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 The Arbors Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with dementia, intact cognition, and chronic bladder and frequent bowel incontinence required moderate assistance with toileting and two staff for toilet use. During observed incontinent care, a CNA washed hands upon room entry but twice removed soiled gloves and donned clean gloves without performing hand hygiene between glove changes while cleaning the perineal and rectal areas and then applying a clean brief. In interviews, the CNA acknowledged knowing hand hygiene was required and that she had forgotten, while the Administrator and an RN confirmed their expectation that staff perform hand hygiene between glove changes. Facility policy stated that hand hygiene is required after removing gloves or aprons.
A resident with cognitive impairment and physical limitations experienced multiple episodes of bowel incontinence and did not receive appropriate assistance from staff with ADLs or cleaning, despite documented care needs. Staff failed to provide direct help, leaving the resident soiled and her environment uncleaned for extended periods, resulting in feelings of humiliation and self-isolation.
A resident with multiple chronic conditions did not receive a physician-ordered estradiol vaginal cream for over a month because the order was not entered into the pharmacy system or administered. Nursing staff and the DON were unaware of the order, and facility policy requiring prompt entry of new medication orders was not followed.
Two CNAs provided catheter care to a resident with an indwelling Foley catheter and on enhanced barrier precautions without donning required gowns and without changing gloves or performing hand hygiene after removing the resident's brief. The resident, who had multiple chronic conditions and required extensive assistance, had a care plan specifying the use of gloves and gowns for catheter care. Despite documented staff training and clear signage, infection control procedures were not followed during the observed care.
A resident with severe cognitive impairment and high ADL assistance needs was provided a shower with water that was not adequately warm, despite staff initially believing it was comfortable. The resident later expressed discomfort, and it was confirmed that the water was cool. Maintenance had been aware of ongoing hot water issues in the area, but the problem was not fully resolved at the time of the incident.
The facility failed to ensure proper securement of indwelling catheters for two residents, leading to potential risks of discomfort and injury. One resident with moderately impaired cognition and multiple health issues was observed without a catheter strap, contrary to physician orders. Another resident with severe cognitive impairment and urinary retention also lacked a securement device, with observations showing the catheter tubing draped across his shoulder. Interviews confirmed that nursing staff were responsible for catheter securement, but facility protocols lacked guidelines for applying securement straps.
Two residents with moderately impaired cognition and incontinence issues were at risk due to inaccessible emergency call lights in their shared bathroom. The facility failed to ensure the call lights were within reach, as required by their care plans, potentially preventing residents from notifying staff of their needs.
A resident with a suprapubic urinary catheter received improper catheter care from a CNA, who failed to wash hands between glove changes and reused a washcloth without changing to a clean portion. The CNA also incorrectly applied barrier cream around the catheter site. These actions, observed during a survey, were contrary to the facility's infection control policy and put the resident at risk of infection.
The facility did not follow its smoking policy, as observed in the smoking area where an ashtray contained an empty cigarette package and paper towels, posing a fire hazard. The previous housekeeping supervisor, responsible for emptying the ashtray and trash can, had not worked for weeks, and the key to the locked trash can was missing. The Maintenance Director and Administrator acknowledged the issue and planned to reassign the task to housekeeping.
Failure to Perform Hand Hygiene Between Glove Changes During Incontinent Care
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to hand hygiene during incontinent care. An [AGE]-year-old female resident with dementia, intact cognition (BIMS score 15), and documented bladder and frequent bowel incontinence required moderate assistance with toileting hygiene and two staff for toilet use per her care plan. During an observation of incontinent care, two CNAs entered the resident’s room and washed their hands upon entry. CNA A performed the perineal care while CNA B assisted with positioning. CNA A appropriately cleaned the front perineal area, then the resident was rolled onto her left side so CNA A could clean the buttocks and rectal area. During this care, CNA A removed soiled gloves and donned clean gloves twice without performing hand hygiene in between glove changes. She first removed gloves after cleaning the front perineal area and put on new gloves without washing or sanitizing her hands, then cleaned the rectal area. After cleaning the rectal area, she again changed gloves without performing hand hygiene and then applied a clean brief. In an interview, CNA A acknowledged she knew she was supposed to wash or sanitize her hands when changing gloves and stated she had forgotten, and she recognized this as an infection risk. The Administrator and an RN both stated they expected staff to perform hand hygiene between glove changes and acknowledged that failure to do so could increase infection risk. The facility’s infection control policy stated that hand hygiene is required after removing gloves or aprons.
Failure to Provide Dignified and Respectful Care During Incontinence Episodes
Penalty
Summary
The facility failed to treat a resident with respect and dignity, and did not provide care in a manner that promoted the maintenance or enhancement of her quality of life. On two separate occasions, the resident, who had diagnoses including type 2 diabetes, vascular dementia, and muscle weakness, experienced episodes of bowel incontinence and did not receive appropriate assistance from staff with activities of daily living (ADLs) or with cleaning herself and her environment. The resident required maximum staff assistance for several ADLs, including toileting hygiene, as documented in her care plan and MDS assessment. On one occasion, the resident reported having an episode of bowel incontinence after breakfast, resulting in feces on herself and the bathroom floor. She activated her call light for assistance, but the CNA who responded told her to clean up the mess herself and did not offer help. The resident remained soiled and her bathroom uncleaned for several hours, as confirmed by observations and interviews with the resident, her private sitter, and staff. The resident expressed feelings of humiliation and self-isolation due to the lack of assistance and the way she was treated by staff. On another occasion, the resident contacted her representative for help after staff again refused to assist her following an episode of incontinence. The representative arrived to find the resident still unattended and had to request staff intervention. Even then, staff only handed the resident towels from outside the bathroom rather than providing direct assistance. Facility policies and staff interviews confirmed that nursing staff were responsible for cleaning biological waste and assisting residents with ADLs, but these expectations were not met in the resident's care.
Failure to Administer Physician-Ordered Medication Due to Order Entry Lapse
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident by not ensuring the accurate acquiring, receiving, and administering of a physician-ordered medication. A female resident with chronic atrial fibrillation, dementia, neuromuscular bladder dysfunction, and chronic kidney disease had a new order for Estrace (estradiol) vaginal cream, prescribed by her gynecologist to address vaginal prolapse and thinning of pelvic tissues. Despite the order being sent to the facility, there was no record of the medication being entered into the pharmacy system or administered to the resident for 32 days. Interviews with nursing staff and the DON revealed that the order was not entered into the resident's chart, and staff were unaware of the estradiol order. The facility's policy required nurses to document or enter new orders into the system, but this was not followed, resulting in the resident not receiving the prescribed medication. The resident confirmed she had not received the medication and had not discussed it with staff.
Failure to Follow Infection Control Protocols During Catheter Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by staff not following established infection control guidelines and procedures during catheter care for a resident. Specifically, two CNAs performed catheter care for a resident with an indwelling Foley catheter and on enhanced barrier precautions without donning the required protective gowns. Additionally, after removing the resident's brief, the CNAs did not change gloves, wash, or sanitize their hands before proceeding to clean the resident's perineal area and catheter tubing. The resident involved was an elderly female with multiple diagnoses, including chronic atrial fibrillation, dementia, acute cystitis, and chronic kidney disease. She was dependent on staff for most activities of daily living, was always incontinent of bowel, and had an indwelling Foley catheter. Her care plan specified the use of gloves and gowns for catheter care due to her being on enhanced barrier precautions, which are intended to reduce the spread of multidrug-resistant organisms (MDROs). Interviews with the involved CNAs, nursing staff, and facility leadership confirmed that all staff had received training in infection control, catheter care, and PPE use, and that residents on special precautions were clearly identified with signage and PPE supply bins. Despite this, the CNAs did not follow the required procedures during the observed care, which was inconsistent with the facility's infection control policies and the resident's care plan.
Failure to Ensure Access to Warm Water for Resident Showering
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, as evidenced by the lack of access to warm water for showering for one resident. The resident in question was an elderly male with a history of left femur fracture, prostate cancer, generalized muscle weakness, severe cognitive impairment, and significant assistance needs for activities of daily living. On the date of the incident, staff initially believed the shower water was warm, but after the resident expressed discomfort, it was found that the water was cool, though not cold. The resident's care plan required a homelike environment and bathing assistance, but the water temperature was not adequately ensured to be comfortable during the shower. Interviews revealed that the maintenance supervisor was aware of ongoing hot water issues in one hallway and had previously replaced a mixing valve. After the incident, he assessed and adjusted the valve, and weekly checks of water temperature in sampled rooms were documented as appropriate. However, the administrator was not aware of any water temperature problems prior to the incident, relying on the maintenance supervisor's logs. The facility's policy states that residents have the right to live in safe, decent, and clean conditions and to make choices regarding their care, but this right was not upheld in this instance.
Failure to Secure Indwelling Catheters
Penalty
Summary
The facility failed to provide appropriate care for residents with indwelling catheters, specifically in ensuring the use of securement devices to prevent urinary tract infections and catheter-related injuries. Resident #9, a female with moderately impaired cognition and multiple diagnoses including type 2 diabetes and chronic kidney disease, was observed without a catheter strap, despite a physician's order requiring one every shift. She reported discomfort due to the catheter pulling on her bladder, indicating a lack of adherence to her care plan. Similarly, Resident #25, a male with severe cognitive impairment and urinary retention, was also found without a securement device for his indwelling catheter. Observations revealed that the catheter was not secured during multiple instances, and the resident was seen with the catheter tubing draped across his shoulder, which could lead to discomfort or injury. Despite orders for a securement strap to be applied every shift, there was no documentation of monitoring the placement of the catheter strap in the Treatment Administration Record. Interviews with staff, including the Director of Nursing and the Administrator, confirmed that the responsibility for ensuring catheter securement lay with the nursing staff. However, the facility's Nursing Policy and Procedure Manual for Catheter Care did not include guidelines for the application of a urinary securement strap, highlighting a gap in the facility's protocols. This oversight contributed to the deficiency in care for residents with indwelling catheters.
Inaccessible Emergency Call Lights in Shared Bathroom
Penalty
Summary
The facility failed to ensure that the emergency call lights in the shared bathroom of two residents were accessible from the floor, which could prevent residents from notifying staff of their needs. Resident #3, a female with moderately impaired cognition, required assistance with toileting and was frequently incontinent. Her care plan indicated that her call light should be within reach to prevent falls. Similarly, Resident #18, also with moderately impaired cognition, required assistance with toileting and was occasionally incontinent. Her care plan also emphasized the importance of having the call light within reach to prevent falls. During observations, it was noted that the emergency call light in the shared bathroom of these residents lacked a string, making it inaccessible from the floor. Interviews with staff, including a CNA, the Administrator, the DON, and the Maintenance Man, confirmed that the call light strings were missing and acknowledged the risk this posed to residents. The staff recognized that without accessible call lights, residents could be unable to call for help in case of a fall or other emergencies.
Infection Control Deficiency in Catheter Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper foley catheter care provided to Resident #15. The resident, who had a history of dementia, acute cystitis with hematuria, and encephalopathy, required substantial assistance with daily activities and had an indwelling suprapubic urinary catheter. During an observation, CNA D was seen performing catheter care without adhering to proper infection control protocols. Specifically, CNA D did not wash or sanitize her hands between glove changes and reused the same portion of a washcloth to clean the catheter tubing, which could lead to contamination. Additionally, CNA D applied barrier cream around the catheter insertion site, which was not part of the recommended procedure. Both CNA D and LVN E acknowledged the errors during interviews, with CNA D admitting to being nervous and forgetting to use hand sanitizer. The facility's policy on catheter care, which outlines the correct procedure, was not followed, putting the resident at risk of infection. The administrator and DON confirmed that nurse managers were responsible for training CNAs in catheter care, and acknowledged the potential risk of infection if care was not performed correctly.
Failure to Follow Smoking Policy
Penalty
Summary
The facility failed to adhere to its established smoking policy in the designated smoking area. During an observation, a metal ashtray with a push button mechanism was found to contain an empty cigarette package and paper towels, along with multiple used cigarette butts. This was contrary to the facility's smoking policy, which mandates that ashtrays should be emptied into a metal container with a self-closing cover. The presence of these items in the ashtray posed a fire hazard, as noted by the Maintenance Director. Interviews revealed that the previous housekeeping supervisor, who was responsible for emptying the ashtray and the red metal trash can, had not been working at the facility for the past 3 to 4 weeks. The Maintenance Director was unable to locate the key to the red metal trash can, which was secured with a padlock. The Administrator confirmed that the housekeeping team would now take over the responsibility of emptying the ashtray and trash can, acknowledging the potential fire risk posed by the improper disposal of smoking materials.
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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 Rusk
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cherokee Trails Nursing Home | 2.5 mi | — | 1 | 0 |
| Legacy At Jacksonville | 13.1 mi | — | 7 | 0 |
| Avir At Jacksonville | 13.3 mi | — | 1 | 0 |
| Twin Oaks Health And Rehabilitation Center | 15.1 mi | — | 12 | 0 |
| Wells Ltc Nursing & Rehabilitation | 23.9 mi | — | 14 | 1 |
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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.