Above average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mercy Hospital Skilled Nursing Facility during CMS and state inspections, most recent first.
A facility failed to document risk assessment, informed consent, risk-benefit education, and routine maintenance for U-Rails used by several residents. One resident’s U-Rail was loose and wobbly, another’s rail was also unsecured, and staff stated the rails were not routinely maintained; records for multiple residents did not show consent or a formal U-Rail assessment, and one resident’s U-Rails appeared to have been installed in error.
A resident with Parkinson’s disease and dementia had a chair alarm used daily for falls and self-transfers, but the record lacked documented risk-versus-benefit review and consent. The resident said the alarm was loud, bothered them, and felt undignified, and staff confirmed the alarm sounded in the resident’s room rather than at the nurses’ station. Interviews also showed the alarm had been continued despite the resident’s complaints and that quarterly reassessment was expected but not consistently completed.
Improper medication administration occurred when an RN gave medications prepared by an LPN to three residents and did not remain with one resident until the medication was taken. One resident had chronic pain and hemiplegia, another had dementia and moderate cognitive impairment, and a third had a stroke history and dysphagia. The LPN documented the medications as administered, while the RN stated they should not have given medications prepared by another nurse and the DON stated this was not proper medication pass protocol.
U-Rails Installed and Used Without Documented Consent, Risk Review, or Maintenance
Penalty
Summary
The facility did not ensure that residents with U-Rails were assessed for entrapment risk before installation, that the risks and benefits were reviewed with the resident or representative, that informed consent was obtained, or that preventive maintenance was documented for the U-Rails used by four residents. The report states that the facility policy required education on risks and benefits and documentation of informed consent, but the procedure did not identify who was responsible for obtaining consent or providing the education. The bed lever instruction manual also stated the device should be regularly checked to ensure it was set up correctly and working as intended. Resident #50 had diagnoses including Alzheimer’s disease, depression, and anxiety, and the MDS documented severe cognitive impairment and that bed rails were not used. The care plan and PT documentation did not reflect U-Rails, and there was no U-Rail assessment decision tree in the record. During observations, the resident’s bed had bilateral U-Rails, and the right U-Rail moved two to three inches forward and backward when pressed and was not secure. Staff observed that the rail was crooked and wobbly, could bust off if pressed too hard, and could cause injury. Maintenance staff stated the rail was loose and bowed and needed replacement, while facility leaders stated there was no routine preventative maintenance program and that the resident should not have had the U-Rails. Resident #27 had diagnoses including anoxic brain damage, hemiplegia, and major depressive disorder, and the MDS documented moderate cognitive impairment and need for partial/moderate assistance with bed mobility. The care plan and PT records documented use of bilateral assistive U-Rails for positioning and mobility, but the U-Rail assessment forms contained no evidence of informed consent or education on risks and benefits. Observations showed the left U-Rail was loose, wobbled two to three inches, and the screws securing it to the bed frame were not secure. Staff and the resident both acknowledged the rail was loose, and staff were unable to tighten it. Resident #7 had diagnoses including spinal stenosis, history of falls, and transient cerebral ischemic attack, and was documented as cognitively intact with supervision for bed mobility. The care plan was revised to include assistive U-Rails for bed mobility, but the Kardex did not document their use and the U-Rail assessment forms showed no evidence of informed consent or education on risks and benefits. Resident #9 had rheumatoid arthritis, joint contractures, and chronic pain syndrome, with moderate cognitive impairment and dependence for bed mobility. The care plan and PT records documented bilateral assist U-Rails, but the U-Rail decision tree forms did not include consent or risk-benefit education, and staff stated they did not know whether consent was required or whether routine maintenance was being done.
Chair Alarm Used Without Documented Consent or Risk-Benefit Review
Penalty
Summary
The facility did not ensure that a resident’s right to dignity and freedom from physical restraints was protected when a chair alarm was used without documented risk-versus-benefit assessments or informed consent. Resident #30 had Parkinson’s disease and dementia, and the MDS dated 6/17/25 described the resident as moderately cognitively intact, usually understanding others and usually being understood by others. The resident’s care plan documented repeated falls and included the use of position change alarms, and physician orders directed that the chair alarm be checked each shift, but the order did not document a medical rationale. Record review showed the chair alarm was used daily and continued through multiple months, with continued-use determinations documenting self-transfers, ambulation on their own, and a history of falls as the reasons for the alarm. The report also noted that the interdisciplinary team was expected to review alarm use quarterly, yet there was a 7-month gap between assessments. During observation, the resident had a chair alarm pad on the recliner connected to an alarm box. The resident stated the alarm was loud, bothered them, and made them feel like a terrorist, and they did not want it. Staff interviews confirmed the resident had complained about the alarm and that it sounded in the resident’s room. A CNA stated the resident hated the alarm, had thrown it across the room, and had tried to pull it out of the wall. The RN unit manager stated the alarm should sound at the nurses’ station and that if it sounded in the resident’s room it could be a quality-of-life issue. The DON stated staff would expect the alarm to be removed right away if the resident complained, and that nursing or the interdisciplinary team should obtain consent for alarms from the resident or responsible party; however, the record did not show documented consent or a documented risk-versus-benefit analysis for the alarm.
Improper Medication Administration by RN and LPN
Penalty
Summary
The facility did not ensure medication administration was consistent with professional standards of care for three residents during a standard survey. The facility policy dated 10/24/24 stated nurses must only administer medications they have personally prepared and must remain with the resident until the medication has been taken. During observation, RN #2 administered medications to Resident #20, Resident #77, and Resident #1 even though the medications had been prepared by LPN #4. For Resident #20, who had chronic pain, hemiplegia, polyneuropathy, and was cognitively intact, RN #2 applied topical medication and then gave a medication cup containing multiple scheduled medications that LPN #4 had documented as administered. For Resident #77, who had dementia, macular degeneration, and anxiety disorder with moderate cognitive impairment, RN #2 delivered a cup of blue liquid medication to the resident and walked away without observing the resident take it, while LPN #4 documented the sodium fluoride as administered. For Resident #1, who had a history of cerebral infarction, dysphagia, and anxiety disorder and was cognitively intact, RN #2 was observed in the resident’s room with a medication cup containing medications and applesauce while LPN #4 walked away from the medication cart. LPN #4 documented administration of buspirone, acetaminophen, and baclofen at that time, but RN #2 stated they should not have administered medications prepared by another nurse and denied giving the resident medications. RN #2 also stated they should not have administered Resident #20’s and Resident #77’s morning medications because those medications were prepared by LPN #4. LPN #4 stated they were the assigned medication nurse, had documented medications as administered even though RN #2 helped with the medication pass, and could not verify whether RN #2 actually administered the medications to Residents #1, #20, and #77. The DON stated nurses should not administer medications prepared by another nurse because that was not proper medication pass protocol.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Lackawanna
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Safire Rehabilitation Of Southtown, L L C | 0.6 mi | ★★★★★ | 16 | 0 |
| Seneca Health Care Center | 2.1 mi | ★★★★★ | 1 | 0 |
| Garden Gate Health Care Facility | 4.8 mi | ★★★★★ | 0 | 0 |
| Highpointe On Michigan Health Care Facility | 5.5 mi | ★★★★★ | 2 | 0 |
| Ellicott Center For Rehabilitation And Nursing | 5.6 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.