Abercorn Rehabilitation Center

Inspectors wroteBased on observation, staff interviews, and review of the facility's policies titled Food Storage Principles, the facility failed to ensure opened food items in the walk-in cooler/freezer were labeled and dated. In addition, the facility failed to discard one food item by the expiration date. This had the potential to affect 80 residents receiving oral diets from the kitchen. Findings Include:Review of the Food Storage policy, revised 11/14/2025, documented under procedure 1. Train employees regarding proper food storage procedures. 5. [...]

Inspectors wroteBased on observation, interviews and review of the facility policy titled Hand Washing/Hygiene, the facility failed to ensure that staff were washing or sanitizing their hands while passing out lunch trays to the residents. The deficient practice had the potential to place residents at risk for infections from cross contamination.

Inspectors wroteBased on observations, resident and staff interviews, and record review, the facility failed to develop a person-centered, comprehensive care plan for one resident (R) (R102) of 43 sampled residents. Specifically, the facility did not develop a care plan for R102 for oxygen (O2) therapy. The deficit practice had the potential to place R102, at risk for medical complications, unmet needs, and a diminished quality of life. Findings Include:A request for a Care Plan policy was made on 02/26/2026 at 2:30 PM and 3:00 PM and was not provided by the facility prior to survey conclusion. Review of R102's Electronic Medical Record (EMR) revealed diagnoses including, but not limited to, chronic atrial fibrillation, and chronic kidney disease, stage 2. [...]

Inspectors wroteBased on observations and interviews, the facility failed to ensure that two bathrooms (one shared bathroom between room [ROOM NUMBER] and 14, and one private bathroom room [ROOM NUMBER]) had water temperatures under 120 degrees Fahrenheit and two resident rooms (Room TB 045A and Room TB 053A) were free of chemicals from a total of 54 rooms. The deficient practice increased the risk to residents for burns and other injuries.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled Oxygen Administration, the facility failed to ensure that oxygen (O2) was administered according to physician orders for one of six residents (R) (R102) reviewed for oxygen administration. This failure had the potential to place R102 at risk of respiratory complications and unmet needs.

Inspectors wroteBased on observation, staff interviews, and facility policy titled, Medications Storage Room, the facility failed to ensure one of four medication carts and two of three medication rooms were free of expired medications. This deficient practice had the potential to place residents at risk of receiving expired medications.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to provide adequate supervision to prevent accidents during incontinence care for one (Resident (R) 295) of four sampled residents reviewed for accidents. The failure resulted in a fall with injury, two fractured knees, and a fractured hip, requiring transfer to the hospital for evaluation.

Inspectors wroteBased on observations, record review, interviews, and policy review, the facility failed to ensure four (Resident (R) 93, R23, R95, and R34) of 90 facility residents observed during initial screening had medications available for self-administration and stored at the bedside only when assessed to do so safely and with a physician's order. These failures placed all four residents at risk for medication errors, overdose, or misappropriation of medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident rooms were clean, creating a homelike environment for three (Residents (R) 63, R59, and R46) of eight residents reviewed for homelike environment. This failure had the potential to negatively impact residents' environment and overall well-being.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to report an allegation of resident-to-resident sexual abuse within two hours after the allegation for two residents (Resident (R) 36 and R294) of seven sampled residents. The deficient practice could result in residents being abused.

Inspectors wroteBased on interviews, record review, and facility policy, the facility failed to develop and implement a baseline care plan that included instructions needed to provide effective and person-centered care within 48 hours of admission for one (Resident (R) 94) of six sampled residents. Failure to develop and implement a baseline care plan could place residents at risk for unmet care needs.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to provide staff assistance with activities of daily living for one (Residents (R) 63) of two residents reviewed for activities of daily living out of a total sample of 31 residents. This failure had the potential to lead to a decline in activities of daily living.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure one (Resident (R)1) in the sample of 31, received wound care per the physician's orders. The facility's deficient practice increased R1's risk of infection which delayed healing and caused discomfort.

Inspectors wroteBased on observations, staff and resident interviews, record review, and facility policy review, the facility failed to provide respiratory care in accordance with professional standards for two (Residents (R) 53 and R63) of three residents reviewed for respiratory care out of a total sample of 22 residents. This failure had the potential to lead to respiratory complications and infections.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure residents were provided with food that was palatable and at a safe and appetizing temperature for three of three residents (Resident (R) 2, R15, and R65) of 31 sample residents. This failure had the potential to affect resident food satisfaction leading to potentially decreased oral intake and weight loss.

Inspectors wroteBased on staff interviews, record review, and a review of the facility's policy titled, Advanced Directives, the facility failed to obtain a Physician's order for one of five residents (R) (#296) reviewed for full code status.

Inspectors wroteBased on observations, staff interviews, and record review, the facility failed to conduct a Level II Preadmission Screening and Resident Review (PASARR) screening for two of 32 sampled residents (R) (#9 and R#57) following a new diagnosis of schizophrenia for R#9, and a new diagnosis of schizoaffective disorder for R#57.

Inspectors wrote3. Record review of the care plan for R#86 dated 5/22/2023 revealed that the resident is at risk of falls, with interventions that include a bed in the low position, fall mats at the bedside, and wedges placed for positioning. Record review of the most recent minimum data set (MDS) for R#86, dated 2/24/2023, revealed that the resident has a Basic Interview for Mental Status (BIMS) score of 12, indicating a mild cognition difficulty. She needs extensive assistance with total dependence for bed mobility and transfers in section G. Review of the facility's falls list; R # 86 had a fall on 5/19/2023. Interview on 5/25/2023 at 8:35 a.m., the resident was interviewed, with a family member at the bedside. She and the aunt both revealed that she had not had a fall. Observations on 5/23/2023 at 12:55 p.m. [...]

Inspectors wroteBased on observations, resident and staff interviews, and record review, the facility failed to ensure that Activities of Daily Living (ADL) care was provided related to showers according to the schedule for one of 32 residents. (R) (#26). This failure had the potential to cause a diminish in residents' quality of life.

Inspectors wroteBased on observation, and staff interviews, the facility failed to ensure the medication error rate was less than five percent (5%). Two medication errors with 28 opportunities for two residents (R) (#43 and #19) were observed during a medication pass. The medication error rate was 7,14%. This failure had the potential to result in medication not being given in accordance with the physician's orders and has the potential to affect the residents' clinical conditions.