Federal inspectors found that Mercy Circle failed to implement proper care plans for the resident, identified as R1, despite the facility's own policies requiring such planning for all diagnoses. The resident had severe cognitive impairment and multiple serious conditions including Alzheimer's disease, kidney disease, and cancer.
The resident's admission record documented diagnoses of urinary tract infection, delirium, benign prostatic hyperplasia with lower urinary tract symptoms, muscle weakness, difficulty walking, chronic kidney disease stage 3, essential hypertension, glaucoma, Alzheimer's, anxiety, and malignant neoplasm of the spleen.
A staff assessment coded the resident's cognitive skills for daily decision making at level 7, indicating severe cognitive impairment. Yet when inspectors reviewed the resident's care plan report dated August 5, 2025, they found no documentation addressing care for the UTI or hernia.
The MDS coordinator and nurse, identified as V6, acknowledged the failures during an interview on September 18. She stated that all diagnoses should be care planned to ensure staff awareness of each resident's care needs.
"If a resident is admitted with a diagnosis of infection such as urinary tract infection this diagnosis should be care planned to ensure staff will be able to plan the care of the resident and monitor sign and symptoms and monitor for adverse reactions and be able to perform appropriate assessments," V6 told inspectors.
She admitted reviewing the resident's admission paperwork, medication list and diagnosis, but said she did not read information under the main diagnosis sheet. V6 blamed nurses for not clarifying in shift reports whether the resident was still being treated for the UTI when transferring to the facility.
"It is part of my responsibility to have care planned the diagnosis of UTI and Hernia," she acknowledged.
V6 explained that hernia care planning was particularly important because nurses need to assess for size changes and monitor for pain to report any changes to the physician.
The facility's own job description for registered nurses makes clear their responsibility for care planning. The undated document states that RNs are "responsible for the independent supervision of the delivery of care to a group of residents" and must "assess residents' needs, develops care plans, administers nursing care, evaluates nursing care."
It specifically requires nurses to "develop and implement Plan of Care for each resident."
Mercy Circle's baseline care plan policy, dated November 1, 2019, reinforces these requirements. The policy states that "the community must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident."
The policy requires providing residents and their representatives a summary of the baseline care plan "in a language and conveyed in a manner the resident and or representative can understand."
It mandates that baseline admission care plans "include information for the provision of effective person-centered care and will include the minimum healthcare information necessary to properly care for each resident immediately upon admission."
Without proper care planning, staff lacked essential guidance for monitoring the resident's UTI symptoms, watching for adverse reactions to treatments, and conducting appropriate assessments. For the hernia, staff had no instructions for assessing size changes or pain levels that could signal complications requiring physician intervention.
The resident's complex medical conditions made proper care planning particularly critical. With severe cognitive impairment from Alzheimer's disease, the resident could not communicate symptoms or changes in condition. Staff needed clear protocols for observation and assessment.
The urinary tract infection required monitoring for signs of worsening or treatment complications, especially given the resident's concurrent kidney disease and prostate problems. The hernia needed regular assessment for changes that could indicate serious complications like strangulation or obstruction.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm, affecting few residents. However, the failure exposed gaps in the facility's care planning system that could affect other vulnerable residents with complex medical needs.
The inspection occurred in response to a complaint, suggesting concerns about care quality at the facility prompted the federal review. The violation demonstrates how administrative failures in care planning can directly impact resident safety and quality of care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Mercy Circle from 2025-09-18 including all violations, facility responses, and corrective action plans.