Mercy Circle: Care Plan Failures for UTI, Hernia - IL
The resident, identified only as R1 in inspection records to protect their identity, was admitted to the facility at 3659 West 99th Street with a list of conditions that included a urinary tract infection, a hernia, Alzheimer's disease, delirium, chronic kidney disease, benign prostatic hyperplasia, muscle weakness, difficulty walking, glaucoma, anxiety, and a malignant neoplasm of the spleen. A cognitive assessment placed R1 at the most severe level of impairment, coded 7 out of 7 for daily decision-making, meaning R1 could not advocate for their own care or flag when something felt wrong.
The care plan dated August 5, 2025, contained no mention of the UTI or the hernia. Neither condition had been documented as a focus for staff monitoring.
When an inspector reviewed the record on September 18, the MDS coordinator and nurse identified in the report as V6 explained what had happened. She said she reviewed admission paperwork and the medication list, but did not read the information under the main diagnosis sheet. She said that if a resident was still being treated for a UTI at the time of transfer, it was the responsibility of the sending nurse to flag it in a handoff report. Then she added: "It is part of my responsibility to have care planned the diagnosis of UTI and Hernia."
The admission had already happened. The care plan had already been written. Nobody had gone back to revise it.
V6 described what a hernia entry in a care plan would actually accomplish: nurses could assess the site for size, monitor for pain, and report changes to the physician. For a UTI, staff would know to watch for symptoms, track adverse reactions to treatment, and conduct appropriate assessments. Without those entries, none of that guidance existed in writing for the nurses and aides working the floor.
R1 had Alzheimer's and was rated at the highest level of cognitive impairment. A resident who cannot reliably communicate pain, confusion, or worsening symptoms depends entirely on staff noticing the right things at the right times. A care plan is how a facility tells its staff what to notice.
The inspection covered a sample of 20 residents. R1 was the one found without a complete care plan.
The facility's own job description for registered nurses, though undated, states that nurses are responsible for assessing residents' needs, developing care plans, and implementing a plan of care for each resident. The facility's baseline care plan policy, dated November 2019, describes the care plan as the document that provides the minimum healthcare information necessary to properly care for each resident immediately upon admission.
The gap between those written expectations and what actually existed in R1's chart is what inspectors cited. CMS classified the deficiency at the level of minimal harm or potential for actual harm, the lower end of the severity scale. The complaint inspection was completed September 18, 2025.
What the record does not show is how long R1. went without that documented guidance, whether symptoms were missed during that window, or who, if anyone, was tracking the hernia site for changes. V6 said it was the transferring nurse's job to flag the UTI verbally. Verbal handoffs end when the conversation does. Care plans stay in the chart.
R1, with Alzheimer's severe enough to eliminate independent decision-making, could not have known the plan meant to guide their care had left out two of their diagnoses. The coordinator who wrote it had not read the page that listed them.
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.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 23, 2026 · Our methodology
MERCY CIRCLE in CHICAGO, IL was cited for violations during a health inspection on September 18, 2025.
The care plan dated August 5, 2025, contained no mention of the UTI or the hernia.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.