Mulder Health Care Facility

In the surveyor’s words

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

• Immediate jeopardy, widespreadF880Apr 14, 2025

  Based on interview and record review, the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable disease and infections. This had the potential to affect all residents residing within the facility at the time of an outbreak on 1/2/25. This outbreak involved 49 out of 83 residents and 37 staff. As of 1/2/25, the facility was in a GI (gastrointestinal) outbreak with 2 staff and 1 resident with noted signs and symptoms of GI outbreak. […]

• Immediate jeopardy, isolatedF741Apr 14, 2025

  Based on observation, record review, and interview, the facility did not have sufficient staff with appropriate competencies and skill sets to provide direct nursing and behavioral health related services to assure resident safety for each resident to attain or maintain their highest practicable physical, mental, and psychosocial well-being for 1 of 1 sampled resident (R11) and 1 of 1 supplemental residents reviewed (R55). R11 had expressed suicidal ideations related to his chronic pain (phantom limb pain) multiple times in the two months preceding R11 stabbing himself in the chest with scissors due to unrelieved pain. R11 was hospitalized for a self-inflicted stab wound to his chest and placed on an emergency psychiatric detention as a result of his suicide attempt. […]

• Immediate jeopardy, isolatedF689Nov 4, 2024

  Based on observation, interview, and record review, the facility did not ensure that each resident received adequate supervision to prevent accidents for 1 of 3 residents reviewed for needing assistance or supervision with meals. On 10/13/24, R1 was in the dining room for her supper meal. R1 was attempting to eat soup and spilled the soup onto herself causing 2nd degree burns to her right arm and abdomen. R1 required supervision during meals; supervision and assistance were not provided. Soup temperature following R1 suffering burns and after meal service was 177 degrees. […]

• Immediate jeopardy, isolatedF686Sep 29, 2021

  Based on observation, interview, and record review, the facility did not implement professional standards of practice to ensure that a resident does not develop pressure injuries (PIs), receives necessary treatment and services to promote healing and prevent infection of PIs, or prevent new PIs from developing for 1 of 3 residents sampled for PIs out of a total sample of 20 residents (R57). R57 was admitted , on 4/09/21, without a pressure injury. R57 was at risk for PI development. The facility did not put interventions in place to prevent PI development until after a pressure injury developed. R57 subsequently developed 5 facility-acquired PIs, one which worsened to a Stage 4. The facility did not implement an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• Immediate jeopardy, isolatedF686Sep 20, 2021

  Based on observation, interview, and record review, the facility did not implement professional standards of practice to ensure that a resident does not develop pressure injuries (PIs), receives necessary treatment and services to promote healing and prevent infection of PIs, or prevent new PIs from developing for 1 of 3 residents sampled for PIs out of a total sample of 20 residents (R57). R57 was admitted , on 4/09/21, without a pressure injury. R57 was at risk for PI development. The facility did not put interventions in place to prevent PI development until after a pressure injury developed. R57 subsequently developed 5 facility-acquired PIs, one which worsened to a Stage 4. The facility did not implement an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . […]