SAN ANTONIO, TX - Federal inspectors found multiple safety violations at Morningside Manor on Babcock Road, including a critical failure to complete ordered neurological assessments that resulted in an immediate jeopardy determination before being corrected during the inspection process.
Critical Assessment Failures Put Resident at Risk
The most serious violation involved a resident who experienced stroke-like symptoms but did not receive ordered neurological assessments every four hours for three days as prescribed by their nurse practitioner. According to inspection records, the resident was admitted in March 2024 with existing conditions including dementia, dysphagia, and traumatic brain injury history.
When the resident's family reported they could not hold their beverage, the nurse practitioner ordered neurological checks every four hours for three days with instructions to notify the provider of any deficits. However, nursing staff failed to complete these critical assessments due to the resident being asleep or family refusal, and crucially failed to notify the physician when assessments could not be performed.
Documentation revealed multiple missed assessments: "Neuro check was not done due to [Resident] being asleep" at 2:02 AM on March 23, and "Neuro check was not done due to family member refusal" at 4:55 AM and 9:06 AM the same day. The resident was subsequently hospitalized and diagnosed with cerebral infarction, hemiparesis affecting the right dominant side, and slurred speech.
Licensed vocational nurses interviewed stated they did not explain stroke risks to the family or attempt reassessment at different intervals when refused. One nurse reported being hit by the resident during an attempted assessment but did not seek alternative approaches or notify the physician.
Neurological assessments following potential stroke symptoms are critical for detecting changes in brain function that could indicate worsening conditions. When a resident shows signs of neurological changes, frequent monitoring allows healthcare providers to identify deterioration quickly and adjust treatment accordingly. Delays in recognizing stroke progression can lead to permanent disability or death.
Comprehensive Care Plan Inadequacies
Inspectors identified systemic failures in care plan development and maintenance affecting six residents. These failures included missing documentation for critical safety equipment and therapeutic requirements that directly impact resident wellbeing.
Three residents with physician orders for quarter bed rails lacked corresponding care plans addressing their use. Bed rails serve as assistive devices for residents with mobility limitations, helping them reposition in bed while preventing falls. Without proper care planning, staff may be unaware of their presence, creating safety risks including entrapment.
One resident receiving thickened liquids had an outdated care plan specifying nectar-thick consistency while physician orders required honey-thick liquids since August 2022. This discrepancy created confusion for nursing staff who followed care plan directives rather than current medical orders. Thickened liquids are prescribed for residents with swallowing difficulties to prevent aspiration, where food or liquid enters the airways instead of the stomach.
Speech therapy staff explained that receiving incorrect liquid consistency could cause aspiration pneumonia, potentially requiring hospitalization. In severe cases, aspiration can be fatal, particularly for residents with compromised health status. Additionally, residents may refuse liquids they cannot safely swallow, leading to dehydration.
Another resident with an indwelling catheter for urinary retention had no care plan interventions despite having the device documented. Proper catheter care requires specific protocols for infection prevention, monitoring for complications, and maintaining catheter function.
Medication Safety Violations
A concerning medication safety violation involved pre-dispensing medications into pill cups for later administration. During the inspection, a licensed vocational nurse was observed storing eleven pills for one resident in a small plastic cup within the medication cart while continuing to prepare medications for other residents.
The nurse explained she had attempted to administer the medications but the resident was unavailable due to showering. Rather than returning medications to their original containers, she stored the loose pills for later administration while serving other residents.
This practice, known as a "nurse workaround," significantly increases medication error risks. Industry standards require medications to remain in original packaging until administration to prevent mix-ups, contamination, or incorrect dosing. The facility's own policy states that only the issuing pharmacy may transfer medications between containers.
Professional nursing organizations identify pre-pouring medications as a high-risk practice that, while intended to save time, exposes residents to potential harm. When errors occur with pre-dispensed medications, consequences can be severe due to the inability to verify medication identity or dosing accuracy.
Grievance Process Failures
The facility failed to properly address resident grievances, specifically regarding a resident with hearing and vision impairments who was left without access to her call light. During inspection, the resident was observed calling for assistance while positioned in her wheelchair approximately three feet from her call light.
The resident stated to staff: "you left me here, you said you would be right back, I had to yell to get you here, you all are always in a rush and leave." When the certified nursing assistant responded, she acknowledged understanding the complaint but failed to document it or report it through proper grievance channels.
Facility policy requires staff to actively work toward resolution of complaints and grievances, including verbal complaints. Proper grievance handling ensures residents can voice concerns about their care without fear of retaliation and helps facilities identify systemic issues requiring correction.
Food Service and Dietary Violations
Multiple food service violations were identified that could affect resident health and safety. The facility failed to offer bedtime snacks to residents despite meal schedules that exceeded 14 hours between dinner and breakfast the following day, violating federal requirements for meal frequency.
Residents interviewed in a group setting reported they were not made aware of snack availability or offered bedtime snacks by staff. Extended periods without food can be particularly problematic for diabetic residents who require regular nutrition to maintain stable blood sugar levels.
Kitchen sanitation issues included improper food storage with boxes positioned less than 18 inches from the ceiling in the walk-in refrigerator and uncovered chocolate pies that were subsequently discarded. These violations increase risks of foodborne illness and contamination.
Additionally, one resident was provided nectar-thickened liquids without a physician's order, as the registered dietitian had modified the consistency based on family request rather than medical prescription. Therapeutic diets require physician orders to ensure appropriate medical supervision and monitoring.
Additional Issues Identified
Inspectors documented several other compliance failures including inadequate documentation for diabetic shoes provided to residents without proper physician orders or care plan integration. Two diabetic residents received therapeutic footwear through an outside vendor without facility awareness or medical oversight.
The facility also failed to maintain accurate records regarding assistive devices and medical equipment, creating gaps in care coordination and monitoring. These documentation failures prevent staff from having complete information necessary for safe resident care.
Temperature and medication storage protocols showed deficiencies that could compromise medication effectiveness and resident safety. Proper pharmaceutical services require strict adherence to storage requirements and dispensing procedures to maintain drug integrity.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Morningside Manor from 2024-06-30 including all violations, facility responses, and corrective action plans.
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