Arbrook Plaza

Inspectors wroteBased on interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights , that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 8 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7 and Resident #8 and Resident# 9) of 9 residents reviewed. The facility failed to update each resident person-centered comprehensive care plan to reflect the need for EBP. This failure could place residents at risk of infection.

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 infection for 1 (Resident #1) of 2 residents reviewed for infection control. The facility failed on 05/08/26 to ensure infection control procedures were followed when CNA A and RA B provided perineal care to Resident #1, who was on enhanced barrier precautions, without donning appropriate PPE. This failure could place residents at risk of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 3 (Resident #1, Resident #51, Resident #111) of 5 residents reviewed for care plans. The facility failed to ensure the Care Plans for Resident #1, Resident #51, and Resident #111 reflected the use of grab/assist bars, the goal of having the grab/assist bars on the resident's beds, and the interventions previously attempted. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to assess the resident for appropriateness and review the risks and benefits of grab/assist bars (smaller bars used by the person in bed to reposition themselves), with the resident or resident representative and obtain informed consent prior to installation or assess for appropriateness for 4 (Resident #1, Resident #32, Resident #51, and Resident #111) of 5 residents observed and reviewed for grab/assist bars. The facility failed to have evidence of informed consent for Resident #1 and Resident #32's grab/enabler bars to be placed on the bed. The facility failed to have evidence of assessment for Resident #1, Resident #51, and Resident #111 for risk of entrapment and ability to safely use the grab/enabler bars. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for three of six (Med Cart #1, Med Cart #2, and Med Cart #3) medication carts reviewed for storage of medication 1. LVN B left Med Cart #1 unlocked and unattended on 01/13/26. 2. Med Aide D failed to secure 5 medications before leaving Med Cart #2 unattended outside Resident #3's room on 01/13/26. 3. Med Aide E failed to ensure Med Cart #3 was free of brown and black sticky substance and brown dust particles in the compartment that had medicine cups and water cups in it on 01/14/26. [...]

Inspectors wroteBased on observations, interviews, and record reviewed the facility failed to ensure appropriate care and services to prevent complications of enteral feeding for one (Resident #75) of three residents reviewed for enteral tube feeding, in that; LVN C failed to ensure Resident #75 was not flat in bed during repositioning while his enteral feeding was still connected and running. This failure placed residents with enteral feedings at risk of receiving inappropriate care and maintenance which could result in fluid overload, vomiting, aspiration (entering the airways or lungs), and hospitalization. Findings Included: Record review of Resident #75's face sheet dated 01/14/26 revealed a [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption for 1 (Residents #4) of 1 resident reviewed for refrigerator in the rooms. The facility failed to place a thermometer in Residents #4's refrigerator and monitor the temperature. This failure could affect residents by placing them at risk for food-borne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents resided and received services in the facility with reasonable accommodation of resident needs and preferences for one (Resident #3) of fifteen reviewed for call lights. The facility failed to ensure Resident #3's call button was not broken and placed within reach. These failures could place residents at risk for needs not being met, decreased quality of life, self-worth and dignity.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 10 (main dining room) of 25 residents served in the facility only resident dining room reviewed for environmental conditions. The facility staff failed to ensure on 01/23/25 the dining room trash was covered with a lid, and the vacuum cleaner was clean and stored away from residents that were dining for lunch. This failure could place residents at risk of living in an unsafe, unsanitary, and uncomfortable environment.

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 #44) of three residents reviewed for parenteral fluids. The facility failed to ensure on 01/23/25 that Resident #44 received IV hydration per parental fluids professional standards by labeling and dating the solution at the time of administration. This failure placed the residents at risk for infections, wrong dose, and clinical monitoring of doses.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for two (Residents #16 and Resident #27) of eight residents reviewed for Respiratory Care. 1. The facility failed to ensure on 01/23/25 that Resident #16's nasal cannula (flexible tube used to deliver oxygen to the nose through two prongs) was stored in a bag and labeled when not in use. 2. The facility failed to ensure on 01/23/25 that Resident #27's breathing mask used for nebulization was stored in a bag and labeled when not in use. These failures could place the residents at risk for respiratory infection and not having their respiratory needs met.

Inspectors wroteBased on observations, interviews, 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 4 of 4 Residents (Resident's #33, #67, #23, and #48) observed for infection control and 1 of 4 quarters reviewed for water management. 1. The facility failed to ensure LVN E followed facility protocol while administering medication via G-tube entering for a resident on enhanced barrier precautions-EBP, Resident #33. 2. The facility failed to implement infection control and prevention, including wound care procedures and cross contamination for Resident #67 during wound care by LVN D and CNA H. 3. The facility failed to perform a water system flush quarterly. 4. [...]

Inspectors wroteBased on interviews and record review the facility failed to ensure residents had the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States for 8 (Residents #6, #21, #31, #39, #50, #57, #65, and #78) of 10 residents, and 1 of 1 residents reviewed for dignity in the dining room (Resident #9). 1. Residents #6, #21, #31, #39, #50, and #57 were not asked by staff if they were interested in voting. 2. Residents # 65 and #78, interviewed in their room, reported not being asked by staff if they were interested in voting. 3. The facility failed to ensure Residents #9 had the right to a dignified existence when the staff stood over the resident while feeding the resident. This deficient practice could affect all residents and could result in residents not being able to exercise their rights as United Stated citizens.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for 2 of 2 residents (Resident #9 and Resident #298) reviewed for ADL care. The facility failed to ensure Resident #9, and Resident #298 were provided nail care as needed. These failures could place residents at risk of not receiving services and a decreased quality of life.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for one (Resident #5) of five residents reviewed for limited range of motion or therapy services. The facility failed to complete a quarterly Physical Therapy Reevaluation screening for Resident # 5 after completion of his physical therapy 4/27/2024. This failure could place residents at risk for a decline in range of motion, decreased mobility, and a decline in physical capabilities.

Inspectors wroteBased on interviews and record review the facility failed to ensure each resident received the necessary behavioral health care and services to attain or maintain the highest practicable mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care for 1 of 1 resident (Resident #85) whose records were reviewed for behavioral health services. The facility failed to follow up to ensure Resident #85 received psychiatric services after a referral was made. This failure could place residents at risk of not receiving needed mental health services and a decrease in quality of life.

Inspectors wroteBased on observations, interviews, 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#301) of seven residents reviewed for pharmaceutical services. The facility failed to obtain heart rate and or pulse parameters for heart medication Digoxin 125 MCG before administering it to Resident #301 since 10/29/2024. These failures could place residents at risk of inadequate therapeutic outcomes, increased negative side effects, and a decline in health. Findings Included: Review of Resident #301's face sheet, dated 10/31/2024, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on interviews and record review the facility failed to ensure that the resident's medical record included documentation that indicated the resident or resident's representative were provided education regarding the benefits and potential side effects of influenza immunization; and that the resident either received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal for 1 of 6 (Resident #299) residents reviewed for immunizations. The facility failed to offer Resident #299 an influenza immunization. This failure could place residents at risk of harm, by contracting and spreading influenza.

Inspectors wroteBased on, interviews, 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 of three (Resident #2) residents reviewed for pharmacy services. The facility failed to ensure that documentation of narcotic medications signed out on the narcotic count sheet were consistent with documentation of narcotic medications administered to Resident #2 as reflected on his MAR. Narcotic count sheets for Resident #2 one showed more doses of oxycodone signed out on Resident #2's narcotic count sheet than what was documented as administered on his MAR on 05/16/24, 05/28/24, and 05/30/24. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that all alleged violations of abuse were reported to Health and Human for one (Resident #1) of 12 residents reviewed for abuse and neglect reporting. The facility failed to report an allegation of abuse when a grievance was filed by a family member on behalf of Resident #1 on 04/04/24 that a staff member (identity unknown) yelled at the resident, told her to go back to sleep, and called her stupid. This failure could place residents at risk of being abused or neglected and lack of oversight by a state agency.

Inspectors wroteBased on observation, interview and record review the facility failed to incorporate the recommendations from the PASARR level II determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care for one (Resident #1) of one resident reviewed for PASRR services. The facility failed to order a standing board for Resident #1 based on PASRR assessment for specialized services. This failure could place residents at risk of not receiving specialized PASRR services which could contribute to a decline in quality of life, physical, mental, and psychosocial well-being .

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and to ensure specialized services or specialized rehabilitative services the nursing facility was provided as a result of PASARR recommendations for one (Resident #1) of one resident reviewed for PASRR. The facility failed to order a standing board for Resident #1 based on PASRR assessment for specialized services as stated in the care plan. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents 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 one of three residents (Resident # 1) reviewed for pressure ulcers. 1. The facility failed to ensure Resident #1 received wound care for her: - right heel, on 08/26/23, 08/27/23 and 08/28/23; - left iliac crest on 08/26/23, 08/27/23, 08/28/23; and - sacrum on 08/26/23, 08/27/23, 08/28/23, and 08/29/23. 2. LVN A failed to enter wound care orders in the MAR when Resident #1 was admitted to the facility on [DATE]. These failures could place residents at risk for worsening of existing pressure ulcers and skin sores or development of new pressure ulcers or skin sores.

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 safety in the facility's only kitchen. 1. The facility failed to ensure food items and clean dishes were kept away from contaminants and an unsanitary environment. 2. The facility failed to ensure the ice machine was clean and sanitary. These failures could place residents at risk for food contamination and food-borne illness.

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 of 17 resident rooms (Resident #71's room) reviewed for infection control. The facility failed to dispose of used push-button lancet (finger-prick needle), blood testing strips (used to obtain a fingerstick blood sugar), one used alcohol wipe, 0.09% sodium chloride injection and one IV catheter (used to provide access to administer IV fluids) in Resident #71's room. This failure could place residents at risk of exposure to communicable diseases and infections.