Above average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Trace Health & Living Community during CMS and state inspections, most recent first.
The facility failed to notify the physician of significant weight gains for two residents, did not apply ACE wraps as ordered for another resident, improperly administered medicated creams to a resident with skin impairments, and failed to verify a urinalysis reorder and provide catheter care for a resident post-hospitalization.
The facility failed to ensure residents were clinically appropriate to self-administer medications. One resident with cognitive impairment had benzocaine and nasal spray without assessments. Another resident had lidocaine patches, and a third had nasal spray, both without self-administration assessments. The DON confirmed assessments were required.
The facility failed to honor a resident's preference for bathing frequency. Despite being cognitively intact, the resident's care plan inaccurately indicated cognitive impairment and did not document her preference for more frequent showers. Interviews with staff confirmed the lack of documentation and adherence to the resident's expressed wishes.
The facility failed to maintain a clean and homelike environment for a resident and two units. A resident reported missing baseboard strips in their room, and observations revealed debris along handrails in two halls. Despite some cleaning efforts, debris remained, and the baseboard strip was still missing during a follow-up observation with the DON.
The facility failed to ensure the accuracy of an MDS assessment for a resident undergoing dialysis. Despite a care plan and physician order indicating the resident received hemodialysis, the MDS assessment did not mark dialysis. The DON confirmed the assessment was conducted due to the resident starting dialysis but was unsure why it was not marked.
The facility failed to develop and implement comprehensive care plans for two residents. One resident did not have care plans for multiple medications and did not receive care in pairs as required. Another resident with an expressive language disorder lacked a communication care plan and consistent use of communication aids.
The facility failed to ensure proper transfer techniques and fall interventions for several residents, leading to deficiencies in care. One resident fell and fractured his pelvis due to poor safety awareness and a missing antirollback device on his wheelchair. Another resident was transferred without a gait belt, and a third resident requiring a Hoyer lift was repositioned without it. The DON confirmed that the facility's fall policy and gait belt utilization practices were not followed.
The facility failed to follow up on pharmacy recommendations for a resident's medication regimen, including a dose reduction for Zoloft and changes to the Flonase nasal spray regimen. The usual process for follow-up by the DON or ADON was not effectively implemented.
The facility failed to maintain proper infection control practices during incontinence care for a resident with a pressure ulcer and diabetes, and during medication administration for another resident. Staff did not follow protocols for PPE and hand hygiene, as confirmed by the DON.
The facility failed to ensure pneumococcal immunizations were offered and/or administered for two residents. One resident had no indication of refusal for the pneumococcal vaccine, and another resident's record showed consent but no administration of the vaccine. The Infection Preventionist was responsible for follow-up.
Failure to Notify Physician, Apply ACE Wraps, Administer Creams Properly, and Provide Catheter Care
Penalty
Summary
The facility failed to ensure physician notification of significant weight gains for two residents, Resident 9 and Resident 50, who were both at risk for fluid volume excess due to conditions such as congestive heart failure and end-stage renal disease. Despite physician orders to notify the physician of weight gains exceeding 3 pounds in one day or 5 pounds in one week, the facility did not document any notifications for several instances of significant weight gain for both residents. This lack of communication could have potentially exacerbated their medical conditions due to unmonitored fluid retention. The facility also failed to apply ACE wraps as ordered for Resident 11, who had diagnoses including Parkinson's disease and edema. Observations on two separate days showed that Resident 11 was not wearing the prescribed ACE wraps while participating in activities. This non-compliance with physician orders could have negatively impacted the resident's condition, particularly in managing edema and preventing pressure ulcers. Additionally, the facility did not follow proper procedures for administering medicated creams to Resident 33, who had skin impairments. The LPN was observed mixing two different creams together in her gloved hand before applying them to the resident's sacrum, contrary to the consulting pharmacist's instructions to apply the creams separately. This improper administration could have affected the efficacy of the treatment. Furthermore, the facility failed to verify a urinalysis was reordered after a probable contamination and did not administer a prescribed dose of vancomycin for Resident 58, who had returned from hospitalization with a urinary tract infection and sepsis. There was also no documentation of catheter care being provided for eight days post-hospitalization, which could have further compromised the resident's health.
Failure to Ensure Clinical Appropriateness for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure residents were clinically appropriate to self-administer medications for three residents. Resident 2 was observed with a labeled bottle of benzocaine and nasal spray in her room, which she used for sore gums and at night, respectively. Despite her diagnoses of herpes viral encephalitis, altered mental status, and mild cognitive impairment, there were no self-administration assessments for these medications. A progress note indicated new orders for Hurricane gel to be self-administered, but there were no instructions for self-administration in the physician order for benzocaine gel. Resident 9 was observed with two unopened lidocaine patches on a table in her room. Her clinical record, which included diagnoses of congestive heart failure and arthritis, lacked a self-administration assessment. Similarly, Resident 22 was observed with a nasal spray in her room on two occasions. Despite having a physician order for Flonase nasal spray, there were no self-administration assessments conducted. The DON confirmed that self-administration assessments were required to determine residents' ability to self-administer medications safely.
Failure to Honor Resident's Bathing Preferences
Penalty
Summary
The facility failed to obtain and honor a resident's preference for bathing frequency. Resident 24, who has diagnoses including dementia, mood disorder, psychotic disorder with delusions, and anxiety, was found to be cognitively intact according to her 3/13/24 and 4/20/24 Quarterly MDS assessments. Despite this, her care plan from 10/19/22 indicated she was cognitively impaired and unable to voice preferences regarding activities of daily living (ADLs). The care plan stated that she should be offered showers per the facility's schedule, which was twice weekly on Mondays and Thursdays. However, Resident 24 expressed during an interview on 5/8/24 that she would prefer to receive showers every other day, a preference that was not being met by the facility. Interviews with the Social Services Director (SSD) and the Director of Nursing (DON) revealed that the resident's bathing preferences were generally discussed upon admission and during care plan meetings, but there was no documentation or verification of Resident 24's preferences. The DON confirmed that the process for documenting bathing preferences was not in effect when Resident 24 was admitted in 2020. Additionally, the Social History Assessment from 10/26/20, which should have documented the resident's bathing preferences, was left blank. The DON and a CNA both confirmed that Resident 24 had expressed a preference for more frequent showers, which was not reflected in her care plan or the facility's practices.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to promote a clean and homelike environment for Resident 37 and two of the five units reviewed. Resident 37, who has a medical diagnosis of dementia with behaviors and was found to be cognitively intact, reported that the baseboard strip from the door to the kitchenette cabinets in their room had been missing for a while. Observations on multiple dates revealed debris along the handrails on the 300 hall, including paper wrappers, a dead insect, and a paper clip, as well as a thumb tack inside the handrails on the 200 hall. Despite the housekeeper's efforts to clean some of the debris, it was noted that not all debris was removed from the corners. The baseboard stripping in Resident 37's room remained missing during a follow-up observation with the DON. The facility's policy on providing a safe, clean, comfortable, and homelike environment was not adhered to in these instances.
Inaccurate MDS Assessment for Dialysis Resident
Penalty
Summary
The facility failed to ensure the accuracy of a resident's Minimum Data Set (MDS) assessment for a resident undergoing dialysis. The clinical record for the resident, who had diagnoses including end-stage renal disease and dependence on renal dialysis, was reviewed. A dialysis care plan and a physician order indicated that the resident received hemodialysis. However, a Significant Change MDS assessment did not mark the resident as receiving dialysis. During an interview, the Director of Nursing (DON) confirmed that the MDS Coordinator conducted the assessment due to the resident starting dialysis but was unsure why dialysis was not marked on the MDS assessment.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, leading to deficiencies in their care. For Resident 53, who had medical diagnoses including diabetes, congestive heart failure, insomnia, GERD, and restless leg syndrome, the facility did not develop care plans for her diabetic medications, antiplatelet medication, sleep aid, and GERD medication. Additionally, the facility did not implement the care plan intervention of providing care in pairs, as evidenced by an incident where only one staff member was present during a lab draw. This was confirmed by interviews with the resident and the Director of Nursing (DON), who admitted to not following the care plan due to a good rapport with the resident. The care plans for the medications were only provided after the surveyor's review, indicating a delay in proper documentation and planning for the resident's needs. For Resident 89, who had an expressive language disorder and was non-verbal, the facility failed to develop a communication care plan. Despite the resident's need for a communication board or other aids, observations and interviews revealed that these tools were not consistently available or used. The resident was observed without a communication board during activities and in his room, and staff interviews indicated a lack of consistent use and awareness of the communication aids. The Social Services Director (SSD) confirmed that other residents with similar issues had care plans, but Resident 89 did not, highlighting a gap in the facility's care planning process for residents with communication impairments.
Failure to Ensure Proper Transfer Techniques and Fall Interventions
Penalty
Summary
The facility failed to ensure proper transfer techniques and fall interventions for several residents, leading to deficiencies in care. Resident 62, diagnosed with dementia, fell and fractured his pelvis after attempting to ambulate independently. The post-fall assessment revealed that the resident was cognitively impaired with poor safety awareness and was resistant to using the call light. Observations showed that the resident's wheelchair was missing an antirollback device on one side, which was not addressed until after the fall. Interviews with staff indicated a lack of awareness and communication regarding the missing device, and it was not listed as a fall intervention in the resident's care plan. Resident 36, diagnosed with Parkinson's disease and repeated falls, was observed being transferred without the use of a gait belt by two CNAs. The resident's care plan indicated the need for substantial assistance with transfers and the use of a gait belt, but this was not followed. Additionally, the resident was often left without engaging activities, despite the care plan's recommendation for diversional activities to prevent falls. Resident 71, with severe cognitive impairment and requiring a Hoyer lift for transfers, was observed being repositioned in her wheelchair by two CNAs without the use of the mechanical lift. The care plan specified the need for a Hoyer lift and two staff members for transfers, but this was not adhered to. The DON confirmed that the facility's fall policy and gait belt utilization practices were not followed, leading to deficiencies in the care provided to these residents.
Failure to Follow-Up on Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure timely follow-up on pharmacy recommendations for a resident's medication regimen. Resident 22, who had diagnoses including bradycardia, nasal congestion, and depressive episodes, had a physician order for Zoloft 50 milligrams daily and Flonase nasal spray as needed. Despite pharmacy reviews recommending a gradual dose reduction of Zoloft and changes to the Flonase nasal spray regimen, these recommendations were not implemented. Specifically, the Zoloft dose reduction from 50 milligrams to 25 milligrams was not carried out, and the Flonase nasal spray remained as needed instead of being scheduled daily or discontinued as recommended by the pharmacy. An interview with the Director of Nursing (DON) revealed that the usual process for following up on pharmacy recommendations was not being implemented effectively. The DON or the Assistant Director of Nursing (ADON) were responsible for this follow-up, but the process was in the midst of being changed. The facility's policy on Medication Regimen Review, updated in March 2009, stated that pharmacy recommendations must be addressed and appropriate action taken in a reasonable time frame, which was not adhered to in this case.
Infection Control Deficiencies During Resident Care and Medication Administration
Penalty
Summary
The facility failed to maintain proper infection control practices during incontinence care for a resident and medication administration for another resident. During an observation, a CNA used the same soiled wipe twice while performing perineal care for a resident with a pressure ulcer and diabetes mellitus. Additionally, the CNA applied cream to the resident's coccyx area with the same soiled gloves. Both the CNA and QMA did not don PPE before conducting incontinence care, despite the resident being on enhanced barrier precautions due to a wound. The care plan for this resident indicated the need for gown and gloves during high-contact care activities. In another observation, a QMA failed to perform hand hygiene between administering medications to two residents. The QMA did not use the hand sanitizer available on the medication cart before preparing medications for the second resident. The QMA only performed hand hygiene after doffing gloves post-administration of eye drops to the second resident. The facility's policies on hand hygiene, perineal care, and enhanced barrier precautions were not followed, as confirmed by the DON during an interview.
Failure to Administer Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure pneumococcal immunizations were offered and/or administered for two residents. For Resident 36, the clinical record indicated that the resident had received Pneumovax-23 in 1997 and Prevnar-13 in 2017. However, a consent form dated 9/29/22 showed consent for the influenza vaccine but not for the pneumococcal vaccine, with no indication of refusal. A Quarterly MDS assessment dated 3/28/24 indicated that the pneumococcal vaccine was not up to date because it was not offered. For Resident 11, the clinical record showed consent for the pneumococcal vaccine, but there was no indication that the vaccine was administered. A Quarterly MDS assessment indicated that the pneumococcal vaccine was not given because it was offered and declined. An interview with the DON revealed that the Infection Preventionist is responsible for immunization consents and follow-up. The facility's policy, dated 11/8/16, stated that both PCV13 and PPSV23 should be administered routinely to adults aged 65 and older, as well as to certain adults aged 19 through 64.
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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 Richmond
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Forest Park Health Campus | 1 mi | ★★★★★ | 12 | 0 |
| Brickyard Healthcare - Golden Rule Care Center | 2.3 mi | ★★★★★ | 16 | 0 |
| Rosebud Village | 3.8 mi | ★★★★★ | 0 | 0 |
| Willows Of Richmond | 3.8 mi | ★★★★★ | 1 | 0 |
| Springs Of Richmond, The | 4.2 mi | ★★★★★ | 14 | 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.