Inspection Reports for East Lake Arbor

The document is a Statement of Deficiencies and Plan of Correction for the facility East Lake Arbor, indicating a regulatory inspection was conducted.

No specific deficiencies or findings are detailed in the provided report; only initial comments are noted without further elaboration.

A health revisit survey was conducted to verify correction of deficiencies cited in a prior Complaint Investigation survey concluded on March 7, 2024.

All deficiencies cited in the previous Complaint Investigation survey were found to be corrected during this revisit survey.

This visit was a follow-up to a Complaint Investigation survey concluded on March 7, 2024, verifying correction of cited deficiencies.

The inspection was conducted as a State Licensure survey to determine compliance with the State Long Term Care Requirements.

The facility failed to maintain an effective pest control program in five of eight resident rooms, with multiple sightings of live and dead roaches and a spider. Pest Control Technician reports and observations confirmed ongoing sanitation issues contributing to the infestation.

An abbreviated/partial extended survey was conducted to investigate Complaint Intake Number GA00253873 on March 7, 2025. The investigation was initiated due to complaints regarding pest control issues within the facility.

The facility failed to maintain an effective pest control program in five of eight resident rooms, with live and dead roaches observed in multiple locations including dresser drawers, cabinets, sink counters, floors, and walls. Pest control technician reports and resident interviews confirmed ongoing infestation issues primarily due to sanitation problems.

Complaint Intake Number GA00253873 was substantiated with deficiency related to pest control issues.

The document is a Statement of Deficiencies and Plan of Correction for the facility East Lake Arbor, indicating a regulatory inspection was conducted.

No specific deficiencies or findings are detailed in the report; only initial comments are noted without further elaboration.

A revisit survey was conducted to verify correction of deficiencies cited in the January 9, 2024 Recertification survey.

All deficiencies cited in the prior recertification survey were found to be corrected during this revisit survey.

A Life Safety Code Survey was conducted to assess the facility's compliance with Medicare/Medicaid participation requirements and the National Fire Protection Association (NFPA) Life Safety Code standards.

The facility was found to be in substantial compliance with the requirements set forth in 42 CFR § 483.73 and the NFPA 101 Life Safety Code 2012 edition.

The inspection was a State Licensure survey conducted from January 6, 2025 through January 9, 2025, to determine compliance with the State Long Term Care Requirements.

The facility was found deficient in multiple areas including failure to secure medication carts and remove expired medications, failure to maintain infection control during wound care, inadequate accessibility of call lights for residents, failure to provide adequate activities of daily living care, and failure to provide and document restorative nursing services as ordered.

A standard survey was conducted from January 6, 2025 through January 9, 2025, including investigation of multiple complaint intake numbers in conjunction with the standard survey.

The facility was found not in substantial compliance with Medicare/Medicaid regulations with multiple deficiencies including failure to ensure call lights were accessible, failure to honor resident rights, inaccurate coding of falls, failure to revise care plans for restorative nursing refusals, failure to provide adequate activities of daily living care, failure to provide restorative nursing services as ordered, failure to lock medication carts and remove expired medications, failure to maintain accurate restorative nursing documentation, and failure to maintain infection control during wound care.

The survey included investigation of multiple complaint intake numbers: GA00248125, GA00250382, GA00248280, GA00240308, GA00245261, GA00243190, GA00245573, GA00241838, GA00247611, GA00245542, GA00248419, GA00240670, GA00240211, GA00250378, and GA00240279.

The facility was reviewed for failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a required seven-day reporting period.

The facility failed to report complete COVID-19 data to the NHSN between 02/12/2024 and 02/18/2024 as required by CMS and CDC regulations, which has the potential to cause more than minimal harm to all residents.

The inspection was conducted due to the facility's failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a required seven-day reporting period.

The facility did not report complete COVID-19 data to the NHSN between 02/05/2024 and 02/11/2024 as required by CMS and CDC regulations, which has the potential to cause more than minimal harm to all residents.

The inspection was conducted due to the facility's failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a required seven-day reporting period.

The facility did not report complete COVID-19 data to the NHSN between 01/29/2024 and 02/04/2024 as required by CMS and CDC regulations, which has the potential to cause more than minimal harm to all residents.

The facility was reviewed for failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a required seven-day reporting period.

The facility did not report complete COVID-19 data to the NHSN between 01/22/2024 and 01/28/2024 as required by CMS and CDC regulations, potentially causing more than minimal harm to residents.

A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.

The surveyor noted that all previously cited deficiencies have been corrected.

The document is a statement of deficiencies and plan of correction for the facility East Lake Arbor, indicating a regulatory inspection was conducted.

No specific deficiencies or findings are detailed in the provided report; only an initial comments section is present without further content.

A revisit survey was conducted to verify correction of deficiencies cited during the October 4, 2023 Standard Survey.

All deficiencies cited in the prior October 4, 2023 Standard Survey were found to be corrected during this revisit survey.

The inspection was conducted as a Licensure Survey from September 26, 2023 through October 4, 2023 to assess compliance with state and federal regulations for the healthcare facility.

The facility was found out of compliance with multiple deficiencies including failure to maintain emergency tracheostomy supplies and staff training, improper medication management, infection control breaches, inadequate care planning, environmental sanitation issues, and unsafe water temperatures. Immediate Jeopardy was identified related to tracheostomy care but was removed after corrective actions.

A standard annual survey was conducted at East Lake Arbor from September 26, 2023 through October 4, 2023 to assess compliance with Medicare/Medicaid regulations and facility licensing requirements.

The survey identified multiple deficiencies including Immediate Jeopardy related to lack of emergency tracheostomy supplies and staff training for resident #69, medication self-administration assessment failure for resident #70, environmental cleanliness issues, failure to obtain criminal background check for the Administrator, incomplete comprehensive care plans for several residents, unsafe hot water temperatures, missing physician order for urinary catheter for resident #349, improper respiratory equipment storage, failure to document duration of psychotropic medication for resident #20, medication administration errors for resident #97, inadequate administrative oversight, and infection control breaches during tracheostomy care and laundry operations.

The inspection report documents the facility's failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a required seven-day reporting period.

The facility did not report complete COVID-19 data to the NHSN between 09/25/2023 and 10/01/2023 as required by CMS and CDC regulations, which has the potential to cause more than minimal harm to all residents.

Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements and NFPA 101 Life Safety Code standards.

The facility was found not in substantial compliance with life safety requirements, including blocked egress corridors, failure to maintain smoke-tight hazardous areas, incomplete sprinkler coverage, lack of electronic monitoring on sprinkler system valves, doors failing to latch or seal properly, missing junction box covers, overdue elevator inspection, missing generator annunciator, and improper use of electrical power strips.

The inspection was conducted to assess the facility's compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).

The facility failed to report complete information about COVID-19 to the NHSN during a seven-day period from 08/15/2022 to 08/21/2022 as required by regulation, which has the potential to cause more than minimal harm to all residents.

The document is a statement of deficiencies and plan of correction for the facility East Lake Arbor, indicating a regulatory inspection was conducted.

The report contains initial comments but does not provide detailed findings or deficiencies within the provided page.

A revisit was conducted on 4/20/2022 to verify correction of deficiencies cited during the previous revisit survey on 2/17/2022.

All deficiencies cited as a result of the revisit survey on 2/17/2022 were found to be corrected as of 3/8/2022.

An abbreviated survey was conducted to investigate complaint #GA00222595.

The complaint was unsubstantiated and no deficiencies were found during the survey.

Complaint #GA0022595 was unsubstantiated with no deficiencies.

An abbreviated/partial extended survey was conducted to investigate complaint GA00220378.

The complaint GA00220378 was found to be unsubstantiated after the investigation.

Complaint GA00220378 was investigated and found to be unsubstantiated.

The revisit survey was conducted from 2/15/22 through 2/17/22 to verify correction of previously identified deficiencies related to nursing care and adherence to resident care plans.

The facility failed to follow the care plan for one resident (R#77) who was required to wear a smoking apron for safe smoking. Observation and interviews confirmed the resident smoked without wearing the apron, and staff did not verify the resident's compliance with the care plan.

A revisit survey was conducted from 2/15/2022 through 2/17/2022, including investigation of Complaint Intake Number GA00220378, which was unsubstantiated. The revisit survey aimed to verify correction of previous deficiencies related to Medicare/Medicaid compliance.

The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies related to failure to follow the care plan for safe smoking practices for one resident (R#77), failure to ensure safe smoking supervision and use of smoking aprons, failure of administration to effectively oversee the smoking program, and failure of the Quality Assurance-Performance Improvement (QAPI) committee to implement corrective actions addressing smoking safety.

Complaint Intake Number GA00220378 was investigated in conjunction with the revisit survey and was found to be unsubstantiated.

The inspection was a licensure survey conducted from 12/5/21 to 12/8/21 to assess compliance with nursing care and safety regulations for residents.

The facility failed to follow care plans for four residents related to weekly skin assessments and safe smoking practices. Specifically, skin assessments were not consistently documented or explained, and residents were observed smoking without required safety aprons.

A standard survey was conducted from December 5, 2021 through December 8, 2021, including investigation of multiple complaint intakes related to the facility's compliance with Medicare/Medicaid regulations.

The facility was found not in substantial compliance with regulations, with deficiencies including failure to prevent abuse of a resident by a contracted CNA, failure to follow care plans for skin assessments and safe smoking, failure to perform weekly skin assessments on residents with pressure ulcers, failure to provide smoking aprons to residents assessed as needing them, and failure to follow physician orders for tube feeding management.

Complaint Intake Numbers GA00215433, GA00216093, GA00217998, and GA00218845 were investigated in conjunction with the standard survey.

A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 Edition.

The facility was found to be in compliance with the Emergency Preparedness Program requirements and Life Safety Code standards during the survey conducted on 12/07/2021.

The document is a statement of deficiencies and plan of correction for the facility East Lake Arbor, indicating a regulatory inspection was conducted.

The report contains initial comments but does not provide detailed findings or deficiencies in the provided page.

A revisit survey was conducted from 7/27/2021 through 7/28/2021 to verify correction of deficiencies cited in the 4/30/2021 COVID-19 Focus Infection Control and Complaint Survey.

All deficiencies cited as a result of the 4/30/2021 COVID-19 Focus Infection Control and Complaint Survey were found to be corrected.

A Licensure Survey was conducted from 4/5/2021 through 4/30/2021 to assess compliance with licensure requirements for the facility.

The facility failed to complete fall risk assessments and implement interventions to prevent falls for one resident out of 14 reviewed, and failed to offer and administer the pneumonia vaccine to five of 30 sampled residents.

An Abbreviated Survey was conducted to verify the removal of Immediate Jeopardy related to COVID-19 infection control and staffing deficiencies identified during a prior extended survey.

The facility was found to have removed the Immediate Jeopardy but remained out of compliance at a lower scope and severity for issues including sufficient nursing staff, administration, governing body oversight, QAPI activities, infection prevention and control, and COVID-19 testing of residents and staff.

A Licensure Survey was conducted from 4/5/2021 through 4/30/2021 to assess compliance with licensure requirements for the facility.

The facility was found deficient in completing fall risk assessments and implementing interventions to prevent falls for one resident, and in offering and administering the pneumonia vaccine to five of 30 sampled residents.

A COVID-19 Focused Infection Control Survey in conjunction with a complaint survey was conducted from 4/5/2021 through 4/30/2021 to investigate multiple complaints related to infection control and COVID-19 testing.

The facility was found not in compliance with infection control regulations, with substantiated complaints citing failures in COVID-19 outbreak testing, insufficient nursing staff, lack of dedicated COVID units and staff, inadequate resident monitoring for COVID symptoms, and ineffective infection control practices. Immediate Jeopardy was identified due to these deficiencies.

Complaint #GA00211683, #GA00212691, #GA00212584, #GA00213946 and #GA00206759 were substantiated. Complaint #GA00212693 was unsubstantiated.

The inspection was conducted to investigate multiple complaints filed against the facility, including complaint numbers GA00204906, GA00206173, GA00205592, GA00205589, GA00205064, GA00204937, GA00203548, GA0019986, and GA00199881, and to assess infection control practices related to COVID-19.

The complaint investigations were unsubstantiated with no deficiencies cited. The desk review of infection control practices related to COVID-19 also found no deficiencies.

The complaint survey conducted from 6/30/2020 to 7/08/2020 found the complaints unsubstantiated with no deficiencies cited. The earlier complaint investigation from 5/1/2020 to 5/4/2020 for complaint GA00204906 was also unsubstantiated with no deficiencies.

A COVID-19 Focused Infection Control Survey was conducted to assess compliance with infection control regulations and preparedness for COVID-19.

The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.

A revisit survey was conducted to verify correction of deficiencies cited in the 9/13/19 Complaint Survey.

All deficiencies cited as a result of the 9/13/19 Complaint Survey were found to be corrected.

A complaint survey was conducted to investigate complaint GA00196498 by a Registered Nurse Surveyor to determine compliance with Federal and State Long Term Care Requirements.

No deficiencies were cited during the complaint investigation survey.

Complaint GA00196498 was investigated and found to have no deficiencies.

A complaint survey was conducted to investigate a complaint by a Registered Nurse Surveyor to determine compliance with Federal and State Long Term Care Requirements.

The complaint was found to be unsubstantiated and no deficiencies were cited during the survey.

Complaint was unsubstantiated with no deficiencies cited.

An unannounced, abbreviated survey was initiated and concluded on 3/11/19 to investigate Complaint # GA00195020, Event # QZ2L11.

The complaint was substantiated without citation.

Complaint # GA00195020 was substantiated without citation.

The inspection was conducted to investigate complaint #GA00194306 and determine compliance with Federal and State Long Term Care regulations.

No deficiencies were cited during the complaint survey conducted on 2/18/19 and 2/20/19.

Complaint #GA00194306 was investigated and found to have no deficiencies.

A complaint survey was conducted from 1/22/2019 through 1/23/2019 to investigate complaints #GA00193741, GA001939833, and GA00193967.

The investigation determined compliance with Federal and State Long Term Care Requirements, 42 CFR, Part 483, Subpart B, and no deficiencies were cited.

Complaints #GA00193741, GA001939833, and GA00193967 were investigated and found to be unsubstantiated as no deficiencies were cited.

A revisit survey was conducted to verify correction of deficiencies cited during the September 23, 2018 recertification survey.

All deficiencies cited in the prior recertification survey were found to be corrected as of October 16, 2018.

A standard survey was conducted from September 17 through September 23, 2018, in conjunction with complaint investigations (GA00191086 and GA00191420) related to infection control and professional standards of care regarding sanitizing glucometers.

The facility failed to ensure licensed nursing staff properly sanitized glucometers between resident uses, risking cross contamination of blood borne pathogens including HIV and Hepatitis C. Licensed staff lacked training on proper sanitization techniques. The facility's Infection Preventionist was not performing required oversight. Immediate Jeopardy was identified and removed after the facility implemented staff training, competency checks, audits, and revised policies. The QAPI committee was found not to have effectively monitored infection control practices prior to the survey.

Complaint Intake Numbers GA00191086 and GA00191420 were investigated in conjunction with the standard survey. Immediate Jeopardy was identified related to infection control failures in sanitizing glucometers, posing risk of serious injury or death to residents.

The inspection was conducted due to concerns about improper cleaning and disinfecting of blood glucose meters used for multiple residents, including those with infectious diseases, potentially risking cross-contamination.

The facility failed to follow its infection control policy and manufacturer's guidelines for cleaning and disinfecting blood glucose meters, with multiple licensed nurses observed not properly sanitizing the glucometers between resident uses. The facility implemented corrective actions including staff training, individual glucometers for residents with infectious diseases, and ongoing audits.

The investigation was complaint-driven based on observations and interviews revealing noncompliance with infection control practices related to blood glucose meter sanitization. The complaint was substantiated with immediate jeopardy removed after corrective actions.

A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 Edition.

The facility was found to be in substantial compliance with the Life Safety Code requirements and the Emergency Preparedness Plan was also in substantial compliance with Appendix Z requirements.

A complaint survey was conducted to investigate complaints #GA00189594 by a Qualified Surveyor to determine compliance with Federal and State Long Term Care Requirements.

No deficiencies were cited during the complaint survey.

Complaint #GA00189594 was investigated and found to have no deficiencies.

A complaint survey was conducted on 6/8/2018 and 6/11/2018 to investigate complaints #GA00188670 and GA00189168 by a Qualified Surveyor to determine compliance with Federal and State Long Term Care Requirements.

No deficiencies were cited during the complaint survey.

Complaints #GA00188670 and GA00189168 were investigated and found to have no deficiencies.

A complaint survey was conducted to investigate complaint # GA00187425 by a Qualified Surveyor to determine compliance with Federal and State Long Term Care Requirements.

No deficiencies were cited during the complaint investigation survey.

Complaint # GA00187425 was investigated and found to have no deficiencies.

A complaint survey was conducted on 2/20/18 - 2/21/18 to investigate complaints GA00184540 and GA00184945 by a Registered Nurse Surveyor to determine compliance with Federal and State Long Term Care Requirements.

No deficiency was cited during the complaint survey.

The survey was conducted in response to complaints GA00184540 and GA00184945; no deficiencies were found.

This document is a Statement of Deficiencies and Plan of Correction for the facility East Lake Arbor, indicating a regulatory inspection was conducted and corrective actions are planned.

The document contains no detailed findings or deficiencies; it only includes an initial comments section without specific content.

A follow-up survey was conducted to verify correction of previously cited deficiencies.

All previously cited tags have been corrected as noted during the follow-up survey.

The visit was a life safety code survey conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and sprinkler system maintenance.

The facility was found not in substantial compliance due to failure to have the sprinkler system annually tested within the required 12-month period, with the last test dated October 3, 2016, making it 21 days overdue at the time of inspection.

The inspection was conducted as a Complaint Survey to investigate complaints GA00180111, GA00179878, and GA00179777 to determine compliance with Federal and State Long Term Care regulations.

No deficiencies were cited during the complaint survey conducted on 09/29/17 and 09/30/17 at East Lake Arbor.

The survey was conducted to investigate three complaints identified as GA00180111, GA00179878, and GA00179777. No deficiencies were found, indicating the complaints were not substantiated.

The inspection was conducted to investigate complaints #GA00171241 and GA00171660 and to determine compliance with Federal and State Long Term Care regulations.

No deficiencies were cited during the complaint survey conducted at East Lake Arbor.

The survey was complaint-related, investigating two complaints, and no deficiencies were found.

A health follow-up visit survey was conducted to a Standard Extended Survey in addition to a Complaint Survey to investigate multiple complaints (#GA00165252, #GA00164512, #GA00164476, #GA00163786, and #GA00163751) from August 28, 2016 through September 19, 2016.

The follow-up survey conducted January 3-5, 2017 determined that the previous deficiencies had been corrected.

The visit was complaint-related, investigating five complaints identified by their numbers, but the previous deficiencies were found corrected.

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