New Mercer Commons

A revisit survey was completed on 12/16/25 for all previous deficiencies cited on 8/20/25. The facility is in compliance with all deficiencies that were cited. Citation coded "0000" or "9999" are initial and final comments of an inspection for informational purposes, this field may also have been left blank intentionally

A relicensure survey and complaint investigation, prompted by #CO40182, #CO36848, and #CO35716 was completed on 8/20/25. A deficiency was cited. Based on interview and record review, the residence failed to implement effective actions that were to be taken by staff to prevent reocurrence of falls for one sample resident (#5) who fell. Findings include: Resident #5 was admitted to the residence on 9/3/24 with diagnoses including generalized weakness and left arm weakness. Progress notes for July and August 2025 revealed the following:On 7/12/25, Resident #5 had an unwitnessed fall in her room, which resulted in a 1.25-inch skin tear on her left elbow. Resident #5 attempted to self-transfer from the recliner to her wheelchair when she fell. On 8/9/25, Resident #5 had an unwitnessed fall in her room. Resident #5 attempted to self-transfer from her wheelchair to a chair when she fell and hit her head. On 8/12/25, Resident #5 had an unwitnessed fall in her room. Resident #5 attempted to self-transfer from her bed to her wheelchair when she fell.A care plan for Resident #5, last updated 8/13/25, revealed the resident was a fall risk and had a history of falls. The care plan contained the following individualized approaches to prevent falls: 10/8/24: Purposeful rounding program, give reminders not to ambulate/transfer without assistance.2/1/25: Encourage to call for assistance with transfers. 7/14/25: Evaluation for transfer pole. Transfer pole was declined by resident. 8/13/25: Power of Attorney to look at .. THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary.The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.13.12 The assisted living residence shall develop and implement policies and procedures for the identification, reporting, and investigation of injuries of unknown origin. Such policies and procedures shall include, but not be limited to, the following requirements:(A) The assisted living residence shall identify and document resident injuries for which the origin of the injury was not observed by or otherwise known by staff, and either:(1) The resident cannot explain how the injury occurred; or(2) The resident can explain the source of the injury, but the source could be addressed to prevent future injuries.(B) The assisted living residence shall document the following:(1) The investigation and identification of any injury identified in (A), above.(2) The implementation and outcome of the following for injuries for which the investigation determines the source/origin: (a) Compliance with Part 13.11, when the source/origin of the injury is suspected to be abuse, neglect, or exploitation; or (b) The steps taken to prevent or mitigate future injuries of like nature for both the injured resident and other residents when the..