 at 2:40 P.M with RN #14 confirmed in medication cart #1 there were 20 famotidine pills with an expiration date of November 2025 and one bottle of bisacodyl with an expiration date of July 2025. Review of the facility medication list by order revealed Resident #3 and Resident #10 had orders for bisacodyl and Resident #3 had orders for famotidine. Review of the facility policy titled Medication Handling and Administration Rules revealed medication must have an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident, family and staff interviews, bed manual review, policy review, and review of the Food and Drug Administration (FDA) guidance, the facility failed to ensure the resident's side rails did not present an entrapment hazard and consent to utilize the side rails was obtained. This affected four (#5, #9, #163 and #164) of 15 residents identified as having side rails. The facility census was 17. Findings included: 1) Review of the medical record for Resident #9 revealed an admission on [DATE]. Resident #9's diagnoses included: acute and chronic respiratory failure with hypoxia, heart failure, chronic obstructive pulmonary disease, constipation, hemorrhoids, occlusion and stenosis of bilateral carotid arteries, chronic kidney disease, myalgia, obesity, polyosteorarthritis, encephalopathy, Vitamin D deficiency, pure hypercholesterolemia, hypertension, paroxysmal atrial fibrillation, hypertrophic osteoarthropathy multiple sites, pulmonary hypertension, panlobular emphysema, hyperosmolality…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy review, the facility failed to timely revise care plans to accurately reflect dental and fall prevention needs. This affected two (#10 and #165) of sixteen residents reviewed for care plans. The facility census was 17. Findings include: 1. Review of Resident #10's medical record review admitted to the facility on [DATE], with diagnoses including: type II diabetes, unspecified persistent mood disorder, unspecified psychosis, unspecified hallucinations, and unspecified cerebral infarction. Review of the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderately impaired cognition, was delusional, had no behaviors, did not wander, and rejected care one-to-three out of seven days per week. Resident #10 was independent with Activities of Daily Living (ADL's) and required supervision and setup assistance. Review of admission assessment dated [DATE] revealed Resident #10 had full lower dentures and an upper…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.