Mulberry Creek Nursing & Rehab Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview the facility staff failed to ensure a complete and accurate clinical record for 1 of 2 residents, Resident #1. The findings included: For Resident #1 the facility staff failed to accurately complete entries on the treatment administration record (TAR). Resident #1's face sheet listed diagnoses which included but not limited to unspecified open wound, left hip, type II diabetes mellitus, and displaced fracture of base of neck of left femur. Resident #1's most recent minimum data set with an assessment reference date of 10/20/24 assigned the resident a brief interview for mental status score of 11 out of 15 in section C, cognitive patterns. This indicates that the resident is moderately cognitively impaired. Resident #1's comprehensive care plan was reviewed and contained a care plan for resident has a surgical wound to: Left hip. Wound has dehisced. Interventions for this care plan included, keep surgical incision site clean and dry as possible, treatment as…

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, staff interview, and clinical record review, the facility staff failed to implement a comprehensive person-centered care plan for supervision to prevent falls for 1 of 7 sampled residents, Resident #4. The findings included: For Resident #4, the facility staff failed to ensure a motion sensor position change alarm was in proper position and functioning. Resident #4's diagnosis list indicated diagnoses, which included, but not limited to Dementia, Anxiety Disorder, Osteoarthritis of Left Hip, Generalized Muscle Weakness, Repeated Falls, Lack of Coordination, and Reduced Mobility. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 6/14/24 assigned the resident a brief interview for mental status (BIMS) summary score of 3 out of 15 indicating the resident was severely cognitively impaired. Resident #4's clinical record included a Fall Risk Evaluation dated 8/08/24 indicating the resident was a high fall risk. A review of Resident #4's clinical record revealed a history of eleven (11) falls occurring in the past four (4) months, one…

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 staff interview and clinical record review, the facility staff failed to ensure 2 of 36 residents were free of unnecessary medications, Residents #63 and #139. The findings included: 1. For Resident #63, the facility staff administered the medication Amiodarone for a heart rate less than 60. The provider order read to hold this medication for heart rate less than 60. Resident #63's diagnoses included, but were not limited to, paroxysmal atrial fibrillation and chronic obstructive pulmonary disease. Section C (cognitive patterns) of Resident #63's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 03/28/24 included a brief interview for mental status (BIMS) summary score of 4 out of a possible 15 points. Resident #63's comprehensive care plan included the focus area at risk for cardiac complications related to atrial fibrillation, hypertension, and congestive heart failure. Interventions included, but were not limited to, administer medications as ordered, observe parameters, and check pulse as ordered. Resident #63's clinical record…

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, staff interview, and facility document review, the facility staff failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. The facility staff failed to discard an out of date food item, failed to label pre-poured beverages, and stacked wet pans together. The findings included: The facility staff failed to discard pre-cooked eggs with a use by date of 11/25/22 and failed to label pre-poured cups of lactose free milk. The facility staff also nested (stacked) wet pans together. During the initial tour of the kitchen on 11/29/22 at 2:35 p.m., surveyor noted a large bowl of prepared eggs labeled, eggs for egg salad with a use by date of 11/25/22, in the reach in cooler. The dietary manager (DM) verified the eggs were out of date and removed them from the cooler to be discarded. In the walk-in beverage cooler, surveyor noted a tray with 15 unlabeled, covered cups of a white beverage. The DM stated that the beverage was lactose free milk. When asked by the surveyor if the cups should be labeled or dated,…

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, Resident interview, staff interview, and family interview the facility staff failed to ensure a clean, comfortable, and home like environment for 2 of 34 residents, Resident #166 and Resident #141. The findings included: 1. For Resident #166 the facility staff failed to ensure trash receptacle was clean, in good repair and contained a liner. Resident #166's face sheet listed diagnoses which included but not limited to chronic obstructive pulmonary disease, dementia, and chronic respiratory failure. Resident #166's most recent minimum data set with an assessment reference date of 10/19/22 assigned the resident a brief interview for mental status score of 9 out of 15 in section C, cognitive patterns. This indicates that the resident is moderately cognitively impaired. Surveyor observed Resident #166 on 11/29/22 at 2 pm. Resident was seated in wheelchair in room. Surveyor observed small trash can located beside resident's bed. Trash can observed to have dried reddish substance on inside and outside of can. No can liner was observed, and trash can was cracked down…

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 staff interview, clinical record review, and facility document review, the facility staff failed to implement written policies and procedures regarding the reporting of resident abuse within the specified timeframe of two (2) hours for 1 of 34 residents in the survey sample, Resident #56. The findings included: For Resident #56, the facility staff failed to implement facility policy regarding the reporting of an incident of resident-to-resident abuse occurring on 12/04/22 in which another resident tied them to their wheelchair with a blanket. Facility staff failed to report the incident within the specified two (2) hour timeframe. Resident #56's diagnosis list indicated diagnoses, which included, but not limited to Unspecified Dementia Moderate with Agitation, Chronic Obstructive Pulmonary Disease, Chronic Diastolic Congestive Heart Failure, Epilepsy, and Generalized Muscle Weakness. The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 10/17/22 assigned the resident a brief interview for mental status (BIMS) summary score of 6 out of…

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 staff interview, clinical record review, and facility document review, the facility staff failed to report an incident of resident-to-resident abuse within two (2) hours of when the abuse was discovered for 1 of 34 residents in the survey sample, Resident #56. The findings included: For Resident #56, the facility staff failed to report an incident of resident-to-resident abuse within two (2) hours occurring on 12/04/22 in which another resident tied them to their wheelchair with a blanket. Resident #56's diagnosis list indicated diagnoses, which included, but not limited to Unspecified Dementia Moderate with Agitation, Chronic Obstructive Pulmonary Disease, Chronic Diastolic Congestive Heart Failure, Epilepsy, and Generalized Muscle Weakness. The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 10/17/22 assigned the resident a brief interview for mental status (BIMS) summary score of 6 out of 15 indicating Resident #56 was severely cognitively impaired. The resident was coded as requiring limited assistance with bed mobility, transfers…

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, resident interview, staff interview, and clinical record review, the facility staff failed to provide activities of daily living (ADL) care for a dependent resident, for 1 of 34 residents, Resident #10. The findings included: The facility staff failed to provide ADL care. Resident #10 was observed to have long and jagged fingernails and toenails. Debris was observed underneath Resident #10's fingernails. Resident #10's diagnoses included, but were not limited to, diabetes, schizophrenia, and cerebrovascular disease. Section C (cognitive patterns) of Resident #10's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 11/22/22 included a brief interview for mental status (BIMS) score of 11 out of a possible 15 points. Section G (functional status) was coded 3/2 for personal hygiene indicating Resident #10 required extensive assistance of one person to complete this task. Resident #10 was coded as having limitations in range of motion in the upper extremity and as using wheelchair/walker for mobility. Resident #10's comprehensive…

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 staff interview and clinical record review the facility staff failed to ensure a complete and accurate clinical record for 1 of 34 residents, Resident #147. The findings included: For Resident #147 the facility staff failed to ensure a Virginia Department of Health Durable Do Not Resuscitate (DDNR) form was complete. Resident #147's face sheet listed diagnoses which included but not limited to chronic kidney disease, dependence of renal dialysis, acute respiratory failure and chronic pain syndrome. Resident #147's most recent minimum data set with an assessment reference date of 09/29/22 assigned the resident a brief interview for mental status score of 14 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Resident #147's clinical record was reviewed and contained a physician's order summary for the month of November 2022, which read in part Do Not Resuscitate Resident #147's clinical record contained a Virginia Department of Health Durable Do Not…

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 clinical record review and staff interview, the facility staff failed to ensure the resident's right to formulate an advanced directive as evidenced by failure to enact a physician order in accordance with the advance directive for 1 of 35 residents in the survey sample (Resident #256). The findings included: For Resident #256, the facility staff failed to obtain a physician's order for code status. Resident #256's diagnosis list indicated diagnoses, which included, but not limited to Acute Respiratory Failure with Hypoxia, Pneumonia, Dementia with Behavioral Disturbance, Essential Hypertension, Atherosclerotic Heart Disease of Coronary Artery without Angina Pectoris, and Epilepsy, Intractable, without Status Epilepticus. The most recent admission MDS (minimum data set) with an ARD (assessment reference date) of 1/24/20 assigned the resident a BIMS (brief interview for mental status) score of 0 out of 15 in section C, Cognitive Patterns. A review of Resident #256's medical record revealed the following documentation: The clinical record included a completed DDNR (Durable Do…

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, resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to ensure resident medications were stored securely for 1 of 35 Residents (Resident #152) as evidenced by leaving medications at the bedside. The findings included: For Resident #152, the facility staff left medications unsecured and unattended at the residents beside. The resident had not been assessed for self-administration of medications. The clinical record was reviewed on 01/29/2020. The face sheet in the clinical record included the diagnoses, paranoid schizophrenia, major depressive disorder, anxiety disorder, and essential hypertension. There was no completed MDS (minimum data set) assessment on this resident. However, section C (cognitive patterns) of this assessment had been completed. The facility had assigned the resident a score of 15 out of 15 points on the BIMS (brief interview for mental status) assessment. Indicating the resident was alert and orientated. On 01/29/2020 at 11:00 a.m., during initial tour of the facility, 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.