Inspection Reports for East Lake Arbor

The facility failed to implement the care plan for mechanical lift transfers for one resident, did not follow nutrition orders for a resident with feeding tubes, and failed to implement Enhanced Barrier Precautions for two residents with feeding tubes, placing residents at risk of harm and infection.

The facility failed to maintain an effective pest control program, with live and dead roaches observed in five of eight resident rooms. Pest Control Technician reports and observations confirmed ongoing sanitation issues contributing to the infestation, and the administrator acknowledged awareness of the problem.

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.

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

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.

The investigation was complaint-driven, focusing on issues such as call light accessibility, resident rights, care planning, restorative services, medication management, and infection control.

The facility was found deficient in multiple areas including failure to ensure call lights were accessible to residents, failure to honor resident choice, inaccurate coding of a major injury fall, failure to revise care plans to reflect refusals of restorative services, failure to provide adequate ADL care, failure to provide restorative nursing services as ordered, failure to maintain medication carts securely and remove expired medications, failure to maintain accurate medical records, and failure to adhere to infection control protocols during wound care.

The visit was complaint-related, triggered by concerns about resident care including call light accessibility, resident rights, assessment accuracy, care planning, ADL assistance, medication management, restorative nursing, documentation, and infection control. Substantiation status is not explicitly stated.

The facility was found deficient in multiple areas including failure to ensure call lights were accessible to residents, failure to honor resident choice, inaccurate coding of a major injury fall, failure to revise care plans for restorative nursing refusals, inadequate assistance with activities of daily living, failure to provide restorative nursing services as ordered, failure to maintain medication carts securely and remove expired medications, failure to maintain accurate medical records, and failure to adhere to infection control protocols during wound care.

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.

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 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 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 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 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 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.

The facility was found deficient in multiple areas including failure to assess resident ability to self-administer medications, inadequate environmental cleanliness, failure to obtain required criminal background checks, incomplete and inaccurate care plans, unsafe water temperatures, lack of physician orders for catheter use, failure to provide emergency tracheostomy care and supplies, medication errors, and inadequate infection prevention and control practices.

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.

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 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.

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 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 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.

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

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.

The complaint investigation was substantiated with findings that CNA SS physically abused resident R#391 by hitting her in the head. The CNA was removed from the facility, terminated from the staffing agency, and reported to the Certified Nursing Assistant Registry. Additional investigations and charges were initiated by local authorities and Adult Protective Services.

The facility failed to protect resident R#391 from physical abuse by a CNA, failed to perform required weekly skin assessments for residents with pressure ulcers, did not follow physician orders for feeding tube care for resident R#53, and failed to ensure smoking safety including use of smoking aprons for residents assessed as needing them. The facility administration also failed to effectively oversee the smoking program and implement corrective actions.

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.

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

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.

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.

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.

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.

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

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 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 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.

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.

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 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.