Inspection Reports for Mesun Health and Rehabilitation Center
88 JOHNSON ROAD, BUILDING #2, LAWRENCEVILLE, GA, 30046
Back to Facility ProfileInspection Report Summary
The most recent inspection on November 4, 2024, found that all previously cited deficiencies had been corrected. Earlier inspections showed recurring issues with timely transmission of Minimum Data Set assessments, care planning, emergency preparedness, and food storage practices. A substantiated complaint investigation in late 2023 identified deficiencies related to failure to protect residents from sexual abuse and failure to report allegations properly. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility appears to be addressing prior deficiencies, as indicated by corrected findings in the latest revisit survey.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
2% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
48 residents
Based on a September 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
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
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
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
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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