Average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Arbor Oaks Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with a history of hip fracture, anxiety, and depression alleged that a CNA inappropriately touched them during bathroom assistance. The allegation was discovered during the night and reported to the state agency more than five hours later, exceeding the required 2-hour reporting window for sexual abuse. Staff interviews revealed confusion about reporting timelines, and the delay was attributed to the belief that the incident did not meet criteria for immediate reporting. Facility policy required immediate reporting, but this was not followed.
A resident in a LTC facility fell and sustained a fracture due to a CNA performing a mechanical lift transfer alone, contrary to the care plan requiring two staff members. Additionally, a cognitively impaired resident had repeated access to cleaning chemicals in their room, violating safety protocols.
The facility's kitchen failed to maintain proper food safety and hygiene standards, affecting 62 residents. Staff did not wash hands between tasks, leading to potential contamination. Food storage was inadequate, with expired items and improper sealing. The kitchen's physical condition, including peeling tiles and rust, further contributed to the deficiencies.
The facility failed to provide regular grooming and hygiene care for residents requiring assistance, as observed in three residents with untrimmed facial hair and one resident left in a soiled brief for an extended period. Despite care plans and protocols requiring regular shaving and changing every two hours, these were not consistently followed. The facility also lacked a formal policy on Activities of Daily Living (ADL), contributing to these deficiencies.
The facility did not adhere to the planned menu, affecting the nutritional needs of residents. A dietary staff member used incorrect scoop sizes for pureed chicken fajita, resulting in smaller portions than specified, and failed to include bread or tortilla. Additionally, cake was not served as planned, with a dietary aid mistakenly serving peaches instead. This affected residents on regular, mechanical soft, and pureed diets.
The facility failed to ensure pureed food items were prepared to a smooth, lump-free consistency for residents requiring pureed diets. Observations revealed that pureed refried rice was runny and lumpy after thickener was added, while pureed refried beans were thick. Staff interviews confirmed inconsistencies, with descriptions of pureed foods being thick, sticky, or lumpy, indicating a failure to meet dietary preparation standards.
A resident with a history of heart failure, diabetes, and arthritis fell from a mechanical lift due to a CNA's failure to follow the care plan requiring two staff for transfers. The resident sustained a sacral fracture and experienced acute pain. Despite the incident being known to the facility's DON and Administrator, it was not reported to the State Survey Agency as required.
Failure to Timely Report Alleged Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of sexual abuse to the State Survey Agency within the required 2-hour timeframe. The incident involved a resident with a history of right hip fracture, anxiety, and depressive disorder, who was assessed as having intact memory and being independent, with occasional bladder incontinence. The resident alleged that a CNA inappropriately touched their groin and breast while assisting them to the bathroom during the night. The resident reported the incident to a nurse after leaving their room in a wheelchair. Documentation showed that the allegation was discovered at 3:03 AM and reported to the Office of Long-Term Care at 8:20 AM, exceeding the mandated 2-hour reporting window for sexual abuse allegations. Interviews with staff revealed confusion about the required reporting timeframe, with some staff believing they had 24 hours to report such incidents. The DON confirmed the allegation was not reported to the Administrator immediately, and the Administrator stated the delay was due to their belief that the incident did not meet the criteria for 2-hour reporting, as they did not feel abuse had occurred and there was no serious bodily injury. Facility policy required immediate reporting of abuse allegations to the Administrator and removal of the accused staff member during the investigation. The investigation was completed, and the allegation was determined to be unfounded based on witness statements. However, the failure to report the allegation within the required timeframe constituted a deficiency, as the facility did not adhere to regulatory requirements for timely reporting of suspected abuse.
Failure to Follow Transfer Protocols and Chemical Safety
Penalty
Summary
The facility failed to ensure that staff followed care-planned interventions requiring two staff members to perform mechanical lift transfers for a resident who was dependent on such assistance. This failure resulted in a resident falling and sustaining a fracture. The care plan for the resident indicated a need for total assistance via a mechanical lift with two staff members, but during the incident, only one CNA was present, leading to the resident slipping out of the lift pad and being assisted to the ground. The incident occurred when a CNA attempted to transfer the resident back to bed using a mechanical lift without the required second staff member. The CNA did not position the lift pad correctly, causing the resident to slip out. The resident initially reported no injury, but later experienced significant pain, leading to a diagnosis of a nondisplaced sacral fracture. The facility's investigation revealed that the CNA had been trained in lift use but failed to follow the protocol of having two staff members present during transfers. Additionally, the facility failed to ensure that chemicals were kept out of reach of residents. A resident with severe cognitive impairment was found to have access to cleaning agents and disinfectant sprays in their bathroom on multiple occasions. Despite the facility's protocol that such items should not be in residents' rooms, they were observed over several days, indicating a lapse in staff vigilance and adherence to safety protocols.
Food Safety and Hygiene Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to maintain proper food safety and hygiene standards in its kitchen, affecting the quality of meals served to 62 residents. Observations revealed that dietary staff did not wash their hands between handling dirty and clean items, leading to potential contamination. For instance, a dietary staff member used a spatula on the grill and then handled bacon with bare hands without washing them. Another staff member turned off a faucet with bare hands after washing and then handled clean dishes, further risking contamination. Food storage practices were also inadequate, with several items improperly stored or expired. Opened bottles of syrup and soy sauce lacked proper labeling and refrigeration, while leftover mushrooms and soy sauce were kept past their expiration dates. Additionally, food items in the freezer and storage room were not sealed or covered, exposing them to potential contamination. The facility also failed to maintain hot food at the required temperature, with chicken fajita served at 128 degrees Fahrenheit instead of the necessary 135 degrees. The physical condition of the kitchen and dishwashing areas contributed to the deficiencies. The floor tile in front of the freezer was peeling, creating a sticky surface, and the dishwashing room had rust and mold buildup. Personal items were found on food preparation counters, and loose food particles were present on shelves where clean pans were stored. These conditions, combined with improper hand hygiene and food storage practices, posed a risk of foodborne illness to the residents.
Deficiencies in Resident Grooming and Continent Care
Penalty
Summary
The facility failed to ensure that residents requiring extensive assistance with personal hygiene were regularly offered grooming services, such as trimming or shaving of facial hair. This deficiency was observed in three residents who were reviewed for activities of daily living (ADLs). Resident #23, who is legally blind and has obsessive-compulsive and anxiety disorders, was observed multiple times with untrimmed facial hair, despite the care plan indicating the resident should be clean and well-groomed daily. Similarly, Resident #49, diagnosed with dementia and Alzheimer's disease, was also observed with untrimmed facial hair, and the facility's ADL sheet did not indicate that shaving was performed. Resident #53, who has Alzheimer's disease, psoriasis, and dementia, was observed with significant facial hair growth and was not provided with regular shaving services. Additionally, this resident experienced a failure in continent care, as they were left in a soiled brief for an extended period, resulting in urine soaking through their clothing and chair cushion. The facility's protocol requires residents to be checked and changed every two hours, but this was not adhered to, as confirmed by interviews with CNAs and the Director of Nursing (DON). The facility lacked a policy on Activities of Daily Living (ADL), which contributed to the oversight in providing necessary grooming and hygiene care. Interviews with staff, including CNAs, LPNs, and the DON, revealed inconsistencies in the implementation of care protocols, particularly regarding the frequency of shaving and changing residents. The absence of a formal ADL policy and the failure to follow existing protocols led to the observed deficiencies in resident care and hygiene.
Failure to Follow Planned Menu and Serve Correct Portions
Penalty
Summary
The facility failed to ensure meals were prepared and served according to the planned written menu, which affected the nutritional needs of residents. During an observation, it was noted that the menu for a noon meal specified that all diets were to receive cake, and residents on pureed diets were to receive 6 ounces of pureed chicken fajita. However, the dietary staff used a #16 scoop to prepare the chicken fajita, resulting in a smaller portion than required, and served it using a #8 scoop, which was less than the specified #6 scoop. Additionally, the dietary staff did not include tortilla or bread in the pureed chicken fajita, citing concerns about choking, but acknowledged that bread should have been used instead. Furthermore, the facility failed to serve the cake as specified in the menu. When questioned, a dietary aid admitted to forgetting to serve the cake, mistakenly believing that peaches were to be served instead. This oversight in meal preparation and service had the potential to affect 36 residents on regular diets, 23 on mechanical soft diets, and 2 on pureed diets, as the meals did not meet the planned nutritional requirements.
Inconsistent Pureed Food Preparation in LTC Facility
Penalty
Summary
The facility failed to ensure that pureed food items were prepared to a smooth, lump-free consistency, which is necessary to minimize the risk of choking or other complications for residents requiring pureed diets. During observations, it was noted that the dietary staff member used a #8 scoop to place servings of refried rice and beans into a blender, but the resulting consistencies were not appropriate. The pureed refried rice was runny, and when thickener was added, it resulted in lumps that were not completely dissolved. Similarly, the pureed refried beans were described as thick, indicating inconsistency in preparation. Further interviews with staff revealed that the pureed food items served to residents on pureed diets were not consistently smooth. A CNA assisting residents with their meals described the pureed food items as thick, while an LPN noted that the pureed refried rice was sticky and thick, and the pureed peaches were thin. Additionally, the dietary staff member admitted that the pureed sausage served for breakfast was lumpy, contrary to the requirement for a smooth consistency. These observations and interviews highlight the facility's failure to adhere to dietary preparation standards for residents on pureed diets.
Failure to Report Resident Fall from Mechanical Lift
Penalty
Summary
The facility failed to report a significant incident involving a resident who fell from a mechanical lift, resulting in a major injury. The incident occurred when a staff member did not adhere to the care plan intervention that required two people for lift transfers. The resident, who had a history of heart failure, diabetes mellitus, arthritis, and other fractures, was cognitively intact and dependent on assistance for transfers. The care plan specified the use of a mechanical lift with two staff members for transfers, but this protocol was not followed, leading to the resident slipping from the lift and sustaining a suspected lower sacral nondisplaced fracture. The incident was documented in various notes and reports, indicating that the resident experienced acute pain following the fall, which required pain management and further medical evaluation. Despite the resident's initial refusal for an x-ray, subsequent medical assessments confirmed the fracture. Interviews with staff revealed that the CNA involved in the transfer attempted to manage the situation alone, contrary to the facility's policy requiring two aides for such procedures. The CNA admitted to not positioning the lift pad correctly, which contributed to the resident slipping out of the lift. The Director of Nursing and other staff members were aware of the incident, and the CNA involved was suspended and later terminated. However, the facility did not report the incident to the State Survey Agency as required. The facility's policy on abuse, neglect, and maltreatment investigation and reporting mandates immediate reporting of such incidents to the Administrator and relevant authorities, but this protocol was not followed in this case.
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 28 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Malvern
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Encore Healthcare And Rehabi Of Malvern | 0.2 mi | ★★★★★ | 2 | 0 |
| The Pines Nursing And Rehabilitation Center | 13.2 mi | ★★★★★ | 0 | 0 |
| The Springs Of Red Oak | 13.2 mi | ★★★★★ | 2 | 0 |
| The Blossoms At Hot Springs Rehab And Nursing Cent | 14.7 mi | ★★★★★ | 0 | 0 |
| Arkansas Health Center | 15.6 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 July 2026) and official state health department websites.