Mercy Retirement & Care Center

Inspectors wroteBased on interview and record review, for one of four sampled residents (Resident 3), the facility failed to ensure care and services were provided according to professional standards of care when:a. Resident 3's multiple episodes of diarrhea, which represents a change in condition, were not reported to the physician.b. Resident 3's physician-ordered oral medications were not administered as ordered. Colace, a stool softener, was either held or refused repeatedly because of diarrhea, but loperamide, an anti-diarrheal medication, was not administered. This failure had the potential to result in delayed medical management, increasing the risk for dehydration, other serious complications and emotional distress.1. [...]

Inspectors wroteBased on observation, interview and record review, for one of four sampled residents (Resident 3), the facility failed to ensure services provided meet professional standards of care when scheduled medications were not administered in a timely manner. This failure had the potential to result in ineffective management of medical conditions. During a review of Resident 3's admission Record (AR), the AR indicated Resident 3 was admitted to the facility in December 2023 with multiple diagnoses that included major depressive disorder (persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities), depression, anxiety disorder (excessive worry, fear and nervousness), and essential hypertension (elevate blood pressure). During an interview on 9/19/25 at 1:05 p.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure accuracy, truthfulness, and completeness of information for the facility census of 51, including two of two sampled residents (Resident 1 and Resident 2) when the facility provided false and misleading information regarding Resident 2's room placement, which prevented the timely readmission of Resident 1 from the hospital. This failure resulted in lack of transparency and inconsistencies between the facility's census record and actual resident placement and reported information to surveyors. These discrepancies had the potential to compromise Resident 2's safety, delay the provision of necessary care and service, and cause a delay in Resident 1's prompt return to the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement written policies and procedures that included screening of prospective employees before being allowed to work with residents when Certified Nursing Assistant (CNA) 1's personal/character references (someone who knows you well, particularly on a personal level, to support your character, integrity, and trustworthiness) and previous employer were not contacted for screening prior to being hired. This failure had the potential to result in exposing vulnerable residents to abuse and mistreatment.

Inspectors wroteBased on interview and record review, for two of three sampled residents (Resident 1 and Resident 2), the facility failed to ensure allegations of abuse or mistreatment were reported to officials that included the State Survey Agency, Office of the Long-Term Care Ombudsman, and law enforcement officials within the required time frame. This failure had the potential to result in a lack of protection for residents alleging abuse or mistreatment.

Inspectors wroteBased on observation, interview and record review, the facility failed to prepare food in accordance with professional standards of food service safety when: 1. An opened tub of ice cream was stored in the freezer without a lid. 2. Multiple food items, stored in walk-in refrigerators # 1, were either not labeled or not dated. 3. Multiple food items, stored in walk-in refrigerators # 2, were either not labeled or not dated. These failures had the potential to result in cross-contamination and food borne illnesses.

Inspectors wrote3) During a subsequent medication pass observation o 2/11/25 at 8:36 a.m. with LVN 2, LVN 2 was observed administering Resident 14's oral medications with disposable gloves on. LVN 2 then touched Resident 14's tray table and picked up the cup of water with straw and assisted Resident 14 to drink. Using the same gloves, LVN 2 touched Resident 14's eyelids and administered the eye drops on both eyes. LVN 2 did not perform hand hygiene and did not change gloves before administering the eye drops to Resident 14. During a follow up interview on 2/11/25 at 9:10 a.m. with LVN 2, LVN 2 stated she forgot to change her gloves in between procedures. LVN 2 stated she should have removed her gloves and performed hand hygiene after she touched Resident 14's table and cup prior to administering the eye drops to Resident 14 because the gloves could have been contaminated. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for one of one sampled resident (Resident 17), when Resident 17 did not receive a routine medication called levetiracetam (anti-seizure medication)100 milligrams/milliliter (mg/ml) solution for five consecutive days according to physician's order. This failure had the potential to cause Residents 17 to have unwanted adverse effects such as seizure (abnormal electrical activity in your brain).

Inspectors wroteBased on observation, interviews, and record review, the facility failed to provide pharmaceutical services and procedures that assure accurate dispensing and administration when: 1. Resident 108's Lidoderm 5% patch (skin patch used to relieve pain) was not available on hand per physician order. 2. Resident 25's hazardous drugs (medications that pose short or long-term harm upon exposure to human via skin or inhalation) was handled by a licensed nurse without protective measures during medication administration These failures had the potential to cause physical discomfort to Resident 108 and unsafe handling of hazardous medications could pose health risk to staff and residents.

Inspectors wroteBased on interview and record review, for two of five sampled residents reviewed for unnecessary medications (Resident 4 and Resident 10), the facility failed to ensure irregularities with medication therapy identified by Consultant Pharmacist's (CP) were acted upon when: 1. For Resident 4, thyroid assessment (i.e. thyroid profile, blood test that measures the levels of hormones produced by the thyroid gland) was not done to monitor current therapy. 2. For Resident 10, pain assessment and pain level for each prn (as needed) narcotic (A substance used to treat moderate to severe pain. Narcotics are like opiates such as morphine and codeine) pain medication use was not clarified with the prescribing physician. These failures had the potential to result in delayed prevention of adverse consequences related to medication therapy.

Inspectors wroteBased an observation, interview, and record review, the facility failed to ensure two of four sampled residents (Resident 37 and Resident 108) received medications without an error. The facility's medication pass observation during the survey resulted in two errors out of 31 opportunities and indicated a medication error rate of 6.45 percent (%). This failure placed Resident 37 and Resident 108 at risk for not getting the full therapeutic effect of their prescribed medications and had the potential to result in undesired health care outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe medication storage and labeling practices with census of 49 when: 1. A box of opened thickened lemon-flavored water did not have an open date and time and was stored in room temperature. 2. The medication cart#2 had oral, eye drops, injectable solution (administered into the body using a needle and syringe), and suppositories (a medication that is inserted into the rectum, vagina, or urethra) medications were stored together. These failed practices could contribute to unsafe use of biologicals and medications and had the potential for medication error.

Inspectors wroteBased on interview and record review, for one of one sampled resident (Resident 10), reviewed for smoking, the facility failed to honor the resident's right to self-determination when Resident 10 was told to stop smoking effective 2/19/25 or Resident 10 will be discharged to another facility. This failure had the potential to result in emotional distress.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a Finger Contracture Cushion (a fabric cushion made of breathable and absorbent material, with three large loops in the middle for: index, middle and third finger, and two tight rings on both ends. The cushion is used to separate the fingers and protect the palm), commonly known as a hand roll, was placed correctly on one of three sampled residents ' (Resident 1) left hand. Resident 1 was left unattended and unsupervised, when his pinky finger was tightly inserted in the last ring of the cushion, for over seven hours. This failure resulted in Resident 1 sustaining an injury to the left pinky finger, as evidenced by purplish discoloration, pain, bleeding, an open wound, and a transfer to the acute care hospital for further care.

Inspectors wroteBased on interview and record review, for one of three sampled residents (Resident 1), the facility failed to follow a written policy on permitting residents to return to the facility when Resident 1, who was transferred to the hospital on [DATE] and continued to require services provided by the facility, was not allowed to return on [DATE]. This failure resulted in an unnecessary hospital stay for nine days from [DATE] to [DATE].

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain safe water temperature for facility residents when hot water temperature from faucets in 31 of 31 bathrooms in resident rooms, and one of one resident shower room measured between 134 to 151.5 degrees Fahrenheit (°F). The facility had 26 of 56 residents (Residents 1, 2, 3, 7, 10, 16, 18, 19, 22, 27, 28, 30, 32, 33, 36, 37, 38, 42, 43, 47, 50, 52, 53, 58, 313, and 365) who were mobile and able to access bathroom faucets. Facility's residents and direct care staff were unaware of water boiler (a tank that heats water) malfunction and unsafe water temperature, even after identifying the issue, for three days. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to identify, monitor, and intervene for weight loss of seven (7) pounds (lbs.), 5.6% in one month, for one of two sampled resident (Resident 8) for more than one month. This failure resulted in Resident 8 to not receive an assessment and intervention to prevent further weight loss for one month and Resident 8 lost 1.8 more lbs. during that period. Resident 8 had a severe weight loss of 13.4 lbs. with a percentage of 10.31% within a period of three (3) months. Resident 8 was at risk for continued weight loss, weakness, malnutrition (not getting proper/enough nutrients for the body) such as protein calorie malnutrition, and decline in functional status.

Inspectors wroteBased on observation, interview, and document review, the facility failed to store, prepare, and serve food in a safe and sanitary manner when: 1. A blender was dirty 2. The chopper was not maintained in good condition. 3. Dry cereal was kept beyond use-by date. These failures had the potential to result in food-borne illnesses to 52 residents who receive food from the kitchen out of a facility census of 56

Inspectors wroteBased observation, interview, and record review, the facility failed to provide a homelike environment for two of four sampled residents (Residents 46 and 53) when the door to facility's designated smoking area was propped open and smoke entered the hallway outside Resident 46 and 53's rooms. This failure resulted in an unhomelike environment and placed Residents 46 and 53 at risk for exposure to second-hand smoke (smoke inhaled involuntarily from tobacco being smoked by others).

Inspectors wroteBased on interview and record review, the facility failed to ensure two of three sampled residents (Resident 20 and Resident 47) received a Quarterly Minimum Data Set (MDS- an assessment used to track resident's status to plan care in between comprehensive assessments to ensure indicators of gradual changes are monitored) assessment. This failure resulted in Resident 20 and Resident 47 to not receive an assessment for over three months and placed them at risk for unidentified changes in health status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure staff performed hand hygiene when entering, exiting resident room, cleaned reusable blood pressure monitoring cuff in-between residents for three (Resident 46, Resident 314, and Resident 18) out of 21 sampled residents. 2. Ensure licensed staff performed hand hygiene when administering medications to resident 31 via G-tube (a tube inserted through the walls of the abdomen into the stomach to give medicine, fluids, and food) after touching resident and resident surroundings 3. Ensure nebulizer (a machine that turns liquid medication into a mist to be inhaled) tubing was dated and labeled for Resident 46 These failures had the potential to result in: Spreading infection which could result in hospitalization.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of two sampled residents (Resident 365) assessed and treated for 2+ pitting edema (swollen part of the body due to excess watery fluid that gets a dimple or a pit up to four millimeters when it's pressed for a few seconds) on both lower extremities for a period of seven days. This failure had the potential for Resident 365's both legs edema to get worsened and to suffer from related complications such as Fluid Overload (a medical condition with excessive accumulation of fluids in body's tissues and organs), Heart Failure (HF- when the heart is unable to pump blood efficiently), Deep Vein Thrombosis (DVT- a blood clot that forms in one of the deep veins in the body, usually in the legs).

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly store all medications for one of 21 sampled residents (Resident 56). For resident 56, one lidocaine patch (a patch placed on the skin generally used to help relieve nerve pain), was found on the bedside table. This deficient practice did not ensure medication was kept secured and had potential for medication errors.

Inspectors wroteBased on interview and record review, the facility failed to ensure a complete and accurate direct care staffing data was submitted to Centers of Medicare and Medicaid Services (CMS) for first quarter (10/2022 till 12/2022) of Federal Fiscal Year (FFY) 2023 (FFY starts on October 1st and ends on September 30th every year). This failure resulted in lack of reporting of facility's direct care staffing data as required by CMS.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper sanitation and food storage practices when: a. One staff member and one vendor representative did not wear hairnets while in the kitchen; b. Five black rubber floor mats were on a food prep table; c. Refrigerator 1 did not have a thermometer on the inside; d. Refrigerator 2 had two containers of yogurt with an expiration date of 1/29/2020; e. Five spice containers did not have a use by date or an expiration date, and; f. A fluffy, gray material was on the filter cover of one ice machine. These failures had the potential to result in foodborne illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain their infection prevention and control program when: 1. Dietary Staff (DS) 1 and DS 2 did not perform hand hygiene (hand washing, antiseptic hand wash, or alcohol, based hand rub) and change gloves between dirty and clean tasks during meal service, 2. Licensed Vocational Nurse (LVN) 4 did not perform hand hygiene and change gloves during medication pass, and; 3. LVN 3 did not perform hand hygiene between dirty and clean tasks during wound care. These failures had the potential to result in the spread of infection.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a care plan for Resident 22's use of escitalopram (an antidepressant medication) and quetiapine (medication for a severe chronic mental disorder). For Resident 22, this failure had the potential to result in unrecognized and unmet needs in relation to the effectiveness of the medications used to treat depression and a severe chronic mental disorder.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure services two of 15 sampled residents (Resident 44 and Resident 34) received services to maintain their ability to communicate when staff did not provide Resident 44 and Resident 34 their hearing aids. This failure resulted in Residents 44 and 34 experiencing feelings of frustration.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of fifteen sampled residents (Resident 5) maintained hydration when Resident 5's fluid intake and output was not monitored as ordered by the physician. For Resident 5, this failure had the potential to result in unrecognized dehydration and delayed treatment.