Mercy Home 3

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on record review , the licensee did not comply with the section cited above having two staff with expire CPR which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation, interview and record revie], the licensee did not comply with the section cited above by not ensuring that Staff #2 (S2) criminal backgrpund clearance was transferred to the facility proior to employment which poses a potential health, safety or personal rights risk to persons in care.

Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that Resident #2 (R2) Admission Agreement was signed and dated by the Licensee/Facility Representative which poses a potential health, safety or personal rights risk to persons in care.

87608 Postural Supports (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do...(5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. (B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by: Based on observation, interview, record review, the licensee did not comply with the section cited above by having a full bed rail for Resident #3 (R3) and R3's not on hospice and no exception was submitted and approved to CCLD which poses an immediate health, safety or personal rights risk to persons in care.

87608 Postural Supports (a) Based on the individuals preadmission appraisal....(3) A written order from a physician indicating the need for the postural support shall be maintained in the residents record. The licensing agency...This requirement is not met as evidenced by: Based on observation, interview and record review, the licensee did not comply with the section cited above by having Resident #2 (R2) and Resident #4 (R4), with half bed rails with no written order from their physician indicating the need for the postural support for mobility which poses a potential health, safety and personal rights risks to resident in care.

This requirement is not met as evidenced based on interview and observation, the licensee did not comply with the section cited above evidenced by not having an auditory devices on the facility exits on the front entry door, the backdoor sliding door, and in Resident R1’s bedroom which poses a potential health, safety, or personal rights risk to persons in care.