Arbor Grace Guest Care Center

In the surveyor’s words

From the most serious findings on record at Arbor Grace Guest Care Center, in the surveyor’s own words.

• Immediate jeopardy, patternF600Feb 8, 2023

  Based on observation, interview, and record review the facility failed to ensure residents had the right to be free from neglect for 8 of 20 residents (Residents #5, #120, #121, #44, #119, #32, #38 and #220) reviewed for neglect. 1. The facility failed to effectively monitor Residents #'s #32, #38, #119, and #220 weights, to prevent weight loss, and nutritional deficits. Failed to input weekly weight orders. 2. The facility failed to provide daily wound care to prevent the decline in wound conditions for Residents #'s #120 and #121. Resident #'s 120 and 121 both had Stage 4 sacral wounds decline resulting in hospitalization s for wound infections. Resident #121 died on [DATE] during his hospitalization . 3. […]

• Immediate jeopardy, patternF686Feb 8, 2023

  Based on observation, interview, and record review the facility failed to ensure residents with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 4 of 20 residents (Residents #5, #49, #120, and #121) reviewed for pressure injury. *The facility failed to provide wound care to Resident #121s sacral pressure injury until [DATE], which was 15 days after his admission with pressure injuries. *The facility failed to consistently provide wound care for Resident #121 after beginning wound care, missing treatments on [DATE] and [DATE]. […]

• Immediate jeopardy, patternF692Feb 8, 2023

  Based on observation, interview, and record review, the facility failed to maintain acceptable parameters for nutritional status such as usual body weight or desirable body weight range by failing to provide nutritional and hydration care and services to residents consistent with the resident's comprehensive assessment for 4 of 21 Residents reviewed for weight loss. (Resident #'s 32, 38, 119, 220) 1.The facility did not address Resident #32's weight loss of 12.7-pounds in one month. 2.The facility failed to provide Resident #32 her magic cup (nutritional ice cream) with lunch and dinner meals. […]

• Immediate jeopardy, patternF770Feb 8, 2023

  Based on interview and record review the facility failed to provide or obtain laboratory services to meet the needs of 3 of 20 residents reviewed for laboratory services. (Resident # 44, Resident #35, and Resident #34) The facility failed to draw PT/INR (A prothrombin time (PT) test measures how long it takes for a clot to form in a blood sample. An INR (international normalized ratio) is a type of calculation based on PT test results) level for medication Coumadin (is a blood-thinning medicine that's used to treat and prevent dangerous blood clots) for Resident # 44 as ordered monthly for five months. The facility failed to draw routine hemoglobin A1C (HBA1C) (a blood test that shows what your average blood sugar (glucose) level was over the past two to three months) for Resident #35. […]

• Immediate jeopardy, patternF686Aug 19, 2022

  Based on observation, interview, and record review, the facility failed to ensure that residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 3 of 5 residents reviewed for pressure ulcers. (Resident #1, Resident #2, and Resident #3) 1. The facility failed to assess Resident #1's skin weekly which led to the resident being diagnosed with a stage 4 pressure wound (a very deep wound involving skin, muscle, and bone) to her sacrum (the bone between the spine and tailbone). […]