Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around October 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 Care Centers - Ord, Llc during CMS and state inspections, most recent first.
The facility did not notify the State Agency within the required timeframe after changes in the Administrator position, as confirmed by record review and interviews with the administrator and owner. Notification forms for two separate administrator changes were submitted late, potentially affecting all 39 residents.
A resident with multiple myeloma did not consistently receive their prescribed chemotherapy medication, lenalidomide, due to repeated lapses in ordering, availability, and administration. The medication was not given according to the required 28-day cycle, with missed and delayed doses documented over several months. Staff and pharmacy interviews confirmed gaps in ordering and delivery, and there was no evidence that the prescribing oncologist was notified of these medication errors.
The facility failed to maintain sanitary conditions in food storage areas, with rodent droppings observed in multiple locations. The Food Services Supervisor acknowledged the issue and the need for more cleaning. This deficiency had the potential to affect all 32 residents.
The facility failed to maintain an effective pest control program, as evidenced by rodent droppings in food storage areas. The Food Services Supervisor acknowledged the issue, noting a lack of live mouse traps in the kitchen. The Facility Administrator was unaware of the problem, despite the facility's policy requiring an ongoing pest control program.
The facility failed to maintain a safe and clean environment, with stained carpets and ceiling tiles, a deceased bug in a light fixture, and loose flooring creating trip hazards in multiple hallways. The Maintenance Manager confirmed these issues, noting that carpets were only cleaned biannually and ceiling tiles had not been replaced after a water leak repair.
The facility failed to complete pre-employment health screenings for staff and did not adhere to hand hygiene protocols during medication administration. Additionally, staff did not follow Enhanced Barrier Precautions for residents with multidrug-resistant organisms, failing to wear gowns and gloves during high-contact care activities. These deficiencies were confirmed by facility management and observed during resident care.
The facility failed to ensure proper bathroom ventilation in three rooms, as the ventilation systems were unable to pull up a single ply of tissue, indicating inadequate ventilation. This was confirmed by the Maintenance Manager, who acknowledged the malfunction.
The facility failed to notify physicians of abnormal lab results for a resident with diabetes and out-of-range blood pressure readings for two residents with Parkinson's Disease and hypertensive heart disease. Despite having orders to notify physicians of these conditions, there was no documentation of such notifications, as confirmed by interviews with facility staff.
A resident with a history of falls and severe cognitive impairment experienced multiple falls due to inadequate fall prevention interventions. Despite the facility's policy, no new interventions were developed after a fall, and the resident was frequently left in a wheelchair instead of a regular chair as per the care plan. Additionally, the resident's mattress was not secured to the bedframe, posing a safety risk. Staff interviews revealed that fall prevention measures were not effectively communicated or implemented.
The facility failed to manage pain effectively for two residents, both experiencing chronic pain conditions. Despite receiving routine and as-needed pain medications, their pain was not adequately controlled, with frequent moderate to severe pain ratings. Staff did not notify providers about the frequent use of as-needed medications, which could have led to adjustments in pain management plans. Interviews confirmed the deficiency in communication and pain management strategies.
A facility failed to limit a PRN psychotropic medication order for a resident to 14 days as required. The resident received Lorazepam beyond the 14-day limit without a documented rationale from a physician. The oversight was noted by a consultant pharmacist, but the facility's Infection Control Coordinator was unaware of the issue until later, and a necessary note to the attending physician was not sent for review.
The facility failed to ensure clear and accurate medication labeling for two residents. One resident's insulin pen label was illegible, obscuring administration directions, while another resident's medication label did not match the physician's order. These issues were confirmed by nursing staff and the Director of Nursing.
Failure to Timely Notify State Agency of Administrator Changes
Penalty
Summary
The facility failed to notify the State Agency within the required five working days following changes in the Administrator position, as mandated by licensure regulations. Record review showed that the Change of Administrator Notification Form for an administrator change occurring between 11/19/2025 and 11/20/2024 was not submitted to the State Agency until 12/16/2025. Similarly, for another administrator change between 6/10/2025 and 6/11/2025, the notification form was not sent until 7/12/2025. Interviews with the administrator and facility owner confirmed that both notifications were submitted outside the required timeframe. This deficiency had the potential to affect all 39 residents in the facility.
Failure to Ensure Timely Administration and Availability of Prescribed Chemotherapy Medication
Penalty
Summary
The facility failed to ensure that a resident with multiple myeloma received their prescribed medication, lenalidomide, according to the physician's orders. The medication was to be administered in a 28-day cycle, with 21 days on and 7 days off, but there were multiple documented instances where the medication was not available or not administered as ordered. Review of the Medication Administration Records (MAR) over several months revealed repeated gaps in administration, with cycles starting late, not restarting on time, or being missed entirely. There was no physician order to stop the medication at any point, and the MARs did not reflect any authorized changes to the regimen. Interviews with facility staff and the infection preventionist (IP) confirmed that the medication was only available through a specialty pharmacy, which required the facility to order the medication for each cycle individually. The IP acknowledged that the medication order would fall off the electronic system after a few months and had to be manually re-entered, which contributed to the missed doses. The pharmacy representative corroborated that there were months when no medication was ordered or delivered, and staff interviews confirmed that there were times when the medication was not available for administration. There was also a lack of documentation or receipts to show that the medication was obtained from any other source during the periods when the pharmacy did not deliver it. Additionally, there was no evidence that the resident's oncologist was notified of the medication errors, despite the ongoing issues with medication availability and administration. Staff interviews indicated inconsistent practices regarding the storage and tracking of the medication, with reports of extra medication being kept in the medication cart at times, but no clear process for ensuring continuous supply. The facility's failure to maintain a consistent supply and administration of the prescribed medication led to significant lapses in care for the resident.
Rodent Droppings Found in Food Storage Areas
Penalty
Summary
The facility failed to store food under sanitary conditions, as evidenced by the presence of rodent droppings in and around the food storage areas. During an observation, the Food Services Supervisor (FSS) directed the surveyor to the kitchen's dry storage area, where food items were stored off the floor. However, there was a 4-inch gap between the shelving and the floor, where individual food packs and wooden snap mouse traps were visible. In the main storage area, which contained a refrigerator, freezers, and dry food shelving units, the floors were observed to have dried pasta, corn kernels, and a buildup of dark soiling. Mouse droppings were littered all over the floor, with a concentration in specific areas, and sticky mouse traps were present by the delivery entryway. The FSS acknowledged awareness of the mouse droppings and stated that live mouse traps were not available in the kitchen. Additionally, the FSS admitted that more cleaning was needed. The facility's policy on dietary sanitation requires that all kitchen and dining areas be kept clean and free from rodents and other pests. The failure to adhere to these standards had the potential to affect all 32 residents of the facility.
Pest Control Deficiency in Food Storage Areas
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of rodent droppings in and around the food storage areas. During an observation, the Food Services Supervisor (FSS) directed the surveyor to a kitchen area with a dry storage section where a 4-inch gap was found under the storage, containing food items and four wooden snap mouse traps. In the main storage area, which included a refrigerator, freezers, and shelving units for dry and canned food items, the floors were observed to have dried pasta, corn kernels, and a buildup of dark soiling. Mouse droppings were littered across the floor, with a concentration in specific areas, and sticky mouse traps with dead bugs were found near the delivery entryway, along with additional mouse droppings. The FSS acknowledged awareness of the mouse droppings and admitted that live mouse traps were not available in the kitchen as they were in other facility areas. The FSS mentioned that some cleaning had been done, but more was needed. The Facility Administrator (FA) was interviewed and revealed they were unaware of the rodent droppings in the dry food storage area. The facility's policy on pest control, which was undated, indicated that an ongoing pest control program should be maintained to keep the building free of insects and rodents, but this was not effectively implemented.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for its residents, as evidenced by several deficiencies observed in multiple hallways. In the 300 Hall, the carpet was stained and discolored, with a large dark ring extending into the hallway. The commons area near the nurse's station also had discolored areas. In the 400 Hall, ceiling tiles were stained and warped, and a deceased bug was found in a light fixture. The carpet and laminate flooring in several rooms were loose, creating trip hazards. The 500 Hall had stained ceiling tiles, and the 700 Hall had loose carpet and cracked tiles at the thresholds, with a buildup of a black, thick brown substance. The Maintenance Manager confirmed the issues, acknowledging that the ceiling tiles were warped and stained due to a previous water leak that had been repaired, but the tiles had not yet been replaced. The carpets were only cleaned twice a year by an outside company, with no interim cleaning, leading to varying degrees of staining throughout the facility. The Maintenance Manager also confirmed the presence of the bug in the light fixture and the loose and cracked flooring at the door thresholds.
Infection Control and Staff Health Screening Deficiencies
Penalty
Summary
The facility failed to complete and review pre-employment health histories for four sampled staff members, which is a critical step in ensuring that employees are free of communicable diseases before working with residents. The Business Office Manager confirmed that the Employee Health History Screen forms for the housekeeper, medication aide, dietary aide, and maintenance manager were incomplete and not reviewed by facility staff. This oversight could potentially expose residents to health risks from staff who may carry communicable diseases. During medication administration, a registered nurse failed to perform hand hygiene between resident contacts, which is a violation of the facility's hand hygiene policy. The nurse did not sanitize hands after administering medications to two residents and before preparing medications for another. Additionally, the nurse did not sanitize hands after removing gloves post-procedure when obtaining a resident's blood sugar. This lack of adherence to hand hygiene protocols increases the risk of cross-contamination and infection among residents. The facility also failed to follow Enhanced Barrier Precautions for residents known to be colonized or infected with multidrug-resistant organisms. Staff did not wear gowns and gloves during high-contact care activities for two residents, despite clear signage and policy requirements. This non-compliance was observed during transfers, toileting, and wound care, where staff had direct contact with residents without the necessary protective equipment. The Director of Nursing Services acknowledged the need for revised training to ensure staff are educated on these precautions.
Inadequate Bathroom Ventilation in Three Rooms
Penalty
Summary
The facility failed to ensure proper bathroom ventilation in three rooms, as required by licensure reference number 175NAC 12-007.04(D). During observations conducted on August 22, 2024, it was noted that the ventilation systems in the bathrooms of three specific rooms were unable to pull up a single ply of tissue, indicating inadequate ventilation. This deficiency was confirmed through an interview with the Maintenance Manager, who acknowledged that the ventilation systems in these rooms were not functioning correctly and should have been able to perform the tissue test successfully.
Failure to Notify Physicians of Abnormal Lab Results and Blood Pressure Readings
Penalty
Summary
The facility failed to notify the provider of abnormal laboratory results for Resident 21, who was admitted with type two diabetes. The resident had a Hemoglobin A1C (HbA1C) test result of 9.10, which was significantly higher than the normal range of 4.80-6.00. Despite the abnormal result, there was no documentation indicating that the provider was notified or had reviewed the abnormal value. Interviews with the facility's Medical Records staff and the Director of Nursing confirmed the lack of notification and review. Additionally, the facility did not notify the physician of out-of-range blood pressure readings for Resident 24 and Resident 4. Resident 24, who was admitted with Parkinson's Disease, had several instances of systolic blood pressure readings below 100, which required physician notification according to the care plan. However, there was no documentation of such notifications. Similarly, Resident 4, who had a diagnosis of cervical spinal cord injury and hypertensive heart disease, also had multiple instances of systolic blood pressure readings below 100, with no evidence of physician notification. Interviews with the facility's Registered Nurse and Director of Nursing confirmed the absence of documentation for physician notifications regarding the out-of-range blood pressure readings for both residents. The expectation was for the nurse or charge nurse on duty to contact the physician's office and document the information in the progress notes, which was not done in these cases.
Failure to Implement Fall Prevention and Secure Mattress
Penalty
Summary
The facility failed to implement adequate fall prevention interventions for a resident, identified as Resident 25, who had a history of falls, anxiety, unsteadiness on feet, and muscle weakness. Despite the facility's policy requiring a Fall Incident and Investigation report and interdisciplinary review after a fall, no new interventions were developed following a fall on March 20, 2024, where Resident 25 and their spouse/roommate, Resident 28, fell while attempting a bathroom transfer. On August 19, 2024, Resident 25 experienced another fall under similar circumstances, yet the care plan only included an intervention to have staff assist Resident 25 back to their room from meals, which was not implemented as observed on August 21, 2024. Observations revealed that Resident 25 was frequently left in a wheelchair at the dining room table, contrary to the care plan's intervention to place them in a regular chair to prevent falls. Staff interviews confirmed that new or revised fall prevention interventions were expected but not effectively communicated or implemented. The Medication Aide-G indicated that staff often did not have time to read updates on the computer dashboard, which lacked information about Resident 25's fall and updated prevention measures. Additionally, the facility failed to ensure the mattress on Resident 25's bed was secured to the bedframe, creating a potential entrapment and fall hazard. The Maintenance Manager confirmed that the facility did not check if mattresses were secured and was unaware of devices to secure them. This oversight further compromised the safety of Resident 25, who had severe cognitive impairment and was at increased risk of falls.
Inadequate Pain Management for Two Residents
Penalty
Summary
The facility failed to manage pain effectively for two residents, Resident 18 and Resident 21, as identified during a survey. Resident 18, admitted with multiple chronic pain-related diagnoses, frequently experienced moderate to severe pain that interfered with daily activities. Despite receiving both routine and as-needed pain medications, the resident's pain was not adequately controlled, as evidenced by frequent high pain ratings. The facility's staff did not notify the resident's provider about the frequent use of as-needed pain medication, which could have led to adjustments in the resident's pain management plan. Similarly, Resident 21, who also had chronic pain conditions, reported frequent pain that disrupted sleep and daily activities. The resident's pain was consistently rated at moderate to severe levels, and the resident often required as-needed pain medication during early morning hours. The staff did not inform the resident's provider about the frequent need for additional pain relief, which might have prompted a review and adjustment of the resident's pain management regimen. Interviews with the facility's nursing staff and the Director of Nursing confirmed that both residents' pain was not adequately controlled and that the providers had not been notified to consider changes in the pain management plans. This lack of communication and failure to adjust pain management strategies contributed to the deficiency in providing appropriate pain management for the residents.
Failure to Limit PRN Psychotropic Medication to 14 Days
Penalty
Summary
The facility failed to ensure compliance with the regulation that PRN psychotropic medications are limited to 14 days unless re-evaluated and re-ordered by a physician. This deficiency was identified for one resident, who had an order for Lorazepam, a psychotropic medication, to be administered every 12 hours as needed for anxiety or agitation. The order, which started on 8/5/24, did not have an end date, and the medication was administered beyond the 14-day limit, specifically on the 15th day. The facility's policy requires that PRN orders for psychotropic drugs be limited to 14 days unless a physician documents a rationale for extending the order. However, the consultant pharmacist noted the absence of a 14-day stop date in their review, and the facility's Infection Control Coordinator was unaware of this note until it was brought to their attention. Additionally, a note to the attending physician regarding the 14-day limit was not sent for review, which contributed to the oversight.
Medication Labeling Deficiencies
Penalty
Summary
The facility failed to ensure medications were labeled clearly and accurately for two residents, leading to deficiencies in medication administration. Resident 18, who was admitted with type two diabetes mellitus, received Humalog Insulin injections per a sliding scale schedule. During a medication administration observation, it was noted that the insulin pen label was illegible due to smeared ink, obscuring the resident's name and administration directions. This issue was confirmed by both the administering nurse and the Director of Nursing, indicating a failure to adhere to the facility's policy on medication labeling. Similarly, Resident 29, admitted with hypertensive heart disease, had a discrepancy between the medication label and the physician's order. The medication card label indicated Potassium Chloride 20 MEQ, while the Medication Administration Record specified Potassium Chloride ER 20 MEQ. This inconsistency was observed during medication administration and confirmed by the nurse and the Director of Nursing. The mismatch between the medication label and the physician's order highlights a failure in ensuring accurate medication labeling and administration.
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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.
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Nursing homes near Ord
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Community Memorial Health Center | 16.1 mi | — | 10 | 0 |
| Rose Lane Home | 22.4 mi | — | 0 | 0 |
| Brookefield Park | 36 mi | — | 0 | 0 |
| Brookestone View | 38.7 mi | — | 0 | 0 |
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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.