Arbor Care Centers - Ord, LLC

Inspectors wroteLicensure Reference Number 175 NAC 12-006.19Based on record review, interviews and observations, the facility failed to ensure cleanliness in the dining room; failed to ensure that room wall fans/ventilation were clean; and failed to ensure that the bath house was cleaned thoroughly to remove the buildup on the tub handles and the exhaust fans were free of dust. This had the potential to affect all facility residents. The facility census was 39.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.04(A)(iii)(3)Based on interview and record review, the facility failed to follow the facility policy and complete criminal background checks, and [NAME] (Sex Offender Registry) checks for 1 of 5 personnel files reviewed. This had the potential to affect all of the facility residents. The facility census was 39.

Inspectors wroteLicensure Reference Number 175 NAC12-006.04(H)(ii) Based on record review and interview, the facility failed to employ a Director of Food and Nutrition Services that met the regulatory educational requirements. This had the potential to affect all of the residents receiving meals from the kitchen. The facility census was 39.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.11(E) Based on record review, interviews, and observations; the facility failed to store and prepare food in safe and sanitary conditions. This had the potential to affect all residents receiving meals from the kitchen. The facility census was 39. Findings Are: A.Record review of an undated facility policy titled Food Safety Requirements revealed food safety practices shall be followed throughout the facility's entire food handling process. Food will be stored in a manner that helps prevent deterioration or contamination of the food. Record review of an undated facility policy titled Defrosting Freezers revealed freezers that are opened and closed frequently, or are located in humid environments, may need to be defrosted every 3 to 6 months. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.01(G)&(H) Based on record review and interview, the facility failed to notify the State Agency within 5 working days when there was a change in Administrator position. This had the potential to affect all facility residents. The facility census was 39.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.05(B) Based on interview and record review, the facility staff failed to provide documentation that a written notice of Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN, a notice issued to a resident and/or their responsible party to inform them that Medicare will likely no longer pay for their services) for 3 (Residents 25, 28, and 46) of 3 sampled residents when their Medicare A services ended. The facility census was 39.

Inspectors wroteLicensure Reference Number 175 NAC 12-007.04(D) Based on observation and interview, the facility failed to ensure that that exhaust fans in the resident rooms on the 400 hallway were in working order. This affected 12 (Residents 3, 5, 10, 14, 17, 18, 19, 30, 31, 39, 40, and 45) of 12 sampled residents. The facility census was 39.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.02(H) Based on record review and interview the facility failed to report incidents and/or accidents as required to the regulatory agency for 1 resident (Resident 38) of 2 sampled residents. The facility census was 39.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H)(vi)(2) Based on interview and record review the facility failed to provide activities in accordance with the residents expressed interests for 1 (Resident 1) of 2 sampled residents. The facility census was 39.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H)(vi)(3)(g) Based on record review, observation, and interview, the facility failed to ensure that reusable respiratory equipment was labeled, cleaned, and stored per facility policy after use to prevent the potential for infection. This affected one (Resident 5) of one resident sampled. The facility census was 39.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.12 Based on record review, observations, and interviews; the facility failed to ensure medications were ordered, available, and administered as ordered by a physician for 1 (Resident 17) of 1 sampled resident. The facility census was 39.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.10(D) Based on record review, observation, and interview; the facility failed to ensure the medication administration error rate was 5% or less. Of the 25 medication administration opportunities, there were 13 errors and the error rate was 52%. This affected 2 (Residents 31 and 16) of 4 sampled residents. The facility census was 39.

Inspectors wroteLicensure Reference Number175 NAC 12-006.10(D) Based on record review, interviews, and observations, the facility failed to ensure that there were no significant medication errors. This affected one (Resident 17) of 7 sampled residents. The facility census was 39.

Inspectors wroteLicensure Reference Number: 175 NAC 12-006.11(E) Based on observations, record review, and interviews; the facility failed to store food under sanitary conditions as evidenced by rodent droppings in and around the food storage areas. This had the potential to affect all facility residents. Facility census was 32.

Inspectors wroteLicensure Reference Number: 175 NAC 1-009.01(C) Based on observations, record review and interviews, the facility failed to maintain an effective pest control program as evidenced by rodent droppings in and around the food storage areas. This had the potential to affect all facility residents. Facility census was 32.

Inspectors wroteLicensure Reference Number 175NAC 12-006.19 Based on observation and interviews; the facility failed to maintain flooring that was stain free, ceiling tiles that are stain free, lighting fixtures that are bug and/or pest free, and thresholds that are free of trip hazards for 4 (Halls 300, 400, 500, and 700) of 5 sampled hallways. The facility census was 33.

Inspectors wroteLicensure Reference Number 175NAC 1-005.06(E) Licensure Reference Number 175NAC 12-006.18(B) Based on record review and interview the facility failed to complete and review pre-employment health histories for 4 of 4 sampled staff. Based on observation, record review, and interview the facility failed to perform hand sanitization during medication administration to 3 or 5 sampled residents (Resident 17, 28, and 18), sanitize blood glucose glucometer after use for 1 of 1 sampled resident (Resident 18), and failed to follow Enhanced Barrier Precautions (gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a multi-drug resistant organism and residents at increased risk) to prevent the potential spread of multidrug-resistant infection for 2 residents (Residents 11 and 8). The facility census was 33.

Inspectors wroteLicensure Reference Number 175NAC 12-007.04(D) Based on observation, and interview; the facility failed to ensure the bathroom ventilation system could pull up a square of single ply tissue in 3 rooms, (room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]), of 16 sampled rooms. The facility census was 33.

Inspectors wroteLicensure Reference Number 175NAC 12-006.09 Based on observation, record review, and interviews; the facility failed to ensure the provider was notified of abnormal laboratory results affecting 1 Resident (Resident 21) of 5 sampled residents, and failed to notify a physican of blood pressures that were out of range per the physcian order for 2 Residents (Resident 24 and Resident 4) of 3 sampled residents. The facility census was 33.

Inspectors wroteLicensure Reference Number 175NAC 12-006.(I) Licensure Reference Number 175NAC 12-006.(I)(i)(3) Based on observation, record review, and interviews; the facility failed to implement fall prevention interventions to prevent falls for 1 resident (Resident 25) and failed to ensure the mattress was secured to the bedframe to prevent the potential for entrapment or falls for 1 resident (Resident 25). The facility census was 33.

Inspectors wroteLicensure Reference Number 175NAC 12-006.09(H) Based on observation, record review, and interviews; the facility failed to manage pain for 2 Residents (Resident 18 and Resident 21) of 2 sampled residents. The facility census was 33.

Inspectors wroteLicensure Reference Number 175NAC 12-006.09(H) Based on record review and interview; the facility failed to ensure that PRN (as needed) psychotropic medications (any medication that affects behavior, mood, thoughts, or perception) were limited to 14 days as required for 1 resident (Resident 135) of 5 residents reviewed. The facility census was 33.

Inspectors wroteLicensure Reference Number 175NAC 12-006.12(D)(vi) Based on observation, record review, and interview; the facility failed to ensure medications were labeled clearly and accurately for 2 Residents (Resident 18 and Resident 29) of 5 sampled residents. The facility census was 33.

Inspectors wroteLicensure Reference Number 175NAC 12-006.02(8) Based on record review and interview the facility failed to ensure that notification of potential abuse and neglect occurred within the required timeframe for 1 resident (Resident 20) of 2 residents reviewed. The facility census was 27.

Inspectors wroteBased on record review and interviews the facility failed to provide written notice to the resident or their representative regarding discharge or transfer to the hospital for 2 residents (Residents 3 and 279) of 2 residents reviewed. The facility census was 27.