Abigail House for Nursing & Rehabilitation

In the surveyor’s words

From the most serious findings on record at Abigail House for Nursing & Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, patternF880Apr 11, 2023

  Based on observation, interview, record review, and policy review, the facility failed to: a. sanitize glucometers between uses for 10 (Resident (R)54, R92, R25, R110, R143, R13, R133, R139, R30, and R152) of 10 residents observed receiving fasting blood sugar tests (FSBS) out of a total sample of 47 residents; b. perform hand hygiene and or wear gloves during FSBS for two residents (R61 and R150). The failure to sanitize glucometers between residents resulted in an Immediate Jeopardy (IJ) at F880-K: Infection Control due to the increased likelihood to cause serious harm due to the potential of cross-contamination of blood-borne pathogens. […]

• No harm, potential for more than minimal, widespreadF812Apr 17, 2025

  This is a repeat deficiency. Based on observation, interview, and record review, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe consistent manner. This deficient practice was evidenced by the following: On [DATE] from 9:39 AM until 10:37 AM, the surveyor observed the following in the presence of the Food Service Director (FSD): 1. The FSD lifted the lid of the ice machine to display its contents. The surveyor noted that the ice release cover had multiple areas of brown and gray debris on it. The surveyor asked the FSD to wipe the area with a paper towel. The FSD wiped the ice release cover and then showed the surveyor the paper towel which was then soiled with a brown substance. […]

• No harm, potential for more than minimal, widespreadF570Apr 11, 2023

  Based on interview and record review, the facility failed to have a surety bond in an amount large enough to cover the highest daily balance of the residents' trust fund account. This had the potential to affect 164 of 164 residents whose trust fund monies were held by the facility. Findings include: Review of the Resident Fund Trust Account bank statement, for the period of [DATE] through [DATE], revealed the lowest daily balance for the period was $202,548.31 on [DATE] and the highest daily balance for the period was $278,324.65 on [DATE]. Review of the Resident Fund Trust Account bank statement, for the period of [DATE] through [DATE], revealed the lowest daily balance for the period was $275,915.65 on [DATE] and the highest daily balance for the period was $354,435.91 on [DATE]. […]

• No harm, potential for more than minimal, patternF657Apr 17, 2025

  Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to revise a resident's individual comprehensive care plan after psychotropic medications were discontinued for 1 of 3 residents (Resident #38) reviewed for mood and behavior. This deficient practice was evidenced by the following: On 4/4/25 at 10:13 AM, the surveyor observed Resident #38 lying in bed. The resident was not experiencing any behaviors at that time. A review of the Admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to, unspecified dementia and unspecified psychosis. […]

• No harm, potential for more than minimal, patternF755Apr 17, 2025

  Based on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to: a.) administer medications according to manufacturers' instructions for 1 of 2 nurses observed during the medication administration pass, b.) ensure the accountability of the narcotic shift to shift count logs were completed for 1 of 3 medication carts inspected, and c.) complete and maintain copies of Federal narcotic order forms (DEA 222 forms) for 3 of 3 DEA 222 forms reviewed. This deficient practice was evidenced by the following: 1.) On 4/7/25 at 9:20 AM, the surveyor observed Licensed Practical Nurse (LPN) #5 prepare medications for Resident #95. […]