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Inspection visit

Follow-up on corrections

MERCY HOME 3License 3318000872 citations on this visit
2 citations recorded

Inspector’s narrative

What the inspector wrote

On 07/22/2024, Licensing Program Analyst (LPA) Melody Brown conducted an unannounced visit to the facility to commence a case management visit. LPA Brown was greeted and granted entrance by a staff. LPA Brown identified herself and discussed the purpose of the visit with Nicole Ajunwa. At the time of the visit, there were six (6) residents, and two (2) staffs present. During today's visit, LPA Brown observed that Resident #3 (R3) has full bed rail and staff interview and records review indicated that R3's not on hospice and no exception report was submitted and approved by Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) Regional Office. Deficiency will be issued. Moreover, during the tour of the facility, LPA Brown observed Resident #2 (R2) and Resident #4 (R4), with half bed rails but staff interviews and document review indicated that there are no written order from their physician indicating the need for half bed rail for mobility. Deficiency will be issued. An exit interview was conducted where this report (LIC809), LIC809D and Appeal Rights were discussed and provided to NIcole Ajunwa.

Citations

2 citations recorded*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

  • 87608(a)(3)Type B

    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.

  • 87608(a)(5)(B)Type A

    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.

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FAQ · About this visit

Common questions about this visit

What happened during the July 22, 2024 inspection of MERCY HOME 3?

This was a other inspection of MERCY HOME 3 on July 22, 2024. 2 citations were issued: 1 Type A (serious) and 1 Type B.

Were any citations issued to MERCY HOME 3 on July 22, 2024?

Yes, 2 citations were issued (1 Type A, 1 Type B). The first citation was for: "87608 Postural Supports (a) Based on the individuals preadmission appraisal....(3) A written order from a physician indi..."

What type of inspection was this?

This was a other inspection. other inspections are conducted by CCLD as part of their licensing oversight.

SourceView on CCLDView original report

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Data from CCLD public records. Last updated . If you believe any information is inaccurate, report it here.