Arbor Rehabilitation & Nursing Center

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, and serve food in accordance with professional standards for food safety when:1. There was no air gap or back flow prevention device installed for the food prep sink or the three compartment sink (a commercial kitchen essential with three basins for washing, rinsing, and sanitizing dishes), 2. Dietary staff (DS) 1 and DS 2 did not wear hygienic hair gear/hair net in the food preparation area,3. Food items for residents were stored inside the utility room. These failures had the potential to affect the flavor and palatability of the food and to lead to food borne illness (nausea, vomiting, diarrhea) for the 123 residents receiving facility prepared food.

Inspectors wroteBased on interview, and record review, the facility failed to provide the COVID-19 vaccine, for four out of five sampled residents (for immunization review) when Resident 58, Resident 36, Resident 29 and Resident 86's electronic health record (EHR) did not contain documented evidence that the COVID-19 vaccine was administered after obtaining consent. This deficient practice placed Resident 58, Resident 36, Resident 29 and Resident 86 at risk to be infected with COVID-19 virus that could lead to severe illness, hospitalization, and/or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe medication management for 1 out of 44 sampled residents (Resident 52) when Resident 52's two inhalers were allowed to remain at Resident 52's bedside for self use without a determination made by the interdisciplinary team if self-administration of medications was safe and appropriate for Resident 52. This deficient practice placed Resident 52 at risk for unsupervised medication administration, incorrect dosing, misuse, adverse medication effects, and lack of monitoring for effectiveness and side effects.

Inspectors wroteBased on observation, interview, and record review, the facility did not provide adequate supervision to protect one of forty-four sampled residents (Resident 112) from alleged physical abuse when a Licensed Nurse (LN) witnessed one unsampled resident (Resident 25) hit Resident 112 on the face on 12/12/25. This failure could potentially result in physical injury and emotional distress that could negatively affect Resident 112's physical and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure podiatry care (Podiatrists (foot care specialists) deal with medical problems related to the feet - in the skin or toenails) was provided to 1 out of 44 sampled residents (Resident 1) when Resident 1 had long, thickened, hard, chipped, toe nails that were sensitive to touch and a request for podiatry service on 12/28/25 was not followed up on by facility staff. This failure had the potential for Resident 1 to sustain injury, impaired skin integrity, and/or acquire an infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received the care and services necessary to attain and maintain the highest practicable physical, mental, and psychosocial well-being, including preventing avoidable decline for 1 of 44 sampled residents (Resident 14) when Resident 14's Physician-ordered Range of Motion (ROM) exercises were not consistently provided as ordered. This deficient practice placed Resident 14 at risk for decline in mobility, development of contractures, muscle stiffness, decreased functional ability, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure safe pharmaceutical services with a census of 128 when:Medications were left at Resident 97's bedside, and;Narcotic (strictly regulated substances due to their high potential for abuse, addiction, or illegal use) sheets were not signed immediately after medication administration. These failures had the potential to negatively affect the health and well-being of Resident 97, the efficacy of the medications being administered, and had the increased risk of drug diversion. 1. A review of Resident 97's admission Record indicated that Resident 97 was admitted to the facility in 2025 with diagnoses which included Type II Diabetes Mellitus and Heart Failure (a chronic condition in which the heart does not pump blood as well as it should, causing fluid to back up into the lungs). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from significant medication errors for one of five sampled residents (Resident 109) during medication administration by failing to follow a physician order when, Resident 109's insulin (medication used to manage blood sugar levels in people with diabetes, a chronic condition where the body does not produce or use insulin properly leading to high blood sugar levels) order indicated to administer the medication on an empty stomach and Resident 109's insulin was administered during the breakfast meal on 1/8/26. This failure had the potential for Resident 109 to experience blood sugar fluctuations of hypoglycemia (when blood sugars are too low) and hyperglycemia (when blood sugars are too high) and increased the risk for unsafe medication administration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe medication storage for a census of 128 when prescribed medications found in the pharmaceutical waste container (where unused and/or discontinued prescribed medications were held for ultimate safe disposal) in the South Station medication room were not disposed of properly where pills, medication bottles, and inhalers (used to deliver medication directly to the lungs) were still recognizable and retrievable by hand. This failure had the potential for misuse of prescribed medications due to unsafe disposal practices. During a medication storage observation and interview on 1/7/26, at 2:41p.m. with Licensed Nurse (LN) 7, the medication room at South Station was inspected. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure an appointment was scheduled within 1 to 2 weeks after a hospitalization for 1 out of 44 sampled residents (Resident 161), when Resident 161's cardiology appointment was not scheduled as ordered. This failure resulted in Resident 161 missing a physician's appointment and a potential risk for causing a delay in care and treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control measures were used to prevent the spread of germs for a census of 128 when the oxygen nasal cannula (a flexible plastic tube connected to an oxygen source with two prongs that fit in the nostrils used to provide extra oxygen through the nose) was not placed in an antimicrobial bag (a bag that reduces the growth of germs on the nasal cannula) as ordered for Resident 134. This failure had the potential to result in the spread of germs and the need for additional medical interventions (medications and/or treatments).

Inspectors wroteBased on interview, and record review, the facility failed to follow their policy and procedure for the pneumococcal (a serious bacterial infection that can cause respiratory illness) immunization for two out of five sampled residents (for immunization review) when: 1. Resident 31's pneumonia vaccine was not documented; and,2. Resident 86's pneumococcal vaccine was not given after being admitted to the facility. These failures had the potential for Resident 31 and Resident 86 to be at risk to be infected with the pneumococcal virus that could lead to severe illness, hospitalization, and/or death.

Inspectors wroteBased on interview and record review the facility failed to follow their surveillance plan (oversight plan to prevent the spread of infection) for scabies (an infection that causes an itchy skin rash when mites [tiny insects] burrow under the skin) prevention and control for one of four sampled residents (Resident 1) when, the Infection Preventionist (IP) did not implement the required six-week contact identification list and failed to train and notify all key healthcare personnels on how to recognize and report signs and symptoms consistent with scabies infestation. These failures had the potential to result in continued transmission of scabies among staff and residents within the facility.

Inspectors wroteBased on observation, interview, and record review failed to implement a comprehensive care plan (a guide that healthcare workers used to ensure residents receive tailored care to meet individual needs and goals) for one of four sampled residents (Resident 1) when Resident 1 did not have water available within reach. This failure placed Resident 1 at risk for dehydration (a condition where your body loses more fluids than it takes in, meaning it doesn't have enough water to perform its normal functions).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four sampled residents' (Resident 1) hydration requirements were met when Resident 1 did not have water available within reach. This failure placed Resident 1 at risk for dehydration (a condition where your body loses more fluids than it takes in, meaning it doesn't have enough water to perform its normal functions) and could have led to illness or kidney injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe and supervised environment to prevent accidents and hazards for three of three sampled residents (Resident 1, Resident 2, and Resident 3) when: 1a. Resident 1 was moved, prior to being assessed, following Resident 1's fall on 3/16/25; b. Resident 1's physician was not notified of Resident 1's blurred vision, on 3/17/25, following a fall on 3/16/25, resulting in a 5-day delay in treatment; 2. Resident 2's clinical documentation was incomplete for a fall on 3/23/25; 3a. Resident 3's clinical documentation was incomplete for a fall on 3/31/25; and, b. Resident 3's care plan interventions to prevent falls were not followed on 5/1/25. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure one of three sampled residents (Resident 1)'s, management and administration of pain relieving medication, (including a narcotic [a drug that could have induced sleep, stupor, or a state of insensitivity to pain]), was done according to professional standards of practice and the narcotic pain medication did not have pain level parameters in place (pain level parameter are assessed using the numeric pain assessment tool: 0=no pain and 10=the worst pain) associated with the narcotic medication order. These failures resulted in Resident 1 not receiving the appropriate type of pain medication for the assessed pain level.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was treated with dignity and respect when Resident 1's request to use the bathroom was denied. This failure had the potential to negatively impact Resident 1's psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1)'s Responsible Party (RP - person responsible for making healthcare and medical decisions) was informed and consented to the use of psychotropic (drugs that affect a person's mind, emotions, and behavior) medications for Resident 1 when, the facility had Resident 1 sign the informed consent for psychotropic medications instead of Resident 1's RP. This failure resulted in Resident 1 receiving the psychotropic medication quetiapine (used to manage symptoms of various mental health condition) for four days. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify Resident 1's Responsible Party (RP - responsible for making medical and healthcare decisions) when Resident 1 fell on 3/16/25. This failure had the potential for Resident 1's necessary and/or preferred medical decisions to be delayed, which could have negatively affected Resident 1's health and well-being.

Inspectors wroteBased on interview and record review the facility failed to ensure one of three sampled residents (Resident 1), was free from unnecessary medications when Resident 1 received the psychotropic (drugs that affect a person's mind, emotions, and behavior) medication quetiapine (used to treat episodes of mania [frenzied, abnormally excited or irritated mood]) or (bipolar disorder - could cause episodes of depression, episodes of mania, and other abnormal moods) without having an accurate diagnosis and indications for use of the medication quetiapine. These failures resulted in Resident 1 receiving the medication quetiapine for four days, potentially negatively affecting Resident 1's health and well-being.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) received care in accordance with professional standards of practice when: 1. Resident 1's blood pressure (BP - the measurement of the pressure in the arteries when the heart contracts and pumps blood through the body) medication (Losartan) was administered without parameters (measurable factors or specific values that are used to assess a resident's health or the effectiveness of a treatment) listed on the order that would have indicated when to not administer the medication, and the order was not clarified with the medical doctor (MD) to not administer the medication if the BP reading or heart rate was too low (a measure of how fast the heart is pumping blood throughout the body); and, 2. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure a safe and effective transition of care after discharge from the facility for Resident 1 when Resident 1 was transferred to a room and board facility (where basic living needs are provided such as meals and housing) that was unable to provide for her care needs. This failure caused Resident 1 to be immediately transferred to the local emergency department from the room and board facility and to spend 26 days in the hospital pending appropriate placement. This failure further had the potential to negatively impact Resident 1 ' s health and psychosocial wellbeing.

Inspectors wroteBased on interview and record review the facility failed to readmit Resident 1 when she was transferred to a local emergency department after an unsafe discharge to a room and board facility (where basic living needs are provided such as meals and housing) that could not accommodate her care needs. This failure put Resident 1 at risk of psychosocial harm and negative health outcomes.

Inspectors wroteBased on observation, interview and documentation review, the facility failed to ensure: 1. Expired medical supplies were removed from the medication storage room, and 2. Medication carts were maintained clean and in an orderly manner. These failures had the potential for accidental use of expired supplies and for drug diversion for a census of 124.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow professional standards for food service safety when Quat (Quaternary Ammonium, a sanitizer) strips (measure the concentration of sanitizer) currently being used were expired. This failure increased the risk for food borne illness for the residents that consumed facility prepared meals in a total facility census of 124.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for of census of 124 residents when: 1. Resident 1's nasal cannula (thin, flexible tube with two prongs that fit into the patient's nostrils and is attached to an oxygen source), and tubing were laying on top of the oxygen condenser (a medical device that takes air from the surroundings, extracts oxygen and filters it into purified oxygen); 2. Hand hygiene was not practiced during the meal service; 3. Resident 72's urinary bag touched the floor; 4. PPE (Personal Protective Equipment) was not donned for Resident 38; and 5. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 26 sampled residents (Resident 72's) dignity was protected when the urine drainage bag was exposed to public view. This failure resulted in Resident 72 feeling embarrassed.

Inspectors wroteBased on observation, interview and record review, the facility failed to accommodate resident needs when call lights were inaccessible for three of 26 sampled residents. A. Resident 479 B. Resident 65 C. Resident 1 This failure prevented the residents from getting help as quickly as possible when experiencing pain, discomfort or for any emergency needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement a care plan for one of 26 sampled residents (Resident 120) when the care plan for fall interventions was not carried out. This failure had the increased potential for injury should Resident 120 fall again.

Inspectors wroteBased on observation, interview and record review, the facility failed to meet the professional standards of practice of nursing for one of 26 sampled residents (Resident 20) when a medication was not administered as ordered. This failure had the potential for ineffective medication therapy for Resident 20.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nail care was provided for one of 26 sampled residents (Resident 96). This failure had the potential for Resident 96 to sustain injury, neglected personal grooming and infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide meaningful ongoing activities for one of 26 sampled residents (Resident 120). This failure caused the resident to feel trapped.

Inspectors wroteBased on observation, interview and record review, the facility failed to supply medication for one of 26 sampled residents (Resident 20) when ferrous sulfate, an iron supplement, was not available for administration. This failure resulted in Resident 20 not receiving the mineral supplement for five days.

Inspectors wroteBased on interview, clinical record and policy and procedure review, the facility failed to ensure wound care teaching was done in preparation for discharge for 1 of 2 sampled residents (Resident 1) when the wound nurses were not aware of the discharge plan and the discharge paperwork did not include wound care instructions. This failure had the risk potential for deterioration of the wounds upon discharge. Additionally, Resident 1 was reported to have been admitted to the hospital with wound infection.

Inspectors wroteBased on interview, clinical record and the facility's policy and procedure review, the facility failed to ensure one of 2 sampled residents (Resident 1) received care consistent with professional standards of practice to prevent pressure ulcers (PUs) when risks were not comprehensively identified, and appropriate preventative measures were not implemented in a timely and consistent manner. This failure resulted in Resident 1 sustaining deep tissue injury (DTI, pressure ulcers that appear as purple localized areas of discolored intact skin or blister due to damage of underlying soft tissue from pressure and /or shear) to bilateral heels within 5 days of admission to the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care and services that met professional standards of practice when one of 3 residents' (Resident 1) oral intake was low, and her fluid intake and output were not monitored to ensure she was not dehydrated. This failure resulted in Resident 1 being sent to the emergency room (ER) and receiving intravenous fluid due to dehydration.

Inspectors wroteBased on interview and record review, the facility failed to provide treatments and services in accordance with professional standards of practice for four sampled residents (Resident 62, Resident 71, Resident 78, and Resident 279), when: 1. Resident 78's Lovastatin (a medication to treat high cholesterol level) was not administered as ordered and the physician was not notified; 2. Resident 279's physician's order for Monurol (an antibiotic to treat urinary tract infection (UTI) was not carried out; 3. continuous oxygen (O²) was administered to Resident 71 without a physician order; 4. a controlled drug was not entered on the narcotic log; and, 5. the medication cart was not locked when unattended. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure showers and personal care was provided for 3 of 25 sampled residents (Resident 10, Resident 68, and Resident 230) when: 1. Resident 10 did not receive showers/ bathing, personal hygiene assistance and was not assisted out of bed consistently; 2. Resident 68 did not receive showers/bathing for 26 days, and 3. Resident 230 did not receive showers for 13 days. This failure had the potential to diminish the residents' dignity and psychosocial well-being and had the potential for residents to feel unable to participate in their favorite activities.

Inspectors wroteBased on interviews and record review, the facility failed to provide thorough medication regimen reviews (MRR) for four of 25 sampled residents (Resident 108, Resident 29, Resident 22, and Resident 99) when irregularities for the physician orders were not identified and reported to the attending physician and/or the director of nursing. These failures had the potential for ineffective psychotropic medication therapy.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain the kitchen in a sanitary condition when: 1. Kitchen floor was dirty with sticky black debris, and 2. The sanitizing agent concentration used for cleaning, was not in the acceptable effective range. These failures placed the residents at risk for food borne illness and exposure to high concentration of sanitizing agents for census of 130.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a sanitary and safe laundry room for a census of 130 residents, when both washing machines and water pipes were covered with a thick, gray accumulation of debris, and the area behind the washers had an accumulation of dust, dirt, and debris. In addition, the dryers were found to have a thick layer of lint on the mesh screen inside the dryers' lint traps. These failures placed the residents at risk for infection and had the potential to result in a fire risk.

Inspectors wroteBased on observation, interview, and documentation review, the facility failed to promote one of 25 sampled residents (Resident 99's) dignity when his long fingernails were not trimmed. This failure resulted in Resident 99 feeling not being respected by staff.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a safe, clean comfortable, and homelike environment for 1 of 25 sampled residents (Resident 13), when roaches were observed in the resident's room. This failure negatively impacted the comfort level and quality of life for Resident 13 and had the potential to harbor pests that could carry diseases or adversely affect the health and safety of vulnerable and medically compromised residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a person-centered care plan was revised for one of 25 sampled residents (Resident 29) when the resident had repeated significant weight loss. This failure resulted in Resident 29's changing care needs not being accurately reflected in the care plan and the current care interventions not being readily available to evaluate for their effectiveness and relevance to the resident's significant weight loss.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure for one of 25 sampled residents (Resident 5) that a humidifier bottle (used to prevent the resident's airways from getting too dry while on concentrated oxygen) was labeled and filled with distilled water. This failure had the potential to cause discomfort and dryness to Resident 5's airway.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of 25 sampled residents (Resident 19), who received Lorazepam (anti-anxiety drug) and Sertraline (anti-depressant,), was adequately monitored for specific target behaviors. Additionally, medication adverse effects (unwanted, uncomfortable or dangerous effects) of Lorazepam and Sertraline were not monitored. These failures had the potential to have a negative impact on Resident 19's physical, mental, and psychosocial well-being and placed the resident at risk for experiencing adverse effects related to the use of psychotropic medications, including, but not limited to drowsiness, dizziness, movement disorders, and death.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure urgent dental services were provided in a timely manner for 1 of 25 sampled residents (Resident 21) when her dental bridges were broken, and she requested to see her former dentist. These deficient practices had the potential to result in, difficulty chewing, choking and/or weight loss.