Arbor Lake Skilled Nursing & Rehabilitation

In the surveyor’s words

From the most serious findings on record at Arbor Lake Skilled Nursing & Rehabilitation, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF565Oct 1, 2025

  Based on record review and interviews, the facility failed to act promptly upon the grievances voiced by residents during monthly Resident Council meetings and failed to demonstrate the facility's response for such grievances. Findings:Review of the facility's policy, Resident Council undated, revealed in part:6. All resident concerns will the addressed and revisited at the resident council meeting the following month. Review of the facility's policy, Filing Grievances/Complaints dated 1/22/2025 revealed in part: Policy Statement - Our facility will assist residents or his/her responsible party in filing grievances or complaints when such requests are made 3. Grievances and/or complaints may be submitted orally or in writing. 4. […]

• No harm, potential for more than minimal, patternF605Oct 1, 2025

  Based on record reviews and interviews, the facility failed to ensure residents that received psychotropic drugs were not subjected to chemical restraints for 4 (#2, #11, #25, #37) of 5 (#2, #11, #25, #37, #65) residents reviewed for unnecessary medications. The facility failed to ensure:1). as needed (PRN) orders for psychotropic drugs were limited to 14 days (#2, #11, #37),2). a gradual dose reduction was attempted (#25, #37), and3). a physician addressed pharmacist recommendations (#25)Findings: Resident #11 Record review revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including dementia with behaviors/agitation, major depressive disorder, and anxiety disorder. […]

• No harm, potential for more than minimal, patternF686Oct 1, 2025

  Based on record reviews and interviews the facility failed to ensure that a resident 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 1 (#40) of 1 residents reviewed for pressure ulcers. The facility failed to 1) have documented evidence of weekly body audits, 2) have documented evidence of wound treatments performed as ordered, and 3) failed to have an accurate pressure ulcer assessment. Findings: Review of the medical record for sampled resident #40 revealed an admission date of 03/05/2024 with diagnoses of somatoform disorder, hyperlipidemia, anxiety, major depression, transient ischemic attack, and pressure ulcer on the back. […]

• No harm, potential for more than minimal, patternF757Oct 1, 2025

  Based on interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs by failing to ensure laboratory tests were collected as ordered for 1 (#11) of 5 (#2, #11, #25, #37, #65) residents reviewed for unnecessary medications. Findings:Record review revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including hypothyroidism, dementia, major depressive disorder, and anxiety disorder. Record review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 had a brief mental status score (BIMS) of 3 which indicated severe cognitive impairment. Further review revealed Resident #11 required substantial/maximal assistance for most activities of daily living (ADL). […]

• No harm, potential for more than minimal, patternF880Oct 1, 2025

  Based 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. The facility failed to 1) disinfect whirlpool A and whirlpool B per Manufacturer's Instructions for Use, and 2) implement standard precautions for proper storage of a non-invasive urine collection system, and administration of medications. Findings: Review of the facility's undated Whirlpool/Shower Cleaning and Disinfecting policy revealed the following: Purpose: To ensure that whirlpool/showers are cleaned and disinfected according to disinfectant manufacturer guidelines. General Guidelines: Whirlpool/shower shall be cleaned and disinfected between each use. […]