Arbors at Gallipolis

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on record review, review of the Self-Reported Incident (SRI) and investigation, review of video recording, review of a police report, review of an employee file, witness interview, resident and staff interviews, and policy review, the facility failed to ensure residents were free from emotional abuse by facility staff. Actual psychosocial harm occurred on or prior to 03/24/26 for Resident #41 when Certified Nursing Aide (CNA) #777 video recorded Resident #71 while the resident was sleeping without the resident's knowledge or consent. CNA #777 added a written statement to the video that reflected severe anger conveyed through threatening and aggressive wording and posted the recording on a social media platform. [...]

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on record review, review of a self-reported incident (SRI), review of facility investigative documentation, review of facility video footage, personnel file review, policy review, and interview the facility failed to protect Resident #70's right to be free from abuse by Certified Nursing Assistants (CNAs) #210, #220 and #225. Actual harm occurred on 04/11/26 when Resident #2, who was cognitively impaired and diagnosed with dementia, was physically and psychosocially abused by CNAs #210, #220, and #225. The three CNAs forced the resident into a chair, held his arms down to keep him seated, and were overheard by other residents teasing and laughing at him. [...]

Inspectors wroteBased on record review, policy review and interview the facility failed to ensure Resident #2, who had a diagnosis of dementia with behaviors received adequate, necessary and effective interventions as per his care plan to de-escalate a behavioral episode and to prevent increased agitation for the resident. This affected one resident (#2) of five residents reviewed for abuse.

Inspectors wroteBased on observation and interviews, the facility failed to ensure opened multi-dose Tuberculin Purified Protein (TB) vials were dated when opened. This had the potential to affect all 81 residents residing in the facility. Findings Include: On 04/17/25 10:15 A.M., observation of the third floor medication room refrigerator revealed an opened vial of Tuberculin Purified Protein one milliliter (ml) was undated to when the first dose was obtained. Registered Nurse (RN) #196 verified the vial of TB solution was not dated when opened at the time of the observation. On 04/17/25 at 10:22 A.M., observation of the second floor medication room refrigerator revealed an opened vial of Tuberculin Purified Protein one milliliter (ml) was undated to when the first dose was obtained. Licensed Practical Nurse (LPN) #157 verified the TB solution was not dated when opened at the time of the observation.

Inspectors wroteBased on observation, record review, facility policy review and interview, the facility failed to implement adequate and effective interventions to promote healing and prevent the deterioration of a left below the knee surgical site with staples for Resident #48 at the time of the resident's admission. This affected one resident (#48) reviewed for surgical wounds and for pressure wounds.

Inspectors wroteBased on record review, observation, interview, and policy review the facility failed to implement interventions to promote skin integrity for a resident ordered to wear a knee brace. This affected one resident (#48) of one resident reviewed for skin integrity. Findings Include: Review of the medical record for Resident #48, revealed an admission date of 3/20/25 (from the hospital). Diagnoses included but were not limited to acquired absence of left leg below knee, need for assistance with personal care, weakness, cerebral infarction, atherosclerosis of native arteries of extremities with gangrene, left leg, hemiplegia, affecting left nondominant side, dementia, and chronic obstructive pulmonary disease. Review of the hospital discharge paperwork dated 03/20/25 for Resident #48 revealed a left knee immobilizer to be on at all times. [...]

Inspectors wroteBased on observation, record review, interview and facility policy and procedure review, the facility failed to ensure physician ordered fall interventions were in implemented as ordered for two residents (#6 and #40) with known falls. This affected two residents of six residents reviewed for accidents. The facility census was 81. Findings Include: 1. Review of the medical record for Resident #6 revealed an initial admission date of 12/26/22 with the diagnoses including but not limited to Alzheimer's disease, atherosclerotic heart disease of native coronary artery, hypothyroidism, anxiety disorder, diverticulosis, dementia with other behavioral disturbances, psychosis, mood disorder, hyperlipidemia, insomnia, polyneuropathy, osteoarthritis, gastro-esophageal reflux disease, cardiomyopathy and dysphagia. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to obtain a physician's order for the administration of oxygen therapy and post an oxygen warning sign. This affected one resident (#48) of one resident reviewed for respiratory care. The facility census was 81.

Inspectors wroteBased on record review, interviews and facility policy and procedure review, the facility failed to comprehensively assess and develop a comprehensive plan of care for one resident (#31) with post traumatic stress disorder (PTSD). This affected one of four residents reviewed for mood/behavior. The facility census was 81. Findings Include: [...]

Inspectors wroteBased on review of facility alternative dispute resolution agreements, resident interview, staff interview, record review, and policy review, the facility failed to ensure residents understood the agreement they signed. This affected two of three residents reviewed for arbitration agreements (Residents #15 and #68). The facility census was 81.

Inspectors wroteBased on observation, record review, review of online manufacturer guidance, and interview the facility failed to ensure equipment was maintained in a safe manner to prevent falls with injury for Resident #43 and Resident #50. The facility failed to provide adequate supervision and assistance to prevent Resident #48 from falls and eloping. Actual harm occurred on 02/03/23 when Resident #50 sustained a fall when the anti-rollbacks on his wheelchair were not properly functioning. The resident complained of severe pain for three days following the incident, with a decrease in functional mobility without any type of interventions. On 02/06/23 the resident was admitted to the hospital with a fractured right hip. [...]

Inspectors wroteBased on review of the facility's infection control logs, record review, staff interview, and policy review, the facility failed to ensure they maintained an effective infection control program that adequately identified organisms causing infections within the facility and properly track those infections to identify any trends or patterns. This had the potential to affect all residents residing in the facility. The facility's census was 80.

Inspectors wroteBased on review of the facility's infection control log, infection reports, record review, review of the McGeer's criteria, staff interview, and policy review, the facility failed to maintain and implement an effective antibiotic stewardship program to ensure residents only received antibiotics when warranted and antibiotics prescribed were appropriate for the infections being treated. This affected four (Resident #33, #75, #77, and #235) of five residents reviewed for infections. The facility census was 80.

Inspectors wroteBased on review of resident medical record, facility's self-reported incident report, facility's abuse policy and procedure, staff personnel file, and staff interview, this facility failed to ensure residents were free from verbal and physical abuse while receiving assistance with care by a staff member. This affected one (Resident #25) of two residents reviewed for abuse. The facility census was 80.

Inspectors wroteBased on record reviews and interviews the facility failed to ensure Minimum Data Set (MDS) assessments were accurately completed to reflect physician documentation of contraindications to Gradual Dose Reductions (GDR's). This affected two residents (#31 and #42) out of the five residents reviewed for unnecessary medications during the annual survey. The facility census was 80.

Inspectors wroteBased on record review, observation, resident interview, staff interview, and policy review, the facility failed to ensure a resident who was depended on staff for assistance with activities of daily living (ADL's) received the assistance needed with the trimming of his fingernails. This affected one (Resident #52) of two residents reviewed for ADL's. The facility census was 80.

Inspectors wroteBased on medical record review, resident and staff interview and facility's hydration review, this facility failed to ensure residents with a fluid restriction was monitored for appropriate fluid intake. This affected one (Resident #38) of one resident reviewed for fluid intake. Facility census was 80.

Inspectors wroteBased on record review and interview the facility failed to provide an appropriate diagnosis for the use of an antipsychotic. This affected one resident (Resident #7) out of five residents reviewed for unnecessary medications. The facility census was 80.

Inspectors wroteBased on medical record review, staff interview, review of Food and Drug Administration (FDA) information, review of a Health Day News Study, and facility policy and review, the facility failed to provide adequate justification for the use of antibiotics for COVID-19 positive residents. This affected 17 residents (Residents #1, #2, #3, #4, #10, #20, #22, #24, #27, #32, #49, #50, #53, #55, #56, #60 and #61) of 56 residents who were COVID-19 positive. Findings Include: Review of medical records of Residents #1, #2, #3, #4, #10, #20, #22, #24, #27, #32, #49, #50, #53, #55, #56, #60 and #61 from 01/18/21 to 02/28/21 revealed the residents received the antibiotic Azithromycin prior to the results of a positive COVID-19 test result. [...]

Inspectors wroteBased on medical record review and interview, the facility failed to honor one resident's bathing preference related to frequency and timeliness. This affected one of one resident (Resident #42) reviewed for choices. Findings Include: Review of Resident #42's medical record revealed an admission date of 03/25/21. Diagnoses included gastroparesis, end stage renal disease, congestive heart failure, anemia, diabetes mellitus, blindness, hypertension, malignant neoplasm of the left breast, insomnia osteoarthritis and major depressive disorder. Review of the resident's quarterly MDS 3.0 assessment dated [DATE] revealed the resident has clear speech, understood others, made herself understood and had no cognitive deficit as indicated by a BIMS score of 15. The resident was dependent on two staff for bathing. [...]

Inspectors wroteBased on record review, staff interview and policy review, the facility failed to ensure the physician was notified of a resident's weight gain of two or more pounds in 24 hours in accordance to his plan of care. This affected one (Resident #63) of one residents reviewed for dialysis.

Inspectors wroteBased on observation, medical record review, staff interview and facility policy and procedure review, the facility failed to consistently and adequately assess one resident's Stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough or bruising. May also present as an intact or open/ ruptured blister.) pressure ulcer. This affected one of one resident (Resident #59) reviewed for pressure ulcers. The facility identified two residents with pressure ulcers. Findings Include: Review of Resident #59's medical record revealed an original admission date of 07/28/20 with the latest readmission of 02/21/21. [...]

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to ensure a resident receiving dialysis, who had an order to be weighed daily, was weighed in accordance to his orders and plan of care and failed to follow the parameters included with the daily weight order by not notifying the physician when the resident had a weight gain of two or more pounds in 24 hours. They also failed to ensure the dialysis center completed the dialysis communication record to include a pre and post assessment of the resident's weights/ vital signs, medications received during his treatment and any other pertinent problems or complications that may have occurred during his dialysis treatment. This affected one (Resident #63) of one residents reviewed for dialysis.

Inspectors wrote2. Review of the medical record for Resident #57 revealed an admission date of 10/05/18. Diagnoses included dementia with behavioral disturbances, cognitive communication deficit, and aneurysm of the carotid artery. Review of Resident #57's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 08 indicating a moderately impaired cognition for decision making abilities. Resident #57 was noted to express verbal behaviors directed towards others. Resident #57 required extensive assistance from two staff members for bed mobility, transfers, dressing, and toilet use. Review of Resident #57's physician orders for May 2021 revealed: [...]