Morning Star Care Center

In the surveyor’s words

From the most serious findings on record at Morning Star Care Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF801Mar 11, 2021

  Based on staff interview and review of the enrollment letter, the facility failed to ensure the dietary manager met the required qualifications. The facility census was 24. The findings were. Interview with the dietary manager on 3/10/21 at 12:17 PM revealed she was not a certified dietary manager, and she was enrolled in the Nutrition & Foodservice Professionals Training Course through the University of North Dakota with an expected completion date of 1/31/22. Review of the enrollment letter showed the dietary manager enrolled in the course on 11/25/20.

• No harm, potential for more than minimal, widespreadF882Mar 11, 2021

  Based on staff interview, the facility failed to ensure the infection preventionist met the qualifications. The facility census was 24. The findings were: Interview with the DON and RN #2 on 3/11/21 at 8:24 AM revealed RN #2 had assumed the responsibilities of the infection preventionist in late January 2021 and was not currently enrolled in the required specialized training course in infection prevention and control. The DON stated the facility's previous infection preventionist had resigned the position, however remained a part-time employee. Interview with RN #2 revealed she had resigned her position as infection preventionist at the end of December 2020. […]

• No harm, potential for more than minimal, patternF756Jan 25, 2024

  Based on medical record review and staff interview, the facility failed to ensure the pharmacist identified and reported irregularities to the physician during the monthly drug regimen review for 3 of 5 sample residents (#2, #19, #23) reviewed for unnecessary medications. The findings were: 1. Review of the 1/9/24 quarterly MDS assessment showed resident #2 received an antianxiety medication and an antidepressant. The following concerns were identified: a. Review of physician orders for resident #2 showed the resident was ordered Trazadone (antidepressant) 50 mg at bedtime PRN on 11/14/23 and lorazepam (antianxiety) 0.5 mg daily PRN on 11/6/23. The PRN orders were not limited to 14 days. b. […]

• No harm, potential for more than minimal, patternF758Jan 25, 2024

  Based on medical record review and staff interview, the facility failed to ensure residents on psychotropic medications received gradual dose reductions (GDRs) and PRN orders for psychotropic medications were limited to 14 days for 3 of 5 sample residents (#2, #19, #23) reviewed for unnecessary medications. The findings were: 1. Review of the 1/9/24 quarterly MDS assessment showed resident #2 received an antianxiety medication and an antidepressant medication. The following concerns were identified: a. Review of the physician orders for resident #2 showed the resident was ordered Trazadone (antidepressant) 50 mg at bedtime PRN on 11/14/23 and lorazepam (antianxiety) 0.5 mg daily PRN on 11/6/23. The PRN orders were not limited to 14 days. b. […]

• No harm, potential for more than minimal, patternF758Jan 12, 2023

  Based on staff interview, medical record review, and policy and procedure review, the facility failed to ensure PRN (as needed) orders for anti-psychotic medications were limited to 14 days for 2 of 5 sample elders (#16, #22) and failed to ensure appropriate behavior monitoring and interventions were in place for 3 of 5 sample elders (#2, #11, #16) reviewed for psychotropic medication use. The findings were: 1. Review of the significant change MDS assessment dated [DATE] showed elder #2 had a BIMS score of 14 out 15, which indicated the elder was cognitively intact, and diagnoses which included diabetes mellitus and thyroid disorder. Further review showed the elder received antidepressant medication on 7 of 7 days during the look back period. […]