Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
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 Arthur Home, The during CMS and state inspections, most recent first.
The facility failed to provide oral care for two residents, one with respiratory and cognitive impairments and another with severe cognitive impairment and dry mouth. CNAs did not clean dentures or provide oral hygiene for one resident, while an LPN failed to ensure medication was taken and oral care was given to another, resulting in discomfort and unswallowed medication.
A resident with severe cognitive impairment and a history of skin issues returned from the hospital with worsening Moisture Associated Skin Dermatitis (MASD). The facility failed to update the care plan and conduct weekly skin audits, leading to a deterioration in the resident's condition. Staff observations noted dark red lines and a beefy red appearance on the resident's skin, which were not addressed in a timely manner.
A resident with a history of anxiety and stroke was verbally abused by a CNA who shouted at the resident to stop using the call light and forcibly removed it from their reach. The incident was witnessed by other staff members, leading to the CNA's termination for founded abuse.
A facility failed to supervise a cognitively impaired resident, resulting in the resident exiting unnoticed and being exposed to cold temperatures and chemicals. The resident's care plan lacked interventions for wandering, and exit doors were unmonitored. Another resident fell in the bathroom due to lack of supervision, despite being a high fall risk. Both incidents highlight deficiencies in supervision and care planning.
The facility failed to employ a full-time Certified Dietary Manager (CDM), affecting all 33 residents. The previous CDM left in mid-October, and an uncertified interim manager, who is not present in the kitchen, was appointed. Staff reported struggles due to the lack of oversight, and the administrator confirmed ongoing interviews to fill the position.
The facility did not ensure that all dietary staff completed the required Food Handlers training, potentially affecting all 33 residents. Dietary Aides were observed serving meals and assisting residents without the necessary training. The Interim Dietary Manager was unaware of the training requirement for staff other than cooks and was inexperienced in managing a dietary department in LTC. The Administrator acknowledged the issue and was working on enrolling staff in the required training.
The facility failed to document temperature logs for kitchen coolers, freezers, and food, with significant gaps in logging for November. The walk-in cooler had a loose seal and leaking fan, creating unsanitary conditions. Staff were not properly trained to prevent cross-contamination, and facility policies on sanitation and food safety were not followed, compromising food safety for residents.
A facility failed to prevent cross-contamination in the dishwashing area after an employee defecated in the kitchen drain, leading to unsanitary conditions. Despite efforts to clean the area, the kitchen continued to operate, serving meals to residents. Additionally, the dishwashing system was not maintained properly, with inadequate sanitization due to a lack of litmus strips and low temperatures, posing a potential risk to all 33 residents.
The facility failed to provide required Dementia training for all staff, affecting 33 residents. Despite a policy mandating competencies for caring for residents with mental disorders, several staff members, including CNAs and a Dietary Aide, lacked documented training. The Administrator and DON acknowledged the lapse, with plans to arrange training. The Social Service Director noted limited training provided, emphasizing the need for comprehensive Dementia management skills.
The facility failed to maintain resident dignity during meal service when a dietary aide and three CNAs engaged in a loud argument over a resident's meal preference. The incident, witnessed by other residents, involved serving eggs to a resident who disliked them, causing distress and disruption in the dining room.
A resident with severe cognitive impairment experienced an unwitnessed fall and was found outside in cold temperatures with chemical exposure. The LPN failed to report these critical details to the physician, who was only informed of the fall without injuries. The DON was also unaware of the full circumstances, highlighting a deficiency in the facility's incident reporting.
A resident with CHF was hospitalized after the facility failed to adhere to a physician-ordered fluid restriction. Despite a daily limit of 1200 ml, the resident was consistently provided with excessive fluids by both dietary and nursing staff. The resident, who was cognitively intact, expressed frustration over the lack of communication and coordination among staff. Incorrect visual aids for fluid amounts contributed to the issue, leading to the resident's worsening condition and eventual hospitalization.
The facility failed to assist three residents with their ADLs, specifically in transferring out of bed. One resident was left in bed for breakfast despite needing assistance, while another's spouse had to call for help to get her out of bed. A third resident was left waiting for assistance with her breakfast out of reach. Staff were either unaware of or did not follow the residents' preferences and care plans.
The facility did not follow its oxygen administration policy by failing to date oxygen tubing, nebulizer tubing, and humidification bottles for two residents. The policy requires weekly changes and labeling of equipment. Observations revealed undated equipment, and residents were unaware of when their tubing was last changed. The DON confirmed the policy of weekly changes on Tuesday nights.
The facility failed to provide palatable hot food to two residents, as observed during a survey. One resident received meals that were cold upon delivery, with breakfast items significantly below the required temperature. The Dietary Manager confirmed the timing of meal delivery, indicating the food would be cold if left uneaten for an hour. Another resident also reported receiving cold breakfast. The facility's policy requires hot foods to be held at 135 degrees Fahrenheit or greater, which was not met.
A facility failed to implement Enhanced Barrier Precautions for a resident with an indwelling urinary catheter, as required by their policy. The resident's care plan indicated the need for such precautions, but observations showed that PPE was not available outside the room, and a CNA performed catheter care without proper protective equipment. The DON confirmed the requirement for Enhanced Barrier Precautions for residents with urinary catheters.
Two residents in an LTC facility were affected by the misappropriation of narcotic medications. A nurse from a private staffing agency, with a history of drug diversion, was involved in discrepancies between medication administration records and narcotic log removals. One resident reported not receiving Hydrocodone, while another did not receive Tylenol #3 as documented. The facility's investigation confirmed these discrepancies, violating the residents' rights to be free from misappropriation.
A facility failed to secure medications by leaving the medication room door open and the medication cart unlocked, allowing three residents to access the area unsupervised. The residents, who were somewhat confused and known to wander, were found near the open door, and a RN later confirmed that the narcotic lock box was not double locked as required by policy. The DON acknowledged the breach, which violated the facility's medication storage policy.
The facility failed to ensure a call light was within reach for a resident, as required by policy and the resident's care plan. The administrator observed the call light on the bed while the resident was in a chair, and the resident confirmed it was not given to him after breakfast. A grievance had been filed earlier by a family member about the same issue.
The facility failed to provide scheduled showers for two residents. One resident did not receive a shower since admission, and another missed multiple scheduled showers. Both residents and staff confirmed the lapses.
A resident sustained a bruise above the left eyebrow when a CNA performed a mechanical lift transfer alone, contrary to facility policy requiring two CNAs. The incident was documented, and the facility's policy mandates two CNAs for such transfers.
Failure to Provide Oral Care for Residents
Penalty
Summary
The facility failed to provide adequate oral care for two residents, R1 and R2, as observed and documented by surveyors. R2, who has medical diagnoses including Acute and Chronic Respiratory Failure, COPD, and Dementia, was noted to require supervision with oral hygiene. However, R2's medical record did not document any oral care being provided. On a specific day, CNAs V10 and V11 assisted R2 after lunch but did not provide oral care, leaving food particles in R2's dentures. V10 admitted to not cleansing R2's dentures or providing oral care during morning routines. Similarly, R1, who is severely cognitively impaired and has medical conditions such as Xerosis Cutis and Dysphagia, was found with a very dry and cracked mouth, tongue, and lips. R1 expressed discomfort due to the lack of oral care, stating that staff never brushed her teeth. An LPN, V9, acknowledged not providing oral care or ensuring R1 took her medication properly, which resulted in unswallowed medications in R1's mouth. The facility administrator noted that the black substance on R1's mouth was due to medications given with chocolate ice cream and milk, and confirmed that oral care was not provided as it should have been.
Failure to Update Care Plan and Conduct Skin Audits
Penalty
Summary
The facility failed to identify the worsening of a skin condition, update the care plan, and conduct weekly skin audits for a resident with Moisture Associated Skin Dermatitis (MASD). The resident, who has a medical history including Xerosis Cutis, Diastolic Congestive Heart Failure, and severe cognitive impairment, returned from a hospital stay with redness on the buttocks. However, the care plan was not updated to reflect the MASD on the perineal, buttocks, and sacral areas. Observations revealed that the resident's skin condition had worsened, with dark red lines on the inner groin area and a dark, beefy red appearance on the perineal, buttocks, and sacral areas. The Wound Nurse/LPN and Director of Nurses acknowledged the worsening condition and the lack of appropriate updates to the care plan and skin evaluations. The Wound Nurse noted that the resident's condition had deteriorated since returning from the hospital, and the Director of Nurses admitted that staff should have alerted them to update the care plan and initiate weekly skin evaluations. The facility is in the process of changing its culture, but the incident highlights ongoing training needs.
Resident Verbal Abuse by CNA
Penalty
Summary
The facility failed to protect a resident's right to be free from verbal abuse by a staff member. The incident involved a resident with a care plan that included diagnoses of Chronic Vulvitis, Vulvar Cancer, Anxiety Disorder, and a history of stroke with right hemiplegia/hemiparesis. On the morning of December 26, 2024, the Social Service Director and the Dietary Manager overheard an argument between the resident and a staff member, identified as a Certified Nurse's Aide (CNA), in which the CNA shouted at the resident to stop pushing the call light. The resident responded by telling the CNA to stop yelling and threatened to report the behavior. The Dietary Manager witnessed the CNA forcibly remove the call light from the resident's hand and place it out of reach, which was corroborated by another CNA present in the room. The second CNA confirmed that the first CNA raised her voice and shouted at the resident multiple times, expressing frustration. The incident concluded with the first CNA leaving the room after realizing her behavior. The facility administrator later verified that the CNA involved in the incident was terminated for founded abuse.
Inadequate Supervision Leads to Resident Elopement and Fall
Penalty
Summary
The facility failed to provide adequate supervision for a severely cognitively impaired resident known to wander, resulting in the resident exiting the facility unnoticed and unsupervised. The resident, who had medical diagnoses including dementia with agitation and Alzheimer's disease, was found outside in 21-degree Fahrenheit temperatures and later in the facility's mechanical room with a chemical spill on her. The resident's care plan did not include interventions for her known wandering behavior, and her elopement risk assessment was outdated. Additionally, the facility's exit doors were not monitored, and the resident's personal alarm was not in place at the time of the incident. The facility also failed to provide supervision during toileting for another resident, resulting in a fall. This resident, who was moderately cognitively impaired and dependent on staff for toileting, was left unattended in the bathroom by an agency RN. The resident attempted to stand up on her own, fell, and sustained minor injuries. The resident's care plan included the use of a personal alarm, and she was identified as a high fall risk prior to the incident. Both incidents highlight deficiencies in the facility's supervision and monitoring of residents, particularly those at risk for elopement and falls. The lack of timely assessments, inadequate care planning, and failure to ensure the proper functioning of personal alarms contributed to these events. The facility's policies on elopement and fall prevention were not effectively implemented, leading to these deficiencies.
Removal Plan
- R8 was placed on 15 minute visual checks, increased sensory alarm checks, and a departure alert band was placed on R8's wheelchair, and the staff assignment sheet and careplan were updated by V2 DON.
- V3 Minimum Data Set (MDS) Coordinator/MDS Careplan Coordinator(CPC)/Licensed Practical Nurse (LPN) updated R8's elopement risk assessment.
- All current residents' elopement risks were reviewed by V2 and V3. Any resident identified to be at risk has interventions in place to keep residents safe and unable to wander away without staff knowledge.
- V3 reviewed and updated all resident care plans of residents identified as at risk for elopement.
- V38 Licensed Social Worker contractor was contacted by V1 Administrator to schedule Dementia training.
- V3 updated the elopement book. A check off list was placed in the staff/new staff/agency binder to address steps to be taken during an elopement. Implemented by V2.
- V2 reviewed the facility's last quarter of falls to ensure interventions were appropriate and careplans updated with each fall. V2 will review falls with the Interdisciplinary Team (IDT) to ensure fall interventions are implemented, and careplans are reviewed and updated as needed by V3.
- The facility fire doors at the North end of skilled unit were alarmed, a keyed lock was placed on the mechanical room door, an alarm audible to staff was placed on the employee dietary east entrance/exit door, a lock was placed on the door separating the kitchen from the dining rooms, with all resident areas remaining open.
- All new admissions/readmissions or those residents with a change in condition, will have an elopement assessment completed and residents at risk of elopement will be added to the elopement book and 15 minute checks will be initiated. Initiated and will be ongoing per V2.
- All staff were educated on the elopement policy by V1 Administrator and V2.
- Random elopement drills will be conducted by V1 Administrator or designee, to assess staff understanding of the policy including the codes/locks for doors and new doors/alarms. The first elopement drill was completed.
- V2 and V26 Assistant Director of Nurses educated staff on the Fall Prevention Program Policy to include assessment of the resident by a Licensed Nurse and the alarm policy.
- A Performance Improvement Tool was initiated by V2 to review residents that are at risk of elopement.
- A Performance Improvement Tool was initiated to review fall reports, appropriate interventions and follow through on interventions by V2. Audits will continue five times weekly for two weeks, three times weekly for two weeks, weekly for two weeks, monthly for three months and then quarterly for three quarters.
- A Performance Tool was initiated by V2 and V26 to randomly review door locks/alarms. The audits will take place seven times per week for four weeks, five times per week for four weeks, three times per week for four weeks, weekly for four weeks, monthly for four months and then quarterly for four quarters.
- The facility Quality Assurance Committee will review the Performance Improvement Tools and make additional recommendations based on the outcome of the tools.
Absence of Certified Dietary Manager in Facility
Penalty
Summary
The facility failed to employ a Certified Dietary Manager (CDM) full-time, which has the potential to affect all 33 residents residing in the facility. The facility's assessment indicated that a Dietician or other clinically qualified nutrition professional should serve as the director of food and nutrition services. However, during the survey conducted from 11/27/24 to 12/9/24, there was no CDM onsite. Interviews with staff revealed that the previous Dietary Manager left in mid-October 2024, and an interim Dietary Manager, who is not certified, was appointed. This interim manager is primarily occupied with another full-time job and is not present in the kitchen, leading to struggles among the kitchen staff. The facility administrator confirmed the absence of a CDM and acknowledged ongoing interviews to fill the position, while also being aware of the existing problems in the kitchen.
Failure to Ensure Dietary Staff Completed Food Handlers Training
Penalty
Summary
The facility failed to ensure that all dietary staff completed the required Food Handlers training, which has the potential to affect all 33 residents residing in the facility. On a specific date, a staff member was observed giving instructions to Dietary Aides on serving and assisting in the dietary department. Later, several Dietary Aides were seen serving meals, providing drinks, and assisting residents in the dining room. The Interim Dietary Manager admitted to being unaware that anyone other than the cooks needed training and acknowledged a lack of experience as a Dietary Manager in a long-term care facility. The manager was in the process of making a list of dietary employees to enroll them in a Safe Food Handlers course. The facility's Administrator confirmed awareness of the training requirement and stated that efforts were underway to register employees for the necessary training.
Deficiencies in Kitchen Sanitation and Temperature Documentation
Penalty
Summary
The facility failed to maintain proper documentation and sanitation standards in its kitchen, which could potentially affect all 33 residents. The facility did not document temperature logs for kitchen coolers, freezers, and food being served or kept on warmers. This lack of documentation was observed for the entire month of November, with significant gaps in temperature logging for both day and evening shifts. Additionally, the facility's food temperature sheets for October and November showed numerous instances where food temperatures were not recorded for entire meals. The facility's walk-in cooler had a loose seal, and the fan was leaking water, which dripped onto the food, walls, and floor, creating unsanitary conditions. The thermometer in the cooler read 42 degrees Fahrenheit, indicating improper temperature maintenance. Large empty trays were placed on the top shelves to catch some of the leaking water, but this was not entirely effective, as water continued to drip onto the food. The local County Health Department's inspection report also noted poor cleanliness of non-food contact surfaces and required corrections, some of which remained unaddressed. Interviews with facility staff revealed that the kitchen staff had not been properly trained to prevent cross-contamination and were not consistently obtaining or documenting temperatures as required. The facility's policies on sanitation and food safety were not being followed, as evidenced by the lack of daily sanitation inspections and failure to maintain safe refrigerated storage practices. These deficiencies in documentation, training, and equipment maintenance contributed to the potential for cross-contamination and compromised food safety for the residents.
Inadequate Sanitation in Dishwashing Area
Penalty
Summary
The facility failed to prevent cross-contamination in the dishwashing area due to an incident involving a dishwasher employee, identified as V6, who defecated in the kitchen drain area. This incident was reported by the Dietary Manager, V5, who upon returning from an errand, noticed a foul smell emanating from the dishroom. V6 was instructed to leave the premises, and efforts were made by the Maintenance Director, V19, and the Head of Housekeeping, V18, to sanitize the area. However, the malodorous stench persisted, and the kitchen continued to operate, serving meals to residents despite the unsanitary conditions. The facility's dishwashing system was not maintained in a sanitary manner, as evidenced by the County Health Department's inspection report, which rated the kitchen's non-food contact surfaces and food contact surfaces as out of compliance. The Dish Machine Part Per Million (PPM) Record Log indicated consistent readings of 100 PPM, but it was later discovered that the facility lacked litmus strips to verify these readings. The dishwasher's sanitize cycle temperatures were recorded below the required 120 degrees Fahrenheit, and the sanitizer was not being properly dispensed due to a weak hose, compromising the sanitization process. Interviews with staff, including the Maintenance Director and a service technician, revealed that the facility had been without litmus strips for months, preventing accurate monitoring of the dishwashing machine's sanitization levels. The service technician confirmed that the dishwasher was a low-temperature style, requiring either a minimum temperature of 120 degrees Fahrenheit or effective sanitizer levels to ensure proper sanitization. The facility's failure to maintain the dishwashing system in a sanitary manner posed a potential risk to all 33 residents residing in the facility.
Failure to Provide Dementia Training for Staff
Penalty
Summary
The facility failed to provide required Dementia training for all staff, which has the potential to affect all 33 residents residing in the facility. The facility's policy on Behavior Health Services, revised in April 2023, mandates that staff have the appropriate competencies and skill sets to care for residents with mental and psychosocial disorders, including Dementia. However, the facility's staff education logs for 2024 show that several staff members, including CNAs and a Dietary Aide, have not received any documented Dementia training. The Social Service Director had only one hour of training. The facility assessment also indicated the need for Dementia management training, but this was not implemented for new hires post-April 2023. Interviews with the facility's Administrator and Director of Nurses revealed that the facility has not kept their staff current with Dementia training since April 2023. The Administrator acknowledged the lapse and mentioned plans to arrange training. The Director of Nurses emphasized the importance of such training, given the number of residents with Dementia in the facility. The Social Service Director noted that the facility provided a two-day online training, which included only one hour of Dementia training, and highlighted the benefits of staff being trained in managing and deescalating behaviors associated with Dementia.
Disruptive Staff Behavior During Meal Service
Penalty
Summary
The facility failed to ensure the dignity of four residents during meal service, as observed through inappropriate staff behavior. The incident involved a dietary aide, V16, and three CNAs, V11, V14, and V15, who engaged in a loud and disruptive argument in the dining room. This occurred when V16 served eggs to a resident, R5, who was known by the staff to dislike eggs, although this preference was not documented in the resident's records. The argument took place in front of other residents, causing distress and disrupting their meal experience. R5, who is moderately cognitively impaired and requires assistance with meals, was served eggs despite not having an allergy or documented dislike for them. The CNAs, V11, V14, and V15, loudly reprimanded V16 for serving eggs to R5, using a 'hateful and mean' tone, according to V16. This behavior was witnessed by other residents, including R6, who expressed a preference to eat meals in their room to avoid such drama, and R4, who was upset by the staff's lack of manners. The incident was further complicated by the fact that the dining room sections were combined due to maintenance, leading to a larger audience for the argument. The interim dietary manager, V20, acknowledged the incident but was unaware of its potential classification as abuse. The facility's policy on dignity and privacy emphasizes the importance of residents living with dignity, privacy, independence, and choice, which was not upheld in this situation.
Failure to Accurately Report Unwitnessed Fall and Exposure
Penalty
Summary
The facility failed to accurately report the circumstances of an unwitnessed fall involving a resident who was severely cognitively impaired. The resident was found on the floor in the kitchen by an outside door, with the wheelchair alarm not in place. The post-fall evaluation indicated that the resident should have a wander-guard applied when near exit doors and that the wheelchair alarm should be checked when the resident self-transfers. However, the Licensed Practical Nurse (LPN) who reported the incident to the physician did not include critical details such as the resident being outside in 20-degree Fahrenheit temperatures, exposure to chemicals, and the lack of a nurse assessment before moving the resident. The Director of Nurses (DON) confirmed that these details were not reported to them either, acknowledging the severity of the oversight. The physician stated that had they been informed of the full circumstances, they would have sent the resident to the emergency room due to the exposure to frigid temperatures and chemicals. The physician emphasized the importance of notifying emergency services in such extreme cases before contacting the physician and family. The failure to report these significant details represents a deficiency in the facility's handling of the incident.
Failure to Adhere to Fluid Restriction Leads to Resident Hospitalization
Penalty
Summary
The facility failed to adhere to a physician-ordered fluid restriction for a resident with Congestive Heart Failure (CHF), leading to the resident's hospitalization. The resident, who was cognitively intact, had a medical history including Chronic Respiratory Failure, Cerebral Infarction, Chronic Diastolic CHF, Atrial Fibrillation, and Chronic Pulmonary Edema. The physician's order specified a daily fluid restriction of 1200 milliliters, with 800 ml to be provided by dietary and 400 ml by nursing, documented each shift. However, the resident was consistently provided with more fluids than prescribed, both by dietary and nursing staff, over several days. Observations and interviews revealed that the resident was served and consumed more fluids than allowed, with dietary providing between 1060 ml and 1100 ml on multiple days, and nursing providing between 420 ml and 480 ml on others. The resident expressed frustration, stating that staff did not communicate effectively about the fluid restriction and continued to provide excessive fluids, despite the resident's attempts to comply. The resident's condition, including shiny, red, and swollen lower legs, indicated worsening edema, which was corroborated by the resident's statements about recent hospitalization for CHF. Further investigation showed that the facility's visual aids for staff to determine fluid amounts were incorrect, leading to the provision of excessive fluids. The Director of Nurses acknowledged the issue, stating that the staff's actions in providing extra fluids were a facility problem. The resident was eventually sent to the emergency room due to weight gain, shortness of breath, and severe edema, requiring intensive care and intravenous diuretics. The Medical Director confirmed that the staff's failure to adhere to the fluid restriction contributed to the resident's re-hospitalization, although the resident's multiple comorbidities also played a role.
Failure to Assist Residents with ADLs
Penalty
Summary
The facility failed to assist three residents with their activities of daily living (ADLs), specifically in transferring out of bed. One resident, identified as R236, was observed lying in bed on two consecutive days, expressing a desire to get up for breakfast but was not assisted by staff. The resident's admission assessment indicated a need for one-person assistance for transfers, ambulation, and dressing. However, the CNAs were either unaware of the resident's usual routine or did not inquire about the resident's preferences, leading to the resident having breakfast in bed against his wishes. Another resident, R28, was found in a wheelchair with a finished breakfast tray after her spouse had to call for assistance to get her out of bed. The resident expressed a preference to get up earlier, as documented in her routine questionnaire, but was not assisted in a timely manner. Similarly, R25 was left in bed with her breakfast out of reach, waiting for assistance to get up and dressed. Her care plan indicated she needed assistance in all ADL areas except eating, yet the staff did not provide the necessary help when her breakfast was delivered.
Failure to Date Oxygen and Nebulizer Equipment
Penalty
Summary
The facility failed to adhere to its oxygen administration policy by not dating the oxygen tubing, nebulizer tubing, and humidification bottles for two residents. The policy, revised on 10/2/24, requires that oxygen tubing and mask/cannula be changed weekly and labeled with the date and initials. During a facility tour, one resident was observed using a nasal cannula with an oxygen concentrator, where the humidifier bottle was labeled with a date of 9/19/24, but the oxygen tubing was not labeled. The resident was unaware of when the tubing was last changed. Another resident was observed with oxygen tubing and a humidifier bottle that were not dated, and nebulizer tubing and a medication mouthpiece that were also not dated. This resident stated that none of his tubing, except for his IV tubing, had been changed. The Director of Nursing confirmed that all oxygen, nebulizer, and CPAP equipment should be changed weekly on Tuesday nights during the night shift.
Failure to Provide Palatable Hot Food
Penalty
Summary
The facility failed to provide palatable hot food to two residents, R25 and R28, as observed during a survey. On multiple occasions, R25 received meals that were cold upon delivery to her room. Specifically, on one occasion, R25's breakfast, consisting of a biscuit with white gravy, sausage, and eggs, was found to have temperatures significantly below the facility's policy requirement of 135 degrees Fahrenheit, with the biscuit at 74 degrees, sausage at 80 degrees, and eggs at 79.4 degrees. The Dietary Manager confirmed that R25's breakfast tray was delivered at 8:05 AM, and if it sat for an hour, it would indeed be cold. Similarly, R28 reported that her breakfast was cold when delivered to her room. The facility's policy mandates that hot foods be held at 135 degrees Fahrenheit or greater, which was not adhered to in these instances.
Failure to Implement Enhanced Barrier Precautions for Resident with Catheter
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions for a resident with an indwelling urinary catheter, as required by their policy. The policy mandates that an order for Enhanced Barrier Precautions be obtained for residents with indwelling medical devices, such as urinary catheters, and that personal protective equipment (PPE) like gowns and gloves be made available near or outside the resident's room. The resident's care plan, updated in April 2024, indicated the need for an indwelling urinary catheter, and the resident had a history of urinary tract infections. However, during observations in October 2023, it was noted that the entrance to the resident's room did not indicate Enhanced Barrier Precautions, and PPE was not available outside the room. Additionally, a CNA performed catheter care without wearing a gown or mask, further indicating a failure to adhere to the required precautions. The Director of Nurses confirmed that residents with urinary catheters should be placed under Enhanced Barrier Precautions.
Misappropriation of Narcotic Medications in LTC Facility
Penalty
Summary
The facility failed to protect residents' rights to be free from misappropriation of narcotic medication, affecting two residents, R1 and R2. R1's medical records indicated a prescription for Hydrocodone-Acetaminophen for pain management, which was not administered as documented. The discrepancy was noted when R1 requested Tylenol and was informed by an LPN that Hydrocodone had already been administered, which R1 denied receiving. The investigation revealed that the medication was signed out by a nurse from a private staffing agency, V5, who had a history of drug diversion. R2's records showed prescriptions for Tramadol and Tylenol #3 for pain management. On the same day as R1's incident, R2's records indicated that Tramadol and Tylenol #3 were removed from the narcotic lock box by V5, but the administration records did not match the removal times. R2, who was cognitively intact, reported not receiving the Tylenol #3, corroborating the discrepancies found in the records. The facility's investigation into the misappropriation of narcotic medications involved reviewing the narcotic logs and interviewing staff. The Director of Nursing confirmed the discrepancies and reported the findings to the local police department. The facility's policy on abuse, neglect, and exploitation emphasizes the residents' right to be free from misappropriation of property, which was violated in this case.
Medication Security Breach in Facility
Penalty
Summary
The facility failed to secure medications, including controlled substances, by leaving the medication room door open and the medication cart unlocked. This incident was observed when three residents, who were independently propelling their wheelchairs, were found outside the medication room. The door was propped open with an exercise barbell, and the medication cart was within reach of the residents. There was no staff present in the medication room or nearby halls, leaving the medications accessible to the residents for a total of nine minutes. A Registered Nurse later confirmed the situation, acknowledging that the narcotic medication lock box was not double locked as required by the facility's policy. The residents involved were somewhat confused at times and known to wander the halls. One resident expressed a need for pain medication and requested assistance from the surveyor, who was mistaken for a staff member. The Director of Nursing later acknowledged the breach in protocol, confirming that the narcotic controlled medications were not secured under double lock as per the facility's medication storage policy. The facility's policies on controlled substance administration and medication storage emphasize the importance of double-locking controlled substances and ensuring medication security, which were not adhered to in this instance.
Failure to Ensure Call Light Accessibility
Penalty
Summary
The facility failed to ensure a call light was within reach for one resident reviewed for accommodation of needs. The facility's policy requires staff to ensure the call light is within reach with each interaction in the resident's room or bathroom. The resident's care plan also specified that the call light should be kept in reach at all times. On the specified date, the administrator observed that the resident's call light was on the bed and not within reach while the resident was sitting in a chair. The resident confirmed that the call light was not given to him after returning from breakfast. A grievance had been filed earlier by a family member, noting that the resident was left without the call light after being assisted to bed. The administrator acknowledged that the call light should have been within reach and confirmed previous complaints regarding this issue.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to assist with showers as scheduled for two residents. According to the facility's undated Resident Showers policy, residents are to be provided showers as per request or facility schedule protocols. The facility's Shower List indicated that one resident was to receive showers on Wednesdays and Saturdays, but there was no documentation that the resident received a shower on the specified Saturday. A family member confirmed that the resident had not been showered since admission. Additionally, another resident, also scheduled for showers on Wednesdays and Saturdays, did not have shower sheets for multiple Saturdays. This resident confirmed that they did not always receive their scheduled showers and expressed a preference for them. The Director of Nursing acknowledged that residents should be showered on their designated days.
Failure to Provide Safe Transfer Using Mechanical Lift
Penalty
Summary
The facility failed to provide a safe transfer for one resident (R2) of three reviewed for transfers. On 5/22/24, R2 was observed with a three-inch bruise above the left eyebrow, which R2 stated was caused by the mechanical lift arm hitting her in the eye during a transfer. R2 reported that the Certified Nurse's Assistant (CNA), V25, was assisting her alone at the time of the incident. V25 confirmed that she performed the transfer by herself, despite facility policy requiring two CNAs to be present during mechanical lift transfers. The event report dated 5/19/24 documented the incident and the resulting bruise. The facility's mechanical lift policy mandates that two CNAs must be present, with one operating the controls and the other guiding the lift, which was not followed in this case.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
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 199 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Arthur
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Haven Of Arcola | 9.6 mi | ★★★★★ | 20 | 0 |
| Eastview Healthcare & Senior Living | 9.8 mi | ★★★★★ | 9 | 0 |
| Sullivan Healthcare & Senior Living | 11.2 mi | ★★★★★ | 22 | 0 |
| The Haven Of Tuscola | 11.5 mi | ★★★★★ | 6 | 0 |
| The Haven Of Bement. | 15.7 mi | ★★★★★ | 20 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.