Onyx Care of Bernice

In the surveyor’s words

From the most serious findings on record at Onyx Care of Bernice, in the surveyor’s own words.

• Immediate jeopardy, patternF600Dec 18, 2023

  40238 Based on record review, observation and interview, the facility failed to ensure a resident's right to be free from resident to resident physical abuse for 4 (Residents #2, #3, #4, #5) of 5 (Residents #1, #2, #3, #4, #5) residents reviewed for abuse. The facility failed to provide sufficient, competent direct care staff to ensure resident safety was maintained in the secure unit. The Immediate Jeopardy began on 11/16/2023 as a result of the secure unit having: 1) a resident to resident physical abuse altercation on 11/16/2023 between Resident #2 and Resident #3 which occurred when Resident #2 grabbed Resident #3 by the neck and hit him in the back of the head with a closed fist. Resident #3 retaliated and hit Resident #2 with a closed fist. […]

• Immediate jeopardy, patternF741Dec 18, 2023

  Based on observations, interviews, and record reviews the facility failed to ensure sufficient staffing to assure residents safety and maintain the highest practicable physical, mental and psychosocial well-being for 4 (Residents #2, #3, #4, #5) of 5 (Residents #1, #2, #3, #4, #5) residents reviewed for abuse. The facility failed to: 1. Provide sufficient direct care staffing to ensure residents safety. 2. Interview or assess all residents on the secure unit regarding concerns of physical abuse after incidents that involved abuse. […]

• Immediate jeopardy, patternF835Dec 18, 2023

  Based on interview and record review, the facility failed to administer its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 4 (Residents #2, #3, #4, #5) of 5 (Residents #1, #2, #3, #4, #5) residents reviewed for abuse. The administration failed to provide sufficient, competent direct care staff to ensure resident safety was maintained in the secure unit. The Immediate Jeopardy began on 11/16/2023 as a result of the secure unit having: 1) a resident to resident physical abuse altercation on 11/16/2023 between Resident #2 and Resident #3 which occurred when Resident #2 grabbed Resident #3 by the neck and hit him in the back of the head with a closed fist. […]

• Actual harm, isolatedF600Jul 15, 2024

  Based on observation, record review and interview, the facility failed to protect the resident's right to be free from physical abuse and psychosocial harm by staff for 1 (#1) of 3 (#1,#2, #3) sampled residents. The deficient practice resulted in actual harm for resident #1 (who was cognitively impaired) on 06/27/2024 at 9:01 p.m. when S4CNA (certified nursing assistant) physically abused resident #1 by using her left hand to grab the back of resident #1's shirt in an attempt to pull him towards his room. At this time resident #1 turned his back to S4CNA and his left elbow made contact with S4CNA's left shoulder. S4CNA used her closed right hand to make contact with the back of resident #1's head and then wrapped both her arms around resident #1's chest. […]

• No harm, potential for more than minimal, patternF677Mar 19, 2025

  Based on observations, record reviews, and interviews, the facility failed to ensure a resident who is unable to carry out Activities of Daily Living (ADL) receives the necessary services to maintain good personal hygiene for 1 (#73) of 6 (#15, #26, #27, #56, #65, and #73) residents reviewed for ADL care. The provider failed to ensure resident #73's fingernails were trimmed and cleaned. Findings: Review of the medical record revealed resident #73 was admitted to the facility on [DATE] with diagnoses that included in part, Alzheimer's disease and dementia. […]