Mulberry Health & Rehabilitation

In the surveyor’s words

From the most serious findings on record at Mulberry Health & Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, patternF600Jul 19, 2021

  Based on policy review, video camera footage review, medical record review, observation, and interview, the facility failed to ensure adequate supervision of residents and ensure interventions were implemented for residents with physically aggressive and wandering/exit-seeking behaviors for 5 of 14 sampled residents (Resident #34, #80, #81, #91 and #96) reviewed for abuse. The facility's failure resulted in Immediate Jeopardy when Resident #80 willfully pushed Resident #81. Resident #81 fell to the floor, hit his head, began having seizures, was transferred to the hospital, and expired at the hospital. […]

• Immediate jeopardy, patternF726Jul 19, 2021

  Based on policy review, agency contract review, employee personnel file review, observation, and interview, the facility failed to ensure licensed nurses and certified nursing assistants (CNA) had the knowledge and skills necessary to assess residents, prevent abuse, and provide appropriate care to meet the residents needs for 5 of 16 sampled residents (Resident #34, #80, #81, #91, and #96) with physically aggressive and wandering/exit-seeking behaviors. The facility's failure resulted in Immediate Jeopardy when Resident #80 willfully pushed Resident #81. Resident #81 fell to the floor, hit his head, began having seizures, was transferred to the hospital, and expired at the hospital. […]

• Immediate jeopardy, patternF744Jul 19, 2021

  Based on policy review, medical record review, observation, and interview, the facility failed to provide care and services to meet each resident's Dementia care and behavior needs for 6 of 16 residents (Resident #34, #80, #81, #91, #96, and #303) reviewed for Dementia care and behaviors. The facility's failure to provide care and services for Dementia and behaviors resulted in Immediate Jeopardy when a physical altercation occurred between Resident #80 and #81, Resident #80 willfully pushed Resident #81, Resident #81 fell to the floor, hit his head, began having seizures, was transferred to the hospital, and expired at the hospital. […]

• Immediate jeopardy, patternF835Jul 19, 2021

  Based on policy review, job description review, and interview, facility Administration failed to administer the facility in a manner that enabled the facility to use its resources effectively and efficiently to attain the highest practicable well-being of the residents with behaviors and dementia. The Administration failed to provide oversight to monitor and provide a safe resident environment related to residents with behaviors and dementia. The Administration failed to provide oversight and training of staff to prevent abuse and provide appropriate care to meet residents needs with behaviors and dementia. These failures resulted in Immediate Jeopardy for Resident #34, #80, #81, #91, #96, and #303. […]

• Immediate jeopardy, patternF867Jul 19, 2021

  Based on policy review, Administrator job description review, Director of Nursing (DON) job description review, Registered Nurse (RN) job description review, Licensed Practical Nurse (LPN) job description review, medical record review, video camera footage review, and interview, the Quality Assurance Performance Improvement (QAPI) committee failed to ensure an effective QAPI program that recognized concerns related to resident to resident abuse, failed to perform follow up on monitoring of residents with behaviors, failed to evaluate and re-evaluate interventions implemented for residents with behaviors, failed to ensure nursing staff were competent to provide care to residents with behaviors and Dementia, and failed to ensure systems and processes were in place and consistently followed… […]