Mulberry Health & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Mulberry Health & Rehabilitation Center, in the surveyor’s own words.

• Actual harm, isolatedF684Mar 4, 2021

  Based on interview and record review, the facility failed to ensure residents were assessed, including neurological assessments, after falls and changes in condition and sent out of the facility for treatment in the emergency room in a timely manner, for 3 of 4 residents reviewed for falls (Residents B, C and E). This resulted in Resident B experiencing a delay in treatment for [REDACTED]. Findings include: 1. Resident B's record was reviewed on 3/1/21 at 11:26 a.m. The record indicated she was admitted on [DATE], and had [DIAGNOSES REDACTED]. physician's orders [REDACTED]. a. Toilet resident upon rising, before or after each meal, at bedtime, and as needed every shift. b. […]

• No harm, potential for more than minimal, widespreadF812Feb 17, 2023

  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. […]

• No harm, potential for more than minimal, isolatedF644Jun 24, 2025

  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. […]

• No harm, potential for more than minimal, isolatedF761Jun 24, 2025

  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. […]

• No harm, potential for more than minimal, isolatedF550May 8, 2024

  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. […]