Arbor Village

Inspectors wroteThe 2567 had been amended based on a determination resulting from an Informal Dispute Resolution (IDR). Existence of Immediate Jeopardy (IJ) has been removed. Based on observation, record review, and interview, the facility failed to:a. ensure supervision for residents who smoke and to secure smoking materials to prevent accident hazards for 1 (#5) of 3 sampled residents reviewed for smoking; andb. prevent elopement for 1 (#7) of 3 sampled residents reviewed for elopement. The DON identified 15 residents at risk for elopement resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to develop a comprehensive care plan for 1 (#5) of 3 sampled residents reviewed for care plans. The DON identified 65 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to assess, monitor, and intervene to prevent worsening pressure ulcers for 1 (#2) of 3 sampled residents reviewed for pressure ulcers. The DON identified 7 residents with pressure ulcers resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure medications were administered as ordered for 1 (#5) of 3 sampled residents reviewed for medications. The DON identified 65 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure infection control was maintained for residents with indwelling urinary catheters for 1 (#8) of 3 sampled residents reviewed for infection control. The DON identified 5 residents with indwelling urinary catheters.

Inspectors wroteBased on record review and interview, the facility failed to provide an environment free of accident hazards for 1 (# 69) of 20 sampled residents reviewed for accident hazards. The administrator identified 84 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to:a. review infection prevention control policies and procedures at least annually,b. assess locations Legionella and other opportunistic waterborne pathogens can grow and spread,c. implement measures to prevent the growth of waterborne pathogens, andd. have monitoring in place to evaluate effectiveness of water pathogen program. The administrator reported 64 residents resided in the facility. FindingsA facility policy titled Legionella Surveillance, implemented on 08/22/22, did not include a plan for assessing, evaluating and monitoring the measures to prevent the growth of waterborne pathogens. On 08/07/25 at 2:20 p.m., the infection prevention coordinator was asked about annual review of policies. They stated they were not current and had not been reviewed in a few years. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure the arbitration agreement provided the selection of a neutral arbitrator for 3 (#2, 11, and #71) of 3 sampled residents whose arbitration agreements were reviewed. The administrator identified 63 residents had signed binding arbitration agreements.

Inspectors wroteBased on record review and interview, the facility failed to ensure quarterly assessments were completed within 14 days of the assessment reference date for 3 (#6, 27, and #28) of 20 sampled residents whose assessments were reviewed. The administrator identified 64 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure assessments were submitted/transmitted within 14 days of completion for 2 (#27 and #28) of 20 sampled residents whose assessments were reviewed. The administrator identified 64 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure assessments were accurate for 1 (#2) of 20 sampled residents whose assessments were reviewed. The administrator identified 64 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure care plans were updated for 1 (#2) of 20 sampled residents reviewed for care plans. The administrator identified 64 residents resided in the facility. A care plan, dated 05/09/25, did not include restorative care for Resident #2. An admission assessment, dated 05/17/25, showed the Resident #2 had diagnoses which included hemiplegia and hemiparesis and a BIMS score of 15 which indicated the resident was cognitively intact. A restorative care order dated, 07/07/25, showed a resting hand splint was to be applied daily to the right hand and removed after 6-8 hours. A progress note, dated 07/07/25, documented restorative care treatment with the application of a splint to Resident #2's right hand. On 08/10/25 at 10:01 a.m. [...]

Inspectors wroteBased on record review and interview, the facility failed to complete a performance review of nurse aides, hired over one year ago, at least once every 12 months for 1 (CNA #1) of 2 reviewed for performance reviews. Human resources identified 13 CNAs have been employed over one year.

Inspectors wroteBased on observation, record review, and interview the facility failed to store, prepare, and serve food under sanitary conditions for 77 residents who ate meals prepared by the kitchen. The administrator identified 77 residents who resided in the facility and ate meals prepared by the kitchen.

Inspectors wroteBased on observation, record review, and interview the facility failed to maintain an infection prevention and control program for one (#10) of one resident reviewed for pressure ulcers. The director of nursing identified 12 residents who received wound care.

Inspectors wroteBased on record review and interview, the facility failed to ensure the PASRR for a resident with a serious mental health diagnosis was filled out correctly and referred to the OHCA for two (#14 and #25) of three sampled residents reviewed for PASRR evaluations. The Administrator identified 77 residents resided in the facility.

Inspectors wroteBased on record review and interview the facility failed to ensure the physician responded to the pharmacist medication reviews related to the GDR request with a clinical rational for three (#1, 25, and #34) of five sampled residents reviewed for unnecessary medications. The Administrator reported 77 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure a baseline care plan included fall risk and interventions for one (#1) of three sampled residents reviewed for falls. The DON identified 70 residents resided in the facility.

Inspectors wroteBased on record review, observation, and interview, the facility failed to develop a comprehensive person-centered care plan for one (#42) of six residents reviewed for care plans. The Resident Census and Conditions of Residents, dated 01/23/23, documented a census of 78.

Inspectors wroteBased on record review and interview, the facility failed to develop a discharge summary for one (#77) of one resident reviewed for discharge summary. The Entrance Conference Worksheet, completed on 01/23/23, documented 10 residents had been discharged in the last six months.

Inspectors wroteBased on observation and interview, the facility failed to ensure pureed meals were prepared in a sanitary manner. The administrator reported two residents received pureed meals from the kitchen.