Abbotts Creek Center

In the surveyor’s words

From the most serious findings on record at Abbotts Creek Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF641Jul 11, 2022

  Based on observations, record reviews, resident and staff interviews, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the areas of restraints and alarms (Residents #17 and #40), skin conditions (Residents #22 and 63) and medications (Residents #6 and #44). This was for 6 of 21 resident records reviewed. The findings included: 1. Resident #17 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A quarterly MDS assessment dated [DATE] indicated Resident #17 had severe cognitive impairment and was not coded for a wander/elopement alarm. Resident #17's active care plan, last reviewed 5/13/22 included a focus area wanders the facility and talking about leaving to go home. […]

• No harm, potential for more than minimal, patternF684Jul 11, 2022

  Based on record reviews, observations, Medical Director, Wound Physician and staff interviews, the facility failed to provide treatments as ordered by the physician to non-pressure related wounds on the lower extremity for 1 of 2 residents reviewed for skin conditions (Resident #22). The findings included: Resident #22 was originally admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Infectious Disease progress note dated 1/24/22, revealed Resident #22 had chronic open wounds over the right knee with tunneling and drainage due to right knee prosthetic infection. There were open areas around the right knee and an abscess to the right mid-shin. […]

• No harm, potential for more than minimal, patternF698Jul 11, 2022

  Based on record review, observation and interview from the [CONDITION(S)] center staff, Physician, resident and facility staff, the facility failed to obtain orders for the care and monitoring of a [CONDITION(S)] resident (Resident #33) and failed to utilize the communication sheets to exchange information about resident's treatment and care with the [CONDITION(S)] center for 2 of 2 sampled residents reviewed for [CONDITION(S)] (Residents #33 & # 58). Findings included: 1. Resident #58 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #58 had severe cognitive impairment and was on [CONDITION(S)]. […]

• No harm, potential for more than minimal, patternF757Jul 11, 2022

  Based on record reviews, Medical Director and staff interviews, the facility failed to hold blood pressure medications as ordered by the physician for 2 of 6 residents whose medications were reviewed (Residents #40 and #18). The findings included: 1. Resident #40 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #40's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Call physician if systolic blood pressure (SBP) greater than 180 or diastolic blood pressure (DBP) greater than 105. Hold if SBP less than 110. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #40 had severe cognitive impairment. […]

• No harm, potential for more than minimal, patternF759Jul 11, 2022

  Based on record review, review of the medication manufacturer's instruction, observation and staff interview, the facility failed to have a medication error rate of less than 5 % as evidenced by 5 medication errors of 26 opportunities, resulting in a 19 % error rate for 2 of 3 residents observed during medication pass (Residents # 116 & # 56). Findings included: 1 a. Resident #56 was admitted to the facility on [DATE]. Resident #56 had a doctor's order dated 6/8/22 for [MEDICATION(S)] extended release (ER) 50 milligrams (mgs) 1 tablet by mouth daily for hypertension. […]