Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 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 Glen Center during CMS and state inspections, most recent first.
A resident with multiple chronic conditions experienced significant lethargy, low oxygen saturation, and inability to eat or take medications. Despite these changes and staff awareness, the physician was not notified for several hours, and action was only taken after the resident's family requested hospital transfer. Facility policy required immediate physician notification for such changes, but this was not followed.
A resident with significant medical needs and cognitive impairment alleged rough handling by a CNA and HHA during a transfer, resulting in a bruise. Despite the allegation, the accused CNA continued to care for other residents without additional supervision, and the facility did not follow its abuse policy requiring immediate removal of the accused staff and thorough investigation, including interviews with other residents. The DON confirmed that these steps were not taken, leading to Immediate Jeopardy.
The facility failed to have the LNHA and DON present at required QAPI meetings, potentially affecting the care of 111 residents. The LNHA and IP were absent from a January meeting, and the DON was absent from a July meeting, with the LNHA citing vacations as the reason. However, the IP's timesheet showed they were working on the day of the meeting.
A facility failed to provide a resident and their representative with written notification of the bed hold policy during multiple hospital transfers. Despite the policy requiring notification prior to transfer, documentation was only available for one transfer date. The resident, who was cognitively intact, was transferred on several occasions, but the Business Office Manager confirmed the absence of notifications for other dates.
The facility inaccurately coded the MDS for three residents, leading to deficiencies in care management. A resident was incorrectly coded as discharged to a hospital instead of the community. Another resident's MDS failed to reflect venous ulcers despite treatment records. A third resident's MDS did not document an unstageable sacral wound present at admission. The facility lacked a specific MDS policy, relying on RAI manual guidelines.
The facility failed to act on a urologist's recommendations for a resident with an indwelling catheter, delaying the start of Tamsulosin for nearly three months. Additionally, the facility did not adjust medication administration times for a dialysis resident, resulting in Vitamin D3 being documented as given at 5 PM despite the resident returning from dialysis after 6 PM. Both the LPN and RN/UM acknowledged the need for timing adjustments, but the facility's policies did not address this issue.
A facility failed to maintain an active smoking care plan for a resident identified as an independent smoker. The resident's smoking evaluation was incomplete, and the care plan section was not filled out, despite being on the facility's list of smokers. The resident, with intact cognitive status, was observed smoking in the designated area, and staff confirmed the need for a care plan. The facility's policy required regular re-evaluation and updates to the care plan, which were not followed.
A facility failed to comprehensively evaluate and care plan for a resident with a history of PTSD, despite staff awareness of the condition. The resident's medical records did not list PTSD as a diagnosis, and care plans lacked any mention of PTSD or its triggers. Interviews with staff, including an LPN and a PPA, confirmed the absence of a comprehensive interdisciplinary evaluation or care plan, despite the resident exhibiting symptoms indicative of PTSD. The facility's policy on Trauma Informed Care was not effectively implemented for this resident.
A facility failed to monitor the target behavior for a resident prescribed an antipsychotic medication, Aripiprazole, for psychosis. The resident's care plan did not include the target behavior of hallucinations, and there was no order for behavior monitoring in the eMAR. Interviews with staff confirmed the absence of necessary documentation and orders, which should have been included according to facility policy.
The facility failed to follow proper hand hygiene and transmission-based precautions. A housekeeper did not perform hand hygiene after glove removal due to the absence of ABHR. A resident with ESBL in urine lacked documentation for contact precautions, and another resident on enhanced barrier precautions had no care plan or physician order. These deficiencies indicate lapses in infection control practices and documentation.
A resident with dementia and hypertension sustained an injury of unknown origin, with a bluish-purplish discoloration around the left eye. The facility's investigation suggested the injury was caused by leaning on a bedside rail, but there was no supporting documentation or witness statements. The care plan lacked specific interventions for the injury, and there were no documented visual checks or orders for monitoring the resident's location. The facility's policy on person-centered care plans was not effectively implemented.
A resident with severe cognitive impairment and multiple pressure ulcers did not receive consistent care as per professional standards. The facility failed to document and investigate all acquired wounds, and several treatment orders were left unsigned, indicating potential lapses in care. Interviews with staff revealed inconsistencies in following wound care protocols, highlighting deficiencies in the facility's pressure ulcer management.
Delayed Physician Notification After Resident's Change in Condition
Penalty
Summary
The facility failed to notify a physician in a timely manner following a significant change in a resident's condition. The resident, who had a history of congestive heart failure, COPD, and obstructive sleep apnea, was found lethargic, slow to respond, and unable to eat or take medications. Vital signs showed low oxygen saturation, and the respiratory therapist documented that the resident was not wearing the oxygen cannula properly, resulting in a SpO2 of 67%. Interventions were initiated, including the use of a non-rebreather mask, which improved the resident's oxygen saturation. Despite these interventions and the resident's continued lethargy and inability to take medications, the physician was not notified immediately. Documentation revealed that the resident's condition remained concerning throughout the morning, with multiple staff members, including the respiratory therapist, nurse, and nursing supervisor, being made aware of the situation. The resident was unable to participate in incentive spirometry and continued to be lethargic and unresponsive to commands. The physician was not contacted until the resident's daughter arrived in the early afternoon, expressed concern, and requested that the resident be sent to the hospital. Only at that point was the physician notified and orders obtained for hospital transfer. Interviews with facility staff confirmed that the expected protocol for a change in condition, such as desaturation and lethargy, was to assess the resident and notify the physician promptly. However, in this case, there was a delay of approximately three to four hours between the initial episode of desaturation and the notification of the physician. Facility policy also required immediate notification of the physician and the resident's representative in the event of a significant change in condition, which was not followed in this instance.
Failure to Remove Accused Staff and Conduct Thorough Abuse Investigation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of staff-to-resident physical abuse involving a Certified Nursing Assistant (CNA), a Home Health Aide (HHA), and a resident. The incident began when the resident reported that their skin was bruised due to rough handling by two staff members during a transfer. Despite this allegation, the accused CNA continued to care for other residents without additional supervision after the complaint was made and again on a subsequent date before the investigation was completed. Interviews with facility leadership confirmed that the investigation was not thorough and that the facility did not follow its own abuse policy. The facility's abuse policy required immediate removal of the accused employee from duty pending investigation, as well as prompt initiation of an investigation within 24 hours, including interviews with the accused staff, the resident, and other residents under the accused staff's care. However, the accused CNA was not sent home and continued to work with other residents. The DON acknowledged that other residents assigned to the accused CNA were not interviewed, and there was no increased supervision of the accused staff member. The investigation was considered complete by the DON without these required steps, and the facility's policy was not followed. The resident involved had significant medical conditions, including sepsis, metabolic encephalopathy, acute kidney failure, diabetes, heart failure, anemia, and was receiving palliative care. The resident was cognitively impaired and dependent on staff for all activities of daily living, requiring assistance from two or more helpers for mobility and transfers. The failure to remove the accused staff from duty and to conduct a thorough investigation as per policy placed all residents under the care of the accused CNA at risk and resulted in the identification of Immediate Jeopardy.
Absence of Key Personnel in QAPI Meetings
Penalty
Summary
The facility failed to ensure the presence of required members at the Quality Assurance Performance Improvement (QAPI) meetings, which are crucial for maintaining the quality of care for all residents. Specifically, the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) were absent from one of the three quarterly QAPI meetings. The absence of these key personnel was confirmed through interviews and a review of the QAPI sign-in sheets. On January 17, 2024, the LNHA and the Infection Preventionist (IP) did not attend the meeting, and on July 17, 2024, the DON was absent. The LNHA explained that these absences were due to vacations, but the IP's timesheet indicated that they were working on the day of the meeting, raising questions about their absence. The facility's policies require the QAPI committee to include the Administrator, DON, Medical Director (MD), IP, and other interdisciplinary team members, and to meet at least quarterly. The failure to have the LNHA and DON present at the meetings could potentially affect the quality of care for all 111 residents in the facility. The survey team noted these deficiencies during their review and communicated the findings to the facility management, who did not provide additional information or refute the findings.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification of its bed hold policy to a resident or their representative during multiple hospital transfers. Resident #82, who was cognitively intact with a BIMS score of 14 out of 15, was transferred to the hospital on several occasions as documented by various nursing staff. However, the Business Office Manager (BOM) only provided a Bed Hold Notice for one of these transfers, dated 5/15/24, and confirmed that no other notifications were available for the other transfer dates of 5/05/24, 5/23/24, and 7/05/24. The facility's policy requires that the Bed Hold Policy Notice & Authorization form be given to the resident and their representative prior to transfer, with the representative's copy delivered within 24 hours if not present. Despite this policy, the facility did not have documentation to show compliance for the specified dates. The surveyor's findings were communicated to the Licensed Nursing Home Administrator (LNHA) and Director of Nursing during the exit conference, and the facility did not provide additional information or refute the findings.
Inaccurate MDS Coding for Three Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for three residents, leading to deficiencies in the management of care. For Resident #109, the MDS assessment inaccurately coded the discharge status as being to a short-term general hospital, while progress notes indicated the resident was discharged to the community. This discrepancy was identified during a review of the electronic health record and was acknowledged by the Director of Nursing (DON) after a discussion with the surveyor. Resident #23's MDS assessment was also inaccurately coded. Although the resident had chronic non-pressure ulcers on both lower legs and was receiving treatment for venous ulcers, the MDS assessment indicated that the resident had no venous or arterial ulcers. This error was discovered through observation and review of the resident's health records, which included wound consultant notes confirming the presence of venous ulcers. For Resident #167, the MDS assessment failed to document an unstageable, necrotic sacral wound that was present upon admission from the hospital. The hospital records indicated the presence of this wound, but the MDS was coded as having no unhealed pressure ulcers. This inaccuracy was brought to the attention of the DON, who confirmed the error after consulting with the MDS Coordinator. The facility did not have a specific MDS policy and relied on the Resident Assessment Instrument (RAI) manual guidelines.
Failure to Follow Urologist Recommendations and Adjust Medication Times for Dialysis
Penalty
Summary
The facility failed to act upon the recommendations of a urologist for a resident with an indwelling catheter. The resident, who was cognitively intact, had been admitted with diagnoses including benign prostatic hyperplasia and urinary retention. A urology consultation on 5/15/24 recommended starting Tamsulosin, but there was no evidence that the medical doctor was notified or that the medication was ordered. The Director of Nursing (DON) acknowledged that the recommendations were not acted upon until almost three months later, following the surveyor's inquiry. Another deficiency involved a resident undergoing dialysis, where the facility failed to adjust medication administration times to accommodate the resident's dialysis schedule. The resident, who was also cognitively intact, had a physician's order for Vitamin D3 to be administered daily at 5 PM. However, on dialysis days, the resident returned to the facility after 6 PM, and the medication was still documented as administered at the scheduled time. Both the Licensed Practical Nurse (LPN) and the Registered Nurse Unit Manager (RN/UM) acknowledged that medication times should be adjusted for dialysis schedules, but this was not done. The surveyor reviewed the facility's policies and found that the provided dialysis policy did not address the adjustment of medication schedules for dialysis residents. The facility's general medication administration policy stated that medications should be administered according to the prescriber's written orders, but did not specifically address the issue of timing adjustments for dialysis. The DON confirmed that the medication schedule for the resident was clarified after the surveyor's inquiry.
Failure to Maintain Active Smoking Care Plan
Penalty
Summary
The facility failed to maintain an active care plan for a resident who was identified as an independent smoker. The deficiency was identified during a survey when it was discovered that the resident's smoking evaluation was incomplete, and the care plan section was not filled out. Despite being on the facility's list of smokers, the resident did not have an active care plan for smoking until the surveyor's inquiry prompted a revision. The resident, who had intact cognitive status as per the most recent Minimum Data Set (MDS) assessment, was observed smoking in the designated area, and staff confirmed that the resident should have had a care plan for smoking. The facility's policy required a smoking evaluation and care plan for residents who smoke, which should include necessary supervision and safety measures. However, the resident's care plan had been resolved earlier in the year and was not reactivated until the surveyor's inquiry. The Director of Nursing and Licensed Nursing Home Administrator acknowledged the oversight, noting that the care plan should have been active. The facility's policy also mandated regular re-evaluation and updates to the care plan, which were not adhered to in this case.
Failure to Address PTSD in Resident Care Plan
Penalty
Summary
The facility failed to ensure that a resident with a history of post-traumatic stress disorder (PTSD) was comprehensively evaluated and care planned to receive appropriate treatment and services. This deficiency was identified for a resident who was reviewed for mood and behavior. The resident, who had diagnoses including depression, hemiplegia, hemiparesis following a stroke, and hypertension, did not have PTSD listed as a diagnosis in their admission record. The comprehensive Minimum Data Set (MDS) assessment indicated moderate cognitive impairment and only coded for depression under psychiatric/mood disorders. The facility's medication administration records for June and July 2024 did not address the resident's history of PTSD or any identified triggers. Additionally, the resident's care plans did not include any plans addressing PTSD. Interviews with facility staff, including a Licensed Practical Nurse (LPN) and a Psychiatry Physician Assistant (PPA), revealed that while the staff were aware of the resident's history of PTSD, there was no comprehensive interdisciplinary evaluation or care plan in place. The PPA noted that the resident exhibited symptoms such as being jumpy and anxious, which could be indicative of a history of PTSD. The Director of Social Services (DSS) and the Director of Nursing (DON) acknowledged that a resident with a reported history of PTSD should be evaluated and care planned, as unknown PTSD triggers could cause the resident to re-experience trauma. The facility's policy on Trauma Informed Care emphasized the importance of identifying triggers and collaborating with healthcare professionals to develop individualized care plan interventions. However, the facility did not provide additional information or evidence of such evaluations or care plans for the resident in question.
Failure to Monitor Target Behavior for Antipsychotic Medication
Penalty
Summary
The facility failed to adequately monitor the target behavior for the use of a psychotropic medication, specifically an antipsychotic medication, for one of the residents reviewed for unnecessary medications. The deficiency was identified through observation, interview, and review of medical records and facility documentation. The resident in question, who was admitted with diagnoses including acute kidney failure, parkinsonism, and major depressive disorder, was prescribed Aripiprazole for psychosis. However, the resident's care plan did not indicate the target behavior of hallucinations to be monitored for the use of this medication. The surveyor's review of the resident's electronic Medication Administration Record (eMAR) for July and August revealed that there was no order for behavior monitoring related to a target behavior for the antipsychotic medication. Additionally, there was no documented evidence that the resident was being monitored for side effects of the medication. Interviews with the Registered Nurse and the Director of Nursing confirmed that there should have been an order for behavior monitoring, including a target behavior, and that this information should have been included in the resident's care plan. The facility's policy on behavior management emphasized the use of non-pharmacological interventions as the first line of approach and required behavior monitoring to be documented in the medical records. However, the facility did not have a specific policy for psychotropic or antipsychotic medications, only a general policy on behaviors. This lack of specific guidance contributed to the oversight in monitoring the resident's target behavior for the antipsychotic medication.
Infection Control Deficiencies in Hand Hygiene and Precaution Protocols
Penalty
Summary
The facility failed to adhere to proper hand hygiene practices and transmission-based precautions, as observed by a surveyor. A housekeeper was seen exiting a toilet room wearing gloves and a surgical mask, then proceeding to a cleaning cart without removing the gloves or performing hand hygiene. The housekeeper continued to clean another area with the same gloves, and upon changing gloves, did not perform hand hygiene due to the absence of alcohol-based hand rub (ABHR) in the vicinity. This was contrary to the facility's policy, which mandates hand hygiene after glove removal and before donning new gloves. In another instance, the facility did not follow proper procedures for a resident with an indwelling catheter who tested positive for Extended Spectrum Beta Lactamase (ESBL) in urine. The resident's medical records lacked documentation of physician notification, a care plan, or a physician order for contact precautions, despite the positive lab results. The Director of Nursing acknowledged the oversight, noting that the infection preventionist nurse was on vacation, which may have contributed to the lapse in protocol adherence. Additionally, a resident undergoing hyperbaric treatment for a diabetic wound was observed to have no care plan or physician order for enhanced barrier precautions, despite being on such precautions due to the wound. The RN/UM confirmed the absence of necessary documentation, which should have been in place. These deficiencies highlight lapses in infection control practices and documentation within the facility.
Failure to Implement Appropriate Care Plan for Resident Injury
Penalty
Summary
The facility failed to ensure that a resident with an injury of unknown origin received appropriate treatment and interventions according to a comprehensive assessment and person-centered care plan. The resident, who had medical diagnoses including repeated falls, unspecified dementia, and hypertension, was found with a bluish-purplish discoloration around the left eye. The facility's investigation concluded that the injury was caused by the resident leaning or pushing their face on a bedside rail, but there was no documented evidence or witness statements to support this conclusion. The resident's care plan did not include specific interventions for the injury of unknown origin that occurred on 8/21/23. Although the care plan included interventions for fall risk, anticoagulation therapy, and pain management, it lacked a focus and interventions specifically addressing the injury to the left eye. The Director of Nursing (DON) provided a care plan with interventions for pillows and positioning, but these were initiated before the incident and did not specifically address the injury. During discussions with the surveyor, the DON acknowledged that there was no specific documentation or orders for visual checks of the resident's location every shift. The staff was expected to check the resident periodically, but there were no specific times or frequencies established. The facility's policy on person-centered care plans aimed to eliminate or mitigate triggers for re-traumatization, but it was not effectively implemented in this case, as the care plan did not address the specific incident of injury.
Deficient Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide care and services consistent with professional standards of clinical practice for a resident with pressure ulcers. This deficiency was identified for a resident with severe cognitive impairment, who had multiple diagnoses including dementia and muscle weakness. The resident's medical records revealed several instances where physician's orders for pressure ulcer care and prevention were not signed by the nurse and left blank, indicating that the treatments may not have been administered as required. The resident developed multiple pressure ulcers, including a right heel wound, a left lateral calf deep tissue injury (DTI), a sacral DTI, and a left heel DTI. Despite the presence of these wounds, the facility did not complete incident reports for all of them, particularly for the sacral and left lateral calf wounds acquired in December 2022. The lack of documentation and investigation into these wounds suggests a failure to adequately monitor and address the resident's skin integrity and wound care needs. Interviews with facility staff, including a Licensed Practical Nurse and the Director of Nursing, revealed that the expected protocols for wound care and incident reporting were not consistently followed. The facility's policy on skin integrity and wound management emphasized the importance of comprehensive assessments and timely interventions, yet these were not fully implemented for the resident in question. The absence of signed treatment administration records and incomplete incident reports highlight significant gaps in the facility's pressure ulcer care and prevention practices.
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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 Cedar Grove
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Complete Care At St Vincents Llc | 0.7 mi | — | 0 | 0 |
| Alaris Health At Cedar Grove | 1.6 mi | — | 28 | 0 |
| Complete Care At Cedar Grove | 1.8 mi | — | 1 | 0 |
| Canterbury At Cedar Grove | 2 mi | — | 13 | 0 |
| Complete Care At West Caldwell Llc | 2.8 mi | — | 1 | 0 |
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