Abbey Senior Health

Inspectors wroteBased on interview and record review, the facility failed to communicate transfers and/or discharges to the State Long-Term Care Ombudsman (a trained advocate, often a volunteer, who works to protect the rights and improve the quality of life for residents in long-term care facilities, such as nursing homes and assisted living facilities) for three residents (Resident #44, #70 and #34), in a review of 14 sampled residents, and for two discharged residents (Residents #4 and #38). The facility census was 49. Review of the undated facility policy, Transfer and Discharge from the Facility, showed the following:-The facility forwards a copy of all discharge notices to the Office of the State Long-Term Care Ombudsman;A. Facility staff will document in the residents' record:iv. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer insulin according to manufacturer's recommendations for one resident (Resident #3), in review of 14 sampled residents, and for two additional residents (Residents #25 and #47). The failure had the potential to result in residents not receiving their full dose of ordered insulin. The facility census was 49. Review of the undated facility policy, Insulin Administration, showed the following:-All licensed nursing staff shall administer insulin in strict accordance with a practitioner's order, state regulations, and established standards of clinical practice;-Mandatory priming protocol: For every injection using an insulin pen, the nurse must dial and prime 2 units of insulin into the needle before dialing the actual prescribed dose. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff followed proper infection control techniques as directed in facility policy and failed to follow physician's orders to treat a Stage III pressure ulcer (Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling) for one resident (Resident #6), in a review of one sampled residents who had a pressure ulcer. The facility census was 49. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident #1), in a review of five sampled residents, remained free from misappropriation of property. Certified Nurse Aide (CNA C) took the resident's wallet containing cash and the resident's debit card without the resident's knowledge or permission and used the debit card to pay Instant Credit Auto $450.00 (loan company for car loans), Spectrum (an internet and cable provider) $378.00 and $139.29 at Five Below (a retail store). The facility census was 53. On 9/11/25 at 12:30 P.M. the administrator was notified of the past non-compliance which occurred on 9/5/25. On 9/8/25, the administrator became aware of the violation of misappropriation of the resident's debit card and cash by CNA C when the resident logged onto his/her bank account and found the money had been withdrawn from the account. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure one resident (Resident # 1 ) in a review of eleven residents was free from verbal and mental abuse when Dietary Aide E threw a ceramic dinner plate towards the resident, hitting the wall behind the resident, shattering the plate and called the resident a fucking bitch. The facility census was 50. On 12/19/24 at 11:00 A.M. the administrator was notified of the past non-compliance which occurred on 12/15/24. On 12/15/24 the administrator identified Dietary Aide E verbally and physically abused Resident #1. Upon discovery, staff suspended Dietary Aide E, conducted an investigation and notified appropriate parties. Staff reviewed the abuse and neglect policies, and all facility staff was educated on the facility abuse and neglect policies. Dietary Aide E was terminated. The deficiency was corrected on 12/16/24. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and serve food to residents in a safe and sanitary manner when staff failed to employ proper hand hygiene and gloving practices and failed to store food in a manner that prevented potential contamination. Staff failed to ensure beverage and ice machines were clean and an air gap was present at ice machine drains. Staff failed to document and demonstrate knowledge of the use and testing parameters of the facility's dishwashing machines to ensure dishes were cleaned and sanitized properly. The facility census was 49. Review of the facility policy, Food and Nutrition Services Staff, revised November 2022, showed the following: -Food and nutrition services staff should wash their hands before serving food to residents; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were aware of posted resident rights in an easily accessible area for review at their leisure. The resident census was 49. Review of the facility's policy, Resident Rights, revised February 2021 showed the following: -Federal and state laws guarantee certain basic rights to all residents of the facility; -These rights include the resident's right to: -Communication with and access to people and services, both inside and outside the facility; -Be informed about his or her rights and responsibilities; -Communicate with outside agencies (e.g., local, state, or federal officials, state and federal surveyors, state long-term care ombudsman, protection or advocacy organizations, etc.) regarding any matter; -Copies of resident rights are posted throughout the facility. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to protect the resident rights when the facility did not provide accessible information regarding the State Long Term Care Ombudsman program and the State Survey Agency in a location that was readily accessible and could be read by residents in the facility without assistance. The facility census was 49. Review of the facility's policy, Filing Grievance/Complaints, revised April 2017, showed the following: -Residents and their representatives have the right to file a grievance, either orally or in writing, to the facility staff or the agency designated to hear grievances (e.g. the State Ombudsman); -A copy of the grievance/complaint procedure is posted on the resident bulleting board. During group interview, on 10/23/24 at 10:02 A.M., seven of seven residents said the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff safely transported residents in wheelchairs for four residents (Residents #26, #27, #25, and #4), in review of 19 sampled residents, and for two additional residents (Residents #11 and #40). The census was 49. During an interview on 11/05/24 at 10:19 A.M., the Director of Nursing (DON) said the facility did not currently have a policy for transporting residents in wheelchairs or the use of wheelchair foot rests. 1. Review of Resident #26's undated face sheet showed the resident's diagnoses included difficulty in walking, unsteadiness on feet, psychoactive substance-induced sleep disorder, history of falls, major depression, anxiety disorder, and mild cognitive impairment. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure bed rails assessments were consistent with facility policy to evaluate the resident's risk for entrapment and failed to conduct ongoing assessments to ensure the proper use and safety of the bed rails for eight residents (Residents #12, #102, #24, #25, #23, #207, #4 and #45), in a review of 20 sampled residents. The facility census was 49. Review of the facility policy, Bed Safety and Bed Rails, revised on August 2022, showed the following: -Bed rails are adjustable metal or rigid plastic bars that attach to the bed. They are available in a variety of types, shapes, and sizes ranging from full to one-half, one- quarter, or one-eighth lengths. Some bed rails are not designed as part of the bed by the manufacturer and may be installed on or used along the side of a bed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in a manner to prevent the development and transmission of diseases and infections for eight residents (Residents #24, #12, #39, #27, #102, #103, #202, and #42), in a review of 20 sampled residents. Staff failed to failed to utilize Enhanced Barrier Precautions (EBP) during personal care for three residents (Residents #24, #12, and #39) who had urinary catheters (a tube inserted into the bladder to drain urine); failed to maintain a system to ensure one resident's (Resident #24's) urinary catheter tubing and dignity bag (containing the urinary drainage bag) were kept off the floor; failed to utilize proper handwashing and gloving when providing incontinence care to one resident (Resident #27); [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to complete inspection of bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment for eight residents (Resident #12, #102, #24, #25, #23, #207, #4 and #45), in a review of 20 sampled residents. The facility census was 49. Review of the facility policy, Bed Safety and Bed Rails, revised on August 2022, showed the following: -Resident beds meet the safety specifications established by the Hospital Bed Safety Workgroup; -Bed frames, mattresses and bed rails are checked for compatibility and size prior to use; -Regardless of mattress type, width, length, and/or depth, the bed frame, bed rail and mattress will leave no gap wide enough to entrap a resident's head or body. Any gaps in the bed system are within the safety dimensions established by the FDA; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide two residents (Residents #4 and #26), or their responsible party, with a bed hold policy at the time of transfer to the hospital, in a review of 20 sampled residents. The facility census was 49. Review of the facility's policy, Bed Hold Policy, revised May 2024, showed the following when a resident was transferred to a hospital: -Neither a resident nor the responsible party is required to pay a nursing facility to hold a bed; -If the resident/responsible person chooses to, he/she may pay a nursing facility in order to reserve the same bed the participant is leaving; -A nursing home has an obligation to inform a resident or the responsible person that paying them to hold a bed is voluntary; [...]

Inspectors wroteBased on interview and record review, the facility failed to review the baseline care plan with the resident/responsible party within 48 hours of admission or provide a copy of the baseline care plan to the resident/responsible party for two residents, (Resident #202 and #207) in a review of 20 residents. The facility census was 49. Review of the facility policy, Baseline Care Plans, revised March 2022, showed the following: -A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within 48 hours of admission; -The resident and/or representative are provided a written summary of the baseline care plan (in a language that the resident/representative can understand) that includes, but is not limited to the following: -The stated goals and objectives of the resident; -A summary of the resident's medication and dietary instructions; [...]

Inspectors wroteBased on record review, staff and resident interview, and policy review, the facility failed to ensure seven residents (Resident (R) 3, R207, R27, R31, R22, R39, R52, and R40) of 24 sampled residents remained free of accidents/hazards and received adequate supervision to prevent accidents. The facility failed to ensure coffee that was accessible to residents and served to residents was within a safe temperature range. On [DATE], R3 spilled coffee on her lap resulting in blisters on both sides of her inner thigh, and on [DATE], R40 spilled coffee on his lap. The Director of Nursing (DON) failed to ensure R207, R27, R31, R22, R39 and R52, who had falls, lacked adequate supervision, a comprehensive fall investigation after each fall, and remained free from injury.

Inspectors wroteBased on record review, observation and staff interview, the facility failed to ensure the facility was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Facility Assessment was maintained accurately. Specifically, the Facility Assessment had not been reviewed/revised annually and did not accurately reflect the current resident population.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the activities program was directed by a qualified activities professional. Specifically, the current Activities Director was not a qualified activities professional who was licensed or registered by the state.

Inspectors wroteBased on interview and record review, the facility failed to complete a significant change in status Minimum Data Set (MDS) for one (Resident (R) 32) of one resident reviewed for hospice in a total sample of 24 residents.

Inspectors wroteBased on interview and record review, the facility failed to complete a discharge assessment using the Minimum Data Set (MDS) process within the required timeframe for two (Resident (R) 11 and R47) discharged residents reviewed in a total sample of 24 residents.

Inspectors wroteBased on observation, record review, staff interview, and policy review, the facility failed to ensure a comprehensive care plan was developed for three residents (Resident (R)1, R3, and R7) of 24 sampled residents.

Inspectors wroteBased on staff interview, record review, and policy review, the facility failed to ensure there were weekly skin assessments completed for one resident (Resident (R) 3) of three residents sampled for skin assessments, from a total sample of 24. Specifically, the facility failed to consistently complete weekly skin assessments for R3, specifically skin assessments after blisters were identified on 05/18/23, which increased the likelihood of R3 developing a significant skin issue.

Inspectors wroteBased on interview, record review, and facility policy review, the pharmacist failed to identify and report irregularities regarding inadequate indications for use of an antipsychotic medication for two (Resident (R) 3 and R22) of five residents reviewed for unnecessary medication use.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure psychotropic medication had an appropriate indication for use for two of five residents (Resident (R) 3 and R22) reviewed for unnecessary medication. The facility further failed to ensure that a PRN (as needed) psychotropic medication had a documented rationale for use beyond 14 days for one of five residents (R22) reviewed for unnecessary medication.

Inspectors wroteBased on interview, record review, and the facility's hospice contract, the facility failed to ensure the appropriate coordination of Hospice care by specifically failing to maintain hospice care plans, Hospice election form and Physician certification and recertification of the terminal illness specific to each patient for two (Resident (R)27, and R32) of two residents sampled for Hospice. This failure had the potential result in the interruption of the residents' coordination of care.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to adhere to enhanced barrier precautions for one resident (R)15 from a sample of 24 residents, and failed to properly sanitize one of two glucometers on one of the two nursing units. Findings Include: Review of the facility's policy titled Enhanced Barrier Precautions dated August 2022 read in part Enhanced barrier precautions (EBPs) employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room). Personal protective equipment (PPE) is changed before caring for another resident. Face protection may be used if there is also a risk of splash or spray. [...]

Inspectors wroteBased on interview, record review, and policy review, the facility failed to provide abuse prohibition training for one (Certified Nursing Assistant (CNA) 4) of five staff hired in the last six months.