Abbeville Crossing of Journey LLC

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to provide supervision to prevent accidents for one of one resident (Resident (R) 47) reviewed for accidents out of a total sample of 18. This failure caused actual harm on 06/9/25 when Certified Nursing Assistant (CNA) 3 gave R47 a bowl of hot ramen noodles and allowed him to go down the hallway with them on his lap to his room, which was on the other hallway. R47 had not been assessed to be able to safely handle hot liquids. R47 spilled the hot noodles on his leg and sustained a burn that resulted in a blister to his upper left thigh.

Inspectors wroteBased on record review, staff interview and review of the facility policy titled Conducting and Accurate Resident Assessment, the facility failed to accurately assess and code behavior symptoms on the Minimum Data Set (MDS) for three residents (R) (R1, R4 and R10) from a sample of 14 residents. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility's Administrator and Assistant Director of Nursing were informed of the Immediate Jeopardy on [DATE], at 11:47 am. The noncompliance related to the Immediate Jeopardy (IJ) was identified to have existed on [DATE]. An Acceptable IJ Removal Plan was received on [DATE]. [...]

Inspectors wroteBased on record review, staff interviews and review of the facility policy's titled Comprehensive Care Plans and Elopements and Wandering Residents, the facility failed to develop interventions in resident (R1) care plan to include supervision/monitoring and management of the resident's risk for elopement from a sample of 14 residents. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility's Administrator and Assistant Director of Nursing were informed of the Immediate Jeopardy on [DATE], at 11:47 am. The noncompliance related to the Immediate Jeopardy (IJ) was identified to have existed on [DATE]. An Acceptable IJ Removal Plan was received on [DATE]. [...]

Inspectors wroteBased on interviews, record review and review of the facility policy titled, Elopements and Wandering Residents, the facility to provide adequate supervision and frequent monitoring of resident (R1) and failed to ensure a kitchen door was locked to prevent the elopement of R1. The facility also failed to provide adequate supervision of the steam table that was turned on and left unsupervised in the dining room. The sample was 14 residents. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility's Administrator and Assistant Director of Nursing were informed of the Immediate Jeopardy on [DATE], at 11:47 am. [...]

Inspectors wroteBased on interviews, record reviews, and review of the job descriptions for the Executive Director and the Director of Nursing (DON), the facility Administration failed to provide frequent monitoring and protective oversight of the facility environment to prevent the elopement of resident (R1) and prevent resident access to potentially hazardous kitchen equipment. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility's Administrator and Assistant Director of Nursing were informed of the Immediate Jeopardy on [DATE], at 11:47 am. The noncompliance related to the Immediate Jeopardy (IJ) was identified to have existed on [DATE]. An Acceptable IJ Removal Plan was received on [DATE]. [...]

Inspectors wroteBased on interviews, record reviews and policy titled Resident Trust Fund Account, the facility failed to ensure that four residents (R) (R5, R6, R7, and R8) were free from misappropriation of their resident trust account money, from a total sample of 10 residents.

Inspectors wroteBased on observations, interviews, record reviews and review of the policy titled Abuse and Neglect - Clinical Protocol, the facility failed to protect the resident's right to be free from verbal abuse by Certified Nursing Assistant (CNA) JJ for one resident (R) (A) of 10 sampled residents.

Inspectors wroteBased on interviews, record reviews, and review of the Abuse and Neglect - Clinical Protocol and Abuse Investigation and Reporting policies, the facility failed to ensure that allegations of abuse were reported to the State Survey Agency in a timely manner for one resident (R) (A), from a total sample of 10 residents.

Inspectors wroteBased on resident and staff interviews, record review and review of the facility policy titled, Resident Trust Account Medicaid Over $2000 the facility failed to ensure four out of 54 resident's personal fund accounts were under the $2000.00 limit to maintain eligibility for Medicaid services.

Inspectors wroteBased on observations, staff interviews, review of facility policy titled, Cycle Cleaning, and review of facility job description titled, Maintenance Supervisor the facility failed to maintain a safe, clean, sanitary environment related to a heavy build-up of dust on vent covers in three of three adjoining bathrooms, 102/104, 106/108, 110/112, and bathroom [ROOM NUMBER] and 101 on the 100 Hall. The deficient practice had the potential to affect 17 residents residing in nine rooms on the 100 hall.

Inspectors wroteBased on observation, resident and staff interviews, and record review, the facility failed to apply a topical medication for psoriasis (a chronic disease of the skin marked by red patches covered with white scales) twice per day as ordered by the physician for one resident (R) (#49) of 25 sampled residents. The deficient practice had the potential to increase the progression of residents' current skin condition by not applying topical medication as ordered by the physician.

Inspectors wroteBased on record review and interview the facility failed to ensure a Certified Dietary Manager with appropriate credentials was employed. This deficient practice had the potential to effect 60 of 64 residents who received meals in the facility.

Inspectors wroteBased on observation, interview, and review of policy titled, Food Receiving and Storage, the facility failed to store, prepare, and serve food under sanitary conditions as evidenced by uncovered and undated items in the refrigerator, mold on food, no expiration dates on prepared food, thawing of chicken at room temperature, and unclean storage. This had the potential to affect 60 of 64 residents who received oral nutrition.

Inspectors wroteBased on record reviews, interviews, and review of facility polices titled Infection Prevention and Control Program and Antibiotic Stewardship Program, the facility failed to ensure that the person in the role of Infection Preventionist completed specialized training in infection prevention and control. This failure created the potential for an ineffective infection control program that placed residents at risk for the potential transmission of infections and communicable diseases. The facility census was 64.

Inspectors wroteBased on record reviews and interviews, the facility failed to promote and facilitate a resident's right to make choices about showers. This affected one of 16 sampled residents (R) #21).

Inspectors wroteBased on record review and interview, the facility failed to ensure that a resident received proper treatment to maintain vision. This affected one of 16 sampled residents (R)#37).

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy titled, Pressure Injury Management and Prevention the facility failed to perform weekly skin assessments to identify the development of a pressure ulcer in accordance with professional standard of quality for one of seven residents (R) #11) with pressure ulcers.

Inspectors wroteBased on observations, interviews, and review of facility policy titled, Ordering Non-controlled Medications, the facility failed to order medications timely for one of 16 residents (R)#14) sampled.

Inspectors wroteBased on observations and interview, the facility failed to dispose of garbage and refuse properly as evidenced by overflowing garbage bins for two of four days of the survey period.

Inspectors wroteBased on record reviews, interviews, and review of facility policies, the facility failed to implement an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use. The facility census was 64.

Inspectors wroteBased on record review, staff interview and review of facility policy titled Transfer or Discharge, Preparing a Resident for, the facility failed to develop a discharge summary and a recapitulation of the residents stay for one resident (R) (R#155) who was discharged to the community. The sample size was five residents.