Inspection Reports for
Arbor Lake Skilled Nursing & Rehabilitation
1155 STERLINGTON HIGHWAY, FARMERVILLE, LA, 71241
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Inspection Report — Oct 1, 2025
Routine CMS
Date: Oct 1, 2025
Visit Reason
Routine inspection of Arbor Lake Skilled Nursing & Rehabilitation to assess compliance with regulatory standards including resident dignity, medication management, care planning, pressure ulcer care, infection control, and equipment safety.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity during meal assistance, inadequate follow-up on resident grievances, improper use and monitoring of psychotropic medications, incomplete care plans, insufficient pressure ulcer care and documentation, failure to obtain ordered lab tests, inadequate infection control practices including whirlpool disinfection and improper storage of urine collection tubing, unsafe medication administration practices, and unsafe kitchen equipment maintenance.
Deficiencies (8)
F 0550: The facility failed to ensure staff did not stand over residents while assisting with meals, violating dignity and respect policies.
F 0565: The facility failed to promptly address grievances voiced during resident council meetings and lacked documentation of follow-up actions.
F 0605: The facility failed to prevent unnecessary psychotropic medication use by not limiting PRN orders to 14 days, not attempting gradual dose reductions, and not addressing pharmacist recommendations for 4 residents.
F 0656: The facility failed to develop and implement a comprehensive care plan for a resident's urinary collection system, including proper storage and care instructions.
F 0686: The facility failed to provide appropriate pressure ulcer care by missing documentation of treatments, weekly body audits, and having inaccurate pressure ulcer assessments for a resident.
F 0757: The facility failed to ensure a resident's drug regimen was free from unnecessary drugs by not obtaining ordered thyroid stimulating hormone and iron lab tests.
F 0880: The facility failed to maintain infection prevention and control by not disinfecting whirlpools per manufacturer instructions, improper storage of urine collection tubing near food, and unsafe medication administration practices.
F 0908: The facility failed to keep essential equipment safe by allowing a leaking pipe under the kitchen sink and grease buildup in the deep fryer.
Report Facts
Residents affected: 1
Residents affected: 4
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents receiving whirlpool baths: 58
Residents reviewed for unnecessary medications: 5
Residents affected by psychotropic medication issues: 4
Residents affected by infection control issues: Some
Residents affected by pressure ulcer care: 1
Residents affected by dignity issue: 1
Residents affected by grievance follow-up: Some
Residents affected by medication lab test failure: 1
Residents affected by unsafe medication administration: 1
Residents affected by equipment issues: 93
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S2 Director of Nursing | Director of Nursing | Confirmed staff should not stand over residents during meals and acknowledged medication and infection control deficiencies. |
| S3 Assistant Director of Nursing | Assistant Director of Nursing | Confirmed dignity and care plan deficiencies and improper storage of urine collection tubing. |
| S7 SSD | Social Services Director | Grievance official who provided grievance logs and confirmed lack of follow-up. |
| S11 Wound Care Nurse | Wound Care Nurse | Confirmed missing documentation of pressure ulcer treatments and body audits. |
| S18 CNA | Certified Nursing Assistant | Reported whirlpool cleaning process and lack of disinfectant. |
| S26 LPN | Licensed Practical Nurse | Admitted to picking up dropped pills and administering them to a resident. |
| S8 Dietary Manager | Dietary Manager | Confirmed leaking pipe and grease buildup in kitchen equipment. |
Inspection Report — Oct 31, 2024
Routine CMS
Date: Oct 31, 2024
Visit Reason
Routine inspection survey conducted to assess compliance with healthcare regulations including medication administration, restraint use, resident transfers, activities, supervision, and medication regimen review.
Findings
The facility was found deficient in multiple areas including failure to assess resident for self-administration of medications, improper use and documentation of physical restraints, inadequate documentation for resident transfers, failure to provide adequate activities, insufficient supervision of a resident who smokes, incomplete medication administration documentation, failure of pharmacist to identify medication irregularities, and use of psychotropic medication without acceptable diagnosis.
Deficiencies (8)
F554: Facility failed to assess resident #152 for self-administration of medications and allowed unauthorized medications at bedside.
F604: Facility failed to ensure residents #42, #64, and #92 were free from physical restraints without proper consent, physician orders, and monitoring.
F622: Facility failed to document adequate reason and family notification for transfer of resident #61 to hospital.
F679: Facility failed to provide ongoing activities based on resident #97's preferences and needs.
F689: Facility failed to provide adequate supervision to resident #1 who smokes, resulting in unsafe smoking practices.
F700: Facility failed to obtain informed consent including risks and benefits for side rail use for residents #18 and #22.
F726: Facility failed to ensure nursing staff documented medication administration for residents #17, #50, #59, #68, #83, and #93 consistently.
F758: Facility failed to ensure psychotropic medication was used only with acceptable diagnosis for resident #93 and failed to implement gradual dose reductions appropriately.
Report Facts
Missed medication documentation: 15
Missed medication documentation: 5
Missed medication documentation: 3
Missed medication documentation: 13
Missed medication documentation: 11
Missed medication documentation: 9
Inspection Report — Nov 15, 2023
Routine CMS
Date: Nov 15, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication administration, laboratory services, and nursing competencies at Arbor Lake Skilled Nursing & Rehabilitation.
Findings
The facility failed to ensure timely personal hygiene care for residents, proper documentation of wound care and medication administration, pharmacist reporting of lab irregularities, and timely laboratory testing as ordered. Deficiencies were noted in care for multiple residents including inadequate nail care, missing medication administration records, and failure to obtain ordered lab tests.
Deficiencies (4)
F 0677: The facility failed to ensure residents unable to perform activities of daily living received necessary services to maintain good personal hygiene, specifically resident #49's fingernails were not trimmed and cleaned timely.
F 0726: The facility failed to ensure licensed nurses had appropriate competencies, evidenced by lack of documented wound care for resident #83 and missing medication administration documentation for resident #100 on 11/13/2023.
F 0756: The pharmacist failed to report irregularities to the attending physician and nursing staff by not identifying that a yearly Fasting Lipid Panel was not obtained for resident #68 as ordered.
F 0770: The facility failed to provide timely laboratory services by not obtaining a yearly Fasting Lipid Panel for resident #68 as ordered by the physician.
Report Facts
Residents reviewed for activities of daily living: 2
Residents reviewed for medication administration: 1
Residents reviewed for unnecessary medications: 5
Fluorouracil treatments not documented: 30
Fluorouracil treatments not documented: 7
Vaseline and Dove soap applications not documented: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (S5CNA) | Stated nurses cut and clean resident nails when needed | |
| Licensed Practical Nurse (S4LPN) | Confirmed CNAs responsible for nail care if resident is not diabetic | |
| Director of Nursing (S2DON) | Confirmed nail care responsibility and lack of documentation for treatments and lab tests | |
| Licensed Practical Nurse (S7LPN) | Unable to sign electronic MAR on 11/13/2023 and did not use paper MAR | |
| Assistant Director of Nursing (S6ADON) | Confirmed no documentation of medication administration and lab test not drawn | |
| Licensed Practical Nurse/Treatment Nurse (S3LPN) | Confirmed no documented evidence of treatments completed as ordered for resident #83 |
Inspection Report — Jun 7, 2023
Routine CMS
Date: Jun 7, 2023
Visit Reason
Routine inspection of Arbor Lake Skilled Nursing & Rehabilitation to assess compliance with regulatory requirements including resident assessments, pain management, and laboratory services.
Findings
The facility failed to ensure accurate weekly skin assessments for resident #3, failed to provide timely pain management for resident #3, and failed to obtain ordered laboratory tests for resident #1.
Deficiencies (3)
F0641: The facility failed to ensure resident #3 received an accurate weekly skin assessment, missing a skin tear and edema on bilateral lower extremities.
F0697: The facility failed to provide timely pain management for resident #3, who complained of pain but did not receive ordered Tylenol until the following day.
F0770: The facility failed to obtain laboratory tests ordered by the physician for resident #1, including CBC, CMP, ESR, CRP, and stool for GI pathogen panel.
Report Facts
Body audit dates with no skin breakdown identified: 8
Skin tear size: 1.5
Tylenol dosage: 500
Tylenol tablets: 2
BIMS score: 10
BIMS score: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S2DON (Director of Nursing) | Confirmed inaccurate skin assessment and delayed pain medication administration for resident #3; confirmed lab orders not obtained for resident #1 | |
| S10Treatment RN (Registered Nurse) | Performed weekly body audits and confirmed skin issues and pain for resident #3 | |
| S5CNA (Certified Nurses Aide) | Reported resident #3's swelling, redness, and pain to nurses | |
| S3Corporate Administrator | Reported resident #3's Braden scale score | |
| S9ADON | Confirmed Tylenol order and administration issues for resident #3 |
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