Inspection Report Summary
The most recent inspection on June 18, 2025, found no deficiencies after a revisit survey verified correction of prior issues cited in April 2025. Earlier inspections showed a pattern of deficiencies primarily related to resident care, including care plan accuracy, medication management, and respiratory equipment sanitation, as well as life safety concerns such as fire safety system maintenance and door functionality. Complaint investigations were mixed, with some substantiated complaints resulting in deficiencies, particularly around medication errors and notification protocols, while many complaints were unsubstantiated. There were no fines, immediate jeopardy findings, or license actions listed in the available reports. The facility’s record shows improvement over time, with recent surveys confirming correction of previously cited deficiencies.
Deficiencies (last 9 years)
Deficiencies (over 9 years)
9.9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
102% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
24
18
12
6
0
Census
Latest occupancy rate
102 residents
Based on a June 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Deficiencies: 0
Date: Jun 18, 2025
Visit Reason
The document is a statement of deficiencies and plan of correction for Warner Robins Rehabilitation Center, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide specific findings or deficiencies in the provided page.
Inspection Report
Re-Inspection
Census: 102
Deficiencies: 0
Date: Jun 18, 2025
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the April 16, 2025, standard survey.
Findings
All deficiencies cited in the prior April 16, 2025, survey were found to be corrected during this revisit survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jun 2, 2025
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
Census: 108
Deficiencies: 6
Date: Apr 16, 2025
Visit Reason
A standard survey was conducted from April 14, 2025 through April 16, 2025, including investigation of multiple complaint intake numbers.
Complaint Details
Multiple complaint intake numbers were investigated; some were unsubstantiated, some substantiated without deficiency, and one substantiated with deficiency related to complaint intake number GA00253768.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies related to care plan accuracy, diabetic blood sugar monitoring, oxygen therapy administration, pain management, respiratory equipment sanitation, and resident assessments.
Deficiencies (6)
Failed to ensure resident R29's care plan reflected patient-centered interventions to meet needs.
Failed to ensure finger stick blood sugars were ordered and completed for resident R70 to monitor blood glucose.
Failed to ensure oxygen therapy was administered according to physician's orders for two residents receiving oxygen therapy.
Failed to properly manage pain in one resident sampled.
Failed to assess resident #36 (details not fully provided).
Failed to maintain sanitary conditions for respiratory equipment (nebulizer masks) for two residents receiving nebulizer treatments.
Report Facts
Residents sampled: 53
Residents receiving oxygen therapy: 23
Residents receiving nebulizer treatments: 12
Deficiency count: 6
Resident census: 108
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Josiane Delorme | LPN | Created care plan for resident R29 |
| Danielle Bohach | RN | Revised care plan for resident R29 |
| FF | Licensed Practical Nurse | Performed wound care on resident R29 |
| DD | Licensed Practical Nurse | Interviewed regarding oxygen therapy and pain management |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies including oxygen therapy, pain management, and respiratory equipment sanitation |
| LPN II Unit Manager | Licensed Practical Nurse | Interviewed regarding insulin orders and blood sugar monitoring |
| CC | Certified Nursing Assistant | Provided care and reported pain for resident R29 |
Inspection Report
Routine
Deficiencies: 2
Date: Apr 16, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to respiratory care, laboratory services, and overall resident care at Warner Robins Rehabilitation Center.
Findings
The facility failed to ensure oxygen therapy was administered according to physician orders for two residents, and laboratory tests were not conducted in accordance with professional standards for one resident. These deficiencies posed potential risks of respiratory complications and unmet medical needs.
Deficiencies (2)
Failed to ensure oxygen therapy was administered in accordance with physician's orders for two residents (R77 and R29).
Failed to ensure laboratory tests were conducted in accordance with professional standards for one resident (R70).
Report Facts
Residents with oxygen therapy orders: 23
Residents sampled for laboratory services: 53
Oxygen flow rate ordered for R77: 3
Oxygen flow rate observed for R77: 4
Oxygen flow rate ordered for R29: 2
Oxygen flow rate observed for R29: 3
Insulin dosage for R70: 35
Employees mentioned
| Name | Title | Context |
|---|---|---|
| FF | Licensed Practical Nurse (LPN) | Stated residents received O2 according to physician's order. |
| DD | Licensed Practical Nurse (LPN) | Revealed licensed nurses were responsible for setting and monitoring O2 flow rate. |
| EE | Licensed Practical Nurse (LPN) | Confirmed R29's O2 was administered at 3 LPM and nurses were responsible for checking flow rate. |
| AA | Licensed Practical Nurse (LPN) | Verified R70 received insulin injections and no physician orders for daily blood sugar checks. |
| II | Licensed Practical Nurse (LPN) | Stated expectation for physician's order for blood sugar checks for residents receiving insulin. |
| Director of Nursing (DON) | Director of Nursing | Confirmed oxygen therapy should be administered according to physician's orders and nurses should monitor O2 flow rate and blood sugar orders. |
| Administrator | Administrator | Stated Unit Manager and DON were responsible for checking physician orders. |
Inspection Report
Routine
Deficiencies: 3
Date: Apr 16, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to respiratory care, laboratory services, and medication administration in the facility.
Findings
The facility failed to ensure oxygen therapy was administered according to physician orders for two residents, failed to ensure laboratory tests were conducted according to professional standards for one resident, and lacked physician orders for daily blood sugar checks for a resident receiving insulin injections. These deficiencies posed potential risks of respiratory complications, medical complications, and unmet needs.
Deficiencies (3)
Failed to ensure oxygen therapy was administered in accordance with physician's orders for two residents (R77 and R29).
Failed to ensure laboratory tests were conducted in accordance with professional standards for one resident (R70).
Failed to have physician orders for daily blood sugar checks for a resident (R70) receiving insulin injections.
Report Facts
Residents with oxygen therapy orders: 23
Residents sampled for laboratory services: 53
Oxygen flow rate ordered for R77: 3
Oxygen flow rate observed for R77: 4
Oxygen flow rate ordered for R29: 2
Oxygen flow rate observed for R29: 3
Insulin dosage for R70: 35
Employees mentioned
| Name | Title | Context |
|---|---|---|
| FF | Licensed Practical Nurse (LPN) | Stated residents received oxygen according to physician orders. |
| Director of Nursing (DON) | Director of Nursing | Confirmed oxygen should be administered according to physician orders and verified oxygen flow meter settings and expectations for monitoring. |
| DD | Licensed Practical Nurse (LPN) | Revealed licensed nurses were responsible for setting and monitoring oxygen flow rate but did not always check settings. |
| EE | Licensed Practical Nurse (LPN) | Confirmed oxygen was administered at ordered flow rate and nurses were responsible for checking flow rate. |
| AA | Licensed Practical Nurse (LPN) | Verified resident received insulin injections and no physician orders for daily blood sugar checks. |
| II | Licensed Practical Nurse (LPN) | Stated expectation for physician's order for blood sugar checks for residents receiving insulin. |
| Administrator | Administrator | Stated Unit Manager and DON were responsible for checking physician orders. |
Inspection Report
Life Safety
Census: 111
Capacity: 126
Deficiencies: 8
Date: Apr 15, 2025
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and NFPA 101 Life Safety Code standards.
Findings
The facility was found not in substantial compliance with life safety requirements, including deficiencies related to self-closing doors, cooking facility suppression system tagging, fire alarm pull station accessibility, sprinkler system maintenance, electrical safety, and oxygen cylinder security.
Deficiencies (8)
Storage room doors were not self-closing, specifically the Therapy Storage Room missing a door closer.
Vent Hood Fire Suppression system was red-tagged due to impairments, affecting all smoke compartments; system was repaired on the survey date.
Fire alarm pull station was blocked by a patient lift in the West Wing hallway.
Sprinkler heads above washing machines were corroded in the Laundry Room.
Power strips were found on the floor in the RCS Office.
Exposed wires were observed behind dryers in the Laundry Room.
A 6-way outlet was installed in a receptacle in the Unit Manager's Office.
Oxygen cylinders were not secured in the East Wing.
Report Facts
Certified beds: 126
Census: 111
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed multiple findings during the facility tour on 4/15/2025 |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Mar 26, 2024
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Warner Robins Rehabilitation Center following a survey completed on 03/26/2024.
Findings
The report contains initial comments and a summary statement of deficiencies, but no specific deficiencies or severity levels are detailed in the provided page.
Inspection Report
Re-Inspection
Census: 111
Deficiencies: 0
Date: Mar 26, 2024
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the January 30, 2024 complaint survey.
Complaint Details
The visit was a follow-up to a complaint survey conducted on January 30, 2024; all cited deficiencies were corrected.
Findings
All deficiencies cited as a result of the January 30, 2024 complaint survey were found to be corrected.
Report Facts
Census: 111
Inspection Report
Original Licensing
Deficiencies: 1
Date: Jan 30, 2024
Visit Reason
A State Licensure survey was conducted at Warner Robins Rehabilitation Center from January 23, 2024, through January 30, 2024, to assess compliance with state health regulations.
Findings
The facility failed to ensure the medication error rate was less than 5%, with four medication errors observed out of 34 opportunities for two residents, resulting in an 11.7% error rate. Specific failures included missed administration of prescribed medications due to unavailable medications and an empty insulin pen.
Deficiencies (1)
Failed to ensure medication error rate was less than 5%, with four errors for two residents (R13 and R15) involving missed medication administrations.
Report Facts
Medication opportunities observed: 34
Medication errors: 4
Medication error rate (%): 11.7
Insulin units ordered: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| BB | Licensed Practical Nurse | Failed to administer finasteride tablet, esomeprazole magnesium delayed-release capsule, and wixela inhalation aerosol powder as scheduled |
| DD | Registered Nurse | Failed to administer insulin detemir due to empty insulin pen |
Inspection Report
Abbreviated Survey
Census: 110
Deficiencies: 2
Date: Jan 30, 2024
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate multiple complaints (GA00235889, GA00237812, GA00237813, GA00237837, and GA00242231) at Warner Robins Rehabilitation Center.
Complaint Details
The survey investigated complaints GA00235889, GA00237812, GA00237813, GA00237837, and GA00242231. Complaints GA00235889, GA00237812, and GA00242231 were unsubstantiated. Complaints GA00237813 and GA00237837 were substantiated with deficiencies.
Findings
The survey found substantiated deficiencies related to medication errors and failure to reorder medications timely for two residents, resulting in an 11.7% medication error rate, exceeding the facility's policy threshold of less than 5%. The facility failed to ensure medications were administered as ordered and available at the correct times.
Deficiencies (2)
Failed to ensure medication error rate was less than 5%, with 4 errors out of 34 opportunities for two residents.
Failed to ensure two residents were free from significant medication errors by not ensuring medications were reordered on time.
Report Facts
Medication error rate: 11.7
Facility census: 110
Medication doses missed: 4
Medication administration opportunities observed: 34
Insulin units ordered: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| BB | Licensed Practical Nurse (LPN) | Failed to administer medications to resident R13 as scheduled; stated medications were not available. |
| DD | Registered Nurse (RN) | Failed to administer insulin detemir to resident R15 as scheduled; insulin pen was empty. |
| AA | Regional Nurse | Stated nurses are responsible for reordering medications when supply is down to a week. |
Inspection Report
Routine
Deficiencies: 2
Date: Jan 30, 2024
Visit Reason
The inspection was conducted to evaluate medication administration practices and ensure medication error rates were below 5%, as well as to verify that residents were free from significant medication errors related to medication availability and timely reordering.
Findings
The facility failed to maintain medication error rates below 5%, with an observed error rate of 11.7% involving two residents (R13 and R15). Medication errors included failure to administer prescribed medications due to unavailability and failure to reorder medications on time, placing residents at risk for adverse clinical effects.
Deficiencies (2)
Failed to ensure medication error rate was less than 5%, with four errors out of 34 opportunities for two residents (R13 and R15).
Failed to ensure residents were free from significant medication errors by not reordering medications on time, affecting two residents (R13 and R15).
Report Facts
Medication error opportunities observed: 34
Medication errors observed: 4
Medication error rate: 11.7
Units of insulin detemir ordered: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| BB | Licensed Practical Nurse (LPN) | Failed to administer finasteride, esomeprazole, and wixela inhalation aerosol powder as scheduled; stated medications were not available |
| DD | Registered Nurse (RN) | Failed to administer insulin detemir as scheduled; stated insulin pen was empty |
| AA | Regional Nurse | Stated nurses were responsible for reordering medications when supply was down to a week |
Inspection Report
Life Safety
Census: 109
Capacity: 126
Deficiencies: 0
Date: Jun 14, 2023
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 Program requirements and Life Safety Code standards.
Inspection Report
Annual Inspection
Deficiencies: 1
Date: May 30, 2023
Visit Reason
A State Licensure survey was conducted at Warner Robins Rehabilitation Center from May 26, 2023 through May 30, 2023 to assess compliance with state health regulations.
Findings
The survey revealed deficiencies related to the facility's failure to provide written bed-hold notices to three residents transferred to the hospital, potentially risking denial of re-admission and loss of the resident's room.
Deficiencies (1)
Failure to ensure three residents and/or their representatives received written bed-hold notice including all required information upon transfer to hospital.
Report Facts
Residents reviewed for transfer bed-hold notice: 3
Survey dates: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director | Interviewed regarding responsibility for sending bed-hold forms at time of transfer. | |
| Director of Nursing | DON | Interviewed confirming lack of bed-hold documentation in EMR and ongoing education of nursing staff. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 30, 2023
Visit Reason
An Abbreviated/Partial Extended Survey was conducted from 5/24/2023 to 5/30/2023 to investigate complaints GA00235541, GA00233794, GA00234835, and GA00235167. Two complaints were substantiated with deficiencies, and two were unsubstantiated.
Complaint Details
Complaint numbers GA00235541 and GA00234835 were substantiated with deficiencies. Complaint numbers GA00233794 and GA00235167 were unsubstantiated.
Findings
The facility failed to ensure that three residents transferred to the hospital and/or their representatives received written bed-hold notices containing all required information, potentially risking denial of re-admission and loss of the resident's home. Documentation was missing for residents #1, #2, and #3, and staff interviews confirmed the lack of proper bed-hold notice documentation in the electronic medical records.
Deficiencies (1)
Failure to ensure residents transferred to hospital and/or their representatives received written bed-hold notice with all required information.
Report Facts
Complaint numbers investigated: 4
Residents reviewed for bed-hold notice: 3
Discharge dates: Resident #1 discharged 3/29/2023, Resident #2 discharged 3/27/2023, Resident #3 discharged 5/26/2023
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 30, 2023
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to provide written bed-hold notices to residents transferred to the hospital or their representatives, as required by policy and regulations.
Complaint Details
The complaint investigation revealed that three residents (R#1, R#2, and R#3) discharged to the hospital did not have documented written bed-hold notices provided to them or their representatives, as required by facility policy and federal/state guidelines. The Social Services Director and Director of Nursing confirmed the lack of documentation and ongoing corrective education.
Findings
The facility failed to ensure that three residents transferred to the hospital and/or their representatives received written bed-hold notices including all required information. Interviews and record reviews confirmed no documentation of bed-hold notices for these residents, and the Director of Nursing acknowledged the deficiency and ongoing education efforts.
Deficiencies (1)
Failure to notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Report Facts
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Confirmed lack of bed-hold documentation and ongoing education efforts |
| Social Services Director | Social Services Director | Reported Charge Nurses are responsible for sending bed-hold forms and lack of facility file copies |
Inspection Report
Deficiencies: 0
Date: May 9, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for Warner Robins Rehabilitation Center following a survey completed on May 9, 2023.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Re-Inspection
Census: 106
Deficiencies: 0
Date: May 9, 2023
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the March 16, 2023 Standard Survey.
Findings
All deficiencies cited in the March 16, 2023 Standard Survey were found to be corrected during the May 9, 2023 revisit survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: May 5, 2023
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
Annual Inspection
Deficiencies: 1
Date: Mar 16, 2023
Visit Reason
A State Licensure survey was conducted at Warner Robins Rehabilitation Center from March 14, 2023 through March 16, 2023 to assess compliance with state health regulations.
Findings
The survey revealed a deficiency where the facility failed to report an allegation of resident-to-resident abuse to the State Survey Agency for one resident. The incident involved a resident being pushed down by another resident, but the facility did not report it to the state because there were no injuries.
Deficiencies (1)
Facility failed to report an allegation of resident-to-resident abuse to the State Survey Agency for one resident.
Report Facts
Residents reviewed related to abuse: 4
Date of abuse incident: Feb 13, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| EE | Licensed Practical Nurse (LPN) | Interviewed regarding resident-to-resident abuse incident |
| Social Services Manager | Interviewed regarding procedures for resident altercations | |
| Administrator | Interviewed regarding reporting of abuse incident |
Inspection Report
Routine
Census: 108
Deficiencies: 3
Date: Mar 16, 2023
Visit Reason
A standard survey was conducted from March 14, 2023 through March 16, 2023, including investigation of multiple complaint intake numbers, to assess compliance with Medicare/Medicaid regulations for Warner Robins Rehabilitation Center.
Complaint Details
Multiple complaint intake numbers were investigated in conjunction with the standard survey. Two complaint intakes were unsubstantiated, while five were substantiated without deficiencies.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to report resident-to-resident abuse, failure to timely change PICC line dressings, and failure to ensure psychotropic medications were not ordered as needed for more than 14 days without clinical indication.
Deficiencies (3)
Failed to report an allegation of resident-to-resident abuse to the State Survey Agency for one resident.
Failed to change the Peripherally Inserted Central Catheter (PICC) Line dressing in a timely manner for one resident.
Failed to ensure psychotropic medications, specifically a hypnotic, were not ordered as needed for more than 14 days unless clinically indicated for one resident.
Report Facts
Resident census: 108
Sampled residents for PICC line dressing: 24
Residents reviewed for unnecessary medications: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| EE | Licensed Practical Nurse (LPN) | Interviewed regarding resident-to-resident abuse incident. |
| AA | Licensed Practical Nurse (LPN) | Interviewed regarding responsibility for changing PICC line dressings. |
| BB | Licensed Practical Nurse (LPN) Wound Care Nurse | Interviewed regarding PICC line dressing change schedule and responsibility. |
| Regional Nurse Consultant | Interviewed regarding pharmacy consults and medication orders. | |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding expectations for PICC line dressing changes. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Mar 16, 2023
Visit Reason
The inspection was conducted due to complaints related to failure to timely report resident-to-resident abuse, failure to change PICC line dressing timely, and failure to ensure psychotropic medications were not ordered as needed for more than 14 days without clinical indication.
Complaint Details
The complaint investigation found that the facility did not report an incident of resident-to-resident abuse that occurred on 2/13/2023, where one resident pushed another down. The facility also failed to follow physician orders for PICC line dressing changes and did not address pharmacy recommendations to discontinue a psychotropic medication.
Findings
The facility failed to report an allegation of resident-to-resident abuse to the State Survey Agency, failed to change a resident's PICC line dressing in a timely manner as ordered, and failed to ensure psychotropic medication (zolpidem) was not ordered as needed for more than 14 days without clinical indication.
Deficiencies (3)
Failed to timely report an allegation of resident-to-resident abuse to the State Survey Agency.
Failed to change the Peripherally Inserted Central Catheter (PICC) Line dressing in a timely manner for one resident.
Failed to ensure psychotropic medications, specifically a hypnotic, were not ordered as needed (PRN) for more than 14 days unless clinically indicated.
Report Facts
Residents reviewed for abuse reporting: 4
Residents sampled for PICC line dressing: 24
Residents reviewed for unnecessary medications: 5
Date of resident abuse incident: Feb 13, 2023
Date of PICC line dressing observed: Feb 28, 2023
Date of physician order for PICC line dressing change: Feb 7, 2023
Date of pharmacy consults recommending discontinuation of zolpidem: Oct 26, 2022
Date of pharmacy consults recommending discontinuation of zolpidem: Dec 30, 2022
Date of pharmacy consult recommending discontinuation of zolpidem: Feb 28, 2023
Date physician agreed to discontinue zolpidem: Mar 14, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| EE | Licensed Practical Nurse (LPN) | Interviewed regarding resident-to-resident abuse incident |
| AA | Licensed Practical Nurse (LPN) | Interviewed regarding PICC line dressing responsibility |
| BB | Licensed Practical Nurse (LPN) Wound Care Nurse | Interviewed regarding PICC line dressing changes |
| Regional Nurse Consultant | Interviewed regarding psychotropic medication orders and pharmacy consults | |
| Administrator | Interviewed regarding reporting of resident abuse incident | |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding PICC line dressing change expectations |
| Social Services Manager | Interviewed regarding procedures for resident altercations |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Mar 16, 2023
Visit Reason
The inspection was conducted to investigate complaints related to failure to timely report resident-to-resident abuse, failure to change PICC line dressing timely, and failure to ensure psychotropic medications were not ordered as needed for more than 14 days without clinical indication.
Complaint Details
The complaint investigation revealed failure to report resident-to-resident abuse, failure to follow physician orders for PICC line dressing changes, and failure to discontinue psychotropic medication without clinical indication. The resident-to-resident abuse was not reported because the administrator believed no injuries meant no reporting was required.
Findings
The facility failed to report an allegation of resident-to-resident abuse to the State Survey Agency, failed to change a resident's PICC line dressing in a timely manner according to physician orders, and failed to ensure psychotropic medication (zolpidem) was not ordered as needed for more than 14 days without clinical indication.
Deficiencies (3)
Failed to timely report an allegation of resident-to-resident abuse to the State Survey Agency for one resident.
Failed to change the Peripherally Inserted Central Catheter (PICC) Line dressing in a timely manner for one resident.
Failed to ensure psychotropic medications, specifically a hypnotic, were not ordered as needed (PRN) for more than 14 days unless clinically indicated for one resident.
Report Facts
Residents reviewed for abuse reporting: 4
Residents sampled for PICC line dressing: 24
Residents reviewed for unnecessary medications: 5
Date of resident pushed down: Feb 13, 2023
Date of PICC line dressing observed: Feb 28, 2023
Physician order date for PICC line dressing change: Feb 7, 2023
Physician order date for zolpidem: Oct 19, 2022
Pharmacy consult dates recommending discontinuation of zolpidem: 3
Date physician agreed to discontinue zolpidem: Mar 14, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| EE | Licensed Practical Nurse (LPN) | Interviewed regarding resident pushed down incident and facility response. |
| Social Services Manager | Interviewed regarding procedures for resident altercations. | |
| Administrator | Interviewed regarding non-reporting of resident-to-resident abuse due to no injuries. | |
| AA | Licensed Practical Nurse (LPN) | Interviewed about responsibility for changing PICC line dressings. |
| BB | Licensed Practical Nurse (LPN) Wound Care Nurse | Interviewed about PICC line dressing change schedule and failures. |
| Director of Nursing (DON) | Director of Nursing | Interviewed about expectations for PICC line dressing changes. |
| Regional Nurse Consultant | Interviewed about pharmacy consults and psychotropic medication orders. |
Inspection Report
Life Safety
Census: 105
Capacity: 126
Deficiencies: 24
Date: Mar 14, 2023
Visit Reason
The inspection was conducted as a Life Safety Code Survey to assess compliance with fire safety and emergency preparedness regulations.
Findings
The facility was found not in substantial compliance with multiple Life Safety Code requirements including emergency preparedness plan deficiencies, blocked exits, malfunctioning emergency lighting and exit signage, improper door latches, missing ceiling tiles, unsealed penetrations, outdated hood suppression system, missing fire alarm and smoke detector testing documentation, painted and loaded sprinkler heads, blocked fire extinguishers, blocked electrical panels, improperly installed power strips, missing fire drill documentation, combustible decorations not treated, presence of prohibited space heaters, and missing generator maintenance documentation.
Deficiencies (24)
Emergency Preparedness Program plan was not in substantial compliance; missing documentation to verify annual updates.
Exit E hall was blocked by storage.
Laundry room door failed to close properly.
Non-approved parts installed on smoke doors in Hall 200 and 300.
Emergency lights failed to operate in corridor outside therapy room and therapy room kitchen.
Exit signs failed to operate in corridor outside therapy room and therapy room kitchen.
Missing ceiling tile behind dryers in laundry room.
Penetrations not properly sealed in kitchen at extinguishment system and riser room hall 200.
Hood suppression system in therapy room was out of date (last serviced 10/07/2021).
Missing vent hood cleaning reports for past 12 months in kitchen.
Fire alarm batteries not marked with manufactured date, month, and year.
Missing documentation for annual fire alarm inspection and smoke detector sensitivity test.
Painted sprinkler heads in restorative dining room and loaded sprinkler heads in laundry room.
Escutcheon ring outside therapy room not installed properly.
Fire extinguisher in boiler room expired (last serviced 10/04/2021) and missing service report.
Kitchen fire extinguishers blocked by food cart.
Penetrations in fire/smoke wall hall 300 above doors not properly sealed.
Storage blocking panel boxes in therapy room.
Power strips in therapy director's office and room 507 were on the floor, improperly installed.
Missing fire drill documentation for June third shift, August second shift, and September third shift.
Combustible decorations (construction paper) covering window across from activity room not treated with fire retardant.
Prohibited portable space heaters found in therapy director's office and nursing admin assistant office without thermostatic documentation.
Missing generator run times and load bank test documentation for entire facility.
Storage blocking panel room in therapy room.
Report Facts
Census: 105
Total Capacity: 126
Fire extinguisher last service date: Oct 4, 2021
Hood suppression last service date: Oct 7, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed multiple findings during facility tour on 03/14/2023 | |
| Staff N | Confirmed emergency preparedness plan findings |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jun 9, 2022
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate multiple complaints identified by numbers #GA00220923, #GA00221853, #GA222560, #GA00222573, #GA00223161, and #GA00224614.
Complaint Details
The complaints investigated during the survey were unsubstantiated.
Findings
The complaints were unsubstantiated and no regulatory violations were cited. The facility was found to be in compliance with vaccination requirements for facility staff under CFR 483.80 (i) (1) - (3) (i) - (x).
Inspection Report
Deficiencies: 0
Date: Dec 9, 2021
Visit Reason
The document is a statement of deficiencies and plan of correction for Warner Robins Rehabilitation Center following a state inspection.
Findings
The report contains initial comments and a summary statement of deficiencies identified during the inspection.
Inspection Report
Re-Inspection
Census: 97
Deficiencies: 0
Date: Dec 9, 2021
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the prior 10/6/21 Standard Survey and to investigate Complaint Intake Number GA00218826.
Complaint Details
Complaint Intake Number GA00218826 was investigated and found to be unsubstantiated.
Findings
All deficiencies cited in the prior survey were found to be corrected. The complaint investigated was unsubstantiated.
Inspection Report
Abbreviated Survey
Census: 97
Deficiencies: 0
Date: Dec 9, 2021
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint #GA00218826.
Complaint Details
Complaint #GA00218826 was investigated and found to be unsubstantiated.
Findings
The complaint was unsubstantiated and no regulatory violations were cited during the survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Nov 22, 2021
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The survey noted that all previously cited deficiencies had been corrected.
Inspection Report
Original Licensing
Deficiencies: 0
Date: Oct 6, 2021
Visit Reason
Licensure Survey conducted from 10/3/2021 through 10/6/2021 to assess compliance for facility licensure.
Findings
No deficiencies were identified during the licensure survey conducted from 10/3/2021 through 10/6/2021.
Inspection Report
Complaint Investigation
Census: 98
Deficiencies: 2
Date: Oct 6, 2021
Visit Reason
A standard survey was conducted from 10/03/2021 through 10/06/2021, including investigation of Complaint Intake Number GA00215954, to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Complaint Details
Complaint Intake Number GA00215954 was investigated in conjunction with the standard survey.
Findings
The facility was found not in substantial compliance with regulations, with deficiencies including failure to maintain and clean oxygen concentrator filters for a resident receiving respiratory treatment, and failure to employ a certified Dietary Manager as required by regulations.
Deficiencies (2)
The facility failed to ensure the filter for the oxygen concentrator for one resident receiving respiratory treatment was cleaned and/or changed.
The facility failed to ensure that the staff designated as the Dietary Manager was certified or had a similar food service management certification or degree.
Report Facts
Resident census: 98
Residents receiving respiratory treatment: 24
Residents affected by dietary manager deficiency: 87
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN DD | Registered Nurse | Interviewed regarding oxygen concentrator filter condition for resident R#36. |
| MD | Maintenance Director | Interviewed regarding maintenance of oxygen concentrators and filter replacement. |
| DM | Dietary Manager | Not certified; scheduled to take Dietary Manager's Certification Test in November 2021. |
| NHA | Nursing Home Administrator | Acknowledged Dietary Manager certification requirement and interview regarding certification status. |
Inspection Report
Annual Inspection
Census: 98
Deficiencies: 2
Date: Oct 6, 2021
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to respiratory care and dietary management at the facility.
Findings
The facility failed to ensure proper maintenance of oxygen concentrator filters for one resident receiving respiratory treatment and failed to employ a certified Dietary Manager, potentially affecting many residents.
Deficiencies (2)
Failed to ensure the filter for the oxygen concentrator for one resident was cleaned and/or changed.
Failed to ensure the staff designated as the Dietary Manager was certified or had a similar food service management certification or degree.
Report Facts
Residents affected: 24
Residents affected: 87
Total residents receiving oral diet: 98
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DD | Registered Nurse | Named in oxygen concentrator filter deficiency finding |
| Maintenance Director | Named in oxygen concentrator filter deficiency finding | |
| Administrator | Named in oxygen concentrator filter deficiency finding | |
| Dietary Manager | Named in dietary certification deficiency finding | |
| Nursing Home Administrator | Named in dietary certification deficiency finding |
Inspection Report
Life Safety
Census: 96
Capacity: 126
Deficiencies: 1
Date: Oct 4, 2021
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with 42 CFR Subpart 483.90(a) and NFPA 101 Life Safety Code 2012 edition requirements.
Findings
The facility was found not in substantial compliance due to failure to properly seal fire walls in 2 of 5 smoke compartments, specifically the main hall by the exit door to the courtyard and the 400 hall corridor above the doors. These findings were confirmed by staff during the tour.
Deficiencies (1)
Failure to properly seal fire walls in smoke compartments, affecting 2 of 5 smoke compartments.
Report Facts
Census: 96
Total Capacity: 126
Smoke Compartments Affected: 2
Total Smoke Compartments: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings of improperly sealed fire walls during facility tour |
Inspection Report
Deficiencies: 0
Date: Jul 9, 2021
Visit Reason
The document is a statement of deficiencies and plan of correction for Warner Robins Rehabilitation Center following a survey completed on July 9, 2021.
Findings
The report contains initial comments but does not provide detailed findings or deficiencies within the provided page.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jul 9, 2021
Visit Reason
A revisit survey was conducted by desk review on 7/9/2021 to verify correction of deficiencies cited during the 5/5/2021 Complaint Survey.
Complaint Details
The visit was a follow-up to a complaint survey conducted on 5/5/2021; all cited deficiencies were corrected.
Findings
All deficiencies cited as a result of the 5/5/2021 Complaint Survey were found to be corrected.
Inspection Report
Original Licensing
Deficiencies: 1
Date: May 5, 2021
Visit Reason
A Licensure Survey was conducted from 5/3/2021 through 5/5/2021 to assess compliance with licensure requirements.
Findings
The facility failed to notify the responsible party of significant weight loss for one of four sampled residents, despite documented weight loss and changes in nutritional interventions. Interviews confirmed the family was not informed, constituting a deficiency in communication and notification protocols.
Deficiencies (1)
Failure to notify the responsible party of significant weight loss for one resident.
Report Facts
Weight loss percentage: 22
Brief Interview of Mental Status (BIMS) score: 5
Inspection Report
Complaint Investigation
Census: 97
Deficiencies: 1
Date: May 5, 2021
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints #GA00212505 and #GA00212862. The investigation was initiated on 2021-05-03 and concluded on 2021-05-05.
Complaint Details
Complaint #GA00212505 was unsubstantiated. Complaint #GA00212862 was substantiated with deficiencies related to failure to notify the responsible party of weight loss for one resident (R#1).
Findings
Complaint #GA00212862 was substantiated with deficiencies related to failure to notify the responsible party of significant weight loss for one resident. The facility did not notify the resident's family or representative about the resident's 22% weight loss and changes in treatment interventions.
Deficiencies (1)
Failure to notify the resident's responsible party of significant weight loss and changes in treatment interventions for one resident.
Report Facts
Resident census: 97
Weight loss percentage: 22
BIMS score: 5
Protein supplement dosage: 90
Protein supplement dosage: 120
Inspection Report
Abbreviated Survey
Census: 98
Deficiencies: 0
Date: Feb 26, 2021
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint number GA00212264.
Complaint Details
Complaint number GA00212264 was investigated and found to be unsubstantiated.
Findings
The complaints investigated during the survey were found to be unsubstantiated.
Report Facts
Census: 98
Inspection Report
Complaint Investigation
Census: 103
Deficiencies: 0
Date: Feb 15, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted in conjunction with a complaint survey investigating complaints #GA00211669 and #GA00211692.
Complaint Details
Complaints #GA00211669 and #GA00211692 were investigated and found to be unsubstantiated with no regulatory violations cited.
Findings
The complaints were unsubstantiated and no regulatory violations were cited. The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Total census: 103
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Dec 29, 2020
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00210596.
Complaint Details
Complaint #GA00210596 was investigated and found to be unsubstantiated with no regulatory violations.
Findings
The complaint #GA00210596 was unsubstantiated with no regulatory violations found during the survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Dec 15, 2020
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint GA00210336 from 12/14/2020 to 12/15/2020.
Complaint Details
Complaint GA00210336 was investigated and found unsubstantiated with no deficiencies cited.
Findings
The complaint GA00210336 was unsubstantiated with no deficiencies cited during the survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Nov 23, 2020
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00209716.
Complaint Details
Complaint #GA00209716 was investigated and found to be unsubstantiated.
Findings
The complaint was unsubstantiated and no regulatory violations were cited during the survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Nov 10, 2020
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints #GA00207776 and #GA00208042.
Complaint Details
Complaints #GA00207776 and #GA00208042 were investigated and found to be unsubstantiated with no deficiencies.
Findings
The complaints #GA00207776 and #GA00208042 were unsubstantiated with no deficiencies found during the survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Oct 27, 2020
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint #GA00208977.
Complaint Details
Complaint #GA00208977 was investigated and found to be unsubstantiated.
Findings
The complaint was unsubstantiated and no regulatory violations were cited during the survey.
Inspection Report
Re-Inspection
Census: 99
Deficiencies: 0
Date: Oct 6, 2020
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the August 12, 2020 complaint survey.
Complaint Details
This was a follow-up to a complaint survey conducted on August 12, 2020; all deficiencies were corrected.
Findings
All deficiencies cited as a result of the August 12, 2020 complaint survey were found to be corrected.
Inspection Report
Re-Inspection
Census: 99
Deficiencies: 0
Date: Oct 6, 2020
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited as a result of the August 12, 2020 Complaint survey.
Complaint Details
This revisit survey followed a complaint survey conducted on August 12, 2020. The deficiencies from that complaint survey were corrected.
Findings
All deficiencies cited in the prior complaint survey were found to be corrected during this revisit survey.
Report Facts
Facility census: 99
Inspection Report
Renewal
Census: 88
Deficiencies: 2
Date: Aug 12, 2020
Visit Reason
A Licensure Survey was conducted from 8/5/2020 through 8/12/2020 to assess compliance with licensure requirements.
Findings
The facility failed to follow the approved menu for 79 residents receiving an oral diet, with multiple substitutions and missing items noted. Additionally, the facility failed to provide a thorough initial assessment and staging of a pressure ulcer for one resident (#7) as required by policy.
Deficiencies (2)
Facility failed to follow the approved menu for 79 residents receiving an oral diet, with substitutions and missing items such as butter and frosting.
Facility failed to provide a thorough initial assessment and staging of a pressure ulcer for one resident (#7).
Report Facts
Residents receiving oral diet: 79
Facility census: 88
Pressure ulcer measurements: 1.5
Pressure ulcer measurements: 3.5
Pressure ulcer measurements: 0.2
Pressure ulcer measurements: 6
Pressure ulcer measurements: 0.1
Pressure ulcer surface area: 36
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Interviewed regarding menu substitutions and discrepancies | |
| Administrator | Interviewed regarding menu substitutions and facility practices | |
| Interim Director of Nursing | Interviewed regarding wound staging practices | |
| Wound Care Physician | Interviewed regarding wound assessment and staging for resident #7 |
Inspection Report
Abbreviated Survey
Census: 88
Deficiencies: 4
Date: Aug 12, 2020
Visit Reason
An Abbreviated/Partial Extended Survey was conducted from 08/05/2020 to 08/12/2020 to investigate multiple complaints against the facility.
Complaint Details
The survey investigated complaints GA00202859, GA00202973, GA00203277, GA00203880, GA00204932, GA00206291, and GA00206352. Complaints GA00202859, GA00203277, GA00203880, GA00204932, and GA00206291 were unsubstantiated. Complaints GA00202973 and GA00206352 were partially substantiated with deficiencies.
Findings
The facility was found deficient in implementing care plan interventions for weight loss supplements, conducting thorough initial assessments of pressure ulcers, serving ordered nutritional supplements, and following approved menus for residents. Several complaints were partially substantiated with deficiencies.
Deficiencies (4)
Failed to implement a care plan intervention to provide supplements as ordered for weight loss for one resident.
Failed to provide a thorough initial assessment of a pressure ulcer for one resident.
Failed to serve one resident a strawberry milkshake as ordered by the physician.
Failed to follow the approved menu for 79 residents receiving an oral diet; substitutions and omissions were noted.
Report Facts
Facility census: 88
Resident weight loss percentage: 8.3
Pressure ulcer size: 6
Number of residents receiving oral diet: 79
Inspection Report
Routine
Census: 83
Deficiencies: 0
Date: Jul 22, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
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.
Inspection Report
Routine
Census: 102
Deficiencies: 0
Date: Jun 17, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey and a COVID-19 Focused Infection Control Survey were conducted to assess the facility's compliance with relevant CMS and CDC regulations 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: 102
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Dec 20, 2019
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints GA00201160, GA00201330, and GA00201548.
Complaint Details
Complaint GA00201160 was substantiated without deficiency; complaints GA00201330 and GA00201548 were unsubstantiated.
Findings
Complaints GA00201330 and GA00201548 were found to be unsubstantiated. Complaint GA00201160 was substantiated but without any deficiency.
Inspection Report
Re-Inspection
Census: 117
Deficiencies: 0
Date: Dec 12, 2019
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the 10/25/19 Complaint Survey.
Complaint Details
This revisit survey followed a complaint survey conducted on 10/25/19. All cited deficiencies were corrected.
Findings
All deficiencies cited in the previous complaint survey were found to be corrected during this revisit survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: May 6, 2019
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints GA00196389, GA00196107, and GA00195997.
Complaint Details
The survey investigated three complaints identified as GA00196389, GA00196107, and GA00195997, all of which were unsubstantiated.
Findings
The complaints investigated during the survey were found to be unsubstantiated.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Nov 20, 2018
Visit Reason
A revisit survey was conducted at Warner Robins Rehabilitation Center from 11/19/18 until 11/20/18 to verify correction of deficiencies cited in the prior survey of 9/20/18.
Findings
All deficiencies cited as the result of the survey of 9/20/18 were found to be corrected during this revisit survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Nov 6, 2018
Visit Reason
A follow-up survey was conducted to verify that all previously cited survey tags had been corrected.
Findings
The follow-up survey noted that all previously cited survey tags have been corrected.
Inspection Report
Annual Inspection
Census: 97
Deficiencies: 6
Date: Sep 20, 2018
Visit Reason
A standard survey was conducted from September 17, 2018 through September 20, 2018, including investigation of Complaint Intake Number GA00190870, to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Complaint Details
Complaint Intake Number GA00190870 was investigated in conjunction with the standard survey.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to ensure call lights were within reach for a resident at risk of falls, improper use and assessment of position alarms as restraints, failure to revise care plans to reflect assistive device needs, inadequate supervision and positioning during meals for a resident with swallowing disorder, and failure to provide palatable food with appropriate seasoning and assistive utensils for residents.
Deficiencies (6)
Failure to ensure call light was within reach for a resident with history of falls and incontinence, increasing fall risk and lack of dignity.
Failure to assess position change alarms as possible restraints prior to use on a resident with dementia and history of falls.
Failure to revise nutritional care plan to include use of weighted silverware for a resident with tremors.
Failure to provide adequate supervision and assistance to ensure proper positioning during meals for a resident with swallowing disorder, placing resident at risk for choking and aspiration.
Failure to provide palatable food with seasoning and condiments, and failure to prepare pureed foods according to recipes, resulting in bland and unappetizing meals for multiple residents.
Failure to provide weighted utensils to a resident with tremors, despite assessment indicating need and resident's desire to use them.
Report Facts
Resident census: 97
Sample size: 28
Weight loss: 15
BIMS score: 14
BIMS score: 15
BIMS score: 10
BIMS score: 11
BIMS score: 13
Resident weight: 168
Resident weight: 137
Resident weight: 127
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DD | Certified Nurse Assistant | Named in call light deficiency and resident care |
| MM | Licensed Practical Nurse / Unit Manager | Named in call light deficiency and resident care |
| PP | Licensed Practical Nurse | Interviewed about alarms not considered restraints |
| RR | Regional Consultant | Interviewed about position alarms and restraint definitions |
| Cook TT | Cook | Interviewed about pureed food preparation |
| Cook SS | Cook | Observed preparing pureed foods |
| BB | Certified Nursing Assistant | Interviewed about assistive device needs for resident #67 |
| GG | Licensed Practical Nurse | Interviewed about assistive device needs for resident #67 |
Inspection Report
Routine
Deficiencies: 1
Date: Sep 20, 2018
Visit Reason
The inspection was conducted to assess compliance with nursing care requirements, specifically reviewing the facility's adherence to revising nutritional care plans according to residents' needs.
Findings
The facility failed to revise the nutritional care plan for one resident (R#67) to include the use of weighted silverware as recommended by Occupational Therapy, despite the resident's need and desire for the assistive device. Staff interviews confirmed the care plan was not updated due to a missed order in the computer system.
Deficiencies (1)
Failure to revise nutritional care plan for resident R#67 to include use of weighted silverware as recommended by Occupational Therapy.
Report Facts
Resident sample size: 28
Resident ID: 67
Brief Interview Mental Status (BIMS) score: 11
Brief Interview Mental Status (BIMS) score: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| GG | Licensed Practical Nurse | Interviewed regarding unawareness of resident's assistive device needs |
| East Unit Manager | Interviewed about dietary tray ticket and missed order in computer system | |
| MDS Coordinator | Interviewed about responsibility for revising care plans and confirmed missed order |
Inspection Report
Life Safety
Census: 97
Capacity: 125
Deficiencies: 3
Date: Sep 17, 2018
Visit Reason
The visit was a Life Safety Code Survey conducted to assess compliance with fire safety regulations and related NFPA standards at Warner Robins Rehabilitation Center.
Findings
The facility was found not in substantial compliance with Life Safety Code requirements, including failure to provide continuously illuminated exit signs at all required exits, failure to properly inspect and maintain the sprinkler system, and failure to ensure corridor doors close and latch properly. These deficiencies posed risks to residents in the event of a fire.
Deficiencies (3)
Facility failed to identify all required exits with continuously illuminated exit signs, specifically the west wing lobby exit lacked an illuminated exit sign.
Facility failed to inspect, test, and maintain the fire sprinkler system in accordance with NFPA 25; gauges on sprinkler riser were overdue for testing and no 5-year internal pipe test had been done.
Facility failed to provide corridor doors that close and latch properly; doors to resident rooms B-7 and 604 would not latch, and doors to rooms C-7, C-9, 408, and 409 were impeded from closing due to door bottoms dragging on the floor.
Report Facts
Residents at risk due to exit signage deficiency: 38
Total residents: 97
Total licensed beds: 125
Residents at risk due to door deficiencies: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Staff member who confirmed findings related to exit signage, sprinkler system deficiencies, and door issues during the inspection. |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: May 11, 2018
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints GA00184933 and GA00185131, initiated on February 12, 2018 and concluded on February 13, 2018, with a re-entry on May 11, 2018 for further investigation.
Complaint Details
Complaint GA00185131 was substantiated with no deficiencies; complaint GA00184933 was unsubstantiated.
Findings
Complaint GA00185131 was substantiated with no deficiencies found, while complaint GA00184933 was unsubstantiated.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 9, 2018
Visit Reason
The inspection was conducted as a Complaint Survey to investigate complaint #GA00187331 and determine compliance with Federal and State Long Term Care regulations.
Complaint Details
Complaint #GA00187331 was investigated and found to have no deficiencies cited.
Findings
No deficiencies were cited during the complaint survey, indicating compliance with the applicable regulations.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Mar 30, 2018
Visit Reason
A Revisit Survey was conducted on 3/30/18 to investigate Complaint Intake Number GA00187076 in conjunction with this revisit survey.
Complaint Details
Complaint Intake Number GA00187076 was investigated and found unsubstantiated with no deficiencies.
Findings
All deficiencies cited as a result of the Complaint survey of 2/2/18 were found to be corrected. The complaint investigation found GA00187076 was unsubstantiated with no deficiencies.
Inspection Report
Abbreviated Survey
Census: 101
Deficiencies: 0
Date: Mar 30, 2018
Visit Reason
An abbreviated survey was conducted to investigate complaint #GA00187076 during an unannounced visit, along with a revisit to a prior complaint survey with deficiencies.
Complaint Details
Complaint #GA00187076 was investigated; the facility was found in substantial compliance.
Findings
The complaint survey revealed the facility was in substantial compliance with Medicare/Medicaid regulations at 42 C.F.R. Part 483 for Long Term Care Facilities.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Dec 27, 2017
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Warner Robins Rehabilitation Center following a survey completed on December 27, 2017.
Findings
The document contains no specific deficiencies or findings detailed; it primarily serves as a form for reporting deficiencies and the provider's plan of correction.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 11, 2017
Visit Reason
A follow-up survey was conducted to verify that all previously cited survey tags had been corrected.
Findings
The follow-up survey noted that all previously cited deficiencies had been corrected.
Inspection Report
Life Safety
Census: 116
Capacity: 126
Deficiencies: 5
Date: Oct 23, 2017
Visit Reason
The inspection was a 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 2012 edition.
Findings
The facility was found not in substantial compliance with fire safety requirements, including failure to properly enclose hazardous areas with smoke-resisting partitions, failure to maintain the UL 300 fire suppression system in the kitchen, lack of a readily available evacuation and relocation plan for staff, failure to conduct fire drills at varying times and conditions, and improper use of electrical power strips and extension cords in patient care areas.
Deficiencies (5)
Failed to separate hazardous areas from the rest of the facility with smoke resisting partitions, including holes in ceilings above sprinkler heads in electrical closets.
Failed to inspect and maintain the UL 300 fire suppression system on the kitchen commercial hood every 6 months as required.
Failed to provide the evacuation and relocation plan in a readily available location for staff to keep informed of their duties in an emergency.
Failed to conduct fire drills at various times under varying conditions; drills were conducted only within narrow time frames on each shift.
Failed to provide electrical equipment and wiring in accordance with NFPA 70 and NFPA 99; multiple rooms had multiplug adapters in use.
Report Facts
Residents at risk: 116
Residents at risk: 116
Residents at risk: 116
Residents at risk: 28
Certified Beds: 126
Census: 116
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Staff member who confirmed findings during the tour and record reviews |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Sep 29, 2017
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints GA00180063, GA00180207, and GA00180316.
Complaint Details
Complaints GA00180063, GA00180207, and GA00180316 were investigated and found to be unsubstantiated.
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.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 21, 2017
Visit Reason
An unannounced complaint survey was conducted on 09/17/2017 and 09/21/2017 to investigate complaint intake number GA 00179144.
Complaint Details
Complaint intake number GA 00179144 was investigated and found substantiated.
Findings
The complaint was substantiated, but no Federal deficiencies were cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 20, 2017
Visit Reason
The inspection was conducted to investigate complaint #GA00177407 and determine compliance with Federal and State Long Term Care regulations.
Complaint Details
Complaint #GA00177407 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 27, 2017
Visit Reason
A complaint investigation was conducted at Warner Robins Rehabilitation Center on May 27, 2017 related to complaint GA 00175389, event # LZBN11.
Complaint Details
Complaint GA 00175389, event # LZBN11 was investigated and found to be unsubstantiated due to lack of evidence.
Findings
The complaint investigation was found to be unsubstantiated due to lack of evidence.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 3, 2017
Visit Reason
The inspection was conducted as a complaint survey for complaint GA00173275.
Complaint Details
Complaint GA00173275 was investigated and found to be unsubstantiated as no deficiencies were cited.
Findings
No health deficiencies were cited. The facility was found to be in compliance with Federal and State Long Term regulations 42 CFR, Part 483, Subpart B for Long Term Care Requirements.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 1, 2017
Visit Reason
The inspection was conducted as a complaint survey to investigate Complaints #GA00170532, #GA00172085, and self-reported allegation #GA00171879 to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
The survey was complaint-related, investigating three specific complaints and a self-reported allegation; no deficiencies were found.
Findings
The complaints were referred to the appropriate regulatory agency and no deficiencies were cited during the investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 17, 2017
Visit Reason
The inspection was conducted as a complaint survey to investigate Complaint number #GA00170532 and determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
Complaint number #GA00170532 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint survey conducted on January 17-18, 2017.
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