Inspection Reports for
Arbor View Nursing and Rehabilitation

The visit was complaint-related based on complaints MO2647279 and 2646309. The complaint involved concerns about the unsafe transfer of Resident #1. The complaint was investigated and substantiated as the facility did not follow proper transfer procedures.

The facility failed to perform a proper and safe transfer of Resident #1, who was upset and resisted during the transfer. Staff did not follow the care plan or use appropriate transfer techniques such as a gait belt, resulting in minimal harm or potential for harm to the resident.

The facility was found deficient in multiple areas including failure to promote resident dignity during meals, failure to honor resident preferences, inadequate notification of transfers and bed hold policies, unsafe and unsanitary food handling practices, insufficient staffing and training, lack of gradual dose reductions for psychotropic medications, failure to maintain essential equipment, and unsafe environmental conditions such as items stored on overbed light fixtures.

Complaint #MO00249132 triggered the investigation into inconsistent showering and personal care for residents.

The facility failed to provide consistent showers to three sampled residents, resulting in residents going weeks without showers. Shower sheets were often incomplete or inaccurately marked as refused. Staff interviews revealed issues with staffing and compliance with shower schedules, particularly on evening shifts.

Complaint numbers MO00245733 and MO00246557 were investigated related to food temperature and quality concerns.

Facility staff failed to maintain hot food temperatures at or above 120°F for 12 sampled residents during meal service and lacked a system to monitor food tray temperatures. Observations confirmed multiple food items served below required temperatures, and the facility did not have a food service policy or temperature logs.

Complaint #MO 242770 triggered the investigation. The complaint was substantiated as the resident missed five doses of cenobamate, leading to a seizure.

The facility failed to administer five doses of cenobamate seizure medication to Resident #1, resulting in a seizure. The medication was misplaced in the nurse's medication cart instead of the Certified Medication Technician's cart, and communication failures occurred among staff regarding the missing medication. The facility's medication administration policy did not address procedures for unavailable medications.

Complaint #MO239985 involved concerns about revocation of LOA privileges and resident rights related to substance use policies. Complaint MO00240601 involved issues with resident financial management and access to funds.

The facility revoked LOA privileges for several cognitively intact residents based on suspected or alleged violations of a new policy prohibiting illegal substances, alcohol, and marijuana. The facility also restricted visitation for a resident's family member based on an assumption of drug possession. Additionally, the facility failed to obtain proper authorization for resident fund withdrawals and did not consistently provide residents access to their funds.

The facility was found deficient in ensuring safe smoking supervision for residents, proper dialysis communication and monitoring, sanitary food storage and preparation, proper garbage disposal, infection prevention practices, and effective pest control measures to manage flies within the facility.

The complaint investigation found that the facility did not separate six residents who tested positive for COVID-19 from six residents who tested negative, despite CDC and facility policies requiring isolation or cohorting of positive residents. The immediate jeopardy began on 2023-10-01 and was removed on 2023-10-13 after corrective actions.

The facility failed to separate six COVID-19 positive residents from six COVID-19 negative residents who were roommates, placing residents at increased risk of contracting COVID-19. The facility was found to be in immediate jeopardy but had implemented corrective actions by the time of the survey.

The complaint investigation was substantiated by evidence showing the facility did not investigate or follow up on grievances filed by Residents #1 and #2 regarding rude and inappropriate comments by CNA A. The grievances were lost, and staff responsible did not conduct required investigations.

The facility failed to investigate or follow up on grievances filed by two residents regarding inappropriate comments made by a CNA. Multiple staff interviews confirmed that grievances were lost and no proper investigation was conducted, violating the facility's grievance policy.

The facility was found deficient in multiple areas including resident dignity and privacy, obtaining physician orders, maintaining a safe and clean environment, notification of transfers and bed hold policies, accurate resident assessments and care plans, medication administration, infection control, food safety, and maintenance of physical plant elements such as handrails.