Abbyshire Place Health and Rehabilitation Center L

Inspectors wroteBased on record review, review of the facility's fall investigation, review of a self-reporting incident (SRI) and for an allegation of neglect and the facility's related investigation, observation, staff interview, family interview and policy review, the facility failed to ensure a resident with cognitive impairment, who was at risk for falls and had a history of falls, received the appropriate level of supervision to prevent him from falling in the facility's enclosed patio area. This affected one (Resident #65) of three residents reviewed for falls.

Inspectors wroteBased on observation and interview, the facility failed to maintain proper hand hygiene during tray line. This had the potential to affect all 90 residents in the building.

Inspectors wroteBased on observation, staff interview, and record review the facility failed to maintain a clean, homelike environment related to walls in disrepair and a dirty bathroom. This affected five residents (#5, #11, #52, #57, and #72) who resided in rooms [ROOM NUMBER]. The facility census was 90.

Inspectors wroteBased on review of a facility self-reporting incident (SRI) report for misappropriation of property, review of the facility's related investigation, record review, resident interview, staff interview, and policy review, the facility failed to provide a prompt effort to resolve a grievance/ concern from a resident regarding missing personal property. This affected one resident (#58) of one resident reviewed for missing personal property.

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to ensure a resident's medication was not misappropriated and was administered to the resident it was intended for. This affected one resident (#61) of two residents reviewed for misappropriation of property.

Inspectors wroteBased on review of a facility self-reporting incident (SRI) report for misappropriation of property, review of the facility's related investigation, record review, resident interview, staff interview, and policy review, the facility failed to ensure a resident's allegation of misappropriation was thoroughly investigated and included interviews with all relevant employees that may have had knowledge of the alleged misappropriation. This affected one resident (#58) of two residents that were reviewed for misappropriation of property.

Inspectors wroteBased on record review and interview, the facility failed to accurately complete a level one Pre-admission Screening/Resident Review (PASRR) and did not list post traumatic stress disorder (PTSD) on the serious mental illness section to be reviewed for a level two. This affected one resident (#82) of two residents reviewed for PASRRs. The facility census was 90.

Inspectors wroteBased on observation, record review, resident interview, and staff interview, the facility failed to ensure residents had a comprehensive care plan in place to address Post Traumatic Stress Disorder (PTSD) and impaired vision. This affected two residents (#25 and #82) of 20 residents reviewed for care plans.

Inspectors wroteBased on record review, observation, and staff interview, the facility failed to ensure care plans were revised to reflect a resident's non-compliance with the use of hand splints to manage contractures and another resident's care plan was revised to reflect the use of a leg bag collection system with the use of his indwelling urinary catheter. This affected two residents (#72 and #73) of 20 residents reviewed for care plans.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide services to prevent Resident #82 from experiencing triggers related to post traumatic stress disorder (PTSD). This affected one resident (#82) of two residents reviewed for behaviors. The facility census was 90.

Inspectors wroteBased on record review, and staff interview the facility failed to ensure a resident had appropriate monitoring of the anticoagulant medication coumadin. This affected one resident (#8) of five residents reviewed for unnecessary medications. The facility census was 90.

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to ensure medications were properly stored to include labeling that identified who the medication belonged to, date multi-use vials/ insulin pens were first accessed/ used, and medications did not exceed the expiration date on stock medication supplies. This affected one resident (#70) of two residents reviewed for medication administration and two residents (#12 and #236) with review of two of three medication administration carts.

Inspectors wroteBased on record review, and staff interview the facility failed to promptly notify the physician of a high and critical high INR (international normalized ratio) lab value for the anticoagulant medication coumadin. This affected one resident (#8) of five residents reviewed for unnecessary medications. The facility census was 90.

Inspectors wroteBased on observation and interview, the facility failed to follow a dietary order for a resident and did not ensure texture of pureed foods was without grainy texture. This affected one resident (#54) and had the potential to affect six residents receiving pureed diets. The facility census was 90.

Inspectors wroteBased on record review and interview the facility failed to ensure a Pre-admission Screening and Resident Review (PASARR) was accurate for Resident #41. This affected one resident (#41) of two residents reviewed for PASARR.

Inspectors wroteBased on observation, record review, facility policy and procedure review and interview the facility failed to ensure Resident #46, who required staff assistance with personal hygiene received adequate and timely nail care to maintain proper grooming/hygiene. This affected one resident (#46) of four residents reviewed for activities of daily living.

Inspectors wroteBased on observation, record review, facility policy and procedure review and interview the facility failed to timely identify and comprehensively monitor non-pressure related skin impairments for Resident #220. This affected one resident (#220) of one resident reviewed for non pressure skin alterations.

Inspectors wroteBased on observation, record review, facility policy and procedure review and interview the facility failed to timely identify and provide services to address limitations to range of motion and a hand contracture for Resident #41. This affected one resident (#41) of one resident reviewed for range of motion.

Inspectors wroteBased on observation, record review, facility policy and procedure review and interview the facility failed to ensure oxygen tubing was changed weekly and failed to ensure humidification was being administered appropriately for Resident #25. This affected one resident (#25) of the two residents reviewed for respiratory care.