Inspection Reports for Mulberry Health & Rehabilitation Center
502 W JACKSON ST, IN, 46058
Back to Facility ProfileInspection Report Summary
The most recent inspection on May 13, 2025, was a complaint investigation in which no deficiencies were cited and the facility was found to be in compliance with relevant regulations. Earlier inspections showed a pattern of deficiencies related primarily to life safety code compliance, such as fire extinguisher inspections and electrical wiring issues, as well as resident care concerns including dignity, medication labeling, and documentation. Complaint investigations over time were consistently unsubstantiated, with no deficiencies found related to the allegations. No fines, immediate jeopardy findings, or enforcement actions were listed in the available reports. The facility’s record suggests some improvement in life safety and complaint outcomes, though care and documentation issues appeared intermittently in prior inspections.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
7.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
83% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
122 residents
Based on a May 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 122
Deficiencies: 0
May 13, 2025
Visit Reason
This visit was for the investigation of complaints IN00458744 and IN00448797.
Findings
No deficiencies related to the allegations in complaints IN00458744 and IN00448797 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00458744 and Complaint IN00448797 were investigated with no deficiencies cited related to the allegations.
Report Facts
Census SNF/NF beds: 110
Census SNF beds: 12
Total Census: 122
Census Medicare: 5
Census Medicaid: 86
Census Other: 31
Inspection Report
Re-Inspection
Census: 122
Capacity: 149
Deficiencies: 0
Jul 11, 2024
Visit Reason
This was a Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
Mulberry Health and Rehabilitation Center was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the NFPA 101 Life Safety Code. The facility was fully sprinklered except for a detached storage shed that was not sprinklered.
Report Facts
Facility capacity: 149
Census: 122
Inspection Report
Annual Inspection
Census: 128
Capacity: 149
Deficiencies: 2
May 24, 2024
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health on 05/24/2024 to assess compliance with Medicare/Medicaid participation requirements and life safety codes.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was not in compliance with Life Safety Code requirements due to failure to inspect 28 portable fire extinguishers monthly and improper use of a power strip in the Assistant Director of Nursing's office. No residents were negatively affected.
Severity Breakdown
SS=F: 1
SS=E: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to inspect 28 of 28 portable fire extinguishers monthly as required by NFPA 10. | SS=F |
| Failed to ensure the Assistant Director of Nursing's office did not use flexible cords as a substitute for fixed wiring, violating NFPA 70 electrical code. | SS=E |
Report Facts
Certified beds: 149
Census: 128
Portable fire extinguishers: 28
Staff potentially affected: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Heidi Wallar | Executive Director | Signed as Laboratory Director's or Provider/Supplier Representative |
| Maintenance Director | Acknowledged deficiencies related to fire extinguisher inspections and power strip usage |
Inspection Report
Renewal
Census: 129
Capacity: 129
Deficiencies: 3
May 8, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted on May 1, 2, 3, 6, and 8, 2024.
Findings
The facility was found deficient in ensuring residents' rights to dignity and proper care, accurate PASARR assessments, and proper labeling and storage of medications. Specific deficiencies included a resident wearing another's clothing and staff feeding while standing, incomplete PASARR documentation for a resident, and unlabeled over-the-counter medications and improper storage of beverages in medication refrigerators.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to ensure a resident was dressed in her own clothing and staff was not standing while feeding a resident for 1 of 2 residents reviewed for dignity (Resident 50). | SS=D |
| Facility failed to complete an accurate level 1 Preadmission Screening and Resident Review (PASARR) for 1 of 3 residents reviewed (Resident 105). | SS=D |
| Facility failed to ensure over the counter medications were labeled and beverages were not stored in the medication refrigerator for 3 medication carts and 1 medication room observed. | SS=D |
Report Facts
Census SNF/NF: 116
Census SNF: 13
Total Census: 129
Medicare Census: 6
Medicaid Census: 90
Other Payor Census: 33
Medication tablets: 500
Medication tablets: 240
Medication capsules: 90
Medication caplets: 500
Medication tablets: 225
Inspection Report
Renewal
Deficiencies: 0
May 8, 2024
Visit Reason
The inspection was a paper compliance review related to the Recertification and State Licensure survey conducted on May 8, 2024.
Findings
Mulberry Health & Rehabilitation Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Inspection Report
Complaint Investigation
Census: 122
Capacity: 122
Deficiencies: 0
Mar 4, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00429382.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00429382 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census SNF/NF beds: 122
Census total residents: 122
Census Medicare residents: 13
Census Medicaid residents: 88
Census other payor residents: 21
Inspection Report
Original Licensing
Census: 126
Capacity: 149
Deficiencies: 0
Jan 30, 2024
Visit Reason
A Life Safety Code and Pre-Occupancy Survey was conducted by the Indiana State Department of Health related to a bed conversion from residential to comprehensive licensed beds in several resident rooms.
Findings
The facility was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 NFPA 101 Life Safety Code. The building is fully sprinklered with appropriate smoke detection systems and all resident-accessible areas and service areas were sprinklered.
Report Facts
Facility capacity: 149
Census: 126
Inspection Report
Complaint Investigation
Census: 122
Capacity: 122
Deficiencies: 0
Nov 30, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00422104.
Findings
No deficiencies related to the allegations of Complaint IN00422104 were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Complaint Details
Complaint IN00422104 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census SNF/NF: 122
Census Payor Type Medicare: 9
Census Payor Type Medicaid: 90
Census Payor Type Other: 23
Inspection Report
Complaint Investigation
Census: 124
Capacity: 124
Deficiencies: 0
Nov 8, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00419171 and IN00420029.
Findings
No deficiencies related to the allegations in complaints IN00419171 and IN00420029 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00419171 and IN00420029 were investigated with no deficiencies cited related to the allegations.
Report Facts
Census: 124
Total Capacity: 124
Medicare Census: 10
Medicaid Census: 90
Other Payor Census: 24
Inspection Report
Complaint Investigation
Census: 123
Capacity: 123
Deficiencies: 0
Jun 5, 2023
Visit Reason
This visit was for the investigation of complaints IN00409803 and IN00405818 and included a COVID-19 Focused Infection Control Survey.
Findings
No deficiencies related to the allegations in complaints IN00409803 and IN00405818 were cited. The facility was found to be in compliance with relevant regulations including 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Complaint Details
Complaint IN00409803 and Complaint IN00405818 were investigated with no deficiencies related to the allegations cited.
Report Facts
Census SNF/NF: 123
Total Capacity: 123
Census Payor Type Medicare: 12
Census Payor Type Medicaid: 89
Census Payor Type Other: 22
Inspection Report
Follow-Up
Census: 122
Capacity: 149
Deficiencies: 0
May 3, 2023
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 03/16/23.
Findings
At this PSR Emergency Preparedness survey, the facility was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers. At the PSR Life Safety Code survey, the facility was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code.
Report Facts
Certified beds: 149
Census: 122
Inspection Report
Life Safety
Census: 120
Capacity: 149
Deficiencies: 13
Mar 16, 2023
Visit Reason
An Emergency Preparedness Survey and Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a) respectively.
Findings
The facility was found not in compliance with Emergency Preparedness Requirements and Life Safety Code requirements including deficiencies in emergency power system testing and fuel quality testing, exit door locking and signage, exit discharge surface, fire alarm and sprinkler system policies, corridor door latching, electrical panel security, evacuation plan completeness, and improper use of power strips and multi-plug adapters.
Severity Breakdown
SS=F: 6
SS=E: 7
Deficiencies (13)
| Description | Severity |
|---|---|
| Failed to implement emergency power system inspection, testing, and maintenance requirements including missing three-year 4 hour test and annual fuel quality test report. | SS=F |
| Exit door near 400 West exit was magnetically locked without posted access code. | SS=E |
| Exit discharge from 400 West hall had uneven walking surface with a 2 inch crack. | SS=E |
| Courtyard doors not posted with 'NO EXIT' signage. | SS=E |
| Fire alarm system out of service policy incomplete, missing required notification procedures. | SS=F |
| Sprinkler heads in laundry area covered with dust or showing signs of loading. | SS=E |
| Sprinkler system out of service policy incomplete, missing required fire watch procedures. | SS=F |
| Two corridor doors failed to self-close and latch properly. | SS=E |
| Electrical panels in corridors were unsecured and unlocked. | SS=F |
| Facility failed to provide a complete fire safety plan addressing all required components including battery operated smoke detectors. | SS=E |
| Emergency power system failed to provide documentation of required three-year 4 hour test and annual fuel quality test. | SS=F |
| Power strip used as substitute for fixed wiring to power high current draw equipment. | SS=E |
| Multi-plug adapters used at 100 hall nurses station as substitute for fixed wiring. | SS=E |
Report Facts
Certified beds: 149
Census: 120
Deficiencies cited: 13
Four hour emergency generator test interval: 36
Quarterly audit frequency: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Heidi Wallar | Executive Director | Named as Laboratory Director or Provider/Supplier Representative signing the report |
Inspection Report
Renewal
Census: 120
Capacity: 120
Deficiencies: 5
Feb 17, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from February 13 to 17, 2023.
Findings
The facility was cited for multiple deficiencies including inaccurate coding of resident discharge status in MDS assessments, failure to document targeted behaviors in care plans, inadequate skin assessments for bruising, improper labeling and dating of medications, and unsanitary food storage practices.
Severity Breakdown
SS=D: 4
SS=F: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to accurately code a resident's discharge status in the Minimum Data Set (MDS) assessment for 1 of 1 resident reviewed. | SS=D |
| Failed to document targeted behaviors in the comprehensive care plan for a resident receiving antipsychotic medication for delusional behaviors. | SS=D |
| Failed to accurately assess and document bruising on the skin for 2 of 2 residents reviewed for skin issues and skin assessments. | SS=D |
| Failed to date multi-dose bottles of medication when opened in medication storage refrigerator. | SS=D |
| Failed to label, date, and store food in a sanitary manner in the kitchen cooler. | SS=F |
Report Facts
Census SNF/NF: 103
Census SNF: 17
Total Census: 120
Medicare Census: 4
Medicaid Census: 84
Other Payor Census: 32
Medication storage refrigerators reviewed: 4
Multi-dose bottles not dated: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Heidi Wallar | MSN | Laboratory Director or Provider/Supplier Representative signature on report |
| RN 3 | Nurse interviewed regarding skin assessments and bruising documentation | |
| LPN 8 | Nurse interviewed regarding medication labeling and dating | |
| Director of Nursing | Interviewed regarding MDS discharge coding and medication storage policy | |
| MDS Coordinator | Interviewed regarding MDS assessment coding errors | |
| Social Service Director | Interviewed regarding care plan deficiencies and audits | |
| Dietary Manager | Interviewed regarding food storage and labeling practices | |
| Registered Dietician | Interviewed regarding food storage policies |
Inspection Report
Renewal
Deficiencies: 0
Feb 17, 2023
Visit Reason
Paper compliance review to the Recertification and State Licensure survey conducted on February 17, 2023.
Findings
Mulberry Health & Rehabilitation Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper compliance review.
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