Abbey Senior Health

In the surveyor’s words

From the most serious findings on record at Abbey Senior Health, in the surveyor’s own words.

• Actual harm, isolatedF689Jun 9, 2023

  Based 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. Findings include: 1. […]

• No harm, potential for more than minimal, widespreadF812Oct 25, 2024

  Based 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. […]

• No harm, potential for more than minimal, widespreadF835Jun 9, 2023

  Based 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. Findings include: Review of the Facility Assessment updated 11/2021 for 2022, revealed, Quality Assurance overall has been delegated as a top oversight priority of our new DON (Director of Nursing). The Q1/A (Quality Improvement/Assurance) process, its' administration and report to the QA Committee and Administrator about progress, problem areas and trouble shooting [sic] will be an outgrowth of weekly UR/High Risk meetings, Monthly QA review and quarterly meetings. […]

• No harm, potential for more than minimal, widespreadF838Jun 9, 2023

  Based 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. Findings include: Review of a facility policy titled, Facility Assessment, revised October 2018, revealed, Once a year, and as needed, a designated team conducts a facility-wide assessment to ensure that the resources are available to meet the specific needs of our residents. This policy further revealed, The facility assessment includes a detailed review of the resident population. This part of the assessment includes . c. factors that affect the overall acuity of the residents, such as the number and percentage of residents with . […]

• No harm, potential for more than minimal, patternF628Jun 11, 2026

  Based 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. […]