Helen Bernardy Center D/P SNF

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not honor a resident's responsible party's preference for showers for one of 13 residents (Res 1).As a result, Resident 1 did not receive showers in over two years as requested by the responsible party. Findings:Per the Facility admission Record, Resident (Res) 32 was admitted to the facility on [DATE], with diagnosis that included epilepsy (a chronic neurological {brain and nerve} disorder characterized by seizures {a sudden surge of abnormal electrical activity in the brain, leading to symptoms like uncontrollable muscle jerking, staring spells, confusion, or loss of consciousness}). Res 32 was dependent on a ventilator (a life-support machine that breathes for patients unable to breathe sufficiently on their own due to illness, trauma, or surgery) and depended on staff for all activities of daily living (ADL-dressing, eating, bathing, washing and oral hygiene, mobility, and control of bladder and bowels). Res 32 is unable to move voluntarily…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to ensure a resident's privacy and dignity were protected during personal care for one of 13 residents (Res 4). This had the potential to cause embarrassment for Res 4 by being exposed during personal care.According to the Resident admission Record, Resident 4 (Res 4) was admitted to the facility on [DATE], with diagnosis that included cerebral palsy (a group of permanent disorders that affect movement, muscle tone, and posture, caused by abnormal brain development or brain injury) and repeated Urinary Tract Infections (UTI- common bacterial infection). Res 4 does not speak, and is dependent on staff for all Activities of Daily Living (ADL's-movement, eating, oral hygiene, dressing, transfer, change of position, and bathing). Res 4 cannot control bladder and bowels, and is changed by staff. On 3/8/26 at 1:32 P.M. CNA 12 and 13 were observed from the doorway at Res 4's room. The bed and Res 4 were visible, and a privacy curtain was pushed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement and maintain infection control practices when a tube feeding syringe for 1 of 13 sampled residents (22) was found hanging on the tube feeding pole and not in its plastic bag. This failure had the potential to spread bacteria to Resident 22. Per the facility admission record, Resident 22 was admitted to the facility on [DATE] with diagnoses that included gastrostomy status (placement of a plastic tube into the stomach to administer medications, nutrition and fluids). On 3/8/26 at 1:00 P.M., an observation of Resident 22's room was conducted. An inspection of Resident 22's tube feeding equipment was done and a tube feeding syringe (device used to administer medications, fluids and nutrition) was found hung on the pole and not in the plastic bag. On 3/11/26 at 11:30 A.M., an interview was conducted with the administrator and the director of nursing (DON). The DON stated it was her expectation that the tube feeding syringe be placed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure appropriate services were consistently implemented for four of four sampled residents (Resident 1, 2, 3, and 4) when: 1) care plans were not followed 2) the Interdisciplinary Team (IDT) recommendation was not followed 3) care plan was not updated/revised As a result, there was a potential for the residents ' overall care and health to be negatively impacted. Findings: 1a)Resident 1 was admitted to the facility on [DATE] with diagnoses which included cerebral palsy (a group of conditions that affect movement and posture) per the facility ' s face sheet. A review of records was conducted. The Physical Therapy (PT) note dated 11/22/24 indicated Resident 1 will benefit from prone [on his tummy] position under direct supervision for a minimum of 10 min, 3-4x/wk. The Multidisciplinary Summary Report dated 12/2/24 indicated the planned actions/care plan included the Clinical Activities Assistant (CAA) 1 will begin matt/tummy time per the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure food safety and sanitation practices were met in the kitchen according to standards of practice when: 1. Two (2) floor sinks had piping without an air gap of at least 1 (inch) between the pipe and drain. 2. Three (3) cutting boards with deep cuts and food stains were stored in the clean area. 3. Two (2) ice machines had debris inside the storage parts of the ice bin. 4. Food thermometers were not calibrated per facility policy. These failures exposed residents to unsanitary practices, which had the potential to place them at risk of developing foodborne illness. 1. During the initial kitchen tour conducted on 11/19/24 at 8:44 A.M., a floor sink drain next to the salad prep/catering area was observed with the PVC (polyvinyl chloride) white pipe extending into the floor drain. Also, a brown pipe that extended from a walk-in freezer was observed disconnected from the freezer door and laying directly into a floor sink drain. The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS - health status screening and assessment tool) was accurately completed for 1 of 6 sampled residents (Resident 3). This failure had the potential for Resident 3 to receive inappropriate care. Findings: According to the admission and Discharge Record, Resident 3 was admitted on [DATE] with diagnoses that included cerebral palsy (a condition that affects movement and posture) and traumatic brain injury (damage to the brain caused by an outside force). During a record review for Resident 3, the Nursing Communication indicated, During the day, CIC [Intermittent Catheterization, a procedure where a tube is inserted into the bladder to drain urine) .Foley (foley catheterization, a tube is inserted to drain urine and is left in) for continuous drainage from 8pm to 8am . During a record review for Resident 3, the MDS dated [DATE] Section H- Bladder and Bowel indicated .C. Ostomy (including urostomy, ileostomy, and colostomy).…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to revise a comprehensive care plan for intermittent and indwelling catheterization (a procedure where a tube is inserted to remove urine from the bladder) for one of six sampled residents (Resident 3). This failure had the potential for Resident 3 to have negative clinical outcomes. Findings: A review of the facility's admission and Discharge Record indicated Resident 3 was admitted on [DATE] with diagnoses which included cerebral palsy (abnormal brain development causing a disorder of movement, muscle tone or posture), and severe developmental delay. A review of Resident 3's medical record indicated, Insert foley overnight from 8pm to 8am, prior to removal at 8am please instill gent [SIC] irrigation solution through connector to foley bag, allow to drain via void. Use sterile or clean technique with alcohol swabs to the attaching ends . and .During the day, CIC [SIC] at 1400 with gentamicin flushes (8am and 1400). Foley at night for continuous drainage…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to upload the Minimum Data Set (MDS) for three of three residents (59, 63, 66) within an appropriate time frame. This failure had the potential of not having the residents not receiving the appropriate care. Findings: During an interview with the Program Manager (PM) 11/21/24 at 3:34 P.M., the PM stated the Minimum Data Set (MDS, a standardized tool to identify a resident's health needs and strengths to develop an individualized care plan) was used to create care plans. The PM stated the MDS needed to be accurate to ensure the residents were getting the appropriate care. During an interview with the Director of Nursing (DON) 11/22/24 at 1:37 P.M., the DON stated the expectation is to have documentation completed the same shift. The DON further stated .a reasonable time frame for loading it [the MDS assessment] into EPIC [the electronic health record] would be within the week. Months would not be acceptable. During a review of Resident 59's electronic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow infection control practices when a licensed nurse did not perform hand hygiene after administering medications via gastrostomy tube (GT- a tube inserted directly into the stomach used to provide nutrition and medication) and before doing tracheostomy (a surgical opening created through the neck to help someone breathe) site care to one of five residents observed for medication pass. As a result, there was the potential for cross contamination of microorganisms (bacteria, virus, fungus). Findings: According to the admission and Discharge Record, Resident 115 was admitted on [DATE] with diagnoses that included cerebral palsy (a condition that affects movement and posture), gastrostomy tube dependent, and chronic lung disease. On 11/22/24 at 7:53 A.M., a medication administration observation was conducted with Licensed Nurse (LN) 1. LN 1 was observed administering medications to Resident 115 via GT. After all the medications were…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure: 1. All controlled medications/drugs (medications/drugs with a potential for addiction and abuse) were stored separately in locked, permanently affixed compartments for storage of controlled drugs when three out of six medication carts had controlled medications stored among the non-controlled medications. 2. A medication cart located inside the medication room, containing controlled medications, was locked. As a result of this deficient practice, a controlled medication was unaccounted for. In addition, there was the potential for drug diversion (unauthorized distribution of controlled drugs for purposes not intended by the prescriber). Findings: On 10/18/23 at 3:23 P.M., a medication administration was observed with licensed nurse (LN) 1. LN 1 prepared a resident's medication at the medication cart. Phenobarbital (a controlled drug) was stored inside the medication cart's main compartment among non-controlled medications. On 10/19/23 at 8:51 A.M., a medication administration was observed with LN 2.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to post the federally required daily actual hours worked by the staff in an area accessible to the public when the information was not posted until the last shift for the day clocked in. As a result, the actual hours worked by the staff was not readily accessible to residents, family, or visitors. Finding: On 10/19/23 at 11:36 A.M., the staffing posting was reviewed, the only information posted at this time were yesterday's staffing hours. The unit clerk was responsible for completing the form. The unit clerk stated the staffing is actual, not projected and, is only posted after all shifts for the day have signed in. She stated the posting visible today are yesterday's numbers and the the posting was not current.

Based on observation, interview, and record review, the facility failed to ensure: 1. All controlled drugs (medications/drugs with a potential for addiction and abuse) were reconcilled and accounted for. 2. Licensed Nurse (LN) 4 safeguarded a resident's medications during the medication administration when the LN left the resident's dispensed medications unattended in the hallway. As a result of these deficient practices, the facility could not provide an accurate accounting of all controlled medications and there was a potential for controlled drug diversion (unauthorized distribution of controlled drugs for purposes not intended by the prescriber). In addition, unattended medication had the potential to be tampered with and not administered as intended. Findings: 1. On 10/19/23 at 8:51 A.M., an observation of a medication administration was observed with LN 2. Two bottles (for Resident 65) of liquid Diazepam (a controlled medication) were kept inside the medication cart and were stored in the main medication drawer. One 150 milliliter (ml) bottle of Diazepam had a facility…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that one of 12 sampled residents (Resident 4) was free from unnecessary psychotropic medications (medications affecting mood, thoughts, and behavior) when the resident had been prescribed Trazodone (a medication used to treat major depressive disorder, a serious mood disorder affecting how a person thinks and feels) for sleep which was a non-FDA approved indication for use. This deficient practice had the potential to cause the resident harm. Findings: A review of Resident 4's admission and Discharge Record indicated the resident was admitted to the facility on [DATE]. A review of Resident 4's Annual History and Physical (H&P) dated 5/1/23, indicated the resident received Trazodone 50 milligrams (mg) nightly. The H&P listed Resident 4's active diagnoses. Resident 4 did not have a diagnosis of insomnia (inability to sleep) or major depressive disorder. A review of Resident 4's physician's order dated 1/16/20, indicated, Trazodone (Desyrel) tablet…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.