Mulberry Creek Nursing & Rehab Center

In the surveyor’s words

From the most serious findings on record at Mulberry Creek Nursing & Rehab Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF812Dec 5, 2022

  Based on observation, staff interview, and facility document review, the facility staff failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. The facility staff failed to discard an out of date food item, failed to label pre-poured beverages, and stacked wet pans together. The findings included: The facility staff failed to discard pre-cooked eggs with a use by date of 11/25/22 and failed to label pre-poured cups of lactose free milk. The facility staff also nested (stacked) wet pans together. During the initial tour of the kitchen on 11/29/22 at 2:35 p.m., surveyor noted a large bowl of prepared eggs labeled, eggs for egg salad with a use by date of 11/25/22, in the reach in cooler. […]

• No harm, potential for more than minimal, isolatedF842Nov 15, 2024

  Based on clinical record review and staff interview the facility staff failed to ensure a complete and accurate clinical record for 1 of 2 residents, Resident #1. The findings included: For Resident #1 the facility staff failed to accurately complete entries on the treatment administration record (TAR). Resident #1's face sheet listed diagnoses which included but not limited to unspecified open wound, left hip, type II diabetes mellitus, and displaced fracture of base of neck of left femur. Resident #1's most recent minimum data set with an assessment reference date of 10/20/24 assigned the resident a brief interview for mental status score of 11 out of 15 in section C, cognitive patterns. […]

• No harm, potential for more than minimal, isolatedF689Aug 21, 2024

  Based on observation, staff interview, and clinical record review, the facility staff failed to implement a comprehensive person-centered care plan for supervision to prevent falls for 1 of 7 sampled residents, Resident #4. The findings included: For Resident #4, the facility staff failed to ensure a motion sensor position change alarm was in proper position and functioning. Resident #4's diagnosis list indicated diagnoses, which included, but not limited to Dementia, Anxiety Disorder, Osteoarthritis of Left Hip, Generalized Muscle Weakness, Repeated Falls, Lack of Coordination, and Reduced Mobility. […]

• No harm, potential for more than minimal, isolatedF757May 9, 2024

  Based on staff interview and clinical record review, the facility staff failed to ensure 2 of 36 residents were free of unnecessary medications, Residents #63 and #139. The findings included: 1. For Resident #63, the facility staff administered the medication Amiodarone for a heart rate less than 60. The provider order read to hold this medication for heart rate less than 60. Resident #63's diagnoses included, but were not limited to, paroxysmal atrial fibrillation and chronic obstructive pulmonary disease. Section C (cognitive patterns) of Resident #63's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 03/28/24 included a brief interview for mental status (BIMS) summary score of 4 out of a possible 15 points. […]

• No harm, potential for more than minimal, isolatedF580Apr 4, 2023

  Based on interviews, clinical record review, and facility document review, the facility staff failed to notify a medical provider and/or responsible party (RP) of a change in condition for one (1) of four (4) residents (Resident #1). The findings include: Licensed practical nurse (LPN) #3 failed to notify Resident #1's medical provider and/or responsible party (RP) when a yellow area to the resident's lower extremity was reported to LPN #3 by certified nursing aides (CNAs). Resident #1's minimum data set (MDS) assessment, with an assessment reference date (ARD) of 3/9/23, was signed as being completed on 3/13/23. Resident #1 was assessed as being able to make self understood and as usually being able to understand others. […]