Mercy Circle

Inspectors wroteBased on observation, interviews and record review, facility failed to follow their policy and federal regulation and failed to ensure that the Daily Nursing Staffing Posting was completed appropriately. These failures have the potential to affect all 23 residents residing at the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that the medication carts were kept clean and free of loose pills, failed to ensure multi-use medications were labeled with an open date, failed to discard expired medications and failed to discard expired medication supplies. These failures have the potential to affect all 23 residents assigned to the medication cart.

Inspectors wroteBased on observations, interviews and record review, facility failed to follow their policy and federal regulation; failed to ensure that food safety is maintained during lunch serving from a steam table by staff touching ready to eat food with bare hands, wearing only one glove and not washing hands before glove applying or after glove removal; failed to follow proper sanitation practices to ensure that the dishwasher machine sanitized dishes at the proper temperature; and failed to properly contain and label open food in the freezer. These failures affected one resident (R22) and have the potential to cause foodborne illnesses for all 23 residents receiving oral nourishment in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to label and date nebulizer mask for one resident (R34). These failures affected one resident (R34) reviewed for respiratory equipment in total sample of 21 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to reconcile control substance form and maintain an accurate account of the controlled substance record for one resident (R38) reviewed for controlled substance in a sample of 21 residents.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to properly store respiratory equipment in a sanitary manner to help prevent transmission of disease and infection. This failure could potentially affect 1 (R18) resident reviewed for infection prevention and control in a sample of 21. On 04/27/2026 at 12:27PM surveyor and V2 (Director of Nursing/Infection Preventionist, DON/IP) entered R18's room and observed R18 awake in bed. A suction machine inside a plastic bag was observed laying on the floor next to a chair. An oxygen mask with oxygen tubing inside a plastic bag was observed laying on the floor next to the suction machine. Surveyor asked V2 if suction machine and oxygen mask with tubing should be on the floor and V2 said, No. V2 took suction machine and oxygen mask with tubing out of R18's room. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure that one resident (R1) had an informed signed consent prior to administering a psychotropic medication.

Inspectors wroteBased on interview and record review, the facility failed to implement and revise the resident-centered care plan for a resident with a diagnosis of urinary tract infection and hernia which affected one resident (R1) in the sample of 20 residents reviewed for care plan revision.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide showers to a resident. This failure affected one resident (R1) reviewed for ADLs (activities of daily living) in a sample size of 20 residents.

Inspectors wroteBased on observation and interview, the facility failed to have signage posted identifying a resident who has oxygen in use in the resident's room to prevent a possible hazard. This affected one resident (R12) in a total sample of 21 residents.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure kitchen staff wearing hair restraint while in the kitchen and failed to ensure frozen meats were stored six inches above the floor in the freezer. These failures have the potential to affect 22 residents in the facility who are receiving oral diet. Findings Include: On 1/23/24 at around 9:36 AM, during the initial tour in the kitchen, V15 (Utility Worker) was observed handling the dishes in the dishwashing machine area. V15 had short length hair on V15's head and was not wearing any hair restraint. At 9:49 AM, the main freezer was inspected with V14 (Director of Dining) and observed a frozen packed beef brisket and a frozen packed beef eye round on the floor under the shelving unit. V14 stated that foods should not be stored on the floor. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their policies and procedures to ensure proper infection control guideline practices are followed related to Personal Protective Equipment (PPE) was not worn prior to entering a contact/droplet isolation room for 1 (R20) out 4 residents reviewed for transmission-based precautions in sample of 12. This failure has the potential to affect all 22 residents residing in the facility. Findings Include: On 01/23/24 at 10:42 AM, surveyor noticed R20's door was closed with droplet/contact isolation sign for staff and visitor was posted on the front of R20's door. Surveyor observed V9 R20's son entered R20's droplet/contact isolation (Covid-19) room with surgical mask but without the proper Personal Protective Equipment (PPE) gown, gloves, N95 mask, and face shield. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their policies and procedures to ensure a resident received their medications according to the physician's order for 1 (R20) out of 3 residents reviewed for pharmaceutical services in a sample of 12. Findings Include: On 1/23/24 at 11:30 AM, during record review surveyor observed V20 has order for antibiotic starting from 1/18/24 to 1/22/24 for Zithromax 250 MG tablet, to give 2 tablets on the first day, then 1 tablet daily for 4 days was administered until 1/23/24. On 1/23/24 at 11:50 AM, R20 stated, R20 has received medications this morning. On 1/24/24 at 9:50 AM, V12 (Registered Nurse) stated V12 discontinued the medication (Zithromax 250mg tablet) this morning (1/24/24). V12 stated the medication was signed off in the medication administration record yesterday (1/23/24). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to (a) properly date opened multi-dose eyedrops for 1 (R9) resident and (b) ensure that medication was stored properly in the correct medication packaging and for the right resident for 2 (R2 and R9) residents. These failures could potentially affect 2 (R2 and R9) residents from one of one medication carts inspected for medication storage and labeling.