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 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 |