Resident 3 was readmitted to the nursing home on October 13, 2025, according to a nursing note written at 6:36 p.m. that same day. The note documented that he had developed an unstageable pressure ulcer to his left heel during his hospital stay. The resident required assistance from staff for daily care needs and had been diagnosed with a left hip fracture.
The facility's Treatment Administration Record showed no evidence that staff obtained physician orders for treating the heel wound until October 15, when a Certified Nurse Practitioner wound consultant examined the resident. For two days after his return, the pressure ulcer received no documented treatment.
Unstageable pressure ulcers represent the most severe category of these wounds, where the depth cannot be determined because the wound bed is covered by dead tissue or other material. Without proper treatment, such wounds can lead to serious infections, bone involvement, and life-threatening complications.
When treatment orders finally came through on November 13, they were specific and comprehensive. The physician ordered daily cleaning of the left heel with wound cleanser, followed by patting the area dry, applying medical-grade honey, and covering with an ABD pad designed to absorb drainage from heavily weeping wounds. The orders specified this routine should occur daily and as needed.
Medical-grade honey serves multiple therapeutic purposes in wound care. It protects against bacterial infection, reduces odor, and helps clean and remove dead tissue from the wound bed. For a resident with cognitive impairment who cannot advocate for himself, consistent application of these treatments becomes critical to preventing deterioration.
But the facility's own records revealed gaps in following the physician's orders. The November Treatment Administration Record showed no documented evidence that staff completed the wound treatments on November 23 and November 25, 2025.
The Director of Nursing confirmed the failures during an interview with state inspectors on December 22. She acknowledged that the facility had no documented evidence showing they obtained wound treatment orders when Resident 3 was readmitted in October. She also confirmed that staff failed to document completion of the ordered treatments on the specified November dates.
These documentation gaps raise questions about whether the treatments occurred at all. In nursing homes, the standard practice holds that if care is not documented, it did not happen. For wound care specifically, consistent treatment is essential to prevent infection and promote healing.
The inspection occurred in response to a complaint, suggesting someone outside the facility raised concerns about the quality of care. State inspectors reviewed clinical records and interviewed staff as part of their investigation into the facility's wound care practices.
Resident 3's case illustrates how vulnerable cognitively impaired residents depend entirely on nursing home staff to recognize their medical needs and follow through with ordered treatments. A resident with dementia or other cognitive limitations cannot remind staff about missed treatments or advocate for proper wound care.
The facility's failures occurred during a particularly vulnerable period for the resident. Having just returned from a hospital stay with a new, serious wound, he needed immediate and consistent care to prevent complications. The two-day delay in obtaining treatment orders, followed by missed treatments weeks later, created multiple opportunities for the wound to worsen.
Pennsylvania regulations require nursing homes to provide nursing services that meet residents' needs and follow physician orders. The state found that Mulberry Healthcare violated these requirements through its handling of Resident 3's pressure ulcer care.
The inspection classified the violation as causing minimal harm or potential for actual harm, but pressure ulcer complications can escalate quickly. Untreated wounds can become infected, involve underlying bone, or lead to sepsis. For elderly residents with multiple medical conditions, such complications can be fatal.
Resident 3 remains at the facility, dependent on the same staff who failed to provide his ordered wound care. The inspection report does not indicate whether his heel ulcer has healed or what condition it was in when inspectors arrived in December.
The facility must submit a plan of correction to state regulators, but the damage to this particular resident's care has already occurred. Two months passed between his hospital readmission and the state inspection, time during which proper wound care could have made the difference between healing and deterioration.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Mulberry Healthcare and Rehabilitation Cent from 2025-12-22 including all violations, facility responses, and corrective action plans.
Additional Resources
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