Arbor Trail Rehab And Skilled Nursing Center

Based on observation, interview, and record review, the facility failed to ensure food items were stored, labeled, and discarded according to professional standard of practice. Findings include: During an observation while conducting an initial tour of the kitchen on 4/27/2025 at 9:07 AM, there were three ready-to-eat chicken sandwiches wrapped in a bag with a date label reading 4/21, eight pieces of unpackaged meat wrapped together with no identifier label or date, two plates of salad containing lettuce, tomato, eggs and ham with a label dated 4/23 in the refrigerator. There were brown-stained bananas and one opened bag of pasta in the dry storage, and there was poultry stored in the freezer with no identifier label or date. During an observation while conducting the second tour of the kitchen on 4/28/2025 at 10:52 AM, there was a three-tiered kitchen cart obstructing the handwashing sink and eyewash station. The kitchen cart contained soiled oven mitts, an unlabeled and uncovered empty drinking cup, and a green bucket containing liquid and a rag. The green bucket was on the second…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Minimum Data Set (MDS) assessments were accurate for 2 of 8 residents reviewed, Resident #16, and #21. Findings include: 1) During an interview on 4/27/2025 at 9:32 AM, Resident #16 stated she had never had pneumonia in the facility. Review of Resident #16's MDS assessment dated [DATE] showed the resident had pneumonia under Infections under Section I. Active Diagnoses. During an interview on 4/29/2025 at 10:00 AM, the Infection Preventionist confirmed that Resident #16 did not have pneumonia while in the facility. During an interview on 4/29/2025 at 11:02 AM, the MDS Registered Nurse stated, There is a discrepancy on [Resident #16's Name]'s most recent MDS dated on 3/25/2025 because [Resident #16's Name] didn't have pneumonia. I need to revise it. When asked for the facility policy, the MDS Registered Nurse stated, We do not have a policy. We follow the RAI [Resident Assessment Instrument). 2) Review of Resident #21's physician order dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure residents received intravenous (IV) therapy in accordance with professional standards of practice for 1 of 3 residents reviewed for IV medication administration, Resident #156. Findings include: During an observation on 4/28/2025 at 12:38 PM, Staff A, Licensed Practical Nurse (LPN), was preparing Resident #156's Peripherally Inserted Central Catheter (PICC) line on her upper right arm for administration of Meropenem Intravenous Solution Reconstituted 1 gram (Meropenem). Staff A sanitized and flushed the PICC line with 10 ml (milliliters) of normal saline and initiated Meropenem 1 gram antibiotic via infusion pump. Staff A did not check the patency of the line by aspiration for blood return to determine patency prior to flushing or administering medication. During an interview on 4/28/2025 at 12:38 PM, Staff A, LPN, stated, We do not have to aspirate prior to flushing unless there is a physician order to do so. We just flush with saline first and then give the medications as ordered. During an interview…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure the physician/prescriber documented the rationale for declining the pharmacist's recommendations for 2 of 5 residents reviewed for unnecessary medications, Residents #21, and #27. Findings include: Review of Resident #21's physician order dated 10/8/2024 read, Nitrofurantoin Macrocrystal Capsule 50 mg [milligram], Give 1 capsule by mouth in the morning for prophylactic ABT [Antibiotic] therapy . Status: Active. Review of Resident #21's medication regimen review showed the consultant pharmacist's recommendation dated 4/1/2025 that read, Comment: [Resident #21's name] has received nitrofurantoin for UTI [Urinary Tract Infection] prophylaxis since 10/2024. Recommendation: Please reevaluate and perhaps discontinue nitrofurantoin while monitoring for signs and symptoms of recurrent UTI. Rationale for Recommendation: The potential for developing pulmonary fibrosis, hepatotoxicity, C difficile infection, and peripheral neuropathy increases with duration of use . Physician's Response . I decline the recommendation(s) above…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles in 3 of 4 medication carts. Findings include: During an observation of 400 Hall Medication Cart on [DATE] at 9:18 AM with Staff B, Licensed Practical Nurse (LPN), there were one opened bottle of Timolol Maleate Ophthalmic Solution 0.5% eye drops for Resident #77 with no opened or expiration dates and one opened bottle of Latanoprost 0.005% eye drops for Resident #47 with no opened or expiration dates. During an interview on [DATE] at 9:23 AM, Staff B, LPN, stated, There is no open date or expiration date written on the eye drops. When the eye drops are opened, the date opened and the expiration date are written on the bottle. The eye drops expire in 28 days. During an observation of 300 Hall Medication Cart on [DATE] at 9:29 AM with Staff C, LPN, there was one opened Insulin Lispro 100 unit/ml…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure staff followed practice standard for infection prevention and control during medication administration to prevent the possible spread of infection and communicable diseases for 2 of 6 residents reviewed for medication administration, Residents #243 and #7. Finding include: During an observation on 2/6/2024 at 6:48 AM, Staff G, Licensed Practical Nurse (LPN), completed blood sugar monitoring using glucose meter for Resident #73. Staff G did not sanitize the glucose meter before or after use and returned the glucose meter back into the medication cart. During an interview on 2/6/2024 at 6:48 AM, Staff G, LPN, stated, It's my first day on the floor by myself and the glucose meter should be cleaned before and after each patient with the bleach wipe. During an observation on 2/6/2024 at 8:30 AM, Staff H, LPN, popped Carvedilol tablet 6.25 mg (milligram) and Furosemide tablet 20 mg for Resident #243 into her bare non-gloved hand and placed the medication in the medication cup. Staff H proceeded to administer…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents receive respiratory care services for oxygen administration consistent with professional standards of practice for 4 of 5 residents reviewed for respiratory care, Residents #195, #61, #82, and #32 in a total sample of 33 residents. Findings include: 1) During an observation conducted on 8/22/2022 at 11:04 AM, Resident #195 was observed resting in bed with the head of his bed flat with 4 liters of oxygen being administered through a nasal cannula connected to an oxygen concentrator. The oxygen humidification bottle was empty and not dated. Review of the medical record documented Resident #195 was admitted to the facility on [DATE] with the following diagnoses, COVID-19 Viral pneumonia, liver cirrhosis, liver cell cancer, iron deficiency anemia, chronic obstructive pulmonary disease, chronic kidney disease, major depressive disorder, essential (primary) hypertension, hyperlipidemia, and status post tracheostomy Review of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview the facility failed to complete a discharge summary to include a recapitulation of the resident's stay for 1 of 3 residents, Resident #90, sampled for closed record reviewed. Findings include: Review of Resident #90's record revealed documentation the facility had stopped billing for Resident #90 on 8/1/2022. Review of Resident #90's progress note, dated 8/1/2022, revealed Resident #90 was discharged to an assisted living facility with an effective date of 8/1/2022 at 5:57 PM. Review of Resident #90's discharge records failed to reveal documentation the facility completed a discharge summary to include a recapitulation of stay for Resident #90. During an interview on 8/24/22 at 7:55 AM, the Director of Nursing reported the facility was unable to locate a discharge summary for Resident #90. During an interview on 8/24/22 at 9:04 AM, the Administrator confirmed the facility was unable to find a discharge summary related to Resident #90's discharge that contained a recapitulation of stay. Review of the facility policy titled Transfer and Discharge,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide care for central venous access devices in accordance with professional standards of practice for 1of 1 resident with a central venous access device, in a total of 36 residents, Resident #194. Findings include: During an observation of Resident #194 conducted on 8/22/2022 at 10:30 AM Resident #194 was observed sitting in a wheelchair, there was a left upper arm midline catheter with a 2 x 2 gauze that covered the insertion site of the catheter, under a transparent dressing that was dated 8/16/2022. During an interview conducted on 8/22/2022 at 10:30 AM Resident #194 stated, I got that [right midline catheter] put in, in the hospital, they have not changed the dressing on that since I was in the hospital. During an interview conducted on 8/22/2022 at 10:30 AM Staff C, Licensed Practical Nurse (LPN) stated, [Resident #194's name] has one more dose of IV [intravenous] antibiotics, she has a midline, the dressing is within date and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to ensure appropriate treatment and services to prevent the possibility of urinary tract infection for 1 of 3 residents observed for indwelling foley catheters, Resident #77. Findings include: Review of the medical record documented Resident #77 was admitted to the facility on [DATE] with the following diagnoses: neuromuscular bladder dysfunction, atherosclerotic heart disease of native coronary artery (heart disease) without angina pectoris (chest pain), type 2 diabetes mellitus, and peripheral vascular disease. Review of the physician order dated 3/17/2022 reads, Diagnosis for indwelling catheter: Neuromuscular bladder dysfunction. Change catheter as needed, size 14f [French]. Review of the Nursing Care plan reads, Ensure proper positioning of drainage tube at all times, keep drainage bag below the level of the bladder. During an observation conducted on 8/24/2022 at 7:35 AM Resident #77 was resting in bed, there was an indwelling urinary catheter bag…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure the medical record for 1 of 3 residents, Resident #55, reviewed for nutrition was complete. Findings include: Record review of Resident #55's care plan, date Initiated 02/01/21, documented Resident #55 was at risk for decreased nutritional status and dehydration related to a history of COVID-19, dysuria, cough, and difficulties with swallowing. Resident #55's care plan documented nutritional interventions to include Monitor PO [by mouth] intakes. Record review of Resident #55's Point of Care Response History for Eating Meal Percentage dated 7/26/22 - 8/23/22, failed to reveal completed documentation of the intake amounts Resident #55 consumed at each meal. Resident #55's meal intake was not recorded on 2 of 28 days, was recorded for 1 of 3 meals for 15 of 28 days and was recorded for 2 of 3 meals for 10 of 28 days. During an interview on 8/24/2022 at 8:32 AM, Staff A, Licensed Practical Nurse/West Unit Manager confirmed staff should be recording Resident #55's meal intake percentages for three meals a day. During an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.