Mercy Manor Transition Center

In the surveyor’s words

From the most serious findings on record at Mercy Manor Transition Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Jan 30, 2025

  Based on interview and record review, the facility did not ensure that each resident received, and the facility provided, care and services consistent with professional standards of practice (N6, Wisconsin Nurse Practice Act) for 1 of 4 residents (R1) reviewed for change of condition. On [DATE], R1 presented with a change of condition including weakness, abnormal lung sounds, a fever of 102.6, cough, influenza positive, and shortness of breath. As the day progressed, R1 continued to deteriorate with increased symptoms of difficulty breathing and weakness. The facility failed to complete a comprehensive nursing assessment by a registered nurse and failed to consult with a physician even as R1's condition continued to deteriorate. R1 expired at the facility on [DATE] at 11:58 PM. […]

• Immediate jeopardy, isolatedF686Feb 16, 2022

  Based on observation, interview and record review the facility did not ensure that resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers for 3 of 5 sampled residents (R1, R2, and R3). R1 was noted to be at risk for pressure injury (PI) development; R1 primarily sat up and slept in the recliner. The facility failed to ensure R1 had an intervention in place in the recliner to prevent PI development. R1 developed an unstageable, infected wound to her coccyx. The facility's failure to ensure residents at risk for pressure injuries have interventions in place to prevent development of pressure injuries created a finding of immediate jeopardy that began on 1/17/22. […]

• No harm, potential for more than minimal, widespreadF812May 30, 2024

  Based on observation, interview and record review, the facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. This has the potential to affect all 8 residents who reside in the facility. Surveyor observed a box of spoiled lemons in the refrigerator. Surveyor observed undated food in the dry storage area, in freezer (1) and the smaller freezer. Surveyor observed a staff member's personal water bottle in the food prep area. Surveyor observed chunks of rubber missing from ,d+[DATE] spatulas. Surveyor observed the flip tops of 2 garbage cans open and one large garbage can without a lid. Facility staff was observed testing the temperature of the water in the sanitizing sink. […]

• No harm, potential for more than minimal, widespreadF812Jun 7, 2023

  Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This has the potential to affect all 11 residents. Surveyor observed kitchen staff miss handwashing opportunities while preparing residents' meals. Surveyor observed food in circulation that was opened and undated. Surveyor observed a hair net not properly worn. Surveyor observed a dented can in circulation. Surveyor observed the oven was not cleaned properly. Surveyor observed no temperature logs for the refrigerator/freezer unit in the facility's dining room. This is evidenced by: Hand Washing The facility policy entitled, Hand Hygiene, revised on [DATE], states in part: Policy Statement . […]

• No harm, potential for more than minimal, widespreadF880Jun 7, 2023

  Based on interview and record review the facility did not establish and maintain an infection prevention and control program designed to provide safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This has the potential to affect 11 of 11 residents (R). Surveyor reviewed staff surveillance/call in list for three months and noted a certified nursing assistant (CNA) called in with symptoms of COVID-19 and returned to work without being tested . Surveyor noted 2 staff members had symptoms of COVID without reporting and turned out to be COVID positive while working. Facility does not provide laundry service for residents' personal laundry. Residents' families transport personal laundry home. […]