Arbrook Plaza

In the surveyor’s words

From the most serious findings on record at Arbrook Plaza, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF880Nov 1, 2024

  45507 48520 Based 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. […]

• No harm, potential for more than minimal, patternF656May 8, 2026

  Based 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. […]

• No harm, potential for more than minimal, patternF656Jan 15, 2026

  Based 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. […]

• No harm, potential for more than minimal, patternF700Jan 15, 2026

  Based 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. […]

• No harm, potential for more than minimal, patternF761Jan 15, 2026

  Based 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. […]