Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
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 Mercy Home during CMS and state inspections, most recent first.
The facility failed to notify physicians of head injuries for three residents who experienced falls. Despite incidents resulting in bruising and head injuries, clinical records lacked evidence of immediate physician notification. Interviews confirmed that providers were not informed, contrary to expectations for such notifications.
The facility failed to offer and document influenza and pneumococcal vaccinations for several residents as per CDC recommendations. Despite signed consents, records lacked evidence of offering, receiving, or refusing the vaccines. Interviews confirmed the deficiency in following vaccination protocols.
A resident admitted after hip surgery did not have a baseline care plan developed within 48 hours, failing to address therapy services, oxygen use, and medication monitoring for pain, depression/anxiety, and a blood thinner. This deficiency was confirmed by a surveyor during an interview with the DON.
A facility failed to develop a care plan for falls for a resident after two comprehensive assessments indicated the need for such a plan. The resident's care plan lacked documentation addressing falls, including problem identification, interventions, and goals. This deficiency was confirmed by the DON during an interview.
A facility failed to provide individualized activities for a resident with communication difficulties, as outlined in their care plan. The resident's care plan aimed to address social isolation by engaging them in one-on-one activities with staff three times weekly. However, records showed no evidence of these activities being offered, received, or refused during July. The Activities Coordinator confirmed the absence of structured activities for the resident.
The facility failed to complete fall assessments per policy for two residents, omitting required Glasgow Coma Scale scores and neglecting to address pain and range of motion. Additionally, a resident received medication against a physician's order to hold it if blood pressure was below a certain threshold. These deficiencies were confirmed through interviews with facility staff.
A resident known to be exit-seeking managed to elope from the facility due to inadequate supervision. After dinner, the resident wandered and attempted to exit to the patio, bypassing staff redirection efforts. An alarm was triggered, but it took time for staff to identify the source. The resident was eventually found outside after being out of camera sight for several minutes.
A resident's tube feeding was not administered according to facility policy, as an LPN used a syringe plunger instead of gravity for feeding and mixed medications with the formula. Additionally, bacitracin was applied around the feeding tube area without a physician's order. The DON confirmed these practices were against policy.
Expired medications were found in a medication cart and supply cabinet during a survey. A bottle of Calcium 600 mg + D 5 mcg with an expiration date of June 2024 was found in the medication cart. In the supply cabinet, three bottles of Calcium 600 mg + D 5 mcg, one bottle of Melatonin 1 mg, and four bottles of Vitamin B-12 100 mcg were found with expiration dates ranging from October 2023 to June 2024. These findings were confirmed with a CNA-M.
The facility failed to maintain professional standards for food service safety, including not monitoring food temperatures, improper hair restraint by staff, unsanitary dish storage, and unclean kitchen floors. These issues were observed over several days and confirmed with the Dietary Manager.
The facility failed to document medical records accurately for two residents. One resident's records lacked evidence of pulse checks before administering Metoprolol Tartrate and showed Tramadol was given without prior acetaminophen, against orders. Another resident's records did not document ROM exercises as part of a restorative program, despite the resident's report of reduced ROM in their left elbow and shoulder.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a feeding tube. An LPN was observed providing care without wearing a gown, as required by the facility's policy. Additionally, the LPN did not follow proper hand hygiene protocols, failing to change gloves at appropriate times and not using hand sanitizer or washing hands between glove changes. This was confirmed during an interview with the LPN, who admitted to not adhering to the correct procedures.
A CNA in a long-term care facility was reported for physical and verbal abuse towards residents. The CNA was rough and rude while washing a resident's hair, causing distress, and verbally abused another resident in the dining room. The incidents were corroborated by witness statements and led to the CNA's termination.
A resident with dementia eloped from the facility through an unsecured loading dock door, which was not alarmed. The resident, who had a history of wandering, was found outside with minor injuries after a neighbor alerted the facility. Staff were unaware of the resident's absence until notified by the neighbor, highlighting a lack of adequate supervision.
Failure to Notify Physician of Head Injuries
Penalty
Summary
The facility failed to immediately notify the resident's physician of accidents involving head injuries for three out of four sampled residents. Resident #24 experienced multiple falls, including one observed by a surveyor, where the resident hit their head, resulting in bruising. Despite these incidents, there was no evidence in the clinical records or fall reports that the physician was notified immediately. This pattern of non-notification was consistent across other incidents involving Resident #24, where falls resulted in head injuries, yet the physician was not informed. Similarly, Resident #22's incident report indicated a fall with a head injury, but there was no documentation of physician notification. Resident #11 also experienced a fall with a head injury, resulting in a large bruise, and again, the clinical record lacked evidence of immediate physician notification. Interviews with the nursing staff and the Director of Nursing confirmed that the provider was not notified of these incidents, despite expectations for such notifications in cases of head injuries or significant changes in the resident's condition.
Failure to Offer and Document Vaccinations
Penalty
Summary
The facility failed to ensure that residents were offered influenza and pneumococcal vaccinations in accordance with CDC recommendations. Specifically, four out of five residents reviewed for immunizations did not have documented evidence of being offered, receiving, or refusing the recommended vaccinations. Resident #13, #23, and #26 were all recommended to receive the Prevnar 20 vaccine, but their records lacked evidence of being offered or receiving the vaccine. Resident #28 was recommended to receive the Influenza Vaccine, and although consent was signed by the resident's representative, there was no evidence in the records that the vaccine was offered, received, or refused. The facility's policy, revised in February 2024, indicated that physicians would order immunizations following the CDC immunization schedule. However, during interviews with the Administrator and Nursing Supervisor, it was confirmed that the vaccines were not offered according to CDC recommendations. This deficiency highlights a failure in the facility's process to ensure compliance with vaccination protocols, as evidenced by the lack of documentation and follow-through on vaccination offers and administration.
Failure to Implement Baseline Care Plan for New Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident who was admitted following a hip injury that required surgery. The care plan did not address the admission orders, which included necessary services for therapy, the use of oxygen, and the monitoring of medications prescribed for pain, depression/anxiety, and a blood thinner. This deficiency was confirmed during an interview with the Director of Nursing by a surveyor.
Failure to Develop Falls Care Plan for Resident
Penalty
Summary
The facility failed to develop a care plan for falls for a resident after two comprehensive assessments. The clinical record of the resident was reviewed, and it was noted that the admission Minimum Data Set (MDS) and a significant change MDS indicated that the resident should be care planned for falls. However, upon review of the resident's care plan, no care plan addressing falls, including problem identification, interventions, and goals, was found. This deficiency was confirmed during an interview with the Director of Nursing, who also could not locate a care plan for falls for the resident.
Failure to Provide Individualized Activities for Resident
Penalty
Summary
The facility failed to provide individualized activities to promote the psychosocial well-being of a resident as directed by the care plan. The resident, identified as having difficulty with communication, expressed not participating in activities due to a lack of applicable options. The care plan for this resident identified social isolation as a problem and set a goal for the resident to participate in one-on-one activities with staff at least three times each week. However, the clinical record review showed no evidence that these one-on-one activities were offered, received, or refused three times per week for the month of July. The Activities Coordinator confirmed that there were no structured activities for the resident, and the clinical record lacked documentation of the required one-on-one activities.
Failure to Complete Fall Assessments and Adhere to Medication Orders
Penalty
Summary
The facility failed to complete fall assessments according to its policy for two residents, R24 and R11. The policy required that after a fall, a nurse should assess and document various health indicators, including neurological status using the Glasgow Coma Scale, for three days post-fall. However, for R24, multiple instances were noted where neurological assessments were documented as normal or negative without including a Glasgow Coma Scale score. Additionally, there were occasions where pain and range of motion were not addressed in the documentation. A surveyor observed R24 fall and noted that the resident was moved before a licensed staff member assessed them for injuries, which was against the facility's policy. Similarly, for R11, the documentation of fall assessments also lacked the inclusion of a Glasgow Coma Scale score, despite the resident having a head injury. The documentation repeatedly noted neuro checks as within normal limits or negative without the required scoring. This omission was confirmed during an interview with the facility's Administrator, who acknowledged the missing fall assessment documentation per policy. Additionally, the facility failed to adhere to a physician's order for resident R30, which specified that the medication Amlodipine Besylate should be held if the resident's blood pressure was less than or equal to 140/80. Despite this order, the medication was administered on multiple occasions when the resident's blood pressure was below the specified threshold. This was confirmed during an interview with the Nurse Supervisor, who acknowledged that the medication was given contrary to the physician's order.
Inadequate Supervision Leads to Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision for a resident who was known to be exit-seeking. On the evening of 7/30/24, after dinner, the resident wandered around the dayroom for 10 minutes before attempting to exit to the patio. Although staff attempted to redirect the resident, these efforts were ineffective, and the resident managed to push through the door to the patio. The resident was outside for less than 30 seconds before being retrieved by an LPN. An alarm went off on the East Wing, but it took time for staff to determine which alarm was triggered. A CNA, who was providing care behind closed doors, heard the alarm and eventually located the resident outside the East Wing door. The facility's investigation noted that the CNA did not initially see the resident outside and had to search room to room before realizing the resident was missing. The resident was found after being out of camera sight for several minutes.
Improper Tube Feeding Administration and Dressing Application
Penalty
Summary
The facility failed to administer tube feedings according to its policy for a resident with a gastrostomy tube (G-tube). The policy outlined specific steps for bolus feedings, including flushing the G-tube with water to ensure patency, using gravity to administer the formula, and not mixing medications with the formula. However, during an observation, a Licensed Practical Nurse (LPN) was seen using a syringe plunger to push the formula into the feeding port, contrary to the policy that requires gravity feeding. Additionally, the LPN mixed medications with the Jevity formula, which was not in accordance with the facility's policy. Furthermore, the LPN applied bacitracin around the feeding tube area before applying a clean gauze dressing, despite the absence of a physician's order for such an application. The Director of Nursing (DON) confirmed that bacitracin should not be used unless ordered, and that medications should not be mixed with the Jevity. These actions were observed during a survey, and the DON acknowledged the discrepancies between the observed practices and the facility's established policies.
Expired Medications Found in Medication Cart and Supply Cabinet
Penalty
Summary
The facility failed to ensure that expired medications were removed from the supply available for use, as observed during a survey on July 29, 2024. During a review of the medication cart and the medication supply cabinet in the charge nurse room, a surveyor, along with a Certified Nursing Aid-Medications (CNA-M), found several expired medications. In the medication cart, a bottle of Calcium 600 mg + D 5 mcg was available for use with an expiration date of June 2024. In the medication supply cabinet, three bottles of Calcium 600 mg + D 5 mcg with expiration dates of June 2024, one bottle of Melatonin 1 mg with an expiration date of April 2024, and four bottles of Vitamin B-12 100 mcg, three with expiration dates of April 2024 and one with an expiration date of October 2023, were available for use. These findings were confirmed by the surveyor with the CNA-M at the time of observation.
Deficiencies in Food Service Safety and Sanitation
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey. On multiple occasions, the facility did not monitor food temperatures to prevent foodborne illness, did not ensure that kitchen staff restrained their hair with hair nets, and did not store dishes in a sanitary manner. Specifically, on one day, a kitchen aid was observed with a long ponytail not contained by a hair net. Additionally, serving pans were wet stacked and stored facing upward, allowing them to accumulate debris from the environment. These issues were confirmed with the Dietary Manager (DM) at the time of observation. The facility also failed to maintain cleanliness in the kitchen area. Over the course of four days, the kitchen floor, particularly in the dishwashing area, was consistently found to be unclean and uncleanable due to ongoing repairs. The dry food storage room floor was soiled with dark grey black streaks, and Freezer #4 was heavily soiled with food debris. These conditions were observed and confirmed with the DM, indicating a persistent issue with maintaining sanitary conditions in the food preparation and storage areas.
Deficiencies in Medication Administration and ROM Documentation
Penalty
Summary
The facility failed to maintain complete documentation of medical records for two residents, leading to deficiencies in care. For one resident, the clinical record included physician orders for Metoprolol Tartrate, a blood pressure medication, with specific parameters to hold the medication if the pulse was less than or equal to 55. However, there was no evidence in the clinical record that the pulse was checked prior to each administration of the medication. Additionally, the same resident had an order for Tramadol, an opioid pain medication, to be given as needed if pain was not relieved by acetaminophen. On one occasion, Tramadol was administered without prior administration of acetaminophen, contrary to the physician's orders. For another resident, the facility failed to document the provision of range of motion (ROM) exercises as part of a restorative program intended to reduce the risk of contractures. The resident reported that the facility did not address the reduced ROM in their left elbow and shoulder. The clinical record lacked evidence that the resident was offered, participated in, or refused ROM exercises on several specified days in July. These findings were confirmed by a surveyor during an interview with the Director of Nursing.
Inadequate Infection Control Practices for Resident with Feeding Tube
Penalty
Summary
The facility failed to maintain an effective Infection Control Program, specifically in the application of Enhanced Barrier Precautions (EBP) for a resident with a feeding tube. The facility's policy, revised in February 2024, mandates that EBP, including the use of gowns and gloves, should be implemented for residents with indwelling medical devices. However, during an observation, a Licensed Practical Nurse (LPN) was seen providing care to a resident with a feeding tube without wearing a gown, which is a requirement under EBP. The LPN only wore gloves and did not adhere to the facility's policy of wearing a gown before entering the resident's room. Additionally, the LPN failed to follow proper hand hygiene protocols during the care process. The LPN was observed changing the dressing around the resident's feeding tube and performing other tasks without changing gloves at appropriate times or using hand sanitizer or washing hands between glove changes. This lack of adherence to hand hygiene and EBP was confirmed during an interview with the LPN, who admitted to not wearing a gown for the resident's care and not following the correct procedures for glove changes and hand hygiene.
Resident Abuse by CNA in LTC Facility
Penalty
Summary
The facility failed to protect a resident from physical abuse and two residents from verbal abuse. The incident involved a Certified Nursing Assistant (CNA1) who was reported to have been rough and rude to a resident (R1) while washing their hair. According to a witness, CNA1 became frustrated with R1, threatened not to change or wash them if they continued moving, and was forceful during the process. CNA1 was reported to have yanked R1's hair into a ponytail, causing the resident to cry. R1, who has Huntington's Disease, confirmed that their hair was pulled and described CNA1 as mean. Additionally, CNA1 was involved in a separate incident of verbal abuse towards another resident (R3). During an interaction in the dining room, CNA1 reportedly swore at R3 after the resident accidentally ran over CNA1's toe. CNA1 admitted that the comment might have slipped out impulsively. The facility's internal investigation and witness statements corroborated these incidents of abuse. The facility's records indicate that CNA1 received an employment termination notice due to the reported actions and behaviors. Furthermore, a Registered Nurse (RN) received a written warning for hearing CNA1's inappropriate comment and not taking immediate action. These findings were confirmed by a surveyor during an interview with the facility's Administrator.
Resident Elopement Due to Unsecured Exit
Penalty
Summary
The facility failed to ensure that doors were locked and/or alarmed to prevent a resident identified as an elopement risk from leaving the building unnoticed. This deficiency resulted in an avoidable elopement incident involving a resident with a diagnosis of neurocognitive disorder with Lewy bodies, a form of dementia. The resident's care plan indicated a history of wandering into unsafe situations and a risk for falls due to poor safety awareness. Despite these known risks, the resident was able to exit the facility through a loading dock door that was not alarmed, leading to an unwitnessed elopement. The incident occurred when a nearby neighbor alerted the facility that the resident was outside near another healthcare building. The resident was found sitting on the side of the road with superficial abrasions to the forehead and nose. Video surveillance footage confirmed that the resident exited the building at approximately 4:52 a.m. and was outside the facility for about 18 minutes before being returned. Interviews with staff revealed that the resident's absence was not noticed until the neighbor's call, indicating a lack of adequate supervision and monitoring at the time of the incident.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Eagle Lake
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Forest Hill Manor | 15.8 mi | — | 3 | 0 |
| High View Rehabilitation And Living Center | 25.7 mi | — | 0 | 0 |
| Caribou Rehab And Nursing Center | 29.9 mi | — | 1 | 0 |
| Maine Veterans Home - Caribou | 30.5 mi | — | 5 | 0 |
| Borderview Rehab & Living Ctr | 31.9 mi | — | 0 | 0 |
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