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.

The facility was found deficient in multiple areas including resident rights, self-determination, notice and conveyance of personal funds, safe and homelike environment, in-service training for nursing personnel, medication management, trauma-informed care, staffing, food service, and environmental safety. Deficiencies ranged from failure to promote resident dignity to inadequate maintenance and training.

The facility failed to maintain exit signage in working order, maintain the sprinkler system free of dust and debris, ensure fire extinguishers were properly inspected and maintained, and properly use power strips and extension cords in patient care areas. These deficiencies potentially affected all residents and staff.

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 #MO00249132 was investigated. The complaint concerned residents not receiving showers as scheduled and poor personal hygiene. The complaint was substantiated based on observations, interviews, and record reviews.

The facility failed to provide consistent care for activities of daily living, including bathing and personal hygiene, for three sampled residents. Observations and interviews revealed residents went extended periods without showers, and staff did not always complete shower sheets accurately.

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 numbers MO00245733 and MO00246557 were investigated. The complaint was substantiated based on observations and interviews confirming food temperature issues.

The facility failed to maintain proper hot food temperatures at or above 120 degrees Fahrenheit for 12 sampled residents and did not provide temperature logs for food served on hall trays. Interviews and observations confirmed food was served cold and not at safe temperatures.

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 #MO 242770 triggered the investigation into medication administration errors for Resident #1, which was substantiated by findings of missed doses and improper medication handling.

The facility failed to follow physician's orders for Resident #1, resulting in missed doses of seizure medication. The investigation revealed medication was misplaced in the wrong medication cart, leading to multiple missed doses and a resident seizure.

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.

Complaint #MO239985 involved concerns about resident rights related to leave of absence revocation and visitation restrictions. Complaint MO00240601 related to resident funds management issues.

The facility failed to protect the rights of residents regarding self-determination by revoking leave of absence privileges without proper oversight and restricting visitation rights based on assumptions about contraband. Deficiencies were found in managing resident funds and ensuring residents' rights to communicate and live without undue restrictions.

The facility was found deficient in multiple areas including accident hazards related to resident smoking supervision, dialysis care documentation, food safety and sanitation, infection prevention and control, and pest control. Several residents were observed smoking unsupervised contrary to facility policy, and lapses in infection control and pest management were noted.

The facility failed to maintain high hazardous areas free of penetrations through smoke barriers, had missing ceiling tiles, lacked proper fire alarm notification devices in the courtyard, and did not install all components of the emergency generator system. Additionally, improper use and installation of power strips and extension cords were observed.

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 found an imminent danger Class I level violation related to infection control and COVID-19 transmission. The violation was initially at immediate jeopardy level K but was lowered to serious level E after corrective actions. The facility had not separated COVID-positive and negative residents, increasing exposure risk.

The facility failed to maintain an infection prevention and control program to prevent the spread of COVID-19, resulting in an immediate jeopardy situation that was later lowered to a serious deficiency. The facility did not properly separate COVID-positive and negative residents, increasing the risk of transmission.

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 complaint investigation found that the facility failed to promptly resolve grievances for two residents, did not conduct investigations or follow-up, and lost grievance documentation. The grievance process was not properly managed or communicated to residents and families.

The facility failed to make prompt efforts to resolve grievances for two of three sampled residents, potentially affecting all residents. Investigations and follow-ups on grievances were not completed or documented properly.

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.

The facility failed to meet several fire safety requirements including maintenance of kitchen equipment, proper storage and use of alcohol-based hand rub dispensers, sprinkler system maintenance, smoking area regulations, and electrical equipment wiring. These deficiencies potentially affected all residents and staff.

Complaint #MO 00197896 is referenced but no substantiation status is provided.

The facility failed to prevent the misappropriation of narcotic medication for eight residents. The investigation revealed tampering with medication cards and compromised medication packs, with disciplinary actions taken and corrective measures implemented.

The facility was found deficient in developing and implementing comprehensive care plans, meeting professional standards for services provided, tube feeding management, nurse aide in-service training, and infection prevention and control. Deficiencies were documented with specific resident cases and facility policy reviews.

The facility failed to maintain emergency egress lighting, safeguard hazardous areas with a one-hour fire barrier, and properly mount portable fire extinguishers. These deficiencies affected all residents, staff, and occupants in the event of a fire.

Complaint #MO163453 was substantiated. The investigation found failures in wound care and physician order verification for Resident #1, leading to wound infection and inadequate follow-up care.

The facility failed to develop and implement a comprehensive baseline care plan addressing postoperative wound care and treatment for one resident. The facility also failed to verify physician orders and provide appropriate wound care, resulting in wound dehiscence, infection, and inadequate follow-up care.

The facility was found deficient in multiple areas including catheter care, tube feeding management, dialysis services, nurse aide training, medication storage, infection prevention and control, and water management. Several residents were affected by these deficiencies, and systemic corrective actions were planned.

The facility failed to maintain fire alarm testing documentation, maintain gas-fired equipment ventilation, maintain smoking regulations, and ensure proper use of electrical equipment. These deficiencies affected all residents, staff, and occupants in the event of a fire.

Complaint #MO151621 triggered the investigation. The complaint was substantiated based on observations and interviews confirming medication storage and labeling deficiencies.

The facility failed to label and store medications in a safe and effective manner, with medication carts unlocked and unattended, containing open and unlabeled medications. Staff were not following policies for securing medication carts, and the medication cart lock was broken for two weeks.

Complaint #150079 was substantiated. The violation was initially at immediate jeopardy level 'J' but was lowered to 'D' and 'II' levels after corrective actions were implemented during the onsite visit.

The facility failed to provide sufficient monitoring of a resident with a history of sexual offenses, resulting in an incident where one resident was found with his hand on another resident's peri area. Staff were not informed of the offender's criminal background and no preventive interventions were in place.

Complaint #MO 00145216 and Complaint #MO 00145326 were investigated. The complaints involved failure to provide adequate care plans, assistance with meals and call lights, food safety violations, equipment maintenance issues, and pest control deficiencies. The complaints were substantiated as evidenced by observations, interviews, and record reviews.

The facility failed to implement comprehensive care plans addressing residents' specific needs, did not provide timely assistance with meals and call lights, failed to maintain food service sanitation, did not maintain equipment properly, and lacked an effective pest control program. Multiple deficiencies were cited related to care planning, ADL assistance, food safety, equipment maintenance, and pest control.

The facility was found deficient in multiple areas including resident rights, safe environment, bed hold policy, quarterly assessments, comprehensive care plans, discharge summaries, quality of care, infection control, medication administration, and staff training. Several systemic measures and plans of correction were implemented to address these deficiencies.

The facility failed to meet several life safety requirements including means of egress, emergency lighting, sprinkler system maintenance, fire extinguishers placement, smoke barrier integrity, HVAC safety, portable space heaters, and electrical equipment safety. The deficiencies affected all residents, staff, and occupants in the event of a fire.