Morrow Manor Nursing Center

In the surveyor’s words

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

• Actual harm, isolatedF689Aug 25, 2025

  Based on medical record review, facility staff interview, and review of facility investigation reports, the facility failed to provide adequate supervision to one resident (Resident #4) who required substantial/maximal assistance with bathing, resulting in a fall with fracture. Actual harm occurred on 03/19/25 when Resident #4 was left unattended in the shower. Resident #4 fell and sustained a fracture to the right humerus (upper arm bone). This affected one (Resident #4) of one resident reviewed for falls. The facility census was 28. […]

• No harm, potential for more than minimal, widespreadF812Aug 25, 2025

  Based on observation, interview, and review of facility policy the facility failed to ensure food was served in a sanitary manner. This had the potential to affect 27 residents of 27 residents who consumed food from the kitchen. The facility identified one resident (#29) who ate nothing by mouth.Findings include: Observation on 08/20/25 of the lunch meal from 11:15 A.M. to 11:40 A.M. revealed Dietary Staff #137 serving the meal. Multiple times throughout the service she was observed using the same serving spoon for two pans of vegetables, one was peas, and the other was a capri mix (broccoli, cauliflower, and carrots). Additionally, during meal service the tongs used to serve the chicken (that was covered in sauce) fell in the container and were visibly soiled. […]

• No harm, potential for more than minimal, widespreadF880Jun 27, 2022

  Based on observation, record review, and staff interview, the facility failed to maintain infection control during the medication administration observation when she touched resident's medications with her bare hands and administered them to residents. This affected two (Residents #8 and #19) of five residents observed during medication administration. Furthermore, the facility failed to ensure they initiated and maintained an appropriate Legionella prevention plan. This had the potential to affect all 26 residents residing in the facility. Findings include: 1. Review of the medical record for Resident #19 revealed an admitted [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, isolatedF569Aug 25, 2025

  Based on interview, record review and facility policy review the facility failed to ensure resident funds were timely dispersed to the resident's representative in a timely manner. This affected one resident (#34) of one reviewed for dispersed funds. The facility census was 28.Findings include:Review of Resident #34's closed medical records revealed an admission date of [DATE] and a deceased date of [DATE].Interview on [DATE] at 2:12 P.M. with Business Office Manager (BOM) #145 revealed she had received information a check had been issued in the amount of $6523.67 on [DATE] for Resident #34. BOM #145 stated she was unaware of the date when Resident #34's funds had been issued to her power of attorney (POA) and stated she had only been aware the funds had been dispersed. […]

• No harm, potential for more than minimal, isolatedF605Aug 25, 2025

  Based on interview, medical record review, review of Depakote (antiepileptic) prescribing information, and review of facility provided articles, the facility failed to ensure Resident #7 had the appropriate diagnoses for prescribed psychotropics. This affected one resident (#7) of five residents reviewed for unnecessary medications. The facility census was 28.Findings include:Review of Resident #7's medical record revealed an admission date of 06/26/25 with diagnoses including Alzheimer's disease, dementia, hereditary and idiopathic neuropathy, and gastro-esophageal reflux disease without esophagitis.Review of Resident #7's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severely impaired cognition. […]