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Deficiency Records for The Mulberry at Waverly
A list of the most recent deficiencies for The Mulberry at Waverly. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for The Mulberry at Waverly. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-02-12 | 2024-03-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-02-12 | 2024-03-11 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-01-10 | 2024-02-23 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2024-01-10 | 2024-02-23 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2024-01-10 | 2024-02-23 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-10 | 2024-02-23 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2024-01-10 | 2024-02-23 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-01-10 | 2024-02-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-01-10 | 2024-02-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-01-10 | 2024-02-23 | N |
| Implement emergency and standby power systems. | Fire Safety | 2024-01-03 | 2024-02-23 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-01-03 | 2024-02-23 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2024-01-03 | 2024-02-23 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2024-01-03 | 2024-02-23 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-01-03 | 2024-02-23 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-01-03 | 2024-02-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-01-03 | 2024-02-23 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-01-03 | 2024-02-23 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2024-01-03 | 2024-02-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-12-12 | 2024-01-12 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2023-03-08 | 2023-04-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-08 | 2023-04-20 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-03-09 | 2023-04-06 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-03-09 | 2023-04-06 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-03-09 | 2023-04-06 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-03-09 | 2023-04-06 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-03-09 | 2023-04-06 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-03-09 | 2023-04-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-09 | 2023-04-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-03-09 | 2023-04-06 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-03-09 | 2023-04-06 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2023-03-09 | 2023-04-06 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-03-09 | 2023-04-06 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-03-09 | 2023-04-06 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-09 | 2023-04-06 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2023-03-09 | 2023-04-06 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-03-08 | 2023-04-06 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-03-08 | 2023-04-06 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-03-08 | 2023-04-06 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-03-08 | 2023-04-06 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-03-08 | 2023-04-06 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-03-08 | 2023-04-06 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-03-08 | 2023-04-06 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-03-08 | 2023-04-06 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-03-08 | 2023-04-06 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-03-08 | 2023-04-06 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-03-08 | 2023-04-06 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-03-08 | 2023-04-06 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-03-08 | 2023-04-06 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2023-03-08 | 2023-04-06 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-03-08 | 2023-04-06 | N |
| Meet requirements for the use and maintenance of medical gas equipment. | Fire Safety | 2023-03-08 | 2023-04-06 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-11-17 | 2022-01-01 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-11-17 | 2022-01-01 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-11-17 | 2022-01-01 | Y |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2021-11-17 | 2022-01-01 | Y |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2021-11-17 | 2022-01-01 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-11-17 | 2022-01-01 | Y |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2021-11-17 | 2022-01-01 | Y |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2021-11-17 | 2022-01-01 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-11-17 | 2022-01-01 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-11-17 | 2022-01-01 | Y |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2021-11-17 | 2022-01-01 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-11-17 | 2022-01-01 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-11-17 | 2022-01-01 | Y |
| Have enough outside ventilation via a window or mechanical ventilation, or both. | Health | 2021-11-17 | 2022-01-01 | Y |
| Implement emergency and standby power systems. | Fire Safety | 2021-11-15 | 2022-01-01 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-11-15 | 2022-01-01 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2021-11-15 | 2022-01-01 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-11-15 | 2022-01-01 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-11-15 | 2022-01-01 | N |
| Construct fire resistant interior walls. | Fire Safety | 2021-11-15 | 2022-01-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-11-15 | 2022-01-01 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-11-15 | 2022-01-01 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-11-15 | 2022-01-01 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-11-15 | 2022-01-01 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-11-15 | 2022-01-01 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-11-15 | 2022-01-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-11-15 | 2022-01-01 | N |
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