Abundant Acres Care and Rehab

In the surveyor’s words

From the most serious findings on record at Abundant Acres Care and Rehab, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600May 31, 2023

  Based on interview and record review, the facility failed to ensure four out of nine sampled residents (Resident #1, #2, #3, and #5) were free from neglect when a staff member transported them in a reckless and unsafe manner. On 5/12/23, Driver A was arrested on scene while conducting a transport to a medical appointment for one resident (Resident #1) in the facility transportation van. Driver A did not fully secure residents' wheelchairs (Resident #1, #2, and #3), did not lock wheelchair brakes (Resident #1 and #5), and made residents feel unsafe (Resident #1, #2, #3, and #5). The facility census was 54. The administrator was notified on 5/25/23 at 3:44 P.M., of an Immediate Jeopardy (IJ) which began on 5/12/23. The IJ was removed on 5/31/23 as confirmed by surveyor onsite verification. […]

• Actual harm, isolatedF684Jan 19, 2023

  Based on observation, interviews and record reviews, the facility failed to provide the necessary care, treatment, services and equipment in accordance with professional standards to attain or maintain the highest practicable physical, mental, or psychosocial well-being for one of 13 sampled residents (Resident #42). The facility failed to ensure the resident maintained and/or improved his/her highest level of range of motion (ROM) and mobility. When he/she admitted to the facility on [DATE], he/she had active ROM (the performance of an exercise to move a joint without any assistance or effort of another person to the muscles surrounding the joint) in both ankles. […]

• No harm, potential for more than minimal, widespreadF880Aug 21, 2025

  Based on observation, interview and record review, facility staff failed to develop and implement complete policies and procedures for the inspection, testing and maintenance of the facility's water systems to inhibit the growth of waterborne pathogens and reduce the risk of an outbreak of Legionnaire's Disease (LD) (a serious type of pneumonia(lung infection) caused by Legionella bacteria, which places all residents at risk of exposure which could lead to illness. This had the potential to affect all residents of the facility. Additionally, the facility failed to ensure staff washed or sanitized their hands between dirty and clean tasks which affected one of 12 sampled residents (Resident #12). The facility census was 44. […]

• No harm, potential for more than minimal, widespreadF921Jun 26, 2024

  Based on observation and interview, the facility staff failed to ensure all shower hoses had a backflow preventer. This affected all five shower hoses and had the potential to affect all residents. A backflow preventer keeps toxins from backing up into the facility's potable water supply. The facility census was 47. 1. Observation on 6/26/24 starting at 11:15 A.M., showed: - Two shower hoses without backflow preventer in the 400 hall shower room; - Two shower hoses without backflow preventer in the 500 hall shower room; - One shower hose without a backflow preventer in the only shower in a resident's room. During an interview on 6/26/24 at 4:30 P.M., the Maintenance Supervisor said he did not realize all shower hoses needed a backflow preventer and that none of the shower hoses had them.

• No harm, potential for more than minimal, widespreadF835May 14, 2024

  Based on observation, interview, and record review, the facility was not administered in a manner that effectively utilized resources needed to provide essential services for residents, when the facility failed to pay essential service vendors including staffing agencies. Additionally, the facility failed to ensure the continuity of administration and that the administrator was actively involved in the supervision of the facility during an upcoming transition of ownership, causing the residents and/or families to experience stress and anxiety. This affected nine of eleven sampled residents (Residents #1, #2, #3, #4, #5, #6, #8, #10 and #11). The facility census was 47. The facility did not provide a policy regarding administration and vendor payment. […]