Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Abbotsford Health Care Center during CMS and state inspections, most recent first.
A resident with intact cognition reported missing money after a hospital stay, stating $200 was gone while staff had only verified seeing $50 in the room. The facility’s investigation included interviewing the resident, searching for the money, contacting law enforcement, and interviewing staff, but it could not confirm the total amount missing beyond the $50 observed. Although the facility’s abuse/exploitation policy required interviewing all involved persons and providing staff training with demonstrated competency, there was insufficient evidence that residents were systematically interviewed about missing items or that staff received timely misappropriation education, and other residents did not recall being questioned about missing belongings.
A resident was accepted for admission from a hospital with the understanding that she was a pivot transfer, but upon arrival she was placed in a too-small wheelchair, slid to the floor when reaching down, and was sent to the ED by EMS because staff could not get her up. The facility’s record contained only pre-admission documents and lacked admission notes, assessments, incident documentation, or discharge records. Leadership acknowledged that no admission paperwork was completed and that the facility lacked appropriate bariatric equipment, yet there was no documented assessment of transfer status, no evidence that the resident or representative received required written transfer/discharge notices, appeal rights, Ombudsman contact information, or bed-hold and return-rights information, and no documented communication with the hospital explaining the reason for discharge or confirming re-admission.
A resident with severe cognitive impairment, history of falls, and documented wandering and elopement risk was care planned to have a Wanderguard and redirection from doors, but surveyors observed the resident without a Wanderguard or chair alarm and independently leaving the room and entering another resident’s room before staff intervened. Staff confirmed the resident was supposed to always wear a Wanderguard, yet could not account for how long it had been off, including around the time of a recent fall and ED visit, and there was no documentation of assessments or routine checks to ensure the device was in place, despite facility policies requiring elopement assessment, care planning, and implementation of accident-prevention interventions.
Two residents did not receive proper skin assessments and wound documentation as required by professional standards. One resident with a surgical incision did not have assessments or documentation of the wound site, including after the removal of steri strips and an episode of bleeding. Another resident with multiple comorbidities and a new heel wound did not receive a comprehensive initial wound assessment, with missing documentation of wound size and delayed follow-up.
A resident admitted with an unstageable pressure injury to the left heel did not receive a comprehensive PI assessment, including measurements and description, upon admission. The initial assessment only noted the presence of the PI, and a detailed wound assessment was not completed until several days later by the wound clinic. The DON confirmed that a complete assessment was expected but not documented.
A resident with moderate cognitive impairment and a history of wandering left the facility without staff authorization after independently arranging transportation. Although the care plan noted the guardian's permission for the resident to leave for smoking, no new interventions or monitoring were added following the incident, despite facility policy requiring updates to care provision after such events.
A resident with mild cognitive impairment and a history of wandering left the facility without staff knowledge or authorization after independently arranging transport, despite care plan requirements for supervision. The facility lacked documentation of sign-out procedures, did not complete a thorough investigation, and failed to educate staff on elopement protocols following the incident.
The facility did not complete required background checks for an employee before hire, as mandated by its abuse prevention policy. Due to miscommunication between the facility and corporate office, the employee began working without a Background Information Disclosure, DOJ response, or Government Findings report, and was observed in resident care areas despite the lack of screening.
A resident with multiple diagnoses and intact cognition had side rails removed from her bed after a hospital stay, but the care plan was not updated to reflect this change. Despite audits indicating updates, the care plan continued to list side rails as an intervention, and the resident did not receive an alternative assistive device as discussed. The DON confirmed the removal was per protocol and that side rails would not improve mobility, but the care plan was not revised accordingly.
The facility did not have a director of food and nutrition services who met the minimum qualification requirements, as the current Dietary Manager is still completing the necessary certification program. Additionally, there is no full-time Registered Dietician on staff, with the RD only present one to two days per week. This deficiency could potentially impact all residents in the facility.
Surveyors observed improper food handling and storage practices, including stacking wet dishes, unsanitary handwashing sinks, and unlabeled or undated food items in refrigerators and freezers. Staff acknowledged these actions did not meet facility policies or food safety standards.
Surveyors found widespread frayed carpeting, stained floors, and damaged walls throughout the facility, with staff unable to identify the causes of carpet spots or provide documentation of follow-up. The Maintenance Director reported limited cleaning and maintenance, and the DON confirmed the issues had persisted for an extended period. These deficiencies affected all areas used by residents, staff, and visitors.
Two residents did not have complete, person-centered care plans: one lacked documented accommodations for vision and hearing deficits during activities and had no assessment or interventions for meal preferences, while another did not have a safe smoking plan in place despite being observed smoking unsupervised and having physical limitations. Staff interviews and record reviews confirmed these omissions.
A resident with diabetes and chronic wounds did not receive consistent wound care, as treatment orders from the wound clinic were not promptly transcribed or implemented, nutritional and zinc supplement recommendations were missed, and a protective boot was not applied as ordered. Documentation and monitoring of wound care were incomplete, and staff interviews revealed confusion about order follow-through, resulting in gaps in necessary treatment and services to promote wound healing.
Surveyors observed two residents for whom infection control protocols were not followed: a resident's catheter bag was repeatedly seen dragging on the floor while attached to a wheelchair, and during a dressing change for another resident, clean gauze and a measuring tool were contaminated by contact with the floor and then used in the procedure. Both the infection preventionist and DON confirmed these practices did not meet facility expectations.
A facility failed to ensure the safety of mechanical lifts and proper sling size determination, leading to an incident where a resident was injured during a transfer. Staff were unaware of how to select the correct sling size, and maintenance staff lacked training to inspect lift safety. The facility did not have a system for labeling sling sizes or a reference chart, contributing to potential risks for all residents using mechanical lifts.
A resident with dementia and a fall risk was injured during a Hoyer lift transfer when a CNA failed to follow the facility's policy requiring two staff members for such transfers. The CNA attempted the transfer alone, resulting in the resident slipping from the sling and sustaining severe head injuries. The incident highlighted a lack of adherence to established procedures and inadequate supervision during the transfer.
The Bedrock corporation governing body failed to maintain current payments with service providers, leading to service disruptions and potential risks to resident care. The facility's aging vendor report showed significant outstanding balances, some over three years old. The Nursing Home Administrator was unaware of past due amounts and payment statuses, indicating a lack of communication and oversight.
A resident with severe cognitive impairment and multiple medical conditions was sent to the hospital for emergency evaluation but faced a delay in returning to the facility due to confusion over transportation responsibilities. The facility and managed care organization were unclear about who should arrange transport, resulting in the resident staying overnight at the hospital. The facility's van service operates only during daytime hours, and alternative options were unavailable, highlighting a recurring issue in rural areas.
The facility failed to provide adequate nursing staff, resulting in delayed responses to call lights and unmet resident needs. Observations and interviews revealed that residents waited extended periods for assistance, with staff overwhelmed by high acuity demands. Despite complaints, the administration did not effectively address staffing concerns, leading to ongoing deficiencies in care.
Failure to Thoroughly Investigate Alleged Misappropriation of Resident Funds
Penalty
Summary
The facility failed to thoroughly investigate an allegation of misappropriation of a resident’s money and did not ensure required interviews were completed. One cognitively intact resident (BIMS 15/15) reported that $200 was missing after returning from the hospital, while staff had previously observed a $50 bill in the resident’s room the day before. The facility’s investigation included an interview with the resident, a search for the missing money that was not found, contact with law enforcement, and staff interviews. However, the amount of money allegedly missing could not be confirmed beyond the $50 observed by staff, and the resident continued to state that $200 was missing. The facility’s abuse/neglect/exploitation policy required identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations, as well as training staff on changes made and demonstrating staff competency after training. During the survey, the Social Services Director stated that resident interviews were conducted through daily “Angel Rounds” and provided a blank Angel Rounds form and a typed list of 26 residents with yes/no responses regarding missing items, with only the involved resident reporting missing money. Other interviewed residents did not recall being interviewed about missing items or money. A CNA familiar with the incident reported not remembering any staff education or training related to misappropriation after the money was reported missing. The surveyor determined the facility did not complete a thorough investigation due to lack of evidence of resident interviews and lack of timely staff training on misappropriation.
Failure to Document Admission/Discharge and Provide Required Transfer, Appeal, and Bed-Hold Notices
Penalty
Summary
The deficiency involves the facility’s failure to provide a resident with required transfer/discharge notices, appeal rights information, Ombudsman contact information, and written bed-hold and return-rights information, as well as failure to document the admission, fall, and discharge. A resident (R7) was accepted for admission from a referring hospital with the understanding that she was a pivot transfer. Upon arrival, she traveled approximately two hours and was placed in a wheelchair that was too small. Shortly after arrival, while seated in the wheelchair, she reached down to pick something up and slid from the chair onto the floor. EMS was called because staff were unable to get her up from the floor, and she was transported to the emergency room. The facility’s electronic record for the resident contained only pre-admission documents such as advance directives, hospital discharge summary, and insurance information, but no admission documentation, progress notes, assessments, incident reports, or discharge documentation. The facility’s Admissions Coordinator stated that the resident was not admitted to the facility and reported that the resident could not transfer as reported by the hospital, slid from the wheelchair, and was sent to the hospital via EMS. The Nursing Home Administrator, however, stated that the facility had accepted the resident as an admission and that no admission paperwork had been completed. The Administrator reported that therapy was asked to assess the resident’s transfer status, but before that occurred, the resident had already fallen from the wheelchair. The Administrator stated that the facility did not have the appropriate equipment, such as a bariatric hoyer lift or sling, to care for the resident when it was determined she could not pivot transfer. The facility did not provide evidence that the resident was assessed at the facility to determine her transfer status, nor did it provide documentation that the resident’s needs could not be met in the facility as required by its transfer/discharge policy. The facility did not provide evidence that the required transfer/discharge process was followed. There was no documentation that the resident or her representative received written notice of transfer or discharge, including the specific reason for transfer, effective date, location of transfer, appeal rights, or the name, address, phone number, and email of the State Long-Term Care Ombudsman. There was also no evidence that the resident or representative received written information on the facility’s bed-hold duration, reserve bed payment policy, or the right to return to the facility. The facility did not provide evidence of communication with the receiving hospital explaining the reason for the resident’s discharge or documenting agreement to re-admit the resident. Although the Administrator reported being told that a correct hoyer sling would be ordered for the resident, the facility did not provide evidence that such a sling was ordered. The facility was unable to provide evidence that its own transfer and discharge policy requirements were met for this resident. The surveyor’s review of communications showed only an email chain in which the Admissions Coordinator initially accepted the resident for admission and later informed the referring hospital that there were issues when the resident arrived, that she could not transfer as reported, and that she slid to the floor and was taken to the hospital by ambulance. No further communication with the hospital after the resident’s transfer was provided. A discharge summary from the receiving hospital documented follow-up needs related to deconditioning, weakness, ankle and knee instability, bariatric management, and UTI, but the facility did not produce any pre-admission assessment indicating the resident’s transfer status or any documentation that the discharge process, including notices and appeal information, was followed. Overall, the facility failed to document the resident’s admission, fall, and discharge and failed to provide the required notices and information related to transfer/discharge, appeal rights, Ombudsman contacts, and bed-hold and return policies.
Failure to Maintain Wanderguard and Supervision for Elopement-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and use of assistance devices to prevent accidents for one resident identified as an elopement risk. The resident had diagnoses including altered mental status, history of falling, alcohol dependence with withdrawal delirium, age-related physical debility, and metabolic encephalopathy, and an MDS BIMS score of 00 indicating severe cognitive impairment. The baseline care plan identified the resident as at risk for elopement related to wandering and specified interventions including a Wanderguard on the right wrist and redirection from doors. Facility policies on elopement and accidents/supervision required elopement risk assessment at admission, development of an elopement prevention care plan, use of an alarm system to notify staff when exit doors are opened, and implementation of specific interventions to reduce risk from environmental hazards, including adequate supervision. On the survey date, the NHA identified the resident as one of two residents using the Wanderguard system, but the surveyor observed the resident alone in a wheelchair without any Wanderguard device in place and speaking incoherently about needing to meet family. A CNA confirmed the resident was supposed to always have a Wanderguard but could not locate it, and an RN then placed a Wanderguard on the resident’s ankle, stating the resident had fallen the previous night and been sent to the ED, with no ability to determine how long the resident had been without the device. The surveyor later observed the resident independently exit the room at a fast walk, cross the hall, and enter another resident’s room without a chair alarm in place, requiring immediate staff intervention and redirection. Record review showed prior documentation of wandering and attempts to go through doors looking for beer, with a Wanderguard previously placed due to elopement risk, but there was no documentation regarding whether the Wanderguard was in place before or after the fall and ED visit, no documentation of assessment upon return, and no CNA or nursing documentation of routine monitoring to ensure the Wanderguard was in place. Staff interviews indicated reliance on a binder listing residents requiring Wanderguards and a shared responsibility among all staff interacting with the resident to ensure the device was in place.
Failure to Complete and Document Wound Assessments
Penalty
Summary
The facility failed to provide appropriate skin assessments and treatment in accordance with professional standards of practice for two residents. For one resident with multiple traumatic injuries and a surgical incision on the left upper extremity, staff did not assess or document the condition of the surgical site, nor did they document the removal of steri strips as ordered. There was no evidence of ongoing assessments of the surgical incision, despite a physician's order for dressing changes and a noted incident of partial dehiscence and bleeding at the site. For another resident with a history of chronic ulcer, diabetes, peripheral vascular disease, and recent amputation, staff did not complete a comprehensive wound assessment when a new wound was first identified. The initial documentation lacked details such as wound size, and there was a delay in completing a full assessment. The resident was later found to have a pressure ulcer on the left heel, but the facility did not have documentation of an initial assessment with measurements when the wound was first discovered.
Failure to Complete Comprehensive Pressure Injury Assessment on Admission
Penalty
Summary
A deficiency occurred when staff failed to implement professional standards of practice for pressure injury (PI) care and prevention for a resident admitted with an unstageable PI to the left heel. Upon admission, the resident had multiple diagnoses including hemiplegia, hemiparesis, MRSA infection, deep tissue damage to the left heel, diabetes mellitus, protein-calorie malnutrition, atrial fibrillation, chronic kidney disease, anxiety disorder, and depression. The resident was assessed as having intact cognition but required moderate to maximum assistance with activities of daily living and was identified as being at risk for pressure injuries. Despite the presence of a pressure injury on admission, staff did not complete a comprehensive PI assessment that included measurements and a detailed description of the wound. The initial clinical assessment only noted the existence of an unstageable PI without further specifics. The first documented wound assessment with measurements and description was not completed until several days after admission by the wound clinic. During an interview, the DON confirmed that there was no documented comprehensive admission assessment of the PI, despite acknowledging that such an assessment was expected.
Failure to Update Care Plan After Resident Elopement
Penalty
Summary
The facility failed to update a resident's care plan with new interventions or monitoring following an incident of unauthorized elopement. The resident, who was admitted under guardianship with diagnoses including benign neoplasm of meninges and mild cognitive impairment, had a BIMS score of 7, indicating moderate cognitive impairment, and a documented history of wandering and attempted elopement. The resident's care plan allowed for leaving the premises to smoke, as permitted by the guardian, but did not include specific interventions to address the risk of elopement despite the resident's known behaviors and history. On a specific date, the resident independently arranged for transportation and left the facility without staff authorization to attend an appointment that had been cancelled by the guardian. The facility's Director of Nursing confirmed that, although the guardian refused the use of a wander guard and Adult Protective Services were notified, no new interventions or monitoring were added to the care plan to prevent recurrence of such incidents. This lack of updated care planning was not in accordance with facility policy, which requires defining how care provision will be changed or improved to protect residents after such events.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Documentation
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents, resulting in a resident leaving the premises without staff knowledge or authorization. The resident, who was under guardianship and had diagnoses including mild cognitive impairment and a history of wandering and elopement, was permitted by their guardian to leave the facility to smoke, as the facility is smoke-free. Despite this, the resident's care plan required staff supervision due to confusion and altered mental status. On the day of the incident, the resident independently arranged for transport and left the facility to attend an appointment that had been previously canceled by the guardian, without signing out or informing staff. The facility's investigation into the incident was incomplete, as there was no documentation of resident or staff interviews, and no evidence that the resident had been signing out when leaving the premises. Staff members, including CNAs, reported not receiving education on elopement procedures following the incident, and the DON was unable to provide documentation of interventions implemented to prevent recurrence. The facility's policy required adequate supervision for residents at risk of elopement, but this was not followed in the case of this resident.
Failure to Screen Employee for Abuse and Neglect History Prior to Hire
Penalty
Summary
The facility failed to implement its policies and procedures regarding the screening of employees for a history of abuse, neglect, exploitation, or misappropriation of resident property. Specifically, one of eight employees reviewed, identified as Intern D, was hired without the required Background Information Disclosure (BID), Department of Justice (DOJ) response, or Government Findings report being completed prior to starting work. The facility's policy mandates that all potential employees, including students affiliated with academic institutions, must undergo background, reference, and credential checks before employment. During the survey, it was discovered that both the facility and the corporate office assumed the other party was responsible for conducting Intern D's background check, resulting in the process not being completed. Despite this oversight, Intern D was observed in resident care areas obtaining paperwork for surveyors, even though the administrator stated that Intern D was being kept in the office. This failure to follow established screening procedures directly contravened the facility's abuse prevention policy.
Failure to Revise Care Plan After Removal of Side Rails
Penalty
Summary
The facility failed to revise the care plan for a resident after the removal of side rails from her bed. The resident, who had diagnoses including congestive heart failure, morbid obesity, and anxiety disorder, was cognitively intact and had previously expressed a desire to have side rails to promote independence. The care plan, last updated in June, still listed side rails as an intervention for mobility impairment, despite their removal. Audits by the speech-language pathologist indicated the care plan had been updated, but the intervention remained unchanged in the documentation. Observations on July 8 confirmed that the resident's bed no longer had side rails, and the resident reported that the rails were removed during a hospitalization and not returned, with no alternative assistive device provided as promised. The DON confirmed the side rails were removed per protocol after the resident's hospital discharge and stated that side rails would not improve the resident's bed mobility. The failure to update the care plan to reflect the removal of side rails constituted the deficiency.
Lack of Qualified Director and Full-Time Dietician in Food and Nutrition Services
Penalty
Summary
The facility failed to designate a director of food and nutrition services who met the minimum qualification requirements as outlined in their own policy. The current Dietary Manager (DM) is enrolled in a Nutrition & Food Service Professional Program but has not yet completed it, having received an extension to finish the program by a later date. The facility policy requires the director to have certification as a dietary manager, certification as a food service manager, an associate or higher degree in food service management or hospitality with relevant coursework, or at least two years of experience in the position along with completion or enrollment in a food safety management course. The DM does not currently meet these qualifications, as she is still in the process of completing her required program. Additionally, the facility does not have a full-time Registered Dietician (RD) on staff. The RD is only present in the facility one to two days per week, which does not fulfill the requirement for a full-time RD. This lack of appropriately qualified staff in the food and nutrition services department could potentially affect all 48 residents residing in the facility, as noted by the surveyor during interviews and record review.
Deficient Food Handling, Storage, and Sanitation Practices
Penalty
Summary
The facility failed to prepare, store, and distribute food in a sanitary manner, as evidenced by multiple observations and staff interviews. A dietary aide was seen removing clean drinking glasses and plastic mixing containers from the dishwasher, stacking them together while still wet, and placing them in storage, causing water to drip on the floor and counter. The dietary aide acknowledged that dishes should be dry before being stacked and stored, and the dietary manager confirmed that this practice did not meet facility expectations or established food safety standards. Additionally, the kitchen's handwashing sink was observed to have heavy lime and dirt buildup on the faucet handles, drain, and basin. The dietary aide was unable to recall when the sink was last deep cleaned, and the dietary manager confirmed that the cleanliness of the sink did not meet expectations. The cleaning schedule was found to be lacking a specific task for deep cleaning the handwashing sink, which was only added after the surveyor's observation. Further deficiencies were noted in the storage of resident food brought in from outside sources. Refrigerators and freezers contained multiple opened food items without labels indicating the contents, resident names, or dates. Some food items prepared by the facility and not consumed during mealtimes were also stored without proper labeling. The dietary manager acknowledged that these practices did not meet facility policy and expressed concern about the potential for expired foods to cause foodborne illness.
Environmental Deficiencies: Unsafe, Unsanitary, and Uncomfortable Facility Conditions
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for all 48 residents, as evidenced by multiple observations of frayed carpeting, stained flooring, and damaged walls throughout the building. Surveyors noted frayed carpet in several hallways and common areas, with specific mention of fraying around metal circles in the floor and along seams. Numerous dark and white spots were observed on the carpets in various hallways, with some spots being large in size. Staff, including housekeeping, RN, and DON, were unable to identify the cause of the spots, and the DON confirmed that the spots had been present since her hire date in 2022. The Maintenance Director indicated that the carpets had been shampooed only a few times in the past six months and suggested that improper cleaning or treatment may have contributed to the stains. Additionally, a bathroom floor was found to be completely stained, and staff acknowledged the poor condition of the flooring. Further deficiencies were observed in the condition of the walls, including unfinished sheetrock, puncture marks, black marks, missing paint, and cracks. The Maintenance Director attributed some of the wall damage to wheelchairs or carts and acknowledged being unable to address all maintenance needs due to limited staffing. The DON stated that these issues had been reported to corporate but was unable to provide documentation of any follow-up. No specific residents were identified as being directly affected at the time of the survey, but the environmental deficiencies were present in areas accessible to all residents, staff, and the public.
Failure to Develop and Implement Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered care plans that addressed all identified needs and preferences for two residents. For one resident, there was no activity care plan that included accommodations for vision and hearing deficits, despite the resident reporting difficulty hearing and seeing during activities such as bingo, and needing to sit close to the caller to participate effectively. The resident also stated that food preferences were not assessed or accommodated, and no alternatives were offered for foods she could not eat. Review of the care plan and interviews with staff revealed that vision and hearing accommodations, as well as specific food preferences, were not documented or implemented, and the process for assessing and updating these preferences was inconsistent or incomplete. For another resident with a history of spina bifida, pressure ulcers, osteomyelitis, and catheter-associated urinary tract infections, the care plan did not include a safe smoking plan, even though the resident was observed smoking outside without staff assistance and was unable to pick up a dropped lighter. Although a smoking safety assessment indicated the resident could smoke without supervision, the care plan lacked details on supervision requirements, safety measures, and storage of smoking materials. Staff interviews confirmed that the omission of a smoking care plan was an oversight.
Failure to Provide Ordered Wound Care and Services for Resident with Diabetic Ulcers
Penalty
Summary
A resident with multiple chronic conditions, including diabetes, peripheral vascular disease, and a history of wounds, did not receive necessary wound care and related services as ordered. The resident had active wound treatment orders that lapsed for several days, leaving a period with no documented wound care provided. Orders from a wound clinic, including those for nutritional supplements and the use of a protective boot, were not transcribed or implemented in a timely manner. Additionally, recommendations from a registered dietician for a zinc supplement to promote wound healing were not addressed or documented as ordered. Observations and interviews revealed that wound care was not consistently performed according to the prescribed schedule, and the resident reported that dressing changes were missed for up to two days. The Prevalon boot, ordered to be worn at all times, was not consistently applied, with documentation showing it was only in use during certain shifts and not daily as required. There was no evidence of resident refusal or documentation of risks and benefits related to the boot in the care plan. The treatment administration record (TAR) did not reflect all required treatments, and staff interviews indicated confusion or lack of clarity regarding the implementation and monitoring of wound care orders. The facility's failure to ensure timely transcription and implementation of physician and wound clinic orders, as well as to follow through on dietician recommendations, resulted in gaps in care for the resident. Documentation and monitoring were inconsistent, and there was a lack of communication and follow-up regarding new orders and recommendations. These actions and inactions led to the resident not receiving the necessary treatment and services to promote wound healing as required by facility policy and physician directives.
Failure to Maintain Infection Control During Catheter Care and Dressing Change
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for two of four sampled residents. For one resident with a urinary catheter, repeated observations showed the catheter urine collection bag was positioned on the lowest part of the wheelchair crossbars, causing it to rest on and drag across the floor as the resident moved throughout the facility. The facility's catheter care policy did not address proper positioning of the catheter bag, and the infection preventionist confirmed that catheter bags should be kept off the floor to prevent contamination. In a separate incident, during a dressing change for another resident with multiple pressure injuries and receiving hospice care, clean gauze intended for use between the toes was observed touching the floor and lying under the nurse's foot. Additionally, the measuring tool used for wound assessment was also in contact with the floor. The nurse acknowledged that items which had touched the floor should not have been used during the dressing change, and the Director of Nursing confirmed this expectation.
Deficiency in Mechanical Lift Safety and Sling Size Determination
Penalty
Summary
The facility failed to ensure the resident environment was free from accident hazards, specifically concerning the use of mechanical lifts for resident transfers. On one occasion, staff did not verify the proper sling size or the safe functioning of the mechanical lift before transferring a resident, resulting in the lift tipping over and causing the sling bar to strike the resident in the face. This incident led to a bruise and laceration below the resident's left eye, requiring hospital transfer and tissue adhesive repair. Observations revealed that staff were not aware of how to determine the proper sling size for residents, and the care plans did not specify the type or size of sling to be used. The maintenance staff lacked the necessary knowledge to inspect and ensure the safety of the mechanical lifts. The Maintenance Director admitted to not receiving specific training on the equipment and was unable to determine if the lifts were operating safely. A mechanical lift used in the incident had a defect that allowed its base legs to move to a closed position without using the foot lever, a condition that had been reported but not addressed. This lack of proper maintenance and inspection posed a safety risk to all residents using mechanical lifts. Additionally, the facility did not have a clear system for determining and labeling sling sizes. Staff relied on visual comparison to choose slings, as there were no labels or reference charts available to guide them in selecting the appropriate size based on residents' weight and height. The Nursing Home Administrator was unaware of the manufacturer's guidelines for sling size determination and the available sizes in the facility. This lack of knowledge and resources contributed to the potential for unsafe transfers, affecting all residents who required mechanical lifts.
Inadequate Supervision During Hoyer Lift Transfer Leads to Resident Injury
Penalty
Summary
The facility failed to ensure adequate supervision and assistance during a Hoyer lift transfer for a resident, leading to a serious accident. A Certified Nursing Assistant (CNA) transferred the resident using a Hoyer lift without the required assistance of another staff member, contrary to the facility's policy that mandates two people for all mechanical lift transfers. During the transfer, the resident slipped out of the sling and fell to the floor, resulting in a subarachnoid hemorrhage, subdural hematoma, and other injuries, necessitating hospitalization. The resident involved had a history of dementia and anxiety disorder and required total assistance with activities of daily living. The resident was identified as a fall risk, with a care plan that included the use of a Hoyer lift for transfers. On the day of the incident, the CNA did not request assistance from a nearby nurse and proceeded with the transfer alone, using an uncrossed sling, which was not specified in the care plan. This oversight led to the resident sliding out of the sling and sustaining severe head injuries. The incident was immediately investigated by the facility, revealing that the CNA was aware of the two-person policy but did not adhere to it. The facility had previously conducted education on Hoyer lift use, but the care plan lacked specific instructions on crossing the straps between the resident's legs. The failure to follow established procedures and ensure proper supervision during the transfer resulted in significant harm to the resident.
Removal Plan
- The facility completed resident care plan reviews for the residents who require mechanical lift transfers.
- The facility provided reeducation on mechanical lift use, requirement for 2 staff to be present during the entire transfer, and use walkie talkies to ask for assistance, and if unsure how to transfer a resident, staff is to seek clarification from a nurse.
- Licensed nursing staff educated on updating a resident care plan if the straps are to be crossed for the transfer.
- CNA C's employment with the facility was terminated.
Financial Mismanagement Leads to Service Disruptions
Penalty
Summary
The Bedrock corporation governing body failed to ensure adequate funds were available for the safe and efficient management of the facility, affecting all 51 residents. The governing body did not maintain current payment status with several service providers and vendors, leading to vendors refusing to provide services or issuing discontinuation notices until payment was received. This included the abrupt termination of the facility's pharmacy provider after a past due notice, and the potential disruption of services due to unpaid state bed taxes and civil money penalties. The facility's aging vendor report revealed significant outstanding balances with multiple vendors, some dating back over three years. The surveyor verified these balances with various service providers, confirming discrepancies between the amounts owed and those reported by the facility. For instance, the facility owed substantial amounts to a gas supplier, food supplier, and transportation services, with some services already halted due to non-payment. Additionally, the facility breached its contract with a garbage removal service, leading to legal action. The Nursing Home Administrator (NHA) was interviewed and stated that they only see invoices for services and supplies, which are then sent to corporate for payment. The NHA was not informed of past due amounts or when invoices were paid, and was unaware of the reasons behind the change in pharmacy service. Despite these financial issues, the NHA reported no disruptions in utilities, internet, or food services, although the facility's financial mismanagement posed a risk to the quality of care and life for residents.
Failure to Provide Timely Transportation for Resident
Penalty
Summary
The facility failed to provide necessary transportation services for a resident, identified as R2, who was sent to the hospital for an emergency evaluation due to chest pain and shortness of breath. R2, who has severe cognitive impairment and multiple medical conditions including atrial fibrillation and hepatocellular carcinoma, was discharged from the hospital on the same day but was unable to return to the facility until the following morning. This delay was due to confusion over transportation responsibilities between the facility and the managed care organization, resulting in R2 remaining at the hospital overnight. Interviews with facility staff and the managed care organization revealed a lack of clarity regarding who was responsible for arranging transportation for R2. The Assistant Director of Nursing and the Nursing Home Administrator both indicated that transportation is typically arranged by the managed care organization for residents under their care, but the facility also has a van service available during daytime hours. However, this service does not operate after hours, and alternative transportation options were not available. The facility's inability to secure transportation during off hours has been a recurring issue, particularly in rural areas where services are limited.
Inadequate Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, as evidenced by observations, interviews, and record reviews. The staffing ratios did not align with the facility's assessment of staffing needs, particularly during the night shift, where the licensed nurse-to-resident ratio was higher than planned. This discrepancy resulted in delayed responses to call lights and unmet resident needs, as observed by surveyors and reported by residents and staff. Residents expressed dissatisfaction with the timeliness of care, with some waiting extended periods for assistance, leading to discomfort and unmet personal care needs. Multiple residents reported waiting for assistance with daily activities, such as getting ready for the day or being helped to the toilet, for extended periods. One resident, for example, had their call light on for nearly 45 minutes before receiving help. Staff interviews revealed that they were overwhelmed and unable to complete their tasks due to the high acuity of residents and insufficient staffing levels. The facility's staffing plan did not account for the increased needs of residents requiring two-person assistance or those with high acuity conditions, leading to rushed and incomplete care. The facility's failure to address staffing concerns was further highlighted by resident council minutes and grievance reports, which consistently noted issues with call light response times and inadequate staffing. Despite staff and resident complaints, the administration had not effectively addressed these concerns, resulting in ongoing deficiencies in care. The lack of agency staff and the facility's rural location compounded the staffing challenges, leaving the facility unable to meet the care needs of its residents adequately.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 42 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Abbotsford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Colonial Health Services | 1.9 mi | ★★★★★ | 2 | 2 |
| Clark County Rehabilitation & Living Center | 11.1 mi | ★★★★★ | 18 | 0 |
| Aspirus Care & Rehab-medford | 13.4 mi | ★★★★★ | 2 | 0 |
| Three Oaks Health Services | 18.9 mi | ★★★★★ | 9 | 0 |
| Norwood Health Ctr-central | 19.5 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.