Inspection Reports for Mulberry Manor

The facility failed to develop and implement complete care plans that included measurable objectives and time frames for 3 residents, specifically lacking care plans for mechanical lift use and hospice services. Additionally, the facility failed to collaborate adequately with hospice representatives and maintain required hospice documentation for one resident, risking inadequate end-of-life care.

The facility failed to maintain an effective infection prevention and control program, as staff (CNA-A, CNA-B, and CNA-C) did not perform proper perineal care for Residents #1 and #2, placing residents at risk of infections. Observations and interviews confirmed improper techniques such as reusing wipes and not retracting the foreskin during care.

The complaint investigation was triggered by allegations of unsanitary living conditions, verbal abuse by CNA D towards residents #4 and #5 on 07/04/2024 witnessed by RN C, failure to report the abuse allegation to the state, failure to investigate the abuse allegation thoroughly, and unsafe conditions caused by the DON bringing a dog to work that bit a resident and was aggressive toward others.

The facility failed to ensure a safe, clean, and homelike environment for residents due to unsanitary conditions and unsafe bathroom fixtures. The facility also failed to prevent verbal abuse by a CNA towards residents and failed to properly investigate and report the abuse allegations. Additionally, the facility allowed a dog to be present that bit a resident and was aggressive toward others, creating an unsafe environment.

The complaint investigation revealed multiple issues including resident dignity violations, medication errors, inadequate care planning, staffing shortages, missed physician visits, infection control lapses, and medication storage problems.

The facility failed to ensure residents were treated with dignity and privacy, develop comprehensive care plans, administer medications as ordered, maintain adequate staffing, ensure timely physician visits, provide proper infection control, and maintain medication storage protocols. Specific failures included privacy curtain not pulled during care, missed insulin and IV antibiotic doses, inadequate staffing levels, missed physician visits, improper peri-care and hand hygiene, and unsecured medication storage.

The complaint investigation focused on Resident #1's revoked smoking privileges, which the facility imposed due to safety concerns after elopement attempts. Interviews with staff, the Director of Nursing (DON), Assistant Director of Nursing (ADON), and Resident #1's family revealed concerns about violation of resident rights and lack of person-centered care planning. The facility also failed to implement appropriate measurable objectives in the care plan. Medication storage issues were also identified during the investigation.

The facility failed to honor Resident #1's rights by revoking his smoking privileges without adequate person-centered care planning and measurable objectives. Additionally, the facility failed to develop a comprehensive care plan addressing Resident #1's mental and psychosocial needs related to smoking safety and elopement. Medication storage deficiencies were also noted with loose pills found in medication carts.

The facility failed to provide an ongoing program of activities meeting residents' interests and needs on the Secure Unit, failed to ensure proper respiratory care by not storing nebulizer equipment correctly for two residents, and failed to maintain a safe, clean, and comfortable environment due to broken or missing window blinds in several resident rooms. These deficiencies posed risks of emotional harm, respiratory infections, and diminished quality of life.

The complaint investigation focused on allegations of sexual abuse involving Resident #35 and Resident #57. The facility failed to conduct a thorough investigation or maintain documentation thereof. The Abuse Coordinator admitted to incomplete investigations and lack of documentation. The facility also failed to ensure proper supervision and medication management to reduce inappropriate sexual behaviors.

The facility failed to thoroughly investigate allegations of abuse for two residents, did not maintain documentation of a thorough investigation, failed to provide required RN coverage for 8 consecutive hours on multiple days, failed to follow the posted menu for some residents, failed to properly store and label food items, and failed to ensure staff wore masks properly in the presence of residents.