Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Abercorn Rehabilitation Center during CMS and state inspections, most recent first.
Food items in the walk-in cooler and freezer were found without required labels and dates, including meat items lacking open or use-by dates and refrigerated items such as apple juice and soy sauce without open dates. The DM confirmed the items should have been labeled with the proper dates, and one food item was not discarded by its expiration date.
Hand hygiene was not performed during meal service when staff passed out lunch trays and drinks. Residents were brought to the dining area without being offered hand hygiene, and staff were observed not sanitizing between trays, before opening straws, or before passing out drinks. A CNA stated she did not think sanitizing between trays was necessary, and the Infection Prevention Specialist confirmed staff should sanitize between trays and before passing out drinks.
Failure to Care Plan Oxygen Therapy: A resident with chronic atrial fibrillation and CKD stage 2 had a physician order for continuous O2 at 2 LPM via NC, but the comprehensive care plan had no documented oxygen care plan. Survey observations showed the resident receiving O2 by concentrator via NC at 1.0 LPM, and the MDS Coordinator confirmed the missing oxygen care plan and the ordered O2 rate.
Surveyors found pressurized aerosol containers and liquid disinfectant solution containers stored on bedside tables in two resident rooms, and the items remained there on repeated checks until the DON removed them. Surveyors also found hot water in two bathroom sinks, with temperatures measured at 127.6 F and 128.4 F. Residents in the affected rooms had significant care needs, including severe cognitive impairment, dependence for ADLs, and assistance with toileting, bathing, or ambulation.
Oxygen Administered at Incorrect Flow Rate: A resident with chronic atrial fibrillation and CKD stage 2 had a physician order for continuous O2 at 2 LPM via NC, but staff observed the oxygen concentrator set at 1.0 LPM. An LPN confirmed she had not checked the ordered setting because the resident's O2 saturation was 99%, and the DON confirmed the resident received O2 at the wrong flow rate and not per the physician order.
Expired and unlabeled medications were found in multiple medication storage areas. An LPN Unit Manager and RN confirmed two IV bags of 0.45% sodium chloride had no label or date after the outer covering was removed, three bottles of ProSight were expired, and items on a TCU medication cart included expired Nepro plus a Novolog FlexPen and Latanoprostat eye drops without open or expiration dates. The DON stated nurses and unit managers were responsible for weekly cart checks and for confirming medications were not expired before placement on the cart.
A resident with a history of muscle weakness and hemiplegia fell and sustained multiple fractures due to inadequate supervision during incontinence care. A CNA, not assigned to the resident, failed to review the Kardex or seek assistance, leading to the resident falling off the bed while being changed. The resident was initially sent to the ER and later found to have multiple fractures.
The facility failed to ensure safe self-administration of medications for four residents, who were found with medications at their bedside without proper assessments or physician's orders. This included pain relief cream, medicated powder, throat spray, eye drops, and inhalers. The facility's policy requires an interdisciplinary team assessment and physician's order for self-administration, which was not followed, placing residents at risk for medication errors.
The facility failed to ensure a clean and homelike environment for three residents. One resident's room was littered with trash, which was not cleaned for several days. Another resident's room was cluttered with personal items due to hoarding behavior, and the facility lacked a policy for maintaining cleanliness. A third resident had a damaged bed footboard, posing a potential injury risk, which had not been reported or addressed. These deficiencies were observed during a survey, highlighting lapses in housekeeping and maintenance protocols.
The facility failed to report an allegation of resident-to-resident sexual abuse within the required two-hour timeframe. Two residents with severe cognitive impairments were involved in the incident, which was observed by a CNA and reported to an RN. However, the RN did not report the event immediately, citing instructions from the unit manager. The delay in reporting violated the facility's policy, which mandates reporting such allegations within two hours.
A facility failed to develop a baseline care plan within 48 hours for a resident with multiple medical conditions, including diabetes and a chronic ulcer. The resident was admitted with specific needs for wound care and pain management, but the care plan lacked focus, goals, or interventions for these issues. Interviews revealed that the Admission Data Set, necessary for generating the care plan, was not completed, leading to the deficiency.
A resident with dementia, requiring partial assistance, was observed in poor hygiene and struggling with daily activities due to inadequate staff support. Despite documentation of care, the resident had not received a shower for 15 days and was seen attempting to manage independently. Staff interviews revealed inconsistencies in care provision and a potential change in the resident's condition.
A resident with a nostril lesion did not receive daily wound care as ordered by the physician, increasing the risk of infection and discomfort. The Treatment Administration Record showed multiple days without documented care, and observations confirmed the bandage was not changed daily. Staff interviews revealed that the responsible nurse was unable to audit treatment records regularly, leading to missed care.
The facility failed to provide proper respiratory care for two residents, leading to potential respiratory complications. One resident's nebulizer mask was left uncovered, and she reported not receiving her treatment, while another resident lacked active orders and documentation for oxygen therapy. Observations showed undated oxygen tubing and lapses in following facility policies, highlighting issues in equipment handling and record maintenance.
The facility failed to provide food at safe and appetizing temperatures for three cognitively intact residents. Residents reported consistently cold meals, especially when served in their rooms. A test tray evaluation confirmed that hot food items were below the required temperature, and cold items were above the desired temperature. The Dietary Manager and Administrator acknowledged the issue, attributing it to short staffing and insufficient staff during meal service.
Food Items Not Properly Labeled or Dated
Penalty
Summary
The facility failed to ensure opened food items in the walk-in cooler and freezer were labeled and dated, and it failed to discard one food item by the expiration date. During observation and interview with the Dietary Manager, a bag of what appeared to be meat in the freezer was labeled with a prepared date of 2/8 but had no use-by date, another bag of meat was not labeled or dated, and an item labeled Chix had a prepared date of 1/28/2026. The Dietary Manager confirmed that these items should have an open date and a use-by date. In the refrigerator, a box of Ready Care Apple Juice and a bottle of Kikkoman Soy Sauce were observed without open dates, and the Dietary Manager confirmed they should have been labeled with an open date. The report also states the Dietary Manager confirmed all items should be labeled with a delivery date and open date and that training on labeling and dating had been done.
Hand Hygiene Not Performed During Meal Service
Penalty
Summary
The facility failed to ensure that staff were washing or sanitizing their hands while passing out lunch trays to residents, despite the facility policy titled Hand Washing/Hygiene and the Centers for Medicare and Medicaid State Operations Manual indicating that hand hygiene should be performed before and after assisting a resident with meals. During observation of dining on 02/25/2026 at 12:10 PM, residents were brought into the dining area and seated at tables without washing their hands, and they were not offered wet wipes, hand sanitizer, or soap and water by facility staff. Staff were also observed not washing or sanitizing their hands between serving trays, not sanitizing hands before opening straws, and not sanitizing hands before passing out drinks. During a second observation on 02/26/2026 at 12:20 PM, staff were again observed not sanitizing their hands between passing out residents' trays during lunch meal service. In interview, CNA AA stated she tries not to touch residents' food and believed it was not necessary to sanitize her hands in between passing out trays. The Infection Prevention Specialist later confirmed that staff should be sanitizing their hands in between trays and before passing out drinks.
Failure to Care Plan Oxygen Therapy
Penalty
Summary
The facility failed to develop a person-centered, comprehensive care plan for R102 that included oxygen therapy. R102’s EMR listed diagnoses including chronic atrial fibrillation and chronic kidney disease, stage 2, and a physician order dated 09/15/2025 directed oxygen at 2 liters per minute continuously via nasal cannula. Review of the comprehensive care plan on 02/24/2026 showed no documented care plan for oxygen use. Observations on 02/25/2026 at 9:44 AM and 10:09 AM showed R102 receiving oxygen by concentrator via nasal cannula at a flow rate of 1.00 LPM. During an interview on 02/26/2026 at 1:45 AM, the MDS Coordinator confirmed there was no care plan area for oxygen and confirmed the physician order for oxygen at 2.0 LPM.
Chemicals Stored in Resident Rooms and Hot Water in Bathroom Sinks
Penalty
Summary
The facility failed to keep two resident rooms free of chemicals when surveyors observed pressurized aerosol containers and liquid disinfectant solution containers stored on bedside tables in Room TB 045-A and Room TB 053-A. The items remained in place during repeated observations over several days. A CNA and the DON both confirmed that the aerosol containers and liquid disinfectant solution containers were in the residents’ rooms and were not supposed to be there, and the DON removed the items from the bedside tables during the survey. The facility also failed to maintain safe water temperatures in two bathrooms. Surveyors observed that the water in the private bathroom sink in one room and the shared bathroom sink between another room and Room 14 felt hot. Using a maintenance thermometer, the water temperature measured 127.6 degrees Fahrenheit in the shared bathroom and 128.4 degrees Fahrenheit in the private bathroom. The Maintenance Director stated he did not have a digital thermometer and later used a dual laser targeting infrared thermometer to recheck the sinks. Resident records showed that the affected rooms housed residents with significant care needs, including residents with severe cognitive impairment, dependence for activities of daily living, and need for assistance with toileting, bathing, or ambulation. The Administrator stated staff were checking temperatures hourly and reviewing audit logs, but also confirmed the facility was not aware of the high temperatures in the two bathrooms. The Maintenance Director stated the boiler temperature had been turned down, and later measurements showed the sink temperatures had decreased.
Oxygen Administered at Incorrect Flow Rate
Penalty
Summary
The facility failed to ensure oxygen was administered according to physician orders for one resident receiving continuous oxygen therapy. The resident had diagnoses including chronic atrial fibrillation and chronic kidney disease stage 2, and the clinical physician order dated 09/15/2025 directed oxygen at 2 liters per minute continuously via nasal cannula. Observations on 02/25/2026 showed the resident receiving oxygen from a concentrator via nasal cannula at 1.00 LPM instead of the ordered 2.0 LPM. During an interview on 02/26/2026, an LPN confirmed the concentrator was set at 1.0 LPM and stated she had not checked the setting because the resident's oxygen level was 99 percent during her earlier rounds. The LPN then verified the order at the nurses' station and changed the flow rate to 2.0 LPM. The DON later confirmed the resident had received oxygen at the wrong flow rate and that it did not follow the physician order.
Expired and Unlabeled Medications Found in Storage Areas
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored according to policy and accepted professional principles. During observation of the Transitional Care Unit hallway medication room, two 1000 mL IV bags of 0.45 percent sodium chloride were found in a red bin with the outer protective covering removed, and the bags were not labeled or dated. The LPN Unit Manager confirmed the bags were not labeled and did not know how long they had been out of the outer covering. Additional observations found expired and improperly labeled medications in multiple storage areas. In the Central Supply room, three bottles of Pro Sight vitamin and mineral supplements were found with an expiration date of 11/2025, and the LPN Unit Manager confirmed they were expired. On the TCU bottom cart, Nepro was expired on June 1, 2025, while a Novolog FlexPen insulin syringe and Latanoprostat ophthalmic solution eye drops did not have open or expiration dates. The RN confirmed the Nepro was expired and that the Novolog FlexPen and Latanoprostat were missing required dates; she also stated the Latanoprostat box had not been opened and should be in the refrigerator. The DON stated nurses and unit managers were responsible for weekly cart checks for expired medications, labeling, and cleanliness, and that nurses were responsible for confirming medications were not expired before placing them on the cart. The DON also confirmed the expired ProSight bottles and stated IV fluids are only viable for 24 hours after the outer protective covering is removed.
Inadequate Supervision During Incontinence Care Leads to Resident Fall
Penalty
Summary
The facility failed to provide adequate supervision during incontinence care for a resident, resulting in a fall with significant injuries. The resident, who had a history of anxiety, muscle weakness, and hemiplegia following cerebrovascular disease, required two staff members for assistance with bed mobility as per their care plan. However, a CNA, who was not assigned to the resident, attempted to provide care without reviewing the Kardex or seeking assistance from another staff member. During the process, the resident was rolled onto their left side and subsequently fell off the bed, sustaining injuries. The incident occurred when the CNA, while changing the resident's brief, did not follow proper procedures and failed to roll the resident towards themselves, as trained. The resident expressed an inability to hold on, and their legs began to fall over the side of the bed, leading to the fall. The resident was initially sent to the emergency room and returned with no fractures detected, but continued to experience pain and was later found to have multiple fractures upon further evaluation. The CNA admitted that the incident could have been prevented by reviewing the Kardex and requesting assistance.
Failure to Ensure Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that four residents had medications available for self-administration and stored at the bedside only when assessed to do so safely and with a physician's order. This deficiency was observed during an initial screening of 90 residents. The facility's policy requires that residents can only self-administer medications if the interdisciplinary team has determined it is clinically appropriate, and a physician's order is obtained. However, the facility did not adhere to this policy, placing the residents at risk for medication errors, overdose, or misappropriation of medications. One resident, admitted with rheumatoid arthritis and fractures, was found with a tube of pain relief cream and a medication cup of white cream at her bedside without a physician's order or an assessment for self-administration. Another resident with type 2 diabetes was observed with a cup of medicated powder at her bedside, which she claimed was left by a nurse. There was no physician's order for the powder, nor an assessment for self-administration. A third resident, also with type 2 diabetes, had multiple medications at her bedside, including throat spray and eye drops, without any orders or assessments for self-administration. She stated she brought these medications upon admission and was unaware they needed to be stored in the medication cart. The fourth resident, with COPD and heart failure, had inhalers left on her bed by a nurse who was distracted by another task. The nurse admitted to leaving the medications unsecured, which could have led to another resident taking them. The Director of Nursing stated that residents were only assessed for self-administration if they expressed a desire to do so, and if not assessed, medications should be stored securely until the assessment and proper orders are obtained.
Failure to Maintain a Clean and Homelike Environment for Residents
Penalty
Summary
The facility failed to maintain a clean and homelike environment for three residents, which was observed during a survey. Resident 63, who was cognitively intact with a BIMS score of 13, had a room littered with trash, including old meal plates, a dirty fork, and various other items scattered on the floor. Despite the presence of trash over several days, the housekeeping staff only cleaned the room after being prompted by a CNA. The housekeeper admitted to noticing the meal trays but did not clean them up, as there were no specific requirements for more frequent cleaning in this resident's care plan. Resident 59, also cognitively intact with a BIMS score of 15, had a room cluttered with personal items, including Styrofoam cups, snacks, and toiletries, which covered the walls, nightstand, chair, and walker. The resident admitted to hoarding items, and the staff confirmed that the room remained cluttered because the resident insisted on keeping her belongings. The facility was working with the resident and her family to address the issue, but no policy was provided regarding maintaining a clean and homelike environment. Resident 46, who was severely cognitively impaired with a BIMS score of 5, had a damaged footboard on their bed, exposing a rough surface that could potentially cause injury. The CNA assigned to the resident had not noticed the damage, and the Director of Maintenance was unaware of the issue until it was pointed out during the survey. The facility had a preventive maintenance program in place, but the damaged bed had not been reported or addressed prior to the survey.
Failure to Timely Report Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of resident-to-resident sexual abuse within the required two-hour timeframe, involving two residents with severe cognitive impairments. Resident 36, diagnosed with dementia and a cognitive communication deficit, had a BIMS score indicating severe cognitive impairment. Similarly, Resident 294, also diagnosed with dementia, had a BIMS score reflecting severe cognitive impairment. The incident was reported to have occurred on 05/18/24, but the facility did not notify the state authorities until 05/21/24, which is beyond the mandated reporting period. The incident was initially observed by a CNA who informed an RN, but the RN did not report the event immediately, citing instructions from the unit manager to provide privacy to the residents. The Director of Nursing acknowledged the delay in reporting and identified that the RN was responsible for notifying the authorities. The facility's policy mandates reporting such allegations within two hours, but this protocol was not followed, leading to a deficiency in timely reporting of the suspected abuse.
Failure to Implement Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident, identified as R94, which is a requirement according to the facility's policy. R94 was admitted with several medical conditions, including an amputation of the right great toe, a non-pressure chronic ulcer of the left foot and heel, type 2 diabetes, hypertension, and a fracture of the left great toe. The resident was prescribed antibiotics for osteomyelitis, supplements for wound healing, insulin for diabetes, and pain management medications. Despite these needs, the care plan did not include focus, measurable goals, or interventions for wound care, pain management, or activities of daily living (ADLs). Interviews with facility staff revealed that the baseline care plan should have been based on the Admission Data Set evaluation, which was to be completed upon admission or during the same shift. However, the Director of Nursing confirmed that the Admission Data Set had not been completed, and therefore, the baseline care plan was not generated. This oversight was acknowledged by the Director of Nursing, who stated there was no reason for the delay. The facility's policy emphasizes the importance of completing the baseline care plan within 48 hours to ensure continuity of care and communication among staff, increase resident safety, and prevent adverse events post-admission.
Failure to Assist Resident with Activities of Daily Living
Penalty
Summary
The facility failed to provide necessary staff assistance with activities of daily living for a resident diagnosed with dementia, who was cognitively intact and required partial assistance for bathing, dressing, using the toilet, and eating. Observations revealed the resident wearing a dirty sweater with food stains, no pants, and unkempt hair, indicating a lack of personal hygiene care. The resident was observed struggling to eat independently and had not received a shower for approximately 15 days, despite documentation indicating otherwise. Interviews with staff revealed inconsistencies in care provision, with a CNA admitting to not providing a bed bath due to an error and the resident often refusing help. Further observations showed the resident attempting to wash independently and standing without clothing, suggesting a lack of adequate supervision and assistance. Staff interviews indicated the resident's preference for independence and occasional refusal of care, but also noted a potential change in the resident's condition. The Social Services Director acknowledged the unusual nature of the resident's recent behavior and planned to inform the doctor, highlighting a potential oversight in monitoring and addressing the resident's changing needs.
Failure to Provide Daily Wound Care as Ordered
Penalty
Summary
The facility failed to provide wound care to a resident as per the physician's orders, which increased the resident's risk of infection, delayed healing, and caused discomfort. The resident, who was admitted with a diagnosis of encephalopathy, had a physician's order to clean a nostril lesion and apply a bandage daily. However, the Treatment Administration Record (TAR) showed that staff did not document the completion of this care on eleven occasions over several months. Observations revealed that the resident's bandage was not changed daily as required, with the same bandage being observed on consecutive days. Interviews with the Director of Nursing (DON), Wound Care Nurse (WN), and Registered Nurse (RN1) confirmed that the daily wound care was not consistently performed. RN1, who was responsible for auditing the treatment records, admitted to not being able to perform audits regularly due to covering two units, which contributed to the oversight in wound care.
Deficiencies in Respiratory Care for Two Residents
Penalty
Summary
The facility failed to provide respiratory care in accordance with professional standards for two residents, R53 and R63, which had the potential to lead to respiratory complications and infections. For R53, the facility's policy on the care and handling of respiratory equipment was not followed. Observations revealed that R53's nebulizer mask was left uncovered on a nightstand, and the resident reported not receiving her nebulizer treatment in the morning, experiencing shortness of breath. Additionally, the oxygen tubing and water tank used for R53's oxygen therapy were not dated, indicating a lack of adherence to the facility's policy on equipment maintenance. For R63, there was a failure to maintain proper documentation and orders for oxygen therapy. R63 was readmitted with acute and chronic respiratory conditions, yet there were no active orders for oxygen therapy or oxygen saturation measurements after her return from the hospital. Observations showed R63 on oxygen therapy with undated tubing, and at another time, without her oxygen on, with the tubing lying undated on the bed. Interviews with staff, including the DON and a regional consultant, confirmed the absence of active orders and documentation for oxygen therapy, which was expected to be in place. The deficiencies in respiratory care for both residents highlight lapses in following facility policies and maintaining accurate medical records. These oversights in equipment handling, documentation, and adherence to prescribed treatments could potentially compromise the respiratory health of the residents involved.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to provide food that was palatable and at a safe and appetizing temperature for three residents, all of whom were cognitively intact. Resident 2 reported that the food was consistently cold, especially at breakfast, and there was not always time to warm it up. Resident 15 noted that while food was hot in the dining room, it was not when served in their room, where they had to eat dinner. Resident 65 stated that food was cold at all meals, attributing this to the food sitting in the hall for too long. These observations were corroborated by a test tray evaluation, which revealed that the hot food items were below the required temperature of 135 degrees Fahrenheit, and the cold items were above the desired temperature of 40 degrees Fahrenheit. The Dietary Manager acknowledged awareness of the residents' complaints about cold food and attributed the issue to short staffing, which limited the number of residents eating in the dining room. The Administrator, who was aware of the complaints upon her arrival in August, stated that the process during meals was to have all hands on deck to ensure trays were passed out. However, during an observation, it was noted that there were insufficient staff members in the hallway to complete tray service, resulting in delays and cold food being served to residents.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Savannah
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pruitthealth - Savannah | 1.5 mi | ★★★★★ | 1 | 0 |
| Savannah Post Acute Llc | 4.3 mi | ★★★★★ | 2 | 0 |
| Candler Skilled Nursing Unit | 4.4 mi | ★★★★★ | 3 | 0 |
| Azalealand Nursing Home | 4.9 mi | ★★★★★ | 6 | 0 |
| Riverview Health & Rehab Ctr | 5.4 mi | ★★★★★ | 11 | 0 |
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