Mabry Health Care

In the surveyor’s words

From the most serious findings on record at Mabry Health Care, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF812May 6, 2026

  Based on facility policy review, observations, and interviews, the facility failed to maintain kitchen equipment in good repair to store food under sanitary conditions and at proper temperatures to prevent foodborne illnesses, which had the potential to affect 71 of 73 residents. The findings include: Review of the facility's undated policy titled, Sanitation and Food Safety: Food Storage, revealed .Food storage areas are maintained within optimal temperature ranges .Freezers -10-0 F [Fahrenheit] .Food stock and prepared food products are stored at safe temperature ranges at all times . Review of the facility's undated policy titled, Sanitation and Food Safety: Equipment Failure and Repair, revealed .Dining services equipment shall be maintained in a good state of repair . […]

• No harm, potential for more than minimal, patternF658Sep 1, 2023

  Based on interview, record review, and facility policy review, the facility failed to report elevated fingerstick blood glucose (sugar) test results to the physician in accordance with professional standards and facility policy for 2 (Resident #11 and Resident #12) of 3 residents reviewed who were receiving insulin for diabetes mellitus. Findings included: A review of an undated facility policy titled, Blood Glucose Monitoring, indicated, Blood sugars found to be below 70 or above 400 will be reported immediately to the physician and the resident's representative. Any orders received from the physician will be implemented. 1. […]

• No harm, potential for more than minimal, isolatedF656May 6, 2026

  Based on facility policy reviews, medical record reviews, observations, and interview, the facility failed to implement the comprehensive care plan's fall interventions for 2 residents (Residents #1 and #66) of 4 residents reviewed for accidents. The findings include: Review of the facility's policy titled, Guidelines For Incidents/Accidents/Falls, dated 6/2023, revealed .The resident has a care plan put into place with interventions . Based on the results of the incident/accident/fall, the residents care plan will be addressed to ensure that any needed points of focus have measurable goals with appropriate interventions in place . […]

• No harm, potential for more than minimal, isolatedF880May 6, 2026

  Based on facility policy review, medical record review, observation, and interview, the facility failed to maintain infection control practices when staff failed to implement and use Enhanced Barrier Precautions (EBP) for 1 resident (Resident #20) of 5 residents reviewed for EBP. The findings include:Review of the facility's policy titled, Enhanced Barrier Precautions, dated 8/2025, revealed .The facility should use Enhanced Barrier Precautions (EBP) .during high-contact resident care activities .EBP are indicated for residents with .wounds and/or indwelling medical devices .wounds generally include chronic wounds .examples of chronic wounds include .pressure ulcers, diabetic foot ulcers, unhealed surgical wounds .indwelling medical device examples include .urinary catheters .examples of… […]

• No harm, potential for more than minimal, isolatedF693Feb 5, 2025

  Based on facility policy review, medical record review, observations, and interviews, the facility failed to ensure tube feeding formula was appropriately labeled for 1 resident (Resident #41) of 1 resident reviewed for tube feeding management. The findings include: Review of the facility's undated policy titled, GUIDELINES FOR ENTERAL FEEDING [a tube surgically inserted in the stomach to provide nutrition, hydration, and medication] [gasrtric tube] : ADULT, revealed .hanging and maintaining and managing and administering Tube/Feedings and Enteral Nutrition .OPEN .ENTERNAL FEEDING SYSTEM .or use of formula from cans or bottles which is poured into a feeding tube bag .Enteral Feeding Formula .instructions .to be followed . […]