Mulberry Health & Rehabilitation Center

Based on interview and record review, the facility failed to ensure a PASARR (Preadmission Screening and Resident Review) was completed when residents received new mental health diagnoses and were prescribed medications for 2 of 4 residents reviewed for PASARR (Resident 100 and 62). Findings include: 1. The clinical record for Resident 100 was reviewed on 6/20/25 at 2:41 p.m. The diagnoses included, but were not limited to, dementia, hypertension, anxiety disorder, and osteoporosis. A physician's order, dated 9/5/24, indicated to give Buspirone HCL (an anti-anxiety medication) three times a day for anxiety disorder. A PASARR level 1 was not repeated to reflect the new mental health medications ordered on 9/5/24, until 4/7/25. During an interview, on 6/20/25 at 3:05 p.m., the Executive Director (ED) indicated they did not complete a new PASARR for the Buspirone when the medication was added. 2. The clinical record for Resident 62 was reviewed on 6/20/25 at 9:35 a.m. The diagnoses included, but were not limited to, dementia-unspecified severity, major depressive disorder, anxiety…

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, interview and record review, the facility failed to keep medication carts free of expired medications and to dispose of a controlled medication with compromised packaging in 2 of 4 medication carts (300 unit and 100 unit) and to properly store drug busters and chemical solutions in 2 of 2 medication storage rooms (300 unit and 200 unit) reviewed for medication storage. Findings include: 1. The 300-unit medication cart 1 was reviewed on 6/23/25 at 9:39 a.m. In the second drawer of the medication cart, the following were observed: a. Docusate Sodium (a laxative medication) 100 mg (milligram) oral tablets for Resident 75 were found with an expiration date of 5/31/25. b. Ondansetron (a nausea medication) 4 mg tablets for Resident 75 were found with an expiration date of 5/31/25. During an interview, on 6/23/25 at 9:55 a.m., RN 2 indicated the pharmacy audited the medication carts once a month and pulled expired medications from the cart. The nurses would also audit the carts for loose pills and narcotic book review. 2. The 100-unit medication cart 2 was reviewed on…

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, record review and interview, the facility failed to ensure a resident was dressed in her own clothing and to ensure staff was not standing while feeding a resident for 1 of 2 residents reviewed for dignity. (Resident 50) Finding includes: During an observation, on 5/1/24 at 12:52 p.m., CNA 6 was standing on the left side of Resident 50's wheelchair feeding the resident. During an observation, on 5/1/24 at 12:59 p.m., CNA 6 took a chair from another table and sat down to continue feeding the resident. During an observation, on 5/3/24 at 9:30 a.m., the resident was sitting at a table in the dining room facing the door. There was a resident sitting across the table from the resident and five other residents were in the dining room. The resident was wearing a long-sleeved shirt with the top of the shirt pulled down exposing a large portion of the resident's chest. The shoulder seams were touching her elbows. CNA 5 pulled the front of the shirt up to cover her chest. CNA 5 checked the tag on the back of the shirt and indicated the shirt belonged to the resident's…

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 interview and record review, the facility failed to complete an accurate level 1 Preadmission Screening and Resident Review (PASARR) for 1 of 3 residents reviewed for PASARR. (Resident 105) Finding includes: The clinical record for Resident 105 was reviewed on 5/2/24 at 4:30 p.m. The diagnoses included, but were not limited to, major depressive disorder, dissociative identity disorder, and anxiety disorder. A physician's order, with a start date of 1/25/24, indicated the resident received alprazolam (an antianxiety medication) 0.5 milligrams twice a day. A notice of PASARR level 1 screen outcome indicated the resident did not have any mental health diagnoses known or suspected. The PASARR did not include the residents major depressive disorder diagnosis, dissociative identity disorder diagnosis, or the resident's alprazolam medication. During an interview, on 5/6/24 at 3:10 p.m., the Social Services Director indicated the diagnoses and medication should have been listed on the PASARR. The person who submitted the PASARR may not have had all the information. During an…

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, interview and record review, the facility failed to ensure over the counter medications were labeled and beverages were not stored in the medication refrigerator for 3 of 3 medication carts and 1 of 1 medication room observed for medication storage. (cart 1 and 2 on the 100 hall, cart 1 on the 200 hall, and the medication room on 200 hall) Findings include: 1. During an observation, on 5/2/24 at 9:55 a.m., with LPN 2, the medication cart 2 on the 100 hall was observed to have the following: a. one bottle of chest congestion relief (guaifenesin) for Resident 69, with no pharmacy label. b. one bottle of aspirin 81 mg which contained 500 tablets had Resident 69's first initial and last name in black marker on the top of the bottle, with no pharmacy label. c. one bottle of melatonin 5 mg which contained 240 tablets with Resident 69's name written on the top, with no pharmacy label. d. one bottle of B12 1000 mcg had black ink and indicated morning, there was no resident name or pharmacy label. The clinical record for Resident 69 was reviewed on 5/2/24 at 11:26 a.m.…

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, interview and record review, the facility failed to label, date and store food in a sanitary manner. This deficient practice had the potential to affect all residents who consume food from the kitchen. Findings include: During an observation, on 02/13/23 at 9:55 a.m., the kitchen cooler was noted with Dietary Manager (DM) and the following was observed: a. on the cooler shelf was a name brand open can of coffee like drink with no open date on the can. b. on the cooler shelf was a plastic bottle of name brand soda pop with no label or date on the bottle. c. on the cooler shelf was a large plastic cup from a gas station with an uncovered straw in the cup with no label or date on the cup. d. on the cooler shelf was a soft sided plastic lunch box with no label or date on the lunch box. During an interview, on 02/13/23 at 9:55 a.m., the DM indicated I don't know if the open and undated drinks and lunch container could be kept in the walk-in cooler. During an interview, on 02/16/23 at 2:28 p.m., the Registered Dietician (RD) indicated we (facility) do not have a…

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 interview and record review, the facility failed to accurately code a resident's discharge status in the Minimum Data Set (MDS) assessment for 1 of 1 resident reviewed for MDS assessments. (Resident 129) Finding includes: The record for Resident 129 was reviewed on 2/15/23 at 2:56 p.m. Diagnoses included, but were not limited to, fracture of left pubis, hypertensive chronic kidney disease, pulmonary fibrosis, chronic kidney disease, and hypertension. A discharge MDS assessment, dated 1/13/23, indicated the resident was discharged to an acute hospital on 1/1/23. During an interview, on 2/15/23 at 10:07 a.m., the Director of Nursing indicated Resident 129 was discharged home with daughter and not to the hospital. The discharge MDS assessment, completed on 1/13/23, was coded wrong. During an interview, on 2/17/23 at 11:00 a.m., the MDS Coordinator indicated the MDS assessment was coded wrong and should have been coded as discharged to the community. The facility followed the RAI manual. 3.1-31(i)

Based on interview and record review, the facility failed to document targeted behaviors in the comprehensive care plan for a resident receiving an antipsychotic medication for delusional behaviors for 1 of 3 residents reviewed for comprehensive care plans. (Resident 101) Finding includes: The record for Resident 101 was reviewed on 2/14/22 at 2:49 p.m. Diagnoses included, but were not limited to, schizoaffective disorder, right femur fracture, vascular dementia, restlessness and agitation, Alzheimer's disease, delusional disorder, depression, and mood disorder. A history and physical, dated 6/15/22, indicated Resident 101 had a diagnosis of dementia and no diagnosis of schizoaffective disorder. A physician's order, dated 8/31/22, indicated to add a diagnosis of schizoaffective disorder due to hallucinations and delusions. A history and physical, dated 12/16/22, indicated Resident 101 had a diagnosis of schizoaffective disorder and the diagnosis was very unclear and there was no prior documentation to support. She had no documentation for schizoaffective disorder or no use 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 observation, interview and record review, the facility failed to accurately assesses and document bruising on the skin for 2 of 2 residents reviewed for skin issues and skin assessments. (Resident 2 and 20) Findings include: 1. During an observation of Resident 2, on 02/13/23 at 12:39 p.m., the resident was found to have a red bruise on her left arm at the wrist area. During an observation of Resident 2, on 02/14/23 at 2:02 p.m., the resident was found to have a red bruise on her left arm at the wrist area. During an observation of Resident 2, on 02/15/23 at 1:10 p.m., the resident was found to have a red discoloration/bruise on her left forearm at the wrist area. The record for Resident 2 was reviewed on 02/13/23 at 2:48 p.m. Diagnoses included, but were not limited to, anemia, gastrointestinal hemorrhage, and thrombocytopenia (a low platelet count and platelets stop bleeding by clumping and forming plugs in blood vessel injuries). A physician's order, initiated on 11/24/22, indicated to give aspirin (a medication which was used to prevent platelets from sticking together…

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, interview and record review, the facility failed to date multi-dose bottles of medication when they were opened in 1 of 4 medication storage refrigerators reviewed for medication storage. (300 Unit) Finding includes: During a medication storage observation in the 300 Unit medication refrigerator, on 02/14/23 at 9:45 a.m., with LPN 8, two (2) bottles of Ativan concentrate were found open without a date to indicated when the multi-dose bottles had been opened. During an interview, on 02/14/23 at 9:47 a.m., LPN 8 indicated the bottles should have been labeled with the date they had been opened. A facility policy, titled Medication Storage and Labeling, dated January 2023 and provided by the Director of Nursing on 02/15/23 at 11:30 a.m., indicated .multi-dose vials which have been opened .should be dated 3.1-25(j)