Arbor Grove Village

In the surveyor’s words

From the most serious findings on record at Arbor Grove Village, in the surveyor’s own words.

• Actual harm, isolatedF600Mar 16, 2023

  Based on interview and record review, the facility failed to ensure a cognitively impaired resident was free from mental and physical abuse. Using the reasonable person concept, the resident would likely have chronic or recurrent fear and anxiety from the purposefully actions to agitate and physically contain the resident. These deficient actions resulted in psychological harm for 1 of 24 residents reviewed for abuse. (Resident 59). Findings include: During an interview on 03/13/23 at 1:45 P.M., Resident 59's family member indicated there was an incident about a month ago involving some staff members that were reportedly rough with the resident. The resident's clinical record was reviewed on 03/15/23 at 4:09 P.M. […]

• Actual harm, isolatedF744Mar 16, 2023

  Based on interview and record review, the facility failed to adequately implement care planned interventions and strategies for a resident with anxiety, combative behaviors, and a diagnosis of dementia that resulted in the resident's increased agitated state and poor behavior management for 1 of 3 residents reviewed for Dementia Care. (Resident 59) Findings include: The resident's clinical record was reviewed on 03/15/23 at 4:09 P.M. A Quarterly MDS (Minimum Data Set) Assessment, dated 01/12/23, indicated the resident was severely cognitively impaired. The diagnoses included, but were not limited, dementia with behavioral disturbances, anxiety, and depression. […]

• No harm, potential for more than minimal, widespreadF921Apr 24, 2026

  Based on observation and interview, the facility failed to provide a homelike environment related to hot water temperatures. This deficient practice had the potential to effect 75 of 75 residents residing in the facility. Findings include:During an observation, on 04/20/2026 at 9:51 A.M., in room [ROOM NUMBER] the bathroom sink water was tested for water temperature. The water in the residents bathroom sink was immediately too hot to place your hands under the water without discomfort or redness. During an observation, on 04/20/2026 at 9:54 A.M., in room [ROOM NUMBER] the bathroom sink water was tested for water temperature. […]

• No harm, potential for more than minimal, patternF690Apr 24, 2026

  Based on interview, record review, and observation, the facility failed to educate a resident and follow appropriate infection control guidelines related to urinary care for 4 of 4 residents reviewed for Urinary Tract Infections (UTIs) and indwelling urinary catheters. (Residents 5, 4, 27, and 56)Findings include:1. During an interview, on 04/20/2026 at 11:31 A.M., Resident 5 indicated she had recently been on an antibiotic for a UTI. It currently burned when she urinated and her urine was milky yellow in color. During an interview, on 04/22/2026 at 10:52 A.M., Licensed Practical Nurse (LPN) 4 indicated the resident required stand-by assistance of one staff member for toileting. The resident preferred to be independent with toileting. […]

• No harm, potential for more than minimal, patternF812Apr 28, 2025

  Based on observation, interview, and record review, the facility failed to maintain resident snack refrigerators appropriately related to the storage of staff food items, incomplete labeling, and the storage of non-food items for 2 of 3 resident snack refrigerators observed. (100/200 Hall Resident Snack Refrigerator and the 400 Hall Resident Snack Refrigerator) Findings include: 1. The 100/200 Hall Resident Snack Refrigerator was observed on 04/28/25 at 12:38 P.M., with Licensed Practical Nurse (LPN) 7, and contained the following: - LPN 7's lunch bag, - One unopened carton of vanilla ice cream with no resident name, date, or room number, - One opened carton of vanilla ice cream dated 03/11/25 with no resident name or room number, - A tan plastic grocery bag with a paper note labeled with… […]