A list of the most recent deficiencies for Mother of Mercy Senior Living. 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? |
|---|---|---|---|---|
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-01-24 | 2024-02-16 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-01-24 | 2024-02-09 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2023-10-25 | 2024-01-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-25 | 2023-12-22 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-10-26 | 2023-12-04 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-10-26 | 2023-12-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-26 | 2023-12-04 | N |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2023-10-26 | 2023-12-04 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-10-25 | 2023-11-28 | 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 | 2023-10-25 | 2023-11-28 | N |
| Have horizontal exits used in accordance with safety requirements. | Fire Safety | 2023-10-25 | 2023-11-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-10-25 | 2023-11-28 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-10-25 | 2023-11-28 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2023-10-25 | 2023-11-28 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-10-25 | 2023-11-28 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-08-23 | 2023-09-26 | Y |
| 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 | 2023-02-17 | 2023-04-06 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-02-17 | 2023-04-06 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-17 | 2023-04-06 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-02-17 | 2023-04-06 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-02-17 | 2023-04-06 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-02-17 | 2023-04-06 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-02-17 | 2023-04-06 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-02-16 | 2023-04-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-02-16 | 2023-04-06 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-27 | 2023-03-01 | Y |
| 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 | 2022-11-02 | 2022-12-04 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-08-31 | 2022-08-26 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-02-24 | 2022-04-16 | Y |
| Assess the resident when there is a significant change in condition | Health | 2021-11-18 | 2021-12-22 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-11-18 | 2021-12-22 | N |
| 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 | 2021-11-18 | 2021-12-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-11-18 | 2021-12-22 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2021-11-18 | 2021-12-17 | N |
| Respond appropriately to all alleged violations. | Health | 2021-12-14 | 2021-12-15 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-11-17 | 2021-12-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-11-17 | 2021-12-15 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2021-11-18 | 2021-12-10 | N |
| Inform each resident of his or her visitation rights and ensure that all visitors enjoy equal visitation privileges. | Health | 2021-11-18 | 2021-12-06 | N |
| Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency. | Health | 2021-11-18 | 2021-12-02 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-11-18 | 2021-12-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-11-17 | 2021-12-01 | N |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2021-11-18 | 2021-11-30 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-11-17 | 2021-11-22 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-11-17 | 2021-11-21 | 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 | 2021-11-17 | 2021-11-21 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2021-11-17 | 2021-11-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-04-22 | 2021-05-21 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-04-22 | 2021-04-26 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-04-22 | 2021-04-22 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2021-03-03 | 2021-04-06 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-03-03 | 2021-04-06 | Y |
