Benedictine Living Community Mother of Mercy

In the surveyor’s words

From the most serious findings on record at Benedictine Living Community Mother of Mercy, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jun 4, 2026

  Based on interview and document review the facility failed to implement interventions to reduce the risk of falls for 1 of 3 residents (R1) reviewed for accidents and supervision. R1's care plan directed bed mobility with assistance of two staff. On 5/4/26, R1 fell out of her bed while one staff provided cares without assistance. This resulted in R1's left hip fracture, pain, and fear. The immediate jeopardy (IJ) began on 5/4/26 when nursing assistant (NA)-A provided cares, including bed mobility, without the assistance of another staff person. R1's care plan, dated 4/28/26, directed assistance of two staff for bed mobility. The IJ was removed on 5/5/26 when the facility provided education to staff regarding following care plans, audits to monitor staff performance and policy review. […]

• Immediate jeopardy, isolatedF760Aug 31, 2022

  Based on interview and document review, the facility failed to ensure residents were free of significant medication errors for 1 of 3 residents (R1) who did not receive his anticoagulation medication. This deficient practice resulted in an immediate jeopardy situation (IJ) for R1 who suffered a [CONDITION(S)] ([CONDITION(S)]) and subsequent death as a result of the medication errors. The immediate jeopardy began on [DATE], when R1 did not receive his scheduled dose of [MEDICATION(S)] (an anticoagulant medication, prescribed to prevent blood clots). In addition, R1 had not received his scheduled [MEDICATION(S)] on [DATE], [DATE], [DATE], for a total of four days. […]

• Actual harm, isolatedF689May 12, 2026

  Based on observation, interview and document review, the facility failed to assess the independent use of an electric lift chair for 1 of 3 residents (R1) reviewed for accidents. This resulted in actual harm when R1 attempted to self-transfer from the lift chair, fell, hit her head, and sustained a hematoma (a collection of blood in the tissues after an injury) and laceration of the forehead, sent to the emergency department (ED) for further evaluation, wound care, pain control, and received four stitches to the right forehead. R1 sustained an additional fall from a wheel chair, hit her head, sustained a hematoma to right lateral proximal (point of attachment) hip, sent to ED for further evaluation and pain control. […]

• Actual harm, isolatedF684Dec 20, 2024

  Based on interview and document review, the facility failed to monitor and implement interventions for heart failure for 2 of 2 residents (R33, R43) reviewed. This resulted in actual harm to R33 who was re-hospitalized on exacerbation of heart failure. Findings include: R33's significant change Minimum Data Set (MDS) dated [DATE], indicated R33's diagnoses included dementia, chronic diastolic congestive heart failure (CHF), diabetes, phantom limb pain (from below knee amputation), and cellulitis (bacterial infection) of left lower limb. R33's cardiology clinic note dated 2/28/24, indicated R33 presented with her family member (FM)-B for a cardiology provider visit on 2/26/24. R33 had CHF with noted congestion in lungs and reported occasional shortness of breath and lower extremity edema. […]

• Actual harm, isolatedF745Feb 17, 2023

  Based on observation, interview and document review, the facility failed to provide medically related social services for 1 of 1 residents (R23) who expressed desire to be moved to another facility. The failed practice resulted in psychosocial harm when the facility failed to follow up on recommendations R23 be assisted in finding alternate placement at a lower level of care (LOC). Findings include: R23's face sheet printed 2/17/23, indicated R23's diagnoses included Friedrich's ataxia (causes difficulty walking, loss of sensation in arms and legs and impaired speech). R23's quarterly Minimum Data Set, dated dated dated [DATE], indicated R23 was able to communicate needs and cognition was intact. […]