Abbott Skilled Nursing & Rehabilitation Center

Inspectors wroteBased on observations, interviews and records reviewed, the facility failed to implement the infection prevention and control program. Specifically, the facility failed to implement an infection control surveillance plan for identifying, tracking, monitoring and/or reporting of infections, communicable diseases and outbreaks among residents and staff.

Inspectors wroteBased on observation, interviews and records reviewed, the facility failed to implement written policies and procedures for the investigation of allegations of abuse, protection of residents during investigations, reporting of allegations and investigative findings, and taking corrective actions to protect other residents from potential abuse, for one Resident (#192), out of a total sample of 13 residents.

Inspectors wroteBased on observations, records reviewed and interviews, the facility failed to report allegations of potential abuse (injuries of unknown source) to the State Agency for one Resident (#192) out of a total sample of 13 residents.

Inspectors wroteBased on observation, interviews and records reviewed, the facility failed to Initiate an investigation of an alleged violation of abuse including injuries of unknown source for one Resident (#192) out of a total sample of 13 residents. Specifically for Resident #192 who on 5/19/25, was found to have bruising and open skin areas to his/her upper extremities, the facility failed to prevent further potential abuse or mistreatment while the investigation of an alleged violation is in progress.

Inspectors wroteBased on observations, interviews and records reviewed, the facility failed to provide care, consistent with professional standards of practice one Resident (#192) out of a total sample of 13 residents. Specifically, for Resident #192 the facility failed to identify a change in his/her skin condition and failed to ensure weekly skin checks were completed.

Inspectors wroteBased on record review and interviews, the facility failed to formulate an advance directive for one Resident (#5) out of a total sample of 14 residents. Specifically, the facility failed to initiate the court process to renew an expired [NAME] guardianship (a treatment plan that states that antipsychotic medications are so intrusive, and their side effects are potentially so severe, that a court must approve them).

Inspectors wroteBased on observation, interview and record review, the facility failed to provide assistance with activities of daily living (ADLs) for residents who are dependent on staff for one Resident (#22) out of a total sample of 14 residents. Specifically, the facility failed to provide supervision while eating for Resident #22.

Inspectors wroteBased on record review and interview, the facility failed to follow up with recommendations made by the Audiologist for one Resident (#17) out of a total sample of 14 residents. Specifically, for Resident #17 the facility failed to follow up with the Audiologist's recommendation to remove ear wax from the Resident's right ear within a reasonable amount of time.

Inspectors wroteBased on observation, interviews, policy review and record review the facility failed to maintain respiratory equipment according to professional standards of practice for two Residents (#289 and #9), out of a total sample of 14 residents. Specifically, 1. For Resident #289 the facility failed to obtain a physician's order for the use of a continuous positive airway pressure machine (CPAP, machine used to treat sleep apnea). 2. For Resident #9, the facility failed to ensure the oxygen concentrator filter was clean.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide food in a form that meets the needs of one Resident (#22) out of a total sample of 14 residents. Specifically, for Resident #22 the facility failed to provide food in a cut-up texture as ordered by the physician.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure infection control standards of practice for the prevention of infections were implemented. Specifically, housekeeping staff failed to perform hand hygiene after removing personal protection equipment (PPE) and moving from one resident room to another. The facility has one resident care unit.

Inspectors wroteBased on record review and interview the facility failed to 1. maintain for Resident (#2), out of sample of five residents, documentation that the resident was screened for the eligibility for the Covid-19 vaccination, or that the resident had been immunized for Covid-19, and 2. failed to ensure documentation was maintained for the Covid-19 vaccine status for one of two employees reviewed.

Inspectors wroteBased on records reviewed and interview, the facility failed to ensure an Abnormal Involuntary Movement Scale (AIMS) assessment (a test used monitor for adverse consequences of antipsychotic medication) was completed for 3 Residents(#23, #8 and #32) who were receiving antipsychotic medications out of a total sample of 17 Residents.

Inspectors wroteBased on record review and interview the facility failed to notify the physician of a change in status, specifically for a significant weight gain for 1 Resident (#11) out of a total sample of 17 residents.

Inspectors wroteBased on observations, record review and interviews the facility failed to ensure a scoop mattress implemented for 1 Resident (#29) was assessed as a potential restraint, out of a total sample of 17 residents.

Inspectors wroteBased on observations, records reviewed and interviews the facility failed to ensure the plan of care was implemented for 2 Residents (#29 and #4), out of a total sample of 17 residents for 1.) Resident #29 the facility failed to implement the use of fall mats on either side of Resident #29's bed per the fall risk care plan and for 2.) Resident #4, the facility failed to follow the physician's orders, specifically failed to apply (Thrombo-Embolic Deterrent, TED) stockings as ordered.

Inspectors wroteBased on record review and interview the facility failed to ensure professional standards of nursing practice; 1.) the facility failed to administer a physician's ordered medicated vaginal cream and failed to document in the medical record why the medication was not administered for 1 Resident (#20) out of a total sample of 17 residents and 2.) the facility failed ensure nursing obtained a physician's order for a RN (Registered Nurse) to perform a pronouncement of death for 1 discharged Resident (#35), out of three discharged records reviewed.

Inspectors wroteBased on observation, interview, policy review and record review, the facility failed to identify and address a significant weight gain for 1 Resident (#11) out of a sample of 17 Residents.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure they maintained an updated communication book for dialysis care and failed to ensure the dialysis communication book consistently went with the Resident to and from dialysis for 1 Resident (#20) out of a total sample of 17 residents.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure it was free from a medication error rate of greater than 5 percent. One nurse out of two nurses observed made 3 errors in 34 opportunities resulting in a medication error rate of 8.82%. These errors impacted 2 Residents (#5 and #16) out of 5 residents observed.

Inspectors wroteBased on observations, records reviewed and interviews, the facility failed to accurately document in the medical record for 2 Residents ( #4 and #20) out of a sample of 17 Residents. 1). For Resident #4, the facility failed to accurately document on the Treatment Administration Record (TAR), specifically, nursing documented that Resident #4 was wearing (Thrombo-Embolic Deterrent) TED stockings when he/she was not. 2). For Resident #20, the facility failed to accurately identify a diagnosis of cervicalgia (neck pain) for a physician's order.