Mullican Care Center

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the emergency crash cart was equipped with a readily available oxygen supply when an empty oxygen cylinder was identified on the crash cart for 1 of 1 crash carts reviewed. The facility failed to ensure the facility's crash cart had an oxygen cylinder that was not empty and ready for use on 07/22/2026. This failure placed resident at risk of delay if administration of oxygen during a resident emergency placing resident at risk of delayed emergency treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services. The facility failed to ensure:a pan with ground sausage was labeled and dateda container of turkey pot roast was discarded by the use by date of 07/16/2026. These failures could place residents at risk for food contamination and foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for 1 of 1 Women's Secure Unit reviewed for a comfortable environment. The facility failed to ensure a comfortable environment was provided in the Women's Secure Unit dining room when the temperature was between 87-90.7 F on 07/21/2026. This failure could place residents at risk for heat-related illness, hospitalizations, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 out of 2 residents (Resident #25) reviewed for pressure ulcers. LVN A failed to provide wound care to Resident #25 according to physician orders for a state III pressure ulcer. This failure could place residents at risk of complications which include worsening of existing wounds, development of new wounds, and infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible in 1 of 6 shower rooms (located on the men's memory care unit) and in 1 of 8 Resident's room (Resident #40 in room [ROOM NUMBER]a) observed for safety hazards. 1. The facility failed to ensure the hygiene supply storage cupboard located on the men's memory care unit in the community shower room with supply items to include bottles of shampoo, body wash, shaving cream, and razors were secure and hygiene items were not accessible to cognitively impaired residents on 07/20/2026 at 12:27 p.m 2. The facility failed to ensure five disposable razors were secured and not left in room [ROOM NUMBER]a on Resident #40's over the bed table on 07/20/2026 at 11;57 a.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were offered sufficient fluid intake to maintain proper hydration and health for 1 of 3 residents (Resident #4) reviewed for hydration. The facility failed to ensure Resident #4 had water available in her room to drink on 7/20/26 and 07/21/26 . This failure could place residents at risk for dehydration (occurs when your body loses more fluid than you take in), electrolyte imbalance (occurs when certain mineral levels in your blood get too high or too low), and infections.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that the medication error rate was not 5 percent or greater. The facility had a medication error rate of 8%, based on 2 errors out of 25 opportunities, which involved 2 of 5 residents (Resident #42 and Resident #10) reviewed for medication administration. 1. The facility failed to ensure Resident #10's was free from medication error when LVN A did not prime insulin pen Novolin R (medication used to treat high blood sugar) on 07/22/2025. 2. The facility failed to ensure Resident #42's was free from medication error when LVN A did not prime insulin pen Novolog (medication used to treat high blood sugar) on 07/22/2025. These failures could place residents at risk of not receiving the therapeutic effects of their medications, possible adverse reactions, and medication errors.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents were free of significant medication errors for 2 of 5 residents (Resident #10 and Resident #42) reviewed for pharmacy services. 1. The facility failed to ensure LVN A primed Resident #10's insulin pen Novolin R (medication used to treat high blood sugar) on 07/22/2025 according to manufacture instructions. 2. The facility failed to ensure LVN A primed Resident #42's insulin pen Novolog (medication used to treat high blood sugar) on 07/22/2025 according to manufacture instructions. This failure could place residents at risk of medical complications and not receiving necessary medications.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 1 of 3 medication carts (Secure Unit Medication Cart) reviewed for drugs and biologicals. The facility failed to ensure MA F secured the Secure Unit Medication Cart, when it was not in use on 07/21/2026. This failure could place residents at risk of not receiving drugs and biologicals as needed, medication errors, medication misuse, and drug diversion.

Inspectors wroteBased on record reviews, interviews and observations, the facility failed to maintain medical records in accordance with the accepted professional standards and practices that are complete and accurately documented for1 of 6 (Resident #46) residents reviewed for documentation. Resident #46's electronic medical record did not contain complete and accurate documentation that reflected that a quarterly care plan conference was completed. This failure could result in the residents' records not accurately documenting completion of plan of care conference.

Inspectors wroteBased on interviews and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure the quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 2 of 4 residents (Resident #4 and Resident #3) reviewed for hospice services.1. The facility failed to maintain Resident #4's hospice binder containing information related to hospice services provided for the resident such as an updated care plan or the last IDG also known as Interdisciplinary Group meetings (a regular, collaborative team review of a patient's care meetings).2. The facility failed to obtain Resident #3's most up to date hospice medication list. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 4 residents (Resident #20 and Resident#11) reviewed for infection control.1. The facility failed to ensure CNA B wore PPE which consisted of gown and gloves while in Resident #20's room on 07/21/26 who was on contact isolation for ESBL also known as extended-spectrum beta-lactamase, (infections are primarily transmitted through direct or indirect contact with the bacteria) and the facility failed to provide containers for the disposal of linen and trash.2. The facility failed to ensure LVN A wore PPE (gown) while performing wound care for Resident #11. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understood and sent a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman for 1 of 4 residents (Resident #1) reviewed for discharge. 1. The facility failed to notify the resident representative, (Office of the State Long-Term Care Ombudsman,) of the transfer or discharge with the reasons for the move in writing in a language and manner they understand. 2. The facility failed to send a copy of the notice of transfer or discharge to the representative of the Office of the State LTC Ombudsman involving Resident #1. 3. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in (1 of 1) kitchen reviewed for dietary services. 1) The facility failed to dispose of expired food items. 2) The facility failed to label and date all food items in the refrigerator and freezer. 3) The facilty failed to main safe holding temps on the steam table. These failures could place residents at risk for food contamination and foodborne illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide food that was palatable, attractive and at a safe and appetizing temperature for 1 of 3 meals (lunch) reviewed for palatability and temperature. 1. The facility failed to provide food that was palatable and appetizing temperature for 1 of 3 meals observed on 5/28/25 (lunch) meal. 2. The facility failed to follow puree recipe for lunch meal served on 5/28/25. These failures could place residents at risk of decreased food intake, hunger, and unwanted weight loss.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that each resident receives and the facility provides at least three meals daily, at regular times comparable to normal mealtimes in the community, in that: The facility failed to serve meals, at the specific times posted, in the main dining room. This failure placed residents at risk of increased hunger, thirst, frustration, and decreased feelings of self-worth.

Inspectors wroteBased on interview and record review, the facility failed to ensure prompt efforts were made to resolve grievances for 1 of 16 residents (Resident #17) reviewed for grievances. The facility did not ensure a grievance was filed and Resident #17 was appropriately apprised of progress toward a resolution when Resident #17 reported to the Administrator that she was missing her $250 from her room on 1/31/25. This failure could place residents at risk for a decreased quality of life, and grievances not being addressed or resolved promptly.

Inspectors wroteBased on interviews and record review the facility failed to coordinate assessments with the PASRR program to the maximum extent practicable to avoid duplicative testing and effort for 1 of 5 residents (Resident #34) reviewed for PASRR. The facility failed to coordinate quarterly PASRR IDT meetings to discuss specialized services with the PASRR Coordinator for Resident #34. This failure could place residents with positive PASRR status at risk of not receiving specialized services which would enhance their highest level of functioning and could contribute to residents decline in physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 2 residents (Resident #39) reviewed for treatment and services related to indwelling catheters. The facility failed to ensure Resident #39's foley catheter was secured on 05/27/2025. This failure could place residents at risk for urinary tract infections and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to establish a system of receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation and determine that drug records were in order and that an account of all controlled drugs were maintained and periodically reconciled for 1 of 6 residents (Resident #28) reviewed for pharmacy services. The facility failed to ensure RN A accurately reconciled Resident #28's narcotic medication log when she disposed Resident #28's clonazepam (controlled medication used for anxiety) tablet on 05/27/25. This failure could place residents at risk for loss of prescribed medications, resident's safety, and drug diversion.

Inspectors wroteBased on interview and record review, the facility failed to ensure laboratory services were obtained to meet the needs of 1 of 16 residents reviewed for laboratory services (Residents #4). The facility failed to obtain Resident #4's Keppra level (level obtained to ensure medication is in therapeutic range) as ordered. This failure could place residents at risk of not receiving timely diagnoses, treatment, and services to meet their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 of 3 residents (Resident #11) reviewed for infection control. The facility failed to ensure LVN C and CNA D followed enhanced barrier precautions while providing wound care to Resident #11 on 05/28/2025. This failure could place residents at risk for cross contamination and the spread of infection due to lack of implementation of orders.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure assessments accurately reflected the resident status for 3 of 12 residents (Resident # 17, Resident #4, Resident 11) reviewed for MDS assessment accuracy. The facility failed to ensure Resident # 17's, Resident #4's, and Resident #11's, restraints were accurately coded. These failures could place residents at risk of not receiving care and services to meet their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, for 1 of 5 halls (C hall) reviewed for physical environment. The facility failed to ensure the flooring on the C hall was free from trip hazards. This failure could place residents who reside in the facility at-risk of falls and further injuries due to an unsafe environment.

Inspectors wroteBased on interview and record review the facility failed to refer all residents with possible serious mental disorder or a related condition for level II for 1 of 3 residents (Resident #17) whose records were reviewed for mental disorders. The facility failed to refer Resident #17 for a PASARR evaluation based on mental disorder diagnoses of Psychosis. This deficient practice could affect residents with mental illness and contribute to a delay in services needed.

Inspectors wroteBased on interviews and record reviews the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 14 residents (Residents #2) reviewed for care plans. 1. The facility failed to include Resident #2's diagnosis and interventions for post-traumatic stress disorder (PTSD) in the care plan. This failure could have placed residents at risk for not having their needs met.

Inspectors wroteBased on observation, interview, and record review the facility failed to review and revise the person-centered care plan to reflect the current condition for 3 of 3 (Resident #17, Resident #15, and Resident #25) residents reviewed for care plan revisions. 1. The facility failed to revise Resident #17's care plan to include he removed his Foley catheter leg strap (a device used to reduce the risk of tension or pulling on the catheter, which could cause some very unpleasant trauma within the bladder or urethra) as ordered at times. 2. The facility failed to revise Resident #15 care plan to remove her wander guard. 3. The facility failed to revise Resident #25 care plan to remove he was a smoker. These deficient practices could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents requiring respiratory care were provided such care, consistent with professional standards of practice for 2 of 12 residents (Resident #8 and #31) reviewed for respiratory care. 1. The facility failed to ensure Resident #8 had oxygen orders. 2. The facility failed to ensure Resident #31 oxygen concentrator filters were cleaned. These failures could place residents who receive respiratory care at risk of developing respiratory complications and a decreased quality of care.

Inspectors wroteBased on interview and record review the facility failed to maintain medical records on each resident that were complete and accurately documented, in accordance with accepted professional standards and practices, for 1 (Resident #17) of 4 residents whose records were reviewed for accuracy and completeness. The facility failed to maintain accurate documenation in the MAR for April 2024 for Resident #17. This deficient practice could place residents at risk of having incomplete or inaccurate records and inadequate care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 residents (Resident #26) reviewed for infection control practices. CNA D failed to wash or sanitize hands when changing gloves between dirty and clean while providing peri care for Resident #26. This failure could place residents and staff at risk for cross contamination and the spread of infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement their written policies and procedures to prohibit abuse and neglect for 1 of 15 residents reviewed for abuse. (Residents #1) The facility failed to report\per policy to the state agency within 2 hours of Resident #1's allegations of abuse. This failure could place residents at risk of unreported abuse, neglect, and exploitation.

Inspectors wroteBased on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 15 (Resident #1) residents reviewed for abuse and neglect. The facility failed to report to the state agency within 2 hours of Resident #1's allegations of abuse. This failure could place the residents at risk for abuse.

Inspectors wroteBased on interview and record review, the facility failed to notify the Office of the State Long-Term Care Ombudsman of the transfer or discharge and the reasons for the transfer or discharge in writing for 1 of 3 residents (Residents #1) reviewed for transfer and discharge. The facility initiated a discharge for Resident #1 due to a change of condition and did not notify the State Long-Term Care Ombudsman by phone or in writing. This failure could place residents at risk of improper discharge planning and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to establish and follow written policy on permitting residents to return to the facility after they were hospitalized for one (Resident #1) of 3 residents reviewed for transfer/discharge. 1. The facility failed to admit Resident #1 back to facility after he was sent to the psychiatric hospital on [DATE]. 2. The facility failed to give Resident #1 a 30-day discharge notice. This failure could place residents at risk of not receiving the care and services to meet their needs and could affect their mental and emotional well-being.