Inspection visit
Health inspection
4 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 4 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0686
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview and record review the facility failed to avoid contamination of a stage 4
pressure ulcer during a dressing change for one (R6) of three residents reviewed for pressure ulcers in a
sample of 23.
Residents Affected - Few
Findings include:
Facility Clean Dressing Change Policy, undated, documents: it is the policy of this Facility to provide wound
care in a manner to decrease potential for infection and/or cross-contamination; loosen the tape and
remove the existing dressing, then remove gloves, pulling inside out over the dressing and discard in to the
appropriate receptacle, then wash hands and put on clean gloves; cleanse the wound as ordered, then
wash hands and put on clean gloves; discard disposable items and gloves into appropriate trash receptacle
and wash hands, then return Resident to comfortable position.
The Facility Wound Log, dated 11/7/22, documents that R6 has a Left Buttock Pressure Ulcer (measuring
5.0 centimeters/cm by 8.0 cm x 1.0 cm) and is being treated daily with a medicated solution and a dry
dressing.
On 11/16/22 at 12:01 pm, V4 (Certified Nursing Assistant/CNA) and V5 (Licensed Practical Nurse/LPN)
were in R6's room assisting with perineal care and wound care. V4 (CNA) entered R6's room, applied
gloves, rolled R6, pulled back the covers, removed R6's urine soiled incontinence brief. V4 (CNA) retrieved
clean incontinence wipes from a container that was in R6's bedside table drawer. V4 performed perineal
care and disposed of the soiled wipes into the trash receptacle. V4 then placed the clean container of
incontinence wipes back into R6's bedside drawer. V5 (LPN) entered the room with a bottle of medicated
solution and a bottle of wound cleanser and placed them on R6's bedside table. V5 applied gloves and
initiated the removal of R6's soiled pressure ulcer dressing, at the same time, V4 reached over R6 and
assisted V5 (LPN) with removing R6's soiled Pressure Ulcer dressing, by peeling back the dressing. As V4
was helping position R6 for V5 to apply the clean dressing, V4's right hand was placed on R6's soiled
coccyx and buttock. V5 (LPN) then retrieved the bottle of wound cleanser and cleansed R6's Pressure
Ulcer, by spraying the cleanser into R6's wound and wiping with gauze pads. V5 (LPN) then retrieved and
applied the medicated solution and covered the coccyx/buttocks pressure ulcer with a clean dry dressing.
V4 and V5 did not perform any hand hygiene or glove change during R6's cares.
On 11/16/22 at 12:10 pm, V4 (CNA) stated, We only change our gloves or wash our hands if our hands are
visibly soiled.
On 11/16/22 at 12:35 pm, V4 (CNA) stated, I always try and help the nurses take off the soiled dressings
when I can.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 9
Event ID:
146138
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146138
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/18/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Mercer Manor Rehabilitation
309 N W 9th Avenue
Aledo, IL 61231
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0686
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
On 11/16/22 at 12:11 pm, V5 (LPN) stated, We do not have to wash our hands, put new gloves on or use
hand sanitizer unless our hands are visibly dirty.
On 11/17/22 at 1:30 pm, V1 (Administrator) stated, We will in-service them on handwashing and glove
changes. They should be changing their gloves and washing their hands during cares, especially when they
are soiled from wound care or incontinence care.
Event ID:
Facility ID:
146138
If continuation sheet
Page 2 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146138
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/18/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Mercer Manor Rehabilitation
309 N W 9th Avenue
Aledo, IL 61231
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0688
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM
and/or mobility, unless a decline is for a medical reason.
Based on observation, interview, and record review the facility failed to provide a palm guard for one
resident (R26) with bilateral hand contractions of two residents reviewed for mobility in the sample of 25
residents.
Findings include:
On 11/15/22 at 10:30am R26 was in her room, both hands were severely contracted. R26 was wearing
cloth arm/hand skin sleeves on both arms. R26 stated that she would like her nails trimmed because they
can dig into her skin, but the cloth sleeves help protect her skin.
R26 was seen on 11/15/22 and 11/16/22 without palm guards on either hand.
PT (Physical Therapy)/OT (Occupational Therapy) Screen Form dated 8/29/22 indicates Reason for
Screen: Decline in functional mobility and worsening of contracture of right hand. Screen indicates right
hand contracture worse Has bilateral palm guards in order to decrease possible skin irritation. Contractures
are worse due to not wearing palm guards during day and removing. Screen indicates Recommend therapy
to address device for right hand contracture.
Resident Concern Form dated 10/20/22 indicates R26 has missing palm guards and that palm guards were
ordered.
On 11/16/22 at 3:15pm V2 (Director of Nursing) stated that the concern for R26's palm guards came up at
R26's last care conference by R26's family. V2 stated she ordered them and was still waiting for them.
On 11/17/22 at 10am V10 (Certified Occupational Therapy Assistant) stated R26 should still being using a
palm guard on her left hand. The right is too contracted to get anything in there anymore. I recommended
and gave elastic/cloth sleeves to wear to protect R26's skin from her nails. It's all that will fit into her right
hand. V10 stated that R26 has had four palm guards and they all ended up missing. V10 stated that R26
can't tolerate anything in her right hand anymore but she will keep the left palm guard in her hand. Nursing
is responsible to ensure R26 has a palm guard for her left hand.
Current Care Plan did not include R26's bilateral severe hand contractures or interventions including palm
guards.
On 11/18/22 V1 (Administrator) stated they have no policy for contractures or splints.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146138
If continuation sheet
Page 3 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146138
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/18/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Mercer Manor Rehabilitation
309 N W 9th Avenue
Aledo, IL 61231
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0758
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated,
prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic
medications are only used when the medication is necessary and PRN use is limited.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review the facility failed to identify an appropriate indication for use of an
antipsychotic medication. The facility also failed to identify specific target behaviors for administration of an
antipsychotic medication for three residents with a diagnosis of dementia (R19, R46, R100) of seven
residents reviewed for unnecessary medications in the sample of 25.
Findings include:
Facility Psychotropic Medication Policy dated 12/4/19 documents:
1. An assessment must be made to identify specific behaviors/symptoms, potential causative factors, and
recommendations for managing identified behaviors.
2. The medical record documentation must reflect the specific behaviors/symptoms and the resident's
response to non-pharmacological interventions to manage the behaviors/symptoms.
4. The physician should evaluate the use of antipsychotic medications if one or more of the following are the
only indication:
Wandering
Poor self-care
Restlessness
Impaired Memory
Anxiety/ Depression
Insomnia, Unsociability
Indifference to surroundings
Fidgeting/nervousness
Uncooperativeness
Agitated behaviors which do not represent danger to resident or others.
12. A plan of care will be developed including precipitating factors, non-pharmacologic interventions, and
potential side effects.
1.) Facility diagnosis Sheet indicates R19 was admitted to the facility 2/23/17 with diagnosis of Dementia
with Lewy Bodies and Delusional Disorder. In 2019 R19 was diagnosed with Schizophrenia and in 2021
diagnosed with Unspecified Dementia with Behavioral Disturbance and General Anxiety Disorder.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146138
If continuation sheet
Page 4 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146138
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/18/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Mercer Manor Rehabilitation
309 N W 9th Avenue
Aledo, IL 61231
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0758
Level of Harm - Minimal harm
or potential for actual harm
Physician Order Sheets indicate Seroquel (antipsychotic) was initiated on admission at 25mg (milligram) at
bedtime for Dementia with Lewy Bodies and increased as follows:
10/9/21 Seroquel increased to 25mg twice daily and diagnosis changed to Long Term Usage related to
Delusional Disorder.
Residents Affected - Some
11/22/21 Seroquel increased to 50mg at bedtime, 25 mg daily and diagnosis changed to Schizophrenia.
12/21/21 Seroquel increased to 50mg twice daily
2/15/22 Seroquel increased to 75mg twice daily
8/5/22 Seroquel increased to 100mg twice daily
10/7/22 Seroquel Increased to 125mg twice daily
11/11/22 Seroquel increased to 150mg twice daily
Current Seroquel order (11/11/22) indicates Schizophrenia, Unspecified as diagnosis for Seroquel.
Progress Notes dated 10/2022 thru 11/16/22 do not include justifications or documentation of an increase
in behaviors other than (R19) continues to hear voices.
On 11/17/22 at 1:30pm V8 (Licensed Practical Nurse/LPN) stated (R19) has multiple versions of herself
and talks to (an alternate R19). V8 stated that they used to argue sometimes, now they just talk. V8 stated
R19 also has OCD (obsessive compulsive disorder) and has very ritualistic behaviors at times. V8 stated
that R19 has never been violent or aggressive. V8 stated that the residents are seen by a Nurse
Practitioner for psychiatry needs thru a Telehealth company.
Telehealth Note dated 10/3/22 at 1:30pm indicates (R19) has reported significant symptoms related to
dementia and psychosis. (R19) reports talking to voices she refers to as her friends. Note indicates R19
continues to talk under her breath with a voice and states everyone talks to her as they are her friends.
Note indicates R19 denies the voices are commanding stating They just talk to me. Note indicates R19
reports difficulty hearing, reports hallucinations, memory loss and dementia; denies depression, no sleep
disturbances, no suicidal thoughts, and normal appetite.
R19 was observed in the community areas of the memory care unit as well as in her room at various times
on 11/15/22 and 11/16/22. R19 was accepting of care, mostly stayed to herself, and ambulated between
the dining area and her room with a walker. R19 did seem preoccupied, however was not distressed.
Current Care Plan indicates on 2/15/22 R19's Seroquel was increased to 75mg twice daily. No target
behaviors, diagnosis or indication for use are identified in the care plan. Care Plan was not updated to
reflect the continued increases of Seroquel after 2/15/22.
Behavior Tracking Sheets dated 10/1/22 thru 11/16/22 indicate R19 is being monitored for refusing care,
insomnia, restlessness, yelling out when anxious related to hallucinations and delusions and talking in third
person to her friends.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146138
If continuation sheet
Page 5 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146138
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/18/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Mercer Manor Rehabilitation
309 N W 9th Avenue
Aledo, IL 61231
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0758
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Psychotropic Medication Consent dated 11/11/22 indicates consent was received on that date to increase
R19's Seroquel to 150mg BID with Indication for Use: Schizophrenia.
Consent dated 10/7/22 indicates Seroquel was increased to 125mg with Indication for Use: Antipsychotic.
Consents indicates Antipsychotics are used to treat behavior problems such as combativeness,
explosiveness, manic behaviors, and treatment of psychotic disorders. Consent does not indicate specific
target behaviors or conditions to justify the use of an antipsychotic medication.
Consent also include Black Box Warning: Elderly patients with dementia-related psychosis treated with
antipsychotics are at increased risk of death compared to placebo.
No consents were found or presented for the increase in Seroquel on 2/15/22 or 8/5/22.
2.) Physician's Order Summary Report (POS) indicates R46 was admitted to the facility on [DATE] with
diagnoses that include Unspecified Dementia without Behavioral Disturbance, Psychotic and Mood
Disturbance and Anxiety.
Physician Order Sheet indicates Seroquel (antipsychotic) 25mg (milligram) every night at bedtime for
Unspecified Dementia without behavioral disturbance; Restlessness/Agitation was ordered on 9/11/22.
Physician Order Sheet indicates Seroquel 25mg every night at bedtime was revised on 10/27/22 with
diagnosis changed to Delusional Disorder.
Current Physician Order Sheet indicates Seroquel 25mg was increased to be given twice daily on 11/9/22
for Delusional Disorder.
Telehealth Note dated 11/7/22 indicates R46 had increased exit-seeking, wandering into other resident's
rooms, yells and refuses care and had been verbally/physically aggressive with staff. Note indicates R46
wanted a gun to kill herself and was sent to the hospital, diagnosed with Cystitis, and started on antibiotics.
Note indicates R46 reported feeling better. Telehealth recommendations on 11/7/22 were to increase R46's
Seroquel to 25mg twice daily with diagnoses of Conduct Disorder, Restlessness/Agitation, Depressive and
Delusional Disorder and Anxiety.
Current Care Plan indicates R46 is currently on antipsychotic therapy related to dementia without
behavioral disturbance. Care Plan does not include target behaviors, specific indications for use or specify
Seroquel as the antipsychotic medication.
Psychotropic Medication Consent indicates consent was received on 9/12/22 for Seroquel 25mg at bedtime
with Indication for Use: Dementia with Aggression.
Psychotropic Medication Consent indicates consent was received on 11/9/22 for Seroquel 25mg twice daily
with Indication for Use: Delusional Disorder.
Behavior Tracking 10/1/22 to 11/16/22 indicates incomplete monitoring of behaviors identified as
exit-seeking and agitation.
3.) Physician's Order Sheet (POS) indicates R100 was admitted to the facility on [DATE] with diagnoses of
Unspecified Dementia without Behavioral Disturbance, Anxiety and Alzheimer's Disease.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146138
If continuation sheet
Page 6 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146138
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/18/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Mercer Manor Rehabilitation
309 N W 9th Avenue
Aledo, IL 61231
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0758
Level of Harm - Minimal harm
or potential for actual harm
POS indicates Risperdal (antipsychotic) 0.5mg once daily was ordered on 11/10/22 with diagnosis of
Dementia with other behavioral disturbance.
Psychotropic Medication Consent indicates consent for Risperdal 0.5mg was received on 11/10/22 with
Indication for Use: Dementia with Behavioral Disturbance.
Residents Affected - Some
Progress Notes dated 10/1/22 thru 11/16/22 indicate R100 was having a difficult time adjusting to the
locked unit, was exit-seeking and attempting to take screens off windows in empty rooms.
Telehealth Note dated 11/8/22 at 2:34pm indicates Recommend starting Risperdal; Diagnosis Dementia
with Behavioral Disturbance.
Current Care Plan indicates R100 is on an antipsychotic therapy related to Dementia. Care Plan does not
identify target behaviors.
On 11/15/22 at 10:15am R100 was working on a puzzle with a staff member. R100 was pleasant, smiling
and engaged. Several minutes later a hairdresser asked R100 if she wanted a haircut and R100 thanked
the hairdresser and allowed her to cut her hair. R100 seemed very happy to be getting her hair cut.
On 11/16/22 at 1:15pm R100 was smiling and interacting with staff.
At that time V8 (LPN) stated that both R46 and R100 are fairly new and can become very intent on going
back home.
On 11/17/22 at 1:30pm V1 (Administrator) stated that they are aware the Telehealth practitioners are
ordering more antipsychotic medications for residents with dementia than they should and are looking to
get a psychiatrist who will come to the facility and be part of the team.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146138
If continuation sheet
Page 7 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146138
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/18/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Mercer Manor Rehabilitation
309 N W 9th Avenue
Aledo, IL 61231
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
3.) On 11/16/2022 at 12:00 pm, V4 (CNA) and V6 (CNA) entered R43's room and stated they were there to
clean her up and help her lay down for a nap. Neither V4 nor V6 washed their hands upon entering the
room. Once in the bed, R43 rolled on her left side, V4 (CNA) washed bowel movement off her buttocks with
disposable wipes and V4 then applied skin protectant cream and then took off her right glove.
Residents Affected - Few
V4 and V6 continued to wash R43's front and back sides, never washing their hands and never changing
gloves. V4 (CNA) pulled up R43's covers, clipped her call light on her pillow and pulled her bedside table
over across the bed while touching items on the table. V6 (CNA) pushed the electronic lift to the hallway
and touched the door and touched roommate's bed with gloves still on from R43's incontinence care.
On 11/17/22 V2 (Director of Nursing) stated Staff should always wash their hands before, during and after
incontinence care before they touch anything else or leave the room.
Based on observation, interview and record review the facility failed to perform hand hygiene and glove
changes during incontinence care and wound care for three residents (R6, R12, R43) of five reviewed for
infection control in a sample of 23.
Findings include:
Facility Perineal/Incontinence Care Policy and Procedure, revised 11/5/2019, documents: to provide hand
hygiene and apply gloves; remove soiled brief/underpad and assure all area affected by incontinence have
been cleansed then remove gloves and perform hand hygiene and apply clean gloves; apply protective
ointment as a part of incontinence care, remove gloves and perform hand hygiene, discard contaminated
items in container, remove gloves and perform hand hygiene then reposition resident.
1.) On 11/16/22 at 12:01 pm, V4 (Certified Nursing Assistant/CNA), V5 (Licensed Practical Nurse/LPN) and
V6 (CNA) were in R6's room assisting with perineal care and wound care. V4 (CNA) entered R6's room,
applied gloves, rolled R6 pulled back the covers, removed R6's urine soiled incontinence brief. V4 (CNA)
removed clean incontinence wipes from a container that was retrieved out of R6's bedside table drawer. V4
performed perineal care and disposed of the soiled wipes into the trash receptacle. V4 then placed the
clean container of incontinence wipes into R6's bedside drawer. V4 then assisted V5 (LPN) with R6's stage
four coccyx/buttock pressure ulcer. V4 peeled back R6's soiled dressing, and as V4 was helping position R6
for V4 to change the dressing, R6's right hand was placed on R6's soiled coccyx and buttock. V4 then
applied a new incontinence brief, repositioned R6 and pulled up R6's bed covers. Then V4 (CNA)
proceeded to run V4's contaminated gloved hands through R6's hair and rubbed R6's ears and cheeks. V4
adjusted V4's face mask, and then adjusted R6's bed height and removed the contaminated gloves, and
exited R6's room. V4 did not perform any hand hygiene or glove change during R6's cares.
2.) R12's Physician Order Sheet, dated 11/17/22, documents that R12 has a skin tear to the right lower leg
(ankle) and has a treatment order for a daily dressing.
R12's Hospital Microbiology Report, dated 11/2/22, documents that R12 has Methicillin Resistant
Staphylococcus Aureus (MRSA) in the right leg (ankle).
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146138
If continuation sheet
Page 8 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146138
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/18/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Mercer Manor Rehabilitation
309 N W 9th Avenue
Aledo, IL 61231
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
On 11/16/22 at 12:25 pm, R12 was residing in an isolation room.
Level of Harm - Minimal harm
or potential for actual harm
On 11/16/22 at 12:25 pm, V4 (CNA) and V5 (LPN) were performing wound care to R12. V5 was out of
R12's room retrieving wound treatment supplies and V4 (CNA) entered R12's isolation room, and without
performing hand hygiene, applied gloves. V4 (CNA) proceeded to attempt to remove R12's right ankle
dressing, by inserting three middle fingers inside of R12's wound dressing. V4 then stated, I cannot get that
off, I need to get some scissors.
Residents Affected - Few
V4 (CNA), without V5 (LPN) in the room, then removed R12's infected Left Shin (MRSA) outer dressing,
and with the same contaminated gloves, attempted to remove the impacted wound bed dressing and was
unsuccessful. Then without performing hand hygiene and/or a glove change, V4 (CNA) proceeded to
remove R12's necklace and placed it on R12's bedside table. V4 (CNA) then adjusted R12's blankets and
clothing, then caressed/rubbed R12's face and neck. V4 then touched items on R12's bedside table and
walker. V4 then adjusted R12's bedroom slippers and walker. V5 (LPN) then entered R12's room and V4
(CNA) then helped position R12. V4 did not perform any hand hygiene or glove change during R12's cares.
On 11/16/22 at 12:10 pm, V4 (CNA) stated, We only change our gloves or wash our hands if our hands are
visibly soiled.
On 11/16/22 at 12:35 pm, V4 (CNA) stated, I always try and help the nurses take off the soiled dressings
when I can.
On 11/16/22 at 12:11 pm, V5 (LPN) stated, We do not have to wash our hands, put new gloves on or use
hand sanitizer unless our hands are visibly dirty.
On 11/16/22 at 12:37 pm, V5 (LPN) stated, (R12) is in isolation for MRSA infection in (R12's) left shin.
On 11/17/22 at 1:30 pm, V1 (Administrator) stated, We will in-service them on handwashing and glove
changes. They should be changing their gloves and washing their hands during cares, especially when they
are soiled from wound care or incontinence care.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146138
If continuation sheet
Page 9 of 9
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Back to topCitations
4 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F688 - Mobility
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
F758 - Medication Errors
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
F880 - Infection Control
Provide and implement an infection prevention and control program.
FAQ · About this visit
Common questions about this visit
What happened during the November 18, 2022 survey of MERCER MANOR REHABILITATION?
This was a inspection survey of MERCER MANOR REHABILITATION on November 18, 2022. The surveyor cited 4 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at MERCER MANOR REHABILITATION on November 18, 2022?
Yes, 4 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate pressure ulcer care and prevent new ulcers from developing."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.