Inspection Reports for
Mulberry Health & Rehabilitation Center
502 W JACKSON ST, MULBERRY, IN, 46058
Back to Facility Profile18 Reports
Inspection Report — Jun 24, 2025
Routine
Date: Jun 24, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to pre-admission screening and resident review (PASARR) and medication storage and labeling practices.
Findings
The facility failed to ensure PASARR screenings were updated when residents received new mental health diagnoses and medications for 2 of 4 residents reviewed. Additionally, the facility failed to keep medication carts free of expired medications, dispose of controlled medications with compromised packaging, and properly store drug busters and chemical solutions in medication storage rooms.
Deficiencies (2)
F 0644: The facility failed to complete updated PASARR screenings when residents received new mental health diagnoses and were prescribed new mental health medications for 2 of 4 residents reviewed.
F 0761: The facility failed to keep medication carts free of expired medications and dispose of controlled medications with compromised packaging in 2 of 4 medication carts and failed to properly store drug busters and chemical solutions in medication storage rooms.
Report Facts
Residents reviewed for PASARR: 4
Residents affected: 2
Medication carts reviewed: 4
Medication carts with deficiencies: 2
Medication storage rooms reviewed: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Interviewed regarding PASARR screening and facility policies | |
| RN 2 | Interviewed about pharmacy audits of medication carts | |
| LPN 4 | Interviewed about medication storage awareness | |
| RN 3 | Interviewed about medication disposal and packaging | |
| Director of Nursing | Interviewed about medication storage and disposal policies |
Inspection Report — May 13, 2025
Complaint Investigation
Date: May 13, 2025
Visit Reason
This visit was for the investigation of complaints IN00458744 and IN00448797.
Complaint Details
Complaint IN00458744 and Complaint IN00448797 were investigated with no deficiencies cited related to the allegations.
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.
Report Facts
Census Medicare: 5
Census Medicaid: 86
Census Other: 31
Inspection Report — Jul 11, 2024
Re-Inspection
Date: 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
Inspection Report — May 24, 2024
Annual Inspection
Date: 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.
Deficiencies (2)
Failed to inspect 28 of 28 portable fire extinguishers monthly as required by NFPA 10.
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.
Report Facts
Certified beds: 149
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 — May 8, 2024
Renewal
Date: 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.
Deficiencies (3)
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).
Facility failed to complete an accurate level 1 Preadmission Screening and Resident Review (PASARR) for 1 of 3 residents reviewed (Resident 105).
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.
Report Facts
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 — May 8, 2024
Renewal
Date: 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 — May 8, 2024
Annual Inspection
Date: May 8, 2024
Visit Reason
The inspection was conducted as a routine annual survey to assess compliance with regulatory requirements related to resident rights, PASARR screening, and medication storage and labeling.
Findings
The facility was found deficient in ensuring residents' dignity by dressing a resident in another's clothing and improper feeding posture. The facility failed to complete an accurate PASARR level 1 screening for one resident. Medication storage and labeling deficiencies were noted, including unlabeled over-the-counter medications and improper storage of food and beverages in the medication refrigerator.
Deficiencies (3)
F 0550: The facility failed to ensure a resident was dressed in her own clothing and staff did not sit while feeding the resident, violating the resident's right to dignity.
F 0644: The facility failed to complete an accurate level 1 PASARR screening for one resident, omitting mental health diagnoses and medication information.
F 0761: The facility failed to ensure over-the-counter medications were labeled properly and stored medications were kept free of food and beverages in the medication refrigerator.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 3
Medication tablets count: 500
Medication tablets count: 240
Medication tablets count: 500
Medication tablets count: 225
Medication tablets count: 90
Medication tablets count: 500
Inspection Report — Mar 4, 2024
Complaint Investigation
Date: Mar 4, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00429382.
Complaint Details
Complaint IN00429382 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Medicare residents: 13
Census Medicaid residents: 88
Census other payor residents: 21
Inspection Report — Jan 30, 2024
Original Licensing
Date: 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
Inspection Report — Nov 30, 2023
Complaint Investigation
Date: Nov 30, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00422104.
Complaint Details
Complaint IN00422104 was investigated and found to have no deficiencies related to the allegations.
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.
Report Facts
Census Payor Type Medicare: 9
Census Payor Type Medicaid: 90
Census Payor Type Other: 23
Inspection Report — Nov 8, 2023
Complaint Investigation
Date: Nov 8, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00419171 and IN00420029.
Complaint Details
Complaint IN00419171 and IN00420029 were investigated with no deficiencies cited related to the allegations.
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.
Report Facts
Medicare Census: 10
Medicaid Census: 90
Other Payor Census: 24
Inspection Report — Jun 5, 2023
Complaint Investigation
Date: 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.
Complaint Details
Complaint IN00409803 and Complaint IN00405818 were investigated with no deficiencies related to the allegations cited.
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.
Report Facts
Census Payor Type Medicare: 12
Census Payor Type Medicaid: 89
Census Payor Type Other: 22
Inspection Report — Jun 5, 2023
Annual Inspection
Date: Jun 5, 2023
Visit Reason
Annual inspection survey of Mulberry Health & Rehabilitation Center to assess compliance with health regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report — May 3, 2023
Follow-Up
Date: 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
Inspection Report — Mar 16, 2023
Life Safety
Date: 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.
Deficiencies (13)
Failed to implement emergency power system inspection, testing, and maintenance requirements including missing three-year 4 hour test and annual fuel quality test report.
Exit door near 400 West exit was magnetically locked without posted access code.
Exit discharge from 400 West hall had uneven walking surface with a 2 inch crack.
Courtyard doors not posted with 'NO EXIT' signage.
Fire alarm system out of service policy incomplete, missing required notification procedures.
Sprinkler heads in laundry area covered with dust or showing signs of loading.
Sprinkler system out of service policy incomplete, missing required fire watch procedures.
Two corridor doors failed to self-close and latch properly.
Electrical panels in corridors were unsecured and unlocked.
Facility failed to provide a complete fire safety plan addressing all required components including battery operated smoke detectors.
Emergency power system failed to provide documentation of required three-year 4 hour test and annual fuel quality test.
Power strip used as substitute for fixed wiring to power high current draw equipment.
Multi-plug adapters used at 100 hall nurses station as substitute for fixed wiring.
Report Facts
Certified beds: 149
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 — Feb 17, 2023
Renewal
Date: 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.
Deficiencies (5)
Failed to accurately code a resident's discharge status in the Minimum Data Set (MDS) assessment for 1 of 1 resident reviewed.
Failed to document targeted behaviors in the comprehensive care plan for a resident receiving antipsychotic medication for delusional behaviors.
Failed to accurately assess and document bruising on the skin for 2 of 2 residents reviewed for skin issues and skin assessments.
Failed to date multi-dose bottles of medication when opened in medication storage refrigerator.
Failed to label, date, and store food in a sanitary manner in the kitchen cooler.
Report Facts
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 — Feb 17, 2023
Renewal
Date: 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.
Inspection Report — Feb 17, 2023
Date: Feb 17, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments, care planning, treatment and care, medication storage, and food safety at Mulberry Health & Rehabilitation Center.
Findings
The facility was found deficient in accurately coding resident discharge status, documenting targeted behaviors in care plans, assessing and documenting bruising, labeling multi-dose medication bottles, and labeling and storing food in a sanitary manner. All deficiencies were noted with minimal harm or potential for actual harm.
Deficiencies (5)
F 0641: The facility failed to accurately code a resident's discharge status in the Minimum Data Set assessment for 1 of 1 resident reviewed.
F 0656: The facility failed to document targeted behaviors in the comprehensive care plan for 1 of 3 residents reviewed receiving antipsychotic medication for delusional behaviors.
F 0684: The facility failed to accurately assess and document bruising on the skin for 2 of 2 residents reviewed for skin issues and assessments.
F 0761: The facility failed to date multi-dose bottles of medication when opened in 1 of 4 medication storage refrigerators reviewed.
F 0812: The facility failed to label, date, and store food in a sanitary manner, potentially affecting all residents consuming food from the kitchen.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 2
Medication storage refrigerators reviewed: 4
Medication bottles unlabeled: 2
Residents affected: Many
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Indicated Resident 129 discharge status was coded wrong | |
| MDS Coordinator | Indicated MDS assessment was coded wrong for Resident 129 | |
| Social Service Director | Indicated Resident 101 care plan was not updated to remove diagnosis | |
| RN 3 | Registered Nurse | Not aware of bruising on Resident 2 and completed skin assessment on Resident 20 |
| LPN 8 | Licensed Practical Nurse | Indicated medication bottles should have been labeled with date opened |
| Dietary Manager | Observed unlabeled and undated food items in kitchen cooler | |
| Registered Dietician | Indicated lack of policy on staff food labeling in walk-in cooler |
4 CMS Surveys
CMS Survey — Feb 17, 2023
Feb 17, 2023
CMS Survey — May 8, 2024
May 8, 2024
CMS Survey — Jun 24, 2025
Jun 24, 2025
CMS Survey — Jun 5, 2023
Jun 5, 2023
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