Inspection Reports for
Mercy Retirement and Care Center

The complaint was substantiated based on observation, interview, and record review indicating missed and delayed medication administration for Resident 3.

The facility failed to ensure professional standards of care when scheduled medications were not administered timely to Resident 3, potentially resulting in ineffective management of medical conditions. Delays in medication administration were confirmed through interviews, observations, and record reviews.

The complaint investigation found that the facility provided inaccurate census information and failed to update room assignments properly, which delayed the readmission of Resident 1 from the hospital. Resident 2's room change was not executed as directed, and census records were inconsistent from 8/22/25 through 8/26/25.

The facility failed to ensure accuracy and truthfulness of census information, resulting in discrepancies in resident room assignments and delayed readmission of a resident from the hospital. The census records were not updated correctly due to errors in room changes and lack of documentation.

The investigation was triggered by complaints from residents and staff about CNA 1's rough and aggressive behavior, failure to respond to call lights, and poor attitude. The allegations were substantiated with grievances filed by residents and interviews with staff. Reporting to authorities was delayed beyond the required 2-hour timeframe.

The facility failed to develop and implement adequate employee screening policies and timely report suspected abuse. Multiple complaints were documented against a Certified Nursing Assistant (CNA 1) for poor attitude, rough care, and failure to respond to call lights. Allegations of abuse were not reported to authorities within the required timeframe.

The complaint was substantiated. Resident 10 was told to stop smoking or be discharged, which violated their right to self-determination.

The facility failed to honor Resident 10's right to self-determination by enforcing a new smoke-free policy that required the resident to stop smoking or face discharge. The resident had been a smoker prior to the policy and was given notice to comply or relocate, causing potential emotional distress.

The facility had multiple deficiencies including failure to administer medications as ordered, improper handling of hazardous drugs, failure to act on pharmacist recommendations, medication errors exceeding acceptable rates, unsafe medication storage, improper food labeling and storage, and lapses in infection prevention and control procedures.

The complaint was substantiated. Resident 1 sustained an injury due to improper placement of the hand roll, resulting in an open wound and infection requiring hospital care and antibiotic treatment.

The facility failed to ensure the hand roll was placed correctly on Resident 1's left hand, resulting in the resident's pinky finger being tightly inserted in the cushion's ring for over seven hours. This caused purplish discoloration, pain, bleeding, an open wound, and transfer to an acute care hospital for further treatment.

The complaint was substantiated as the facility did not allow Resident 1 to return after hospitalization despite eligibility and clinical readiness, violating the bed-hold policy.

The facility failed to follow its written policy by not allowing Resident 1 to return after hospitalization despite clinical readiness and eligibility, resulting in an unnecessary nine-day hospital stay. The facility lacked clarity on long-term versus short-term beds and did not have a policy defining these terms.

The facility was found deficient in multiple areas including failure to maintain a smoke-free environment, incomplete resident assessments, untreated medical conditions, unsafe hot water temperatures, inadequate nutrition monitoring, improper medication storage, unsanitary food preparation, incomplete staffing data submission, and lapses in infection control practices.

The facility was found deficient in developing and implementing care plans for medication monitoring, ensuring residents received hearing aids, monitoring hydration, maintaining food safety and sanitation, and adhering to infection prevention and control protocols including hand hygiene.