Morton Bakar Center

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF761Jul 27, 2023

  Based on observation, interview, and record review, the facility failed to ensure pharmaceutical products were stored and labeled correctly, when: 1a. One open and expired medication was available for use for Resident 23 in the medication cart, which put residents 23 at risk of receiving expired medication, 1b. One open and expired medication was available for use for Resident 45 in the medication cart, which put residents 45 at risk of receiving expired medication, 1c. Two open and expired medications were available for use for Resident 59 in the medication cart, which put residents 59 at risk of receiving expired medication, 1d. […]

• No harm, potential for more than minimal, isolatedF684Feb 23, 2023

  Based on interview and record review, for one of three sampled residents (Resident 1), the facility failed to ensure Resident 1, who had a diagnosis of dysphagia (difficulty swallowing) was provided adequate supervision during meals. This failure had the potential to result in avoidable accidents such as choking. Findings: Review of Resident 1's Admission Record indicated, Resident 1 had been known to the facility since September 2008. Resident 1 was recently readmitted to the facility on [DATE] with diagnoses that included dysphagia, glaucoma (eye condition that can cause blindness) and schizoaffective disorder (mental illness). Review of Resident 1's Post-Event Assessment Form 1 dated 12/24/21 indicated, Resident 1 had appeared pale, was unable to talk and had difficulty breathing. […]

• No harm, potential for more than minimal, isolatedF600Feb 24, 2022

  Based on interview and record review, for one of three sampled residents (Resident 1), the facility failed to ensure Resident 1 was free from physical abuse. During an unprovoked incident, Resident 2 pushed Resident 1 by the shoulder causing Resident 1 to fall backwards. This failure resulted in Resident 1's emotional distress and had the potential to cause physical harm related to the fall. Findings:had been known to the facility since 11/20/17 with Review of Resident 1's Admission Record indicated Resident 1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 2's Admission Record indicated Resident 2 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, isolatedF600Feb 23, 2022

  Based on interview and record review, for one of two sampled residents (Resident 1), the facility failed to ensure Resident 1, who had aggressive behavior, was free from physical abuse when Resident 2 punched Resident 1 in the face and back of the head during a verbal confrontation. This failure had resulted in Resident 1 being punched by Resident 2 causing redness on the face. Findings: Review of Resident 1's Admission Record dated 10/6/21 indicated Resident 1 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, isolatedF600Jul 29, 2021

  Based on observation, interview, and record review, the facility failed to keep one of three sampled residents (Resident 10) free from abuse. Resident 10 was verbally abused by the Certified Nursing Assistant (CNA 1) on 9/30/20 when CNA 1 was observed using command language and making disparaging comments to Resident 10 while providing incontinence (loss of bladder or bowel control) care. This failure resulted in Resident 10 being verbally abused and suffering psychosocial harm. Findings: During an interview with the facility's transport Driver (DVR) on 10/19/20, at 12:35 p.m., DVR stated he went to Resident 10's room to transport Resident 10 to a scheduled appointment. […]