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Deficiency Records for Mercy Health Services

View the most recent health deficiencies and inspection results for Mercy Health Services. Stay informed about quality of care issues.

View the most recent health deficiencies and inspection results for Mercy Health Services. Stay informed about quality of care issues.

Deficiency Type of Deficiency Deficiency Date Date Corrected Resulted from a Complaint?
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2026-03-02 2026-03-18 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2025-12-03 2025-12-16 Y
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2025-12-03 2025-12-16 Y
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 2025-05-21 2025-06-21 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 2025-05-21 2025-06-21 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2025-05-21 2025-06-21 N
Provide rooms that can be unlocked from inside without a key. Fire Safety 2025-05-21 2025-06-21 N
Ensure each resident?s drug regimen must be free from unnecessary drugs. Health 2025-05-21 2025-06-21 Y
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Health 2025-05-21 2025-06-21 N
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. Health 2025-05-21 2025-06-21 N
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 2024-09-19 2024-10-18 Y
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2024-09-19 2024-10-18 Y
Respond appropriately to all alleged violations. Health 2024-09-19 2024-10-18 Y
Respond appropriately to all alleged violations. Health 2024-08-05 2024-09-04 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2024-08-05 2024-09-04 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2024-05-13 2024-06-07 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 2024-02-29 2024-04-01 N
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2024-02-29 2024-04-01 N
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2024-02-29 2024-04-01 N
Ensure medication error rates are not 5 percent or greater. Health 2024-02-29 2024-04-01 N
Provide and implement an infection prevention and control program. Health 2024-02-29 2024-04-01 N
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Health 2024-02-29 2024-04-01 Y
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Health 2024-02-29 2024-04-01 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2024-02-29 2024-04-01 Y
Respond appropriately to all alleged violations. Health 2024-02-29 2024-04-01 Y
Establish staff and initial training requirements. Fire Safety 2024-02-29 2024-03-27 N
Conduct risk assessment and an All-Hazards approach. Fire Safety 2024-02-29 2024-03-25 N
Install proper backup exit lighting. Fire Safety 2024-02-29 2024-03-21 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2024-02-29 2024-03-11 N
Ensure proper usage of power strips and extension cords. Fire Safety 2024-02-29 2024-03-08 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2024-02-29 2024-03-05 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 2024-02-29 2024-02-28 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2022-12-21 2023-02-03 N
Install a fire alarm system that can be heard throughout the facility. Fire Safety 2022-12-21 2023-02-03 N
Meet requirements for the installation and maintenance of electrical systems. Fire Safety 2022-12-21 2023-02-03 N
Provide a written emergency evacuation plan. Fire Safety 2022-12-21 2023-02-03 N
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Fire Safety 2022-12-21 2023-02-03 N
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Fire Safety 2022-12-21 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 2022-12-21 2023-02-03 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 2022-12-21 2023-02-03 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 and implement an infection prevention and control program. 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
Ensure medication error rates are not 5 percent or greater. 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
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
Provide safe, appropriate dialysis care/services for a resident who requires such services. 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
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
PASARR screening for Mental disorders or Intellectual Disabilities Health 2022-12-21 2023-01-26 N
Allow residents to self-administer drugs if determined clinically appropriate. Health 2022-12-21 2023-01-26 N

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