Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Retirement & Care Center during CMS and state inspections, most recent first.
A resident with leukemia, severe sepsis, acute kidney failure, and malnutrition experienced ongoing diarrhea with several large loose stools per day and reported feeling punished and mistreated by staff related to frequent bathroom use. Physician orders directed Colace BID, to be held for loose stools, and PRN loperamide after each loose stool, but review of the MAR showed that Colace doses were repeatedly held on multiple days without administration of loperamide. Nursing staff acknowledged the resident continued to have loose stools, that Colace and Ensure were on hold, and that no care plan addressed the diarrhea. The DON confirmed there was no documentation that the physician was notified of the repeated loose stools as a change in condition, despite facility policy requiring physician notification when medications are refused two or more consecutive times.
A resident with multiple chronic conditions did not receive scheduled medications, including antihypertensives and supplements, within the required time frame due to unfamiliarity of new nursing staff with the medication routine. The resident reported delays and inconsistencies, and review of the MAR showed missed and late doses, as well as elevated blood pressure readings. Facility policy requiring timely and accurate medication administration was not followed.
The facility did not complete required reference checks for a CNA before hire, despite policy requiring screening for abuse, neglect, and mistreatment history. After hire, the CNA received multiple complaints from staff and residents, including rough care, poor attitude, and failure to respond to call lights. The lack of reference checks was confirmed by both HR and leadership, and the issue was identified during review of the CNA's employment file and interviews with staff and residents.
Two residents with significant care needs reported incidents of rough care and verbal mistreatment by a CNA. The DSD delayed interviewing the CNA and did not report the allegations to the State Survey Agency, Ombudsman, or law enforcement within the required timeframe, instead waiting until after speaking with the CNA. Both incidents were reported several days after the initial allegations, contrary to facility policy requiring immediate reporting.
The facility failed to follow professional food service safety standards, with an opened tub of ice cream stored without a lid and multiple food items in refrigerators not labeled or dated. These practices violate the facility's policy and could lead to cross-contamination and foodborne illnesses.
The facility failed to follow infection control procedures during medication administration and in droplet precaution rooms. An LVN did not change gloves or perform hand hygiene between tasks, risking contamination. Additionally, staff did not wear appropriate PPE in droplet precaution rooms, increasing the risk of infection spread.
A facility failed to honor a resident's right to self-determination by enforcing a new smoke-free policy, requiring the resident to stop smoking or face discharge. The resident, who had been living at the facility since 2016, was informed of the policy change and its consequences, despite having a history of smoking and a preference for going outside. The facility's actions led to a deficiency in respecting the resident's rights and preferences.
A resident with epilepsy did not receive their prescribed anti-seizure medication, levetiracetam, for five days due to a transition to an EHR system, where the medication order was marked as pending confirmation. The DON confirmed the medication was an active order, but it was not included in the resident's scheduled medications, leading to a lapse in care.
A facility failed to provide proper pharmaceutical services, resulting in a resident not receiving a prescribed Lidoderm patch due to insurance and delivery issues, while an LVN incorrectly documented a refusal. Additionally, hazardous drug handling protocols were breached when an LVN handled finasteride without gloves, posing health risks. The facility's policies for medication administration and safety were not followed, leading to these deficiencies.
The facility failed to act on the Consultant Pharmacist's recommendations for two residents. One resident did not receive necessary thyroid assessments to monitor Levothyroxine therapy, while another resident's pain levels were not documented for PRN narcotic use. The facility did not follow its policy to address these medication therapy irregularities.
Two residents in an LTC facility experienced medication administration errors. One resident with congestive heart failure received pantoprazole after breakfast instead of before, potentially reducing its effectiveness. Another resident with chronic kidney disease did not receive a prescribed Lidoderm patch due to unavailability, and the LPN failed to notify the pharmacy or doctor. The facility's medication error rate was 6.45%, exceeding the acceptable threshold.
The facility failed to ensure proper medication storage and labeling, with an opened box of thickened lemon-flavored water stored at room temperature and various medications stored together in a medication cart without separation by administration route. This practice did not align with the facility's policies and could lead to medication errors.
A resident with a left-hand contracture was injured due to improper placement of a Finger Contracture Cushion, resulting in a severe injury to the pinky finger. The resident was left unattended for over seven hours with the finger tightly inserted in the cushion's ring, leading to discoloration, pain, and an open wound. Staff interviews revealed a lack of awareness and understanding of the proper use of the hand roll, contributing to the oversight.
Failure to Manage and Report Resident Diarrhea and Follow PRN Medication Orders
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services according to professional standards and physician orders for a resident with acute myeloblastic leukemia, severe sepsis, acute kidney failure, and malnutrition. The resident, who had a BIMS score indicating moderately impaired cognition, reported ongoing diarrhea with up to three large loose stools in 24 hours and stated feeling punished due to staff frustration with frequent bathroom use. The physician’s orders included Colace 100 mg, two capsules by mouth twice daily, to be held for episodes of loose stool, and loperamide 2 mg by mouth as needed after each loose stool, with a maximum of 8 mg in 24 hours. Review of the MAR and progress notes for March showed that the 9 a.m. Colace dose was held for loose stools on multiple dates, and both 9 a.m. and 5 p.m. doses were held on additional dates, yet loperamide was not administered on any of those occasions. The resident also reported refusing Colace because it worsened already loose stools. The facility also failed to recognize and report the resident’s multiple episodes of diarrhea as a change in condition to the physician. The DON confirmed there was no documentation that the physician was informed of the repeated loose stools between early February and late March, despite acknowledging that multiple episodes of diarrhea represent a change of condition requiring prompt reporting. RN 1 stated the resident continued to have loose stools and that Colace and Ensure were on hold, but there was no care plan in place for the diarrhea. LVN 1 stated that multiple diarrhea episodes require a change of condition report and that he would not have known about the loose stools unless they were documented in the 24-hour report. The facility’s policy on change in a resident’s condition or status indicated that the nurse should notify the attending physician when a resident refuses a medication two or more consecutive times. Social services notes documented that the resident felt mistreated by a CNA during care, particularly in response to several episodes of diarrhea.
Failure to Administer Scheduled Medications Timely
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including major depressive disorder, anxiety disorder, and essential hypertension, did not receive scheduled medications in a timely manner. The resident reported having to ask repeatedly for medications, and new nursing staff were unfamiliar with the medication administration routine. Observation confirmed that the resident had not received morning medications, including carvedilol, aspirin, ferrous sulfate, multivitamins, and vitamin C, as scheduled. The registered nurse on duty admitted to missing the scheduled administration time due to being new and unfamiliar with the shift routine. Review of the Medication Administration Record (MAR) showed that the resident's blood pressure readings were elevated on several occasions, and that medications were not administered within the facility's required two-hour window. The Director of Staff Development confirmed that delays in medication administration could result in medical conditions not being addressed promptly. Facility policy requires medications to be administered safely, accurately, and in a timely manner, adhering to the six rights of medication administration, which was not followed in this instance.
Failure to Conduct Required Employee Reference Checks Prior to Hire
Penalty
Summary
The facility failed to develop and implement written policies and procedures for screening prospective employees, specifically by not conducting reference checks for a Certified Nursing Assistant (CNA) prior to hire. Although the CNA's employment application listed a former employer and three personal references, Human Resources did not require or complete reference checks, despite the facility's policy stating that all potential employees should be screened for a history of abuse, neglect, exploitation, or mistreatment, including attempts to obtain information from previous employers and references. The Assistant Executive Director confirmed that reference checks were still required and should have been completed by the Director of Staff Development. Following the CNA's hire, multiple complaints were documented regarding the CNA's work performance and behavior, including discrepancies in vital sign documentation, refusal to follow infection control protocols, use of personal devices during work hours, and reports from residents and staff of rough or non-caring behavior and failure to respond to call lights. One resident with moderate cognitive impairment and dependence on renal dialysis reported rough and aggressive care, while another resident filed a grievance about delayed response to call lights. Staff interviews corroborated concerns about the CNA's attitude and lack of responsiveness.
Failure to Timely Report Alleged Abuse and Mistreatment
Penalty
Summary
The facility failed to ensure that allegations of abuse or mistreatment involving two residents were reported to the appropriate authorities within the required timeframe. One resident, admitted with anxiety disorder and requiring assistance with personal care, reported during a resident council meeting that a CNA was rough and aggressive during perineal care. The Director of Staff Development (DSD) did not interview the CNA until four days after the allegation was made, waiting until the CNA was next scheduled to work. The incident was not reported to the State Survey Agency, Long-Term Care Ombudsman, or law enforcement until nine days after the initial report. A second resident, admitted with dependence on renal dialysis and muscle weakness, filed a grievance alleging that the same CNA pointed a finger and made a dismissive comment after the resident expressed frustration over a delayed response to a call light. The DSD received this grievance the day after the alleged incident but delayed interviewing the CNA for two days, again waiting until the CNA was scheduled to work. Both incidents were reported to the required authorities only after the DSD had spoken with the CNA, contrary to the facility's policy, which requires immediate reporting, but not later than two hours after an allegation is made.
Deficiencies in Food Storage and Labeling Practices
Penalty
Summary
The facility failed to adhere to professional standards of food service safety, as observed during a survey. An opened tub of ice cream was found in the freezer without a proper lid, covered only with brown parchment paper. Kitchen staff indicated that the lid was being washed and later admitted they could not find it, opting to temporarily cover the ice cream with paper. This practice does not align with the facility's policy, which requires all opened food items to be properly closed and labeled. Additionally, multiple food items in walk-in refrigerators #1 and #2 were not labeled or dated, which is a violation of the facility's policy. In refrigerator #1, a pan of brown-colored puree food was loosely covered and unlabeled, and several opened boxes of food items lacked opened-on dates. In refrigerator #2, various opened bags of cheese were found without opened-on dates. The Registered Dietician acknowledged these issues and removed the opened bags of cheese, indicating they would be discarded. These lapses in food storage practices have the potential to lead to cross-contamination and foodborne illnesses.
Infection Control Lapses in Medication Administration and PPE Use
Penalty
Summary
The facility failed to adhere to infection prevention and control procedures during medication administration and while managing residents under droplet precautions. On February 11, 2025, a Licensed Vocational Nurse (LVN) was observed administering oral medications to a resident without changing gloves or performing hand hygiene between tasks. The LVN touched the resident's tray table and assisted with drinking before administering eye drops, all without changing gloves, which could lead to contamination. The Director of Nursing (DON) confirmed that the LVN should have changed gloves and performed hand hygiene to prevent the risk of bacterial infection. Additionally, multiple staff members did not wear appropriate Personal Protective Equipment (PPE) in droplet precaution rooms, which are necessary to prevent the spread of infections like the flu. A Housekeeping Aide entered a resident's room, which had signage indicating droplet precautions, without wearing a face shield or protective eyewear. Similarly, a Certified Nursing Assistant (CNA) was observed providing care to a resident in a droplet precaution room with only a mask, which was improperly worn. The Infection Preventionist confirmed that the CNA did not follow the facility's infection control protocol for droplet precautions.
Facility Fails to Honor Resident's Right to Self-Determination in Smoking Policy
Penalty
Summary
The facility failed to honor a resident's right to self-determination by enforcing a new smoke-free policy that required the resident to stop smoking or face discharge. The resident, who had been living at the facility since January 2016, was informed on January 19, 2025, that smoking would not be allowed effective February 19, 2025, and non-compliance would result in discharge. The resident expressed feelings of unfairness due to the sudden change in policy after being a long-term resident. The facility's administrator confirmed the issuance of a letter to the resident, stating the new policy and the consequences of non-compliance, but acknowledged that the resident should be grandfathered in due to their long-standing smoking habit prior to the policy change. The resident's Minimum Data Set (MDS) indicated an intact cognitive status with a Brief Interview for Mental Status (BIMS) score of 15, and a preference for going outside to get fresh air. The facility's Smoke Free Policy, revised on January 10, 2025, required a 30-day notice for residents who were smokers before the policy's implementation. The resident's Safe Smoking Assessment allowed for independent or unsupervised smoking in designated areas, which were no longer available under the new policy. The facility's actions led to a deficiency in respecting the resident's rights and preferences, as the resident was not accommodated under the new policy despite their long-term residency and previous smoking permissions.
Failure to Administer Anti-Seizure Medication
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for a resident diagnosed with epilepsy. The resident did not receive a routine anti-seizure medication, levetiracetam, for five consecutive days as per the physician's order. This lapse occurred after the facility transitioned to an electronic health record (EHR) system, during which the medication order was marked as pending confirmation. The Director of Nursing (DON) acknowledged that the medication should have been administered and that the order was not discontinued by the physician. The Licensed Vocational Nurse (LVN) did not administer the medication because it was not listed in the resident's scheduled medications. The DON confirmed that the medication was an active order and should have been included in the resident's medication administration record. The facility's policy and procedure on medication administration and quality of care emphasize that medications should be administered as ordered by the physician and in accordance with professional standards of practice. The failure to administer the medication as ordered had the potential to cause adverse effects, such as seizures, for the resident.
Deficiencies in Medication Administration and Hazardous Drug Handling
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate dispensing and administration of medications for its residents. Resident 108, who was admitted with chronic kidney disease and had a BIMS score indicating intact cognitive status, did not receive the prescribed Lidoderm 5% patch for pain relief. The medication was not available because it was not approved by the insurance, and the pharmacy had not delivered it due to a lack of prior authorization and a back order. Despite this, the LVN documented that the resident refused the medication, which was not the case according to the resident's statement. The Director of Nursing acknowledged that the LVN should have notified the doctor and requested an alternative medication. Additionally, the facility did not adhere to proper handling procedures for hazardous drugs. During a medication pass, an LVN handled finasteride, a hazardous drug, without wearing gloves, which is against the facility's policy. The LVN admitted to the oversight, acknowledging the potential risk of unwanted side effects from handling the medication without protective measures. The Director of Nursing emphasized the importance of wearing gloves to prevent direct exposure to hazardous drugs, which could pose significant health risks. The facility's policies and procedures for pharmacy services and handling hazardous drugs were not followed, leading to deficiencies in medication administration and safety protocols. The Consultant Pharmacist confirmed that the facility should have sought an alternative for the unavailable Lidoderm patch and highlighted the risks associated with improper handling of hazardous medications like finasteride. These failures could have resulted in physical discomfort for Resident 108 and health risks for staff handling hazardous drugs.
Failure to Act on Pharmacist's Medication Therapy Recommendations
Penalty
Summary
The facility failed to ensure that irregularities identified by the Consultant Pharmacist (CP) in the medication therapy of two residents were acted upon. For Resident 4, who had multiple diagnoses including hypothyroidism, the facility did not conduct a thyroid assessment to monitor the current therapy with Levothyroxine. Despite recommendations from the CP in November and December 2024 to perform routine thyroid profiles and other blood tests, there was no record of these tests being conducted, and no response from the prescribing physician was documented. For Resident 10, the facility did not clarify the pain assessment and pain level for each PRN narcotic pain medication use with the prescribing physician. The CP's Medication Regimen Review recommended assessing pain using a 1-10 scale and clarifying the pain level for each PRN dose. However, the Medication Record for December 2024 and January 2025 showed that oxycodone-acetaminophen was administered multiple times without documenting the pain level for each dose. The facility's policy and procedure on Medication Regimen Review and Reporting required that findings be communicated to the Director of Nursing and the Medical Director, and that recommendations be documented and acted upon within 30 days. However, the facility did not follow up on the CP's recommendations, leading to a failure in addressing the identified irregularities in medication therapy for both residents.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that two residents received their medications without error, resulting in a medication error rate of 6.45%. Resident 37, who was admitted with congestive heart failure, had an order for pantoprazole to be administered 30 minutes before breakfast and dinner. However, during a medication pass observation, the LVN administered the pantoprazole after the resident had already eaten breakfast, which could have reduced the medication's effectiveness. The LVN acknowledged the error, and the Director of Nursing confirmed the importance of administering pantoprazole on an empty stomach. Resident 108, diagnosed with chronic kidney disease, had an order for a Lidoderm patch to be applied in the morning for pain relief. During the medication pass, the LVN did not apply the patch because it was not available and did not contact the pharmacy or notify the doctor about the missing medication. The LVN incorrectly documented that the resident refused the patch, which the resident later denied. The Director of Nursing noted that the LVN failed to document the reason for the supposed refusal and should have sought an alternative from the doctor. The facility's medication administration policy requires medications to be administered as ordered and within specified time frames.
Improper Medication Storage and Labeling Practices
Penalty
Summary
The facility failed to ensure proper medication storage and labeling practices, as observed during a survey. An opened box of thickened lemon-flavored water was found on top of a medication cart at room temperature, with a handwritten date indicating it was opened five days prior. The manufacturer's instructions specified that the product should be refrigerated after opening to prevent bacterial growth. Interviews with the LVN and DON revealed a lack of awareness regarding the proper storage requirements and the correct dating of the product upon opening. The facility's policy on food storage emphasized the importance of maintaining appropriate temperatures to prevent foodborne illness, which was not adhered to in this instance. Additionally, the medication cart was found to have various medications stored together without separation by administration route. This included oral medications, eye drops, injectable solutions, and suppositories, which were all stored in the same bin. The DON acknowledged that this practice did not align with the standard of practice, which requires medications to be stored separately to prevent confusion and potential medication errors. The facility's policy on medication storage also highlighted the need for proper organization to maintain medication integrity and support safe administration.
Improper Use of Hand Roll Leads to Resident Injury
Penalty
Summary
The facility failed to ensure the proper placement of a Finger Contracture Cushion, commonly known as a hand roll, on a resident's left hand. The resident, who had a diagnosis of a left-hand contracture and was at high risk of developing skin injuries, was left unattended with the pinky finger tightly inserted in the last ring of the cushion for over seven hours. This improper placement led to the resident sustaining an injury to the left pinky finger, characterized by purplish discoloration, pain, bleeding, and an open wound, necessitating a transfer to an acute care hospital for further treatment. The incident occurred when the resident was under the care of different staff members throughout the day. The Restorative Nursing Aide (RNA) responsible for placing the hand roll was not on duty on the day of the incident. Certified Nursing Assistant (CNA) 1, who was on the morning shift, stated that she placed the hand roll on the resident's left hand but did not insert the fingers into the loops. CNA 2, who was on the evening shift, discovered the issue when she noticed the resident's discomfort and observed the pinky finger inserted in the tight ring, causing discoloration. Despite the presence of staff, the resident's condition went unnoticed for several hours. Interviews with the nursing staff revealed a lack of awareness and understanding of the proper use of the hand roll. RN 1, who was alerted by CNA 2, was unsure if the pinky finger was supposed to be in the ring and struggled to remove it safely. RN 2, the charge nurse, was unaware of the resident's need for a hand roll and did not notice its use during his shift. The progress notes documented by RN 1 indicated the severity of the injury, with the finger almost falling off and bone visible, leading to the resident's transfer to the hospital for treatment of an acute infection at the wound site.
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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 Oakland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Garfield Neurobehavioral Center | 0.6 mi | ★★★★★ | 0 | 0 |
| Fruitvale Healthcare Center | 0.6 mi | ★★★★★ | 1 | 0 |
| Bellaken Skilled Nursing Center | 0.7 mi | ★★★★★ | 1 | 0 |
| Bay Marina Post Acute | 0.7 mi | ★★★★★ | 3 | 0 |
| Oakland Heights Nursing And Rehabilitation | 1 mi | ★★★★★ | 0 | 0 |
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