Morristown Manor

In the surveyor’s words

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

• Actual harm, isolatedF580Jan 24, 2023

  Based on interview and record review, the facility failed to immediately notify a resident's physician of an x-ray result timely which indicated, the resident had sustained an elbow fracture from a fall that occurred days prior resulting in delayed treatment and a significant change in the resident's condition for 1 of 2 residents reviewed for accidents. (Resident 56) Findings include: The clinical record for Resident 56 was reviewed on 1/20/23 at 11:57 a.m. Resident 56's diagnoses included, but not limited to, irritable bowel syndrome, congestive heart failure, weakness, and chronic obstructive pulmonary disease. A nursing note dated 10/8/2022 at 5:18 p.m. […]

• Actual harm, isolatedF689Jan 24, 2023

  Based on observation, interview and record review, the facility failed to ensure staff were present while a resident with a history of losing his balance and falling was toileting, resulting in the resident falling and obtaining a clavicle (collar bone) fracture; review a resident's fall during a collective Interdisciplinary Team meeting; and evaluate a resident's reported fall, per policy, for 1 of 3 residents reviewed for falls, 1 of 1 resident reviewed for notification of change, and 1 of 2 residents reviewed for pain. (Residents L, 42, and 76) Findings include: 1. The clinical record for Resident 42 was reviewed on 1/18/23 at 12:30 p.m. The diagnosis for the resident included, but was not limited to, left and right above the knee amputation. […]

• No harm, potential for more than minimal, patternF880Aug 10, 2021

  Based on observation, interview and record review, the facility failed to properly prevent and/or contain COVID-19 by not screening staff members entering the facility for signs/symptoms of COVID-19 or who had close contact outside of the facility to others with COVID-19. This had the potential to affect 41 of 110 residents that were cared for by unscreened staff members. Findings include: 1. The facility's daily schedule was provided on 8/10/21 at 11:52 a.m. from SDC (Staffing Development Coordinator). It indicated, CNA (Certified Nursing Assistant) 2 and CNA 4 were scheduled to work on 8/10/21 during the day shift. An observation was made on 8/10/21 at 1:10 p.m. with SDC of the facility's start of shift daily staff screening sheets for 8/10/21. […]

• No harm, potential for more than minimal, patternF886Aug 10, 2021

  Based on interview and record review, the facility failed to test a staff member with signs/symptoms of COVID-19 timely for 1 of 5 staff members reviewed for infection control. This had the potential to affect 41 of 110 residents CNA 2 was caring for the 48 hours prior to her showing signs and symptoms. (CNA 2) Findings include: An interview with SDC (Staff Development Coordinator) was conducted on 8/10/21 at 11:42 a.m. She indicated, CNA (Certified Nursing Assistant) 2, who was not vaccinated for COVID-19, was tested for COVID-19 on 8/3/21 at the facility via a POC (Point of Care) test. The POC test was resulted as positive. The facility followed up the POC test with a PCR (polymerase chain reaction) test on 8/3/21. The PCR test was resulted on 8/4/21 as positive. […]

• No harm, potential for more than minimal, isolatedF554May 22, 2025

  Based on observation, interview, and record review, the facility failed to have the interdisciplinary team (IDT) determine and document whether self-administration of medications was clinically appropriate for 1 of 8 residents observed during medication administrations. (Resident 52) Findings include: The clinical record for Resident 52 was reviewed on 5/21/25 at 9:00 a.m. The diagnoses included, but were not limited to, hypertension. A Quarterly Minimum Data Set (MDS) assessment, dated 2/26/25, indicated the resident was cognitively intact. A physician's order, dated 1/7/25, indicated the resident was to receive 400 milligrams (mg) of magnesium oxide twice a day. […]