Inspection Reports for Arbor Lake Nursing and Rehabilitation

The facility failed to act as a fiduciary for nine residents by not monitoring or managing resident trust fund balances, allowing funds to exceed Medicaid resource limits, which placed residents at risk of losing Medicaid eligibility and potential involuntary discharge. Multiple residents had trust fund balances over $3,000 with no evidence of spend down efforts.

The facility was found deficient in multiple areas including failure to maintain a safe, clean, and homelike environment; failure to protect residents from abuse; inadequate assistance with activities of daily living; failure to provide appropriate dementia care; and failure to maintain an effective infection prevention and control program. Specific issues included broken blinds, uninstalled resident television, resident-to-resident abuse, inadequate grooming and nail care, insufficient dementia-related interventions, and lapses in infection control practices such as failure to disinfect equipment and improper use of personal protective equipment.

The complaint investigation found that Resident #33 wandered into another resident's room and was pushed, causing injuries. The facility failed to provide adequate care plans and interventions to address wandering behaviors. Interviews with staff revealed inconsistent supervision and lack of dementia-related care training. The psychiatric provider and staff acknowledged the need for increased supervision and redirection of wandering residents.

The facility failed to ensure that Resident #33, diagnosed with dementia, received appropriate treatment and services to address wandering behaviors, resulting in an incident where Resident #33 was pushed by another resident causing abrasions. The facility lacked specific care plans and person-centered interventions to manage the resident's wandering behavior, increasing risk to residents with dementia.

The complaint investigation focused on Resident #1's discharge without a 30-day notice and lack of discharge planning. The resident was discharged due to being a registered sex offender and 'too friendly' in the dining room, but no inappropriate behavior was documented or observed by staff or residents. The family was notified on the day of discharge and given an ultimatum to pick up the resident or law enforcement would be called. The facility offered another facility placement, but it was too far, so the family took the resident home.

The facility failed to provide a 30-day written discharge notice and discharge planning for Resident #1, a registered sex offender discharged due to 'being too friendly' without documented inappropriate behavior. Interviews with staff and residents revealed no observed inappropriate behavior. The discharge was planned the day prior with the social worker and family over the phone, and the family was not given adequate notice.

The complaint investigation focused on an incident on 03/16/25 where Resident #1 was shocked by a loose electrical outlet in her room, resulting in burns and blisters. The facility failed to immediately report the incident to the Administrator and delayed treatment. An Immediate Jeopardy (IJ) was identified on 04/14/25 related to electrical hazards. The IJ was removed on 04/15/25 after the facility implemented a Plan of Removal including staff education and maintenance checks. Additionally, on 05/28/25, Resident #1 was found with ant bites, indicating a failure in pest control.

The facility failed to immediately report the incident involving Resident #1 being shocked by a loose and malfunctioning electrical outlet, delayed treatment of the resident's burns, and failed to maintain a safe environment free from electrical hazards. Additionally, the facility was found to have an immediate jeopardy related to electrical hazards and later a minimal harm deficiency related to pest control when Resident #1 was found with ant bites.

The facility failed to ensure proper routine PICC line dressing changes for Resident #1, placing residents at risk for infection. Additionally, the facility failed to investigate and report a shigella infection in Resident #2 to the County Health Department, risking infection transmission.

The complaint investigation revealed substantiated issues with wound care documentation. Resident #1 reported not receiving daily wound care despite documentation indicating otherwise. Staff interviews confirmed falsification of records and failure to follow physician orders, with some nurses documenting care not provided and not reporting refusals of care.

The facility failed to accurately document wound care for Resident #1, with evidence of falsified records where nurses documented wound care that was not provided. Interviews revealed staff knowingly documented care not given, and the resident sometimes refused care. This failure could lead to missed wound care and infection.

The complaint investigation focused on Resident #1's discharge process. The family expressed concern about lack of proper education and instructions on wound care and inability to be present all day to provide care. The social worker could not provide documentation of refusal of home health services. The wound physician recommended home health care for safe discharge. Facility staff expressed concerns about safety of discharge without home health. The family refused to pay for private pay days to remain at the facility. The resident was discharged with wound care supplies and some training provided to family.

The facility failed to ensure Resident #1's home health and wound care services were confirmed and in place prior to discharge, placing the resident at risk for care disruption and unmet needs. Interviews revealed inadequate education and training for the family on wound care, refusal of home health services without documented refusal, and concerns about the safety of discharge without home health support.

The facility was found deficient in multiple areas including failure to obtain informed consent for psychotropic medications, inadequate cleaning of residents' wheelchairs, inaccurate MDS assessment coding, failure to provide adequate grooming assistance, improper documentation of PICC line dressing changes, incomplete post-dialysis assessments, incomplete medication administration records, and ineffective pest control program resulting in presence of gnats.

The facility was found deficient in ensuring informed consent for psychotropic medications, maintaining clean wheelchairs, providing adequate ADL assistance including nail care, timely PICC line dressing changes, completion of post-dialysis assessments, and accurate medical record documentation.

The complaint investigation focused on medication administration errors for Resident #1 involving Midodrine, failure to notify the physician of abnormal x-ray results for Resident #2, and incomplete medication administration documentation for Residents #2 and #3.

The facility failed to administer Resident #1's blood pressure medication Midodrine according to physician orders, resulting in medication given out of parameters and held without documented blood pressure readings. The facility also failed to promptly notify the physician of Resident #2's abnormal chest x-ray results, delaying medical intervention. Additionally, the facility failed to document medication administration for Residents #2 and #3 on 12/17/23, risking inaccurate medication records.

The complaint investigation focused on Resident #1, who was transferred to another nursing facility without prior notification or consent from the resident's responsible party (RP). The RP was unaware of the transfer date and location until after the transfer occurred and had not given permission for the transfer. The RP also had difficulty being contacted by the facility despite providing multiple phone numbers and availability. The facility failed to document communication attempts and transfer planning in the resident's electronic health record (EHR).

The facility failed to notify Resident #1's responsible party (RP) in writing or verbally about the transfer date and location prior to the transfer, and failed to document the transfer notice contents and RP's acknowledgment in the medical record. The resident was transferred without RP consent, placing residents at risk of not exercising their rights or accessing advocacy services.

The facility failed to develop baseline care plans within 48 hours of admission for one resident, failed to implement comprehensive care plans addressing specific needs for another resident, failed to consult a physician timely for elevated blood sugars, failed to properly monitor and document medication refrigerator temperatures, and failed to properly sanitize thermometers during food temperature checks.