Morrisons Cove Home

In the surveyor’s words

From the most serious findings on record at Morrisons Cove Home, in the surveyor’s own words.

• Immediate jeopardy, patternF689Jul 30, 2022

  Based on a review of policies, clinical records, and facility reports, as well as observations and staff interviews, it was determined that the facility failed to have adequate supervision and interventions in place to prevent elopement for six of six residents reviewed (Residents 1, 2, 3, 4, 5 and 6) who were identified as wanderers and at risk for elopement. The facility's failure created a situation which placed the residents in immediate jeopardy of the likelihood of serious bodily injury, harm or death. […]

• No harm, potential for more than minimal, patternF623Jan 24, 2025

  Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that a written notice regarding emergency transfer to the hospital was provided to the Office of the State Long-Term Care Ombudsman, and failed to ensure that a written notice was provided to the resident and/or the resident's responsible party regarding the reason for transfer to the hospital for five of 33 residents reviewed (Residents 1, 29, 35, 54, 59). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated November 30, 2024, revealed that the resident was cognitively intact, was usually understood, and could usually understand others. […]

• No harm, potential for more than minimal, patternF657Jan 24, 2025

  Based on review of policies, clinical records, and facility investigations, as well as staff interviews, it was determined that the facility failed to ensure that care plans were updated to reflect changes in resident care needs for four of 33 residents reviewed (Residents 8, 26, 53, 66). Findings include: The facility's policy regarding care plans, dated November 7, 2024, indicated that nurses and interdisciplinary team members were responsible for updating the resident's care plan to reflect changes in the resident's status. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 8, dated June 13, 2024, revealed that the resident was understood, could understand others, and had a diagnosis which included dementia. […]

• No harm, potential for more than minimal, patternF868Jan 4, 2024

  Based on review of attendance records for the facility's Quality Assurance Committee, as well as staff interviews, it was determined that the facility failed to ensure that all required members of the Quality Assurance Committee attended quarterly meetings. Findings include: Review of the attendance records for the facility's Quality Assurance Committee meetings revealed that the Medical Director or designee did not attend any meetings from April 2023 through December 2023. Interview with the Nursing Home Administrator on January 4, 2024, at 3:48 p.m. confirmed that there was no documented evidence that the Medical Director or designee attended any meetings in the last three quarterly meetings reviewed. […]

• No harm, potential for more than minimal, patternF584Feb 8, 2023

  Based on a review of facility policies and observations, as well as staff interviews, it was determined that the facility failed to provided a homelike environment during meals in the dining rooms for three of three nursing unit dining rooms. Findings include: The facility's policy for resident dining preferences, dated August 4, 2022, indicated that dining should be a home- inspired environment that was appealing, safe and clean, and only provide trays in the dining room by resident requests or as care planned. Observations in the first floor dining room on February 6, 2023, at 11:45 a.m. revealed that there were ten residents eating their lunch meals with their plates on heated serving plates and all items were on a tray. Observations on February 7, 2023, at 11:48 a.m. […]