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 Circle during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple diagnoses was given Trazodone, a psychotropic medication, without obtaining informed, signed consent from the resident's representative. The family member, who was the power of attorney, was not informed or asked for consent, and expressed concerns about the resident's condition after receiving both Melatonin and Trazodone. Facility staff confirmed that no psychotropic consent was on file, in violation of facility policy and CMS requirements.
A resident with multiple diagnoses, including UTI and hernia, was admitted with severe cognitive impairment, but the care plan did not address these conditions. The MDS coordinator/nurse confirmed that these diagnoses should have been included in the care plan to guide staff in monitoring and care, as required by facility policy and job descriptions.
A resident with severe cognitive impairment and multiple medical conditions, fully dependent on staff for ADLs, did not receive scheduled showers as required. Staff provided bed baths instead of showers due to lack of assistance and time, and documentation of showers and refusals was incomplete. The facility lacked a specific policy for ADLs or showers, and staff did not consistently communicate with the resident's POA or document refusals as required.
The facility failed to develop and implement policies and procedures for coordinating abuse, neglect, and exploitation situations within the QAPI program, potentially affecting all 23 residents. The DON could not demonstrate how the facility's abuse policy integrates with the QAPI program, and no discussions on these issues were found in the QAPI minutes.
A CNA failed to perform hand hygiene between serving meals to residents, affecting several individuals with various medical conditions. Despite initial handwashing, the CNA did not maintain hygiene between interactions, contrary to facility policy and infection control expectations. The DON confirmed the importance of hand hygiene to prevent infection spread.
A facility failed to post required signage indicating oxygen use in a resident's room, posing a potential hazard. An oxygen tank was observed in the room without a sign on the door. The resident, who has chronic obstructive pulmonary disease and other health conditions, uses oxygen as needed. The Director of Nursing confirmed the oversight, noting that staff are responsible for placing the sign according to facility policy.
Psychotropic Medication Administered Without Informed Consent
Penalty
Summary
A resident with severe cognitive impairment, Alzheimer's disease, delirium, and other medical conditions was administered psychotropic medication (Trazodone) without obtaining informed, signed consent from the resident's representative, who held power of attorney. The resident's daughter, who was actively involved in his care, reported that she had not consented to the use of Trazodone and expressed concerns about the resident's lethargy after receiving both Melatonin and Trazodone for sleep. Facility staff confirmed that there was no psychotropic consent on file for this resident and acknowledged the requirement to inform the resident or representative of the medication's risks and obtain signed consent prior to administration. Review of the Medication Administration Record showed that both Melatonin and Trazodone were administered to the resident on a specific date, and physician orders for these medications were in place for a defined period. The facility's policy requires compliance with CMS regulations regarding psychotropic medication use, including informing the resident or representative about the medication's initiation, purpose, and risks. Despite these requirements, the facility failed to secure the necessary informed consent before administering the psychotropic medication.
Failure to Implement and Revise Resident-Centered Care Plan for UTI and Hernia
Penalty
Summary
The facility failed to implement and revise a resident-centered care plan for a resident with multiple diagnoses, including urinary tract infection (UTI) and hernia. The resident's admission record documented several significant medical conditions, such as UTI, delirium, benign prostatic hyperplasia, muscle weakness, chronic kidney disease, hypertension, glaucoma, Alzheimer's, anxiety, and malignant neoplasm of the spleen. The Minimum Data Set (MDS) indicated severe cognitive impairment. Despite these diagnoses, the care plan report did not include documentation or interventions related to the care of the UTI or hernia. During interviews, the MDS coordinator/nurse acknowledged that all diagnoses should be care planned to ensure staff awareness and appropriate monitoring, especially for infections like UTI and conditions such as hernia. The coordinator admitted to not reviewing all relevant diagnosis information and stated it was their responsibility to ensure these conditions were included in the care plan. Facility policy and job descriptions require the development and implementation of individualized care plans for each resident, but this was not done for the resident in question, resulting in a deficiency.
Failure to Provide Scheduled Showers and Document Care for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident who was dependent on staff for all activities of daily living, including bathing, did not receive scheduled showers as required. The resident was observed with oily hair and food debris on clothing, and documentation showed that only one shower was provided since admission, despite being scheduled for showers twice weekly. Staff interviews revealed that bed baths were given instead of showers due to lack of assistance and time constraints, and that showers were often not documented or completed as scheduled. The resident had severe cognitive impairment, was diagnosed with multiple medical conditions including Alzheimer's, chronic kidney disease, and muscle weakness, and required total staff assistance for personal hygiene. The care plan specified that staff should provide a sponge bath when a full bath or shower could not be tolerated, but there was no consistent documentation of refusals or communication with the resident's power of attorney regarding missed showers. The nurse and CNA were responsible for documenting showers and refusals, but records were incomplete for several scheduled shower dates. Interviews with staff, including the CNA, nurse, MDS nurse, and DON, confirmed that the process for documenting and following up on shower refusals was not consistently followed. The facility did not have a specific policy for activities of daily living or showers, and the job descriptions for CNAs and nurses indicated responsibility for assisting with bathing and supervising care. The lack of documentation and follow-up led to the resident not receiving the scheduled showers and appropriate hygiene care.
Lack of Coordination Between Abuse Policy and QAPI Program
Penalty
Summary
The facility failed to develop and implement written policies and procedures that define how staff will communicate and coordinate situations of abuse, neglect, and exploitation within the Quality Assurance and Performance Improvement (QAPI) program. This deficiency has the potential to affect all 23 residents residing at the facility. A review of the facility's QAPI minutes from January 2024 through January 2025 revealed no discussion regarding abuse, neglect, and exploitation. Additionally, the facility's policy on abuse, neglect, and misappropriation of resident funds or property, revised in December 2019, does not indicate how staff will communicate and coordinate these situations within the QAPI program. During an interview, the Director of Nursing (DON) stated that the Administrator is the Abuse Coordinator, and in her absence, the DON assumes this role. The DON mentioned that the facility holds internal and external QAPI meetings, with the medical director attending all meetings. However, when asked if the facility's abuse policy coordinates with the QAPI program, the DON was unable to demonstrate this correlation in the policies. The facility's policy on resident rights guarantees residents the right to be free from abuse, neglect, misappropriation of property, and exploitation, but the integration of these rights into the QAPI program is not evident.
Failure in Hand Hygiene During Meal Service
Penalty
Summary
The facility failed to conduct proper hand hygiene prior to passing meal trays, as observed by a surveyor. On the specified date, a certified nursing assistant (CNA), identified as V4, was seen performing hand hygiene initially but then proceeded to serve multiple residents without washing hands between each interaction. This lapse in protocol was observed multiple times as V4 served food to residents R4, R12, R22, R8, R23, R7, and R11 without performing hand hygiene between each service. The CNA acknowledged the importance of using hand sanitizer or soap and water between serving residents to prevent the spread of germs. The residents affected by this deficiency included those with various medical conditions. Resident R7 had Parkinson's disease and cognitive impairment, while R11 had anxiety disorder and muscle weakness. Resident R12 was cognitively intact but had limitations due to disability, and R22 was recovering from surgery with a history of urinary tract infections. Resident R23 had a history of falling and atrial fibrillation, and R123, who was not directly observed but included in the report, had COVID-19 and chronic kidney disease. The facility's policy on hand hygiene emphasizes its critical role in reducing infection risk, requiring handwashing before and after handling food and assisting residents with meals. The Director of Nursing (DON) confirmed the expectation for staff to maintain hand hygiene between serving residents to prevent infection spread. The facility's job descriptions for the Infection Preventionist and CNA roles also highlight the importance of adhering to infection control procedures, including thorough handwashing, to ensure resident safety.
Failure to Post Oxygen Use Signage
Penalty
Summary
The facility failed to post signage indicating that oxygen was in use in a resident's room, which is necessary to prevent potential hazards. During an observation, a surveyor noted an oxygen tank in a stand on the floor of the resident's room, but there was no 'Oxygen in Use' sign on the door. The Director of Nursing confirmed that such signage should have been present and that the nursing staff is responsible for placing the sign when a resident requires and receives an order for oxygen. The resident involved has a diagnosis of chronic obstructive pulmonary disease, atherosclerotic heart disease, acute heart failure, and type 2 diabetes mellitus. The resident's cognitive status is intact, as indicated by a Brief Interview for Mental Status score of 15. The resident's care plan includes the use of oxygen via nasal cannula at 2 liters as needed. The facility's policy on oxygen administration, dated May 2008, requires an 'Oxygen in Use' sign as part of the procedure.
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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 Chicago
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avantara Evergreen Park | 0.7 mi | ★★★★★ | 4 | 0 |
| Warren Barr Oak Lawn | 1.1 mi | ★★★★★ | 3 | 0 |
| Aliya On 87th | 1.8 mi | ★★★★★ | 18 | 0 |
| Smith Village | 2.6 mi | ★★★★★ | 6 | 0 |
| Thryve Of Burbank | 2.6 mi | ★★★★★ | 18 | 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.