A list of the most recent deficiencies for Mulberry Manor. 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? |
|---|---|---|---|---|
| Provide activities to meet all resident's needs. | Health | 2023-12-15 | 2024-01-05 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-12-15 | 2024-01-05 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-12-15 | 2023-12-20 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-04-28 | 2023-06-30 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-04-28 | 2023-06-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-04-28 | 2023-06-16 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-04-28 | 2023-06-12 | N |
| Respond appropriately to all alleged violations. | Health | 2023-04-28 | 2023-06-10 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-04-27 | 2023-05-24 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2022-05-12 | 2022-06-03 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2022-05-12 | 2022-06-03 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-05-12 | 2022-06-03 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-05-12 | 2022-06-03 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-05-12 | 2022-06-03 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-03-10 | 2022-03-26 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-03-10 | 2022-03-26 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-03-10 | 2022-03-26 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-03-10 | 2022-03-26 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-10 | 2022-03-26 | Y |
| Ensure the activities program is directed by a qualified professional. | Health | 2022-03-10 | 2022-03-26 | 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 | 2022-03-10 | 2022-03-26 | Y |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2022-03-10 | 2022-03-26 | Y |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2022-03-10 | 2022-03-26 | Y |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2022-03-10 | 2022-03-23 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-03-10 | 2022-03-23 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-10 | 2022-03-23 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-16 | 2022-03-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-09-22 | 2021-10-11 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-04-26 | 2021-05-13 | Y |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2020-01-21 | 2020-02-21 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2020-01-21 | 2020-02-21 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2020-01-21 | 2020-02-21 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2020-01-21 | 2020-02-21 | N |
| Develop a communication plan. | Fire Safety | 2020-01-21 | 2020-02-21 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2020-01-21 | 2020-02-21 | N |
| Provide emergency officials' contact information. | Fire Safety | 2020-01-21 | 2020-02-21 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2020-01-21 | 2020-02-21 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2020-01-21 | 2020-02-21 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2020-01-21 | 2020-02-21 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2020-01-21 | 2020-02-21 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2020-01-21 | 2020-02-21 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2020-01-21 | 2020-02-21 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2020-01-21 | 2020-02-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-01-21 | 2020-02-21 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-01-21 | 2020-02-21 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-01-21 | 2020-02-21 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2020-01-21 | 2020-02-21 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2020-01-21 | 2020-02-21 | N |
| Ensure the activities program is directed by a qualified professional. | Health | 2020-01-09 | 2020-02-01 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2020-01-09 | 2020-01-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-01-09 | 2020-01-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-01-09 | 2020-01-10 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2020-01-21 | Not Fixed | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2020-01-21 | Not Fixed | N |
