Arbor Ridge Rehabilitation and Healthcare Center

Inspectors wroteComplaint Intake ID #408686Based on interviews, record reviews and reviews of pertinent facility documents, it was determined that the facility failed to ensure care and treatment were provided timely to Resident #121, to prevent further change in condition. This failure delayed care for Resident #121 who was admitted to the intensive care unit at an acute care hospital with a diagnosis of septic shock (the most severe, life-threatening stage of sepsis [body's extreme response to an infection], which is a critical medical emergency requiring immediate hospitalization.) This deficient practice was identified for 1 of 3 residents (Resident #121) reviewed for hospitalization. On 12/28/24 at 8:00 PM, Resident #121 had a change in condition with rapid, shallow breathing and difficulty breathing at rest, noisy breathing, restlessness, and cold lower extremities. [...]

Inspectors wroteBased on record review, interview, and review of the Resident Assessment Instrument (RAI manual), the facility failed to ensure that one resident (Resident (R) 95) out of 15 sampled residents' Minimum Data Set (MDS) assessments were transmitted in a timely manner.

Inspectors wroteBased on interviews, record reviews, and review of facility policy, the facility failed to ensure a baseline care plan was given to the residents or their representatives for two Residents (R's), R150 and R121) of 25 sampled residents. These failures had the potential to cause the residents and/or their representatives not to be informed of or are included in the development of the plan of care.

Inspectors wroteBased on interviews, record reviews and review of facility policy, the facility failed to develop a comprehensive care plan for one resident, Resident (R) 121, when he/she was readmitted to the facility. This failure had the potential to cause R121 to receive a less effective plan of care which could affect the quality of care and services provided.

Inspectors wroteBased on observations, interviews, record reviews and review of facility policy, the facility failed to ensure devices to prevent hand contractures were applied as ordered and/or according to the plan of care for three of five residents, Resident (R) 34, R93, and R108, reviewed for positioning. These failures had the potential to cause worsened hand contractures.

Inspectors wroteBased on observations, interviews, and review of facility policy, the facility failed to ensure staff used personal protective equipment (PPE) when providing care to two residents on enhanced barrier precautions (EBP's), Resident (R) 93, and R128 out of a sample of 25. These failures had the potential to cause the spread of infection.

Inspectors wroteBased on interview, record review and review of facility policy, the facility failed to provide the SNF ABN (skilled nursing facility advance beneficiary notice) for two (Residents (R) 91 and R109) of three residents reviewed for beneficiary notices. This failure placed the residents at risk of not knowing the costs or appeals process when they remained at the facility.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to protect the resident's right to be free from sexual abuse by a resident for one of four residents (Resident(R) 39) reviewed for abuse out of 27 sample residents when R32, who had no cognitive impairment, kissed R39's hand, who lacked any capacity to give consent. This had the potential to affect all the residents on the 2nd floor of the facility who were at risk of abuse.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to an report an allegation of sexual abuse by a resident for one of four residents (Resident (R) 39) reviewed for abuse out of 27 sample residents when R32 kissed R39 hands who lacked the ability to give consent, this had the potential to affect all the residents on the 2nd floor of the facility who were at risk of abuse.

Inspectors wroteBased on record review, interview and policy review, the facility failed to ensure that MDS assessment was completed timely for one residents R32. This had to affect all the residents with MDS assessments.

Inspectors wroteBased on record review, interview and review of the Resident Assessment Instrument Manual, the facility failed to ensure that a significant change Minimum Data Set (MDS) assessment was completed timely for one residents R27 out of 27 residents reviewed in the sample. This had the potential to affect all residents with a significant change. Findings Include: Review of R27's admission Record, located in the Profile tab of the electronic medical record (EMR) revealed readmission to the facility on [DATE]. Review on 10/14/24 of R27's Significant change MDS under the MDS tab of the EMR, with an Assessment Reference Date (ARD) of 07/30/24. Further review revealed the ARD date for completion was 08/04/24. Review of Physician Orders under the Orders tab of the EMR, dated 07/17/24, revealed an order for hospice. [...]

Inspectors wroteBased on interview, record review, and review of the Resident Assessment Instrument (RAI) manual, the facility failed to ensure a quarterly assessment was coded accurately for one (Resident (R)83) in a total sample of 30. The facility failed to accurately code hospice for R83. This failure placed the residents at risk of unmet care needs.

Inspectors wroteBased on interview, record review, and review of facility policy, the facility failed to ensure a psychotropic medication contained a 14-day stop date, as required for one (Resident (R)106) of five residents reviewed for unnecessary medications. This failure placed the residents at risk of being administered a medication unnecessarily.

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to ensure a valid physician order for a narcotic was obtained for one (Resident (R)25) of six sampled residents reviewed during medication pass. The facility failed to obtain a documented physician order for narcotic medication and failed to ensure there was documentation of symptoms for the use of narcotics. This failure placed the resident at risk of receiving medication

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to ensure the label on an insulin pen matched the physician order for one (Resident (R) 87) of six residents reviewed during medication pass observation. This failure placed the resident at risk of receiving the wrong dose of medication.

Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to ensure kitchen staff properly air-dried pans prior to storage. This failure had the potential to increase the risk of foodborne illness and had the potential to affect all 107 residents who resided in the facility and who received dietary services. There were five residents receiving tube feedings, but they also received food from the kitchen. The facility had a census of 107 residents.

Inspectors wroteBased on interview, record review, and review of facility policy, the facility failed to maintain a complete and accurate medical record for two residents (Residents (R) 210 and R 90) in a total sample of 30. The facility failed to ensure daily, weekly, and monthly weights were in the medical record to ensure continuity of care. This failure placed the residents at risk of unmet care needs.

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure that a.) an expired narcotic medication was removed from active inventory that resulted in repeated administration of an expired medication to Resident #93 for three months and b.) discontinued biologicals were removed from active inventory for 3 of 3 unsampled residents (Resident #6, #32, and #34). This deficient practice was identified during 1 of 1 medication rooms inspected (First-floor) and evidenced by the following: 1. On 11/16/22 at 10:23 AM, the surveyor inspected the First-floor medication room in the presence of Licensed Practical Nurse/Unit Manager (LPN/UM). The surveyor observed an expired, opened bottle of lorazepam concentrate 2 milligram (mg)/1 milliliter (ml; [...]

Inspectors wroteBased on interview, record review, and record review of facility documents, it was determined that the facility failed to ensure the Consultant Pharmacist identified and/or reported a medication interaction during the monthly medication regimen review from August to November 2022. This deficient practice was identified for 1 of 4 residents (Resident #26) reviewed for medication administration via tube feeding and was evidenced by the following: A review of the manufacturer's specifications for Levothyroxine under section 7.0 titled, Drug Interactions, Table 2. Drugs That May Decrease T4 Absorption (Hypothyroidism) included .Potential impact: Concurrent use may reduce the efficacy of levothyroxine sodium by binding and delaying or preventing absorption, potentially resulting in hypothyroidism. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to provide a.) a chair and b.) a clean comfortable mattress to a resident. This deficient practice was identified for 1 of 2 residents reviewed for hospice and end of life care (Resident #1) and was evidenced by the following: On 11/14/22 at 11:05 AM, during the initial tour, the surveyor observed Resident #1 sitting on their bed. Resident #1 informed the surveyor that the bed was not comfortable and that they had previously discussed his/her discomfort with the Licensed Practical Nurse (LPN) and the previous Unit Manager (UM #1). Resident #1 also stated that he/she wanted to sit somewhere else other than their bed but was unable to since he/she has not had a chair for about three weeks. At that time, the surveyor did not observe a chair in the resident's side of the room or the hallway. [...]