Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Arbor Rehabilitation & Nursing Center during CMS and state inspections, most recent first.
A resident with depressive disorder and intact cognition was sitting in a hallway when a former roommate with schizophrenia, depression, and documented hallucinations and mood instability suddenly approached and struck him in the face and head near the nurses’ station. Staff interviews described a pattern of escalating behaviors in the aggressor, including shouting, verbal outbursts, delusional statements about the other resident, reluctance to return to the shared room, and increasing aggression in the weeks before the incident. Despite a PASRR Level 2 determination and care plans noting hallucinations and potential mood problems, the resident was able to physically assault another resident in a common area before an LN could intervene, contrary to the facility’s abuse prevention policy requiring identification, assessment, care planning, and monitoring of residents whose behaviors might lead to conflict.
A resident diagnosed with scabies did not trigger the facility's full surveillance and notification procedures, as the Infection Preventionist failed to conduct the required six-week contact identification and did not provide in-service training or formal notification to all key healthcare personnel. Many staff members, including CNAs, nurses, and housekeeping, were unaware of the case or the necessary precautions, and no documentation of staff education or communication was maintained.
A resident with a history of dehydration, acute kidney failure, and hypertension, who was prescribed diuretics, did not have water within reach despite care plan instructions and facility policy. Staff confirmed the water pitcher was placed out of reach, and the resident was unable to access it, increasing the risk for dehydration.
A resident with a history of dehydration, acute kidney failure, and hypertension, who was prescribed diuretics, did not have water within reach while in bed. Staff confirmed the water pitcher was placed out of reach, and facility policy required fluids to be accessible to residents without restrictions. This failure did not follow the resident's care plan or facility hydration policy.
Three residents experienced deficiencies in accident prevention and supervision, including a resident who was moved before being assessed after a fall and whose physician was not promptly notified of post-fall symptoms, resulting in delayed treatment. Another resident had incomplete post-fall documentation, and a third had incomplete neurochecks and was not provided with required nonskid footwear, despite being at high risk for falls. These failures led to delayed care and increased risk of harm.
A resident with multiple rib fractures did not receive pain medications according to established pain level parameters, with acetaminophen given for higher pain levels than ordered and hydrocodone-acetaminophen administered without clear pain level guidelines. The DON confirmed a lack of documentation for these deviations, and the facility's pain management policy requiring consistent assessment and documentation was not followed.
A resident with muscle weakness and rib fractures, who was on a toileting program, requested to use the bathroom after a fall but was told by a CNA to use her incontinence brief instead. Another CNA and the DON acknowledged this was inappropriate and a dignity concern, as facility policy requires staff to treat residents with respect and respond to their needs.
A resident who lacked mental capacity was administered psychotropic medications without the informed consent of their Responsible Party (RP). The facility had the resident, rather than the RP, sign the consent forms, and the RP was not informed or consulted about the medications or their risks and benefits, contrary to facility policy.
A resident with multiple rib fractures experienced a fall, and the facility failed to notify the resident's Responsible Party (RP) as required. Documentation inaccurately listed the resident as her own RP, and the LPN confirmed that the actual RP was not notified. The DON verified the inaccuracy and acknowledged that the facility's policy required RP notification after such incidents.
A resident received the psychotropic medication quetiapine for several days without an accurate or appropriate diagnosis documented in their clinical record. The medication was ordered for bipolar disorder, but the resident did not have this diagnosis, and the facility's policy requiring a documented indication for psychotropic use was not followed. Both the DON and the physician confirmed the lack of proper diagnosis and rationale for the medication administration.
A resident with hypertension and diabetes was given Losartan without specific hold parameters in the physician's order, and staff did not clarify the order with the MD. The same resident had two significantly elevated BP readings in one day, but the physician was not notified as required by facility policy. Both nursing staff and the DON confirmed these omissions, and the MD stated he was not contacted about the abnormal results.
A resident with significant care needs was inappropriately discharged from an LTC facility to a room and board facility that could not meet her needs. The resident required substantial assistance with daily activities and was reliant on oxygen therapy. Upon arrival, the room and board facility, which only accepted independent residents, sent her to the emergency department. The hospital confirmed the discharge was unsafe, and the resident remained hospitalized for 26 days awaiting proper placement.
A resident with significant care needs was unsafely discharged from an LTC facility to a room and board facility that could not accommodate her. The resident, requiring substantial assistance and being oxygen reliant, was not informed about the type of facility she was transferred to. Upon arrival, she was unable to care for herself and called 911, leading to her transfer to an emergency department. The LTC facility refused to readmit her, citing non-payment and claiming she did not need skilled nursing care, despite the failed discharge plan.
The facility failed to remove expired medical supplies and maintain medication carts in an orderly manner. Expired supplies, including a Mic-Key continuous feed extension set and Covid-19/Flu test kits, were found in the medication storage room. Additionally, loose and broken pills were observed in medication carts across various nursing stations. These findings were verified by LNs and the ADON, highlighting a lapse in adherence to the facility's policies.
The facility used expired Quat strips to measure sanitizer concentration in the kitchen, increasing the risk of foodborne illness for 124 residents. The Dietary Manager and Registered Dietician acknowledged the oversight, and the facility's policies lacked instructions to check expiration dates.
The facility failed to maintain an effective infection prevention and control program. A resident's nasal cannula was found uncovered, and staff did not practice hand hygiene during meal service. Another resident's urinary bag touched the floor, and PPE was not donned for a resident on enhanced precautions. Additionally, a linen cart was partially covered, and a laundry aide's uniform touched clean clothes, all contrary to facility policies.
A resident's dignity was compromised when their urine drainage bag was left exposed to public view, causing embarrassment. The resident, admitted with prostate gland enlargement, had their urine bag visible from the hallway due to an open door. The Infection Preventionist and DON acknowledged the bag should have been covered with a dignity bag.
The facility failed to ensure call lights were within reach for three residents, preventing timely assistance. One resident with multiple fractures had his call light hooked to the wall, another with hemiplegia had it looped away, and a third with cognitive impairment had it on the floor. Staff confirmed these observations, acknowledging the call lights should be accessible.
A resident with mobility issues and a history of falls did not have fall mats placed as per their care plan, increasing the risk of injury. Despite a previous fall incident resulting in a head injury, the necessary fall prevention measures were not in place, as confirmed by an LN during an observation.
A resident with chronic lymphocytic leukemia did not receive their prescribed daily dose of Ferrous Sulfate due to unavailability, as confirmed by an LPN. The facility's policy and the Nursing Practice Act require adherence to medication orders, which was not followed in this instance.
A resident with a contracted right hand and multiple health conditions, including diabetes, did not receive adequate nail care, leading to long fingernails that were not trimmed despite the resident's reports to staff. The facility's policy required licensed nurses or podiatrists to cut the nails of diabetic residents, but there was no documentation of consultation with a podiatrist or other resources to address the resident's nail care needs.
A resident with right-sided paralysis and heart and lung issues felt trapped due to the facility's failure to provide meaningful activities. The resident spent most of the time watching TV in bed, as the facility did not assist in getting him into a wheelchair or provide activity materials. The Activity Director confirmed the lack of engagement and acknowledged the need for more meaningful activities.
A resident with chronic lymphocytic leukemia did not receive a prescribed iron supplement for five days due to unavailability. The resident's medical records showed low red blood cell counts and mean platelet volume. The LN confirmed the medication was unavailable and acknowledged the facility's policy to notify central supply when medications were low. The DON and ADON acknowledged the failure to supply the medication as ordered.
Failure to Adequately Supervise Resident With Psychiatric and Behavioral History, Resulting in Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and protection from abuse for one resident when another resident physically struck him. A resident with depressive disorder and an intact BIMS score of 14/15 reported that while he was sitting in the hallway minding his own business, his former roommate suddenly approached and hit him on both sides of his head before he could react. A licensed nurse and a CNA both described that the aggressor resident walked toward the victim near the North Nurses Station and hit him in the face, with the licensed nurse stating she saw the aggressor hit the victim twice on the face before she could intervene. The Social Service Director reported that the victim sustained a scratch and redness on the right cheek as a result of being hit. The aggressor resident had been admitted with schizophrenia and depression and had documented auditory and visual hallucinations, including hearing voices and seeing snakes and the devil, as well as a care plan noting potential mood problems with racing thoughts, increased irritability, agitation, and hyperactivity. Staff interviews indicated that this resident had a history of shouting at staff, lunging at staff, and having verbal outbursts, including calling staff devils and talking about snakes. CNAs reported that in the weeks prior to the incident, the resident, who had previously been quiet, became very talkative, expressed delusional beliefs about the other resident having guns and being a bad person, did not want to return to his room, and was observed becoming mad and aggressive. The facility was aware of the aggressor resident’s serious mental illness, as evidenced by a positive PASRR Level 1 screening requiring a Level 2 mental health evaluation and a Level 2 individualized determination report listing services and supports to address mental health needs. The Director of Nursing acknowledged awareness of the resident’s psychiatric diagnosis on admission and stated that the goal was resident safety and that altercations could make residents feel unsafe, fearful, or scared. Despite the known behavioral history, hallucinations, and escalating behaviors, the incident occurred in a common area near the nurses’ station where the aggressor resident was able to approach and hit the other resident before staff could prevent the assault, contrary to the facility’s abuse prevention policy requiring identification, assessment, care planning, and monitoring of residents with behaviors that might lead to conflict.
Failure to Implement Scabies Surveillance and Staff Notification Procedures
Penalty
Summary
The facility failed to follow its established surveillance plan for the prevention and control of scabies after a resident was diagnosed with the condition. The Infection Preventionist (IP) did not implement the required six-week contact identification list, instead conducting contact identification for only six days. Additionally, the IP did not assign a dedicated care team member to provide care for the affected resident, as specified in the facility's surveillance plan. The facility's policy required the development of a contact identification list for all individuals who may have had direct, physical contact with the case within the previous six weeks, but this was not completed. Key healthcare personnel, including staff from various departments such as environmental services and nursing, were not properly notified or trained on how to recognize and report signs and symptoms consistent with scabies infestation. The IP verbally notified only a limited group of staff during a huddle at the north station, and there was no documentation or sign-in sheet to confirm who attended. Many staff members, including CNAs, housekeepers, and nurses, reported that they were not informed of the scabies case through official channels and did not receive any in-service training or formal communication regarding the diagnosis or necessary precautions. The facility's records showed that no in-service training on scabies was provided after the diagnosis, and there was no documentation of communication or education in the resident's progress notes. The facility's surveillance plan and policy required prompt notification and education of all healthcare personnel and volunteers, as well as the assignment of a dedicated care team and the maintenance of a contact identification list for six weeks. These steps were not followed, resulting in a failure to implement the facility's own infection prevention and control procedures for scabies.
Failure to Ensure Water Was Accessible for Resident at Risk of Dehydration
Penalty
Summary
A deficiency was identified when a resident with a history of dehydration, acute kidney failure, and essential hypertension did not have water available within reach. The resident was admitted with these diagnoses and was prescribed diuretic medications, which increase the risk of dehydration. The resident's care plan included instructions to offer and encourage fluids between meals. However, during observations, the resident was found in bed with the water pitcher placed on a dresser out of reach, and the straw remained wrapped. The resident confirmed being unable to reach the water pitcher. Further interviews with facility staff, including a licensed nurse and the Assistant Director of Nursing, verified that the water pitcher was not accessible to the resident. Staff acknowledged the resident's risk for dehydration due to their medical condition and medication regimen. Facility policy requires that beverages be available and within reach for all residents unless there are fluid restrictions or contraindications, neither of which applied in this case.
Failure to Ensure Hydration Needs Met for Resident on Diuretics
Penalty
Summary
A deficiency occurred when a resident with a history of dehydration, acute kidney failure, and essential hypertension did not have water available within reach. The resident was observed in bed with the water pitcher placed on a dresser out of reach, and the straw remained wrapped. The resident confirmed being unable to access the water. The clinical record indicated the resident was on diuretic medications, which increase the risk of dehydration, and the care plan specified that fluids should be offered and encouraged between meals. A licensed nurse verified that the water pitcher was out of reach and acknowledged the resident's risk for dehydration due to diuretic use. The Assistant Director of Nursing stated that it was expected for all residents without fluid restrictions or contraindications to have water within reach. Facility policy also required beverages to be available and accessible to residents. The failure to provide water within reach did not align with the resident's care plan or facility policy.
Failure to Prevent Accident Hazards and Ensure Adequate Supervision
Penalty
Summary
The facility failed to maintain a safe and supervised environment to prevent accidents and hazards for three residents. In one instance, a resident with multiple rib fractures fell and was moved by staff before being assessed for injuries, contrary to facility policy and staff training. The licensed nurse involved acknowledged that the resident should not have been moved prior to assessment, and the Director of Nursing confirmed that the correct procedure was to assess for injuries before moving any resident after a fall. Additionally, the resident experienced blurred vision and headaches following the fall, but the physician was not notified of these symptoms until five days later, resulting in a delay in treatment. The physician stated that if he had been informed earlier, he would have ordered the resident to be transferred to the emergency department for evaluation. For another resident, clinical documentation was incomplete following a fall, specifically the post-fall assessment for the night shift was not completed. The Director of Nursing confirmed this omission and explained that post-fall assessments are necessary to ensure there are no hidden injuries and to implement appropriate interventions. In a third case, a resident with hemiplegia and hemiparesis had incomplete neurocheck documentation after a fall, with most vital signs recorded prior to the fall rather than after. Additionally, this resident was observed wearing regular socks instead of the required nonskid footwear, despite care plan interventions specifying the use of nonskid socks to prevent falls. Both a CNA and a licensed nurse confirmed that the resident should have been wearing nonskid socks to reduce the risk of further falls. Facility policies reviewed indicated that residents should be assessed for injuries before being moved after a fall, that post-fall monitoring should occur for at least 72 hours, and that changes in condition should be promptly communicated to the physician. The failures identified in these cases resulted in delayed treatment, incomplete documentation, and failure to follow care plan interventions, all of which had the potential to negatively affect the health and well-being of the residents involved.
Failure to Follow Pain Medication Parameters and Documentation Standards
Penalty
Summary
The facility failed to ensure safe and appropriate pain management for a resident with multiple rib fractures, specifically in the administration and management of pain-relieving medications. The resident's care plan indicated the need for analgesia as per physician orders, with pain levels to be assessed using a numeric scale. However, the Medication Administration Record showed that acetaminophen, ordered for mild pain (1-3), was administered for higher pain levels (4 and 5) without documented rationale. Additionally, hydrocodone-acetaminophen, a narcotic, was administered for pain levels of 3, despite the absence of specific pain level parameters in the physician's order for this medication. The Director of Nursing confirmed that medications were given outside of the ordered parameters and that there was no documentation explaining the rationale for these decisions. The physician stated that pain level parameters are typically included in orders and that hydrocodone would have been intended for moderate pain (4-6), not mild pain. The facility's pain management policy required consistent assessment, management, and documentation of pain and medication effectiveness, which was not followed in this case.
Resident Denied Dignified Access to Bathroom
Penalty
Summary
A resident admitted with muscle weakness and multiple rib fractures was on a toileting program, as indicated in the care plan, which specified assistance with toileting upon rising, before or after meals, at bedtime, and as needed. Following a fall, the resident requested to use the bathroom, but a Certified Nursing Assistant (CNA) informed the resident that she was wearing an incontinence brief and could use it instead of being assisted to the restroom. Another CNA stated that she would never instruct a resident to use their brief if the resident requested to use the restroom and was able to do so with assistance, identifying this as a dignity concern. The Director of Nursing (DON) confirmed that it was inappropriate to deny the resident's request and emphasized the importance of preserving the resident's dignity. Facility policy also required staff to promote and maintain resident dignity and respond to requests for assistance in a timely and respectful manner.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident's Responsible Party (RP) was informed and provided consent for the use of psychotropic medications. Despite documentation indicating that the resident did not have the mental capacity to make healthcare decisions, the facility had the resident sign the informed consent forms for quetiapine and escitalopram. The resident received quetiapine for four days and escitalopram throughout their stay without proper informed consent from the RP. Record review and interviews confirmed that the RP was not informed about the use of these medications, nor were the risks and benefits discussed with them. The facility's policy required informed consent for psychotropic medications to be verified prior to use, but this was not followed. The DON acknowledged that the resident lacked capacity and that the RP should have signed the consent forms, while the RP confirmed they were never approached regarding the medications.
Failure to Notify Responsible Party After Resident Fall
Penalty
Summary
The facility failed to notify a resident's Responsible Party (RP) after the resident experienced a fall. Review of the resident's admission record indicated the resident had multiple rib fractures on the left side of the ribcage. Documentation in the SBAR Fall Report of Incident incorrectly listed the resident as her own RP and stated that the RP was notified. However, during interviews, the licensed nurse confirmed that he documented the resident as her own RP and did not notify the actual RP. Further review with the Director of Nursing (DON) confirmed that the clinical record was inaccurate and that the RP should have been notified, especially in case the RP wanted to make decisions such as sending the resident to the emergency room. The facility's policy on Fall Prevention and Response required notification of both the physician and the RP following a fall, but this was not followed in this instance.
Psychotropic Medication Administered Without Accurate Diagnosis
Penalty
Summary
A resident was administered the psychotropic medication quetiapine for four days without an accurate or appropriate diagnosis documented in their clinical record. The medication was ordered for bipolar disorder, but the resident did not have a diagnosis of bipolar disorder; their admission record only listed depression among their diagnoses. The Medication Administration Record showed that quetiapine was given from March 7 to March 10, despite the lack of a proper indication for its use as required by facility policy. During interviews, the DON confirmed that the physician's order for quetiapine did not have an accurate diagnosis, emphasizing the importance of matching medications to the resident's documented conditions. The resident's physician also stated that a review of the medications should have been completed and that the facility should have clarified the rationale for prescribing a psychotropic medication. The facility's policy requires that psychotropic medications be used only when necessary and that the clinical record reflect the diagnosis and specific condition being treated, which was not followed in this case.
Failure to Clarify Blood Pressure Medication Parameters and Notify Physician of Elevated Readings
Penalty
Summary
A deficiency occurred when a resident with hypertension and type 2 diabetes mellitus was administered the blood pressure medication Losartan without specific parameters in the physician's order to guide when the medication should be withheld. The medication order did not include instructions regarding minimum systolic blood pressure or heart rate thresholds, and the nursing staff did not clarify the order with the physician. Multiple licensed nurses and the Director of Nursing confirmed that the order lacked these parameters, and it was the facility's usual practice to include such parameters or verify them with the physician. The physician also stated that he expected staff to clarify orders and that parameters should have been in place to prevent adverse effects such as hypotension. Additionally, the same resident experienced two episodes of elevated blood pressure readings, with systolic values of 173 and 168, on the same day during different shifts. These readings were significantly higher than the resident's baseline and outside the normal range. Despite this, there was no documentation that the physician was notified of these abnormal values. Nursing staff and the Director of Nursing acknowledged that the physician should have been informed of these elevated readings, and the physician confirmed that he was not contacted and would have expected notification for such results. Facility policy required licensed nurses to assess, document, and communicate changes in condition, including abnormal vital signs, to the primary care provider. The failure to clarify medication parameters and to notify the physician of significant changes in blood pressure constituted a lack of adherence to professional standards of practice and facility policy, resulting in the identified deficiency.
Inappropriate Discharge to Room and Board Facility
Penalty
Summary
The facility failed to ensure a safe and effective transition of care for a resident who was discharged to a room and board facility that could not meet her care needs. The resident, who was admitted to the facility with diagnoses including morbid obesity, repeated falls, and weakness, required substantial assistance with activities of daily living such as toileting, bathing, and dressing. Despite these needs, the facility discharged her to a location that only accepted residents who were independent in their care needs. Interviews with facility staff revealed that the resident was heavily dependent on assistance for mobility and personal care. The Certified Nurse Assistant and Licensed Nurse both confirmed that the resident required significant help with basic activities and was not capable of independent living. The facility's social services department had communicated to the room and board facility that the resident was ambulatory and needed only toileting assistance, which was inaccurate. Upon arrival at the room and board facility, the resident was unable to manage her care independently and was immediately sent to the emergency department. The room and board facility owner stated that they had been misinformed about the resident's capabilities. The hospital's social worker confirmed that the discharge plan was unsafe and inappropriate, as the resident required a skilled nursing facility due to her care needs and reliance on oxygen therapy. The facility's failure to provide an accurate assessment and safe discharge plan resulted in the resident spending 26 days in the hospital awaiting appropriate placement.
Failure to Safely Discharge and Readmit Resident
Penalty
Summary
The facility failed to readmit a resident after she was transferred to a local emergency department following an unsafe discharge to a room and board facility that could not accommodate her care needs. The resident, who was admitted to the facility in the fall of 2022, had diagnoses including morbid obesity, repeated falls, and weakness. Her Minimum Data Set (MDS) assessment indicated she required substantial assistance with activities such as toileting hygiene, bathing, dressing, and transferring in and out of a tub or shower. Despite these needs, the facility discharged her to a room and board facility that only accepted residents who were independent in their care needs. Upon arrival at the room and board facility, the resident was unable to move or get out of her wheelchair by herself, contrary to what the nursing home had communicated. The room and board facility owner stated that the resident was not informed about the type of facility she was being transferred to and that she was unable to clean herself after using the toilet. Consequently, the resident called 911 and was taken to the emergency department. The hospital's Master of Social Worker confirmed that the room and board facility could not meet the resident's care needs, and she was oxygen reliant without having any oxygen with her. The hospital's physical therapy evaluation recommended that the resident required short to long-term care. The facility's administrator acknowledged a disconnect in the transfer process but did not provide a clear explanation for the failure. The facility's policy on admission, transfer, discharge, and bed-holds emphasized the importance of ensuring a safe and orderly discharge, which was not adhered to in this case. The hospital's social worker noted that the facility refused to take the resident back, citing non-payment of her share of cost and claiming she did not meet the requirements for skilled nursing care, despite the failed discharge plan and the resident's evident need for continued care.
Expired Supplies and Disorganized Medication Carts Found
Penalty
Summary
The facility failed to ensure the removal of expired medical supplies from the medication storage room and maintain medication carts in a clean and orderly manner. During a check of the medication storage room, an expired Mic-Key continuous feed extension set and Covid-19/Flu test kits were found, with expiration dates that had already passed. A Licensed Nurse verified these findings and acknowledged that the expired supplies should have been discarded. The facility's policy requires that expired medications and biologicals be stored separately until they are destroyed or returned to the provider. Additionally, during checks of medication carts in various nursing stations, loose and broken pills, as well as residue, were found in the carts. Licensed Nurses and the Assistant Director of Nursing verified these findings, and it was noted that the facility's expectation was for no loose pills to be present in the medication carts. The Director of Nursing acknowledged the oversight regarding the expired biologicals and clarified that the facility found a manufacturer's memo extending the expiration date of the Covid-19 test kits after the initial inspection.
Expired Sanitizer Strips Used in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety by using expired Quaternary Ammonium (Quat) strips to measure the concentration of sanitizer used in the kitchen. During an initial tour of the kitchen, the Dietary Manager (DM) was observed testing the sanitizer level of the Quat solution, which measured at 150 parts per million (ppm). Upon checking, it was verified that the Quat strips being used were expired. The DM acknowledged that the expiration dates of the sanitizer strips should be checked frequently enough to ensure they are not expired. Further interviews revealed that the Registered Dietician (RD) also expected that the expiration dates of the Quat strips should be checked before usage. A review of the facility's policy and procedure on chemical sanitizing did not include instructions to check the expiration date of the strips. Additionally, the facility's Sanitizer Log lacked instructions to verify the expiration date of the test strips. This oversight increased the risk of foodborne illness for the residents consuming meals prepared at the facility, which had a total census of 124 residents.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several observations. Resident 116's nasal cannula was found uncovered on top of the oxygen concentrator, contrary to the facility's policy that requires storing tubing in a sanitary manner. The Director of Nurses confirmed the observation and acknowledged the expectation for the oxygen tubing to be covered when not in use. Additionally, during meal service, hand hygiene was not practiced by staff members, as observed with a CNA and an RNA who did not wash their hands after touching residents and before serving drinks, which was against the facility's infection control expectations. Resident 72's urinary bag was observed touching the floor, which posed a risk of bacterial infection. The facility's policy requires that the collection bag and tubing be kept off the floor to prevent contamination. Licensed nurses verified the observation and acknowledged the risk of infection due to the improper positioning of the urinary bag. Furthermore, Resident 38, who was on enhanced precautions, did not have PPE donned by the LN administering insulin, which was a requirement for infection control. Additional deficiencies included a partially covered linen cart and a laundry aide's uniform touching clean personal clothes, both of which were against the facility's infection control policies. The Environmental Services Manager confirmed that clean linens must be fully covered, and uniforms should not touch clean clothes to prevent cross-contamination. The Infection Preventionist reiterated the importance of these practices to maintain a sanitary environment and prevent the spread of infections.
Resident's Dignity Compromised by Exposed Urine Drainage Bag
Penalty
Summary
The facility failed to protect the dignity of Resident 72, who was admitted with a diagnosis of prostate gland enlargement that could cause urination difficulty. During an observation, it was noted that Resident 72's urine drainage bag was hanging at the side of the bed, facing the hallway, with the room door wide open, making it visible from the hallway. The Infection Preventionist confirmed that the urine drainage bag was exposed and should have been covered with a dignity bag. The Director of Nursing, along with the Assistant DON, acknowledged that the urinary drainage bag should have been covered. Resident 72 expressed feeling embarrassed due to the lack of a dignity bag covering the urine drainage bag.
Failure to Ensure Call Light Accessibility for Residents
Penalty
Summary
The facility failed to accommodate the needs of three residents by not ensuring their call lights were within reach, preventing them from obtaining assistance promptly. Resident 479, admitted with multiple fractures and a history of falls, was observed with his call light hooked to the wall, out of reach, despite being alert and oriented. This was confirmed by a Licensed Nurse who acknowledged the call light should be accessible. Similarly, Resident 65, who has hemiplegia and cognitive impairments, was found with his call light looped and hung by the wall, away from his reach. A Certified Nursing Assistant confirmed this observation, stating the call light should be within reach. Resident 1, with hemiplegia and moderate cognitive impairment, was found with his call light on the floor, out of reach, while he was awake and expressing discomfort. This was confirmed by a CNA who stated the call light should be near the resident's bedside. The facility's policy requires call lights to be accessible to residents while in bed, but this was not adhered to, as confirmed by the Assistant Director of Nursing. These observations indicate a failure to meet the residents' needs for timely assistance.
Failure to Implement Fall Prevention Care Plan
Penalty
Summary
The facility failed to implement a care plan for a resident identified as at risk for falls. The resident, who was admitted with right side paralysis, generalized muscle weakness, and other mobility issues, had a care plan created to manage fall risks. This care plan included interventions such as placing fall mats on the sides of the bed, which were to be implemented by a specific date. However, during an observation and interview, it was noted that the fall mats were not present in the resident's room, contrary to the care plan. The deficiency was further highlighted by a previous incident where the resident had an actual fall, resulting in a head injury and requiring hospital evaluation. Despite this incident, the necessary fall prevention measures were not in place during the surveyor's visit. A licensed nurse confirmed the absence of the fall mats and acknowledged that they should have been placed according to the care plan. This oversight increased the potential for further injury to the resident.
Medication Administration Deficiency
Penalty
Summary
The facility failed to meet professional standards of nursing practice for one of the residents, identified as Resident 20, when a prescribed medication was not administered as ordered. Resident 20, who was recently admitted to the facility with a diagnosis of chronic lymphocytic leukemia, had a physician's order for Ferrous Sulfate 325 mg to be taken daily. During a medication administration observation, it was noted that the medication was not given to the resident as per the physician's order. Licensed Nurse (LN 2) confirmed in an interview that the medication was not administered because it was unavailable. The facility's policy and procedure, as well as the Nursing Practice Act Rules and Regulations, require compliance with medication administration orders. The Director of Nursing, along with the Assistant DON, acknowledged that the medication should have been administered as ordered.
Failure to Provide Adequate Nail Care for a Resident with Contracted Hand
Penalty
Summary
The facility failed to provide adequate nail care for a resident, identified as Resident 96, who was unable to perform activities of daily living due to a contracted right hand. Resident 96 was admitted with multiple diagnoses, including Type 2 Diabetes Mellitus, gout, sepsis, and muscle weakness. Despite having intact cognition and no history of rejecting care, the resident's right hand was observed to be contracted with long fingernails and a brownish/blackish substance underneath. The resident reported that the long fingernail had been digging into his skin for a year, and although he informed the nurses, they did not address the issue. Attempts by some nurses to trim the nails were unsuccessful, and the issue was not escalated or documented properly. Interviews with facility staff, including a licensed nurse and the Assistant Director of Nursing (ADON), confirmed the resident's need for assistance with daily care, including nail trimming. The ADON acknowledged that the resident's nails could cause injury due to their length and the inability to trim them. The facility's policy required licensed nurses or podiatrists to cut the nails of diabetic residents, but there was no documentation of consultation with a podiatrist or other resources to address the resident's nail care needs. This lack of action and documentation contributed to the deficiency in care provided to Resident 96.
Failure to Provide Meaningful Activities for Resident
Penalty
Summary
The facility failed to provide meaningful ongoing activities for a resident, identified as Resident 120, who was admitted with right-sided paralysis and heart and lung problems. During an observation, the resident was found lying in bed with the TV on and expressed a desire to engage in activities to strengthen his paralyzed side. The resident reported that he spent most of his time watching TV because the facility did not assist him in getting out of bed and into a wheelchair. He expressed a preference for attending group activities and noted the absence of books, magazines, or other activity materials in his room. The resident felt trapped and insignificant due to the lack of engagement and activity options. The facility's policy on residents' rights to refuse activities emphasized offering a wide range of activity programs and ensuring continuous engagement through group programs, one-to-one contacts, or independent leisure materials. However, the care plan for Resident 120, initiated in July, indicated that he would spend most of his time in his room involved in independent leisure pursuits, with interventions including room visit check-ins and offering materials for independent use. An interview with the Activity Director revealed that Resident 120 did not attend group activities, and there was no documentation of one-on-one room visits or a list of activity materials provided. The Activity Director acknowledged that watching TV all day was not a meaningful activity and admitted that the facility should have facilitated more engagement for the resident.
Failure to Administer Prescribed Iron Supplement
Penalty
Summary
The facility failed to provide necessary pharmaceutical services for a resident, resulting in the resident not receiving a prescribed iron supplement, ferrous sulfate, for five consecutive days. The resident, who was recently admitted with chronic lymphocytic leukemia, had a physician's order for ferrous sulfate 325 mg to be administered daily. However, during a medication administration observation, it was noted that the supplement was not given due to its unavailability. The resident's medical records indicated low red blood cell counts and low mean platelet volume, which could be related to the lack of the iron supplement. The Licensed Nurse (LN) confirmed that the medication was unavailable and acknowledged that it was the facility's policy to notify central supply when medications were running low. The Director of Nursing (DON) and Assistant DON also acknowledged that the facility should have ensured the medication was supplied as per the physician's order.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 375 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lodi
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fairmont Rehabilitation Hospital | 0.5 mi | — | 2 | 0 |
| Lodi Nursing & Rehabilitation | 0.7 mi | — | 20 | 0 |
| Lodi Creek Post Acute | 1.6 mi | — | 22 | 0 |
| Vienna Nursing And Rehabilitation Center | 2.2 mi | — | 27 | 0 |
| Creekside Center | 6.8 mi | — | 14 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Arbor Rehabilitation & Nursing Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.