A list of the most recent deficiencies for Mercy Health Services. 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? |
|---|---|---|---|---|
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2023-02-22 | 2023-03-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-02-22 | 2023-03-29 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-02-22 | 2023-03-29 | 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 | 2022-12-20 | 2023-02-03 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-12-20 | 2023-02-03 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2022-12-20 | 2023-02-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-12-20 | 2023-02-03 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-12-20 | 2023-02-03 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-12-20 | 2023-02-03 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-12-20 | 2023-02-03 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2022-12-20 | 2023-02-03 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-12-21 | 2023-01-26 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-12-21 | 2023-01-26 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-12-21 | 2023-01-26 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-12-21 | 2023-01-26 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-12-21 | 2023-01-26 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2022-12-21 | 2023-01-26 | 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 | 2022-12-21 | 2023-01-26 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-12-21 | 2023-01-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-12-21 | 2023-01-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-12-21 | 2023-01-26 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2022-12-21 | 2023-01-26 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-10-07 | 2022-11-02 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-06-07 | 2022-07-07 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-06-07 | 2022-07-07 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-06-07 | 2022-07-07 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-07 | 2022-07-07 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-09-13 | 2021-10-11 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-09-13 | 2021-10-11 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-09-13 | 2021-10-11 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-09-13 | 2021-10-11 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-13 | 2021-10-11 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-09-13 | 2021-10-11 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-09-13 | 2021-10-11 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-09-09 | 2021-10-11 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-09-09 | 2021-10-11 | 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 | 2021-09-09 | 2021-10-11 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-09-09 | 2021-10-11 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-09-09 | 2021-10-11 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-09-09 | 2021-10-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-09-09 | 2021-10-11 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-09-09 | 2021-10-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-09-09 | 2021-10-11 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-09-09 | 2021-10-11 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-07-27 | 2021-08-26 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-07-27 | 2021-08-26 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-07-27 | 2021-08-26 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-07-27 | 2021-08-26 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-27 | 2021-08-26 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-07-27 | 2021-08-26 | Y |
| 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 | 2021-07-27 | 2021-08-26 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-03-30 | 2021-04-09 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-10-08 | 2019-10-31 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-10-08 | 2019-10-31 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-10-08 | 2019-10-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-10-08 | 2019-10-31 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-10-08 | 2019-10-31 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-10-08 | 2019-10-31 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-10-08 | 2019-10-31 | 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 | 2019-10-08 | 2019-10-31 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2019-10-08 | 2019-10-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-10-08 | 2019-10-31 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-10-08 | 2019-10-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-08 | 2019-10-31 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2019-10-07 | 2019-10-12 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2019-10-07 | 2019-10-12 | N |
