Mercy Circle

Inspection findings

1. Apr 30, 2026 Fire Safety · 11 findings
   • Not serious Scope/severity F

     E0022 Emergency Preparedness Deficiencies

     Establish policies and procedures for sheltering.

     Corrected May 5, 2026 · CMS fire safety

   • Not serious Scope/severity F

     E0037 Emergency Preparedness Deficiencies

     Establish staff and initial training requirements.

     Corrected May 5, 2026 · CMS fire safety

   • Not serious Scope/severity F

     E0041 Emergency Preparedness Deficiencies

     Implement emergency and standby power systems.

     Corrected May 1, 2026 · CMS fire safety

   • Not serious Scope/severity D

     F0695 Quality of Life and Care Deficiencies

     Provide safe and appropriate respiratory care for a resident when needed.

     Corrected May 29, 2026 · CMS health inspection

   • Not serious Scope/severity F

     F0732 Nursing and Physician Services Deficiencies

     Post nurse staffing information every day.

     Corrected May 29, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected May 29, 2026 · CMS health inspection

   • Not serious Scope/severity F

     F0761 Pharmacy Service Deficiencies

     Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

     Corrected May 29, 2026 · CMS health inspection

   • Not serious Scope/severity F

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected May 29, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected May 29, 2026 · CMS health inspection

   • Not serious Scope/severity F

     K0345 Smoke Deficiencies

     Have approved installation, maintenance and testing program for fire alarm systems.

     Corrected May 1, 2026 · CMS fire safety

   • Not serious Scope/severity E

     K0923 Gas, Vacuum, and Electrical Systems Deficiencies

     Have proper medical gas storage and administration areas.

     Corrected Apr 30, 2026 · CMS fire safety

2. Sep 18, 2025 Health · 3 findings
   • Not serious Scope/severity D Complaint

     F0605 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

     Corrected Oct 9, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0656 Resident Assessment and Care Planning Deficiencies

     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

     Corrected Oct 9, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0677 Quality of Life and Care Deficiencies

     Provide care and assistance to perform activities of daily living for any resident who is unable.

     Corrected Oct 9, 2025 · CMS health inspection

3. Feb 6, 2025 Health · 5 findings
   • Not serious Scope/severity D

     F0695 Quality of Life and Care Deficiencies

     Provide safe and appropriate respiratory care for a resident when needed.

     Corrected Feb 20, 2025 · CMS health inspection

   • Not serious Scope/severity F

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Feb 26, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0363 Smoke Deficiencies

     Install corridor and hallway doors that block smoke.

     Corrected Feb 21, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0372 Smoke Deficiencies

     Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

     Corrected Feb 21, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected Feb 21, 2025 · CMS fire safety

4. Jan 26, 2024 Health · 5 findings
   • Not serious Scope/severity D

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Feb 14, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0761 Pharmacy Service Deficiencies

     Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

     Corrected Feb 14, 2024 · CMS health inspection

   • Not serious Scope/severity F

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Feb 14, 2024 · CMS health inspection

   • Not serious Scope/severity F

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Feb 14, 2024 · CMS health inspection

   • Not serious Scope/severity F

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected Feb 14, 2024 · CMS fire safety

5. Aug 5, 2023 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

     Corrected Aug 19, 2023 · CMS health inspection

Owners and managers (as published by CMS)

• BARRETT, JOHN — corporate director, NOT APPLICABLE, since 07/01/2023
• BARRETT, JOHN — corporate officer, NOT APPLICABLE, since 07/01/2025
• CONNELLY, KEVIN — corporate officer, NOT APPLICABLE, since 03/01/2017
• CONNELLY, KEVIN — corporate director, NOT APPLICABLE, since 03/01/2017
• CYPSER, DELORES — corporate director, NOT APPLICABLE, since 07/01/2018
• FLANAGAN, ANNA — corporate director, NOT APPLICABLE, since 07/01/2018
• HENDRICKS, GINNY — adp of the snf, NOT APPLICABLE, since 08/01/2025
• HENDRICKS, GINNY — operational/managerial control, NOT APPLICABLE, since 08/01/2025
• HOULIHAN, NANCY — corporate officer, NOT APPLICABLE, since 07/01/2025
• HOULIHAN, NANCY — corporate director, NOT APPLICABLE, since 07/01/2025
• JOHNSON, MARGARET — corporate director, NOT APPLICABLE, since 07/01/2017
• KNIGHTLY, EILEEN — corporate director, NOT APPLICABLE, since 07/01/2025
• LACHOWICZ, FRANCES — operational/managerial control, NOT APPLICABLE, since 03/17/2025
• LACHOWICZ, FRANCES — adp of the snf, NOT APPLICABLE, since 03/17/2025
• LACHOWICZ, FRANCES — corporate director, NOT APPLICABLE, since 03/17/2015
• O'CALLAGHAN, DARLENE — corporate officer, NOT APPLICABLE, since 07/01/2023
• O'CALLAGHAN, DARLENE — corporate director, NOT APPLICABLE, since 11/01/2019
• PALER-DOMINGUEZ, CAROLYN — adp of the snf, NOT APPLICABLE, since 10/20/2025
• SHEEHAN, CAROLYN — corporate director, NOT APPLICABLE, since 07/01/2023
• WALTON, JOHN — corporate director, NOT APPLICABLE, since 07/01/2025
• SISTERS OF MERCY OF THE AMERICAS, INC — 5% or greater security interest, NOT APPLICABLE, since 06/01/2022
• TRINITY CONTINUING CARE SERVICES — operational/managerial control, NOT APPLICABLE, since 09/01/2013
• TRINITY CONTINUING CARE SERVICES — adp of the snf, NOT APPLICABLE, since 07/15/2025
• TRINITY SENIOR SERVICES MANAGEMENT — adp of the snf, NOT APPLICABLE, since 07/02/2025
• TRINITY SENIOR SERVICES MANAGEMENT — operational/managerial control, NOT APPLICABLE, since 09/01/2025