Abbotsford Health Care Center

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure residents received services in the facility with reasonable accommodation of needs for 2 of 3 residents (R1, R5) reviewed from a sample of 5 residents.-R1 did not have a wheelchair available at all times and did not have the ability to get out of bed during those times.-R1 did not have assistance in obtaining eyeglasses replaced or fixed causing skin injuries.-R5 was unable to get out of bed at times due to the Hoyer lift not working properly.

Inspectors wroteBased on interview and record review, the facility did not revise a comprehensive person-centered care plan for each resident, consistent with the resident rights, for 1 of 3 residents reviewed from a sample of 5 residents (R1).-R1's care plan did not include the use of a Broda chair or interventions related to sharing a Broda chair with another resident.

Inspectors wroteBased on 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 and to help prevent the development and transmission of communicable diseases and infections, which has the potential to affect all 39 residents.-The facility's infection control surveillance was incomplete and missing pertinent information to help prevent the spread of infection.-A wet/soiled incontinence brief was observed on the nightstand of a resident's room (R32).

Inspectors wroteBased on interview and record review, the facility did not ensure the Infection Prevention and Control Program included an Antibiotic Stewardship Program monitoring antibiotic use which has the potential to affect all 39 residents.-The facility does not currently have an antibiotic stewardship program in place.

Inspectors wroteBased on interview and record review, the facility did not ensure the facility designated one or more individuals as the Infection Preventionist, who has completed specialized training in infection prevention and control. This has the potential to affect all 39 residents.-The facility does not have a certified infection preventionist.

Inspectors wroteBased on interview and record review, the facility did not immediately report to the physician on call of R22's decline of a groin wound for 1 of 2 residents (R) reviewed for pressure injuries (R22). R22's groin pressure injury (PI) increased in size on 05/30/26, and the facility did not notify the physician of the change. This is evidenced by:R22 was admitted to the facility on [DATE]. R22's current diagnoses include progressive multiple sclerosis, spinal stenosis of the lumbar region, and venous insufficiency (chronic peripheral). On 04/16/26, Minimum Data Set (MDS) documented R22 was independent with cognitive skills for daily decision making. R22 had impairment on both sides of lower extremities. R22 is dependent on staff assistance for toileting hygiene, lower body dressing and transfers. R22 requires maximum assistance of staff for personal hygiene and bed mobility. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident's medication regimen was free from medications used in excessive duration and without adequate indications for use for 1 of 5 sampled residents (R) reviewed for unnecessary medications (R5). R5 is a resident with dementia who has a physician's order for an antipsychotic medication. R5 has been on the same dose of the medication for over a year and has not had any behaviors for the past three months. This medication has not been reviewed by a physician for possible reduction in the past 9 months. This is evidenced by:The facility's policy titled Psychotropic Medication Use dated revised February 2026 states, Psychotropic medication management is an interdisciplinary process that involves the resident, family and/or the representative and includes a. determining adequate indications for use; .d. [...]

Inspectors wroteBased on staff interview and record review, the facility did not ensure a Significant Change Minimum Data Set (MDS) assessment was completed for 1 resident (R) (R6) of 17 sampled residents. The facility did not complete a Comprehensive Significant Change MDS assessment when R6 revoked Hospice services. This is evidenced by:The Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual (October 2025) indicates: If a nursing home resident elects the hospice benefit, the nursing home is required to complete an MDS Significant Change in Status Assessment (SCSA). The nursing home is required to complete an SCSA when the resident comes off the hospice benefit (revoke). An SCSA is required to be performed when a resident is receiving hospice services and then decides to discontinue those services (known as revoking of hospice care). [...]

Inspectors wroteBased on interview and record review, the facility did not assess a resident using the quarterly review instrument specified by the State and approved by Centers for Medicare and Medicaid Services (CMS) not less frequently than once every 3 months for 1 of 17 residents (R7).-R7's Quarterly MDS assessment was completed 40 days late and not submitted to CMS until survey was in process.

Inspectors wroteBased on interview and record review, the facility did not complete an accurate assessment on residents (R) Minimum Data Set (MDS) that reflects the resident's status for 1 of 17 residents reviewed. (R25) -R25 had an admission MDS dated [DATE]. The facility coded the MDS, in section A, indicating R25 does not meet the federal definition of a serious mental illness and the PASARR I, diagnoses, and medications indicate otherwise.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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: [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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]. [...]

Inspectors wroteBased 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; [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident utilizing a Hoyer lift for transfers received adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (R1) reviewed. Certified Nursing Assistant (CNA) transferred R1 utilizing a Hoyer lift from the bed to the chair without assistance from another staff member. Facility policy states all mechanical lift transfers require 2 people. R1 slipped out of the Hoyer lift sling, fell to the floor, and struck R1's head sustaining a subarachnoid hemorrhage, subdural hematoma, a right posterior scalp laceration and hematoma, and required hospitalization. R1's condition declined as a result. R1 was verbal, but nonsensical prior to the fall, and is now nonverbal. R1's code status changed from Full Code to Do Not Resuscitate (DNR). R1 is now residing in a hospice facility. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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).

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure the posted nurse staffing information included census and the correct working staff at the beginning of each shift. This has the potential to affect all 55 residents.