Mercy Health Services

Inspectors wroteBased on interview and record review the facility did not ensure 1 (R4) of 4 residents had a complete and accurate medical record. R4 was on hospice and a full code. On [DATE] the nurses note documents (R4) time of death per hospice 1840 (6:40 p.m.). There is no documentation of an assessment or actions that preceded R4's death. Interim Director of Nursing (DON)-B stated he documented the assessment and actions on a facility risk management form and did not transfer this information into R4's medical record.

Inspectors wroteBased on facility policy review, record review, facility document review, and interview, the facility failed to protect the resident's right to be free from verbal and mental abuse by staff, which affected 1 (R1) of 3 residents reviewed for abuse. Specifically, Certified Nursing Assistant (CNA) C yelled at and threatened R1.

Inspectors wroteBased on facility policy review, record review, facility document review, and interview, the facility failed to ensure allegations of abuse were reported timely, which affected 1 (R1) of 3 residents reviewed for abuse. Specifically, the facility failed to report an incident of verbal and mental abuse to the state survey agency withing two hours when Certified Nursing Assistant (CNA) C yelled at and threatened R1.

Inspectors wrote3) Surveyor reviewed R2's medical record. On 12/16/24 the nurses note indicate R2 had a change of condition and experiencing chest pain and shortness of breath. R2 was sent to the hospital with an admitting diagnoses of exacerbation CHF (congestive heart failure) and UTI (urinary tract infection). On 5/19/25 during the daily exit meeting with DON (director or nursing)-B and NHA (nursing home administrator)-A, Surveyor asked for the transfer and bed hold notice for R2's hospitalization on 12/16/24. On 5/20/25, at 12:00 p.m., VP (Vice President) of Success D explain to Surveyor they have no bed hold and transfer notice for any resident. 4) Surveyor reviewed R10's medical record. On 2/24/25 R10's medical record documents: was experiencing seizures and was sent to the hospital. R10 was admitted for seizures. [...]

Inspectors wroteBased on interview and record review the facility did not ensure adequate monitoring for unnecessary medications for 2 (R26 and R5) of 2 residents requiring neurological testing related to Abnormal Involuntary Movement Scale (AIMS). * R26 had an AIMS assessment score requiring a referral for a complete neurological exam, was not followed through. * R5 had an AIMS assessment score requiring a referral for a complete neurological exam, was not followed through.

Inspectors wroteBased on observation, record review and staff interviews, the facility did not ensure food was mechanically altered per provided recipe for 3 (R1, R11 & R19) of 3 sampled residents with puree textured diet orders. On 5/19/25, Surveyor observed Dietary Aide-M not preparing pureed breakfast sausage links according to a recipe to provide the highest level of nutrition to residents receiving a puree diet.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to investigate a potential misappropriation of medication for one of one resident (Resident (R) 3) reviewed for misappropriation of medication out of total sample of 11. Specifically, the failure to ensure misappropriation had not occurred, had the potential to allow one nurse to continue to pass medications to residents for an indefinite period.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to exercise reasonable care for the protection of personal items for one of one sampled resident (Resident (R) 3) reviewed for protection of personal property out of a total sample of 11 residents. Specifically, when R3 was discharged from his five-day respite stay, the facility was unable to provide him with all of the personal items he had admitted to the facility with. This failure has the potential to cause undue stress and expense to the family and/or resident.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to clarify a physician's order for as needed (PRN) lorazepam (Ativan, a controlled anti-anxiety medication) for one of 11 sampled resident (Resident (R) 3) reviewed for medication administration out of a total sample of 11. Specifically, the failure to clarify the order caused confusion in medication administration for R3.

Inspectors wroteBased on record review and staff interview, the facility did not ensure that 1 allegation of a Resident to Resident altercation involving 2 Residents (R2 and R9) was reported immediately to the State Survey Agency. * On 7/14/24, R2 received a closed fist hit to the left forearm resulting in a bruise which was not reported to the State Survey Agency. Findings Include: The facility's policy Abuse, Neglect, and Exploitation policy and procedure implemented 3/2018 and last reviewed/revised on 7/15/2022 documents: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each Resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of Resident property. V. Investigation of Alleged Abuse, Neglect and Exploitation A. [...]

Inspectors wroteBased on record review and staff interview, the facility did not ensure that 2 allegations of Resident to Resident altercations involving 4 Residents(R2 and R3 and R2 and R9) were thoroughly investigated. *On 7/12/24 the facility submitted a Misconduct Incident Report describing an altercation of R2 scratching R3 on 7/5/24. The facility did not complete a thorough investigation including staff statements, other resident statements, and a root/cause analysis of the altercation. *On 7/14/24 the facility did not complete a thorough investigation of the altercation between R9 and R2. R9 hit R2 with a closed fist on the left forearm resulting in a bruise. The facility did not obtain staff statements, other resident statements, and a root/cause analysis of the altercation. Findings Include: [...]

Inspectors wroteBased on observation, interview, and record review the Facility did not ensure each Resident received adequate supervision and assistance devices to prevent accidents for 2 (R1 & R2) of 3 Residents reviewed for accidents. *R1 was assessed to require one-to-one staff supervision. R1 was left unattended and sustained a fall on 04/16/2024 that resulted in multiple fractures. Surveyor had observations of R1 not having fall prevention interventions in place of antiroll back equipment or a fall mat in place as documented in the care plan. *R2 was observed to not have current fall prevention interventions of auto lock brakes and Dycem in place.

Inspectors wroteBased on observations, interviews, and record review, the facility did not ensure residents received care consistent with professional standards of practice to prevent pressure ulcers and to ensure residents do not develop new pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable. This affected 2 of 4 residents (R23 and R12) reviewed for pressure injuries. *R23 was admitted to the facility with hospital discharge documents indicating R23 was being discharged with three stage 3 pressure injuries: one to the left and right buttock and one to the coccyx. The facility did not comprehensively assess these areas upon admission. The facility did not take note of the pressure injuries on R23's buttocks upon admission. [...]

Inspectors wroteBased on interview and record review the facility did not ensure residents the right to refuse and/or discontinue treatment for 1 of 12 (R33) residents reviewed for choices. * R33 was forced by facility staff to get out of bed against his wishes.

Inspectors wroteBased on interviews and record review the facility did not ensure residents the right to be treated with respect and dignity, including the right to be free from any physical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms for 1 of 1 (R33) reviewed. * R33 was physically held down by facility staff to get dressed against his wishes.

Inspectors wroteBased on interview and record review the facility did not ensure 1 (R24) of 5 allegations of abuse and injuries of unknown source were reported to the state agency. * On 12/18/23 the nurses note indicate R24 was holding her right wrist and crying out in pain. R24 was unable to say what happened. R24 was transferred to the emergency department for evaluation of the right wrist pain. The hospital x-ray report of the right wrist reveals an acute displaced intra-articular fracture of the distal radius. The facility did not report this injury of unknown source to the state agency.

Inspectors wroteBased on interview and record review the facility did not ensure 3 (R24, R101 and R20) of 5 residents reviewed had thorough investigations into allegations of misappropriation and injuries of unknown source. * On 12/18/23 R24 was discovered with a wrist fracture and a thorough investigation into the injury was not conducted. * On 11/18/23 R101 was complaining of neck pain and was sent to the hospital for evaluation. While at the hospital they discovered R101 had a hematoma to the scalp. R101 alleges he was injured during a transfer while at the facility. The facility did not conduct a thorough investigation into the hematoma to the scalp. * R20 alleged missing money and a thorough investigation was not conducted.

Inspectors wroteBased on observation, record review, and interview, the facility did not ensure medications were administered to meet the needs of 1 (R32) of 2 residents observed receiving as needed medications. * R32 was administered Furosemide, a diuretic, with no assessment to determine if the medication was indicated, and the order to administer Furosemide did not have any parameters or physical indicators of when the medication should be administered.

Inspectors wroteBased on record review and interview, the facility did not ensure residents on psychotropic medications have a diagnosis for the use of the medication and is being followed for medication management for 1 (R20) of 5 residents reviewed for unnecessary medications. * R20 had an order for Buspirone, an antianxiety medication, with no diagnosis of anxiety. The order stated the medication was for depressive disorder. R20 was seen on 8/31/2023 at an outpatient mental health clinic and the progress note indicated R20 would not be followed by the clinic physician due to mental health services that were available to R20 at the facility. The facility was not aware R20 was not being seen by the outpatient mental health clinic until Surveyor during the survey brought this to their attention.

Inspectors wroteBased on observation, record review, and interview, the facility did not ensure the medication error rate was below 5 percent in 1 (R32) of 3 resident observed receiving medications. The facility medication error rate was 6.9 percent. * R32 received a crushed Omeprazole delayed release tablet, making the medication ineffective, and Licensed Practical Nurse (LPN)-F would have administered an inhaler that was ordered for a different resident if Surveyor had not intervened.

Inspectors wroteBased on observation, record review, and interview, the facility did not ensure sanitary practices were maintained during medication pass for 1 (R32) of 3 residents observed during medication pass. Licensed Practical Nurse (LPN)-F touched each medication administered to R32 with LPN-F's bare hands before placing them into a medication cup.

Inspectors wroteBased on interviews, document review, and facility policy review, it was determined that the facility failed to ensure a registered nurse (RN) was scheduled seven days a week for eight consecutive hours per day for 1 (second quarter of 2022) of 4 quarters reviewed. This deficient practice has the potential to affect all 46 residents residing in the facility at the time of survey.

Inspectors wroteBased on observation, interviews, and document review, it was determined the facility failed to ensure staff were operating the dish machine in the kitchen at the required rinse temperature of 180 degrees Fahrenheit (F) or above for 1 of 1 high temperature dish machine. This had the potential to affect all residents and staff who received food from the kitchen.

Inspectors wroteBased on interviews and document review, it was determined that the facility failed to ensure certified nursing assistants (CNAs) received at least 12 hours of training per year to ensure continuing competence for 4 (CNA J, CNA L, CNA N, and CNA O) of 6 CNAs whose training records were reviewed. This deficient practice has the potential to affect all 46 residents residing in the facility.

Inspectors wroteBased on observations, interviews, record reviews, and facility policy review, it was determined that the facility failed to maintain a medication error rate of less than 5% for 2 (R13 and R36) of 3 residents observed during medication administration. Medication errors were made by 2 of 2 licensed nursing staff observed during medication administration, with a total of 4 medication errors detected out of 28 opportunities for error, which resulted in a medication error rate of 14.28%.

Inspectors wroteBased on observation, interviews, record review, and facility policy review, it was determined that the facility failed to ensure that before allowing a resident to self-administer medications, the interdisciplinary team (IDT) completed an assessment to determine if the resident could safely and accurately do so for 1 (R32) of 1 sampled resident reviewed for self-administration of medications.

Inspectors wroteBased on interviews, record review, and facility policy review, it was determined that the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) level I and level II screening were completed for 1 (R37) of three residents reviewed for PASARR.

Inspectors wroteBased on observations, record reviews, interviews, and facility policy review, it was determined that the facility failed to ensure care plans were developed to address residents' individual concerns and care needs for 2 (R16 and R32) of 16 sampled residents whose care plans were reviewed. Specifically, the facility failed to ensure a care plan for diabetes management was developed for R32 and failed to ensure care plans for management of respiratory diagnoses and oxygen therapy were developed for R16.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, it was determined that the facility failed to provide necessary respiratory services in accordance with professional standards of practice for 1 (R16) of 2 sampled residents reviewed for respiratory services. Specifically, the facility failed to ensure R16 received oxygen that was humidified and administered at the physician-ordered flow rate.

Inspectors wroteBased on record review, interviews, and facility policy review, it was determined that the facility failed to ensure consistent communication between the facility and the dialysis center for 1 (R19) of 1 sampled resident reviewed for dialysis.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, it was determined that the facility failed to complete an assessment and obtain consent for the use of side rails for 1 (R37) of 2 sampled residents reviewed for the use of side rails.

Inspectors wroteBased on observations, interviews, document review, and facility policy review, it was determined that the facility failed to ensure staff cleaned and disinfected glucometers (machines used to monitor blood sugars) after each use by 1 of 2 nurses observed during medication pass. This had the potential to affect the 8 of 8 sampled residents with orders for blood sugar monitoring.