Deficiency Records for Mulberry Healthcare and Rehabilitation Cent
Updated as of March 01, 2024
A list of the most recent deficiencies for Mulberry Healthcare and Rehabilitation Cent. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-12-07 | 2024-02-05 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-12-07 | 2024-02-05 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-12-07 | 2024-02-05 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-07 | 2024-02-05 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-12-07 | 2024-02-05 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-12-07 | 2024-02-05 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-07 | 2024-02-05 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-12-07 | 2024-02-05 | N |
| Post nurse staffing information every day. | Health | 2023-12-07 | 2024-02-05 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-12-07 | 2024-02-05 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-12-07 | 2024-02-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-12-07 | 2024-02-05 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-12-07 | 2024-02-05 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-12-07 | 2024-02-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-12-07 | 2024-02-05 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-12-05 | 2024-02-03 | N |
| Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Fire Safety | 2023-12-05 | 2024-02-03 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-12-05 | 2024-02-03 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-12-05 | 2024-02-03 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-12-05 | 2024-02-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-12-05 | 2024-02-03 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-12-05 | 2024-02-03 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-12-05 | 2024-02-03 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-12-05 | 2024-02-03 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-12-05 | 2024-02-03 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2023-12-05 | 2024-02-03 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-12-05 | 2024-02-03 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-03-15 | 2023-05-14 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-03-15 | 2023-05-14 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-03-15 | 2023-05-14 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-03-15 | 2023-05-14 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-03-15 | 2023-05-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-15 | 2023-05-14 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-03-15 | 2023-05-14 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-03-10 | 2023-05-03 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-03-10 | 2023-04-25 | N |
| Respond appropriately to all alleged violations. | Health | 2023-03-10 | 2023-04-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-10 | 2023-04-25 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-10 | 2023-04-25 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-03-10 | 2023-04-25 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-03-10 | 2023-04-25 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-03-10 | 2023-04-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-10 | 2023-04-25 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-03-10 | 2023-04-25 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-03-10 | 2023-04-25 | Y |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2023-03-10 | 2023-04-25 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-12-29 | 2023-01-19 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-12-29 | 2023-01-19 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-12-29 | 2023-01-19 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-12 | 2023-01-18 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-12-12 | 2023-01-18 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-12-12 | 2023-01-18 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-11-07 | 2022-12-12 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-11-07 | 2022-12-12 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-11-07 | 2022-12-12 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-08-04 | 2022-09-07 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-18 | 2022-06-07 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-04-06 | 2022-05-09 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2022-04-06 | 2022-05-09 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-04-06 | 2022-05-09 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-04-06 | 2022-05-09 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2022-04-06 | 2022-05-09 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-04-14 | 2022-05-09 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-04-14 | 2022-05-09 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-04-14 | 2022-05-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-04-14 | 2022-05-09 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-04-14 | 2022-05-09 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-04-14 | 2022-05-09 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-04-14 | 2022-05-09 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-04-14 | 2022-05-09 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2022-04-14 | 2022-05-09 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-05-21 | 2021-06-03 | Y |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-05-21 | 2021-06-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-05-03 | 2021-05-25 | Y |
