Abbotsford Health Care Center

In the surveyor’s words

From the most serious findings on record at Abbotsford Health Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jul 22, 2024

  Based 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. […]

• Immediate jeopardy, isolatedF686Dec 28, 2021

  Based on observation, interview, and record review, the facility did not ensure the necessary treatment and care to prevent pressure ulcers and promote healing of pressure ulcers for 2 of 2 Residents (R40, R30). This resulted in R40 sustaining a left ischial stage IV pressure ulcer with 6 cm tunneling to the bone with subsequent VRE ([MEDICATION(S)] Resistant Enterococcus) in bone, causing [CONDITION(S)] to pelvis, [CONDITION(S)], Intravenous antibiotic therapy for 3 weeks, wound vacuum therapy, and multiple surgical interventions. The facility did not implement a ROHO cushion or pressure mapping as ordered for R40 on 7/7/21 and again on 9/17/21. The facility did not add these to the care plan or update the care plan from 6/30 - 9/30/21. […]

• Actual harm, isolatedF684Oct 5, 2022

  Based on interviews and record reviews, the facility did not identify the need to seek further medical treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 was admitted after transmetatarsal amputation. R1's dressing was not changed, nor was the surgical wound assessed on a regular basis. R1 developed infection in the wound along with dehiscence of the wound that required hospitalization . This was evidenced by the following: R1, a [AGE] year-old, was admitted to the facility on [DATE] from the hospital with history of a right great toe amputation. Past history of infections. R1 made their own medical decisions. R1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Admission MDS (Minimum Data Set) indicated that R1 had a BIMS (Brief Interview for Mental Status) score of 13. […]

• No harm, potential for more than minimal, widespreadF880Jun 2, 2026

  Based 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).Findings include:The facility policy titled, Infection Prevention and Control Program, last revised 07/2025 includes: A system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections… […]

• No harm, potential for more than minimal, widespreadF881Jun 2, 2026

  Based 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.Findings include:The facility policy titled, Antibiotic Stewardship Program, last revised November 2017, includes: It is the policy of this facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. […]