Abbington Vlge Nrsg & Rhb Ctr

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was prepared in a sanitary manner by not labeling stored foods, not performing hand hygiene when necessary, not wearing gloves while preparing ready to eat foods, and not storing personal items in designated areas separated from the resident's food. This failure applies to all 60 residents who receive food prepared by the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow their policy for monitoring their water management plan for Legionella. The facility also failed to follow their policy for handling soiled linens. The facility failed to follow infection control measures during medication administration. This applies to all 61 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a clean and sanitary homelike environment by failing to repair a leaking ceiling in the common area and resident's room. This applies to 4 of 7 residents (R7, R15, R47 and R51) reviewed for homelike environmental concerns in a sample 16.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide timely assistance for incontinence care and grooming to residents who require assistance with ADLs (Activities of Daily Living). This applies to 4 of 4 residents (R13, R29, R30, and R52) reviewed for ADL care in the sample of 16.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician orders to provide dietary interventions for a resident with significant weight loss. This applies to 1 of 3 residents (R58) reviewed for weight loss in the sample of 16.

Inspectors wroteBased on interview and record review, the facility failed to document changes in skin condition, failed to ensure a physician assessed a new wound. The facility also failed to develop and implement care plan interventions for a resident who was admitted with pressure wounds to both heels, was identified with risk factors for further pressure wound development, and who developed sacral pressure wounds. This applies to 1 of 3 residents (R1) reviewed for pressure ulcers in the sample of 5.

Inspectors wroteBased on observation, interview and record review, the facility failed to serve resident meals at regular times per the facility meal schedule. This applies to all 60 residents residing in the facility receiving oral diets.

Inspectors wroteBased on interview and record review, the facility failed to provide palatable food at warm temperatures. This applies to 4 of 5 residents (R1, R5, R7, and R9) reviewed for food palatability in a sample of 5.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide timely Activities of Daily Living (ADL) assistance to residents who were dependent on staff for incontinence care. This applies to 3 of 3 residents (R1, R7 and R9) reviewed for incontinence care in a sample of 10.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure residents had functioning call lights within their reach. This failure applies to 6 of 9 residents (R1, R2, R6, R7, R8, and R9) reviewed for accommodation of needs.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure resident's clothing items were labeled and safeguarded from loss. This failure applies to 3 residents (R1, R2, and R3) reviewed for laundry services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow sanitary practices in the facility kitchen. This applies to 57 residents that received foods prepared in the facility kitchen.

Inspectors wroteBased on interview and record review, the facility failed to follow their water management plan for Legionella. The facility also failed to have control measures in their water management plan to address prolonged closure of a resident unit. This applies to all 57 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a homelike environment for residents residing in the facility. This applies to 4 of 15 residents (R9, R24, R43, R45) reviewed for homelike environment in the sample of 15.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents' rooms were located at or above ground level. This applies to 13 residents (R1, R5, R6, R7, R8, R23, R30, R33, R43, R44, R45, R52, and R53) on the first floor reviewed for room/level/location.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide privacy during provision of wound care. This applies to 1 of 15 residents (R41) reviewed for privacy in the sample of 15.

Inspectors wroteBased on interview and record review, the facility failed to implement a person-centered care plan for a resident with a diagnosis of PTSD (Post Traumatic Stress Disorder) This applies to 1 of 1 resident (R44) reviewed for PTSD in the sample of 15.

Inspectors wroteBased on observation, interview, record review, the facility failed to provide hygiene and grooming for residents who require assistance for activities of daily living (ADL) care. This applies to 3 of the 4 residents (R4, R9, R31) reviewed for ADL care in the sample of 15.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who needed foot care is seen by a podiatrist. This applies to 1 of 1 resident (R26) reviewed for foot care in the sample of 15.

Inspectors wroteBased on observation, interview, and record review, the facility failed to apply pain adhesive patches to residents that had a Physician order for the same. This applies to 2 of 2 residents (R19, R203) reviewed for pain management in the sample of 15.

Inspectors wroteBased on interview and record review, the facility failed to identify triggers and provide trauma-informed care for a resident with a diagnosis of PTSD (Post Traumatic Stress Disorder). This applies to 1 of 1 resident (R44) reviewed for PTSD in the sample of 15.

Inspectors wroteBased on observation, interview, and record review, the facility failed to serve pureed consistency diets for residents that have an order for the same. This applies to 2 of 2 residents (R13, R32) reviewed for pureed diets in the sample of 15.

Inspectors wroteBased on observation, interview and record review, the facility failed to serve food items to residents as shown on the facility's planned and approved menu. This applies to all 27 residents residing in the facility reviewed for missing food items and menus served as planned.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the toaster in the kitchen was functional. This applies to all residents that receive a regular diet from the facility kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents dependent upon staff for ADLs (activities of daily living) received nail grooming. This applies to 4 residents (R49, R35, R54, & R18) of 24 residents were reviewed for ADLs in the sample of 24.

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor the refrigerator temperatures for 4 residents' refrigerators (R49, R18, R5, & R19) in a sample of 24.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess a resident for self-administration of medication and obtain physician orders for resident medication to be at the bedside. This applies to 1 of 3 residents (R8) reviewed for medications in the sample of 24.

Inspectors wroteBased on interview and record review, the facility failed to maintain accurate advanced directives for 2 residents' (R31 & R256) medical records in a sample of 24.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a functional privacy curtain/curtain track. This applies to 1 resident (R16) reviewed for privacy in a sample of 24.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe, warm, home-like environment for 1 resident (R49) in a sample of 24.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide meaningful activities for a resident. This applies to 1 of 24 residents (R31) in a sample of 24.

Inspectors wroteBased on observation, interview and record review, facility failed to ensure residents return their smoking materials back to the receptionist for safe-keeping after smoking. This applies to 2 (R1, R26) of 6 residents reviewed for smoking in the sample of 24.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's urinary catheter drainage bag was kept off the floor. This applies to 1 of 4 residents (R49) reviewed for catheter care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer medications as ordered. There were 32 opportunities with 3 errors, resulting in a 9.38% error rate. This applies to 2 (R26 and R41) out of 6 residents observed for medication pass.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents are free from repeated significant medication errors with blood pressure medications. This applies to 1 (R26) out of 6 residents observed for medication administration in a sample of 24.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to perform handwashing and glove changes when moving from soiled to clean areas. This applies to 2 of 24 residents (R5, R56) reviewed for infection control practices in the sample of 24.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents' rooms were located at or above ground level. This applies 11 residents (R3, R7, R13, R16, R20, R26, R34, R37, R45, R51, and R52) reviewed for facility environment.