Morada Temple

In the surveyor’s words

From the most serious findings on record at Morada Temple, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Mar 3, 2024

  Based on observations, interviews, and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible and failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 5 of 5 residents (Resident #s 1, 2, 3, 4, and 5) reviewed for accidents and supervision. The facility failed to ensure Resident #1 was assessed for safety regarding hot liquids resulting in Resident #1 sustaining 1st and 2nd degree burns on 02/23/2024 when he spilled his coffee on himself and was not assessed for hot liquids safety after the incident. […]

• Immediate jeopardy, isolatedF578Feb 20, 2024

  Based on Interview and record review, the facility failed to protect the resident right to request, refuse and/or discontinue treatment for 1 (Resident #1) of 34 residents reviewed for advance directives. The facility failed to ensure Resident's # 1 OOHDNR was processed and updated in EMR and care plan when signed by physician on [DATE]. The resident had a seizure on [DATE] that resulted in life saving measures being given, as the EMR showed resident was a full code, AED was applied and shock given, CPR was started, and resident was transferred to the hospital . An Immediate Jeopardy (IJ) situation was identified on [DATE]. […]

• Immediate jeopardy, isolatedF655Feb 20, 2024

  Based on interview and record review, the facility failed to develop and implement a baseline care plan to include the minimum healthcare information necessary to properly care for a resident for 1 of 24 residents (Resident #1) reviewed for baseline care plans. The facility failed to update Resident #1 baseline care plan on [DATE] when his code status changed from Full code to DNR, resulting in Resident #1 receiving CPR and the use of an AED which delivered a shock on [DATE] the Resident # 1 suffered a seizure and stopped breathing. An Immediate Jeopardy (IJ) situation was identified on [DATE]. […]

• Immediate jeopardy, isolatedF678Feb 20, 2024

  Based on observation, interview, and record review the facility failed to follow physician orders and the resident's advance directives for 1 of 35 residents (Resident #1) whose records were reviewed for DNR code status. The facility failed to ensure nursing staff followed emergency protocol and failed to ensure staff did not provide Resident #1, who had a DNR in place, CPR started after the resident had a seizure and stopped breathing, according to professional standards of practice. On [DATE] Resident # 1 had a seizure and stopped breathing, was listed as a full code in the EMR. Life saving measures were initiated. Upon review of the medical record order signed by the physician on [DATE] out-of- hospital do not resuscitate. […]

• Immediate jeopardy, isolatedF684Feb 20, 2024

  Based on interview and record review, the facility failed provide care and services in accordance with physician orders for 1 (Resident # 1) or 34 reviewed for Physician's orders. The facility failed to follow physician's order for out of hospital DNR for Resident # 1. An Immediate Jeopardy (IJ) situation was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of No actual harm with potential for more than minimal harm that was not Immediate Jeopardy at a scope of isolated. These deficient practices could contribute to a resident's potential of prolonged suffering, pain, physical injury and psychosocial harm due to receiving CPR against physicians' orders. […]