Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 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 Mercer Manor Rehabilitation during CMS and state inspections, most recent first.
The facility failed to ensure adequate nursing staff and relied on uncertified CNA students as independent caregivers, resulting in repeated reports of delayed care and unmet basic needs. Several residents who required substantial or total assistance with ADLs described call light response times of up to an hour or more, missed or postponed showers, and episodes of incontinence where assistance was not provided in a timely manner. A family member frequently found a resident wet and malodorous, with a urine‑soaked wheelchair cushion, and reported long waits for staff assistance. Staffing schedules and staff interviews confirmed that CNA students, who had not yet completed CNA training or state testing, were regularly assigned their own halls and counted as CNAs, while shifts often ran with fewer CNAs than the four typically expected. Resident council minutes documented complaints about long call light waits, unclean bathrooms between uses, soiled incontinence products left on the floor, and lack of fresh water, despite a facility policy requiring sufficient, competent staff to meet residents’ assessed needs.
The facility failed to ensure nurse aides were fully trained and competent or appropriately enrolled and supervised before working independently, as CNA students were scheduled and counted as regular CNAs with their own hall assignments. Staff interviews indicated that students who had not completed CNA classes or state testing were routinely used to fill CNA positions, contributing to perceived short staffing and workload issues. A CNA student reported being in an in-house CNA course for 1–2 months, completing online coursework and limited clinical days, yet being independently assigned to a hall and additional rooms on other days that were treated the same as clinical hours. The ADON and DON stated that once classroom work and skills sign-offs were done, they considered students able to work their own assignments and counted them as CNA staff on the schedule, affecting all residents in the building.
Nursing staff failed to protect resident health information during medication administration. An LPN conducting a medication pass in the dining room and an RN passing medications in a hallway repeatedly left electronic medical records visible on the medication cart computer screen while away from the cart, allowing personal medical information for multiple residents to be seen by visitors, staff, and other residents walking by. Facility leadership later confirmed that nurses are expected to close or hide the computer screen when leaving the cart to maintain confidentiality.
The facility did not complete required quarterly MDS 3.0 assessments for multiple residents within the three‑month interval specified by its own IDT policy. Several residents had quarterly assessments that were significantly overdue, with some eventually completed well past the due date and others still not completed at the time of surveyor review. The MDS Coordinator demonstrated a scheduling report showing numerous overdue assessments and acknowledged the backlog, while the Administrator and a corporate MDS nurse confirmed that corporate staff were aware they were behind on completing MDS assessments, without providing a specific reason for the delays.
A resident with dementia, disorientation, delusional disorder, and chronic pain had ordered doses of Tramadol 50 mg and Tylenol 325 mg that were placed in a pill cup and left on a dining room table without staff ensuring ingestion. Dietary staff later gave the unattended cup, containing two Tylenol tablets and one Tramadol tablet, to an LPN, who brought it to the DON, and then to an RN who stated she had assumed the resident took the medications but admitted she had not observed the resident place them in her mouth. This sequence of events, observed during mealtime for multiple residents dining in the main dining room, did not follow the facility’s policy requiring direct observation of medication administration and prohibiting medications from being left on tables.
Surveyors found that staff failed to properly secure a PPE gown while performing a gastrostomy tube dressing change for a resident with a history of cerebral infarction, feeding difficulties, dysphagia, and severe protein-calorie malnutrition. Despite physician orders for enteral feeding, gastrostomy site care, and Enhanced Barrier Precautions requiring gown and glove use during direct contact and device care, an ADON wore a gown that was not tied at the neck or back, causing it to open toward the resident. The DON and ADON both acknowledged that the gown should have been securely tied in accordance with CDC guidance and the facility’s EBP policy.
The facility failed to provide an ongoing program of activities for residents in the Memory Care Unit due to insufficient activity staff and unrealistic expectations for CNAs to lead activities. Observations revealed residents sitting idle without engagement, and scheduled activities were not conducted. The activity director acknowledged staffing shortages and the unsuitability of certain activities for residents' needs.
The facility failed to document appropriate indications for antipsychotic medication use for several residents, lacking specific behaviors or symptoms in their care plans. Despite facility policy requiring documentation of behaviors and responses to non-pharmacological interventions, residents were prescribed medications like Haloperidol and Risperidone without proper justification. The Director of Nursing acknowledged the issue, noting that some staff believed medication was the solution to behavioral issues, contributing to the problem.
A facility failed to include a resident's oxygen use in their comprehensive care plan, despite a physician's order for oxygen at 2 liters per minute via nasal cannula for dyspnea or chest pain. Observations confirmed the resident was using oxygen, but the care plan lacked information or goals regarding this need. The care plan coordinator confirmed the omission.
A facility failed to follow a care plan for a resident with CHF, neglecting to document daily weights and report significant weight changes to the cardiologist as ordered. The MAR showed missing weight entries and unreported weight gains over several months, despite clear discharge instructions. The DON confirmed the oversight, acknowledging the cardiologist should have been notified.
A facility failed to assess and document a pressure ulcer for a resident, identified as having multiple open areas on the coccyx. The facility's policy requires weekly assessment of skin impairments, but the wound was consistently documented as irritant contact dermatitis without measurements. The DON confirmed reliance on telehealth wound care doctors and acknowledged the wound's location over a pressure point, yet it was not documented as a pressure ulcer.
A facility failed to change a resident's oxygen equipment as ordered, with the nasal cannula and humidifier bottle not being replaced weekly as required. The resident's Physician Order Sheet specified weekly changes for infection control, but records showed the last change was documented mid-month, with no updates for subsequent weeks. Observations confirmed the equipment was not updated, and the DON acknowledged the oversight.
A registered nurse failed to follow infection control protocols during medication administration for a resident with a gastric tube. The nurse placed a medication cup on the resident's bed, causing it to tip over and spill pills onto the sheet. The nurse picked up the pills and administered them, acknowledging later that the bed sheet was not clean.
A resident with severe cognitive impairment and a history of exit-seeking behavior eloped from a memory care unit due to inadequate alarm systems and supervision. The resident was found outside with significant injuries, including facial and cervical spine fractures, after exiting the facility unnoticed. The facility failed to update the resident's care plan and did not report the elopement to the State Agency, contributing to the severity of the incident.
Facility dietary staff failed to have their hair restrained while handling and preparing food, potentially affecting all 60 residents. Observations revealed multiple instances of non-compliance, including a Dietary Assistant serving food without a hair net, another with loose hair hanging from a cap, and a Dietary Cook with an improperly worn hair net. The Dietary Manager confirmed the requirement for full hair restraint.
The facility failed to provide twice-weekly showers for a resident diagnosed with Dementia and Parkinson's Disease, who required assistance for all ADLs. Despite being scheduled for showers on Wednesdays and Saturdays, the resident only received 20 out of 34 scheduled showers. Staff confirmed the missed showers and noted that the resident enjoyed showers and did not resist them. The DON verified the missing shower records.
Inadequate Staffing and Use of Uncertified CNA Students Leading to Unmet Care Needs
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate nursing staff to meet residents’ needs and the use of uncertified CNA students as independent staff. Multiple residents who require substantial or total assistance with ADLs reported prolonged call light response times and unmet toileting and hygiene needs. One resident with spinal stenosis, neuropathy, osteoarthritis, CHF, and other conditions, who requires substantial to maximal assistance for toileting, stated that it took an hour for staff to answer a morning call light when she needed to use the bathroom. She reported that, after waiting and hoping staff would at least transfer her to the toilet, she was unable to wait any longer and had a bowel movement in her pants. Another resident, admitted with multiple myeloma, convulsions, anemia, and other diagnoses, is alert, oriented, has an unsteady gait and poor balance, and is dependent for all care except eating. This resident reported that call light responses on second and third shifts frequently take an hour or more, and that on one occasion the call light was placed on the privacy curtain out of reach, requiring the roommate to retrieve it. A third resident, with flaccid hemiplegia, spinal stenosis, and other conditions, is dependent on staff for most care and reported that there are often not enough CNAs, that there is high turnover, and that showers were missed due to short staffing, including a night when only two CNAs were on second shift and the resident’s shower was postponed. Additional residents and a family member corroborated staffing concerns. One resident stated that staffing is "a joke," reporting that there was only one CNA on a recent Saturday and that call light responses sometimes take up to an hour and a half. Another resident’s daughter reported frequently finding her mother wet and smelling of urine, including on the day of observation when the resident’s pants and wheelchair cushion were wet and odorous, and she described a 20‑minute wait for assistance. A largely independent resident reported that call light responses for requests such as ice water and bedding changes often take over an hour several days per week, and that on third shift there is usually only one CNA, with her incontinent roommate’s bedding often not changed until just before bedtime. Review of staffing schedules for the prior two weeks showed that CNA students were regularly assigned their own halls and counted as CNAs on multiple dates, with schedules frequently showing only 2–3 CNAs on first and second shifts instead of the 4 CNAs staff reported as needed for the south end. CNAs reported that students, who had not completed CNA classes or testing, were given independent assignments after limited clinical sign‑off, and that this contributed to difficulty answering call lights and completing showers. One CNA stated they had given notice due to staffing issues and confirmed that students were being used as regular staff. The ADON and DON acknowledged that typical staffing often ran with fewer CNAs than planned, that students were counted as independent staff once signed off on skills, and that weekends were particularly difficult due to call‑ins. Resident council minutes documented complaints about call light wait times, bathrooms not being cleaned between uses, soiled incontinence products left on the floor, lack of fresh water, and staff saying they would return but not doing so. The facility’s written staffing policy states that the facility will provide sufficient staff with appropriate competencies and skill sets to provide nursing and related services to assure resident safety and to help residents attain or maintain their highest practicable well‑being, based on resident assessments, plans of care, and the facility assessment. Despite this policy, observations, interviews, and record review showed that the facility did not ensure adequate numbers of qualified CNAs on duty and used CNA students as independent staff members before certification, resulting in repeated reports and observations of delayed responses to call lights, missed or delayed showers, and residents remaining wet or soiled.
Use of CNA Students as Independent Staff Without Completed Training and Competency Evaluation
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nurse aides had completed a training and competency evaluation program or were appropriately enrolled and supervised prior to working independently. Surveyors reviewed the resident roster showing 58 residents in the building and examined nursing and CNA schedules for the prior two weeks, which showed CNA students assigned their own halls on multiple dates. Staff interviews revealed that CNA students were being scheduled and counted as regular CNAs, assigned full hall responsibilities, and included in staffing numbers once they were “signed off” on certain skills, despite not having completed CNA certification or state testing. The facility’s DON acknowledged counting CNA students as independent staff members on the schedule once their skills were signed off and avoiding scheduling them in memory care only because there was a single CNA there. CNA staff reported that students were frequently working as part of the regular staffing pattern, being given their own assignments without being paired with a CNA for training. One CNA stated that there were supposed to be four CNAs on the south end but that they were short staffed and that students who had not finished class or testing were being given hall assignments. Another CNA reported struggling to complete showers and answer call lights while working with students who were treated as fully capable staff. A CNA student confirmed being in the facility’s CNA course for 1–2 months, taking online classes with clinical hours twice weekly, but also picking up additional days that were no different from clinical days, and being independently assigned to a hall and additional rooms. The ADON and DON both indicated their understanding that once classroom work and skills sign-offs were completed, students could work their own assignments prior to certification, which conflicted with the requirement that nurse aides be trained and competent or appropriately enrolled and supervised within the first four months of employment.
Failure to Protect Resident Health Information During Medication Pass
Penalty
Summary
The deficiency involves failure to maintain privacy and confidentiality of residents' medical records during medication administration. Facility policy on Medication Administration-General Guidelines, dated November 2021, requires that the medication cart be kept closed and locked when out of sight, that no medications be kept on top of the cart, and that privacy be maintained at all times for resident information, including the Medication Administration Record (MAR), when not in use. On 1/20/2026 at 11:26 AM, an LPN (V6) was observed conducting a medication pass in the dining room and repeatedly left resident information visible on the computer screen each time she left the cart to administer medications to residents R5, R12, and R58. This made their personal medical records visible to visitors, staff, and residents passing by the medication cart. When questioned, V6 acknowledged that the screen should have been hidden and indicated she should have used the icon to hide the screen before leaving the cart. On 1/21/2026 at 11:15 AM, an RN (V7) was observed passing medications to residents R1, R37, and R51 in the hallway outside the dining room and similarly left resident information visible on the computer screen each time she left the cart to administer medications. This again made personal medical records visible to anyone passing by the cart. When asked, V7 stated she realized too late that she had left the screen up and agreed she should have closed the screen so nobody could see it. At 11:31 AM on the same day, the DON (V2) stated that when passing medications, nurses should either close their computer screen or press the hide screen icon before leaving their carts to protect patient information, confirming that the observed practice was inconsistent with facility expectations and policy.
Failure to Complete Quarterly MDS Assessments Within Required Timeframes
Penalty
Summary
The facility failed to ensure that each resident’s assessment was updated at least once every three months using the standardized MDS 3.0 assessment tool, as required by its own Interdisciplinary Team (IDT) policy dated 11/1/15. The policy specifies that quarterly assessments must be completed no less than every three months, but seven residents (R2, R6, R9, R16, R27, R45, R53) had quarterly MDS assessments that were either significantly overdue or not completed at all. For example, one resident’s quarterly assessment due on 11/13/25 was not completed until 1/14/26, making it 46 days overdue, and another resident’s assessment due on 11/14/25 was completed on 1/14/26, 47 days overdue. Additional residents had quarterly MDS assessments that remained incomplete past their due dates at the time of the survey. One resident’s assessment due on 1/5/26 was 16 days overdue and still not completed, while others had due dates in late December and early January and were between 20 and 24 days overdue without completion. During an interview and demonstration of the Clinical-MDS Scheduler report, the MDS Coordinator showed that the report identified MDS assessments that were not completed and how long they were overdue, and acknowledged that many assessments were overdue. The Administrator stated that corporate oversees the MDS process, and during a phone call, the Corporate MDS Nurse confirmed that the corporation was aware they were behind on completing the MDS assessments. No specific reason for the delays or failures to complete the assessments was provided in the report.
Unsupervised Oral Medications Left on Dining Table and Not Verified as Ingested
Penalty
Summary
The deficiency involves the facility’s failure to administer medications in a safe manner and in accordance with its own medication administration policy. Surveyors observed an unlabeled pill cup containing three pills on a medication cart; an LPN stated the cup contained a specific resident’s medications that dietary staff had handed to her after finding the cup left on a dining room table. The LPN reported that the resident was not on her assignment and that she intended to take the medications to the DON. The DON then took the cup to an RN, explaining that the cup had been found on a dining room table. The RN identified the medications as two 325 mg Tylenol tablets and one 50 mg Tramadol tablet and acknowledged that she believed the resident had taken the pills. The RN further stated that she did not actually see the resident place the pills in her mouth and admitted she should have ensured the medications were taken before walking away. The resident involved had diagnoses including delusional disorder, unspecified disorientation, unspecified pain, and unspecified dementia of unspecified severity, and had physician orders for Tramadol 50 mg one tablet three times daily for pain and Tylenol 325 mg two tablets three times daily for pain. The facility’s written policy required that medications be administered as prescribed, that residents be observed after administration to ensure the full dose is ingested, and that medications not be left unattended. The DON confirmed that nurses are expected to remain with residents and watch them take their medications and that medications should never be left on a table.
Improper PPE Gown Use During Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves a failure to correctly don personal protective equipment (PPE), specifically a gown, during care of a resident under Enhanced Barrier Precautions (EBP). The facility’s EBP policy, dated 10/28/2024, requires staff to wear a clean, non-sterile gown and gloves during direct resident contact, including device care and wound care, and to follow CDC guidance that the gown be fastened in the back. The CDC sequence for putting on PPE specifies fastening the back of the gown when putting it on. The resident involved was admitted with a principal diagnosis of cerebral infarction due to unspecified occlusion or stenosis of the left anterior cerebral artery, with additional diagnoses including feeding difficulties, dysphagia, and severe protein-calorie malnutrition. The resident had active physician orders for enteral feeding via a gastrostomy tube every shift, gastrostomy site dressing care, and an order for EBP requiring staff to wear gown and gloves during direct contact and device or wound care. On the survey date at 10:45 a.m., the DON and the ADON performed a gastrostomy dressing change for this resident in accordance with the physician’s order. During this procedure, the ADON’s gown was not tied around the neck or back, causing the gown to open and fall forward toward the resident. When questioned, the DON stated that proper procedure for donning a gown is to put it on and tie it, and the ADON acknowledged that the gown should have been tied securely, explaining that her gown would not stay tied. The DON further stated that she should have tied the ADON’s gown. These observations and interviews demonstrated that staff did not follow the facility’s EBP policy and CDC guidance for properly securing PPE during high-contact resident care involving a gastrostomy device and dressing change.
Inadequate Activity Program in Memory Care Unit
Penalty
Summary
The facility failed to provide an ongoing program of activities for residents in the Memory Care Unit, as required by their policy. Observations and interviews revealed that the activity staff were not consistently present on the unit, and the activities listed on the calendar were not being conducted. For instance, on multiple occasions, residents were found sitting idle without any engagement, and the activity staff did not arrive to conduct scheduled activities like 'Parachute Fun.' The lack of activity staff presence was attributed to staffing shortages, with only one activity aide working part-time and another full-time aide not covering the Memory Care Unit on weekends or certain weekdays. The report highlights specific instances where residents were left without meaningful engagement. On one occasion, a nurse and a CNA were unable to facilitate a craft activity due to insufficient staffing and concerns about residents' safety with small craft pieces. Additionally, residents were observed sitting in common areas without any music, television, or accessible activity materials, contrary to their care plans that emphasized the importance of music and other forms of engagement. The activity director acknowledged the inadequacy of the current staffing levels and the unsuitability of certain activities for the residents' needs. The facility's failure to provide adequate activities was further compounded by the lack of resources and support for the nursing staff to lead activities. The activity director admitted that the expectation for CNAs to lead activities was unrealistic given their other responsibilities. The report also noted that there were no activities on weekends and certain weekdays due to the limited availability of activity staff, leaving residents without structured engagement during these times.
Inadequate Documentation for Antipsychotic Medication Use
Penalty
Summary
The facility failed to ensure appropriate indications for the use of antipsychotic medications and did not identify or document target behaviors for several residents. The report highlights that six residents were administered antipsychotic medications without proper documentation of specific behaviors or symptoms that necessitated such treatment. The facility's policy on psychotropic medication management requires documentation of specific behaviors and the resident's response to non-pharmacological interventions, which was not adhered to in these cases. For instance, one resident with diagnoses including Frontotemporal Neurocognitive Disorder and Schizophrenia was receiving Haloperidol and Quetiapine, yet their care plan did not include target behaviors justifying the use of these medications. Another resident with Moderate Severity Dementia and Mood Disorder was on Risperidone without having been seen by psychiatric services, and their care plan also lacked documentation of target behaviors. Similar issues were noted with other residents, where antipsychotic medications were prescribed for conditions like dementia and anxiety without clear documentation of behaviors that would warrant such treatment. The Director of Nursing acknowledged the issue, stating that the psychiatric services had only recently started, and some staff believed medication was the solution to behavioral issues, contributing to the problem. The care plans for these residents did not include target behaviors as part of the reason for the psychotropic medications, indicating a systemic issue in the management and documentation of antipsychotic medication use in the facility.
Failure to Include Oxygen Use in Resident's Care Plan
Penalty
Summary
The facility failed to develop a comprehensive assessment for the use of oxygen for a resident reviewed for care plans. The facility's policy, revised in June 2024, requires an individualized comprehensive care plan with measurable objectives and timetables to meet each resident's needs. However, the resident's Physician Order Sheet from December 2024 included an order for oxygen at 2 liters per minute via nasal cannula as needed for dyspnea or chest pain, but the current comprehensive care plan did not contain information or goals regarding oxygen usage. Observations on two separate days confirmed the resident was using oxygen, yet the care plan coordinator acknowledged the omission of the resident's oxygen needs in the care plan.
Failure to Monitor and Report Weight Changes in CHF Resident
Penalty
Summary
The facility failed to adhere to the prescribed care plan for a resident with congestive heart failure (CHF), specifically regarding daily weight monitoring and reporting significant weight changes to the cardiologist or CHF clinic. The hospital discharge instructions for the resident required daily weighing at the same time and on the same scale, with any weight gain of 3 pounds in one day or 5 pounds in one week to be reported to the cardiologist. However, the Medication Administration Record (MAR) for the resident showed multiple instances of missing weight documentation across several months, including August, September, October, November, and December. Despite documented weight gains that met the criteria for notification, there was no evidence in the medical records that the cardiologist or CHF clinic was informed of these fluctuations. The Director of Nursing confirmed the missing documentation and acknowledged that the cardiologist should have been notified according to the parameters set on the discharge instructions. This oversight in monitoring and communication represents a failure to provide appropriate treatment and care as ordered, potentially impacting the resident's cardiac health management.
Failure to Assess and Document Pressure Ulcer
Penalty
Summary
The facility failed to thoroughly assess and measure a pressure ulcer for one resident, identified as R23, among two residents reviewed for wounds. The facility's Skin Prevention, Assessment and Treatment policy requires weekly assessment and documentation of all skin impairments, including pressure ulcers, by the Wound Nurse or designee. However, R23's wound care assessments consistently referred to the wound as irritant contact dermatitis and did not include measurements or documentation of multiple open areas on the coccyx, despite the presence of four small slit-like open areas observed during a survey. The Director of Nursing (DON) confirmed that the facility does not measure non-pressure ulcers and relies on telehealth wound care doctors who do not perform hands-on assessments. The DON acknowledged that R23's wound was due to immobility and incontinence and was located directly over the pressure point of the coccyx. Despite this, the wound was not documented as a pressure ulcer, and there was no record of the number of open areas present. This lack of thorough assessment and documentation led to the deficiency identified by the surveyors.
Failure to Change Oxygen Equipment as Ordered
Penalty
Summary
The facility failed to ensure that oxygen equipment was changed as ordered for a resident, identified as R33, who was reviewed for respiratory care. According to the facility's Oxygen Administration and Storage policy, nasal cannulas or masks should be changed weekly or when soiled, and the humidifier bottle should be labeled with the date of application and changed weekly if refillable. R33's Physician Order Sheet dated December 19, 2024, specified that the oxygen water bottle should be changed on the night shift every Sunday and as needed, with the bottle being dated and initialed, and the oxygen tubing changed every Sunday and as needed for infection control. However, the Treatment Administration Record for December 2024 showed that the last documented change of R33's humidification bottle was on December 15, 2024, with no documentation for the subsequent Sundays, December 22 and December 29, 2024. Observations on January 7 and January 8, 2025, revealed that R33's nasal cannula tubing and refillable humidifier bottle were still dated December 16, 2024. The Director of Nursing confirmed that both the nasal cannula and the humidifier bottle should have been changed weekly, indicating a failure to adhere to the prescribed schedule for changing the oxygen equipment.
Medication Administration Breach in Infection Control
Penalty
Summary
The facility failed to adhere to its Standard Precautions policy during a medication administration for a resident. A registered nurse was observed preparing medications for a resident with a gastric tube. During the process, the nurse placed the medication cup on the resident's bed, which resulted in the cup tipping over and spilling two pills onto the fitted sheet. The nurse then picked up the pills with a gloved hand and returned them to the cup, subsequently administering all the medications via the resident's gastric tube. The nurse later confirmed that the pills had fallen onto the bed and acknowledged that the bed sheet would not be considered clean, indicating a breach in infection control practices.
Inadequate Alarm System and Supervision Lead to Resident Elopement and Injury
Penalty
Summary
The facility failed to ensure that the memory care unit exit doors and bracelet alarms were loud and widespread enough to alert staff when activated. This deficiency resulted in a cognitively impaired resident, who was at high risk for elopement, exiting the facility without staff knowledge. The resident was found outside in the parking lot, soaking wet and with significant injuries, including facial and cervical spine fractures, after having eloped from the facility's locked memory care unit. The incident occurred during a time of heavy rain, and the resident was later transferred to a tertiary hospital for intensive care treatment. The resident involved had a history of severe cognitive impairment and was known to be an exit seeker. Despite this, the care plan had not been updated with new interventions since 2023, and the facility failed to follow its own elopement policies. The alarms on the exit doors were not audible enough to alert staff, especially when they were in resident rooms or further up the hall. Staff interviews revealed that the resident had previously managed to exit the building, indicating a pattern of inadequate supervision and alarm system failures. The facility's policies required that all incidents of elopement be reported to the State Agency and result in a comprehensive care plan review and revision. However, the facility did not report the elopement incident to the State Agency, as they believed the resident was still on the property. This oversight, along with the failure to investigate and address previous elopement attempts, contributed to the severity of the incident and the resulting injuries to the resident.
Removal Plan
- An audit of the memory care unit's alarms was conducted and determined that all exit alarms are functioning and audible, including behind closed doors. All 17 rooms were audited on the unit, including the room furthest from the exit.
- All nursing staff present were in-serviced on: Proper monitoring and supervision of residents at risk for elopement - The definition of elopement - Review of the facility's elopement detection and prevention systems - The need to reassess and review a resident's plan of care after an elopement.
- All residents at high risk for elopement have been reviewed and no instances of exiting the building unattended have been identified.
Dietary Staff Non-Compliance with Hair Restraint Policy
Penalty
Summary
Facility dietary staff failed to have their hair restrained while handling and preparing food, which has the potential to affect all 60 residents currently residing in the facility. The facility policy, dated November 5, 2019, directs that hair nets or approved hats covering all hair must be worn while handling or preparing food. However, observations on April 6, 2024, revealed multiple instances of non-compliance. A Dietary Assistant was seen serving food and pouring drinks without a hair net or approved hat, and another Dietary Assistant was observed washing dishes with loose hair hanging from a cap. Additionally, a Dietary Cook was seen with a hair net that did not fully restrain their hair. The Dietary Manager confirmed that all dietary staff are required to have their hair fully restrained while handling and preparing food. The observations were made between 8:30 A.M. and 8:55 A.M. on April 6, 2024. The Dietary Assistant was seen performing various tasks, including plating food, pouring drinks, retrieving and serving brown sugar, and delivering filled plates to residents, all without proper hair restraint. Another Dietary Assistant was observed in the dish room with loose hair hanging from a cap, and the Dietary Cook had a hair net that did not fully restrain their hair. The Director of Nurses verified that 60 residents currently reside in the facility, indicating the potential widespread impact of this deficiency.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to provide twice-weekly showers for one of four residents reviewed for showers. The facility's policy mandates assisting residents with bathing to maintain proper hygiene and prevent skin conditions. Resident R3, diagnosed with Dementia and Parkinson's Disease, was admitted to the facility and required staff assistance for all Activities of Daily Living (ADLs). According to the facility's shower list, R3 was scheduled to receive morning showers on Wednesdays and Saturdays. However, a review of R3's Certified Nursing Assistant Shower Sheet revealed that R3 only received 20 out of 34 scheduled showers from December 9, 2023, through April 3, 2024. Interviews with Certified Nursing Assistants confirmed the missed showers and noted that R3 enjoyed showers and did not resist them. The Director of Nurses verified that R3 had not been discharged during the specified timeframe and confirmed the missing shower records.
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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 Aledo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Arcadia Care Aledo | 0 mi | — | 8 | 1 |
| Monmouth Rehab And Nursing | 20.7 mi | — | 25 | 1 |
| Generations At Rock Island | 21.8 mi | — | 3 | 0 |
| Friendship Manor | 21.8 mi | — | 2 | 0 |
| Aspire Of Muscatine | 22.8 mi | — | 2 | 0 |
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