Arbor Manor Rehabilitation and Nursing Center

In the surveyor’s words

From the most serious findings on record at Arbor Manor Rehabilitation and Nursing Center, in the surveyor’s own words.

• Immediate jeopardy, patternF686Apr 4, 2023

  Based on observation, interview and record review the facility failed to: 1) accurately assess, monitor and prevent the development and worsening of pressure ulcers consistent with professional standards of practice to prevent avoidable pressure ulcers; 2) follow physician orders including wound treatment orders; 3) implement care-planned and non-care-planned interventions; and 4) ensure that those interventions were functional and in place for nine residents (R5, R13, R22, R24, R28, R39, R43, R47, and R218) reviewed for pressure ulcers, from a total sample of 16 residents, resulting in an Immediate Jeopardy, beginning on 03/30/23 when facility staff did not follow facility policy and procedure or physician's orders for pressure ulcer prevention and/or treatment. […]

• Immediate jeopardy, isolatedF755Oct 18, 2021

  This citation pertains to intake number MI 713. Based on observation, interview, and record review the facility failed to ensure two out of two residents (Resident #2 & #3) received their medications from a licensed nursing professional, resulting in Immediate Jeopardy when two unlicensed staff, Certified Nursing Aids (CNAs), administered medications via oral, inhalation, and injection routes, resulting in the likelihood of serious harm, injury, and/or death. Findings Included: Resident #2 (R2): Review of the facility face sheet revealed R2 was admitted to the facility on [DATE], and resided on the North 2 Unit in room 52-2. […]

• Actual harm, isolatedF689Jan 8, 2025

  This 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. […]

• Actual harm, isolatedF686Apr 28, 2022

  Based on observation, interview and record review, the facility failed to prevent the further development of 2 pressure ulcers for 1 (Resident #28) of 4 residents reviewed for pressure ulcers resulting in the development of 2 facility acquired pressure ulcers, [CONDITION(S)] related to pressure ulcer, [CONDITION(S)] (infection in the bone) and subsequent hospitalization . Findings include: Positioning interventions redistribute pressure and shearing force to the skin. Elevating the head of the bed to 30 degrees or less decreases the chance of pressure ulcer development from shearing forces (WOCN, 2010). […]

• No harm, potential for more than minimal, widespreadF812May 7, 2026

  Based 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.Findings include:During an observation and interview on 5/05/2026 at 9:07 a.m., of initial kitchen tour, Food Service Manager (FSM) N reported had worked at facility about 10 months. FSM N directed this surveyor to single hand-washing sink located in kitchen with trash can located next to sink with unfunctional lid. After washing hands, foot pedal on trash can was not functioning properly, and lid had to be handled with clean hands to open, and observe several used paper towels in trash can. […]