Arbor Glen Care Center

In the surveyor’s words

From the most serious findings on record at Arbor Glen Care Center, in the surveyor’s own words.

• Actual harm, isolatedF684Nov 6, 2024

  Based on interview and record review, the facility failed to provide the care and services for one of six sampled residents (Resident 2) according to the facility's policies and procedures (P&P) titled, Resident Care, Monitoring of, Change of Condition Reporting, and Significant Change of Condition, Response, by failing to: 1. Ensure Licensed Vocational Nurse (LVN) 1 notified Resident 2's Primary Care Provider/Medical Doctor (MD) 1 promptly (quickly/with little or no delay) when LVN 1 noted a lump (growth, swelling, or mass that can appear anywhere on the body) in Resident 2's left breast on 4/17/2024 at 12:15 pm. 2. […]

• Actual harm, isolatedF697Mar 29, 2023

  Based on observation, interview, and record review, the facility failed to manage pain for one of three sampled residents (Resident 3) by failing to: 1. Ensure Licensed Vocational Nurse 1 (LVN 1) assessed Resident 3 ' s leg pain (pain on both legs) and re-evaluated the effectiveness of the Tylenol (pain relief medication) administration on 3/16/23, at 2 p.m. as indicated in Resident 3 ' s care plan for pain. 2. Ensure LVN 1 implemented the facility ' s policy and procedure titled, Nursing Administration, when LVN 1 did not notify Medical Doctor 1 (MD 1) regarding Resident 3 ' s uncontrolled/unrelieved leg pain (unrated). As a result, on 3/16/23 and on 3/17/23, Resident 3 experienced physical and emotional distress due to unrelieved/uncontrolled pain on both legs. […]

• No harm, potential for more than minimal, widespreadF921Jul 11, 2023

  Based on observation, interview, and record review, the facility failed provide a safe and functional environment for residents, staff, and the public, due to an inoperable fire alarm control panel (the notification panel for the building's fire alarm system which monitors the status of fire detection devices and notifies the building and emergency services of potential fire). This deficient practice has the potential to have a negative impact on the wellbeing and safety of residents, staff, and the public. Findings: On 7/11/23, at 1:30 pm, during an interview, the director of nursing (DON) stated she was not too familiar with the fire panel project and needed to refer to the administrator. […]

• No harm, potential for more than minimal, patternF755Jul 30, 2026

  Based on interview and record review, the facility failed to administer medications within one hour after the prescribed time for three of three sampled residents (Residents 1, 8, and 9) in accordance with the facility's Policy and Procedure (P&P) titled, Pharmaceutical Services.The deficient practice had the potential to result in the loss of therapeutic drug effects and increased the risk of adverse drug reactions (undesired harmful effect resulting from a medication) to Residents 1, 8, and 9.Findings:a. […]

• No harm, potential for more than minimal, patternF842May 22, 2026

  Based on interview and record review, the facility failed to ensure two (2) of 17 sampled residents' (Resident 1's and Resident 10's) medical records were complete and accurate when Resident 1's and Resident 10's medical records did not contain documentation that the residents were turned and repositioned every two hours in accordance with the residents' care plans.This failure resulted in Resident 1's and Resident 10's medical records containing inaccurate information and had the potential for Resident 1and Resident 10 to receive inappropriate care and treatment.1. […]