Inspection Reports for Morris Park Rehabilitation and Nursing Center

The facility failed to provide sufficient nursing staff consistently to meet residents' needs, resulting in delayed care and unmet resident needs. Staffing levels were repeatedly below facility-assessed levels, with excessively low weekend staffing documented. Multiple residents and staff reported staffing shortages impacting care delivery.

The facility was found to have insufficient nursing staff, particularly Certified Nursing Assistants, resulting in delayed resident care and unmet needs. Medication storage practices were deficient, including unlabeled and expired medications and improperly stored insulin pens. Emergency drug boxes contained expired medications. Food safety violations included unlabeled and undated food items in kitchen and unit refrigerators.

Multiple standard health and life safety code citations including food procurement, drug labeling, nursing staff sufficiency, and HVAC issues. All deficiencies were corrected by March or April 2025.

One deficiency related to abuse reporting documentation.

The facility failed to prevent Resident #1 from eloping undetected on 05/01/24, despite policies on wandering and elopement risk management. Resident #1 was found several days later without injury. The investigation concluded no abuse or neglect occurred. Corrective actions included staff re-education, policy revisions, implementation of an elopement care plan, and termination of the security guard involved.

One standard health citation for accident hazards and supervision, corrected shortly after inspection.

The facility failed to develop and implement a person-centered Comprehensive Care Plan (CCP) for Resident #108's right thumb skin lesion, despite medical orders and treatments. This deficiency was identified through observations, record reviews, and interviews.

The facility was found deficient in multiple areas including failure to ensure residents were treated with dignity, timely completion of Minimum Data Set (MDS) assessments, inadequate supervision leading to resident falls, improper food storage temperatures, infection control lapses, unsecured handrails, and ineffective pest control.

Multiple standard health and life safety code citations including accident hazards, infection prevention, care plan development, and HVAC issues. Some citations involved actual harm. All corrected by August or September 2023.

Two standard health citations related to abuse and neglect and reporting of alleged violations, corrected by April 2023.

The complaint investigation was triggered by an incident on 03/06/2023 where LPN #1 was observed on surveillance footage and by staff forcefully pushing Resident #1's wheelchair causing it to tilt and Resident #1 to fall partially to the floor. Resident #1 complained of pain and was sent to the hospital. The investigation concluded there was evidence to suspect abuse, neglect, or mistreatment. Additionally, a separate abuse allegation reported on 06/21/2022 involving Resident #1's roommate was not reported timely to the state.

The facility failed to ensure Resident #1's right to be free from physical abuse. Surveillance footage and multiple staff interviews confirmed that LPN #1 forcefully pushed Resident #1's wheelchair causing it to tilt and Resident #1 to fall partially to the floor. Resident #1 was evaluated at the hospital with no fractures found. LPN #1 was suspended and terminated. The facility also failed to timely report an abuse allegation involving Resident #1's roommate, which was reported late to the state.

One standard health citation for reporting to national health safety network, widespread scope, not corrected at time of report.

One standard health citation for reporting to national health safety network, widespread scope, not corrected at time of report.

One standard health citation for accident hazards and supervision with actual harm, corrected by November 2022.

One standard health citation for abuse and neglect, corrected by September 2022.

Three standard health citations related to care plan development, investigation of alleged violations, and reporting of alleged violations, corrected by June 2022.

The facility was found deficient in multiple areas including failure to notify a resident's physician of significantly elevated blood sugar levels, inadequate sanitation of a resident's hand splint, lack of medical follow-up for a resident with consistently elevated blood sugars, failure to review and adjust care plans and medications appropriately, and improper infection control practices during wound care.