Abbotsford Health Care Center
ABBOTSFORD HEALTH CARE CENTER in ABBOTSFORD, WI — inspection on August 29, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
reviewed, and revised by a team of health professionals.
interview and record review, the facility did not update R1's care plan with new interventions and/or
of 3 residents (R) (R1) reviewed.
This was evidenced by the facility policy, titled Abuse, Neglect and Exploitation which states under section VII(A)(b): Defining how care provision will be changed and/or improved to protect residents receiving services. R1 was admitted to the facility on [DATE] under guardianship and with diagnoses that include benign neoplasm of meninges and mild cognitive impairment. R1's admission Minimum Data Set (MDS) indicated R1 has a BIMS of 7 (moderately impaired); displays wandering and frequency behavior of these type 1 to 3 days; uses a walker and wheelchair independently, R1's elopement evaluation completed on 07/02/25 indicates in part, R1 has a history of elopement or attempted leaving the facility without informing staff. R1's care plan initiated on 07/03/25 for Safety General/Smoker indicated that R1's guardian had given permission for R1 to go off premises to smoke as facility is a smoke-free facility. On 07/22/25, the facility reported an incident wherein R1 independently contacted a transport van and left the premises without staff authorization to attend an eye appointment that R1's guardian had previously notified R1 the appointment was cancelled until prescription was verified.
Surveyor requested information from Director of Nursing (DON) B regarding interventions added to the care plan to ensure R1 is safe. DON B stated that guardian refuses wander guard, facility did notify Adult Protective Service and placed information into care plan regarding guardian's wishes of allowing resident to leave facility, but no new interventions/monitoring were put on the care plan to prevent this type of incident from reoccurring.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
525435 08/29/2025
Abbotsford Health Care Center 600 E Elm St Abbotsford, WI 54405
prevent accidents.
interview and record review, the facility failed to ensure each resident receives adequate supervision
facility's knowledge and supervision.
This situation represents a risk to the resident's health and safety for 1 of 3 residents (R) R1.
This was evidenced by the facility policy, titled Elopement which states: This facility ensures that resident who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk.
Under section labeled Elopement states: Occurs when a resident leaves the premises or a safe area with authorization. R1 was admitted to the facility on [DATE] under guardianship and with diagnoses that include benign neoplasm of meninges and mild cognitive impairment. R1's admission Minimum Data Set (MDS) indicated R1 has a BIMS of 7 (moderately impaired); displays wandering and frequency behavior of these type 1 to 3 days; uses a walker and wheelchair independently, R1's elopement evaluation completed on 07/02/25 indicates in part, R1 has a history of elopement or attempted leaving the facility without informing staff.R1's Smoking and Safety Evaluation documented on 07/03/25 in part, .Gets confused about location, asking 'where am I'. If resident smokes staff are to be with her d/t altered mental status.R1's care plan initiated on 07/03/25 for Safety General/Smoker indicated that R1's guardian had given permission for R1 to go off premises to smoke as facility is a smoke-free facility. On 07/22/25, the facility reported an incident wherein R1 independently contacted a transport van and left the premises without staff authorization to attend an eye appointment. R1's guardian had previously notified R1 the appointment was cancelled until prescription was verified. On 08/29/25, Surveyor made several attempts to interview R1 but was unsuccessful. On 08/29/25 at 12:40 PM, Surveyor interviewed Licensed Practical Nurse (LPN) C who indicated being the nurse on duty on 07/22/25. LPN C stated that R1's guardian had called regarding not having R1 come to the appointment.
When LPN C went down to room to talk to R1, R1 was not in room. LPN C went to go look for R1.
Another staff member stated they saw R1 go out via transport. LPN C immediately contacted Director of Nursing (DON) B. On 08/29/25 at 1:01 PM, Surveyor interviewed DON B regarding facility reported incident investigation of R1 leaving facility without staff knowledge on 07/22/25. DON B stated that R1's guardian gave permission for R1 to go off premises to smoke as they are a smoke free facility, and R1 is supposed to sign out of facility when goes off premises.
Surveyor requested documentation to support R1 had been signing out when going off premises on day of incident of 07/22/25 and prior.
Surveyor asked DON B if any interventions were put into place to ensure R1 is safe. DON B stated that guardian refuses a wander guard, facility did notify Adult Protective Services and placed information into care plan regarding guardian's wishes of allowing resident to leave facility. DON B was not aware of any additional interventions put into place to prevent the elopement from reoccurring.On 8/29/25 at 1:50 p.m., Surveyor interviewed Certified Nursing Assistant (CNA) D and CNA E, who were aware of the elopement but stated they did not receive any education regarding elopement procedures following this incident.On 8/14/25, staff education was provided to licensed nurses regarding elopement at a nurses meeting.Surveyor asked the Director of Nursing (DON) B for a complete investigation into the elopement and education that had been completed with all staff on elopement procedures and interventions to keep R1 safe.On 08/29/25, facility was unable to provide documentation to support resident or staff interviews were conducted to complete a thorough investigation into the elopement.On 08/29/25 at 1:57 PM, DON B stated she does not have any documentation to support that R1 was signing self out to go off premises prior to incident or on 07/22/25. DON B provided no evidence of other facility staff receiving education regarding resident safety and elopements.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.