Arbor Manor Rehabilitation and Nursing Center

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment effecting 92 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and toxic chemical residue.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure accurate advance directives (legal documents that allow a person to identify decisions about end-of-life care ahead of time) information was in place for two resident (#12, #78) of two residents reviewed for advance directives. Findings Included:Resident #12 (R12)Review of the medical record revealed R12 was admitted to the facility [DATE] with diagnoses that included Alzheimer's disease, vascular dementia, atrial fibrillation, venous insufficiency (when leg veins [NAME] efficiently return blood to the heart), polyosteioarthritis (a form of arthritis affecting five or more joints), asthma, hypertension, anxiety, hypothyroidism (low thyroid hormone), delusional disorders, and depression. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide Activities of Daily Living care (showering and shaving) for one dependent resident (#61) of two residents reviewed. Findings Included: Resident #61 (R61)Review of the medical record revealed R61 was admitted to the facility 08/26/20222 with diagnoses that included Alzheimer's Disease, dementia, polyarthritis (arthritis in five or more joints), insomnia, kidney disease, peripheral neuropathy (nerve damage in nerves), gout (high uric acid in joints), urinary retention, sleep apnea, gastro-esophageal reflux, and muscle weakness. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/09/2026, revealed R61 had a Brief Interview for Mental Status (BIMS) of 3 (severe cognitive impairment) out of 15. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure proper positioning was in place for one resident (resident #28) of two residents reviewed for positioning.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide range of motion (ROM) to one (R11) of two reviewed.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the attending physician documented his/her rationale for not changing medication as requested by the pharmacist for one resident (#6) of five residents pharmacy reviews. Findings Included:Resident #6 (R6)Review of the medical record revealed R6 was admitted [DATE] with diagnoses that included congestive heart failure (CHF), epilepsy (neurological disorder causing seizures), type 2 diabetes, morbid obesity, bladder dysfunction, heart disease, hypothyroidism (low thyroid hormone) atrial fibrillation, restless leg syndrome, insomnia, depression, gout (build-up of uric acid in bone joints), hypertension, and hyperlipidemia (high fat content in blood). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5% when 2 of 26 medications for two residents (R7 and R31) were not administered in accordance with physician's orders resulting in a medication error rate of 7.69%.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection prevention and control practices during medication administration for one (R31) of two reviewed.

Inspectors wroteBased on interview and record review, the facility failed to maintain documentation that pneumococcal immunization education was provided and whether consent or declination was received for one (R11) of five reviewed.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment effecting 84 residents, resulting in the increased likelihood for cross-contamination and bacterial harborage.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a homelike environment for up to 84 residents residing at the facility, resulting in residents being subjected to numerous loud overhead paging throughout the day.

Inspectors wroteBased observation, interview, and record review the facility failed to ensure proper storage of medication in one of three medication carts and one medication room of three reviewed for medication storage.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure appropriate use of Personal Protective Equipment (PPE-protective garments or equipment designed to protect the wearer from injury or infection) and hand hygiene for Transmission-Based Precautions (TBP-used for patients known or suspected to be infected or colonized with infectious agents) for one (Resident #4) of two reviewed.

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice of transfer/discharge for one (R92) of two reviewed.

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice of bed hold policy upon transfer for one (R92) of two reviewed.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure enteral nutrition was administered as ordered and weights were monitored for two (R33 and R41) of four reviewed.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure monitoring of psychotropic medications was completed as ordered for one (Resident #74) of five reviewed.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain complete and accurate medical records for one (Resident #90) of 18 reviewed.

Inspectors wroteThis citation pertains to intake number MI00149135. Based on observation, interview, and record review the facility failed to ensure for one out of three residents (Resident #1) proper and safe transfer with an assistive device was conducted resulting in harm to the resident. Findings Included: Review of Resident #1's (R1) electronic medical record (EMR) revealed R1's had resided at the facility since 2013; Diagnosis included multiple sclerosis and muscle weakness. Review of a progress note dated [DATE], revealed R1 had a fall. The note revealed R1 was noted to be on the floor with her back to the bed, and the assistive device (sit to stand-a device that lifts a person from a sitting to a standing position) in front of her. The note revealed that R1 made a statement that her legs gave out. This was noted in the note to have occurred while the sit to stand was in use on R1. [...]

Inspectors wroteThis citation pertains to MI00147519 Based on observation, interview and record review, the facility failed to initiate new interventions to prevent falls for one resident (Resident #4) of two reviewed for falls, from a total sample of 5, resulting in continued falls and hospitalization for major injury.

Inspectors wroteThis citation pertains to MI00147519 Based on observation, interview and record review the facility failed to implement, revise and evaluate effectiveness of the care plan for one of two sampled residents (Residents #4) reviewed for falls resulting in unnecessary falls and hospitalization with major injury.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment effecting 83 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and toxic chemical residue.

Inspectors wroteResident #27 (R27): Review of the medical record reflected R27 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included generalized atherosclerosis and hypertension (high blood pressure). The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/12/24, reflected R27 scored 12 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). R27's medical record reflected medicaid hospice was effective 7/7/23. The significant change in status MDS, with an ARD of 7/14/23, did not reflect coding for hospice services. During an interview on 03/27/24 at 01:36 PM, MDS Nurse C reported hospice should have been coded on R27's significant change in status MDS, with an ARD of 7/14/23. Resident #59 (R59): [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 83 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased illumination.

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice of transfer for one resident (Resident #20) of two reviewed for hospitalizations, resulting in the potential of residents and/or resident representatives being uninformed of the reason for the transfer.

Inspectors wroteBased on interview and record review, the facility failed to notify the resident of the facility bed hold policy and provide a written copy upon hospital transfer for one resident (Resident #20) of two reviewed for hospitalizations, resulting in the potential of residents and/or resident representatives being uninformed of the bed hold policy.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow pharmacy policy and acceptable clinical practice for maintaining controlled medication for three of four medication carts, record controlled medication for one resident (#24) in a timely manner, and failed to destroy medication for one resident (#77) in an acceptable clinical practice resulting in the potential for controlled medication diversion. Findings Included: Resident #24 (R24) Review of the medical record demonstrated R24 was admitted to the facility 10/15/2021 with diagnoses that included Alzheimer's Disease, dementia, and anxiety. The most recent Minimum Date Set (MDS), with an Assessment Reference Date (ARD) of 01/22/2024, demonstrated R24 had a Brief Interview for Mental Status (BIMS) that was not assessed because she rarely/never could be understood. [...]

Inspectors wroteBased on interview and record review, the facility failed to address medication irregularities for one (Resident #37) of five reviewed.

Inspectors wroteBased on interview and record review, the facility failed to offer pneumococcal immunizations per Centers for Disease Control and Prevention (CDC) recommendations for two (Resident #16 and Resident #37) of five reviewed.