Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 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.
Incomplete Daily Nursing Staffing Posting: Surveyors observed the staffing post in a visible hallway location with the facility name and nursing/CNA hours filled in, but the resident census section was blank. Interviews with the ADON, Admin Services Manager, DON, and Administrator showed uncertainty about the posting requirements, and record review found the census was missing on the staffing sheets reviewed over multiple weeks.
Medication storage and labeling practices were not followed on a 3rd floor med cart and in the med storage room. An RN observed loose unidentified pills in the cart drawers, opened topical medications without open dates, and multiple expired or unreadable items, including meds and a needle supply. The DON stated that expired items should not be in the cart and that loose pills are unacceptable and cannot be properly identified.
Food safety and sanitation practices were not followed during meal service, dishwashing, and freezer storage. A server handled ready-to-eat salad items with bare hands, and another server used only one glove while cutting toast and serving food without hand hygiene before or after glove use. The dish machine final rinse was below required sanitizing temperatures, and open crab cakes in the freezer were not fully covered or dated.
A resident with pulmonary fibrosis and other diagnoses had an undated nebulizer mask found in the room during observation. The resident received daily and PRN nebulizer treatments, and the DON and an RN stated that nebulizer masks should be dated when changed or when therapy is initiated and replaced weekly or as needed for infection control.
A resident receiving phenobarbital for seizures had a controlled substance count discrepancy when the medication cart was reviewed with an RN: the declining inventory record showed 28 tablets remaining, but 27 tablets were observed. The RN stated she forgot to sign the narcotic sheet when removing the medication, and the DON stated that signing the controlled substance form is needed to ensure narcotics are accounted for.
Improper Storage of Respiratory Equipment: A resident with severely impaired cognition, vascular dementia, and dysphagia was observed with a suction machine and an oxygen mask with tubing stored inside plastic bags on the floor next to a chair. The DON/IP stated the items should not have been on the floor because it was an infection control issue and could contaminate the equipment and transfer infection to the resident.
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.
Incomplete Daily Nursing Staffing Posting
Penalty
Summary
Facility failed to follow its policy and federal regulation for Daily Nursing Staffing Posting by not completing the resident census information on the posted staffing sheets. On 4/28/2026, surveyors observed the Daily Nursing Staffing Posting displayed in the hallway by the first nursing station on the 3rd floor unit in a glass-covered cabinet. The posting was prefilled with dates from 4/26/2026 through 5/2/2026 and included the facility name and staffing hours for nurses and CNAs, but the census section was left blank for the dates shown. Interviews confirmed that V8, the Clinical Services Manager/ADON, prepared nursing schedules and provided staffing information to V9, the Administrative Services Manager, who updated the postings daily. V8 stated the posting should include the total hours worked per shift for nurses and nursing assistants, the date, the facility name, and the current census, and V8 acknowledged that the census information was missing. V9 stated that V9 was responsible for completing the forms and updating them daily, but was not familiar with the facility's Daily Nurse Staffing Posting policy and was not positive that census information was required, although V9 acknowledged the form had a place for it and that it had not been filled in. Record review showed that the staffing postings from 3/15/2026 through 4/28/2026 were missing the facility census information for each day reviewed, including the weeks of 3/15/2026 through 3/21/2026, 3/22/2026 through 3/28/2026, 3/29/2026 through 4/4/2026, 4/5/2026 through 4/11/2026, 4/12/2026 through 4/18/2026, 4/19/2026 through 4/25/2026, and 4/26/2026 through 5/2/2026. Facility documents titled Posting of Direct Care Daily Staffing Numbers required posting the facility name, date, total number and actual hours worked by licensed and unlicensed nursing staff, and resident census in a prominent location accessible to residents and visitors. The Administrator, DON, and Administrative Services Manager each stated they were not fully familiar with the staffing posting requirements, and the Administrator stated the facility was not sure if it had a policy for the posting.
Medication Cart Contained Loose Pills, Unlabeled Opened Medications, and Expired Drugs and Supplies
Penalty
Summary
Drugs and biologicals were not maintained in accordance with accepted storage and labeling practices on the 3rd floor medication cart and in the medication storage room. During observation with an RN, 12 loose unidentified pills were found in the medication drawers, along with an opened tube of Diclofenac sodium topical gel 1% and an open tube of bacitracin zinc antibiotic ointment that had no open date. The cart also contained Vitamin B1 100 mg with an expiration date of 02/2026, Omeprazole 20 mg with an expiration date that could not be read, and a tuberculosis needle with an expiration date of 01/31/25. Additional observation in the medication storage room found Aspercreme with an expiration date of 03/2026. The RN stated that loose pills should be discarded because they are trash and unsanitary, and that expired medications and supplies should not be given to residents. The DON stated that there should be no expired medications or supplies in the medication cart, that expired items should be discarded and replaced, and that loose pills are unacceptable and cannot be properly identified if they are not in their original package. The facility policy stated that expired, contaminated, deteriorated, or improperly labeled medications and biologicals should be stored separately until destroyed or returned, and that opened medications with shortened expiration dates should have the date opened recorded.
Food Safety and Sanitation Failures During Meal Service and Dishwashing
Penalty
Summary
The facility failed to follow food safety and sanitation requirements during meal service, dishwashing, and food storage. During a kitchen tour, crab cakes were observed in the walk-in freezer in a silver tray with saran wrap not fully covering the food and the crab cakes were not dated. The Director of Dining Services stated the crab cakes had been in the freezer since Friday and should have been dated. During lunch service on the third floor unit, a server assembled garden salad for a resident with bare, unwashed hands and without using gloves or serving utensils. The server touched sliced cucumber from a container of precut cucumbers with bare hands and placed it on the resident’s plate, and also placed tomato on the plate with bare hands. The resident had a BIMS score of 15, indicating intact cognition, and was on a regular diet with regular texture and consistency. The menu for that lunch included garden salad for all residents receiving regular diets. On another lunch observation, a different server wore only one glove on the left hand while handling toast and other ready-to-eat foods. The server cut toast with the ungloved right hand, removed the glove, did not wash hands after glove removal, then handled items from the refrigerator and freezer, including ice cream, with bare hands. The server again put on only one glove and continued handling ready-to-eat food and resident plates without hand hygiene before applying gloves or after removing them. Staff interviews confirmed that ready-to-eat food should not be touched with bare hands, gloves should be worn on both hands when touching food, and hands should be washed before glove use and immediately after glove removal. The dishwasher sanitation process also failed to meet required temperatures. Testing showed the wash cycle at 155 degrees Fahrenheit and the final rinse at 150 degrees Fahrenheit, while the facility policy required the final rinse to reach 180 to 194 degrees Fahrenheit. Records showed multiple April dates when the temperature-sensitive strips were gray rather than black, and the facility’s work order documentation stated the dish machine final rinse was not rising to the required temperature. The facility’s policies and staff statements identified that the dish machine was not sanitizing dishes at the proper temperature.
Undated Nebulizer Mask Found in Resident’s Room
Penalty
Summary
Provide safe and appropriate respiratory care when needed was not met when a nebulizer mask for one resident was found undated inside the resident’s nightstand. On 4/27/26 at 11:00 AM, the resident was observed in bed with the undated nebulizer mask lying inside the nightstand. The resident stated that he receives nebulizer treatments every day and as needed. The resident involved had diagnoses including pulmonary fibrosis, muscle weakness, obstructive sleep apnea, pulmonary embolism, difficulty walking, and presence of an automatic cardiac defibrillator. The resident’s BIMS score was 15, indicating cognitive intactness. The resident had active physician orders for daily albuterol nebulizer treatment and ipratropium-albuterol nebulizer treatment every 6 hours as needed for shortness of breath or wheezing. The DON stated that nebulizer masks should be dated when changed or when therapy is initiated and changed weekly or as needed for infection control. An RN stated that nebulizer masks are usually changed and dated by Sunday night shift nurses and that any visibly dirty or undated mask would be changed and dated for infection control.
Controlled Substance Count Not Reconciled
Penalty
Summary
The facility failed to reconcile the controlled substance form and maintain an accurate account of controlled substances for one resident, R38, who was receiving phenobarbital 64.8 mg by mouth once daily for seizures. During review of the 3rd floor medication cart with an RN, R38's controlled substance form showed a quantity remaining of 28 tablets, while 27 tablets were observed in the cart. R38's physician's order dated 04/21/26 documented phenobarbital oral tablet 64.8 mg, give 1 tablet by mouth one time a day for seizures. The RN stated she forgot to sign the narcotic sheet when she removed the medication and acknowledged that failing to sign out narcotics at the time of removal could create a count discrepancy and/or diversion. The DON stated that the purpose of signing the controlled substance form is to ensure all narcotics are accounted for and that failing to sign out narcotics at the time of removal could lead to a discrepancy.
Improper Storage of Respiratory Equipment
Penalty
Summary
Provide and implement an infection prevention and control program was not properly followed when respiratory equipment was observed stored in an unsanitary manner. On 04/27/2026 at 12:27 PM, the surveyor and the DON/IP entered R18's room and observed R18 awake in bed. A suction machine inside a plastic bag was laying on the floor next to a chair, and an oxygen mask with oxygen tubing inside a plastic bag was also laying on the floor next to the suction machine. When asked, the DON/IP stated the equipment should not be on the floor and removed both items from the room. R18's BIMS dated 04/10/2026 showed a score of 00, indicating severely impaired cognition. R18's face sheet listed diagnoses including vascular dementia and dysphagia, oropharyngeal phase, and the resident was admitted to hospice on 05/11/2024. The facility's Infection Control document states that it should provide a safe, sanitary, and comfortable environment and help prevent the development and transmission of disease and infection, and that the Infection Preventionist is responsible for monitoring appropriateness of precautionary procedures for individual residents.
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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| Avantara Evergreen Park | 0.7 mi | ★★★★★ | 23 | 0 |
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| Smith Village | 2.6 mi | ★★★★★ | 6 | 0 |
| Thryve Of Burbank | 2.6 mi | ★★★★★ | 6 | 0 |
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