Above average — CMS composite of the measures below.
The next survey window likely opens around October 2026
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 Transitional Care Services At Mercy Medical Center during CMS and state inspections, most recent first.
Failure to Document Advance Directive Offerings: The facility did not ensure that 4 sampled residents were offered the opportunity to develop an advance directive. Each resident's chart contained a MOLST in the advance directives section, but there was no documentation of advance directive discussions or that the opportunity was provided. Staff review confirmed the absence of notes from social work and chaplain services, and the NHA confirmed the findings.
Inaccurate MDS Weight Loss Coding: Facility staff failed to accurately code MDS nutrition assessments for two residents. One resident had a 13.5-lb, 13% weight difference between the acute care discharge weight and the facility admission weight, yet Section K0300 was coded no. Another resident had a 17-lb, 9% weight loss from the hospital weight to the facility weight, but Section K0300 was also coded no. The MDS Coordinator confirmed both assessments should have been coded yes.
A resident admitted with a new liver NET, COPD, HTN, and ambulatory dysfunction did not have a baseline care plan created, reviewed, or given within 48 hours of admission. The record also lacked evidence that the resident or representative received a summary of initial goals, MD orders, therapy, dietary, and social services, or a list of admission meds; the NHA could not locate documentation that the care plan had been discussed.
Failure to monitor weights for residents at risk for malnutrition. Three residents with poor PO intake and documented malnutrition diagnoses did not have follow-up weights obtained after admission. One resident had moderate acute malnutrition with poor intake and family discussion about an appetite stimulant, another had severe chronic malnutrition and reported possible recent weight loss, and a third had severe acute malnutrition with a large discrepancy between hospital and facility weights. The CNM confirmed the missing weights and stated the residents should have been reweighed.
The facility did not consistently review and update resident care plans for accuracy and current interventions. Additionally, the interdisciplinary team, including residents and/or their responsible parties, were not always invited to care plan meetings for residents who had been in the facility for 21 days or more. One case involved a resident whose care plan still included tube feeding despite the feeding tube being discontinued and no active physician orders for tube feeding. Another resident reported not attending any care plan meetings or seeing the social worker since admission, with no documentation of invitations to care plan meetings. Similar issues were identified with other residents due to communication gaps and scheduling conflicts among team members.
The facility failed to report an abuse allegation in a timely manner. A resident accused a sitter of inappropriate behavior, which was reported to a nurse who did not immediately escalate the allegation. The incident was eventually reported to the Administrator and the state agency. The nurse received re-education training after the incident.
The facility failed to initiate a care plan for a resident with a history of sexual assault allegations. The resident, who had previously made an abuse allegation at another facility, did not have a care plan upon arrival. The Administrator admitted that the responsible nurse was too busy, and it was an oversight.
The facility staff failed to treat residents in a dignified manner by improperly placing a breakfast tray in a closet, leaving urinals hanging on a trash can, and serving breakfast next to a urinal containing urine. These deficiencies were observed for two residents during the survey.
The facility failed to maintain a homelike environment, with issues such as stained ceiling tiles, discolored bathroom tiles, fluid stains on walls, and damaged drywall in resident rooms. These deficiencies were confirmed by staff and highlighted inconsistencies in the maintenance reporting process.
The facility failed to notify two residents, their representatives, and the ombudsman in writing of the reason for their transfer to the hospital. The Administrator confirmed that no written notifications were provided, and no transfer summaries were available for review.
The facility failed to notify residents or their representatives in writing of the bed-hold policy upon transfer to an acute care facility. This deficiency was identified for two residents who were hospitalized, with the Administrator confirming the absence of a bed-hold policy and written notification forms.
The facility failed to provide person-centered activities that incorporated the residents' interests, as evidenced by interviews with three residents who were unaware of any activities being offered. A Patient Service Representative confirmed the absence of activities, and the Administrator mentioned that volunteers come three times a week, but this information had not been effectively communicated to the residents.
A resident who is a vegetarian was repeatedly served meat products, despite their dietary preferences being known. The facility's process for meal preparation and distribution failed to catch the error, leading to the resident not receiving appropriate meals.
The facility staff failed to use safe food practices while preparing lunch trays and did not store edible produce properly. Molded zucchini, squash, and wilted lettuce were found in the produce refrigerator. Additionally, a food server did not change gloves after handling the undercarriage while preparing lunch plates. The Dietary Manager and Chef were informed, and the Patient Service Manager acknowledged the issues.
The facility failed to maintain accurate medical records for a resident by not updating the route of administration for Doxepin after the resident's J-tube was discontinued. Despite the resident taking medications orally, the records inaccurately documented administration via the J-tube.
The facility staff failed to maintain infection control practices, with urinals found hanging over trashcans and placed near food, and a wound vac machine on the floor. These deficiencies were confirmed by staff during surveyor rounds.
The facility staff failed to ensure the dishwasher reached the final rinse temperature of 180°F. The surveyor observed the dishwasher making a loud noise and only reaching 132°F. The Patient Service Manager and Dietary Manager confirmed the machine was broken. The Dish Machine Temperature Log showed the last documented temperature was 135°F, and it did not reach 180°F during at least one shift in March 2024.
Failure to Document Advance Directive Offerings
Penalty
Summary
The facility failed to ensure that the resident or responsible party was offered the opportunity to develop an advance directive for 4 of 4 sampled residents reviewed for advance directives. For Resident #18, the medical record showed admission following a revised lumbar decompression and diagnoses including arthritis, asthma, COPD, interstitial lung disease, and rheumatoid arthritis. Although the resident's MOLST was filed in the advance directives section, there was no documentation showing that an opportunity to formulate an advance directive was provided, and Staff #12 confirmed there were no notes documenting advance directive conversations. Similar findings were identified for Resident #2, Resident #12, and Resident #13. Resident #2 had diagnoses including sickle cell anemia, avascular necrosis of the hips with infection, seizure disorder, and SVC syndrome with DVT; Resident #12 had a new diagnosis of NET of the liver, COPD, hypertension, and ambulatory dysfunction; and Resident #13 was admitted after surgery on the left foot for arthritis and had diagnoses including end stage osteoarthritis, hypertension, and colon cancer. In each record, the MOLST was located under the advance directives section, but there was no documentation indicating the resident was offered the opportunity to formulate an advance directive. Staff #12 confirmed the absence of documentation, including social work and chaplain notes, and the NHA confirmed the surveyor's findings.
Inaccurate MDS Weight Loss Coding
Penalty
Summary
Facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded for nutrition-related weight loss for two residents. For Resident #12, the medical record showed admission weight of 90.5 lbs and a prior discharge weight of 104 lbs from the acute care setting, a difference of 13.5 lbs or 13%. The admission MDS with an ARD of 11/4/25 coded Section K0300, weight loss of 5% or more in the last month or 10% or more in the last 6 months, as no, even though the documented weight change met the criteria. The MDS Coordinator reviewed the assessment and stated Section K0300 should have been coded yes and that a re-weight should have been done. For Resident #9, the medical record showed a facility weight of 169 lbs and a hospital weight of 186 lbs, reflecting a 17-lb loss or 9%. The 11/9/25 admission MDS coded Section K0300 Weight Loss as no for loss of 5% or more in the last month. During interview, the MDS Coordinator confirmed the resident should have been coded yes in Section K0300 Weight Loss. These findings were identified during the annual survey review of residents' nutrition assessments.
Failure to Provide Baseline Care Plan Within 48 Hours
Penalty
Summary
Facility staff failed to ensure that Resident #12 had a baseline care plan created and initiated within 48 hours of admission. Medical record review showed the resident was admitted with diagnoses including a newly diagnosed NET of the liver, COPD, hypertension, and ambulatory dysfunction. The record did not contain evidence that a baseline care plan was created, reviewed, or given to the resident. The medical record also did not show that the resident or representative was offered a summary of the baseline care plan within 48 hours of admission. This summary was expected to include initial goals, physician orders, therapy services, dietary services, and social services. The record review also failed to show documentation that the resident was given a list of prescribed admission medications. During review with the surveyor, the NHA could not find a baseline care plan or documentation that it had been discussed with the resident along with the medication list.
Failure to Monitor Weights for Residents at Risk for Malnutrition
Penalty
Summary
The facility failed to thoroughly assess and monitor residents at risk for weight loss by not obtaining follow-up weights for three residents with documented poor intake and malnutrition. Resident #9 was admitted with an admission weight of 169 pounds and was assessed by dietitian as having moderate acute disease or injury related malnutrition and inadequate oral intake. The dietitian documented poor intake, recommended supplements, and later discussed adding preferred foods and an appetite stimulant with the family, but no appetite stimulant was ordered and no additional weights were obtained after the admission weight. Resident #36 was admitted with an admission weight of 125 pounds and 8 ounces and was assessed by dietitians as having severe chronic disease or condition related malnutrition, increased nutrient needs, and inadequate oral intake. One dietitian documented the resident as low risk and planned re-evaluation every 10-14 days, while another note recorded the resident guessed at a 5-pound weight loss over one week due to stress and decreased intake/appetite. The medical record contained no documented weights after admission to determine whether the resident had actually lost weight, and the Clinical Nutrition Manager stated the resident should have been assessed as high risk and re-evaluated weekly. Resident #12 was admitted with diagnoses including a newly diagnosed NET of the liver, COPD, hypertension, and ambulatory dysfunction. The admission weight was documented as 90.4 pounds, while a hospital weight from the prior day was 104 pounds. The initial nutrition assessment documented severe acute disease or injury related malnutrition with visual muscle and fat loss and less than or equal to 50% of estimated energy needs for at least 5 days, and the resident was to be re-evaluated every 5-7 days. Although the resident received a regular diet, appetite stimulant, Ensure twice daily, and vitamin supplements, the record showed no follow-up weights, and the dietitian notes repeatedly stated there were no new weights since the prior nutrition evaluation.
Care Plan Review and Interdisciplinary Team Coordination Deficiencies
Penalty
Summary
The facility failed to review and revise resident care plans for accuracy and current interventions, as well as ensure the full interdisciplinary team, including residents and/or their responsible parties, were invited to care plan meetings for residents who had been in the facility for 21 days or more. This deficiency was identified in the care of four out of 27 residents reviewed during a recertification survey. One specific case involved Resident #4, who had a care plan focused on tube feeding due to protein calorie malnutrition. However, on review, it was found that Resident #4's feeding tube had been discontinued, and there were no active physician orders for tube feeding. The care plan was not updated to reflect this change, indicating a lack of coordination and communication among the interdisciplinary team. Another resident, Resident #12, reported not attending any care plan meetings or seeing the social worker since admission. The medical record review confirmed that there was no documentation of Resident #12 or their family being invited to a care plan meeting. The facility's social worker acknowledged the oversight and attributed it to the patient being missed, highlighting a gap in communication and follow-up procedures. Additionally, Resident #13 and Resident #15 also did not have documented care plan meetings, with reasons ranging from lack of family communication to scheduling conflicts among the interdisciplinary team members.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to report allegations of abuse in a timely manner for Resident #24. The incident involved the resident accusing a sitter of inappropriate behavior when the sitter pulled the blanket down around the resident's knee area. The sitter reported the incident to the nurse (Staff #25) on 10/27/23, but the nurse did not report the allegation immediately. The nurse confirmed during an interview that she did not report the abuse allegation to anyone and acknowledged that the sitter should have been removed from the resident's care. The abuse allegation was eventually reported to the Administrator on 10/30/23 and then to the state agency. The Administrator confirmed that all allegations of abuse are to be reported immediately and that the nurse should have reported the incident right away. The facility provided re-education training to the nurse after the incident. The survey team reviewed the facility's investigation and noted that the abuse was unsubstantiated. The findings were discussed with the Administration team at the time of exit.
Failure to Initiate Care Plan for Resident with History of Sexual Assault Allegations
Penalty
Summary
The facility failed to initiate a care plan to address the specific needs of a resident with a history of sexual assault allegations. This deficiency was identified during a survey when it was found that a resident, who had previously made an allegation of abuse at another facility, did not have a care plan in place upon arrival at the current facility. The resident had presented from an outside hospital for a sexual assault forensic exam. During interviews, the Administrator acknowledged that the Minimum Data Set Nurse, responsible for creating care plans, had not completed one for the resident due to being very busy, which was admitted as an oversight by the facility. The issue was discussed with the Administration team at the time of exit.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility staff failed to treat each resident in a dignified manner by leaving a breakfast tray in a resident's closet, leaving urinals hanging on the trash can in a resident's room, and serving breakfast on a bedside table that had a urinal containing urine. For Resident #4, a breakfast tray dated 3/25/2024 was found in the closet despite the resident being NPO (nothing by mouth). Additionally, three open urinals were observed hanging on a trash can by the foot of Resident #4's bed, which the resident stated should have been kept in the bathroom. The charge nurse and the Administrator confirmed these observations and acknowledged that the breakfast tray and urinals were improperly placed. For Resident #12, a urinal containing urine was found on a bedside table alongside a breakfast tray. The resident confirmed that the urinal was on the table when staff served breakfast. The resident's nurse validated this finding and immediately removed the urinal. The Administrator was informed of these observations and acknowledged the need for staff re-education to prevent such occurrences. These deficiencies were evident for 2 of 27 residents reviewed during the survey.
Failure to Maintain Homelike Environment
Penalty
Summary
The facility failed to maintain a comfortable homelike environment as evidenced by several deficiencies observed in resident rooms. Specifically, a stained ceiling tile was found in one resident's room, discolored tile behind the commode near the trim in another resident's bathroom, fluid stains on the wall in a resident's room, and damaged drywall in another resident's room. These issues were confirmed by various staff members, including a Nursing Tech, the Director of Nursing, and the Administrator during observation rounds conducted by the surveyor. During an interview, the Director of Maintenance indicated that the facility has a ticket system for reporting maintenance issues, with staff available 24 hours a day and a preventive maintenance schedule for equipment. However, the maintenance department was not aware of the issues on the unit. Additionally, an LPN explained that maintenance problems are typically reported by nurses to the Patient Service Representative, who then submits a ticket. The LPN noted that the process can be inconsistent as they only work three days a week.
Failure to Provide Written Notification of Transfer/Discharge
Penalty
Summary
The facility failed to notify the resident, resident representative (RP), and ombudsman in writing of a transfer or discharge, including the reason for the transfer. This deficiency was identified for two residents during a recertification survey. For Resident #7, who was transferred to the hospital emergency department due to a change in mental status, there was no documentation indicating that the resident or their RP was notified in writing of the reason for the transfer. The Administrator confirmed that no written notification was provided and that the ombudsman was not informed. The only documentation available was a progress note indicating that the resident's sister was notified via telephone, but no written notice was given. Similarly, for Resident #17, who was transferred to the hospital, there was no transfer summary or discharge summary available for review. The Administrator stated that a discharge summary is sent with the patient, but no transfer summary was provided. This lack of documentation and written notification for both residents highlights the facility's failure to comply with the requirement to provide timely written notification of transfers or discharges, including the reason for the transfer, to the resident, RP, and ombudsman.
Failure to Notify Residents of Bed-Hold Policy
Penalty
Summary
The facility failed to notify residents or their representatives in writing of the bed-hold policy upon transfer to an acute care facility. This deficiency was identified during a recertification survey for two residents who were hospitalized. For Resident #7, the medical record review revealed that the resident was transferred to the hospital emergency department due to a change in mental status. Although the responsible party was notified via telephone, there was no written documentation provided regarding the bed-hold policy. The Administrator confirmed that the facility did not have a written form for notifying residents or their representatives about the bed-hold policy and that the facility did not have a bed-hold policy in place because their patients were mostly short-term stay and not Medicaid-licensed for about three years. Similarly, for Resident #17, the medical record review showed that the resident was transferred to the hospital, but there was no written notification of the bed-hold policy provided. The Administrator reiterated that the facility did not have a bed-hold policy and did not save beds for patients who were transferred out. The lack of written notification and absence of a bed-hold policy were confirmed through staff interviews and medical record reviews.
Lack of Awareness of Activities Among Residents
Penalty
Summary
The facility failed to provide person-centered activities that incorporated the residents' interests, as evidenced by interviews with three residents who were unaware of any activities being offered. Resident #13, Resident #170, and Resident #8 all verbalized not knowing that the facility offered activities. Additionally, a Patient Service Representative confirmed that there were no activities at the time. The Administrator mentioned that volunteers come three times a week to conduct activities, but this information had not been effectively communicated to the residents, particularly those who are long-term care patients.
Failure to Provide Vegetarian Meals to Resident
Penalty
Summary
The facility failed to develop, prepare, and distribute menus that reflect a resident's nutritional wishes. This deficiency was identified during a recertification survey for one resident who is a vegetarian but was repeatedly served meat products. The resident and their sister confirmed that the resident does not eat meat, yet the resident's meal ticket and the food on the tray did not match, with meat being served instead of the requested vegetarian options. The resident also mentioned that they had only seen the dietitian once since being in the facility. Interviews with the Clinical Nutrition Manager and the Patient Service Manager revealed that the facility has a process in place where a meal concierge takes meal orders from residents, which are then reviewed and modified by the diet office before being served. However, the error was not caught by the server in the kitchen or the meal concierge. The Patient Service Manager acknowledged the mistake and stated that the staff would be re-educated. The assigned dietitian for the resident's unit was informed of the issue and stated that they would follow up.
Unsafe Food Practices and Improper Produce Storage
Penalty
Summary
The facility staff failed to use safe food practices while preparing lunch trays for the Transitional Care Unit and failed to store edible produce properly in the kitchen. During an initial walk-through, the surveyor observed molded zucchini and squash, along with wilted lettuce, in the produce refrigerator. Additionally, a food server was observed preparing lunch plates without changing gloves after handling the undercarriage, which was noted on two separate occasions. The Dietary Manager and Chef were made aware of these issues, and the Patient Service Manager acknowledged the need for proper glove use and produce rotation.
Failure to Maintain Accurate Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards. This deficiency was identified during a recertification survey for one resident. Specifically, the facility staff did not update the medication administration records to reflect the correct route of administration for Doxepin after the resident's jejunostomy tube (J-tube) was discontinued. Despite the resident taking medications orally, the records inaccurately documented that the medication was administered via the J-tube, which had been removed about a week prior. This discrepancy was confirmed through observations, medical record reviews, and interviews with the resident, the Director of Nursing (DON), and the Administrator. On 3/25/2024, an initial observation revealed that the resident no longer had a J-tube and was taking food and medications orally. However, a review of the Medication Administration Record (MAR) for March 2024 showed that staff continued to document the administration of Doxepin via the J-tube. Interviews with the DON and the Administrator confirmed that the order for Doxepin should have been modified to reflect the oral route of administration. The progress notes from 3/21/2024 also validated that the resident's J-tube had been removed, and the resident was tolerating oral intake without issues. The failure to update the medication administration records led to inaccurate documentation of the resident's care.
Infection Control Deficiencies
Penalty
Summary
The facility staff failed to maintain infection control practices as evidenced by several observations. A partially filled urinal was found hanging over the trashcan in a resident's room, and the resident's wound vac machine was on the floor near the end of the bed. Another resident had a urinal on the bedside table next to cups of water and a breakfast tray, and a leg brace was observed on the floor. Additionally, a urinal was seen hanging over the trashcan in another resident's room. These deficiencies were confirmed by the Quality Assurance Director and a Nursing Tech during the surveyor's rounds. The facility administrator acknowledged that urinals should be emptied promptly and not placed near food or trashcans, and that wound vacs should be supported on the bed or a walker.
Dishwasher Final Rinse Temperature Deficiency
Penalty
Summary
The facility staff failed to ensure the dishwasher reached the final rinse temperature of 180°F. On 03/25/24 at 1:01 pm, the surveyor observed the dishwasher in the kitchen and noted it was making a loud noise, with a final rinse temperature of only 132°F. The Patient Service Manager acknowledged the machine was down before it was turned on and needed time to reach the required temperature, while the Dietary Manager confirmed the dishwasher was broken. A review of the Dish Machine Temperature Log revealed the last documented final rinse temperature was 135°F at 11:00 am on the same day. Further review indicated that during at least one shift throughout March 2024, the final rinse temperature did not reach the required 180°F.
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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 Baltimore
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Roland Park Place | 1.2 mi | ★★★★★ | 0 | 0 |
| Fayette Health And Rehabilitation Center | 1.3 mi | ★★★★★ | 23 | 1 |
| Future Care Charles Village | 1.6 mi | ★★★★★ | 30 | 0 |
| Future Care Sandtown-winchester | 1.6 mi | ★★★★★ | 2 | 0 |
| Future Care Homewood | 2 mi | ★★★★★ | 1 | 0 |
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