Inspection Reports for
Mesun Health and Rehabilitation Center
88 JOHNSON ROAD, BUILDING #2, LAWRENCEVILLE, GA, 30046
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
10.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
114% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
28
21
14
7
0
Occupancy
Latest occupancy rate
48% occupied
Based on a September 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Nov 21, 2025
Visit Reason
The inspection was conducted due to complaints regarding the facility's failure to timely return deposited funds to a discharged resident's family and failure to conduct thorough investigations into allegations of potential abuse for two residents.
Complaint Details
The complaint investigation involved review of financial refund delays for Resident 88 and failure to investigate potential financial abuse of Resident 5 by their Responsible Party, as well as inadequate investigation of an injury incident involving Resident 3. The allegations were substantiated by record reviews and staff interviews.
Findings
The facility failed to return deposited funds within the federally required 30-day timeframe after discharge, causing potential financial harm. Additionally, the facility did not conduct thorough investigations into allegations of potential financial abuse and injury for two residents, risking ongoing harm.
Deficiencies (2)
F 0582: The facility failed to ensure timely return of deposited funds to a discharged resident's family, with the refund delayed beyond the required 30 days after discharge.
F 0610: The facility failed to conduct thorough investigations into allegations of potential abuse for two residents, including financial abuse and injury, risking ongoing effects related to abuse.
Report Facts
Refund deposit amount: 9750
Refund amount due: 8150
Resident sample size: 23
BIMS score: 3
BIMS score: 14
Room and board cost: 1300
Daily room and board rate: 325
Days between discharge and refund mailing: 32
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN2 | Licensed Practical Nurse | Named in relation to investigation of Resident 3's injury incident |
| Administrator | Interviewed regarding refund policy and investigation procedures | |
| Director of Therapy | DOT | Interviewed about Resident 3's injury during therapy session |
| DON | Director of Nursing | Interviewed about investigation of Resident 3's injury and facility policies |
Inspection Report
Routine
Deficiencies: 9
Date: Nov 21, 2025
Visit Reason
Routine inspection of Mesun Health and Rehabilitation Center to assess compliance with healthcare regulations, including resident care, medication administration, abuse reporting, and facility policies.
Findings
The facility was found deficient in multiple areas including delayed refund of resident funds, failure to monitor psychotropic medication side effects, untimely reporting and investigation of abuse allegations, lack of written transfer and bed hold notices, inconsistent activity programming, missing physician orders for urinary catheter use, inappropriate antibiotic prescribing, and medication administration errors.
Deficiencies (9)
F 0582: The facility failed to ensure timely return of deposited funds after resident discharge, delaying refund of $8,150 to the family beyond the required 30 days.
F 0605: The facility failed to monitor behaviors and side effects related to psychotropic medications for two residents, risking unnecessary medication effects.
F 0609: The facility failed to timely report suspected financial abuse of a resident and did not report to the State Agency as required.
F 0610: The facility failed to conduct thorough investigations into allegations of potential abuse for two residents, missing key interviews and documentation.
F 0628: The facility failed to provide a written bed hold policy and transfer notice to one resident and their representative after multiple hospital transfers.
F 0679: The facility failed to provide consistent activities per a resident's assessed preferences, with no documented participation over a month.
F 0690: The facility failed to have physician orders for the size and type of an indwelling suprapubic catheter for one resident.
F 0757: The facility failed to ensure clinical criteria were met before prescribing antibiotics for a urinary tract infection, resulting in unnecessary antibiotic use.
F 0759: The facility had a medication error rate of 8%, with two errors in 25 opportunities involving incorrect aspirin and multivitamin administration.
Report Facts
Refund amount: 8150
Medication error rate: 8
Medication errors: 2
Residents reviewed: 23
Residents reviewed for psychotropic medication: 6
Residents reviewed for abuse: 3
Residents reviewed for hospitalization: 1
Residents reviewed for urinary catheters: 2
Residents reviewed for antibiotic use: 1
Refund policy timeframe: 30
Refund policy timeframe (facility): 45
Medication administration opportunities: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN1 | Licensed Practical Nurse | Administered incorrect aspirin to resident R85 |
| RN1 | Registered Nurse | Administered incorrect multivitamin to resident R92 |
| Director of Nursing | Director of Nursing | Confirmed expectations for medication orders and monitoring |
| Administrator | Facility Administrator | Acknowledged delayed refund and failure to report abuse timely |
| Business Office Manager | Business Office Manager | Communicated with family regarding refund and abuse concerns |
| Director of Nursing | Director of Nursing | Confirmed failure to monitor psychotropic medication side effects |
| Social Services Director | Social Services Director | Reported concerns of financial abuse and lack of investigation |
| Activities Director | Activities Director | Confirmed lack of documented resident activity participation |
| Infection Preventionist | Infection Preventionist | Discussed antibiotic prescribing and criteria for UTI |
| Medical Doctor 1 | Physician | Prescribed antibiotic despite lack of clinical criteria for UTI |
| Nurse Practitioner | Nurse Practitioner | Ordered urine analysis and antibiotic for resident R79 |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Nov 4, 2024
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Mesun Health and Rehabilitation Center following a survey completed on November 4, 2024.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings within the provided page.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Nov 4, 2024
Visit Reason
A revisit survey was conducted via desk review on 11/4/2024 to verify correction of deficiencies cited in the 9/17/2024 Revisit Survey.
Findings
All deficiencies cited as a result of the 9/17/2024 Revisit Survey were found to be corrected.
Inspection Report
Deficiencies: 0
Date: Sep 17, 2024
Visit Reason
The document is a statement of deficiencies and plan of correction for Mesun Health and Rehabilitation Center following a survey completed on 09/17/2024.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Re-Inspection
Census: 48
Deficiencies: 1
Date: Sep 17, 2024
Visit Reason
A revisit survey was conducted on 9/17/2024 to assess the facility's compliance following deficiencies identified during the 7/18/2024 recertification survey.
Findings
The facility failed to ensure that required Minimum Data Set (MDS) assessments were transmitted within 14 days after completion to CMS for five out of 51 sampled residents, including current and discharged residents. The facility employed temporary MDS staff and contracted agencies to address the backlog of assessments.
Deficiencies (1)
Failed to ensure timely transmission of required Minimum Data Set (MDS) assessments within 14 days after completion for five sampled residents.
Report Facts
Facility census: 48
Sampled residents: 51
Discharge assessments remaining: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Coordinator | Confirmed backlog of MDS assessments and ongoing efforts to complete them | |
| Administrator | Confirmed contracting agency involvement and oversight of MDS assessments | |
| Director of Nursing | Director of Nursing (DON) | Responsible for completing MDS assessments as part of Plan of Correction |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Responsible for completing MDS assessments as part of Plan of Correction |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Sep 3, 2024
Visit Reason
A follow-up survey was conducted to verify correction of previously cited deficiencies.
Findings
All previously cited E-tags have been corrected as noted during the follow-up survey.
Inspection Report
Annual Inspection
Census: 49
Deficiencies: 5
Date: Jul 18, 2024
Visit Reason
Annual inspection survey conducted to assess compliance with regulatory requirements for nursing home operations including resident care, food safety, infection control, and care planning.
Findings
The facility was found deficient in timely submission of Minimum Data Set (MDS) assessments for 31 residents, failure to develop baseline care plans addressing high-risk medications for one resident, incomplete care plans lacking communication preferences for a non-English speaking resident, improper food storage and labeling practices in the kitchen, and an ineffective water management plan to prevent Legionella and other waterborne pathogens.
Deficiencies (5)
F0640: The facility failed to ensure timely transmission of required MDS assessments to CMS for 31 residents due to lack of RN signatures and staffing issues.
F0655: The facility failed to develop a baseline care plan within 48 hours of admission addressing two high-risk medications for one resident, potentially causing adverse medical effects.
F0656: The facility failed to develop a comprehensive care plan that included communication or language preferences for a non-English speaking resident, potentially impacting quality of care.
F0812: The facility failed to properly store, label, and dispose of food items, including use of dented cans, unlabeled opened foods, and expired products, risking resident safety.
F0880: The facility failed to develop an effective water management plan including routine activities to prevent growth and spread of Legionella and other waterborne pathogens.
Report Facts
Residents affected: 31
Facility census: 49
Residents affected: 47
Staff turnover: 4
Inspection Report
Annual Inspection
Census: 49
Deficiencies: 5
Date: Jul 18, 2024
Visit Reason
Annual inspection survey conducted to assess compliance with regulatory requirements for nursing home operations including resident care, medication management, food safety, infection control, and care planning.
Findings
The facility was found deficient in timely submission of Minimum Data Set (MDS) assessments for 31 residents, failure to develop baseline care plans addressing key medications for one resident, incomplete care plans lacking communication preferences for a non-English speaking resident, improper food storage and labeling practices in the kitchen, and an ineffective water management plan to prevent Legionella and other waterborne pathogens.
Deficiencies (5)
F0640: The facility failed to ensure required MDS assessments were transmitted timely to CMS for 31 residents due to lack of RN signatures and staffing issues.
F0655: The facility failed to develop a baseline care plan within 48 hours of admission addressing two medications (opioid and diuretic) for one resident, risking adverse medical effects.
F0656: The facility failed to develop a comprehensive care plan including communication/language preferences for a non-English speaking resident, potentially impacting quality of care.
F0812: The facility failed to properly store, label, and dispose of food items, including use of dented cans, unlabeled opened foods, and expired products, risking resident safety.
F0880: The facility failed to develop an effective water management plan including routine activities to prevent growth and spread of Legionella and other waterborne pathogens.
Report Facts
Residents affected by MDS transmission deficiency: 31
Facility census: 49
Residents affected by baseline care plan deficiency: 1
Residents affected by communication care plan deficiency: 1
Residents affected by food safety deficiency: 47
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Provided information on staffing and oversight of MDS submission and kitchen management | |
| Assistant Director of Nursing | ADON | Interviewed regarding MDS workflow, baseline care plans, and communication care plans |
| Director of Nursing | DON | Responsible RN for signing MDS assessments; interviewed about MDS submission delays |
| MDS Coordinator | Interviewed about MDS assessment submission issues | |
| Minimum Data Set Licensed Practical Nurse | MDS LPN | Responsible for developing care plans and MDS assessments |
| Certified Dietary Manager | CDM BB | On vacation during inspection; responsible for kitchen food safety oversight |
| Infection Prevention and Control Nurse | IPCN | Interviewed about infection control and water management program |
| Maintenance Director | Interviewed about water system monitoring and Legionella prevention | |
| Registered Dietitian Consultant | RD | Provided dietary compliance observations and recommendations |
Inspection Report
Life Safety
Census: 47
Capacity: 100
Deficiencies: 8
Date: Jul 18, 2024
Visit Reason
The inspection was conducted to review the facility's compliance with emergency preparedness requirements and life safety code standards, including fire safety and related regulations.
Findings
The facility was found not in substantial compliance with emergency preparedness plan requirements, including failure to conduct required annual exercises and update the plan annually. Life safety deficiencies included improperly marked egress doors, hazardous areas not properly enclosed, sprinkler system maintenance issues, unsealed smoke barrier penetrations, electrical safety violations, and improper oxygen cylinder storage.
Deficiencies (8)
Emergency Preparedness Plan was not in substantial compliance; no documentation of annual full-scale community-based exercise and tabletop exercise.
Emergency Preparedness Plan was not reviewed and updated annually; last update was in 2022.
Means of egress door to second floor outdoor patio not properly marked as 'No Exit'.
Fire-fired gas equipment room door held open with wooden wedge and door latch stuffed with paper preventing proper latching.
Sprinkler piping used to support low voltage wiring; storage within 18 inches of sprinkler head in kitchen dry storage room.
Numerous unsealed penetrations in smoke barrier walls on second floor near Room #228 and Quiet Room.
Open electrical junction box in second floor mechanical room; relocatable power taps not mounted to protect against physical damage.
Oxygen cylinder storage not properly separated five feet from combustible storage.
Report Facts
Certified beds: 100
Census: 47
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A and Staff M confirmed findings related to emergency preparedness plan deficiencies. | ||
| Staff M confirmed findings related to life safety code deficiencies during facility tour. |
Inspection Report
Annual Inspection
Census: 49
Deficiencies: 3
Date: Jul 18, 2024
Visit Reason
The inspection was a State Licensure survey conducted to determine compliance with the State Long Term Care Requirements at Mesun Health and Rehabilitation Center.
Findings
The facility was cited for deficiencies including failure to develop a care plan addressing communication/language preferences for a non-English speaking resident, lack of an effective water management plan to prevent Legionella growth, and improper food storage and labeling practices that could affect residents' safety.
Deficiencies (3)
Failure to develop a care plan that included a communication or language preference for one of three sampled residents whose primary language was not English.
Failure to develop an effective water management plan including routine activities to prevent growth and spread of Legionella and other waterborne pathogens.
Failure to ensure food items were properly stored, labeled with expiration dates, and expired foods were disposed of timely, potentially affecting 47 of 49 residents.
Report Facts
Facility census: 49
Residents affected by food storage deficiency: 47
Sampled residents for care plan review: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cook GG | Cook | Interviewed regarding food storage and labeling practices |
| CDM BB | Certified Dietary Manager | Mentioned as responsible for kitchen management and food labeling; was on vacation during inspection |
| Registered Dietitian Consultant | Registered Dietitian Consultant | Interviewed about dietary needs and kitchen compliance observations |
| MDS Licensed Practical Nurse | Licensed Practical Nurse | Interviewed regarding MDS process and resident communication preferences |
| Registered Nurse AA | Registered Nurse | Interviewed about communication tools used with residents |
| Certified Nursing Assistant II | Certified Nursing Assistant | Interviewed about communication methods with non-English speaking residents |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed about care plan responsibilities and communication focus |
| Medical Director | Medical Director | Interviewed about importance of communication focus in care plans |
| Infection Prevention and Control Nurse | Infection Prevention and Control Nurse | Interviewed about water management plan and Legionella prevention |
| Administrator | Administrator | Interviewed about water management practices and kitchen oversight |
| Maintenance Director | Maintenance Director | Interviewed about water system temperature checks and Legionella testing |
Inspection Report
Annual Inspection
Census: 49
Deficiencies: 5
Date: Jul 18, 2024
Visit Reason
A standard annual survey was conducted at Mesun Health and Rehabilitation Center from July 16 through July 18, 2024, including investigation of two complaint intake numbers, one substantiated without deficiency and one unsubstantiated.
Complaint Details
Complaint Intake Number GA00244972 was substantiated without a deficiency cited. Complaint Intake Number GA00242199 was unsubstantiated.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to timely transmit Minimum Data Set assessments, incomplete baseline and comprehensive care plans, improper food storage and labeling, and lack of an effective water management plan to prevent Legionella growth.
Deficiencies (5)
Failed to ensure required Minimum Data Set (MDS) assessments were transmitted within regulatory guidelines for 31 out of 44 sampled residents.
Failed to develop a baseline care plan within 48 hours of admission addressing two medications (opioid and diuretic) for one resident (R33).
Failed to develop a care plan that included communication or language preference for one resident (R179) whose primary language was not English.
Failed to ensure food items were properly stored, labeled with expiration dates, and expired foods were disposed of timely, potentially affecting 47 of 49 residents.
Failed to develop an effective water management plan including routine activities to prevent growth and spread of Legionella and other waterborne pathogens.
Report Facts
Residents sampled for MDS transmission: 44
Facility census: 49
Number of MDS RN Coordinators in last year: 4
Days MDS assessments are to be transmitted within: 14
Baseline care plan development timeframe: 48
Expiration dates found on expired food items: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed regarding MDS submission delays and kitchen oversight during CDM absence | |
| Director of Nursing (DON) | Director of Nursing | Responsible for signing MDS assessments; position vacant during inspection |
| Assistant Director of Nursing (ADON) | Assistant Director of Nursing | Interviewed about MDS workflow and care plan processes |
| MDS Coordinator | Confirmed 31 residents' MDS assessments were not submitted due to lack of RN signature | |
| Cook GG | Interviewed about food storage and labeling practices | |
| Certified Dietary Manager (CDM) BB | Certified Dietary Manager | On vacation during inspection; responsible for kitchen management |
| Registered Dietitian Consultant (RD) | Registered Dietitian Consultant | Conducts monthly kitchen observations and dietary recommendations |
| Infection Prevention and Control Nurse (IPCN) | Infection Prevention and Control Nurse | Interviewed about water management plan and infection control |
| Maintenance Director | Maintenance Director | Performs daily water temperature checks and annual Legionella testing |
Inspection Report
Deficiencies: 0
Date: Jan 22, 2024
Visit Reason
The document is a statement of deficiencies and plan of correction for Mesun Health and Rehabilitation Center following a survey completed on January 22, 2024.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Follow-Up
Census: 42
Deficiencies: 0
Date: Jan 22, 2024
Visit Reason
A health revisit survey was conducted to verify correction of deficiencies cited in the December 6, 2023, Complaint Investigation Survey.
Findings
All deficiencies cited in the prior complaint investigation survey were found to be corrected during this revisit survey.
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Dec 6, 2023
Visit Reason
The inspection was conducted as a State Licensure survey at Mesun Health and Rehabilitation Center from November 8, 2023 through December 6, 2023 to determine compliance with the State Long Term Care Requirements.
Findings
The facility failed to implement policies and procedures to ensure timely reporting of reasonable suspicion of a crime related to sexual abuse allegations involving two residents. Specifically, the facility did not report incidents of resident R5 exhibiting sexually aggressive behavior, including exposing himself to resident R8, to the State Survey Agency within the required timeframe.
Deficiencies (1)
Failure to report allegations of sexual abuse involving resident R5 exposing himself and making sexual advances to resident R8 within the required timeframe.
Report Facts
Residents involved: 2
Survey period: 29
BIMS score for R5: 8
BIMS score for R8: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator AA | Abuse Coordinator | Interviewed regarding awareness and reporting of the sexual abuse incident |
| Activities Assistant BB | Interviewed regarding the incident involving resident R5 and R8 |
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 2
Date: Dec 6, 2023
Visit Reason
An Abbreviated/Partial Extended Survey was conducted from November 8, 2023 to December 6, 2023 to investigate multiple complaints including GA00240798, which was substantiated with deficiencies related to sexual abuse and failure to report allegations properly.
Complaint Details
Complaint number GA00240798 was substantiated with deficiencies related to sexual abuse and failure to report. Other complaints investigated were unsubstantiated.
Findings
The facility failed to protect a resident (R1) from sexual abuse by another resident (R5) who exhibited inappropriate sexual behaviors including exposing himself and touching female residents. The facility also failed to report allegations of sexual abuse involving R5 to the State Survey Agency within required timeframes. Multiple interviews and record reviews confirmed these deficiencies.
Deficiencies (2)
Failed to protect resident R1 from sexual abuse by resident R5 who exposed himself, masturbated, and inappropriately touched female residents.
Failed to report allegations of sexual abuse by resident R5 to the State Survey Agency within the required timeframe.
Report Facts
Residents present: 54
Complaint numbers investigated: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator AA | Administrator and Abuse Coordinator | Aware of incident involving R5 exposing himself; stated incident was not reported to SSA |
| Certified Nursing Assistant CC | Certified Nursing Assistant | Witnessed R5 exposing himself and grabbing resident R1's breast |
| Activities Assistant BB | Activities Assistant | Observed R5 exposing himself to resident R8 and reported behavior |
| Director of Nursing | Director of Nursing | Interviewed regarding lack of trauma assessment and staff education after incident |
| Social Services Director | Social Services Director | Interviewed regarding lack of abuse reporting poster and follow-up with resident R1 |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Dec 6, 2023
Visit Reason
The inspection was conducted due to complaints and allegations of sexual abuse and failure to report suspected abuse involving residents R1, R5, and R8 at the facility.
Complaint Details
The complaint investigation substantiated that resident R5 sexually abused resident R1 and exhibited sexually aggressive behavior toward resident R8. The facility failed to protect residents and failed to report the incidents timely to the State Survey Agency.
Findings
The facility failed to protect resident R1 from sexual abuse by resident R5, who exhibited inappropriate sexual behaviors including exposing himself and touching female residents. Additionally, the facility failed to timely report suspected sexual abuse involving residents R5 and R8 to the State Survey Agency as required.
Deficiencies (2)
F 0600: The facility failed to protect resident R1 from sexual abuse by resident R5, who exposed himself, asked female residents to touch his penis, and groped R1's chest. The facility also lacked a trauma assessment and did not provide emotional support or proper follow-up after the incident.
F 0609: The facility failed to timely report suspected sexual abuse involving resident R5 exposing himself and asking resident R8 to touch his private parts to the State Survey Agency within the required timeframe.
Report Facts
Residents Affected: 2
Date of Incident: Nov 6, 2023
Date of Incident: Oct 25, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CC | Certified Nursing Assistant | Witnessed R5 exposing himself and groping resident R1 |
| AA | Administrator | Abuse coordinator; aware of incidents and reporting failures |
| BB | Activities Assistant | Observed R5 exposing himself to resident R8 and intervened |
| Director of Nursing | Director of Nursing | Interviewed regarding lack of trauma assessment and staff education |
| Social Services Director | Social Services Director | Interviewed about lack of abuse reporting poster and follow-up |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Sep 7, 2022
Visit Reason
A revisit survey was conducted on 2022-09-06 through 2022-09-07 to verify correction of deficiencies cited in the 2022-05-25 Recertification Survey.
Findings
All deficiencies cited as a result of the 2022-05-25 Recertification Survey were found to be corrected during this revisit survey.
Inspection Report
Re-Inspection
Census: 43
Deficiencies: 0
Date: Sep 7, 2022
Visit Reason
A revisit survey was conducted on 9/6/22 through 9/7/22 to verify correction of deficiencies from the 5/25/22 Recertification Survey and to investigate two complaint intake numbers GA00225550 and GA00226367.
Complaint Details
Complaint Intake Number GA00226367 was substantiated with no deficiencies and GA00225550 was unsubstantiated.
Findings
All deficiencies cited in the 5/25/22 Recertification Survey were found to be corrected. The complaint investigation found GA00226367 was substantiated with no deficiencies and GA00225550 was unsubstantiated.
Inspection Report
Re-Inspection
Census: 43
Deficiencies: 0
Date: Sep 7, 2022
Visit Reason
A revisit survey was conducted on 9/6/22 through 9/7/22 in conjunction with complaint investigations of Intake Numbers GA00225550 and GA00226367.
Complaint Details
Complaint Intake Number GA00226367 was substantiated with no deficiencies; GA00225550 was unsubstantiated.
Findings
All deficiencies cited as a result of the 5/25/22 Recertification Survey were found to be corrected. The complaint investigation found GA00226367 was substantiated with no deficiencies and GA00225550 was unsubstantiated.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Aug 4, 2022
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited survey tags.
Findings
All previously cited survey tags have been corrected as noted during the follow-up survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jun 28, 2022
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00225387.
Complaint Details
Complaint GA00225387 was investigated and found to be unsubstantiated with no deficiencies.
Findings
The complaint GA00225387 was unsubstantiated and no deficiencies were found during the survey.
Inspection Report
Annual Inspection
Deficiencies: 4
Date: May 25, 2022
Visit Reason
The inspection was conducted as a State Licensure Survey from May 22, 2022 through May 25, 2022 to assess compliance with healthcare facility regulations including use of restraints, infection control, care planning, and vaccination protocols.
Findings
The facility was found deficient in multiple areas including improper use of physical restraints without physician orders or consent, failure to follow isolation and infection control procedures for residents with COVID-19 and C. difficile, inadequate development of comprehensive care plans for several residents, and failure to offer or properly document pneumococcal vaccinations in accordance with updated CDC guidelines.
Deficiencies (4)
Failure to assess and obtain physician orders, consent, and re-evaluate use of a medical hand mitten restraint for resident #141.
Failure to implement effective infection control program including improper use of PPE and failure to follow isolation precautions for residents #193, #191, #1, and #13.
Failure to develop and implement person-centered comprehensive care plans with measurable goals for residents #29, #12, #40, #1, and #141.
Failure to offer pneumococcal vaccination or properly document consent/refusal for residents #11, #26, and #241 according to updated CDC guidelines.
Report Facts
Residents reviewed for care planning: 20
Residents with care planning deficiencies: 5
Residents reviewed for vaccination: 5
Residents with vaccination deficiencies: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN DD | Registered Nurse | Interviewed regarding mitten restraint use on resident #141 |
| DON | Director of Nursing | Interviewed regarding restraint use and vaccination documentation |
| MD | Medical Director | Interviewed regarding infection control policies and quarantine expectations |
| MDS Coordinator | Confirmed care planning deficiencies for residents #29, #12, and #1 | |
| CNA AA | Certified Nursing Assistant | Observed and interviewed regarding isolation precautions for resident #193 |
| RN BB | Registered Nurse | Observed and interviewed regarding PPE use for residents #191 and #193 |
| PT VV | Physical Therapist | Observed and interviewed regarding PPE use with resident #1 |
| HK TT | Housekeeper | Observed and interviewed regarding PPE use and glove changing |
| LPN EE | Licensed Practical Nurse | Observed and interviewed regarding PPE use with resident #13 |
| CNA II | Certified Nursing Assistant | Interviewed regarding care of resident #13 and PPE use |
| CRNP HH | Certified Registered Nurse Practitioner | Interviewed regarding isolation status of resident #13 |
Inspection Report
Routine
Census: 44
Deficiencies: 15
Date: May 25, 2022
Visit Reason
Routine inspection of Mesun Health and Rehabilitation Center to assess compliance with healthcare regulations including resident care, infection control, and facility operations.
Findings
The facility had multiple deficiencies including failure to provide written advance directive information, improper use of restraints without physician orders or consent, incomplete abuse investigations, delayed baseline and comprehensive care plans, inadequate fall prevention interventions, failure to assess and notify for significant weight loss, incomplete facility-wide assessment, ineffective quality assurance program, missed quarterly QAPI meetings, lapses in infection control practices, failure to offer pneumococcal vaccinations per updated CDC guidelines, delayed COVID-19 notifications to residents and families, and incomplete staff COVID-19 vaccination compliance and policy.
Deficiencies (15)
F 0578: Facility failed to provide written information on advance directives to residents R#12 and R#1 as required.
F 0604: Facility failed to assess, obtain physician orders, consent, and re-evaluate use of a mitten restraint on resident R#141.
F 0607: Facility failed to conduct employment reference checks for the Administrator prior to hire.
F 0610: Facility failed to conduct a thorough investigation for an injury of unknown origin for resident R#1.
F 0655: Facility failed to develop baseline care plans within 48 hours of admission for five residents including R#242, R#1, R#40, R#193, and R#141.
F 0656: Facility failed to develop and implement comprehensive care plans with measurable goals for residents including R#29, R#12, R#40, R#1, and R#141.
F 0689: Facility failed to ensure adequate supervision and fall prevention interventions for resident R#29 who sustained multiple falls.
F 0692: Facility failed to assess nutritional status and notify physician after significant weight loss for resident R#29.
F 0838: Facility failed to conduct and document a comprehensive facility-wide assessment addressing staff competencies, equipment, and resources.
F 0867: Facility failed to implement an effective Quality Assurance Performance Improvement program addressing identified deficient practices.
F 0868: Facility failed to hold required quarterly Quality Assessment and Assurance committee meeting in March 2022.
F 0880: Facility failed to implement infection control precautions for residents R#193, R#191, R#1, and R#13, including improper PPE use and isolation procedures.
F 0883: Facility failed to offer pneumococcal vaccination or document education and consent/refusal for residents R#11, R#26, and R#241 per updated CDC guidelines.
F 0885: Facility failed to timely notify residents and families of COVID-19 positive staff infection and provide cumulative updates as required.
F 0888: Facility failed to ensure 100% staff COVID-19 vaccination compliance and lacked a comprehensive staff vaccination policy consistent with CMS guidelines.
Report Facts
Resident census: 44
Staff vaccination rate: 88.2
Weight loss percentage: 5.26
Number of residents with delayed baseline care plans: 5
Number of residents with incomplete care plans: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN BB | Registered Nurse | Named in injury investigation deficiency for resident R#1 |
| LPN JJ | Licensed Practical Nurse | Named in staff COVID-19 vaccination deficiency |
| CNA LL | Certified Nursing Assistant | Named in staff COVID-19 vaccination deficiency |
| CNA MM | Certified Nursing Assistant | Named in staff COVID-19 vaccination deficiency |
| Administrator | Facility Administrator | Named in employment reference and QAPI deficiencies |
| DON | Director of Nursing | Named in multiple deficiencies including infection control and vaccination |
| MD | Medical Director | Named in infection control and COVID-19 notification deficiencies |
| PT VV | Physical Therapist | Named in infection control deficiency for improper PPE use |
| HK TT | Housekeeper | Named in infection control deficiency for improper PPE use |
Inspection Report
Life Safety
Census: 45
Capacity: 100
Deficiencies: 1
Date: May 23, 2022
Visit Reason
The inspection was conducted to review the Emergency Preparedness Plan and to perform a Life Safety Code Survey for Mesun Health and Rehabilitation Center.
Findings
The Emergency Preparedness Plan was found not to be in substantial compliance with 42 CFR 483.73 due to lack of documentation of the Fire Safety Plan on site. However, the facility was found in substantial compliance with Life Safety Code requirements for Medicare/Medicaid participation.
Deficiencies (1)
Emergency Preparedness Plan was not in substantial compliance with 42 CFR 483.73 due to no documentation of the Fire Safety Plan available for review on site.
Report Facts
Stories: 2
Construction Type: 2
Certified Beds: 100
Census: 45
Construction Completion Date: May 19, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings regarding lack of Fire Safety Plan documentation |
Inspection Report
Life Safety
Census: 2
Capacity: 100
Deficiencies: 0
Date: Jan 6, 2021
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 Edition.
Findings
The facility was found in substantial compliance with the Emergency Preparedness Plan requirements and Life Safety Code standards.
Report Facts
Certified Beds: 100
Census: 2
Inspection Report
Original Licensing
Census: 2
Deficiencies: 0
Date: Nov 24, 2020
Visit Reason
An initial certification survey was conducted at Mesun Health and Rehabilitation between November 23, 2020 and November 24, 2020.
Findings
The facility was in substantial compliance with Medicare/Medicaid regulations at 42 Code of Federal Regulations Part 483, Subpart B - Requirements for Long Term Care Facilities.
Inspection Report
Original Licensing
Deficiencies: 0
Date: Aug 21, 2020
Visit Reason
An initial walk-through licensure survey was conducted at Mesun Health & Rehabilitation Center on August 21, 2020 to determine compliance with state requirements.
Findings
The facility was found to be in compliance with state requirements during the initial licensure survey.
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