Schoenbrunn Healthcare

Inspectors wroteBased on observation, interview and review of facility policy the facility failed to ensure food was stored, prepared and served under sanitary conditions. This had the potential to affect all 91 residents receiving meals from the kitchen. The facility identified one resident (#9) who did not eat by mouth (NPO). The facility census was 92.

Inspectors wroteBased on observation, review of the facility menu and diet spreadsheet, and interviews the facility failed to ensure menus were followed as prepared in advance and failed to ensure residents were notified of substitutions in advance. This affected nine residents (Resident #14, #18, #25, #28, #31, #42, #46, #56, and #73) of 91 residents who received meals from the kitchen. The facility identified one resident (#9) who did not eat by mouth. The facility census was 92.

Inspectors wroteBased on personnel record review, observation and interview, the facility failed to employ a qualified director of food and nutrition services (Dietary Manager) and educate dietary aides. This affected all 86 residents in the facility. The facility census was 86.

Inspectors wroteBased on observation, test tray, and interview, the facility failed to ensure food was prepared by methods that conserve nutritive value, flavor, and appearance. This had the potential to affect all 86 residents in the facility.

Inspectors wroteBased on menu review and interview, the facility failed to ensure appealing options of similar nutritive value were available to residents who chose not to eat food that was initially served or who requested a different meal choice. This had the potential to affect all 86 residents in the facility. The facility census was 86.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to store, prepare and serve food under sanitary conditions. This had the potential to affect all the residents in the facility. The facility census was 86.

Inspectors wroteBased on review of medical records, review of facility policies and procedures, staff and resident observations and interviews, the facility failed to ensure the privacy of Resident #3 during incontinence care. This affected one resident (#3) of one resident reviewed for incontinence care. The facility census was 86.

Inspectors wroteBased on record review, observation and interview, the facility failed to ensure adaptive equipment was available as ordered. This affected one resident (#49) of six residents reviewed who were ordered adaptive equipment for meals. The facility census was 86.

Inspectors wroteBased on observation, staff interview and review of facility policy the facility failed to dispose of expired medications and/or unlabeled medications. The had the potential to affect all 76 residents residing in the facility.

Inspectors wroteBased on observation, interview, review of dishwasher temperature log, review of manufacture guidelines, and policy review the facility failed to ensure the dishwasher and three compartment sink were in proper working order to prevent the potential spread of food borne pathogens. This had the potential to affect all 76 residents residing in the facility.

Inspectors wroteBased on medical record review, observation, interview, and policy review the facility failed to ensure infection control practices were maintained during wound care, dining, incontinence care, and medication administration. This had the potential to affect all 78 resident residing in the facility. Based on medical record review, observation, interview, and policy review the facility failed to ensure infection control practices were maintained during wound care, dining service, incontinence care, and medication administration. This affected Resident #3, #4, #9, #40, #43, #51 and #63 but had the potential to affect all 76 residents residing in the facility.

Inspectors wroteBased on medical record review, interviews, review of information located on Medscape.com, and policy review the facility failed to ensure a resident had an appropriate justification for the use of an antipsychotic medication and also failed to ensure residents had stop dates for antianxiety medications. This affected four (Resident #2, #8, #5 and #35) out of five reviewed for unnecessary medication review.

Inspectors wroteBased on observations, review of the medical record, interview with staff and review of facility policy, the facility failed to ensure the call light was within reach of Resident #26. This affected one resident (Resident #26) of one reviewed for accommodation of need.

Inspectors wroteBased on observation, review of the medical record, and interview with staff, the facility failed to ensure the responsible party, physician and hospice were notified when Resident #27 spilled soup on herself causing a burn and when Resident #45 received a skin tear. This affected two residents (Resident #27 and #45) of five residents reviewed for accidents.

Inspectors wroteBased on record review, and interview, the facility failed to ensure a Level II Preadmission Screening and Resident Review (PASARR) was completed with a new psychiatric diagnosis. This affected one (Resident #34) of two residents reviewed for PASARR. The census was 76.

Inspectors wroteBased on record review, interview and facility policy review, the facility failed to develop a comprehensive plan of care for pain management. This affected one (Resident #38) of two residents reviewed for pain management. Facility census was 76.

Inspectors wroteBased on medical record review, interview, and policy review the facility failed to ensure residents who required staff assistance with activities of daily living received showers per schedule and preferences. This affected two (Resident #4 and #46) of two residents reviewed for shower preferences.

Inspectors wroteBased on observations, review of the medical record, interviews with staff, review of the facility policy, the facility failed to ensure treatment orders were received for burns to Resident #27's thighs and failed to comprehensively assess a skin tear to Resident #45's leg. This affected two residents (Resident #27 and #45) of five residents reviewed for accidents.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure residents had a comprehensive treatment plan in place for the use of hand splints to improve or maintain mobility. This affected one (Resident #60) of one residents reviewed for mobility. The census was 76.

Inspectors wroteBased on observation, review of the medical record, interview with staff and policy review, the facility failed to ensure fall interventions were in place for Resident #12. This affected one resident (Resident #12) of five reviewed for accidents.

Inspectors wroteBased on medical record review and interview the facility failed to ensure medications for the treatment of respiratory illness were implemented timely and administered per orders and failed to ensure diagnostic testing results were timely available. This affected one (Resident #1) of one residents reviewed for respiratory care. The facility census was 76.

Inspectors wroteBased on record review, facility policy review and interview, the facility failed to implement a comprehensive resident centered treatment plan to manage residents receiving hemodialysis. This affected one (Resident #39) of one residents reviewed for dialysis. The facility census was 76.

Inspectors wroteBased on interview and record review the facility failed to ensure antibiotic use was appropriate according to antibiotic stewardship protocols. This affected one resident (Resident #74) of three residents reviewed for antibiotics use. Facility census was 76.

Inspectors wroteBased on medical record review and interview, the facility failed to ensure complete medical records were maintained in regard to activity participation and medication administration. This affected four (Residents #28, #30, #78 and #79) of four residents reviewed.

Inspectors wroteBased on observations, medical record review, review of activity calendars and interview, the facility failed to ensure an individualized activity program was developed based on resident preferences. This affected one (Residents #28) of three residents reviewed for activities.

Inspectors wroteBased on medical record review, review of a facility self-reported incident (SRI) and investigation, review of a personnel records, review of staff schedules and time punches, facility policy review and interviews, the facility failed to ensure Resident #03 was free from an incident of staff to resident abuse which included intimidation, verbal and emotional abuse. Actual psychosocial harm occurred on 09/30/24 to Resident #03 when State Tested Nursing Assistant (STNA) #174, while providing care for the resident, yelled, used profanity and punched/hit the wall above the resident's bed. Resident #03 believed STNA #174's actions were directed toward her. Following the incident, STNA #174 worked additional shifts, providing care for Resident #03, before he was suspended on 10/06/24, and subsequently terminated. [...]

Inspectors wroteBased on review of the facility self-report incident (SRI) and investigation, staff interview and review of facility policy, the facility failed to prevent misappropriation of resident medication. This affected 13 residents (#1, #5, #14, #20, #25, #28, #29, #70, #71, #72, #73, #74 and #75) of 13 residents reviewed for misappropriation. The facility census was 65.

Inspectors wroteBased on resident interview, medical record review, review of a facility self-reported incident (SRI) and investigation, staff interview and review of facility policy, the facility failed to ensure allegations of staff to resident abuse were reported timely. This affected one resident (#03) of three residents reviewed for abuse. The facility census was 65.

Inspectors wroteBased on medical record review, policy review and interview, the facility failed to develop a discharge plan of care. This affected one resident (#75) of four sampled residents. The facility census was 73.

Inspectors wroteBased on medical record review and interview, the facility failed to ensure comprehensive care plans were revised with resident preferences. This affected one resident (#75) of four sampled residents. The census was 73.

Inspectors wroteBased on closed record review, policy review and interview, the facility failed to ensure tracheotomy care was completed as ordered. This affected two residents (#64, #75) reviewed for tracheostomy care. The facility identified no residents currently in the facility with a tracheostomy. The census was 73.

Inspectors wroteBased on observation, medical record review, policy review and interview, the facility failed to ensure proper gloving and hand washing was completed during incontinence care. This affected one resident (#26) observed for incontinence care. The facility identified 41 incontinent residents. The census was 73.

Inspectors wroteBased on medical record review, policy review and interviews the facility failed to ensure Resident #64 received comprehensive and individualized care to prevent/treat constipation. This affected one resident (Resident #64) of two residents reviewed for bowel and bladder management. The census was 72.

Inspectors wroteBased on observation, review of the medical record and interview with staff the facility failed to ensure Resident #10, #37 and #49 had physician ordered adaptive equipment for meals. This affected three residents (Resident #10, #37 and #49) of six residents reviewed for nutrition. The census was 72.

Inspectors wroteBased on medical record review, staff interview and policy review the facility failed to accurately obtain and document resident weights. This affected one (Resident #20) of four residents reviewed for nutritional services. The facility census was 72.

Inspectors wroteBased on medical record review and staff interview the facility failed to ensure comprehensive assessments were accurate. This affected two of two residents (Residents #28 and #64) reviewed for hospice services. The facility census was 72.

Inspectors wroteBased on resident interview, medical record review, observation and staff interview, the facility failed to ensure hospital discharge medications were followed and medications provided as ordered. This affected one resident (#37) of three residents reviewed for medications upon discharge from the hospital. The facility census was 74.

Inspectors wroteBased on observation and staff and resident interview the facility failed to maintain resident over bed tables, window blinds and wheelchairs in good repair and failed to ensure the main shower room on the second floor was free of storage for optimal resident use. This had the potential to affect 16 residents (#9, #19, #20, #23, #29, #33, #38, #48, #59, #64, #65 #366, #367, #368, #369 and #370) who resided on the second floor and five residents (#4, #5, #7, #26 and #51) who resided on the first floor Gardenway unit. The facility census was 66.

Inspectors wroteBased on observation, record review, facility policy and procedure review and interview the facility failed to ensure residents who required staff assistance with activities of daily living received timely and adequate nail care to promote proper hygiene. This affected five residents (#26, #44, #45, #56 and #367) of five residents reviewed for activities of daily living.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure Resident #367 received the appropriate consistency of food in a form designed to meet the resident's needs. This affected one resident (#367) and had the potential to affect nine additional residents (#5, #17, #23, #25, #26, #27, #30, #51 and #60) who were to receive a mechanical soft diet. The facility census was 66.

Inspectors wroteBased on observation, record review, Centers for Disease Control (CDC) guidance, facility policy and procedure review and interview, the facility failed to ensure contaminated N95 masks were stored and discarded appropriately following care of residents in droplet isolation precautions and failed to ensure infection control guidelines were maintained when completing Resident #48's pressure ulcer wound care to prevent the spread of infection including COVID-19. This affected one resident (#48) of one resident reviewed for pressure ulcer wound care, one resident (#366) of one resident reviewed for droplet isolation precautions and had the potential to affect all 16 residents (#9, #19, #20, #23, #29, #33, #38, #48, #59, #64, #65, #366, #367, #368, #369 and #370) who resided on the second floor. The facility census was 66.

Inspectors wroteBased on record review and staff interview the facility failed to ensure new Preadmission Screening and Resident Reviews (PASARR) were completed following the identification of new mental health diagnoses for residents. This affected two residents (#5 and #44) of two residents reviewed for PASRR Level II services.