Morrell Nursing Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Dec 1, 2022

  Based on record reviews, interviews and review of the facility policy titled, Abuse, Neglect and Exploitation, the facility failed to ensure Resident (R)71 and R11 were free from abuse, specifically sexual abuse, by Certified Nursing Assistant (CNA)1, for 2 of 4 residents reviewed for abuse. On 11/29/22 at 6:00 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. On 11/29/22 at 6:00 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 11/15/22. […]

• Immediate jeopardy, isolatedF609Dec 1, 2022

  Based on record reviews, interviews and review of the facility policy titled, Abuse, Neglect, and Exploitation, the facility failed to report alleged sexual abuse to the state agency, as required, no later than 2 hours after the allegation is made for Resident (R)71) for 1 of 4 residents reviewed for Abuse. On 11/29/22 at 6 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 11/15/22. The IJ was related to 42 CFR 483.12 - Reporting of Alleged Violations. On 11/29/2022 at 6 PM, the Administrator and the Director of Nursing were notified the failure to promptly report the sexual abuse of F71 by Certified Nursing Assistant (CNA)1 constituted immediate jeopardy at F609. […]

• No harm, potential for more than minimal, isolatedF760Feb 19, 2026

  Based on review of facility policy, observation and interview, the facility failed to ensure Resident (R)66 was free from a significant medication error. Specifically, R66 was administered insulin via an insulin pen by Registered Nurse (RN)1 who failed to correctly prime the pen before administering the needed 12 units of insulin, for 1 of 1 residents observed receiving insulin during med pass. Findings include: Review of the facility policy titled Insulin Pens states as the policy, It is the policy of this facility to use insulin pens in order to improve the accuracy of insulin dosing and provide increased resident comfort. The Policy Explanation and Compliance Guidelines states under #6, Insulin pens will be primed prior to each use to avoid a collection of air in the insulin reservoir. […]

• No harm, potential for more than minimal, isolatedF761Feb 19, 2026

  Based on review of facility policy, observation and interviews, the facility failed to ensure expired medications were removed, and not stored with medications in date and in use for residents, from Medication Cart #1 on Rehab Hall 400, for 1 of 4 medication carts reviewed.Findings include: Review of the facility policy titled Storage Of Drugs states as the policy, All drugs shall be stored appropriately . Under Procedure, . 4. Drugs shall not be kept on hand after the expiration date on the label. 5. Discontinued drugs shall be returned to the provider pharmacy for destruction. […]

• No harm, potential for more than minimal, isolatedF758Dec 5, 2024

  Based on observations, record reviews, and interviews the facility failed to ensure that Resident (R)66 was appropriately assessed and dosed for 1 of 5 residents reviewed for unnecessary medications. Findings included: The facility policy titled, Psychotropic Medication dated 1/18 stated: Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). Review of the electronic medical record (EMR) revealed R66 was admitted to the facility on [DATE] with diagnoses including but not limited to major depressive disorder, persistent mood [affective] disorder and dementia with behavioral disturbance. […]