Arbor Lake Skilled Nursing & Rehabilitation

Inspectors wroteBased on record review and interviews, the facility failed to act promptly upon the grievances voiced by residents during monthly Resident Council meetings and failed to demonstrate the facility's response for such grievances.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure residents that received psychotropic drugs were not subjected to chemical restraints for 4 (#2, #11, #25, #37) of 5 (#2, #11, #25, #37, #65) residents reviewed for unnecessary medications. The facility failed to ensure:1). as needed (PRN) orders for psychotropic drugs were limited to 14 days (#2, #11, #37),2). a gradual dose reduction was attempted (#25, #37), and3). a physician addressed pharmacist recommendations (#25)

Inspectors wroteBased on record reviews and interviews the facility failed to ensure that a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 (#40) of 1 residents reviewed for pressure ulcers. The facility failed to 1) have documented evidence of weekly body audits, 2) have documented evidence of wound treatments performed as ordered, and 3) failed to have an accurate pressure ulcer assessment.

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs by failing to ensure laboratory tests were collected as ordered for 1 (#11) of 5 (#2, #11, #25, #37, #65) residents reviewed for unnecessary medications.

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. The facility failed to 1) disinfect whirlpool A and whirlpool B per Manufacturer's Instructions for Use, and 2) implement standard precautions for proper storage of a non-invasive urine collection system, and administration of medications.

Inspectors wroteBased on observations and interviews the facility failed to ensure all mechanical equipment was maintained in safe operating condition by having a pipe leaking water under the 3-compartment sink and the deep fryer with grease buildup on the internal compartment. This deficient practice had the potential to affect 93 residents that received meals from the kitchen.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure each resident was treated with dignity and respect in an environment that promotes maintenance and enhancement of his or her quality of life for 1 (#77) of 1 resident reviewed for dignity.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to develop and implement a comprehensive care plan for 1 (#90) of 1 (#90) resident reviewed for care of a urinary collection system. FindingsReview of the medical record for Resident #90 revealed diagnoses that included personal history of urinary tract infections, and overactive bladder. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #90 had a Brief Interview for Mental Status (BIMS) score of 10 which indicated the resident had moderate cognitive impairment. On 09/29/2025 at 9:15 a.m. and 10/01/2025 at 8:22 a.m., observations revealed Resident #90 was in her recliner in her room. Further observations revealed her urine collection system tubing was not covered and was clipped to the upper drawer of her plastic storage bin. [...]

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure residents were free from physical restraints imposed for the purpose of discipline or convenience for 3 (#42, #64, and #92) of 8 (#10, #18, #20, #27, #42, #64, #68, and #92) residents reviewed for restraints. The facility failed to ensure: 1). restraint consents were obtained which included risks and benefits of the restraint use for residents #42, #64, and #92; 2). physician orders were obtained for the lap trays for residents #64, and #92; and 3). monitoring was conducted for the release of the lap trays for residents #42, #64, and #92.

Inspectors wroteResident #18 Review of resident #18's medical record revealed she was admitted to the facility on [DATE] with diagnoses including heart failure, Alzheimer's disease, and anxiety disorder. Review of resident #18's MDS assessment dated [DATE] revealed a BIMS score of 00, which indicated the resident was unable to complete the test. Further review revealed she required extensive assistance with bed mobility. An observation of resident #18 on 10/28/2024 at 9:11a.m. revealed she was lying in bed with a right quarter side rail that was raised. Observations of resident #18 on 10/29/2024 at 9:15 a.m. and 1:48 p.m. revealed she was lying in bed on her right side with the right quarter side rail raised. Review of resident #18's Consent for Assistive Devices revealed the facility failed to identify the assistive device implemented for the resident which was a right quarter side rail. [...]

Inspectors wroteResident #50 Review of the record for resident #50 revealed an admission date of 03/13/2024 with diagnoses including unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, depression, hypertension, edema, hyperlipidemia, neuralgia and neuritis, hypokalemia, other pulmonary embolism without acute cor pulmonale, Parkinson's disease with dyskinesia with fluctuations, anxiety disorder, Alzheimer's disease, and vascular dementia unspecified severity with mood disturbance. Review of the Quarterly MDS assessment dated [DATE] revealed a BIMS score of 4 indicating severe cognitive impairment. Review of resident #50's current Physician's Orders revealed the following orders: 07/13/2024- Lasix oral tablet 20 milligrams (mg) give 1 tablet 1 time a day; [...]

Inspectors wroteBased on record reviews and interviews, the pharmacist failed to identify and report irregularities to the attending physician, the facility's medical director, and the director of nursing. The pharmacist failed to identify the nurses' incomplete medication administration documentation for 4 (#50, #59, #68, and #93) of 5 (#50, #59, #68, #92, and #93) sampled residents reviewed for unnecessary medications, 1 (#17) of 1 sampled resident reviewed for an antibiotic medication, and 1 (#83) of 1 sampled resident reviewed for an anticoagulant medication.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to assess a resident for self-administration of medications for 1 (#152) of 1 sampled residents.

Inspectors wroteBased on record review and interview, the facility failed to have documentation in the medical record regarding the need for a resident to be transferred to the hospital for 1 (#61) of 3 (#45, #61, #99) residents reviewed for hospitalization.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to provide an ongoing program of activities based on the comprehensive assessment, care plan and the preference of each resident to support residents in their choice of activities for 1 (#97) of 3 (#32, #42, and #97) residents reviewed for activities.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure the resident received adequate supervision to remain as free of accident hazards as possible for 1 (#1) of 1 (#1) residents investigated for smoking.

Inspectors wroteBased on record review and interview, the facility failed to ensure resident's drug regimens were free from unnecessary psychotropic medications for 1 (#93) of 5 (#50, #59, #68, #92, and #93) residents reviewed for unnecessary medications. The facility failed to ensure a psychotropic medication was used only when there was an acceptable diagnosis documented in the medical record for resident #93.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure that licensed nurses have the specific competencies and skill sets necessary to care for a resident's need by not having: 1) Documented evidence of wound care completed for resident #83 as ordered; and 2) Documented evidence of medications administered to resident #100 on 11/13/2023 as ordered.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure residents who were unable to carry out activities of daily living receive the necessary services to maintain good personal hygiene by failing to ensure resident's fingernails were trimmed and cleaned in a timely manner for 1 (#49) of 2 (#49, #54) residents reviewed for activities of daily living.

Inspectors wroteBased on record review and interview, the pharmacist failed to report any irregularities to the attending physician, facility's medical director, and director of nursing by failing to report lab not obtained as ordered for 1 (#68) of 5 (#47, #63, #68, #100, and #259) sampled residents reviewed for unnecessary medications. The pharmacist failed to identify that the facility failed to obtain a Fasting Lipid Panel (FLP) for resident #68 yearly.

Inspectors wroteBased on record review and interview the facility failed to obtain laboratory testing as ordered by the physician for 1 (#68) of 5 (#47, #63, #68, #100, and #259) residents reviewed for laboratory services. The facility failed to draw a Fasting Lipid Panel (FLP) yearly for resident #68.