Mulberry Healthcare And Rehabilitation Cent
Inspection Findings
F-Tag F0686
F 0686
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Level of Harm - Minimal harm or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that pressure ulcer care/prevention treatments were provided as ordered for one of four residents reviewed (Resident 3). Findings include: A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated September 19, 2025, revealed that the resident was cognitively impaired, required assistance from staff for daily care needs, and had medical diagnoses that included left hip fracture. A nursing note dated October 13, 2025, at 6:36 p.m. revealed that Resident 3 was admitted back to the nursing home from the hospital and that the resident had
an unstageable pressure ulcer to his left heel. A review of the October 13, 2025, Treatment Administration
Record (TAR) for Resident 3 revealed that there was no documented evidence that the facility obtained an order for treatment of the pressure ulcer on his left heel until he was seen by the Certified Nurse Practitioner wound consultant on October 15, 2025. Physician's orders for Resident 3, dated November 13, 2025, included an order for the resident to have his left heel cleansed with wound cleanser, pat dry, apply medi-honey (medical-grade honey intended for wound care that helps with healing by protecting from bacteria, reducing odor and cleaning/debriding the wound) and an ABD pad (a gauze dressing that absorbs fluid from large or heavily draining wounds), wrap daily and as needed. A review of Resident 3's November 2025 TAR revealed that there was no documented evidence to indicate that his treatment was completed per physician's orders on November 23 and 25, 2025. An interview with the Director of Nursing on December 22, 2025, at 1:32 p.m. confirmed that there was no documented evidence that an order for wound treatments were obtained when the resident readmitted on [DATE REDACTED] for Resident 3. She also confirmed that there was no documented evidence that the wound treatment were completed as ordered on
the dates listed above. 28 Pa. Code 211.12(d)(5) Nursing services.
Residents Affected - Few
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
MULBERRY HEALTHCARE AND REHABILITATION CENT in PUNXSUTAWNEY, PA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in PUNXSUTAWNEY, PA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from MULBERRY HEALTHCARE AND REHABILITATION CENT or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.