Abbotts Creek Center

Based on observations and staff interviews, the facility failed to clean the Packaged Terminal Air Conditioner (PTAC) vents in 2 of 6 on the upper 100 hall. This deficient practice affected 2 of 6 residents reviewed for comfortable, clean, and homelike environment (Resident #46 and Resident #54).The findings included:a. An observation was conducted of Resident #46's room on 1/4/26 at 10:00 AM. The PTAC unit was noted to have dark brown spots that covered every vent slat of the unit. The room was occupied, and the PTAC was running at the time of the observation.b. An observation was conducted of Resident #54's room on 1/4/26 at 12:55 PM. The PTAC unit was noted to have a dark brown substance caked in the corners of every vent slat of the unit. The room was occupied, and the PTAC was running at the time of the observation.On 1/6/26 at 3:00 PM an observation of Resident #46's and Resident #54's room was conducted during a round with the Maintenance Director. He explained the Maintenance Department was responsible for cleaning the vents and filters of the PTAC units every 2 months. The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, and interviews with staff, the Nurse Practitioner, and the Medical Director, the facility failed to obtain a physician's order for supplemental oxygen use for 1 of 1 resident reviewed for respiratory care (Resident #23).Findings included:Resident #23 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD).A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was cognitively intact. She was not coded as using supplemental oxygen.The active orders reviewed for Resident #23 did not include one for supplemental oxygen use.A review of the nurse's progress notes dated 12/28/25 revealed she assessed Resident #23 to have shortness of breath and reported it to the Medical Director for the resident to be assessed. A review of the progress notes revealed a written statement by the Nurse Practitioner during her assessment dated [DATE] to continue oxygen for Resident #23; however, there was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interviews with the Medical Director and staff, the facility failed to hold blood pressure medication as ordered by the physician for 1 of 5 residents reviewed for unnecessary medications (Residents #2 and #3). The findings included: 1) Resident #2 was admitted to the facility on [DATE] with diagnoses that included hypertension. An admission Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #2 had severe cognitive impairment. Review of Resident #2's physician orders included an order dated 11/10/25 for Metoprolol (a medication for high blood pressure) 25 milligrams (mg) one tablet by mouth one time a day for hypertension. Hold for heart rate less than 60 or systolic blood pressure (the top number in the blood pressure reading) less than 100 or diastolic blood pressure (the bottom number in the blood pressure reading) less than 60. The December 2025 Medication Administration Record (MAR) was reviewed and revealed Resident #2 had received Metoprolol despite the heart…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and staff interviews, the facility failed to store and secure a controlled medication that required refrigeration within a separately locked, permanently affixed box within the medication room refrigerator. This deficient practice was for 1 of 2 medication storage rooms reviewed (103 Medication Storage Room).The findings included:An observation and interview were conducted on 01/04/26 at 10:35 AM of the 103 medication storage room refrigerator with Nurse #1. The observation revealed a 30 ml (milliliter) bottle of liquid lorazepam (a benzodiazepine) 2 mg (milligram) /ml located in the refrigerator door. Nurse #1 stated staff did not have a key to the lock box inside of the refrigerator and there was not a lock for the refrigerator door. Nurse #1 explained she was unsure why there was no key for the lock box within the refrigerator and it had been that way for a long time. Nurse #1 confirmed the lorazepam should have been secured within the medication storage refrigerator inside the affixed lock box. An interview was conducted on 01/06/26 at 11:27 AM with the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and staff interviews, the facility failed to develop a comprehensive person-centered plan to address anticoagulant, insulin, and antidepressant use for 1 of 15 residents reviewed for comprehensive care plans (Resident # 18). The findings included: Resident #18 was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure with hypoxia, atrial fibrillation, diabetes mellitus, and major depressive disorder. A review of the physician's orders dated 08/12/24 revealed the following orders: - Insulin Lispro (1 unit dial) Subcutaneous Solution Pen Injector 100 unit/milliliter Inject as per sliding scale subcutaneously four times a day for diabetes mellitus - Insulin Glargine Subcutaneous Solution Inject 10 units subcutaneously in the morning for diabetes mellitus - Sertraline HCL Oral Tablet 50 milligrams Give 1 tablet via PEG Tube one time a day for depression - Apixaban Oral Tablet 5 milligrams Give 1 tablet via PEG Tube two times a day for atrial…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and staff interviews, the facility failed to arrange home health services upon discharge for 1 of 4 sampled residents (Resident #54) reviewed for discharge planning. Findings included: Resident #54 was admitted to the facility on [DATE] with diagnosis of paroxysmal atrial fibrillation, dementia, and congestive heart failure. The admission Minimum Data Set assessment dated [DATE] indicated Resident #54 was severely cognitively impaired. The physician's order dated 5/29/24 documented Resident #54 was to discharge home on 5/31/24. The order revealed the resident would need a hospital bed related to her inability to transfer or lay flat. Resident would need a home health agency (HHA) for ADL (activities of daily living) assistance; home health nursing for medication management; physical therapy (PT) and occupational therapy (OT) to evaluate and treat; and a social worker (SW) for the community. The review of the Discharge Plan Documentation dated 5/30/24 completed by the facility's former…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, resident and staff interviews, the facility failed to determine whether the self-administration of medications was clinically appropriate for 1 of 1 sampled residents (Resident #4) observed to have medications bedside. The findings included: 1. Resident #4 was admitted to the facility on [DATE]. Her diagnoses included chronic obstructive pulmonary disease (COPD). A review of Resident #4's electronic medical record (EMR) revealed physician orders for the following medications; -Albuterol Sulfate HFA (multidose inhaler) aerosol solution 108 MCG (micrograms) to be administered as 2 puffs inhaled orally one time a day for the treatment of asthma with a start date of 9/15/2023. -Breo Ellipta aerosol powder breath activated 100-25 MCG/INH to be administered 1 inhalation a day for treatment of COPD with a start date of 3/11/2021. -Ipratropium Bromide nasal solution 0.03 % to be administered 2 sprays in both nostrils three times a day for allergies with a start date of 10/13/2022.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations and staff interviews, the facility failed to administer oxygen at the prescribed rate for 1 of 1 resident reviewed for respiratory care (Resident #25). The findings included: Resident #25 was admitted to the facility on [DATE] with diagnoses that included congestive heart failure and chronic obstructive pulmonary disease (COPD). A review of the active physician orders revealed an order dated 11/7/23, for oxygen at 2 liters via nasal cannula continuously. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #25 was cognitively intact, had shortness of breath when lying flat and used oxygen. A review of Resident #25's active care plan, last reviewed 11/30/23, included a focus area for exhibited or was at risk for respiratory complications related to COPD and history of acute and chronic respiratory failure. One of the approaches was to provide oxygen as ordered via nasal cannula. On 12/11/23 at 10:00 AM, an observation was made of Resident #25 while she…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and Medical Director, and staff interviews, the facility failed to ensure an as needed (PRN) psychotropic medication was time limited in duration for 1 of 5 residents reviewed for unnecessary medications (Resident #2). The findings included: Resident #2 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease. A significant change Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #2 was severely cognitively impaired and received hospice services. A review of Resident #2's medical record was completed on 12/12/2023 and revealed Resident #2 had a physician's order dated 10/11/2023 for Lorazepam (a psychotropic used to treat anxiety) 0.5 milligrams (mg) one tablet sublingually every four hours as needed for anxiety. The order for the Lorazepam was entered into the Electronic Medical Record (EMR) by Nurse #3 and did not have a stop date. Additionally, the medical record contained an order for hospice services dated 10/16/2023. A phone interview…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, record review and staff interviews, the facility failed to date multi-use medications per manufacturer's recommendations upon opening and failed to discard expired medications in 1 of 2 medication carts (100 Hall medication cart) reviewed for medication storage and labeling. Findings included: An observation was conducted on 12/12/23 at 11:35 AM of the 100 Hall medication cart in the presence of Nurse #1. The observation revealed no open date on the following multi-dose medications: a. One multi-dose Lantus insulin pen with 60 units out of 100 units left in pen. The manufacturer's recommendation was to discard 28 days after opening. b. One multi-dose Victoza insulin pen with 10mg out of 18mg left in pen. The manufacturer's recommendation was to discard 30 days after opening. c. One multi-dose Glargine insulin pen with 220 units out of 300 units left in pen. The manufacturer's recommendation was to discard 28 days after opening. d. One multi-dose package of Albuterol Sulfate 0.63mg/3ml nebulizer solution, 1 pouch contains 5 vials, 2 vials left in pouch. The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record reviews, observations, resident, and staff interviews, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain implemented procedures and monitor interventions the committee put into place following the annual recertification survey conducted on 02/05/21 and annual recertification and complaint survey on 07/11/22. This was for 3 deficiencies that were cited in the areas of Respiratory/Tracheostomy care and Suctioning and Label/Store Drugs & Biologicals which were previously cited on 02/05/21 and Resident Self-Admin Meds-Clinically Appropriate which was previously cited on 07/11/22. The deficient practice area was recited on the current recertification and complaint survey of 12/13/23. The duplicate citations during three federal surveys of record show a pattern of the facility's inability to sustain an effective QAPI program. The findings included: This citation is cross referenced to: 1. F554-Based on observations, record reviews, resident and staff interviews, the facility failed to determine whether the self-administration…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.