Morgan Health Center

In the surveyor’s words

From the most serious findings on record at Morgan Health Center, in the surveyor’s own words.

• Immediate jeopardy, patternF684Apr 30, 2026

  Based on clinical record review and staff interview, the facility failed to ensure that residents received care and services in accordance with professional standards of practice, resulting in Immediate Jeopardy. Specifically, for 3 of 3 residents reviewed who were prescribed anticoagulant (blood-thinning) medications and experienced falls, the facility failed to implement physician orders for post-fall care. This included failure to conduct timely and frequent neurological monitoring (e.g., every 15 minutes for the first hour) and/or the failure to transfer residents to the hospital as ordered. This deficient practice placed Resident IDs #1, #2, and #3 at risk for serious harm, serious impairment, serious injury or death. […]

• Immediate jeopardy, isolatedF689Oct 28, 2021

  Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that a cognitively impaired resident received adequate supervision to prevent elopement from the facility for 1 of 6 sample residents reviewed for elopement Resident ID #1. Findings are as follows: On 10/25/2021, the facility reported an incident of elopement by Resident ID #1, which occurred on 10/24/2021 at approximately 6:45 PM. The facility is in a suburban setting within a short distance of a heavily traveled street. On 10/24/2021 at 6:45 PM it was dark outside. A review of the facility's policy and procedure titled Elopement Procedure states in part, .Policy: It is the policy of this facility to provide a safe and secure environment for all residents. […]

• Actual harm, patternF692Mar 13, 2023

  Based on record review and staff interview, it has been determined that the facility failed to ensure that a resident is offered sufficient fluid intake to maintain proper hydration for 2 of 4 residents reviewed, Resident ID #s 1 and 3. Additionally, the facility failed to ensure residents maintain acceptable parameters of nutritional status, such a usual body weight or desirable body weight and failed to follow their policy relative to weights, for 2 of 4 residents reviewed, Resident ID #s 1 and 2. Findings are as follows: Record review of a community report complaint received at the Rhode Island Department of Health on 3/2/2023 alleges that Resident ID #1 arrived at the hospital with sunken eyes, severely dehydrated, scaly, flaky, and inflamed skin. […]

• Actual harm, isolatedF697Feb 17, 2022

  Based on observation, record review, and staff interview, it has been determined that the facility failed to ensure that pain management was provided to a resident who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 4 resident reviewed for pain management, Resident ID #63. Findings are as follows: Record review for the resident revealed s/he was readmitted to the facility after being evaluated at an acute care facility in December of 2021 due to a fracture to his/her right femur. […]

• No harm, potential for more than minimal, widespreadF880Jun 5, 2024

  Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide a safe and sanitary environment to help prevent the transmission of infections related to implementing a water management program based upon industry standards and/or the Centers for Disease Control and Prevention (CDC) toolkit. Findings are as follows: Record review of the CDC document titled, Developing a Water Management Program to Reduce Legionella [a bacteria that may cause a very serious type of lung infection] Growth & Spread in Buildings, dated June 2021, version 1.1 states in part, .The key to preventing Legionnaires' disease is maintenance of the water systems in which Legionella may grow .Water stagnation: Encourages biofilm growth and reduces… […]