Mabee Health Care Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to post daily information that included the facility name, census, and actual hours worked by registered nurses, licensed practical or licensed vocational nurses, certified nurse aides directly responsible for resident care per shift and the resident census for 3 days (02/24/2026, 02/25/2026, 02/26/2026) of 3 days observed during survey for staff posting. The facility failed to post the daily staffing information for 02/24/2026, 02/25/2026, and 02/25/2026. This failure could place all residents, their families, and facility visitors at risk of not having access to information regarding staffing data and the facility census. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure notices to residents were provided when changes in coverage were made to services covered by Medicare/Medicaid for 3 of 3 residents (Resident #9, Resident #47, and Resident #48) reviewed for resident rights. The facility failed to ensure Resident #9, Resident #47 and Resident #48 was given a Notice of Medicare NON-Coverage CMS form 10123 (NOMNC resident who is not covered on a Medicare Part A skilled nursing stay) and Beneficiary Notice CMS form 10055 (Notice of Medicare Non-Coverage) that inform them how to appeal when residents are discharged from skilled Medicare part A services prior to covered days being exhausted. This failure could place residents, or their representatives, at risk of not being fully informed about services covered by Medicare Part A and not being aware of changes to provided services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents' right to a safe, clean, comfortable, and homelike environment for Resident #20, Resident #31 and Resident #46 in that: The facility failed to ensure that the hot water temperatures in the sinks for 3 resident rooms did not exceed the maximum of 110 degrees Fahrenheit (F).

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure each room was designed or equipped to assure full visual privacy for 3 (Rooms C-8, S-8 and S-18) of 4 dual occupancy rooms reviewed for privacy in the facility. The facility failed to ensure that dual occupancy rooms were provided with ceiling suspended curtains, which extended around the bed, to provide total visual privacy. This failure could lead to a lack of privacy for residents, allow residents' private medical treatment to be observed by roommates or others, and lead to a decline in psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the residents were free from chemical restraints not required to treat the residents' medical symptoms for 2 (Resident #2 and Resident #8) of 10 residents reviewed for unnecessary medications. The facility failed to ensure Resident #2's PRN Lorazepam (medication generally prescribed to treat symptoms of anxiety) was discontinued after 14 days or documented a rationale for the continued provision of the medication. The facility failed to ensure Resident #8's PRN Lorazepam was discontinued after 14 days or documented a rationale for the continued provision of the medication. This failure could place residents at risk for adverse reactions and negative side effects from the administration of medication and dependence on unnecessary medications.

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident of 1 (Scharbauer Cottage) of 2 medication cabinets located in the medication room reviewed for controlled substances and for storage of medications. The facility failed to ensure LVN C signed the Controlled Drugs-Audit Record form after counting and verifying that all controlled substances in the medication cabinet had been accounted for with the off- going nurse at the change of shift on 02/25/26. The failure could place residents at risk for not receiving the intended therapeutic response of prescribed medications and drug diversion of controlled substances.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an Infection Control program designed to help prevent the development and transmission of disease and infection to include hand washing and enhanced precautions for 1 resident (Residents #34) of 5 reviewed for infection control in that:The facility failed to place an Enhanced Barrier Precautions sign outside of Resident #34's door on 02/24/26. This failure could affect the residents who reside at the facility, by placing them at risk for cross-contamination and the spread of infection.

Inspectors wroteBased on observation and interview the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's four of four kitchens. The facility failed to ensure milk was not used or discarded by the use by date in 2 of 4 kitchens. The rehabilitation kitchen drawer had an accumulation of food debris in the drawers. The juice reservoirs under the juice dispensers of 2 of 4 kitchens were not clean and beginning to have white mold growing in the bottom. The rehabilitation kitchen refrigerator had fruits that were fuzzy with mold. Food was unlabeled in 2 of 4 kitchens. The handwashing sinks did not have trash cans that did not require staff to touch them in order to prevent re-contamination of hands in 2 of 4 hands. Dishes were stored face up in 1 of 4 kitchens. [...]

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 12 residents (Residents #6, #14, and #22) reviewed for care plans in that: Resident #6 did not have a care plan in place for fall risk. Resident #14 did not have a care plan in place for dehydration or hand rolls. Resident #22 did not have a comprehensive care plan. This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, included locked secured medications, the appropriate accessory and cautionary instructions, and the expiration date when applicable for 2 of 3 medication carts (Rehab hall and secured unit medication carts), 1 of 2 medication rooms (Secured unit medication room) and to maintain locked medication cabinets for 4 of 60 rooms (Residents #9, #10, #28, #94) reviewed for medication storage. The medication cart used for the secured unit had an insulin pen that had been opened and placed into use but had no open date on it. The medication cart used for the rehab hall had 2 insulin vials that had been opened and placed into use but had no open dates on them. [...]

Inspectors wroteBased on observation and interview the facility failed treat each resident with respect and dignity in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for two of five residents (Residents #31, #32) and two unsampled residents (Residents #3 and #10) reviewed for treatment with respect and dignity. CNA E was on her cell phone and tapped her fingers on Resident # 32's wheelchair arm. CNAF stood while feeding Resident #31 and #10. This failure placed residents at risk of feeling embarrassed, infantilized, dehumanized, or stigmatized due to their need for assisted dining.

Inspectors wroteBased on interviews and record reviews, the facility failed to complete a comprehensive assessment within 14 days after a significant change in the physical condition for 3 of 9 residents (Residents #19, #31 and #32) whose records were reviewed for assessments after significant change. The facility failed to complete a comprehensive MDS assessment after Resident #19, Resident #31 and Resident #32 developed pressure ulcers. These failures placed residents at risk of having assessments that do not reflect significant changes in their conditions and need for additional care/treatment.

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 9 residents (Residents #17, #19, and #32) reviewed for care plans in that: Resident #17 did not have a care plan in place for fall risk. Resident #19 did not have a care plan in place for skin integrity risk, bipolar disorder, or psychotropic medication use. Resident #32 did not have a care plan in place for an indwelling catheter. This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 residents (Residents #18) reviewed for indwelling catheters. The facility failed to ensure Resident #18's indwelling catheter was secured to prevent pulling or tugging. The facility failed to ensure CNA B performed urinary catheter care for Resident #18 during incontinent care. These failures could place residents at risk for discomfort, urethral trauma and urinary tract infections.