Inspection Reports for
Arbor Grove Village

This citation relates to Complaint 1808214. The deficient practice was substantiated and corrected after the facility reviewed records, assessed residents, educated staff, discharged the staff member, and added new audits for monitoring narcotic counts.

The facility failed to prevent misappropriation of medications for 2 of 3 residents reviewed. An employee was found to have altered medication packaging and replaced pills with incorrect medications, leading to termination of the staff member.

The facility was found not in compliance with Life Safety Code requirements due to multiple deficiencies including lint accumulation in laundry dryer rooms, hazardous area doors lacking self-closing devices, sprinkler system installation issues, corridor doors failing to close and latch properly, smoking policy violations, improper use of multi-plug adapters, and incomplete testing and maintenance documentation for electrical equipment.

The facility was found deficient in multiple areas including failure to prevent pressure ulcers, failure to ensure availability of physician-prescribed medications, failure to follow physician orders related to medication dose reduction, improper storage in resident snack refrigerators, and incomplete documentation and monitoring after a resident fall.

The facility was found deficient in multiple areas including failure to prevent pressure ulcers, ensure availability of prescribed medications, follow physician orders for medication dose reductions, maintain proper storage and labeling of resident snack refrigerators, and adequately document and monitor resident falls.

The facility was found not in compliance with fire safety requirements due to one corridor door lacking latching hardware, which could affect residents and staff. The deficiency was previously cited and the facility failed to implement a systemic plan of correction to prevent recurrence.

The facility was found not in compliance with Life Safety Code requirements including obstructions in means of egress, incomplete maintenance documentation for battery operated smoke alarms, missing or malfunctioning self-closing devices on hazardous area doors, missing drip tray on kitchen hood, missing sprinkler escutcheon, corridor doors not latching properly, and an oxygen trans-filling room door failing to latch properly.

Complaint IN00433744 was investigated during this visit. No deficiencies related to the allegations were cited.

The facility was found deficient in following physician's orders for holding blood pressure medication for one resident, ensuring medication availability and documentation for another resident, and proper labeling and storage of medications in the medication storage refrigerator. Corrective actions and systemic changes were planned and implemented to address these issues.

The facility failed to follow physician's orders for blood pressure medication for one resident, did not ensure availability and proper documentation of medication administration for another resident, and failed to label and store medications appropriately in one medication storage refrigerator.

The complaint investigation was substantiated. The incident involved inappropriate sexual behavior between two residents with dementia. Staff observations, interviews, and record reviews confirmed the event and identified deficiencies in care planning and supervision.

The facility failed to provide adequate behavioral health care and services for residents with dementia, resulting in an incident where a male resident inappropriately touched a female resident. The facility lacked a care plan addressing behaviors related to seeking male attention, and staff interventions to keep residents separated and involved in activities were insufficient.

Complaint IN00408115 - No deficiencies related to the allegations are cited. Complaint IN00409588 - Federal/State deficiency related to the allegation is cited at F740.

The facility failed to implement a person-centered dementia care plan related to a female resident seeking male companionship. An incident was observed where a male resident touched the female resident inappropriately. The facility had care plans for both residents but lacked a specific plan addressing behaviors related to seeking male attention. The facility updated care plans and implemented interventions to prevent recurrence.

The facility was found not in compliance with Life Safety Code requirements, with deficiencies including improperly secured egress doors, corridor obstructions reducing aisle width, hazardous area doors lacking self-closing devices, sprinkler heads loaded with dust, corridor doors not latching properly, smoke barrier penetrations, improperly maintained GFCI receptacles, and misuse of power strips and extension cords.

The facility was found deficient in multiple areas including failure to prevent abuse and neglect of a cognitively impaired resident, failure to timely report abuse allegations, inadequate implementation of fall prevention interventions, failure to provide competent staff for dementia care, and improper storage and labeling of insulin pens.

The complaint involved allegations of abuse and poor behavior management of Resident 59, a cognitively impaired resident with dementia and behavioral disturbances. The investigation substantiated that staff agitated and physically restrained the resident, delayed reporting the abuse, and failed to provide competent dementia care.

The facility failed to ensure Resident 59 was free from mental and physical abuse, timely reporting of suspected abuse, and adequate behavior management. The facility also failed to ensure adequate fall prevention interventions for two residents and proper medication storage for insulin pens.

Complaint IN00389819 and Complaint IN00392920 were both unsubstantiated due to lack of evidence. The investigation revealed an unrelated deficiency regarding transportation safety.

The facility failed to ensure a resident's safe transport when the transportation vehicle made an unscheduled stop at the resident's home, resulting in the resident being out of staff's sight and police being called. The bus driver was educated on preapproved stops and corrective actions were implemented to prevent recurrence.