Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Transitional Care Services At Mercy Medical Center during CMS and state inspections, most recent first.
The facility did not consistently review and update resident care plans for accuracy and current interventions. Additionally, the interdisciplinary team, including residents and/or their responsible parties, were not always invited to care plan meetings for residents who had been in the facility for 21 days or more. One case involved a resident whose care plan still included tube feeding despite the feeding tube being discontinued and no active physician orders for tube feeding. Another resident reported not attending any care plan meetings or seeing the social worker since admission, with no documentation of invitations to care plan meetings. Similar issues were identified with other residents due to communication gaps and scheduling conflicts among team members.
The facility failed to report an abuse allegation in a timely manner. A resident accused a sitter of inappropriate behavior, which was reported to a nurse who did not immediately escalate the allegation. The incident was eventually reported to the Administrator and the state agency. The nurse received re-education training after the incident.
The facility failed to initiate a care plan for a resident with a history of sexual assault allegations. The resident, who had previously made an abuse allegation at another facility, did not have a care plan upon arrival. The Administrator admitted that the responsible nurse was too busy, and it was an oversight.
The facility staff failed to treat residents in a dignified manner by improperly placing a breakfast tray in a closet, leaving urinals hanging on a trash can, and serving breakfast next to a urinal containing urine. These deficiencies were observed for two residents during the survey.
The facility failed to maintain a homelike environment, with issues such as stained ceiling tiles, discolored bathroom tiles, fluid stains on walls, and damaged drywall in resident rooms. These deficiencies were confirmed by staff and highlighted inconsistencies in the maintenance reporting process.
The facility failed to notify two residents, their representatives, and the ombudsman in writing of the reason for their transfer to the hospital. The Administrator confirmed that no written notifications were provided, and no transfer summaries were available for review.
The facility failed to notify residents or their representatives in writing of the bed-hold policy upon transfer to an acute care facility. This deficiency was identified for two residents who were hospitalized, with the Administrator confirming the absence of a bed-hold policy and written notification forms.
The facility failed to provide person-centered activities that incorporated the residents' interests, as evidenced by interviews with three residents who were unaware of any activities being offered. A Patient Service Representative confirmed the absence of activities, and the Administrator mentioned that volunteers come three times a week, but this information had not been effectively communicated to the residents.
A resident who is a vegetarian was repeatedly served meat products, despite their dietary preferences being known. The facility's process for meal preparation and distribution failed to catch the error, leading to the resident not receiving appropriate meals.
The facility staff failed to use safe food practices while preparing lunch trays and did not store edible produce properly. Molded zucchini, squash, and wilted lettuce were found in the produce refrigerator. Additionally, a food server did not change gloves after handling the undercarriage while preparing lunch plates. The Dietary Manager and Chef were informed, and the Patient Service Manager acknowledged the issues.
The facility failed to maintain accurate medical records for a resident by not updating the route of administration for Doxepin after the resident's J-tube was discontinued. Despite the resident taking medications orally, the records inaccurately documented administration via the J-tube.
The facility staff failed to maintain infection control practices, with urinals found hanging over trashcans and placed near food, and a wound vac machine on the floor. These deficiencies were confirmed by staff during surveyor rounds.
The facility staff failed to ensure the dishwasher reached the final rinse temperature of 180°F. The surveyor observed the dishwasher making a loud noise and only reaching 132°F. The Patient Service Manager and Dietary Manager confirmed the machine was broken. The Dish Machine Temperature Log showed the last documented temperature was 135°F, and it did not reach 180°F during at least one shift in March 2024.
Care Plan Review and Interdisciplinary Team Coordination Deficiencies
Penalty
Summary
The facility failed to review and revise resident care plans for accuracy and current interventions, as well as ensure the full interdisciplinary team, including residents and/or their responsible parties, were invited to care plan meetings for residents who had been in the facility for 21 days or more. This deficiency was identified in the care of four out of 27 residents reviewed during a recertification survey. One specific case involved Resident #4, who had a care plan focused on tube feeding due to protein calorie malnutrition. However, on review, it was found that Resident #4's feeding tube had been discontinued, and there were no active physician orders for tube feeding. The care plan was not updated to reflect this change, indicating a lack of coordination and communication among the interdisciplinary team. Another resident, Resident #12, reported not attending any care plan meetings or seeing the social worker since admission. The medical record review confirmed that there was no documentation of Resident #12 or their family being invited to a care plan meeting. The facility's social worker acknowledged the oversight and attributed it to the patient being missed, highlighting a gap in communication and follow-up procedures. Additionally, Resident #13 and Resident #15 also did not have documented care plan meetings, with reasons ranging from lack of family communication to scheduling conflicts among the interdisciplinary team members.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to report allegations of abuse in a timely manner for Resident #24. The incident involved the resident accusing a sitter of inappropriate behavior when the sitter pulled the blanket down around the resident's knee area. The sitter reported the incident to the nurse (Staff #25) on 10/27/23, but the nurse did not report the allegation immediately. The nurse confirmed during an interview that she did not report the abuse allegation to anyone and acknowledged that the sitter should have been removed from the resident's care. The abuse allegation was eventually reported to the Administrator on 10/30/23 and then to the state agency. The Administrator confirmed that all allegations of abuse are to be reported immediately and that the nurse should have reported the incident right away. The facility provided re-education training to the nurse after the incident. The survey team reviewed the facility's investigation and noted that the abuse was unsubstantiated. The findings were discussed with the Administration team at the time of exit.
Failure to Initiate Care Plan for Resident with History of Sexual Assault Allegations
Penalty
Summary
The facility failed to initiate a care plan to address the specific needs of a resident with a history of sexual assault allegations. This deficiency was identified during a survey when it was found that a resident, who had previously made an allegation of abuse at another facility, did not have a care plan in place upon arrival at the current facility. The resident had presented from an outside hospital for a sexual assault forensic exam. During interviews, the Administrator acknowledged that the Minimum Data Set Nurse, responsible for creating care plans, had not completed one for the resident due to being very busy, which was admitted as an oversight by the facility. The issue was discussed with the Administration team at the time of exit.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility staff failed to treat each resident in a dignified manner by leaving a breakfast tray in a resident's closet, leaving urinals hanging on the trash can in a resident's room, and serving breakfast on a bedside table that had a urinal containing urine. For Resident #4, a breakfast tray dated 3/25/2024 was found in the closet despite the resident being NPO (nothing by mouth). Additionally, three open urinals were observed hanging on a trash can by the foot of Resident #4's bed, which the resident stated should have been kept in the bathroom. The charge nurse and the Administrator confirmed these observations and acknowledged that the breakfast tray and urinals were improperly placed. For Resident #12, a urinal containing urine was found on a bedside table alongside a breakfast tray. The resident confirmed that the urinal was on the table when staff served breakfast. The resident's nurse validated this finding and immediately removed the urinal. The Administrator was informed of these observations and acknowledged the need for staff re-education to prevent such occurrences. These deficiencies were evident for 2 of 27 residents reviewed during the survey.
Failure to Maintain Homelike Environment
Penalty
Summary
The facility failed to maintain a comfortable homelike environment as evidenced by several deficiencies observed in resident rooms. Specifically, a stained ceiling tile was found in one resident's room, discolored tile behind the commode near the trim in another resident's bathroom, fluid stains on the wall in a resident's room, and damaged drywall in another resident's room. These issues were confirmed by various staff members, including a Nursing Tech, the Director of Nursing, and the Administrator during observation rounds conducted by the surveyor. During an interview, the Director of Maintenance indicated that the facility has a ticket system for reporting maintenance issues, with staff available 24 hours a day and a preventive maintenance schedule for equipment. However, the maintenance department was not aware of the issues on the unit. Additionally, an LPN explained that maintenance problems are typically reported by nurses to the Patient Service Representative, who then submits a ticket. The LPN noted that the process can be inconsistent as they only work three days a week.
Failure to Provide Written Notification of Transfer/Discharge
Penalty
Summary
The facility failed to notify the resident, resident representative (RP), and ombudsman in writing of a transfer or discharge, including the reason for the transfer. This deficiency was identified for two residents during a recertification survey. For Resident #7, who was transferred to the hospital emergency department due to a change in mental status, there was no documentation indicating that the resident or their RP was notified in writing of the reason for the transfer. The Administrator confirmed that no written notification was provided and that the ombudsman was not informed. The only documentation available was a progress note indicating that the resident's sister was notified via telephone, but no written notice was given. Similarly, for Resident #17, who was transferred to the hospital, there was no transfer summary or discharge summary available for review. The Administrator stated that a discharge summary is sent with the patient, but no transfer summary was provided. This lack of documentation and written notification for both residents highlights the facility's failure to comply with the requirement to provide timely written notification of transfers or discharges, including the reason for the transfer, to the resident, RP, and ombudsman.
Failure to Notify Residents of Bed-Hold Policy
Penalty
Summary
The facility failed to notify residents or their representatives in writing of the bed-hold policy upon transfer to an acute care facility. This deficiency was identified during a recertification survey for two residents who were hospitalized. For Resident #7, the medical record review revealed that the resident was transferred to the hospital emergency department due to a change in mental status. Although the responsible party was notified via telephone, there was no written documentation provided regarding the bed-hold policy. The Administrator confirmed that the facility did not have a written form for notifying residents or their representatives about the bed-hold policy and that the facility did not have a bed-hold policy in place because their patients were mostly short-term stay and not Medicaid-licensed for about three years. Similarly, for Resident #17, the medical record review showed that the resident was transferred to the hospital, but there was no written notification of the bed-hold policy provided. The Administrator reiterated that the facility did not have a bed-hold policy and did not save beds for patients who were transferred out. The lack of written notification and absence of a bed-hold policy were confirmed through staff interviews and medical record reviews.
Lack of Awareness of Activities Among Residents
Penalty
Summary
The facility failed to provide person-centered activities that incorporated the residents' interests, as evidenced by interviews with three residents who were unaware of any activities being offered. Resident #13, Resident #170, and Resident #8 all verbalized not knowing that the facility offered activities. Additionally, a Patient Service Representative confirmed that there were no activities at the time. The Administrator mentioned that volunteers come three times a week to conduct activities, but this information had not been effectively communicated to the residents, particularly those who are long-term care patients.
Failure to Provide Vegetarian Meals to Resident
Penalty
Summary
The facility failed to develop, prepare, and distribute menus that reflect a resident's nutritional wishes. This deficiency was identified during a recertification survey for one resident who is a vegetarian but was repeatedly served meat products. The resident and their sister confirmed that the resident does not eat meat, yet the resident's meal ticket and the food on the tray did not match, with meat being served instead of the requested vegetarian options. The resident also mentioned that they had only seen the dietitian once since being in the facility. Interviews with the Clinical Nutrition Manager and the Patient Service Manager revealed that the facility has a process in place where a meal concierge takes meal orders from residents, which are then reviewed and modified by the diet office before being served. However, the error was not caught by the server in the kitchen or the meal concierge. The Patient Service Manager acknowledged the mistake and stated that the staff would be re-educated. The assigned dietitian for the resident's unit was informed of the issue and stated that they would follow up.
Unsafe Food Practices and Improper Produce Storage
Penalty
Summary
The facility staff failed to use safe food practices while preparing lunch trays for the Transitional Care Unit and failed to store edible produce properly in the kitchen. During an initial walk-through, the surveyor observed molded zucchini and squash, along with wilted lettuce, in the produce refrigerator. Additionally, a food server was observed preparing lunch plates without changing gloves after handling the undercarriage, which was noted on two separate occasions. The Dietary Manager and Chef were made aware of these issues, and the Patient Service Manager acknowledged the need for proper glove use and produce rotation.
Failure to Maintain Accurate Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards. This deficiency was identified during a recertification survey for one resident. Specifically, the facility staff did not update the medication administration records to reflect the correct route of administration for Doxepin after the resident's jejunostomy tube (J-tube) was discontinued. Despite the resident taking medications orally, the records inaccurately documented that the medication was administered via the J-tube, which had been removed about a week prior. This discrepancy was confirmed through observations, medical record reviews, and interviews with the resident, the Director of Nursing (DON), and the Administrator. On 3/25/2024, an initial observation revealed that the resident no longer had a J-tube and was taking food and medications orally. However, a review of the Medication Administration Record (MAR) for March 2024 showed that staff continued to document the administration of Doxepin via the J-tube. Interviews with the DON and the Administrator confirmed that the order for Doxepin should have been modified to reflect the oral route of administration. The progress notes from 3/21/2024 also validated that the resident's J-tube had been removed, and the resident was tolerating oral intake without issues. The failure to update the medication administration records led to inaccurate documentation of the resident's care.
Infection Control Deficiencies
Penalty
Summary
The facility staff failed to maintain infection control practices as evidenced by several observations. A partially filled urinal was found hanging over the trashcan in a resident's room, and the resident's wound vac machine was on the floor near the end of the bed. Another resident had a urinal on the bedside table next to cups of water and a breakfast tray, and a leg brace was observed on the floor. Additionally, a urinal was seen hanging over the trashcan in another resident's room. These deficiencies were confirmed by the Quality Assurance Director and a Nursing Tech during the surveyor's rounds. The facility administrator acknowledged that urinals should be emptied promptly and not placed near food or trashcans, and that wound vacs should be supported on the bed or a walker.
Dishwasher Final Rinse Temperature Deficiency
Penalty
Summary
The facility staff failed to ensure the dishwasher reached the final rinse temperature of 180°F. On 03/25/24 at 1:01 pm, the surveyor observed the dishwasher in the kitchen and noted it was making a loud noise, with a final rinse temperature of only 132°F. The Patient Service Manager acknowledged the machine was down before it was turned on and needed time to reach the required temperature, while the Dietary Manager confirmed the dishwasher was broken. A review of the Dish Machine Temperature Log revealed the last documented final rinse temperature was 135°F at 11:00 am on the same day. Further review indicated that during at least one shift throughout March 2024, the final rinse temperature did not reach the required 180°F.
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Nursing homes near Baltimore
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Roland Park Place | 1.2 mi | — | 0 | 0 |
| Fayette Health And Rehabilitation Center | 1.3 mi | — | 21 | 1 |
| Future Care Charles Village | 1.6 mi | — | 28 | 0 |
| Future Care Sandtown-winchester | 1.6 mi | — | 2 | 0 |
| Future Care Homewood | 2 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.