Abbotsford Health Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure a level II PASARR was completed for a resident (R) with a mental health disorder, within 40 calendar days of admission for 1 of 3 residents reviewed. (R25) -R25 was admitted with mental health diagnoses on 02/06/26 and no level II PASARR screen was completed.Findings include:Per regulation S483.20(k)(1)-(3), a level II PASARR is a comprehensive evaluation conducted by a state-designated authority that determines whether an individual has mental disorder (MD), determines the appropriate setting for the individual, and recommends what, if any, specialized services and/or rehabilitative services the individual needs. Under 42 CFR 483.106(b)(2)(ii), If an individual who enters a nursing facility as an exception is later found to require more than 30 days of nursing facility care, the State mental health authority must conduct a Level II resident review within 40 calendar days of admission. R25 was admitted to the facility on [DATE] with…

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 observation, interview, and record review, the facility did not develop or implement a person-centered dialysis care plan to ensure the highest practicable physical well-being for 1 of 1 resident (R) reviewed for dialysis. (R42) -R42 receives dialysis. R42's care plan did not identify the dialysis company, provider, nephrologist, or contact number, days or times R42 attends dialysis, type (fistula/graft/catheter) of dialysis access used, identify which arm not to obtain BP, blood draws or administer IV. Findings include: R42 was admitted to the facility on [DATE] with diagnoses that include end stage renal disease. The facility conducted a Brief Interview of Mental Status (BIMS) assessment on 05/05/2026 that indicated a score of 14/15 meaning R42 had intact cognition. Surveyor reviewed R42's dialysis care plan dated 05/04/2026, that states, Alteration in Kidney Function Due to End Stage Renal Disease (SDRD), evidenced by hemodialysis. Interventions include check access site daily fistula/graft/catheter…

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 interview and record review, the facility did not review/revise the resident's person-centered comprehensive care plan for 1 resident (R6) of 17 resident's care plans reviewed. The facility did not update/revise R6's care plan after R6 revoked hospice services. The care plan was not revised to reflect R6's current goals and interventions according to R6's needs. This is evidenced by:Record review of R6's medical record documented an admission date of 05/23/25. R6's current diagnoses include orthopedic prosthetic devices, acute kidney failure, type 2 diabetes mellitus, depression, anxiety, and mood affective disorder.On 04/09/26, the Minimum Data Set (MDS) significant change assessment documented R6's Brief Interview for Mental Status (BIMS) score of 15/15 meaning intact cognition. Hospice care was elected. On 04/09/26, R6 signed a hospice election form.On 04/22/26, R6 signed a hospice revocation form to be effective on 04/22/26 with the reason for revoking the hospice benefit was hospice philosophy.Surveyor reviewed R6's current care plans. On 04/10/26, R6's care plan 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 interview and record review, the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 4 residents (R32) reviewed for non-pressure skin injuries.-R32 has moisture-associated skin damage (MASD) to buttocks and weekly skin assessments do not reflect monitoring.-Weekly wound rounds indicate only one evaluation completed since wound provider last evaluated in March 2026 that indicated the wound had worsened. Findings include:The facility policy titled, Wound Care, last revised April 2026, includes The purpose of this procedure is to provide guidelines for the care of wounds to promote healing.assess and measure the wound.clean the wound.document the type of wound care given, the date and time wound care was given, and change in the resident's condition.report other information in accordance with facility policy and professional standards of practice.Surveyor…

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 observation, interview, and record review, the facility did not ensure residents receive proper treatment and assistive devices to maintain vision and hearing abilities for 1 of 1 resident (R) reviewed for hearing (R47).-R47 has a severe hearing deficit and has not had working hearing aids for a long period of time. This has not been addressed, and assessments do not reflect accurate information.Findings include:The facility policy titled, Resident Assessments, last revised October 2025, includes information in the Minimum Data Set (MDS) assessment will consistently reflect information in the progress notes, plans of care, and resident observation/interviews.R47 was admitted to the facility on [DATE].On 05/31/26 at 9:49 AM, Surveyor interviewed R47 about the care R47 receives at the facility. R47 emphasized the need for Surveyor to speak very loudly as R47 is very hard of hearing. R47 stated they have hearing aids, but the hearing aids stopped working a while back when they remained in while showering.…

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 interview and record review, the facility did not ensure a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 of 5 residents (R) (R32).-R32 did not receive consistent restorative care.-R32's medical record had incomplete and incorrect documentation for restorative care. Findings include:The facility policy titled, Restorative Nursing Services, last revised July 2025, includes: Residents will receive restorative nursing care as needed to help promote optimal safety and independence.Restorative goals and objectives are individualized and resident-centered, and are outlined in the resident's plan of care.R32 was admitted to the facility on [DATE].R32's medical record documents R32 has a program that includes passive range of motion to bilateral lower extremities every shift.Surveyor noted 14 days in March 2026, 17 days in April 2026, and 28 days in May 2026, the task was documented as not…

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 observation, interview and record review, the facility did not ensure residents (R) who are trauma survivors receive care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization for 1 of 1 resident with post-traumatic stress disorder (PTSD). (R25). -R25 is diagnosed with PTSD. Care plan does not identify type(s) of trauma, triggers, or interventions to prevent re-traumatization.Findings include: R25 was admitted to the facility on [DATE] with diagnoses including post-traumatic stress disorder (PTSD), anxiety, depression, personality disorder, mood (affective) disorder and altered mental status. R25 was admitted for therapy and monitoring following frequent falls at home and a fire with smoke inhalation. On [DATE] at 12:07 PM, Surveyor observed R25 sitting at a table in a small area next to the dining room. The door between the kitchen and dining room slammed shut causing a…

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 interview and record review, the facility did not provide routine and emergency drugs and biologicals for the facility residents for 1 of 17 residents (R) reviewed (R37).-R37 did not have one routine medication available for 12 days with no interventions, alternatives, or monitoring.Findings include:On 06/02/26, Surveyor reviewed R37's medical record. R37 was admitted to the facility on [DATE].R37's Physician orders include Modafinil Oral Tablet 100 MG.give 1 tablet by mouth two times a day for sleep apnea which was ordered on 05/12/26.Surveyor reviewed R37's Medication Administration Record (MAR) for May 2026. The MAR indicated that from 05/12/26 through 05/23/26, R37's Modafinil was not given.R37's nursing progress notes documented:On 05/12/26 at 10:29 AM, Modafinil was not available from pharmacy.On 05/12/26 at 11:27 PM, Modafinil had a hold order for that day as the pharmacy would be sending the medication the next morning.On 05/13/26 at 8:19 AM, Modafinil was not available from pharmacy.On 05/13/26…

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 staff interview and record review, the facility did not ensure an allegation of misappropriation was thoroughly investigated for 1 of 1 resident (R) (R5) reviewed.The facility did not provide evidence of resident interviews and staff training on misappropriation.The facility's policy titled, Abuse/Neglect/Exploitation, read in part, Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations .Training staff on changes made and demonstration of staff competency after training is implemented.On 02/06/26, the facility reported R5 returned from the hospital on [DATE] and it was reported R5 had $200 missing. Staff had observed a $50 bill in R5's room on 02/05/26.The facility completed an investigation which included: -Interview with R5.-Search for the missing money, which was not found.-Contacting law enforcement.-Staff interviews.-Facility reimbursed R5 $50 that had been verified by staff.-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 interview and record review, the facility did not ensure 1 of 3 residents (R7) reviewed for discharge process received the proper notice of transfer, reason for transfer, location of transfer, appeal rights, and name and address (mailing and email) with telephone number of the Office of the State Long-Term Care Ombudsman. In addition, the facility did not ensure R7 and/or their representative received written information on the duration of the bed hold policy, the reserve bed payment policy, and the right to return to the facility.Based on the Surveyor's investigation, there was no evidence of the following:-R7's admission to the facility.-R7's fall and incident at the facility.-R7's discharge from the facility.-Evidence the facility could not meet R7's needs.-R7 was provided with discharge notices and bed hold notice, with appeal rights upon discharge.-Communication with current hospital to assess transfer status and agreement to re-admit R7 to the facility.-A hoyer sling was ordered for R7.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 observation, interview and record review, the facility did not ensure 1 resident (R1) of 3 residents reviewed for accidents received adequate supervision and assistance devices to prevent accidents in a sample of 7 residents. The facility did not have a Wanderguard alarm bracelet placed on R1 to notify staff of R1's attempts to elope from facility which could cause potential for harm if R1 left facility unsupervised. Findings include:The facility policy, titled Elopement, not dated, states in part, An elopement risk assessment should be conducted at time of admission.develop a specific elopement prevention care plan at time of admission for residents identified at risk for elopement.use an alarm system that notifies staff when an exit door is opened.The facility policy, titled Accidents and Supervision, not dated, states in part, Using specific interventions to try to reduce a resident's risk from hazards in the environment.ensuring that the interventions are put into action.Supervision is an…

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 interviews and record reviews, the facility did not provide appropriate skin assessments and treatment by professional standards of practice to maintain a resident's highest practicable level of physical well-being for 2 of 2 residents (R2 and R3) reviewed.Staff did not assess and document R2's surgical incision on the left upper extremity. Staff did not complete a wound comprehensive assessment when R3 first developed the wound. This is evidenced by:R2 was admitted to the facility on [DATE] and discharged on 10/29/25. R2's current diagnoses include multiple fractures of pelvis with unstable disruption of pelvic ring, open wound left lower leg, traumatic subdural hemorrhage, fracture of the lower end of left radius, dislocation of left ulnohumeral joint, displace fracture of head of left radius, displace fracture of lateral epicondyle of left humerus, dislocation of right shoulder, fracture of body of sternum, contusion of lung, multiple fractures of ribs bilateral, pleural effusion, atelectasis, acute…

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 interview and record review, facility did not implement professional standards of practice to ensure that a resident does not develop pressure injuries (PIs), receives necessary treatment and services to promote healing and prevent new PIs from developing for 1 of 1 resident (R) reviewed. (R4)R4 was admitted to the facility with an unstageable pressure injury to left heel. Staff did not complete a comprehensive PI assessment to include measurements and description of the PI. This is evidenced by:R4 was admitted to the facility on [DATE]. R4's current diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, methicillin resistant staphylococcus aureus infection 11/12/24 and 3/20/25, pressure induced deep tissue damage of left heel, type 2 diabetes mellitus without complications, protein-calorie malnutrition, atrial fibrillation, chronic kidney disease stage 3A, anxiety disorder, and depression.R4's Minimum Data Set (MDS) dated [DATE] admission 5 day…

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 interview and record review, the facility did not update R1's care plan with new interventions and/or monitoring to prevent further potential elopements. The facility practice had the potential to affect 1 of 3 residents (R) (R1) reviewed. This was evidenced by the facility policy, titled Abuse, Neglect and Exploitation which states under section VII(A)(b): Defining how care provision will be changed and/or improved to protect residents receiving services. R1 was admitted to the facility on [DATE] under guardianship and with diagnoses that include benign neoplasm of meninges and mild cognitive impairment. R1's admission Minimum Data Set (MDS) indicated R1 has a BIMS of 7 (moderately impaired); displays wandering and frequency behavior of these type 1 to 3 days; uses a walker and wheelchair independently, R1's elopement evaluation completed on 07/02/25 indicates in part, R1 has a history of elopement or attempted leaving the facility without informing staff. R1's care plan initiated on 07/03/25 for…

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 interview and record review, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents, allowing a resident to leave the premises without the facility's knowledge and supervision. This situation represents a risk to the resident's health and safety for 1 of 3 residents (R) R1. This was evidenced by the facility policy, titled Elopement which states: This facility ensures that resident who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Under section labeled Elopement states: Occurs when a resident leaves the premises or a safe area with authorization. R1 was admitted to the facility on [DATE] under guardianship and with diagnoses that include benign neoplasm of meninges and mild cognitive impairment. R1's admission Minimum Data Set (MDS)…

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 review and interview, the facility did not implement policy and procedures related to screening employees for a prior history of abuse, neglect, exploitation of residents, or misappropriation of resident property for 1 of 8 employees reviewed.The facility did not ensure their abuse policy was implemented when one employee's Background Information Disclosure (BID), Department of Justice Response (DOJ), and Government Findings report was not obtained before employee started working at facility. (Intern D).The facility policy, titled Abuse, Neglect and Exploitation dated 10/01/22 states: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.Under section labeled 1A. Screening states Potential employees will be screened for a history of abuse, neglect, exploitation or misappropriate of resident property. 1. Background, reference and credentials' checks shall…

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 observation and record review, the facility failed to revise the care plan for 1 of 3 residents (R) reviewed (R2). -R2's care plan indicated intervention of side rail. The care plan was not revised after removal of the side rail. Findings include: R2 was admitted to the facility on [DATE]; diagnoses include congestive heart failure (CHF), morbid obesity, and anxiety disorder. R2's Minimum Data Set (MDS), completed on 04/22/25, confirmed R2 scored 15/15 during BIMS, indicating intact cognitive function. R2's care plan, last revised on 06/20/25, includes a focus of physical functioning deficit related to mobility impairment with intervention of assistive devices including side rail. Surveyor reviewed R2's bed rail assessment, dated 04/11/25, which showed bilateral side rails were indicated to serve as an enabler to promote independence, and R2 had expressed a desire to have side rails. Surveyor reviewed audits completed on 04/16/25, 04/23/25, 04/30/25, 05/08/25, and 05/16/25, by Speech-language…

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 interview and record review, the facility did not designate a person to serve as the director of food and nutrition services who had completed the minimum qualification requirements for the position. This practice could potentially affect all 48 residents residing in the facility. The facility's Dietary Manager (DM) C is currently enrolled but has not finished the Nutrition & Food Service Professional Program. The facility does not have a full-time Registered Dietician at the facility. Findings include: Surveyor requested and received the facility policy titled Dietary Manager, which is not dated. The policy reads in part: Required Qualifications: Minimal Requirements include one of the following: ~Certification as a dietary manager ~Certification as a food service manager ~Has an associates or higher degree in food service management or in hospitality, if the course of study includes food service or restaurant management, from an accredited institution of higher learning ~Has 2 or more years of experience in the position of director of food and nutrition services in a…

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, interviews and record review, the facility did not prepare, store and distribute food in a sanitary manner. This has the potential to affect all 48 residents. Dietary Aide (DA) D was observed pulling a tray of clean drinking glasses and plastic mixing containers from the dishwasher, stacking them together while wet and placing them in the cupboard while dripping water on the floor and counter. Surveyor observed the kitchen's handwashing sink with heavy lime and dirt build up on facet handles, drain, and basin. Surveyor observed items stored in refrigerators and freezers used to store resident food brought in from outside sources, not dated or labeled with resident names or use by dates. Findings include: It is the policy of the facility to ensure dishes are washed and air dried to prevent contamination. Surveyor requested the facility policy regarding washing dishes. Dietary Manager (DM) C provided policy titled Sanitization which is dated 1/2025. Policy notes the expectations that dishes will be allowed to air dry as discussed with DM C. DM C provided…

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 observation, staff interview and record review, the facility did not provide a safe functional, sanitary and comfortable environment for all 48 residents. Frayed carpet found on three units in the hallways. Spots on carpet on all four units throughout the building. Bathroom floor with stains in room [ROOM NUMBER]. Sections of walls with punctures, black marks, and missing paint. Findings: On 04/03/2025 at 8:30 AM, Surveyor noted frayed carpet on 100 hallway between rooms [ROOM NUMBERS]. There was a circular metal in the floor that is 6 inches in diameter with frayed carpet around it. Frayed carpet noted in sitting room outside of the dining room along the seam that is 3 feet from the wall with windows. This frayed carpet runs the full length of the room. On the 200 hallway outside of room [ROOM NUMBER], there is a circular metal in the middle of the hallway that has frayed carpet around it. On the 300 hallway carpet is frayed around 6-inch metal circle between room [ROOM NUMBER] and 311. There is a…

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 interview, the facility did not provide written notification requirements to the Office of the State Long-Term Care Ombudsman with resident transfers from the facility. This was observed for 3 of 4 residents (R) (R23, R30, and R195) reviewed that were transferred from the facility. - The Office of the State Long-Term Care Ombudsman was not notified of R23, R30, and R195's transfers from the facility. Findings include: Example 1 R23 was admitted to the facility on [DATE] with diagnoses including diabetes, urinary retention, catheter associated urinary tract infections, weakness, and unsteadiness on feet. The Minimum Data Set (MDS) assessment completed on 03/14/25 confirmed R23 scored 12/15 during Brief Interview for Mental Status (BIMS) indicating intact cognition. R23 requires staff assistance with all Activities of Daily Living (ADLs). On 04/01/25, Surveyor reviewed R23's record and noted R23 was hospitalized from [DATE]-[DATE] for influenza. Example 2 R30 was admitted to the facility…

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 interview, the facility did not provide written notification requirements with resident transfers from the facility. This was observed for 2 of 4 residents (R) (R23 and R30) reviewed that were transferred from the facility. - R23 and R30 were transferred to the hospital while residing in the facility and did not have evidence they were provided the required transfer notice information. Findings include: The facility's policy and procedure titled Bed Hold Policy and Notice of Transfer, read in part .When a Resident is discharged to the hospital or goes on a leave of absence, the following bed hold policy takes effect: Medicaid/T19: Medicaid will hold a bed for you up to fifteen (15) days following the leave or until you waive your right to have the bed held, whichever is earlier. After the fifteenth (15) day you will be offered the first appropriate bed available. Medicare/Private Pay: We will hold a bed for you as long as you agree to continue to pay the room and board rate per day of…

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 observation, interview and record review, the facility did not develop and implement a person-centered care plan for each resident consistent with resident rights including services to attain or maintain the resident's highest or practicable physical, mental or psychosocial needs for 2 of 12 residents reviewed (R8, R195). R8 did not have an activity care plan including accommodations for vision and hearing deficits. R8 did not have preferences assessed for meal choices and interventions in place in care plan. R195 did not have a safe smoking care plan. Findings include: Example 1 R8 was admitted to the facility on [DATE]. Facility Policy titled Comprehensive Care Plans, last revised on 10/01/2022, states in part: Person-centered care means to focus on the resident as the locus of control and support the resident in making their own choices and having control over their daily lives. The policy also states in part: Resident's preferences will also be addressed in the plan of care. Minimum Data Set (MDS)…

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 observation, interview and record review, the facility did not ensure a resident with diabetic ulcers received necessary treatment and services to promote healing for 1 of 5 (R8) residents reviewed. -R8 did not receive active wound treatment orders for several days and the medical record did not have orders transcribed from wound clinic for nutritional supplements and protective boot to help promote wound healing and did not address recommendations from Registered Dietician (RD) to help promote wound healing. Findings include: R8 was admitted on [DATE]. Minimum Data Set (MDS), completed on 02/25/2025, confirmed R8 scored 9/15 during Brief interview for Mental Status (BIMS), indicating moderately impaired cognition. The facility policy titled Wound Management reads in part, Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of the dressing change. It also reads in part, In the absence or treatment orders, the licensed…

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 observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of infections for 2 of 4 sampled residents (R96 and R20). *Observations of 1 of 2 residents with a catheter, the catheter bag was positioned in a manner that allowed it to drag across the floor as the resident moved about in their wheelchair. *During 1 of 3 dressing change observed clean dressing was contaminated as it touched the floor. This is evidenced by: Example 1 The facility Policy entitled Catheter Care, no date, does not address the positioning of the catheter bag. R96 was admitted to the facility in March 2025 and has diagnoses that include urinary retention, and benign prostatic hyperplasia. On 03/31/25 at 2:00 PM, Surveyor observed R96 in the hallway sitting in wheelchair with the catheter urine collection bag on the lowest part of the wheelchair cross bars.…

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 observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible having the potential to cause harm to 15 of 15 residents that use mechanical lifts (R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15). Staff did not verify proper sling size or safe functioning of the mechanical lift prior to transfer of R1 on 11/22/24. The lift tipped over resulting in the sling bar striking R1 in the face resulting in a bruise and laceration below the left eye that required transfer to the hospital and tissue adhesive repair. Observations of transfers for R2, R3, and R4 demonstrate staff were not aware of how to determine proper sling size. Maintenance is not knowledgeable on lift inspections to ensure safety of lifts. Findings include: Proactive Medical Products Patient Sling Reference guide states, in part: It is very important to use the correct sized sling and make sure it is fitted properly prior to lifting. This…

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 staff and vendor interview, the Bedrock corporation governing body did not ensure adequate funds were made available to provide for the safe and efficient management of the facility. The failure to maintain current payment status with service providers and vendors has the potential to affect all 51 residents in the facility. The Bedrock corporate governing body failed to maintain current payment status with several service providers and vendors that resulted in vendors refusing to provide or providing discontinuation notices until payment is received, the governing body has not paid State bed tax and the facility pharmacy provider was abruptly terminated after a past due notice was issued including potential of disruption of service. The failure of the Bedrock governing body to maintain current contract payments has resulted in loss of service. Bedrock's corporation's failure to provide sufficient funding to maintain service/vendor contracts resulted in decreased options for services…

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 interview and record review, the facility failed to provide needed service to maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 3 residents (R)2 reviewed for transportation service for medical necessity. R2 was transferred by ambulance to the hospital on [DATE] at 4:15 p.m. Transportation was not provided for R2 to return to the facility from the hospital. R2 had to remain at the hospital from 9:00 p.m. on 07/08/24 until 9:08 a.m. on 07/09/24. Findings include: On 07/17/24 at 1:00 p.m., Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] with diagnoses of atrial fibrillation, cognitive disorder, type 2 diabetes mellitus, hypertension, obesity, hypercholesterolemia, hepatocellular carcinoma, and sleep apnea. R2's Minimum Data Set (MDS) admission assessment, dated 07/08/24, documents R2 is independent with eating, toileting hygiene, dressing, personal hygiene, bed mobility, transfers, and walking. R2's Brief Interview for Mental…

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, interview and record review, the facility did not provide sufficient nursing staff to provide nursing and related services to 20 of 53 residents (R) reviewed. (R13, R11, R14, R4, R12, R7, R8, R9, R1, R15, R16, R17, R18, R19, R20, R21, R22, R23, R28 and R29) This is evidenced by: Facility training completed on 4/24/24 on call light etiquette included the following: 1) Answer call lights promptly 2) Call lights are not to be turned off until needs are met 3) Always ask if you can help with anything else before exiting the room 4) No call light should be unanswered for longer than 10 minutes General resident information Surveyors requested information in relation to residents' falls and a list was provided. It lists 6 residents who were found on floor since May 1. Other witnessed falls include one fall from wheelchair, 4 falls while ambulating, 2 fall/bed incidents. The facility currently has 20 residents with treatments, 31 incontinent residents, 22 residents who require the assistance of 2 people, 24 residents on contact or enhanced barrier precautions, 3…

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 random observation, interview and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to prevent the development and transmission of communicable diseases and infections for 6 of 12 residents (R) Staff did not change gloves or perform hand hygiene during 2 observation of incontinence cares for R10, R27, R40, R2 and R4. Staff did not use appropriate Personal Protective Equipment (PPE) during observation of entering room for a resident who was on contact Transmission Based Precautions (TBP) for R27. Finding include: Facility policy entitled Hand Hygiene states in part: Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice; The use of gloves does not replace hand hygiene; The policy has a Hand Hygiene Table indicating the condition to which hand hygiene is expected to be conducted which states in part: Hand hygiene will be conducted when, during resident care, moving from a contaminated body site to a clean body…

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 observation, record review and interview, the facility did not provide the necessary care to prevent the development of pressure injuries (PI) for R2, by not applying heel boots, not repositioning as directed, and not following prescribed treatment. The facility practices have the potential to affect 1 of 5 residents reviewed for pressure injuries (R2). Findings include: According to the National Pressure Injury Advisory Panel (NPIAP) 2019, page 115, . Repositioning and mobilizing individuals is an important component in the prevention of pressure injuries. The underlying cause and formation of pressure injuries is multifaceted; however, by definition, pressure injuries cannot form without loading, or pressure, on tissue. Extended periods of lying or sitting on a particular part of the body and failure to redistribute the pressure on the body surface can result in sustained deformation of soft tissues and, ultimately, in tissue damage . According to Wound Care Education Institute (2018), for immobile or…

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, interviews and record reviews, the facility did not ensure 2 of 3 residents reviewed for pain (R40 and R258) received necessary treatment and services consistent with professional standards of practice, to manage their pain. This is evidenced by: The facility policy titled Pain Management, dated 10/1/22 states, The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences. The policy continues to state under Recognition, . 1. In order to help a resident attain or maintain his/her highest practicable level of physical\mental and psychosocial well-being and to prevent or manage pain, the facility will: a. Recognize when the resident is experiencing pain and identify circumstances when the pain can be anticipated. b. Evaluate the resident for pain and the cause(s) upon admission, during ongoing scheduled assessments . c.…

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 interview and record review, the facility did not ensure care plans were updated with resident's (R4) hygiene product preference for 1 of 4 residents reviewed. Findings: On 01/30/24, Surveyor reviewed grievance filed by R4, reporting 12/02/23 was the first day R4 was cleaned up. Staff were interviewed by Social Worker and Director of Nursing. Staff reported R4 was provided bed bath twice daily; however, regular soap was being used, not Dial soap, which is R4's preference. Grievance resolution on 12/03/23 included using Dial soap instead of regular soap; grievance documentation indicated R4's care plan would be updated. On 01/30/24 at 9:15 AM, Surveyor interviewed Certified Nursing Assistant (CNA) C. CNA C reported staff are aware R4's skin breaks down easily and staff are conscious of ensuring R4 is repositioned frequently, is provided bed bath twice daily using Dial soap, and medicated powder applied. R4 had no other skin concerns. On 01/30/24 at 9:37 AM, Surveyor interviewed R4. R4 reported moisture associated skin damage (MASD) under left breast. R4 stated staff provide…

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.