MERCY - MCAULEY CENTER

Nursing Home Inspector

906 SCIOTO ST
URBANA, OH 43078
Champaign County
Phone: 937-653-5432
Provider Number: 365650
Last Inspection: 06/22/2017

About the Nursing Home

Number of Beds: 115
Number of Residents: 75
Beds Available: 40
Percent Occupancy: 65%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Both
Ownership: Non profit - Church related
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

26

Facility
19

County
15

OH
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

26

2017
6

2016
6

2015

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

6/22/2017 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Isolated : Minimal 3 9/6/2017
 
Failed To: Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. Pattern : Minimal 4 9/6/2017
 
Failed To: Allow residents the right to participate in the planning or revision of care and treatment. Isolated : Minimal 3 9/6/2017
 
Failed To: Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. Isolated : Minimal 3 9/6/2017
 
Failed To: Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Isolated : Minimal 3 9/6/2017
 
Failed To: Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. Isolated : Minimal 3 9/6/2017
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Isolated : Minimal 3 9/6/2017
 
Failed To: Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. Widespread : Potential 4 9/6/2017
 

3/31/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Allow residents the right to participate in the planning or revision of care and treatment. Isolated : Minimal 3 5/20/2016
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Minimal 3 5/20/2016
 

1/29/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. Pattern : Potential 3 3/18/2015
 
Failed To: Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Isolated : Minimal 3 3/18/2015
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

7/25/2017 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Have a program that investigates, controls and keeps infection from spreading. Isolated : Minimal 3 9/6/2017
 

5/18/2017 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Minimal 3 5/26/2017
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg OH State Avg
Number of Residents 75 58.75 77.13
Registered Nurses 0.60 0.56 0.84
Licensed Practical / Vocational Nurses 1.09 0.98 0.92
Certified Nursing Assistants 1.98 1.85 2.24
Total Staff Hours 3.67 3.39 3.99

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% OH State Avg%
of high risk long-stay residents with pressure ulcers 2 3 5
of long-stay residents assessed and appropriately given the pneumococcal vaccine 98 98 95
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 100 96 94
of long-stay residents experiencing one or more falls with major injury 2 5 3
of long-stay residents who have depressive symptoms 24 23 12
of long-stay residents who lose too much weight 4 5 7
of long-stay residents who received an antianxiety or hypnotic medication 15 21 24
of long-stay residents who received an antipsychotic medication 18 30 16
of long-stay residents who self-report moderate to severe pain 5 5 5
of long-stay residents who were physically restrained 0 0 0
of long-stay residents whose ability to move independently worsened 26 19 18
of long-stay residents whose need for help with daily activities has increased 21 17 15
of long-stay residents with a catheter inserted and left in their bladder 0 0 1
of long-stay residents with a urinary tract infection 4 2 3
of low risk long-stay residents who lose control of their bowels or bladder 44 37 42
of short-stay residents assessed and appropriately given the pneumococcal vaccine 95 85 86
of short-stay residents who had an outpatient emergency department visit 14 14 13
of short-stay residents who made improvements in function 81 81 65
of short-stay residents who newly received an antipsychotic medication 1 4 2
of short-stay residents who self-report moderate to severe pain 7 14 15
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 99 84 82
of short-stay residents who were rehospitalized after a nursing home admission 24 25 23
of short-stay residents who were successfully discharged to the community 65 64 57
of short-stay residents with pressure ulcers that are new or worsened 1 1 0