Arbors at Minerva

Inspectors wroteBased on record review, interview and review of facility policy, the facility failed to ensure residents were administered medications according to ordered parameters. This affected four (Residents #4, #17, #84 and #96) of four reviewed for medication administration. The facility census was 70.

Inspectors wroteBased on record review facility education review, and interview, the facility failed to develop and implement a comprehensive person-centered care plan for each resident to meet specific medical needs. This affected one (Resident 96) resident of three reviewed for care plans. The facility census was 70.

Inspectors wroteBased on record review, interview and review of facility policy, the facility failed to implement interventions to prevent and/or treat constipation for one resident (Resident #96) of three residents reviewed for constipation. The facility census was 70.

Inspectors wroteBased on record review, observation, policy review, and interview, the facility failed to follow physician orders to maintain the patency of Resident #20's feeding tube. This affected one of one resident (Resident #20) reviewed for medication administration via feeding tube. The facility census was 70.

Inspectors wroteBased on record review and interview, the facility failed to maintain accurate medical records on each resident. This affected one (Resident #96) of eight reviewed for accuracy of medical records. The facility census was 70.

Inspectors wroteBased on record review, observation, facility policy review, and interview, the facility failed to ensure care was provided to a resident with a feeding tube in a manner to prevent the development and transmission of communicable diseases and infections. This affected one (Resident #20) of three residents reviewed for Enhanced Barrier Precautions (EBP). The facility census was 70.

Inspectors wroteBased on record review, observations and interviews, the facility failed to ensure transmission-based precautions were followed for Resident #2 and failed to ensure infection control practices were followed during catheter care for Resident #2 and #76. This affected one resident (Residents #2) out of five residents reviewed for transmission-based precautions and two (Residents #2 and #76) out of two residents reviewed for urinary catheters. The facility census was 74.

Inspectors wroteBased on record review, emergency medical services (EMS) run report review, death certificate review, policy review, and interview, the facility failed to adequately monitor and provide timely and necessary care and treatment following a change in condition for Resident #1. This affected one (Resident#1) of three reviewed for change in condition. Actual Harm occurred on 12/27/24 at 1:48 A.M. when Resident #1 (who had previously been medicated for nausea/vomiting on 12/26/24 at 3:56 P.M. and 10:38 P.M.) vomited brown-colored emesis and had a decline in her baseline vital signs. The resident's blood pressure was 94/52 millimeters of Mercury (mm/Hg) (normal blood pressure is 120/60 mm/Hg), heart rate was 120 beats per minute (normal is 60-90), temperature was 99.4 Fahrenheit (F), and oxygen saturation was 90% on room air (normal is 92% or higher on room air). [...]

Inspectors wroteBased on record review, policy review, and interview, the facility failed to ensure physician notification occurred with a change in resident condition . This affected one (Resident#1) of three reviewed for change in condition.

Inspectors wroteBased on employee file review, staff interview and review of facility policy, the facility failed to ensure State Tested Nursing Assistants (STNAs) had evaluations completed as required. This had the potential to affect all 69 residents residing in the facility. Findings Include: Review of the employee file for State Tested Nursing Assistant (STNA) #274 revealed a hire date of 06/14/23. No annual performance evaluation was found. Review of the employee file for STNA #219 revealed a hire date of 08/17/22. No annual performance evaluation was found. Review of the employee file for STNA #501 revealed a hire date of 02/2024. A 90-day performance evaluation was not found. Interview on 08/22/24 at 12:30 P.M. the facility Administrator verified the evaluations for STNAs #274, STNA #219, and STNA #501 were not completed. [...]

Inspectors wroteBased on record review, policy and interview, the facility failed to ensure Enhanced Barrier Precautions were in place, indwelling catheters were not dragging on the floor, handwashing met professional standards and tuberculin testing of staff was conducted on hire and annually. This affected Resident's #35 and #51 and had the potential to affect all the residents in the facility. The census was 69.

Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain accurate medical records. This affected five (Resident's #4, #35, #37, #42, and #49) of 19 records reviewed. The census was 69.

Inspectors wroteBased on observation and interview the facility failed to maintain a clean environment. This affected residents but had the potential to affect all residents residing in the facility. The census was 69.

Inspectors wroteBased on observation, interview, medical record review, and policy review the facility to maintain privacy during Resident 7's wound care and failed provide a covering to prevent Resident #51's urine from being visible related to his catheter. This affected two residents (#7 and #51) of two residents reviewed for dignity. The facility census was 69.

Inspectors wroteBased on observation, medical record review, policy review and staff interview the facility failed to ensure the use of a geri chair was appropriate and not considered a restraint. This affected one (Resident #58) of one residents reviewed for restraints. The facility census was 69.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide comprehensive, resident centered activities for dependent residents. This affected two (Resident's #35 and #42) of three residents reviewed for activities. The census was 69.

Inspectors wroteBased on observation, record review, policy and interview, the facility failed to ensure preventative skin care was provided to residents with pressure ulcers. This affected one (Resident #35) of three residents reviewed for pressure ulcers. The census was 69.

Inspectors wroteBased on medical record review, staff interview, and review of the facility policy, the facility failed to adequately monitor enteral nutrition administration for Resident #42 which resulted in a significant weight loss. In addition, the facility did not notify the physician or Registered Dietitian of the significant weight loss in a timely manner. This affected one resident (#42) of one identified by the facility as receiving enteral nutrition. The facility census was 69.

Inspectors wroteBased on observation, record review and interview, the facility failed to label the contents in a tube feeding/enteral nutrition bag. This affected one (Resident #42) of one residents reviewed for tube feeding. The census was 69.

Inspectors wroteBased on observation, record review, policy and interview, the facility failed to ensure oxygen tubing was dated when changed. This affected two (Resident's #32 and #35) of two residents reviewed for oxygen therapy. The census was 69.

Inspectors wroteBased on medical record review, review of pharmacy recommendations, and staff interview, the facility did not ensure pharmacy recommendations were reviewed and addressed by a physician in a timely manner. This affected three residents (#10, #51, and #58) of five reviewed for unnecessary medications. The facility census was 69.

Inspectors wroteBased on observations, medical record review, staff interview, and review of the facility policy the facility failed to maintain a medication error rate of less than five percent (%). The medication error rate was calculated to be 7.69% which included two medication errors of 26 medication administration opportunities. This affected one resident (Resident #22) of six residents observed for medication administration. The facility census was 69.

Inspectors wroteBased on medical record review, review of a facility Self-Reported Incident, interviews and policy review, the facility failed to prevent an incident of resident to resident sexual abuse. This affected one resident (Resident #44) of four residents reviewed for abuse. The facility census was 74. Findings Include: Review of the facility self reported incident (SRI) tracking number 248709 dated 06/17/24 at 9:54 A.M. revealed an allegation or suspicion of sexual abuse. Local Law enforcement was contacted , and an officer came out to complete a report, #24-0212. Resident #7 was placed on one to one supervision. The facility investigation was completed on 06/24/24 at 12:35 P.M. with the allegation of sexual abuse being substantiated. An interview on 06/24/24 with State Tested Nurse Aide (STNA) #505 revealed witnessing inappropriate touching between Resident # 7 and Resident #44. [...]

Inspectors wroteBased on medical record review , review of a facility self-reported incident, policy review and interviews the facility failed to timely report an allegation of resident to resident sexual abuse to the administrator and state survey agency. This affected one resident (Resident #44) of four residents reviewed for abuse. The facility census was 74. Findings Include: Review of the facility self reported incident (SRI) tracking number 248709 dated 06/17/24 at 9:54 A.M. revealed an allegation or suspicion of sexual abuse. Local Law enforcement was contacted , and an officer came out to complete a report, #24-0212. Resident #7 was placed on one to one supervision. The facility investigation was completed on 06/24/24 at 12:35 P.M. with the allegation of sexual abuse being substantiated. [...]

Inspectors wroteBased on observation, medical record review, resident and staff interviews and policy review, the facility failed to ensure wound care was completed as ordered by the physician. This affected two (Residents #35 and #64) of three residents reviewed for wound care. The facility census was 67.

Inspectors wroteBased on self-reported incident review, record review, policy review and interview the facility failed to ensure residents were free from financial exploitation by staff members. This affected one (Resident #10) of one residents reviewed for misappropriation of resident funds. The facility census was 66.

Inspectors wroteBased on record review and interview the facility failed to provide adequate assistance, including appropriate lower extremity support during transport of Resident #3 (with hemiparesis/hemiplegia to the right side) in a wheelchair. This affected one resident (Resident #3) of one resident reviewed for a fall with major injury. The facility census was 70. Actual Harm occurred to Resident #3 on 02/20/23 when staff failed to provide adequate lower extremity support to the resident during transport resulting in the resident's leg dragging on the floor and the resident falling from the wheelchair and suffering a right clavicle fracture and proximal humeral fracture.

Inspectors wroteBased on medical record review, staff interview, and facility policy review the facility failed to notify residents, their representatives and families of a single occurrence COVID-19 in the facility. This affected five residents (Residents #15, #26, #41, #47, and #61) of five residents reviewed for infection control with the potential to affect all 70 residents in the facility. The facility census was 70.

Inspectors wroteBased on observation, medical record review, facility policy review and staff interview the facility failed to ensure residents in reclined wheelchairs had physician's orders in place for use and were appropriately assessed to determine appropriate indication for use. This affected one resident (Resident #4) of one resident reviewed for possible physical restraint use. The facility identified no current residents utilizing physical restraints. The facility census was 70.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure a behavioral care plan was in place. This affected one (Resident #21) of one resident reviewed for behaviors. The facility census was 70. Findings Include: Review of medical record of Resident #21 revealed an admission date of 02/022/23 and diagnoses included acute and chronic respiratory failure with hypoxia (low blood oxygen), recurrent unspecified major depressive disorder, altered mental status, and cognitive communication deficit. Review of the admission [DATE] Minimum Data Set (MDS) assessment revealed Resident #21 was cognitively intact, required supervision of one person for locomotion, limited assistance of one person for walking and dressing, limited assistance of two persons for bed mobility, and extensive assistance of two persons for transfers. [...]

Inspectors wroteBased on observation, medical record review, and staff interview, the facility failed to ensure thorough weekly skin assessments were completed on the open area to the right palm of Resident #39. This affected one resident (Resident #39) of two residents reviewed for non-pressure skin condition.

Inspectors wroteBased on medical record review, observation,and staff interview the facility failed to ensure bilateral hand splints were applied to the hands of a resident. This affected one resident (Resident #39) of three residents reviewed for mobility.

Inspectors wroteBased on observation, medical record review, staff interview, and facility policy review the facility failed to maintain a sterile field during tracheostomy care for Resident #39. This affected one resident (Resident #39) of one resident reviewed for tracheostomy care and treatment.

Inspectors wroteBased on record review and interview, the facility failed to provide ongoing communication with the dialysis center for Resident #7. This affected one resident (Resident #7) of one resident reviewed for dialysis. The facility census was 70.

Inspectors wroteBased on record review and interview, the facility failed to ensure Resident #60 had appropriate indications for the use of as needed anti-anxiety medication, and non-pharmalogical interventions were attempted before the as needed anti-anxiety medication was administered. This affected one resident (Resident #60) of five residents reviewed for unnecessary medications. Facility census was 70.

Inspectors wroteBased on observation, medical record review, and staff interview revealed the facility failed to provide adaptive feeding utensils for Resident #41 at meal time. This affected one resident (Resident #41) of five residents reviewed for nutrition.