F 0677
Provide care and assistance to perform activities of daily living for any resident who is unable.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to provide twice weekly showers for one of four residents (R3),
reviewed for showers, in a sample of 7.
Residents Affected - Few
Findings Include:
The facility policy, Shower Care, dated November 24, 2020 directs staff, It is the practice of this facility to
assist residents with bathing to maintain proper hygiene and help prevent skin conditions.
R3's Physician Order Sheet, dated April 2024 documents that R3 was admitted to the facility on [DATE]
with the following diagnoses: Dementia and Parkinson's Disease.
The (undated) facility Shower List documents that R3 is to receive morning showers on Wednesday and
Saturday.
R3's Care Plan, dated 12/12/2023 documents that R3 requires staff assistance for all Activities of Daily
Living (ADLs).
A review of R3's Certified Nursing Assistant Shower Sheet documents that R3 only received showers 20
out of 34 times, for the period of 12/9/23 through 4/3/24.
On 4/6/24 at 11:00 AM, V3 (Certified Nursing Assistant) stated, There's no reason why (R3) missed so
many showers. (R3) likes his showers.
On 4/6/24 at 11:10 A.M., V4 (Certified Nursing Assistant) verified the missing showers for (R3) and also
stated that (R3) enjoyed his showers and didn't fight the staff when it was time for a shower.
On 4/6/24 at 12:05 P.M., V1 (Director of Nurses) confirmed that R3 was admitted to the facility on [DATE],
had not been discharged from the facility during the timeframe of 12/9/23 through 4/3/24 and was missing
shower sheets to verify that R3 received his twice weekly showers.
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 2
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
04/07/2024
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 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation, interview, and record review, facility dietary staff failed to have their hair restrained
while handling and preparing food. This failure has the potential to affect all 60 residents currently residing
in the facility.
Findings Include:
The facility policy, Personnel Adherence to Sanitary Procedures, dated November 5, 2019 directs staff,
Food services personnel shall follow appropriate sanitary procedures. In addition to employee personnel
policies, food services and dietary personnel will be required to adhere to the following sanitary standards:
Hair nets or approved hats, covering all of the hair, will be worn while handling or preparing food.
On 4/6/24 from 8:30 A.M. until 8:55 A.M., V11 (Dietary Assistant) was in the facility Main Dining Room
serving the morning meal from the facility steam table. V11 had no hair net or approved hat on. V11's hair
was unrestrained while V11 leaned over the steam table, plating food for the facility residents. V11 was
observed pouring drinks from the facility drink cart; going into the facility kitchen to retrieve a canister of
brown sugar and removing a scoop of sugar, placing it in a small glass dish and placing it in front of R3;
filling the facility heated, wheeled food cart with filled plates; and delivering filled plates of food to R3, R5,
and R6. At that time, V11 stated she had been at work since 6:00 A.M.
During this same timeframe, V12 (Dietary Assistant) was in the facility dish room, washing dishes. V12 had
a black cap covering the top of her head with loose hair hanging from the front, sides and back. V13
(Dietary Cook) was observed going into and out of the facility kitchen, making peanut butter and jelly
sandwiches, with a hairnet in place. Loose hair was unrestrained in the front, sides and back of V13's hair
net.
On 4/6/24 at 10:35 A.M., V10 (Dietary Manager) verified that facility dietary staff were to have all hair
restrained while handling and preparing food.
The facility Room Roster, verified and provided by V1 (Director of Nurses) dated 4/6/24 documents that 60
residents currently reside in the facility.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146138
If continuation sheet
Page 2 of 2
