Inspection Report Summary
The most recent inspection on March 13, 2025 found no deficiencies, confirming that previously cited issues were corrected. Earlier inspections showed a pattern of deficiencies primarily related to medication management, resident care including assistance with activities of daily living, food service quality, and environmental sanitation. Complaint investigations in January 2025 substantiated some of these issues, including failure to report resident-to-resident sexual abuse within required timeframes and inadequate wound and respiratory care, while other complaints were unsubstantiated. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility appears to have addressed prior deficiencies effectively, as indicated by the clean results in the most recent follow-up surveys.
Deficiencies (last 9 years)
Deficiencies (over 9 years)
5.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
18% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
87 residents
Based on a March 2025 inspection.
Census over time
Inspection Report
Deficiencies: 0
Mar 13, 2025
Visit Reason
The document is a statement of deficiencies and plan of correction for Abercorn Rehabilitation Center following a regulatory inspection.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Re-Inspection
Census: 87
Deficiencies: 0
Mar 13, 2025
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the January 24, 2025 recertification/complaint survey.
Findings
All deficiencies cited in the prior January 24, 2025 recertification/complaint survey were found to be corrected during this revisit survey.
Inspection Report
Follow-Up
Deficiencies: 0
Mar 10, 2025
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 by the surveyor.
Inspection Report
Life Safety
Census: 96
Capacity: 100
Deficiencies: 2
Jan 29, 2025
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with life safety requirements due to a housekeeping closet door in the laundry area that did not self-close and a fire sprinkler system that had a yellow tag indicating repairs were needed instead of a green tag.
Severity Breakdown
SS= D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Housekeeping closet door in the laundry area did not self-close as required. | SS= D |
| Fire sprinkler system had a yellow tag on the fire riser indicating repairs required, not a green tag. | SS= D |
Report Facts
Census: 96
Total Capacity: 100
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings related to door closure and fire sprinkler system during tour |
Inspection Report
Annual Inspection
Deficiencies: 6
Jan 24, 2025
Visit Reason
A State Licensure survey was conducted at Abercorn Rehabilitation Center from January 21, 2025 through January 24, 2025 to assess compliance with state health regulations and identify any deficiencies.
Findings
The survey revealed multiple deficiencies including failure to report resident-to-resident sexual abuse within the required timeframe, provision of cold and unpalatable food, unsafe self-administration and storage of medications, inadequate assistance with activities of daily living, and poor environmental sanitation and housekeeping.
Deficiencies (6)
| Description |
|---|
| Failure to report an allegation of resident-to-resident sexual abuse within two hours for two residents. |
| Failure to ensure residents were provided with food that was palatable and at a safe and appetizing temperature. |
| Failure to ensure four residents had medications available for self-administration and stored at bedside only when assessed safe and with physician's order. |
| Failure to provide staff assistance with activities of daily living for one resident, leading to decline in ADLs. |
| Failure to maintain resident rooms in a clean, homelike environment for three residents. |
| Failure to repair damaged bed footboard exposing rough surface, posing risk of injury. |
Report Facts
Residents sampled for abuse reporting: 7
Residents reviewed for food service: 31
Residents reviewed for medication self-administration: 90
Residents reviewed for activities of daily living: 31
Residents reviewed for homelike environment: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN2 | Registered Nurse | Named in failure to report resident-to-resident sexual abuse allegation |
| RN1 | Unit Manager | Involved in decision to allow privacy during resident sexual activity |
| Director of Nursing | Director of Nursing | Provided information on reporting requirements and investigation |
| Dietary Manager | Dietary Manager | Interviewed regarding complaints of cold food |
| LPN1 | Licensed Practical Nurse | Observed medications improperly stored at bedside |
| LPN4 | Licensed Practical Nurse | Left inhalers unattended on resident's bed |
| CNA4 | Certified Nurse Aide | Documented failure to provide bed bath and observed room conditions |
| Housekeeper | Housekeeper | Reported cleaning schedule and observations of resident room |
| Director of Maintenance | Director of Maintenance | Responsible for maintenance and repair of damaged bed footboard |
| Administrator | Administrator | Provided statements on food complaints and resident room clutter |
Inspection Report
Complaint Investigation
Census: 90
Deficiencies: 8
Jan 24, 2025
Visit Reason
A standard survey was conducted at Abercorn Rehabilitation Center from January 21, 2025, through January 24, 2025, including investigations of multiple complaint intake numbers, some of which were substantiated with deficiencies.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to ensure medications were properly self-administered with physician orders, failure to maintain a clean homelike environment, failure to report resident-to-resident sexual abuse within required timeframes, failure to develop a baseline care plan within 48 hours of admission, failure to provide adequate assistance with activities of daily living, failure to provide wound care per physician orders, failure to provide proper respiratory care, and failure to provide food at safe and appetizing temperatures.
Complaint Details
Complaint Intake numbers GA00246947 and GA00240371 were substantiated with deficiencies. Other complaint intake numbers were found unsubstantiated.
Severity Breakdown
Level E: 1
Level D: 7
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to ensure four residents had medications available for self-administration only when assessed safe and with physician's order. | Level E |
| Failure to ensure resident rooms were clean, creating a homelike environment for three residents. | Level D |
| Failure to report an allegation of resident-to-resident sexual abuse within two hours for two residents. | Level D |
| Failure to develop and implement a baseline care plan within 48 hours of admission for one resident. | Level D |
| Failure to provide staff assistance with activities of daily living for one resident. | Level D |
| Failure to provide wound care per physician's orders for one resident. | Level D |
| Failure to provide respiratory care in accordance with professional standards for two residents. | Level D |
| Failure to provide residents with food that was palatable and at a safe and appetizing temperature for three residents. | Level D |
Report Facts
Residents observed for medication self-administration: 4
Residents reviewed for homelike environment: 8
Residents sampled: 7
Residents sampled for baseline care plan: 6
Residents sampled for activities of daily living: 2
Residents sampled for wound care: 31
Residents sampled for respiratory care: 22
Residents sampled for food service: 31
Resident census: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN1 | Registered Nurse | Named in medication self-administration and wound care findings. |
| LPN1 | Licensed Practical Nurse | Observed medication storage issues and interviewed regarding medication findings. |
| LPN4 | Licensed Practical Nurse | Observed medication storage and interviewed regarding medication findings. |
| RN2 | Registered Nurse | Involved in failure to report resident-to-resident sexual abuse. |
| CNA4 | Certified Nurse Aid | Observed unclean resident room and activities of daily living findings. |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple deficiencies including medication, abuse reporting, baseline care plan, respiratory care. |
| Administrator | Administrator | Interviewed regarding food service complaints and resident room cleanliness. |
| Dietary Manager | Dietary Manager | Interviewed regarding food temperature and resident complaints. |
| Infection Preventionist | Infection Preventionist | Interviewed regarding respiratory care and nebulizer treatment. |
| RN3 | Registered Nurse | Interviewed regarding oxygen therapy documentation. |
Inspection Report
Abbreviated Survey
Census: 85
Deficiencies: 0
Nov 21, 2024
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints GA00246237, GA00245156, and GA00243935.
Findings
The complaints were unsubstantiated and no regulatory violations were cited during the survey.
Complaint Details
Complaints GA00246237, GA00245156, and GA00243935 were investigated and found to be unsubstantiated with no regulatory violations cited.
Inspection Report
Deficiencies: 0
Aug 3, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for Abercorn Rehabilitation Center following a survey completed on August 3, 2023.
Findings
No specific deficiencies or findings are detailed in the provided document; only initial comments are noted without further elaboration.
Inspection Report
Re-Inspection
Deficiencies: 0
Aug 3, 2023
Visit Reason
A revisit survey was conducted on 8/3/2023 to follow up on deficiencies cited during the 5/25/2023 Recertification Survey and to investigate Complaint Intake Number GA00236242.
Findings
All deficiencies cited during the 5/25/2023 Recertification Survey and Complaint Investigation Survey were found to be corrected. The complaint investigation was unsubstantiated.
Complaint Details
Complaint Intake Number GA00236242 was investigated and found to be unsubstantiated.
Report Facts
Complaint Intake Number: GA00236242
Previous survey date: 5/25/2023
Inspection Report
Re-Inspection
Deficiencies: 0
Aug 3, 2023
Visit Reason
A revisit survey was conducted on 8/3/2023 in conjunction with an investigation of Complaint Intake Number GA00236242.
Findings
All deficiencies cited during the 5/25/2023 Recertification Survey and Complaint Investigation Survey were found to be corrected. The complaint investigation was unsubstantiated with no regulatory violations cited.
Complaint Details
Complaint Intake Number GA00236242 was investigated and found to be unsubstantiated with no regulatory violations cited.
Inspection Report
Follow-Up
Deficiencies: 0
Jul 12, 2023
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited deficiencies.
Findings
All previously cited survey tags have been corrected as noted by the surveyor.
Inspection Report
Routine
Deficiencies: 2
May 25, 2023
Visit Reason
A State Licensure survey was conducted at Abercorn Rehabilitation Center from May 23, 2023 through May 25, 2023 to assess compliance with state health regulations.
Findings
The survey revealed deficiencies including a medication error rate exceeding 5%, improper medication administration techniques, and failure to develop and implement comprehensive care plans for four sampled residents, increasing the risk of inadequate treatment.
Severity Breakdown
SS= D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Medication error rate was 7.14%, exceeding the allowed 5%, with errors observed during medication passes for two residents. | SS= D |
| Failure to develop and implement comprehensive care plans for four of 32 sampled residents, risking inadequate treatment according to their needs. | SS= D |
Report Facts
Medication error rate: 7.14
Medication error threshold: 5
Residents sampled for care plan review: 32
Residents without comprehensive care plans: 4
Units of Novolog Insulin: 30
Tube feeding rate: 45
Water flush rate: 35
Fall date: May 19, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse | Observed administering medications incorrectly and interviewed about medication administration knowledge. |
| LPN BB | Licensed Practical Nurse | Observed administering medications during medication pass. |
| Director of Nurses | Director of Nursing (DON) | Interviewed regarding proper medication administration and care plan expectations. |
| Certified Nursing Assistant BB | Certified Nursing Assistant | Interviewed regarding hospice staff visits and resident care. |
| Registered Nurse Minimum Data Set Coordinator | RN MDS Coordinator/Resident Care Specialist | Interviewed about care plan expectations and deficiencies. |
| Licensed Practical Nurse RCS | Licensed Practical Nurse Resident Care Specialist | Interviewed confirming lack of advanced directive care plan for hospice resident. |
| Social Services Director | Social Services Director (SSD) | Interviewed about responsibility for care plan components including advanced directives. |
Inspection Report
Annual Inspection
Census: 95
Deficiencies: 5
May 25, 2023
Visit Reason
A recertification survey was conducted at Abercorn Rehabilitation Center from May 23, 2023, through May 25, 2023, including investigation of Complaint Intake Number GA00234926.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to obtain physician orders for full code status, failure to conduct Level II PASARR screenings, incomplete comprehensive care plans for several residents, failure to provide scheduled ADL care related to showers, and a medication error rate exceeding 5%.
Complaint Details
Complaint Intake Number GA00234926 was investigated in conjunction with this standard survey; Complaint Intake Number GA00234296 was unsubstantiated with no deficiencies.
Severity Breakdown
SS= D: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to obtain a Physician's order for one of five residents reviewed for full code status. | SS= D |
| Failed to conduct a Level II PASARR screening for two residents following new psychiatric diagnoses. | SS= D |
| Failed to develop and implement a comprehensive care plan for four residents, including lack of care plans for advanced directives, UTI/Sepsis, and activity involvement. | SS= D |
| Failed to ensure Activities of Daily Living (ADL) care was provided related to showers according to schedule for one resident. | SS= D |
| Failed to ensure medication error rate was less than 5%; two medication errors observed during medication pass. | SS= D |
Report Facts
Resident census: 95
Medication error rate: 7.14
Number of residents reviewed for full code status: 5
Number of residents sampled for PASARR screening: 32
Number of residents with incomplete care plans: 4
Number of residents with shower care deficiency: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse | Observed administering medications incorrectly including eye drops and insulin |
| LPN BB | Licensed Practical Nurse | Observed administering medications and involved in medication pass |
| Director of Nursing (DON) | Director of Nursing | Provided information on medication administration expectations and PASARR process |
| Social Services Director (SSD) | Social Services Director | Responsible for obtaining physician orders for advance directives and care plan input |
| Registered Nurse (RN) Minimum Data Set (MDS) coordinator/Resident Care Specialist (RCS) | RN MDS Coordinator/Resident Care Specialist | Provided information on care planning and advanced directives |
| Admissions Director (AD) | Admissions Director | Provided information on PASARR process and responsibilities |
Inspection Report
Life Safety
Census: 93
Capacity: 100
Deficiencies: 2
May 24, 2023
Visit Reason
The Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the National Fire Protection Association (NFPA) Life Safety Code standards.
Findings
The facility was found not in substantial compliance with NFPA Life Safety Code 2012 edition requirements, specifically related to electrical outlet covers and the use of portable space heaters. Deficiencies included a missing receptacle cover in the employee breakroom and the presence of an undocumented space heater in the Activities Room, both corrected during the inspection.
Severity Breakdown
SS= D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Electrical outlets were not properly covered in the employee breakroom outside the laundry room. | SS= D |
| Failure to provide documentation of thermostatic temperatures on portable space heaters; a space heater was found under a desk in the Activities Room. | SS= D |
Report Facts
Census: 93
Total Capacity: 100
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings and corrected violations during inspection |
Inspection Report
Follow-Up
Census: 90
Deficiencies: 0
Sep 14, 2022
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the complaint survey conducted from 7/6/22 through 7/8/22.
Findings
All deficiencies cited as a result of the 7/6/22 through 7/8/22 complaint survey were found to be corrected during the revisit survey.
Complaint Details
The visit was a follow-up to a complaint survey conducted from 7/6/22 through 7/8/22. All cited deficiencies were corrected.
Inspection Report
Re-Inspection
Census: 90
Deficiencies: 0
Sep 14, 2022
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during a complaint survey conducted from 7/6/22 through 7/8/22.
Findings
All deficiencies cited in the previous complaint survey were found to be corrected during this revisit survey.
Complaint Details
The revisit survey was conducted following a complaint survey from 7/6/22 through 7/8/22. All deficiencies from that complaint survey were corrected.
Inspection Report
Original Licensing
Deficiencies: 1
Jul 8, 2022
Visit Reason
A Licensure Survey was conducted from 7/6/22 through 7/8/22 to assess compliance with licensure requirements for Abercorn Rehabilitation Center.
Findings
The facility failed to ensure that Activities of Daily Living (ADL) documentation related to food and fluid intake was completed for three residents reviewed. Multiple missed documentation opportunities were identified for residents #1, #3, and #6, with no evidence that food or fluids were offered during those times.
Deficiencies (1)
| Description |
|---|
| Failure to complete ADL documentation related to food/fluid intake for residents #1, #3, and #6. |
Report Facts
Missed documentation opportunities: 8
Missed documentation opportunities: 40
Missed documentation opportunities: 9
Missed documentation opportunities: 27
Missed documentation opportunities: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed on 7/6/22 regarding difficulties with ADL documentation and responsibility for ensuring accuracy. | |
| Administrator | Interviewed on 7/8/22 regarding expectations for staff to offer food/fluid and oversight of documentation. |
Inspection Report
Abbreviated Survey
Census: 90
Deficiencies: 2
Jul 8, 2022
Visit Reason
An Abbreviated Survey was conducted from July 6 to July 8, 2022, investigating three complaints (GA00225368, GA00224926, GA00223962). Two complaints were substantiated with deficiencies, and one was unsubstantiated.
Findings
The facility failed to ensure residents on dialysis received treatments per physician orders and failed to maintain ongoing communication with dialysis and transportation services. Additionally, the facility failed to complete documentation of Activities of Daily Living (ADL) related to food and fluid intake for three residents reviewed.
Complaint Details
Complaint GA00225368 was unsubstantiated. Complaints GA00224926 and GA00223962 were substantiated with deficiencies.
Severity Breakdown
Level E: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure residents on dialysis received treatments per physician orders and failed to provide ongoing communication and collaboration with transportation and dialysis facilities. | Level E |
| Failed to maintain complete and accurate documentation of Activities of Daily Living (ADL) related to food and fluid intake for three residents. | Level E |
Report Facts
Facility census: 90
Missed dialysis treatments for Resident #3: 2
Missed dialysis treatments for Resident #6: 5
Missed ADL documentation opportunities for Resident #1: 8
Missed ADL documentation opportunities for Resident #3: 49
Missed ADL documentation opportunities for Resident #6: 38
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding transportation issues and documentation problems |
| Administrator | Administrator | Interviewed regarding expectations for food/fluid offering and documentation |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Jan 25, 2022
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint #GA00220379.
Findings
The complaint was unsubstantiated and no deficiencies were cited during the survey.
Complaint Details
Complaint #GA00220379 was investigated and found to be unsubstantiated.
Inspection Report
Renewal
Deficiencies: 0
Dec 10, 2021
Visit Reason
The inspection was conducted as a Licensure Survey from December 7, 2021 through December 10, 2021 to assess compliance for facility licensure renewal.
Findings
No deficiencies were identified during the Licensure Survey conducted from December 7, 2021 through December 10, 2021.
Inspection Report
Complaint Investigation
Census: 77
Deficiencies: 0
Dec 10, 2021
Visit Reason
A standard survey was conducted at Abercorn Rehabilitation Center, including an investigation of Complaint Intake Number GA00219850 on behalf of the Georgia Department of Community Health.
Findings
The standard survey revealed that the facility was in substantial compliance with Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B - Requirements for Long Term Care Facilities.
Complaint Details
Complaint Intake Number GA00219850 was investigated in conjunction with the standard survey.
Inspection Report
Life Safety
Census: 77
Capacity: 100
Deficiencies: 0
Dec 7, 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 Life Safety Code requirements and the Emergency Preparedness Program was substantially compliant with 42 CFR § 483.73.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Jul 20, 2021
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00215516.
Findings
The complaint was unsubstantiated and no regulatory violations were cited during the survey.
Complaint Details
Complaint #GA00215516 was investigated and found to be unsubstantiated.
Inspection Report
Routine
Census: 68
Deficiencies: 0
Oct 20, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with federal regulations and recommended practices related to COVID-19 preparedness and infection control.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 related to infection control regulations, implementing CMS and CDC recommended practices for COVID-19.
Report Facts
Total census: 68
Inspection Report
Abbreviated Survey
Deficiencies: 0
Oct 19, 2020
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint #GA00208832.
Findings
The complaint was unsubstantiated and no regulatory violations were cited during the survey.
Complaint Details
Complaint #GA00208832 was investigated and found to be unsubstantiated.
Inspection Report
Routine
Census: 74
Deficiencies: 0
Sep 21, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted to assess the facility's compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Sep 8, 2020
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00203628.
Findings
The complaint was unsubstantiated and no regulatory violations were cited during the survey.
Complaint Details
Complaint #GA00203628 was investigated and found to be unsubstantiated.
Inspection Report
Routine
Census: 76
Deficiencies: 0
Jun 18, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey and a COVID-19 Focused Infection Control Survey were conducted by the Centers for Medicare & Medicaid Services (CMS) on June 18, 2020.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 infection control regulations, implementing CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Total census: 76
Inspection Report
Abbreviated Survey
Deficiencies: 0
Feb 13, 2020
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint #GA00202648.
Findings
No deficiencies were cited during the survey.
Complaint Details
Complaint #GA00202648 was investigated; no deficiencies were found.
Inspection Report
Abbreviated Survey
Census: 81
Deficiencies: 0
Jun 21, 2019
Visit Reason
An abbreviated survey was conducted to investigate complaints GA00197392 and GA00196233 at Abercorn Rehabilitation Center.
Findings
The facility was found to be in substantial compliance with Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B-Requirements for Long Term Care Facilities.
Complaint Details
Investigation of complaints GA00197392 and GA00196233; facility found in substantial compliance.
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 7, 2019
Visit Reason
An unannounced complaint investigation for complaint GA00195025 was conducted on 3/7/19 by a State Surveyor.
Findings
The complaint was not substantiated and no regulatory violations were cited.
Complaint Details
Complaint GA00195025 was investigated and found not substantiated with no regulatory violations cited.
Inspection Report
Follow-Up
Deficiencies: 0
Jan 2, 2019
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags had been corrected.
Findings
The surveyor noted that all previously cited deficiencies had been corrected during the follow-up survey.
Inspection Report
Re-Inspection
Census: 77
Deficiencies: 0
Dec 27, 2018
Visit Reason
A revisit survey was conducted to verify correction of all deficiencies resulting from the annual survey conducted November 5-8, 2018.
Findings
All deficiencies from the prior annual survey were found to be corrected during the revisit survey conducted on December 26-27, 2018.
Inspection Report
Routine
Census: 30
Deficiencies: 3
Nov 8, 2018
Visit Reason
The inspection was conducted to evaluate compliance with medical, dental, nursing care, environmental sanitation, housekeeping, infection control, and food handling practices at Abercorn Rehabilitation Center.
Findings
The facility failed to follow the care plan for one resident receiving IV medication, failed to ensure proper infection control practices including hand hygiene and disposal of contaminated materials, and failed to serve food in a sanitary manner as staff did not consistently sanitize hands before handling food.
Deficiencies (3)
| Description |
|---|
| Failure to follow the care plan for one resident receiving intravenous medication, including improper IV site care and lack of orders for flushing or dressing changes. |
| Failure to ensure a Certified Nursing Assistant properly disposed of contaminated water and washed hands after providing care for a resident on transmission-based precautions. |
| Failure to serve food to residents in a sanitary manner, with staff observed not sanitizing hands before feeding residents. |
Report Facts
Sample size: 30
Duration of antibiotic treatment: 16
Number of residents observed in dining room: 16
Number of residents observed in dining room: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN MM | Licensed Practical Nurse | Interviewed regarding resident R#60's IV medication status |
| LPN BB | Licensed Practical Nurse | Interviewed regarding resident R#60's IV medication orders and care |
| CNA HH | Certified Nursing Assistant | Observed and interviewed regarding improper disposal of contaminated water and hand hygiene |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding expectations for IV medication orders, infection control, and food handling policies |
| Housekeeping Supervisor | Housekeeping Supervisor | Interviewed regarding laundry procedures for residents on contact precautions |
| Infection Control Nurse | Infection Control Nurse | Interviewed regarding infection control expectations and procedures |
| LPN DD | Licensed Practical Nurse | Observed handling food and feeding residents without sanitizing hands |
| CNA EE | Certified Nursing Assistant | Observed feeding residents without sanitizing hands |
| CNA GG | Certified Nursing Assistant | Observed feeding residents without sanitizing hands |
Inspection Report
Routine
Census: 82
Deficiencies: 7
Nov 8, 2018
Visit Reason
A standard survey was conducted to assess compliance with Medicare/Medicaid regulations and other federal requirements for long term care facilities.
Findings
The facility was found not in substantial compliance with multiple regulatory requirements including failure to post required notices accessibly, incomplete resident assessments, failure to follow care plans for IV therapy, medication errors exceeding 5%, failure to notify physicians of abnormal lab results, and infection control deficiencies including improper disposal of contaminated water and inadequate hand hygiene during resident care and food service.
Severity Breakdown
SS= D: 6
SS= E: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to post State Agency and Ombudsman contact information accessibly to residents and families. | SS= D |
| Failure to complete a Minimum Data Set (MDS) Discharge Assessment for one resident. | SS= D |
| Failure to follow care plan for IV therapy including lack of orders for flushes, dressing changes, and site monitoring for one resident. | SS= D |
| Failure to obtain physician orders for peripheral IV dressing changes, flushes, and site observation for one resident receiving IV antibiotics. | SS= D |
| Medication error rate of 19.35% due to unavailable medications not administered for three residents. | SS= D |
| Failure to promptly notify physicians of abnormal laboratory results for two residents. | SS= D |
| Infection control failures including improper disposal of contaminated water, failure to perform hand hygiene after care for resident on contact precautions, and failure to follow sanitary food handling practices. | SS= E |
Report Facts
Resident census: 82
Medication error rate: 19.35
Number of medication opportunities observed: 31
Number of medication errors: 6
TSH lab result: 0.02
TSH lab result: 49.98
Inspection Report
Life Safety
Census: 85
Capacity: 100
Deficiencies: 2
Nov 6, 2018
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the NFPA 101 Life Safety Code 2012 Edition.
Findings
The facility was found not in substantial compliance due to failure to maintain caps or plugs on the fire sprinkler system's fire department connection and failure to provide the required emergency generator remote annunciator, placing residents at risk in the event of fire.
Severity Breakdown
SS= D: 1
SS= F: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to maintain caps or plugs on the fire sprinkler system's fire department connection, leaving one inlet open with rust and debris present. | SS= D |
| Failure to provide the required emergency generator remote annunciator at a location readily observed by staff as required by NFPA 99. | SS= F |
Report Facts
Residents at risk: 12
Census: 85
Total licensed capacity: 100
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings related to fire sprinkler system and emergency generator remote annunciator during facility tour. |
Inspection Report
Abbreviated Survey
Census: 78
Deficiencies: 0
Jun 12, 2018
Visit Reason
An abbreviated survey was conducted to investigate complaint GA00187487 at Abercorn Rehabilitation Center.
Findings
The facility was found to be in substantial compliance with Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B-Requirements for Long Term Care Facilities.
Complaint Details
Investigation of complaint GA00187487; facility found in substantial compliance.
Report Facts
Facility census: 78
Inspection Report
Abbreviated Survey
Census: 77
Deficiencies: 0
May 16, 2018
Visit Reason
An abbreviated survey was conducted to investigate complaint GA00188601 at Abercorn Health and Rehabilitation.
Findings
The facility was found to be in substantial compliance with Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B-Requirements for Long Term Care Facilities.
Complaint Details
Investigation of complaint GA00188601; facility found in substantial compliance.
Inspection Report
Abbreviated Survey
Census: 80
Deficiencies: 0
May 9, 2018
Visit Reason
An abbreviated survey was conducted to investigate complaints GA00188601 and GA00188288 at Abercorn Health and Rehabilitation.
Findings
The facility was found to be in substantial compliance with Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B-Requirements for Long Term Care Facilities.
Complaint Details
Investigation of complaints GA00188601 and GA00188288; facility found in substantial compliance.
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 9, 2018
Visit Reason
A complaint survey was conducted to investigate complaints (GA 00185093) and determine compliance with Federal and State Long Term Care Requirements.
Findings
No deficiencies were cited during the complaint survey.
Complaint Details
Complaint survey conducted related to complaint GA 00185093; no deficiencies found.
Inspection Report
Re-Inspection
Census: 74
Deficiencies: 0
Jan 11, 2018
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 11/16/17 Recertification survey.
Findings
All deficiencies cited as a result of the 11/16/17 Recertification survey were found to be corrected.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Jan 10, 2018
Visit Reason
An abbreviated survey was conducted to investigate complaint GA00183680 at Abercorn Rehabilitation Center.
Findings
The facility was found to be in substantial compliance with Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B-Requirements for Long Term Care Facilities.
Complaint Details
Investigation of complaint GA00183680; facility found in substantial compliance.
Inspection Report
Follow-Up
Deficiencies: 0
Jan 8, 2018
Visit Reason
A follow-up survey was conducted to determine if previously cited deficiencies had been corrected.
Findings
The follow-up survey determined that all previously cited tags have been corrected.
Inspection Report
Routine
Census: 84
Deficiencies: 3
Nov 16, 2017
Visit Reason
A standard survey was conducted at Abercorn Rehabilitation Center from November 13, 2017 through November 16, 2017 to assess compliance with Medicare/Medicaid regulations. An abbreviated survey was also conducted on 2/9/18 investigating a complaint which was found to be unsubstantiated.
Findings
The facility was found not in substantial compliance with regulations, with deficiencies including failure to thoroughly investigate a resident's bruise, failure to follow the care plan for skin assessment and use of Hoyer lift, and failure to provide full visual privacy in semi-private rooms due to missing or inadequate privacy curtains.
Complaint Details
An abbreviated survey investigating complaint #GA00185093 was initiated on 2/9/18 and found to be unsubstantiated with no deficiencies cited.
Severity Breakdown
D: 2
E: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to thoroughly investigate bruise of known origin on Resident #102's arm. | D |
| Failed to provide services by qualified persons per care plan, specifically failure to follow care plan for skin assessment and use of Hoyer lift for Resident #102. | D |
| Failed to ensure bedrooms were equipped to afford full visual privacy for each resident; privacy curtains missing or inadequate in semi-private rooms on Hall 1, Hall 2, and Hall 3. | E |
Report Facts
Resident census: 84
Sample size: 29
Date of incident: Aug 14, 2017
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| DD | Certified Nursing Assistant | Named in bruise incident and reassignment from Resident #102 care. |
| GG | Certified Nursing Assistant | Named in bruise incident and reassignment from Resident #102 care. |
| EE | Licensed Practical Nurse | Assisted with taking photo of bruise on Resident #102 and reported incident. |
| BB | Certified Nursing Assistant | Reported bruise incident to former LPN and witnessed bruise on Resident #102. |
| Administrator | Interviewed multiple times regarding bruise incident and privacy curtain deficiencies. | |
| CC | Licensed Practical Nurse | Interviewed regarding bruise incident and reassignment of CNA DD. |
Inspection Report
Routine
Deficiencies: 2
Nov 16, 2017
Visit Reason
The inspection was conducted to assess compliance with nursing service policies, patient care plans, and physical plant standards including privacy curtain requirements in a healthcare facility.
Findings
The facility failed to follow the care plan for a resident requiring a Hoyer lift, resulting in injury from improper transfer technique. Additionally, privacy curtains in semi-private rooms did not provide full privacy as required by regulations.
Deficiencies (2)
| Description |
|---|
| Failure to follow nursing care policies and care plan for resident transfers, resulting in bruising due to use of a two-stand lift instead of a Hoyer lift. |
| Privacy curtains in semi-private rooms did not provide full privacy, with missing tracks and curtains too short to shield residents during personal care. |
Report Facts
Date of Care Plan: Jul 6, 2017
Date of bruise incident: 201708
Observation dates: Nov 13, 2017
Observation dates: Nov 14, 2017
Observation dates: Nov 15, 2017
Observation date: Nov 16, 2017
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN EE | Licensed Practical Nurse | Verified observing bruise on resident and assisted with photo documentation |
| LPN DD | Licensed Practical Nurse | Verified being informed about injury caused by improper lift use |
| Nurse Manager II | Registered Nurse | Witnessed bruise on resident |
| Social Worker HH | Social Worker | Witnessed bruise on resident |
| Certified Nursing Assistant DD | Certified Nursing Assistant | Used two-stand lift instead of Hoyer lift causing resident injury |
| Certified Nursing Assistant GG | Certified Nursing Assistant | Used two-stand lift instead of Hoyer lift causing resident injury |
| Certified Nursing Assistant AA | Certified Nursing Assistant | Unaware of privacy curtain requirements in semi-private rooms |
Inspection Report
Life Safety
Census: 84
Capacity: 100
Deficiencies: 5
Nov 13, 2017
Visit Reason
Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the National Fire Protection Association (NFPA) Life Safety Code standards.
Findings
The facility was found not in substantial compliance with fire safety requirements, including failure to perform required annual forward flow testing of the fire sprinkler system backflow preventer, obstructed patient room doors preventing proper closure during fire evacuation, inadequate maintenance of commercial dryer lint traps, and incomplete fire evacuation plan lacking smoke compartment delineation and emergency phone call instructions.
Severity Breakdown
D: 3
E: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to provide required annual forward flow testing of the fire sprinkler system supply backflow preventer as required by NFPA 101 and NFPA 25. | D |
| Gate valves on the sprinkler system backflow preventer are not supervised in accordance with NFPA standards. | D |
| Patient room doors (Rooms 19 and 44) were obstructed, preventing or impeding closure during fire evacuation. | E |
| Failed to maintain commercial dryers in a safe manner; lint traps were not cleaned often enough to prevent lint buildup. | D |
| Fire evacuation plan did not delineate smoke compartments or corresponding corridor doors and did not list emergency phone call to fire department. | E |
Report Facts
Certified Beds: 100
Census: 84
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and interviews |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Oct 17, 2017
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA0018038.
Findings
The facility was found to be in compliance with Federal and State Long Term Care regulations. The complaint was unsubstantiated and no deficiencies were cited.
Complaint Details
Complaint GA0018038 was investigated and found to be unsubstantiated.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Oct 4, 2017
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints GA00180108 and GA00180326.
Findings
The facility was found to be in compliance with Federal and State Long Term Care regulations. The complaints were unsubstantiated and no deficiencies were cited.
Complaint Details
Complaints GA00180108 and GA00180326 were investigated and found to be unsubstantiated.
Inspection Report
Complaint Investigation
Deficiencies: 0
May 17, 2017
Visit Reason
An unannounced abbreviated survey was conducted to investigate complaint GA00175005 at Abercorn Rehabilitation Center.
Findings
The facility was found to be in substantial compliance with 42 CFR, Part 483, Subpart B, Requirements for long term care facilities.
Complaint Details
Investigation of complaint GA00175005; facility found in substantial compliance.
Inspection Report
Abbreviated Survey
Deficiencies: 0
May 9, 2017
Visit Reason
An unannounced abbreviated survey was conducted to investigate complaint GA00174796 at Abercorn Rehabilitation Center.
Findings
The facility was found to be in substantial compliance with 42 CFR, Part 483, Subpart B, Requirements for long term care facilities.
Complaint Details
Investigation of complaint GA00174796; facility found in substantial compliance.
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 28, 2017
Visit Reason
A complaint survey was conducted to investigate complaints #GA00173418 and #GA00173377 to determine compliance with Federal and State Long Term Care regulations.
Findings
No deficiencies were cited during the complaint survey at Abercorn Rehabilitation Center.
Complaint Details
Complaints #GA00173418 and #GA00173377 were investigated and found to have no deficiencies.
Inspection Report
Re-Inspection
Deficiencies: 0
Mar 1, 2017
Visit Reason
A revisit was conducted on 2/27/17 to the survey conducted at Abercorn Rehabilitation Center from January 17, 2017 through January 19, 2017.
Findings
The facility was in substantial compliance with Medicare/Medicaid regulations at 42 Code of Federal Regulations (C.F.R.) Part 483, Subpart B - Requirements for Long Term Care Facilities as alleged on their Plan of Correction effective 2/26/17.
Inspection Report
Complaint Investigation
Census: 96
Deficiencies: 2
Jan 19, 2017
Visit Reason
A standard survey was conducted from January 17 through January 19, 2017, including investigation of Complaint Intake Numbers GA00166126 and GA00164647, to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Findings
The facility was found not in substantial compliance due to failure to properly label food items in a walk-in cooler and maintain two ceiling vents over a kitchen prep table, which contained moss and leaves, potentially contaminating food. These deficiencies had the potential to affect 92 residents receiving an oral diet.
Complaint Details
Complaint Intake Numbers GA00166126 and GA00164647 were investigated in conjunction with the standard survey.
Severity Breakdown
SS=E: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to properly label food in one walk-in cooler, with missing year and 'Used by' dates on food items. | SS=E |
| Failed to maintain two ceiling vents over a kitchen prep table, which contained moss and leaves and lacked screens to prevent contamination. | SS=E |
Report Facts
Resident census: 96
Residents potentially affected: 92
Number of sandwiches observed: 6
Date of vents cleaning: Dec 27, 2016
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Verified mislabeled food items and discussed food labeling expectations | |
| Administrator | Stated expectations for proper food labeling and vents to be free of debris | |
| Maintenance Supervisor | Reported vents cleaning schedule and source of leaves and moss contamination |
Inspection Report
Life Safety
Census: 96
Capacity: 100
Deficiencies: 0
Jan 17, 2017
Visit Reason
Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements and NFPA 101 Life Safety Code 2012 edition.
Findings
Abercorn Rehabilitation Center was found in substantial compliance with the Life Safety Code requirements and related NFPA standards during the survey.
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