Arbor Trace Health & Living Community

In the surveyor’s words

From the most serious findings on record at Arbor Trace Health & Living Community, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF684May 15, 2024

  Based on observation, interview, and record review, the facility failed to ensure physician notification of a 3-pound (lb.) weight gain over a 24-hour period for 1 of 1 resident reviewed for edema (Resident 9) and 1 of 1 resident reviewed for dialysis (Resident 50). The facility failed to ensure ACE wraps were applied as ordered for 1 of 3 residents reviewed for pressure ulcers. (Resident 11) The facility failed to administer creams to a skin impairment without compounding medicated creams for 1 of 3 residents reviewed for skin impairments (Resident 33). […]

• No harm, potential for more than minimal, isolatedF554May 15, 2024

  Based on observation, interview, and record review, the facility failed to ensure residents were clinically appropriate to self-administer medications for 3 of 3 residents randomly observed with medications at the bedside. (Resident 2, 9, and 22) Findings include: 1. An observation conducted of Resident 2's room, on 5/8/24 at 3:18 p.m., of a labeled bottle that contained benzocaine. Resident 2 indicated she utilized the benzocaine for her sore gums. An observation conducted of Resident 2's room, on 5/10/24 at 10:48 a.m., of a labeled bottle that contained benzocaine. There was also a bottle of nasal spray. Resident 2 indicated she took the nasal spray at night. Her jaw had been hurting for a while and the benzocaine did help. […]

• No harm, potential for more than minimal, isolatedF561May 15, 2024

  Based on interview and record review, the facility failed to obtain a resident's preference for bathing frequency for 1 of 1 resident reviewed for choices. (Resident 24) Findings include: The clinical record for Resident 24 was reviewed on 5/8/24 at 12:04 p.m. Her diagnoses included, but were not limited to: dementia, mood disorder, psychotic disorder with delusions, and anxiety. She resided on a secured unit of the facility. The ADL (activities of daily living) care plan, last reviewed/revised 4/23/24, indicated Resident 24 was unable to independently perform late loss ADLs related to weakness and debility. […]

• No harm, potential for more than minimal, isolatedF584May 15, 2024

  Based on interview and observation, the facility failed to promote a clean and homelike environment for 1 of 4 residents reviewed (Resident 37) and 2 of 5 units reviewed for a clean and homelike environment. Findings include: The clinical record for Resident 37 was reviewed on 5/14/2024 at 1:22 p.m. The medical diagnosis included dementia with behaviors. An annual minimum data set assessment, dated 1/28/2024, indicated that Resident was cognitively intact. An interview and observation on 5/8/2024 at 11:45 a.m. indicated that the baseboard strip from the door to the kitchenette cabinets was missing. Resident 37 stated that it had been missing for a while. An observation on 5/8/2024 at 12:03 p.m. […]

• No harm, potential for more than minimal, isolatedF641May 15, 2024

  Based on interview and record review, the facility failed to ensure accuracy of a resident's MDS (Minimum Data Set) assessment for 1 of 1 resident reviewed for dialysis. (Resident 50) Findings include: The clinical record for Resident 50 was reviewed on 5/13/24 at 10:22 a.m. The diagnoses included, but were not limited to, end stage renal disease and dependence on renal dialysis. A dialysis care plan, dated 2/14/24, indicated Resident 50 received hemodialysis due to end stage renal disease. A physician order, dated 3/13/24, indicated Resident 50 received dialysis. A Significant Change Minimum Data Set (MDS) assessment, dated 2/16/24, indicated no dialysis being marked. […]