Mesun Health and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Mesun Health and Rehabilitation Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Jul 18, 2024

  Based on observations, staff interviews, and review of the facility's policy titled Food Safety Requirements, the facility failed to ensure food items were properly stored, labeled with expiration dates, and that expired foods were disposed of in a timely manner. The deficient practice had the potential to affect 47 of 49 residents who consumed an oral diet. Findings include: Review of the undated facility's policy titled Food Safety Requirements, under Policy revealed, It is the policy of this facility to procure food from sources approved or considered satisfactory by federal, state, and local authorities. Food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety. […]

• No harm, potential for more than minimal, widespreadF880Jul 18, 2024

  Based on staff interviews and review of the facility's policies titled, Infection Prevention and Control Program and Water Management, the facility failed to develop an effective water management plan which included routine water management activities to prevent the growth and spread of Legionella and other opportunistic waterborne pathogens throughout the facility's water system. The facility's census was 49 residents. Review of the undated facility's policy titled, Infection Prevention and Control under Policy Explanation and Compliance Guidelines revealed the following: Number 17. […]

• No harm, potential for more than minimal, widespreadF867May 25, 2022

  Based on interviews, review of facility documentation, and policy review titled Quality Assurance Performance Improvement, the facility failed to ensure policies and procedures were implemented to address the facility's Quality Assessment and Performance Improvement (QAPI) plan and program, in which data was gathered, analyzed, developed, implemented, and re-evaluated to address adverse events related to potential deficient practice. This had the potential to affect all 44 residents residing in the facility at the time of the survey. Findings include: Review of the facility policy titled Quality Assurance Performance Improvement, dated 7/10/20, indicated . […]

• No harm, potential for more than minimal, widespreadF868May 25, 2022

  Based on record review, interviews, and review of facility policy titled Quality Assurance and Performance Improvement (QAPI), the facility failed to ensure that the Quality Assessment and Assurance (QAA) committee met at least quarterly. The census was 44. Findings include: Review of the facility policy titled Quality Assurance & Performance Improvement (QAPI), dated 7/20/20, indicated . Meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program, such as identifying issues with respect to which quality assessment and assurance activities, including performance improvement projects under the QAPI program, are necessary. Review of documents titled QAPI Sign In Sheet, for the year 2021, indicated the facility held QAPI meetings on a monthly basis. […]

• No harm, potential for more than minimal, widespreadF885May 25, 2022

  Based on record review, interview, and review of the Centers for Medicare and Medicaid Services (CMS) policy, the facility failed to ensure that all residents and/or their representatives were informed by 5:00 p.m. the next calendar day following the occurrence of a single resident or staff confirmed COVID-19 positive infection, received cumulative updates, and informed of mitigating actions taken by the facility to prevent or reduce the risk of transmission. The census was 44. Findings include: Review of CMS QSO-20-29-NH, dated 5/6/20, indicated, Facilities must .Inform residents, their representatives, and families of those residing in facilities by 5:00 p.m. […]