Mercy Circle

F 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure that one resident (Resident R1) had an informed signed consent prior to administering a psychotropic medication. Findings include:Resident R1 is an [AGE] year old with diagnosis including but not limited to: Alzheimer's disease, Delirium due to known physical condition, unspecified lack of coordination, difficulty in walking and essential hypertension. Resident R1 has a BIMS (Brief

Interview of Mental Status) score of 7, which indicates severe cognitive impairment. On 9/17/25 at 12:57 pm, Resident R1 was observed sitting in his room with his daughter. At that time, V9 (Resident R1's Family) said the following,

They (facility) were giving my father Trazadone and I asked that they discontinue the Trazadone because once, I came here and he (Resident R1) was very lethargic and looked like a zombie. When I asked what he had, I was told that he had Melatonin and Trazadone for sleep the previous night. Melatonin alone is just fine for my father to sleep. He is [AGE] years old. Why would they give my father both medications to sleep? I never consented for Trazadone and I am his POA (Power of Attorney).On 9/17/25 at 4:15 pm, V6 (Nurse Manager) stated the following, We do not have any psychotropic consents for Resident R1.The purpose of doing the informed consent is to let them know if there are any adverse effects to the medication and to get signed consent to give the medication.On 9/18/25 at 12:40 pm, V7 (Registered Nurse) stated the following, Resident R1 has dementia and is here for rehabilitation. His daughter (V9) is here almost daily and oversees his care. She had concerns about his sleeping medication (Melatonin) and stated that she did not want it scheduled. She (V9) also wanted the Trazodone discontinued and complained that she didn't like the way that her father looked when she visited. I don't give any psychotropic medication without consent from either the patient or

the family.Resident R1's MAR (Medication Administration Record) for the period of 8/1/25- 8/31/25 documents both Melatonin 3 mg (milligrams) and Trazadone 50 mg administered to Resident R1 on 8/6/25. Resident R1's Order Report documents the following orders that started on 8/6/24 and ended on 8/9/25: Melatonin 3 mg and Trazadone 50 mg.Facility policy titled Psychotropic medication use documents the following: Facility should comply with the Centers for Medicare and Medicaid Services (CMS) State Operations Manual Appendix PP, and all other Applicable Laws relating to the use of psychopharmacologic medications including gradual dose reductions; Facility staff should inform the resident and/or resident representative of the initiation, reason for use, and the risks associated with the use of psychotropic medications, per facility policy or applicable state regulations.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Mercy Circle

3659 West 99th Street Chicago, IL 60655

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review, the facility failed to implement and revise the resident-centered care plan for a resident with a diagnosis of urinary tract infection and hernia which affected one resident (Resident R1) in the sample of 20 residents reviewed for care plan revision. Findings include:Resident R1's admission Record documents,

in part, diagnoses of urinary tract infection (UTI), Delirium, Benign Prostatic Hyperplasia with lower urinary tract symptoms Muscle weakness, difficulty in walking, chronic kidney disease stage 3, Essential hypertension, Unspecified Glaucoma, Alzheimer's, Anxiety, Malignant neoplasm of splenic.Resident R1's Minimum Data Set (MDS), dated [DATE REDACTED], documents, in part, a Staff Assessment for Cognitive Skills for Daily Decision Making is coded at 7 which is severe cognitive impairment. Resident R1's Care Plan Report dated 8/5/2025 has no documentation stating care of UTI or hernia was observed in chart. On 9/18/25 at 10:56am, V6 ( MDS coordinator/Nurse) stated all diagnosis are care planned to ensure that staff is aware of plan of care for each resident, and 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. I reviewed Resident R1's admission paperwork, med list and diagnosis, but I do not read the information under the main diagnosis sheet, and if a resident was still being treated for UTI it is the nurse's responsibility to clarify that in nurse-to-nurse report prior to the resident transferring over to the facility. It is part of my responsibility to have care planned the diagnosis of UTI and Hernia. Hernia should be a focus on

a care plan because the nurses can assess for size and monitor for pain and be able to report off to the physician for any changes to site.Facility job description undated and titled (Registered Nurse) documents,

in part, . Position Summary: Responsible for the independent supervision of the delivery of care to a group of residents on a nursing unit. Assesses residents' needs, develops care plans, administers nursing care, evaluates nursing care, and supervises CNA and other personnel in the delivery of nursing care; Develops and implements Plan of Care for each resident.Facility policy titled Baseline Care Plan dated November 1, 2019, documents, in part, Purpose Statement: 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 community must provide the resident and representative a summary of the baseline care plan in a language and conveyed in a manner the resident and or representative can understand.2). The baseline /admission care plan will 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.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Mercy Circle

3659 West 99th Street Chicago, IL 60655

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

brushing teeth, washing/drying face, and hands, combing hair, cutting nails, shaving etc. due to Dementia, Impaired balance, and Fatigue. Intervention/Task: staff will provide [Resident R1] with sponge bath when a full bath or shower cannot be tolerated.On 9/17/2025 reviewed Resident R1's Shower/laundry/AD cleaning schedule, documents that Resident R1 is scheduled to have showers on Sundays and Wednesdays.Skin monitoring: Comprehensive CNA shower review, there were seven sheets to review with listed dates:8/6/25 bed bath completed, 8/31/25 shower completed, 9/3/25 bed bath completed, 9/12/25 refused, asked three times in front of daughter too, refused nurse too, 9/14/25 bed bath, decline shower offered bed bath,9/15/25 bed bath, given bed bath, refused shower,9/17/25 Declined shower, no new skin areas observed, bed bath offered this was signed by V8 and V7.Since admission on [DATE REDACTED] Resident R1 was scheduled to receive 13 showers and only received one shower per document. Dates of scheduled showers that were to be given are listed below:8/10/25: No document provided,8/13/25: No document provided,8/17/25: No document provided,8/20/25: No document provided,8/24/25: No documents provided,8/27/25: No documents provided,9/7/25: No document provided,9/10/25: No document provided. V7 stated that there were no documented showers for dates listed.On 9/18/2025 at 2:30 PM, V1 stated the facility does not have a specific policy for Activity of daily living or showers.Job description titled Certified Nursing Assistant, documents in part; Essential Functions: (c) Attends to the individual needs of residents, which may include assistance with grooming, bathing, oral hygiene, feeding, incontinent care, toileting, transferring, communicating or other needs in keeping with the individuals care requirements.Job description titled Registered Nurse, documents in part; Position Responsibilities: Supervise CNA.Job description titled Licensed Practical Nurse, documents in part; Position Responsibilities: Supervise CNA.

Event ID:

Facility ID:

If continuation sheet