Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Arbor Lake Nursing & Rehabilitation, Llc during CMS and state inspections, most recent first.
Kitchen Pest Control Deficiency: Surveyors observed multiple flies in the kitchen during lunch prep, including on a food processor cord, an outlet, and a prep table. Staff reported flies entered through the back door when trash was taken out, had been seen more often lately, and the pest control logs showed flies had not been a targeted pest.
The facility did not properly monitor or manage resident trust fund balances, resulting in multiple residents exceeding Medicaid resource limits for extended periods. Some residents had significant cognitive impairments and lacked guidance on spending down excess funds, while others were not notified or assisted in managing their accounts. Staff interviews revealed unclear responsibilities and inconsistent processes for trust fund oversight, leading to prolonged over-resourced statuses.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A resident diagnosed with dementia did not receive the necessary treatment and services appropriate for their condition, as required by regulatory standards.
A deficiency was cited for not providing a safe, clean, comfortable, and homelike environment, including failing to ensure that a resident received treatment and supports for daily living in a safe manner.
A resident who was unable to perform activities of daily living did not receive the necessary care and assistance from staff, resulting in unmet care needs.
Surveyors found that the facility did not have an infection prevention and control program in place, indicating a lack of systematic measures to address infection risks for residents and staff.
A resident with multiple medical conditions was discharged without a 30-day written notice or documented discharge planning. Staff interviews revealed no evidence of inappropriate behavior, and the family was only notified on the day of discharge. The facility's policy requiring advance notice and planning was not followed, as confirmed by record review and interviews.
A resident with a history of stroke and seizure disorder suffered electrical burns to her hand after plugging in a phone charger to a damaged wall outlet. The incident was not properly documented or reported, and interviews revealed that electrical outlets in resident rooms were sometimes loose or sparking, with no systematic monitoring in place prior to the event. Staff responses focused on relocating the resident rather than investigating or addressing the underlying hazard.
A resident with multiple medical conditions sustained burns and blisters after being shocked while plugging in a phone charger. The LPN on duty did not immediately report the injury or the incident as a potential neglect or injury of unknown source to the Administrator, only reporting an electrical malfunction. The Administrator was not made aware of the resident's injuries or the allegation until later, contrary to facility policy requiring prompt reporting of such events.
A resident suffered burns and blisters to her fingers after being shocked by a malfunctioning electrical outlet. Despite showing her injuries to staff and reporting pain, the initial nursing assessment documented no visible injuries, and no treatment or follow-up assessments were provided. The incident was not reported in the facility's incident log, and no incident report was completed, resulting in delayed care for the resident's injuries.
A resident with a PICC line for IV antibiotics did not receive routine dressing changes as per physician orders, leading to a soiled and lifting dressing. Despite the resident informing staff, the dressing was not changed on schedule. Interviews revealed that the dressing change was delayed at the resident's request, and staff did not verify the order schedule, increasing the risk of infection.
A resident diagnosed with shigella was not reported to the County Health Department by the LTC facility, as required. The resident, with a history of cancer and stroke, was hospitalized for symptoms including diarrhea and was diagnosed with ESBL bacteremia with shigella. Upon return, the facility staff, including the physician, were unaware of the shigella diagnosis, leading to inadequate infection control measures. The facility's dietary staff confirmed that eggs served were pasteurized and fully cooked, and no other residents reported similar symptoms. The County Epidemiologist highlighted the need for reporting due to the infection's ease of transmission.
A resident with paraplegia did not receive documented wound care, leading to inaccurate medical records. LVN B and RN C admitted to falsifying records to avoid showing missed care, while the Wound Care Nurse failed to document care provided. The DON expected accurate documentation, but discrepancies persisted despite prior training.
A resident with complex medical needs was discharged without confirmed home health and wound care services, despite requiring frequent care and assistance. The facility did not document the family's refusal of home health services, nor did they provide adequate training or instructions for wound care. Staff expressed concerns about the safety of the discharge, as the resident needed significant support due to muscle weakness and incontinence.
The facility failed to maintain an effective pest control program, resulting in the presence of gnats in various areas, including residents' rooms, the dining room, and the conference room. Despite residents' complaints and visible gnats, there was no consistent follow-up or documentation of pest control measures.
The facility failed to ensure a safe, clean, and homelike environment by not maintaining residents' wheelchairs in a sanitary condition. During a group interview, five residents reported that their wheelchairs were not being cleaned, which was confirmed by observations of dust build-up. Staff interviews revealed that the night shift was responsible for cleaning wheelchairs, but this task was not consistently performed, leading to potential infection control concerns.
The facility failed to complete post-dialysis assessments for a resident with end-stage renal failure, chronic kidney disease, Type 2 diabetes, and essential hypertension. The facility did not document pre- and post-dialysis weights and vital signs as required, despite recent in-service training on the importance of these measures. Staff interviews revealed inconsistencies in following the protocol for obtaining and documenting this information.
The facility failed to maintain accurate medical records for two residents, leading to discrepancies in medication administration and PICC line dressing changes. This was confirmed through record reviews, observations, and staff interviews.
A facility failed to accurately code a resident's MDS assessment regarding gastrostomy tube status. The resident had a g-tube but no longer received feedings through it, a fact not reflected in the MDS. Interviews confirmed the error, and the MDS Coordinator acknowledged the mistake. The DON emphasized the need for accurate and timely MDS assessments.
The facility failed to obtain signed informed psychotropic consents from a resident's responsible party before administering several medications, including Zoloft, Buspirone, Seroquel, and Valproic Acid. This lapse in procedure was confirmed by the ADON and DON, who acknowledged that consents should be received before medications are given to ensure residents or their representatives are informed about the medications, including potential risks and benefits.
The facility failed to ensure that a resident with limited mobility and moderate cognitive impairment received necessary grooming services, resulting in long, uncleaned fingernails. Staff interviews revealed confusion about responsibilities, leading to inadequate personal hygiene care.
A facility failed to change a resident's PICC line dressing as ordered by the physician, leading to a potential risk of infection. The resident, with multiple diagnoses including osteomyelitis and paraplegia, had a PICC line for IV antibiotics. The dressing was not changed as scheduled, and the oversight was not caught by the nursing staff, despite being aware of the requirement.
Kitchen Pest Control Deficiency
Penalty
Summary
The facility failed to maintain an effective pest control program for the kitchen, and the kitchen was observed to have flies present during lunch preparation. On 05/19/26 at 10:45 AM, surveyors observed 7 flies in the kitchen: 5 on the cord of a plugged-in food processor, 1 on the outlet, and 1 on the leg of the prep table while 3 staff members were preparing lunch. Record review showed the Pest Control logs for March, April, and May 2025 reflected routine visits, but flies had not been a targeted pest. During interviews, Dietary Aide A said flies entered through the back door when trash was taken out and that they had been bad lately. The Dishwasher said flies were typically seen at this time of year and could not recall how long they had been in the kitchen. The Dietitian said she had seen one fly that day and stated flies should not be in the kitchen because they carry bacteria. The Interim Dietary Manager said he had been overseeing the kitchen for the past two months and that the facility treated the building at least monthly, while the Administrator said he had just been made aware that day that there were flies in the kitchen.
Failure to Safeguard and Manage Resident Trust Funds
Penalty
Summary
The facility failed to properly manage, safeguard, and account for the personal funds of nine residents who had trust fund accounts. Surveyors found that the facility did not monitor resident trust fund balances to ensure they did not exceed Medicaid resource limits, resulting in all nine residents having account balances well above the $2,000 threshold for Medicaid eligibility. In several cases, residents' balances remained over $3,000 for multiple months, with one resident's balance reaching over $9,700 after a large Social Security back payment. The facility did not take adequate steps to assist residents in spending down excess funds, and there was little evidence of proactive management or guidance provided to residents or their representatives regarding allowable purchases or spend-down options. Record reviews and interviews revealed that some residents had severe cognitive impairments, while others were their own responsible parties but lacked understanding of how to manage or spend their funds appropriately. Several residents had minimal personal belongings or room decorations, and there was no indication that the facility facilitated purchases to improve their quality of life or reduce their account balances. In some cases, responsible parties or family members were not notified of the over-resourced status, and documentation of notifications was incomplete or missing. The facility's process for notifying residents or their representatives about excess funds was inconsistent, and staff interviews indicated confusion or lack of involvement in the spend-down process. Staff interviews further highlighted that the business office manager (BOM) was primarily responsible for trust fund management but had been on leave, and the process for spending down funds was not clearly defined or consistently implemented. The activity director and social worker were not actively involved in the spend-down process, and the BOM reported limitations on how funds could be spent, including restrictions on online purchases and cash withdrawals. The facility's own policy assigned responsibility for trust fund management to the administrator, but there was no evidence of effective oversight or coordination among staff to prevent residents from becoming over-resourced and at risk of losing Medicaid eligibility.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure a safe environment for all residents. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Provide Appropriate Dementia Care
Penalty
Summary
A deficiency was identified regarding the provision of appropriate treatment and services to a resident who displays or is diagnosed with dementia. The report indicates that the facility failed to ensure that a resident with dementia received the necessary care and services tailored to their diagnosis and needs. Specific details about the actions or omissions that led to this deficiency are not provided in the report excerpt.
Failure to Ensure a Safe and Homelike Environment
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a safe, clean, comfortable, and homelike environment. The report notes that the facility did not ensure residents received treatment and supports for daily living in a manner that maintained their safety and comfort. Specific details about the actions or inactions leading to this deficiency, as well as information about the residents involved or their medical conditions, are not provided in the report.
Failure to Assist Residents with Activities of Daily Living
Penalty
Summary
A deficiency was identified when care and assistance were not provided to residents who were unable to perform activities of daily living (ADLs) independently. The report notes that residents requiring help with ADLs did not receive the necessary support from staff, resulting in unmet care needs for those individuals. No additional details about the specific residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, as the facility did not have an established or operational program to prevent and control infections among residents and staff. The absence of such a program was observed and documented by surveyors, indicating a lack of systematic measures to address infection risks within the facility. No specific residents, staff, or incidents were detailed in the report, and there were no direct observations of infection events or outcomes related to this deficiency. The deficiency is based solely on the lack of an implemented infection prevention and control program as required.
Failure to Provide 30-Day Written Discharge Notice and Discharge Planning
Penalty
Summary
A deficiency occurred when the facility failed to provide a 30-day written notice of discharge and did not complete discharge planning for one resident. The resident, a male with diagnoses including type 2 diabetes, cognitive communication deficit, and atherosclerotic heart disease, was discharged to home with family. Documentation review revealed no 30-day discharge notice or evidence of discharge planning in the resident's electronic medical record. The discharge was recorded as unplanned, and the transfer/discharge report did not indicate a reason for discharge. Interviews with facility staff, including the Administrator and Director of Nursing, confirmed that the resident was discharged due to being a registered sex offender and making comments about wanting a girlfriend and sitting by females in the dining room. However, there were no documented incidents or reports of inappropriate behavior, and multiple staff members, including nurses, CNAs, and dietary aides, stated they were unaware of any inappropriate actions by the resident. The family member reported being called on the day of discharge and told to pick up the resident or the police would be called, with no prior notice or detailed explanation of the behavior leading to discharge. The facility's transfer and discharge policy requires a 30-day written notice unless exigent circumstances exist, such as a threat to health or safety, which was not substantiated by incident reports or staff observations. The policy also mandates discharge planning and communication with the resident or responsible party, which was not documented in this case. The lack of proper notice and planning was confirmed through record review and staff and family interviews.
Failure to Maintain Safe Electrical Environment Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when the facility failed to ensure the resident environment was free from accident hazards, specifically related to electrical safety. One resident, a female with a history of cerebrovascular accident, seizure disorder, anxiety, and depression, and with no cognitive impairment, experienced an electrical shock and burns to her fingers and hand after plugging in her phone charger to a wall socket. The incident was documented in progress notes, and photographic evidence showed burns and blisters on the resident's hand, as well as a charred electrical outlet and wall. The resident reported pain and anxiety following the incident, and other residents and staff confirmed seeing the injuries and the damaged outlet. The facility's records did not include an incident report for this event, and the incident/accident log showed no similar incidents during the relevant timeframe. Interviews with staff and residents revealed that the electrical outlet in the resident's room was loose, charred, and missing a cover after the incident. The maintenance log indicated that the outlet and breaker were replaced after the event, and an electrician's invoice confirmed that a severed hot wire and defective circuit breaker were found and repaired. Despite these findings, the facility did not have a policy addressing incidents or accidents specifically, and staff responses focused on moving the resident to another room rather than documenting or investigating the injury. Multiple interviews with staff, residents, and the maintenance team highlighted that electrical outlets in resident rooms were sometimes worn out, loose, or prone to sparking, and that these issues were not systematically monitored or reported prior to the incident. The administrator and DON were not fully aware of the extent of the resident's injuries or the details of the incident until questioned by surveyors. The lack of immediate and thorough documentation, investigation, and preventive measures contributed to the deficiency identified by surveyors.
Removal Plan
- All staff in-serviced on the event of any electrical issue or any other hazard; they will immediately place the issue in the maintenance log and follow with phone call to administrator.
- All outlets in resident rooms checked by maintenance director to ensure that they are in working order and do not present a hazard.
- All staff in-serviced on prevention of accidents, incidents and hazards.
- Resident rooms will be randomly audited to ensure electrical outlets are in working order.
- All new hires will be educated on completing maintenance log to report any electrical issues or any other hazard with follow up call to administrator.
- Administrator/Designee will be responsible for monitoring the implementation and effectiveness of in-service.
- Administrator/Regional Director of Operations/Maintenance Director/designee will check rooms to ensure outlets are in working order and report any adverse findings during QAPI.
- Administrator/Maintenance Director/designee will check maintenance log to check for any new risk/electrical issues and report any adverse findings during QAPI.
- Medical Director met with the Interdisciplinary team and conducted a QAPI regarding ensuring all resident room outlets were checked to ensure working and not a hazard and all staff educated on accident/incident/hazard prevention, and all staff educated on reporting any electrical issues or other hazards.
- Administrator will be responsible for the implementation of the new process.
Failure to Immediately Report Resident Injury from Electrical Incident
Penalty
Summary
The facility failed to ensure that an alleged violation involving neglect or injuries of unknown source was reported immediately, as required by policy, for one resident who experienced an electrical incident. The resident, who had a history of cerebrovascular accident, seizure disorder, anxiety, and depression, reported being shocked while plugging in her phone charger, resulting in a charred mark and blisters on her finger and thumb. Despite the resident's immediate complaints and visible injuries, the nurse on duty did not report the incident as an allegation of neglect or injury to the Administrator at the time, only reporting an electrical malfunction. Interviews and record reviews revealed that the resident attempted to show her injuries to staff, including the nurse and social worker, and requested an incident report, which was not completed. The nurse focused on moving the resident to another room for safety but did not document or escalate the injury as a reportable event. The Administrator was only informed of an electrical malfunction and was unaware of the resident's injuries or the allegation of being shocked until questioned by surveyors at a later date. Facility policy required all staff to report known or suspected instances of abuse, neglect, exploitation, mistreatment, injuries of unknown source, or other reportable incidents to the Administrator. The failure to immediately report the resident's injury and allegation of being shocked constituted a violation of this policy and regulatory requirements for timely reporting of suspected neglect or injuries of unknown source.
Failure to Provide Timely Treatment After Resident Burn Injury from Electrical Outlet
Penalty
Summary
A deficiency occurred when a resident sustained burns and blisters to her fingers after coming into contact with a malfunctioning electrical outlet in her room. The incident took place in the early morning hours, when the resident attempted to plug in her charger and was shocked, resulting in visible injuries including black charred marks and white blisters on her fingers and thumb. The resident reported pain, numbness, and anxiety following the event, and took photographs of her injuries and the damaged outlet. Multiple other residents and staff later confirmed seeing the injuries and the damaged outlet, with one resident describing the affected areas as raw, red, and pink, and another resident assisting in documenting the injuries with photographs. Despite the resident's report of being shocked and showing her injuries to staff, including a nurse and a social worker, the initial nursing assessment documented no visible injuries and no complaints of pain at the time. The nurse prioritized moving the resident to a different room for safety but did not provide or document any treatment for the burns or blisters. The incident was not entered into the facility's incident/accident log, and no incident report was completed for the event. Interviews with staff, including the DON, ADON, and Administrator, revealed that follow-up assessments were not conducted, as the initial assessment was believed to show no injury, and staff were not made aware of the resident's subsequent complaints or visible injuries. The facility failed to provide treatment and care in accordance with professional standards of practice and the resident's care plan, as the resident did not receive appropriate assessment or treatment for her injuries following the electrical incident. The lack of documentation, failure to complete an incident report, and absence of follow-up assessments contributed to a delay in treatment for the resident's burns. The event was corroborated by photographic evidence and multiple witness statements, but the facility did not recognize or address the resident's injuries in a timely manner.
Failure to Maintain Routine PICC Line Dressing Changes
Penalty
Summary
The facility failed to ensure the proper administration of parenteral fluids for a resident, specifically in maintaining routine PICC line dressing changes as per physician orders. A resident, who was admitted with conditions including hypertension, diabetes, and an infection reaction due to sepsis, was observed with a PICC line dressing that was soiled and coming off, dated over a week prior. The resident reported that the dressing had been coming off for 2 to 3 days and had informed the nursing staff, but the dressing had not been changed. The resident's care plan and physician orders required the PICC line dressing to be changed every Wednesday and as needed, but records indicated that the dressing change was not documented as completed on the specified date. Interviews with the nursing staff, including an RN and the ADON, revealed that the dressing change was attempted but not completed due to the resident's request to delay it. The RN admitted to not checking the order for the dressing change schedule. The ADON and DON confirmed the importance of adhering to the dressing change schedule to prevent infection, noting that the resident sometimes picked at the dressing, causing it to lift. The facility's policy required obtaining a physician's order for dressing changes, highlighting a lapse in following established protocols, which placed the resident at risk for infection.
Failure to Report and Manage Shigella Infection
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by their handling of a case involving a resident diagnosed with shigella. The resident, a male with a history of cancer, cerebrovascular accident, and seizure disorder, was admitted to the facility and later sent to the hospital for symptoms including altered mental status, diarrhea, nausea, and abdominal pain. Hospital records confirmed a diagnosis of ESBL bacteremia with shigella, yet the facility did not report this to the County Health Department as required. Upon the resident's return from the hospital, there was a lack of communication and awareness among the facility staff regarding the shigella diagnosis. The physician was not informed of the diagnosis and stated that he would have implemented contact isolation precautions had he been aware. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) were also unaware of the shigella diagnosis, with the ADON believing the resident had been treated for E. coli in the urine. The DON mentioned that a liaison group reviewed hospital records, but she did not know who they were, and she was under the impression that the resident had E. coli. The facility's dietary staff confirmed that all eggs served were pasteurized and fully cooked, and there were no reports of other residents experiencing similar symptoms. Despite this, the facility did not investigate the origin of the infection or follow up with other residents. The County Epidemiologist emphasized the importance of reporting shigella due to its ease of transmission, but the facility failed to do so, placing residents at risk for infections.
Inaccurate Wound Care Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, specifically regarding wound care documentation. The resident, a cognitively intact male with paraplegia, was at risk of developing pressure ulcers. Despite physician orders for daily wound care, the resident reported not receiving the care as documented. The facility's Medication Administration Record (MAR) indicated that wound care was consistently provided, but interviews revealed discrepancies in the documentation. Licensed Vocational Nurse (LVN) B admitted to documenting wound care as completed even when it was not performed, to avoid showing late or missed care in the records. LVN B acknowledged awareness of the improper documentation and the potential risk of infection due to non-compliance with physician orders. Similarly, Registered Nurse (RN) C documented wound care as completed without verifying its administration, failing to report the resident's refusal of care to management. The Wound Care Nurse, LVN A, also did not document wound care on the MAR or notify other nurses when care was provided, contributing to the incomplete records. The Director of Nursing (DON) expected accurate documentation of care provided and noted that the resident's refusal of care should be recorded in progress notes. The facility had previously conducted in-service training on documentation, but the issue persisted. The facility's policies required accurate and evidence-based documentation, prohibiting falsification or improper correction of records. The failure to document wound care accurately could lead to infection and non-compliance with physician orders, as acknowledged by the staff involved.
Inadequate Discharge Planning and Documentation
Penalty
Summary
The facility failed to ensure a safe and orderly discharge for a resident, who was discharged without confirmed home health and wound care services in place. The resident, a male with multiple complex medical conditions including osteomyelitis, Brown-Sequard syndrome, and a stage four sacral pressure wound, was discharged home at the family's request. Despite the resident's intact cognition, the facility did not document the refusal of home health services by the family, nor did they provide adequate training or instructions for wound care to the family. Interviews with staff and family members revealed that the resident required frequent wound care and assistance with transfers due to muscle weakness and incontinence, which were not adequately addressed prior to discharge. The social worker and nursing staff acknowledged the resident's need for home health services, but no referral was made due to the family's refusal, which was not documented. The family expressed concerns about their ability to provide necessary care, as they were not present all day and had not received proper education on wound care. The facility provided wound care supplies and some training, but it was deemed insufficient by the staff, who felt the resident's discharge without home health support was unsafe. The facility also failed to provide documentation of discharge instructions or medications sent home with the resident.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of gnats in various areas, including the 100 Hall, dining room, and conference room. Observations over several days revealed gnats in multiple residents' rooms, with residents expressing dissatisfaction and noting that they had resorted to using home remedies to address the issue. Despite the residents' complaints and the visible presence of gnats, there was no documentation of pest control concerns in the maintenance logbook, and staff interviews indicated a lack of awareness or recent action regarding pest control measures. Several residents, including those in the 100 Hall, reported seeing gnats in their rooms and mentioned that the issue had been ongoing. Residents stated that they had informed staff about the gnats, but there was no consistent follow-up or visible pest control efforts. Staff interviews corroborated the residents' accounts, with some staff members unable to recall the last time pest control services were conducted. The Housekeeper Supervisor and Maintenance Supervisor acknowledged the presence of gnats and mentioned that pest control had been contacted, but there was no clear evidence of a systematic approach to addressing the pest issue. The facility's pest control policy, dated August 2020, mandates an ongoing program to keep the building free of pests. However, the review of the pest control binder showed sporadic visits for different pests, including gnats, but did not reflect a comprehensive or effective pest control strategy. The Administrator and other staff members were either unaware of the extent of the issue or had not received recent complaints, indicating a communication gap and a failure to adhere to the facility's pest control policy effectively.
Failure to Maintain Clean and Safe Wheelchairs
Penalty
Summary
The facility failed to ensure that residents had a safe, clean, comfortable, and homelike environment, specifically regarding the cleanliness and maintenance of wheelchairs. During a confidential group interview and observation, five out of ten residents reported that their wheelchairs were not being cleaned. Observations confirmed that the wheelchairs had dust build-up on various parts, including the wheel spokes, footrests, brakes, and frames. The residents expressed dissatisfaction with the dirty wheelchairs and stated that they had not seen anyone clean them. Interviews with staff, including an LVN, CNA, ADON, DON, and the Administrator, revealed that the responsibility for cleaning wheelchairs was assigned to the 10:00 PM-6:00 AM shift. However, it was noted that this task was not being consistently performed, leading to dirty wheelchairs and potential infection control concerns. The LVN and CNA both acknowledged noticing dirty wheelchairs and stated that they would notify the appropriate staff, but the cleaning was not being done regularly. The ADON and DON also confirmed that the night shift staff were responsible for cleaning the wheelchairs and admitted that there had been lapses in this duty. The Administrator reiterated that the night shift was responsible for wheelchair cleaning and emphasized that nursing management should ensure this task is completed. The facility's Resident Rights policy, revised in August 2020, mandates that residents be treated with respect and dignity and that their environment should promote their quality of life. The failure to maintain clean wheelchairs was identified as a violation of this policy, posing potential dignity and infection control risks for the residents.
Failure to Complete Post-Dialysis Assessments
Penalty
Summary
The facility failed to ensure that residents who required dialysis received services consistent with professional standards of practice. Specifically, the facility did not complete post-dialysis assessments for a resident after returning from dialysis treatment. This deficiency was identified for a resident with end-stage renal failure, chronic kidney disease, Type 2 diabetes, and essential hypertension. The resident's care plan included goals and interventions related to dialysis, but the facility did not document pre- and post-dialysis weights and vital signs as required. Interviews with staff revealed that the responsibility for obtaining and documenting these weights and vitals was not consistently followed, despite recent in-service training on the importance of these measures. The report highlighted that the dialysis communication forms lacked completed pre- and post-dialysis weights and vitals for the reviewed period. Staff interviews indicated that the dialysis center was supposed to provide this information, and the receiving nurse was responsible for ensuring it was documented. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) were unaware of the missing information and acknowledged the risks associated with not having accurate pre- and post-dialysis weights. The facility's current Dialysis Care policy required the dialysis provider to communicate vital signs and weights in writing, but this protocol was not followed, leading to the deficiency.
Failure to Maintain Accurate Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents. For Resident #45, the Medication Administration Record (MAR) did not accurately reflect the administration of hydrocortisone cream, which was prescribed for a rash on her lower legs. Despite the resident using the cream twice daily, the MAR only documented two doses. Interviews with the resident and staff confirmed the discrepancy, and the Director of Nursing (DON) acknowledged the failure to document all administrations, which could lead to missed or duplicate doses. For Resident #34, the facility failed to accurately document the dressing changes for his Peripherally Inserted Central Catheter (PICC) line. The MAR indicated that the dressing was changed on a specific date, but observation and interviews revealed that the dressing had not been changed as documented. The resident's PICC line dressing was overdue for a change, and the nurse responsible admitted to documenting the change incorrectly. Both the Assistant Director of Nursing (ADON) and the DON emphasized the importance of accurate documentation to ensure proper care and communication among staff. The deficiencies in documentation for both residents were confirmed through record reviews, observations, and staff interviews. The facility's policies on medication administration and nursing documentation were not followed, leading to incomplete and inaccurate records. This failure in documentation could result in significant risks to resident care, as noted by the DON and ADON during their interviews.
Inaccurate MDS Assessment for Gastrostomy Tube Status
Penalty
Summary
The facility failed to ensure that assessments accurately reflected the resident status for one resident reviewed for MDS assessment accuracy. Specifically, the quarterly MDS assessment for a resident was incorrectly coded regarding the gastrostomy tube status. The resident, a female with a history of cerebrovascular disease, hypokalemia, encephalopathy, and dysphagia, had a gastrostomy tube but was no longer receiving feedings through it. Despite this, the MDS assessment did not indicate the presence of the feeding tube, which was a discrepancy from the resident's care plan and physician orders that documented ongoing care and water flushes via the g-tube. Interviews with the resident, nursing staff, and the MDS Coordinator confirmed the presence of the gastrostomy tube and the discontinuation of feedings through it. The MDS Coordinator acknowledged the coding error and stated that the information was gathered from care plans, progress notes, and other documents. The Director of Nursing also confirmed the resident's current status and emphasized the expectation for timely and accurate completion of MDS assessments. The failure to accurately code the MDS assessment could place residents at risk of not receiving appropriate care and services to meet their needs.
Failure to Obtain Informed Consent for Medications
Penalty
Summary
The facility failed to ensure that residents were fully informed and understood their health status, care, and treatments. Specifically, the facility did not obtain signed informed psychotropic consents from Resident #71's responsible party before administering several medications, including Zoloft, Buspirone, Seroquel, and Valproic Acid. This failure was identified during a review of Resident #71's records, which revealed that the resident had severe cognitive impairment and was admitted with diagnoses including dementia, anxiety disorder, and psychosis. The care plans for Resident #71 did not include interventions to educate the resident or their responsible party about the medications and obtain the necessary consents prior to administration. Interviews with the ADON and DON confirmed that it was the admitting nurse's responsibility to obtain consents from the responsible party or the resident upon admission. The ADON admitted that Resident #71's EHR had been missed during chart audits, which would have identified the missing consents. The DON acknowledged that consents should be received before medications are given to ensure that residents or their representatives are informed about the medications, including potential risks and benefits. The facility's policies on psychotherapeutic drug management and resident rights also emphasized the importance of obtaining informed consent before administering medications. The failure to obtain informed consents for Resident #71's medications could place residents at risk of receiving medications without their prior knowledge or consent, or that of their responsible party. This deficiency highlights a lapse in the facility's processes for ensuring that residents and their representatives are fully informed about their treatment options and the associated risks and benefits. The facility's policies were not followed, leading to a situation where Resident #71 was administered multiple psychotropic medications without the necessary informed consents.
Failure to Maintain Resident's Personal Hygiene
Penalty
Summary
The facility failed to ensure that residents unable to conduct activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene. Specifically, Resident #33, who required extensive assistance for ADLs due to moderate cognitive impairment and limited mobility, had long fingernails that had not been cleaned or cut since her admission. Despite the resident expressing a desire for her fingernails to be short, the staff had not attended to this need. The resident's care plan indicated that she required moderate assistance for personal hygiene, but this was not adequately provided. Interviews with the staff revealed a lack of clarity and follow-through regarding the responsibility for cutting residents' fingernails. The CNA responsible for Resident #33's ADLs noticed the long fingernails but did not cut them, citing uncertainty about the resident's diabetic status. The LVN and DON confirmed that it was the responsibility of CNAs to cut fingernails unless the resident was diabetic, in which case it was the nurse's responsibility. The facility's policy on grooming care of fingernails was not followed, leading to the deficiency observed by the surveyors.
Failure to Change PICC Line Dressing as Ordered
Penalty
Summary
The facility failed to ensure that a resident received parenteral fluids administered consistent with professional standards of practice and in accordance with physician orders. Specifically, the facility did not change the PICC line dressings for a resident as ordered by the physician. The resident, a male with multiple diagnoses including osteomyelitis of the vertebra, paraplegia, and chronic kidney disease, had a PICC line for IV administration of antibiotics. The physician's order required the PICC line dressing to be changed every 7 days, but the dressing was not changed as scheduled, leading to a potential risk of infection. The dressing was last changed on 04/26/24, but it should have been changed again on 05/03/24, which did not occur. The resident's MAR/TAR inaccurately documented that the dressing was changed on 05/01/24, which was a mistake by the nurse responsible for the task. Interviews with the nursing staff, including the LVN, RN, ADON, and DON, revealed that the nurses were aware of the requirement to change the PICC line dressing every 7 days. However, the responsible nurse failed to follow through with the physician's order, and the oversight was not caught by other staff members. The ADON and DON acknowledged that it was their responsibility to ensure that PICC line dressings were being changed and dated correctly. The facility's Central Venous Catheter policy also outlined the procedure for changing and labeling the dressings, which was not adhered to in this case. This failure placed the resident at risk of developing an infection due to the prolonged use of the same dressing.
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Nursing homes near Fort Worth
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Dfw Nursing & Rehab | 0.1 mi | ★★★★★ | 13 | 4 |
| Downtown Health And Rehabilitation Center | 0.2 mi | ★★★★★ | 10 | 0 |
| James L West Center For Dementia Care | 0.8 mi | ★★★★★ | 0 | 0 |
| Fort Worth Transitional Care Center | 0.8 mi | ★★★★★ | 18 | 1 |
| Trinity Terrace | 0.9 mi | ★★★★★ | 0 | 0 |
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