Spring Arbor of Albemarle

The facility failed to implement infection control measures during medication administration. During a medication pass, a medication aide used bare fingers to remove a controlled substance tablet from a bubble pack and placed it into a medication cup, risking contamination and skin absorption.

The facility failed to implement proper infection control measures during a medication pass. A medication aide used bare fingers to remove a controlled substance tablet from a bubble pack and placed it into a medication cup with other medications, violating procedures to prevent cross-contamination.

The facility failed to maintain hot water temperatures at bathroom sinks within the required range of 100°F to 116°F. Specifically, 7 of 18 water fixtures on the 100 hall were found to be outside this range, with some temperatures recorded as high as 121.7°F. Monthly logs also indicated temperatures falling below 100°F in certain resident rooms.

The facility failed to maintain hot water temperatures at bathroom sinks within the required range of 100°F to 116°F. Specifically, 7 of 18 water fixtures on the 100 hall were found to be exceeding the maximum temperature limit, with some readings as high as 121.7°F.

The facility failed to ensure referral and follow-up to meet the healthcare needs of a resident with orders for daily weights. Specifically, the facility did not notify the primary care physician regarding the resident's repeated refusal to be weighed, despite orders to report weight changes of 3 lbs in 24 hours or 5 lbs in one week.

The facility failed to ensure proper referral and follow-up to meet a resident's healthcare needs regarding physician-ordered daily weights. Specifically, the facility did not monitor for a 3lb increase in 24 hours or a 5lb increase in one week as required by the physician's orders. Documentation showed the resident was not weighed daily, and staff lacked a directive to re-approach the resident for weighing during shifts.

The facility failed to ensure medication was administered according to physician orders for 2 of 6 sampled residents. Specifically, for Resident #2, the facility failed to document that Coumadin was held for two days and failed to administer the 2 mg dose as ordered by the physician on 2/20/15.