Arbor Lake Nursing & Rehabilitation, LLC

Inspectors wroteBased on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical and nursing needs to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 3 residents (Residents #1) reviewed for comprehensive care plans in that: Resident #1's care plan did not address he was a smoker/vaper (A vape (short for vaporizer) is a battery-operated electronic device that heats a liquid to create an aerosol (mist or vapor) that is inhaled into the lungs. It simulates cigarette smoking but does not burn tobacco. Vaping refers to the act of using this device). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective pest control program for 1 of 1 kitchen to keep it free of flies. The facility failed to ensure the kitchen was free of flies on 05/19/26. This failure could affect residents who eat from the kitchen placing them at risk for the potential spread of infection and decreased quality of life.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to act as a fiduciary of the residents' funds and hold, safeguard, manage and account for the personal funds of the resident deposited with the facility for nine (Residents #1, #2, #3, #4, #5, #6, #7, #8 and #9) of nine residents reviewed for resident trust accounts. The facility did not monitor resident trust fund account balances to ensure funds did not exceed Medicaid resource limits. The facility allowed Residents #1, # 2, #3, #4, #5, #6, #7, #8 and #9 trust funds to remain over $3,000, which placed them at risk of losing their Medicaid eligibility. This deficient practice could affect all residents with a resident trust account by placing their Medicaid eligibility at risk and becoming ineligible for nursing facility care, financial hardship, and possible involuntary discharge for nonpayment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had the right to be free from abuse for 1 of 6 residents (Resident #33) reviewed for abuse. The facility failed to ensure residents were free resident-to-resident abuse when Resident #33 entered Resident #21's room, and Resident #21 pushed Resident #33 down. Resident #33 sustained abrasions on his nose and right knee. The failure placed residents at risk for abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who displays or was diagnosed with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for 1 of 4 residents (Resident #33) reviewed for dementia services. The facility failed to ensure Resident #33 was provided with treatment and services to address his wandering behaviors related to his diagnosis of dementia which resulted in the resident entering Resident #21's room and being pushed by Resident #1. Upon being pushed, Resident #33's face/head bumped Resident #21's dresser, and Resident #33 sustained abrasions on his nose and right knee. This failure puts residents with dementia at increased risk of not having their dementia-related needs met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary and comfortable interior for 2 of 17 residents (Residents #3 and Resident #13) reviewed for environment. 1. The facility failed to maintain a comfortable or private homelike environment for Residents #3 and #13. These failures placed residents at risk of decreased feelings of self-worth, increased harm and an impersonalized homelike environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 2 of 5 residents (Resident #19 and Resident #59) reviewed for ADL care. The facility failed to provide Resident #19 and Resident #59 assistance with grooming and nail care. Resident #19 and Resident #59's nails were observed to be about half inch long with black debris under nails on both hands. Both resident's appearance was disheveled with their clothing and uncleaned hair. This failure could place the residents at risk for decreased feelings of self-worth and infection. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 2 (Resident #76 and #96) of 3 residents reviewed for infection control during medication administration. The facility failed to ensure MA E disinfected the blood pressure cuff in between blood pressure checks for Resident #98 and Resident #76. RN D failed to wear a gown while providing care for Resident #96, who was on enhanced barrier precautions for Gastronomy tube. These failures could place residents at-risk of cross contamination which could result in infections or illness.

Inspectors wroteThe facility failed to provide a 30-day written notice of discharge as well as discharge planning for 1 of 14 residents reviewed for discharge planning. * The failure to provide a 30-day written discharge notice and discharge planning could result in residents experiencing psychosocial harm due to inappropriate discharges and placed residents at risk of being discharged without alternate placement and not having access to available advocacy services, discharge/transfer options, and denying them their rights in the appeal process.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure the resident environment remains as free of accident hazards as is possible for 1 of 3 residents (Resident #1) reviewed for accidents. The facility failed to ensure Resident #1 was free from accidents/hazards on 03/16/25 when she was shocked after plugging in her phone charger to the wall socket, that resulted in burns to her fingers and hand. An IJ was identified on 04/14/25. The IJ template was provided to the facility on [DATE] at 4:03 PM. While the IJ was removed on 04/15/25, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because the facility was continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could expose residents to risk of injury or death from electrical shock.

Inspectors wroteBased on interviews, and record reviews the facility failed to ensure that an alleged violation involving neglect, or injuries of unknown source were reported immediately for 1 of 3 residents (Resident #1) reviewed for accidents. LVN A failed to immediately report an incident to the Administrator i nvolving Resident #1 on 03/16/25 when she alleged she was shocked after plugging in her phone charger to the wall. Resident #1 sustained a charred mark to her finger and blisters to her finger and thumb from the incident. This failure could have caused residents to suffer cardiac issues.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 of 4 residents (Resident #1) reviewed for quality of care. The facility failed to ensure Resident #1 received treatment after she sustained blisters to her fingers on 03/16/25 after coming into contact with an electrical outlet in her room that sparked and caused scorching on the outlet and surrounding wall area. The failure placed residents at risk of delay treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program to keep the facility free of pests for 1 of 8 residents (Resident #1) reviewed for pest control. The facility failed to prevent pests from entering the facility. On 05/28/25, Resident #1 was found in bed with ants (breed/type unknown) on his body, and he had been bitten multiple times on his torso, arms, and legs. This failure placed residents at risk of physical harm from ant or other pest bites.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure parenteral fluids were administered consistent with professional standards of practice and in accordance with physician orders for one (Residents #1) of three residents reviewed for parenenteral fluids. The facility failed to ensure Resident #1 received routine PICC line dressing changes per physician orders. This failure placed the residents at risk for infections.

Inspectors wroteBased on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #2) of 8 residents reviewed for infection control. The facility failed to investigate and report to the County Health Department when Resident #2 was diagnosed with shigella. This failure placed residents at risk for infections.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain medical records on each resident that were complete and accurately documented, in accordance with accepted professional standards and practices for one of three residents (Resident #1) reviewed for wound records. The facility failed to accurately document Residents #1's wound care. This failure could place residents at risk of missed wound care and infection.

Inspectors wroteBased on interview, and record review, the facility failed to provide and document sufficient preparation to ensure safe and orderly discharge from the facility for one resident (Resident #1) of five residents reviewed for discharge. The facility failed to ensure Resident #1's home health and wound care services were confirmed and in place prior to discharge. These failures could place residents at risk of being discharged without preparation, causing a disruption in their care and place the residents at risk for their needs not being met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident had the right to a safe, clean, comfortable, and homelike environment, which included but not limited to receiving treatment and supports for daily living safely for 5 of 15 residents (confidential residents) reviewed for safe, clean, comfortable, and homelike environment. The facility failed to maintain resident's wheelchairs in a sanitary and safe operating condition according to 5 residents who attended the confidential group interview. These failures could affect residents and place them at risk for not having a safe and sanitary homelike environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice, for 1 of 1 resident (Resident #31) reviewed for dialysis. The facility failed to ensure post-dialysis assessments were completed for Resident #31 after return from dialysis treatment. This failure could place residents at risk of inadequate post dialysis care.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain medical records that were complete and accurately documented for 2 of 5 residents (Resident #45 and Resident #34) reviewed for resident records. 1. The facility failed to ensure Resident #45's Medication Administration Record accurately reflected the medications administered to the resident. 2. The facility failed to accurately document Residents #34's PICC line dressing change. This failure could place the resident at risk of missed or extra doses of her medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program to ensure the facility was free of pests for 1 of 3 Halls (100 Hall), dining room and 1 of 1 conference room reviewed for pests. The facility failed to ensure an effective pest control program was implemented to prevent the presence of gnats throughout the facility. This failure could place residents at risk for the potential spread of infection, cross-contamination, and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents had the right to be informed of the risks, and participate in, his or her treatment which included the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred, for 1 of 30 residents (Resident #71) reviewed for resident rights. The facility failed to obtain a signed informed psychotropic consent based on information of the benefits, risks, and options available from Resident #71's responsible party/representative prior to administering Zoloft 50 mg, Buspirone Hcl 10 mg, Seroquel 25 mg, Valproic Acid Oral Solution 250 mg/5 ml (Valproate Sodium), and Seroquel 50 mg. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure assessments accurately reflected the resident status for 1 of 12 residents (Resident #56) reviewed for MDS assessment accuracy. The facility failed to ensure Resident #56's quarterly MDS assessment, dated 04/17/24, was coded correctly for gastrostomy tube status. This failure could place residents at risk of not receiving care and services to meet their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents unable to conduct activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene for 2 of 8 residents (Resident #33) reviewed for quality of life. The facility failed to ensure Resident #33's fingernails were cleaned and cut. This failure could place residents at risk for poor hygiene, dignity issues, and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received parenteral fluids administered consistent with professional standards of practice and in accordance with physician orders for 1 of 2 residents (Resident #34) reviewed for peripheral intravenous care. The facility failed to ensure Residents #34's PICC line dressings were changed per the physician's order. This failure placed residents at risk of developing an infection.

Inspectors wroteBased on interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for one (Resident #1) of four residents reviewed for medications and pharmacy services. The facility failed to administer Resident #1's blood pressure medications-Midodrine in accordance with the physician orders. Resident #1 was administered Midodrine when his blood pressure was out of parameters and the medication was ordered to be held 17 times in November 2023. Additionally, Resident #1's Midodrine was held 13 times in November 2023, but there were no blood pressure readings documented to indicate what his parameters were and if the medication should have been administered. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to promptly notify the physician, physician assistant, nurse practitioner, or clinical specialist of the results that fall outside of clinical reference ranges in accordance with facility policies and procedures for notification or a practitioner or per the ordering physician's orders for one (Resident #2) of four residents reviews for laboratory services. The facility failed to notify the physician [MD H] of Resident #2's stat x-ray results when she had a change in condition. The x-ray results indicated there were findings. The failure could place residents at risk for not receiving timely medical intervention as needed and ordered by the physician and a potential for decreased health status and discomfort.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that in accordance with accepted professional standard and practices, medical records were complete and accurately documented for two (Residents #2 and #3) of three residents reviewed for clinical records accuracy. The facility failed to document Resident #2 and Resident #3 received their medications during the 6:00 AM-2:00 PM shift on Sunday, 12/17/23. The facility failure could place residents at risk of inaccurate medication administration and inaccurate clinical records that could lead to medication errors and poor health management control.

Inspectors wroteBased on interview and record review, the facility failed to notify the resident, resident's representative, and ombudsman of the transfer or discharge and the reasons for the move in writing and in a language and manner they understood, and record specified contents of notice in the resident's medical record for 1 resident (Resident #1) of 3 residents reviewed for discharge and transfer rights. 1. The facility failed to give written or verbal notice to Resident #1's RP regarding the effective date and location of transfer prior to transferring the resident. Resident #1 was transferred to a different nursing facility without consent from his RP. 2. The facility failed to document in Resident #1's medical record all specified contents of transfer notice and evidence of RP's verbal or written notice of acknowledgment to leave the facility . [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to immediately consult with the resident's physician when there was a significant change in the resident's condition or a need to alter treatment significantly for one (Resident #5) of 18 residents reviewed for physician consultation. RN F and LVN G failed to consult with Resident #5's physician when his blood sugars were above 300 for 23 days in March/April 2023. The failure placed residents, who required finger-sticks for blood sugar, at risk for diabetic complications due to delayed physician intervention.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen. The facility failed to use proper sanitization procedures with thermometer when taking temperature of food items prepared on the holding table. This failure could place all residents who receive food prepared in the facility's only kitchen at an increased risk of exposure to food-borne illnesses.

Inspectors wroteBased on interview and record review, the facility failed to develop a baseline care plan within 48 hours of resident's admission for one (Resident #191) of 18 residents reviewed for baseline care plan completion. The facility failed to complete a baseline care plan within the required 48-hour timeframe for Resident #191. This failure could place residents at risk for not receiving necessary care and services or not having important care needs identified.

Inspectors wroteBased on interview and record review, the facility failed to implement a comprehensive person-centered care plan for each resident to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and described the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for one (Resident #5) of 18 residents reviewed for care plans. The facility failed to develop a care plan to address Resident #5's non-compliance with adhering to a diabetic diet. This failure could place residents at risk of receiving inadequate interventions not individualized to their care needs.

Inspectors wroteBased on observation, record review, and interview, the facility failed to store all drugs and biologicals under proper temperature controls for two (100 and 200 Halls refrigerator) of three medications storage refrigerators reviewed for compliance. The facility failed to ensure the temperatures for the medication refrigerators for 100 and 200 halls were being checked and documented properly to ensure drugs and biologicals stored in the refrigerators were at the proper temperatures. The failure placed residents at risk of receiving medications that were ineffective due to improper temperature control checking and documenting.