Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Arbor Manor Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
Food service equipment was not properly cleaned or monitored. During kitchen observations, the hand-washing area had a trash can with a nonfunctioning foot pedal, the dish machine temperature and chemical logs were incomplete or blank, and observed wash cycles were below the expected temperature. The walk-in freezer had heavy ice buildup on supply lines, ceiling surfaces, bread boxes, and the floor, and during tray service a staff member could not produce the food temp log and reused the same alcohol swab to clean the thermometer probe between multiple items.
Inaccurate advance directive documentation was found for two residents. One resident with severe cognitive impairment had a DNR form with a witness date that was after the resident's signature, and another cognitively intact resident had a DNR form with an undated witness signature. The SW and DON reviewed the forms but could not explain the discrepancies.
A resident with severe cognitive impairment and dependence for bathing and personal hygiene did not receive scheduled shower care on multiple occasions, and staff could not explain the missed care or a documentation entry marking one day as not applicable. The resident was observed with several centimeters of facial hair and said he wanted to be shaved, but staff could not confirm that shaving had been offered on shower days.
Improper Wheelchair Positioning: A resident with HF, severe cognitive impairment, and hospice care was repeatedly observed sitting in a high-back wheelchair with her feet dangling and the footrests missing or not attached. The resident was also seen seated on a wheelchair pad, pillow, and mechanical lift sling, and the DON stated the footrests should have been in place for comfort but was unsure why they were not and noted therapy would not have evaluated wheelchair positioning due to hospice status.
Failure to provide documented ROM assistance for a resident with heart failure and polyarthritis. The resident was cognitively intact, had limited ROM in both lower extremities, and reported that after therapy ended, staff did not help with exercises or ROM. OT and PT discharge summaries noted a home exercise program and education for daily ROM during care, and the care plan called for daily ROM of the upper and lower extremities, but the record had no documentation that ROM was completed.
Physician Failed to Document Rationale for Disagreeing With Pharmacist Medication Review: A resident with CHF, epilepsy, DM2, morbid obesity, bladder dysfunction, heart disease, hypothyroidism, AFib, restless leg syndrome, insomnia, depression, gout, HTN, and HLD had a pharmacist review recommending an Eliquis dose increase based on age, SCr, and weight. The physician chose to continue the same dose, but did not document the clinical rationale for disagreeing with the pharmacist recommendation on the review form, and the DON confirmed the rationale was not documented in the medical record.
Medication error rate exceeded the 5% threshold when two medications for two residents were not given as ordered. An LPN cut ferrous gluconate in half even though it was not authorized to be cut or crushed, and gave metolazone at the same time as bumetanide despite an order to give metolazone 30 minutes before bumetanide. Both residents had moderate cognitive impairment and diagnoses including CHF.
An LPN handled 11 of a resident’s 14 meds with her bare hand before placing them in a pill cup and administering them. The resident had CHF, HTN, and moderate cognitive impairment. The LPN said she normally dispensed pills into her hand and was not aware she should not touch meds with bare hands; the DON stated nurses should not handle meds this way.
A resident who was cognitively intact and had diagnoses including HF and AFib was documented on the MDS as having been offered and declining the pneumococcal immunization, but the medical record contained no documentation of pneumococcal education, consent, or declination. The NHA said the facility could not locate the consent or declination, and the DON reported documentation was available for influenza and COVID-19 immunization decisions, but not for pneumococcal immunization.
The facility failed to maintain cleanliness and proper maintenance of food service equipment, affecting 84 residents. Observations included ice accumulation in the Walk-In Freezer, soiled can opener assembly, and damaged microwave oven door. Additionally, a leaking faucet and soiled spray arm valve were noted, indicating non-compliance with the 2022 FDA Model Food Code and facility policies.
The facility failed to maintain a homelike environment for 84 residents due to frequent and loud overhead paging announcements. Observations and interviews revealed that these announcements were disruptive, with one resident keeping her door closed due to the noise and a family member reporting a resident being startled. The Nursing Home Administrator acknowledged the issue, noting that the facility's policy was to limit such announcements to emergencies only.
The facility failed to ensure proper medication storage in one medication cart and one medication room. An LPN found an open Albuterol inhaler with a mismatched LOT number and an expired open date, along with Timolol Mateate eye drops without an open date label. Additionally, an RN discovered over 20 expired Heparin syringes in a medication room. The DON confirmed that medications should be dated when opened.
A facility failed to ensure proper PPE use and hand hygiene for a resident on Contact Precautions due to a multi-drug resistant organism. A CNA entered the resident's room without PPE and did not perform hand hygiene. Additionally, an LPN did not clean the insulin pen tip before attaching a new needle. These actions indicate lapses in infection control protocols.
A facility failed to provide a written notice of transfer or discharge for a resident with dementia, anxiety, and multiple rib fractures. The resident was transferred to the emergency room due to behaviors and refusals of care and did not return. The Discharge MDS indicated an unplanned discharge with return not anticipated, but the medical record lacked documentation of a written notice. The DON confirmed the absence of a written notice.
A facility failed to provide a written notice of bed hold policy upon the transfer of a resident with dementia, anxiety, and multiple rib fractures to a hospital. The resident was transferred for evaluation due to behaviors and refusals of care and did not return. The Director of Nursing confirmed the absence of a written notice during an interview.
Two residents in a facility did not receive their prescribed enteral nutrition and weight monitoring. One resident missed over two hours of tube feeding, and a significant weight gain was not confirmed. Another resident did not receive the full ordered amount of tube feeding due to pump mismanagement, and their weight was not monitored monthly as required. Staff interviews revealed a lack of adherence to feeding schedules and weight monitoring protocols.
A facility failed to monitor a resident's psychotropic medications as ordered, missing orthostatic blood pressure checks for two months. The resident, with multiple psychiatric diagnoses, was on medications requiring monthly monitoring. The DON confirmed the lack of documentation and adherence to the monitoring schedule.
A facility failed to maintain complete and accurate medical records for a resident with pressure ulcers. The resident's medical records lacked documentation on wound measurements and characteristics, and an LPN was unsure of the treatment details, yet signed off the treatment as completed. The Unit Manager noted the pressure ulcers as stage two upon admission, but documentation was entered late, leading to the deficiency.
A resident with multiple sclerosis and muscle weakness suffered a fall and a fractured femur during a transfer with a sit-to-stand lift. The lift's battery died, leaving the resident unsupported, and the aides did not use a gait belt as required. The care plan called for three-person assistance, which was not followed, leading to the resident's injury.
A resident with severe cognitive impairment experienced multiple falls due to the facility's failure to implement new interventions and update the care plan. Despite requiring substantial assistance, the resident's care plan remained unchanged after eight falls, leading to a hospitalization for a major injury. Staff interviews revealed inadequate supervision and ineffective interventions, with insufficient documentation of care plan updates and family involvement.
A resident with severe cognitive impairment experienced multiple falls and a hospitalization due to the facility's failure to update and evaluate the care plan. Despite weekly reviews and the use of alarms, the care plan was not revised with new interventions, and documentation was incomplete. This lack of action and coordination resulted in repeated falls and a major injury.
Food Service Equipment Not Properly Cleaned or Monitored
Penalty
Summary
The facility failed to effectively clean and maintain food service equipment during kitchen observations and record review. During an initial kitchen tour, the Food Service Manager (FSM) showed a hand-washing sink with a trash can beside it whose foot pedal was not functioning properly, requiring the lid to be handled with clean hands to open. In the dish room, the FSM stated the dish machine was a low-temperature chemical machine and that staff monitored temperatures daily and recorded them on a log, but the posted log had not been documented since 5/1/26. While three wash cycles were observed, the temperature gauge showed 100 degrees Fahrenheit, and the FSM later entered approximate readings for 5/2/26 through 5/5/26 even though the log had not been completed since 5/1/26. The chemical monitoring log was blank for May 2026, and a digital monitor placed through the dish machine read 104.9 degrees Fahrenheit, which the FSM said was still too low. During the same kitchen tour, the walk-in freezer was observed with ice protruding from supply lines, ice droplets on the ceiling near the refrigeration fan unit, and two of three fans functioning. Solid pooled ice was noted on at least eight opened cardboard boxes of bread and on the floor in an area about one inch thick and two feet by four feet. The FSM reported that water had been pouring out of the water lines during defrost for the past two weeks and that the refrigerator company was aware of the ice buildup. Later, during lunch tray service, a staff member stated food temperatures had already been completed but could not produce the completed log. The staff member was unable to locate an alcohol swab to clean the thermometer and used one swab between multiple food temperature checks, with the probe cleaned using the same swab between items.
Inaccurate Advance Directive Documentation
Penalty
Summary
Accurate advance directive information was not ensured for two residents reviewed for advance directives. Resident #12 was admitted with diagnoses including Alzheimer's disease, vascular dementia, atrial fibrillation, venous insufficiency, polyosteoarthritis, asthma, hypertension, anxiety, hypothyroidism, delusional disorders, and depression. The most recent MDS showed a BIMS score of 3, indicating severe cognitive impairment. The medical record contained a DO-NOT-RESUSCITATE ORDER signed by the resident, but the attestation section showed one witness signature dated after the resident's signature. During interview, the SW could not explain why the witness date was after the resident signed the document, and the DON also confirmed the date discrepancy but could not explain it. Resident #78 was admitted with diagnoses including heart disease, osteoarthritis of the knee, type 2 diabetes, stage 3 kidney disease, atrial fibrillation, hyperlipidemia, anemia, and hypertension. The most recent MDS showed a BIMS score of 15, indicating the resident was cognitively intact. The resident's DO-NOT-RESUSCITATE ORDER was signed by the resident, but the attestation section showed one witness signature with no date. During interview, the SW confirmed the missing witness date and could not explain why it was absent, and the DON also reviewed the form and could not explain why the second witness did not date the signature.
Failure to Provide Scheduled Showering and Shaving Assistance
Penalty
Summary
The facility failed to provide Activities of Daily Living care for a dependent resident who was unable to complete showering and personal hygiene independently. The resident had diagnoses including Alzheimer's disease, dementia, polyarthritis, insomnia, kidney disease, peripheral neuropathy, gout, urinary retention, sleep apnea, gastro-esophageal reflux, and muscle weakness. The most recent MDS showed a BIMS score of 3, indicating severe cognitive impairment, and documented the resident as dependent for shower/bathe self and personal hygiene. During observation, the resident was seen sitting at the side of the bed with facial hair approximately 3 to 4 cm long and stated he would like to be shaved, but could not recall the last time he had been shaved. Review of Point of Care documentation showed showers were scheduled twice weekly, but the record did not show showers completed on several scheduled days, and staff could not explain why those showers were missed or why one day was documented as not applicable. The DON also could not confirm that the resident had been offered shaving on shower days.
Improper Wheelchair Positioning
Penalty
Summary
The facility failed to ensure proper positioning was in place for Resident #28, a female resident admitted with heart failure, severe cognitive impairment on the BIMS, and receiving hospice care. On 05/05/2026, she was observed sitting in a high-back wheelchair in her room with the footrests in place, but her feet did not touch the footrests and were dangling. She was also observed sitting on a wheelchair pad, a pillow, and the sling to a mechanical lift. Later that day, she was observed in the dining room at the noon meal with her feet dangling from the wheelchair. Additional observations on 05/06/2026 and 05/07/2026 showed the resident repeatedly sitting in her wheelchair with no footrests attached or the footrests on the floor near the bed, while her feet remained dangling and her toes did not reach the floor. During an interview on 05/07/2026, the DON stated that because the resident was under hospice care, hospice provided the wheelchair, and that for comfort the footrests should have been in place. The DON also stated she was not sure why this had not been done or whether the chair may have been ill fitting, and noted that therapy would not have evaluated the resident for wheelchair positioning due to hospice status.
Failure to Provide Documented ROM Assistance
Penalty
Summary
The facility failed to provide range of motion (ROM) for one resident with documented functional limitation in ROM of both lower extremities. The resident was admitted with diagnoses including heart failure and polyarthritis, had a BIMS score of 15 out of 15, and reported that she had previously received therapy services but that her insurance no longer covered them. She stated that during therapy she performed exercises with her arms and legs, knew what exercises she should do, and that since therapy ended, staff did not assist her with any exercises or ROM. The resident’s OT discharge summary showed she received OT services from 2/20/26 through 4/17/26 and included a home exercise program. The PT discharge summary showed PT services from 2/20/26 through 3/24/26 and stated that staff and the patient had been educated on ROM exercises to incorporate into daily routines and to encourage participation in ROM exercises daily during care. The resident’s Kardex and care plan included an intervention to offer ROM of the upper and lower extremities daily while providing care, but the medical record contained no documentation that ROM was being completed with care. The OT reported believing PT had set up a passive ROM program for staff to provide, and the DON stated the facility did not have a restorative program and that ROM should be in CNA documentation, but there was no specific documentation that the task was completed.
Physician Failed to Document Rationale for Disagreeing With Pharmacist Medication Review
Penalty
Summary
The facility failed to ensure that the attending physician documented the rationale for not changing a medication after a consultant pharmacist recommended an adjustment during the monthly drug regimen review. For Resident #6, who was admitted with diagnoses including CHF, epilepsy, type 2 diabetes, morbid obesity, bladder dysfunction, heart disease, hypothyroidism, atrial fibrillation, restless leg syndrome, insomnia, depression, gout, hypertension, and hyperlipidemia, the most recent MDS showed a BIMS score of 15, indicating the resident was cognitively intact. The pharmacist’s medication regimen review noted that the resident was taking Eliquis 2.5 mg twice daily for atrial fibrillation and recommended increasing the dose to 5 mg twice daily based on the resident’s age, serum creatinine, and weight. The review form showed the physician marked the recommendation as continue, but the physician did not document a clinical rationale on the pharmacist review form for disagreeing with the recommendation. Review of the physician orders showed the Eliquis dose remained unchanged. During interview, the DON confirmed the physician had decided not to change the dose and had not documented the rationale in the medical record, and the attending physician stated she did not follow the pharmacist’s recommendation because the resident had a history of urinary bleeding, but she had not recorded that rationale on the review form and was not aware the form requested a brief clinical rationale note when disagreeing with the pharmacist.
Medication Error Rate Exceeded Due to Improper Administration of Ordered Medications
Penalty
Summary
The facility failed to keep the medication error rate below 5% when 2 of 26 medications for two residents were not administered according to physician's orders, resulting in a 7.69% medication error rate. One resident had diagnoses including dementia and congestive heart failure and a BIMS score indicating moderate cognitive impairment. During observation, an LPN prepared the resident's medications, noted that the resident took medications crushed, separated medications that were not allowed to be crushed, and then used a pill cutter to cut several medications in half, including ferrous gluconate 324 mg. The pharmacist later reported ferrous gluconate should not be cut or crushed, and the resident's record did not contain a physician's order or pharmacy instruction allowing it to be cut. The DON stated the medication cart reference sheet identified medications that could not be crushed, but did not address splitting pills, and staff should contact the pharmacy in that situation. A second resident had diagnoses including congestive heart failure and hypertension and a BIMS score indicating moderate cognitive impairment. The physician's order for metolazone 2.5 mg directed that it be given 30 minutes prior to bumetanide for congestive heart failure/weight gain. During observation, an LPN prepared metolazone and bumetanide and administered both medications at the same time. When questioned, the LPN reviewed the record and agreed the order required metolazone to be given 30 minutes before bumetanide, and acknowledged it was not administered per the physician's order.
Bare-Hand Medication Handling During Administration
Penalty
Summary
The facility failed to maintain infection prevention and control practices during medication administration for one resident. R31 was admitted with diagnoses including congestive heart failure and hypertension, and the MDS with an ARD of 3/3/26 showed a BIMS score of 11 out of 15, indicating moderate cognitive impairment. During an observation on 05/06/2026 at 8:14 AM, LPN S prepared R31's medications and dispensed 11 of the resident's 14 medications into her bare hand before placing each medication into the pill cup. The medications included hydralazine, metformin, bumetanide, colchicine, diltiazem, tamsulosin, duloxetine, eliquis, metolazone, metoprolol, and potassium chloride. LPN S then administered the medications to R31. During interview, LPN S stated she normally dispensed pills/capsules into her hand before placing them into the medication cup and was not aware she was not supposed to touch medications with her bare hands. The DON stated nurses should not handle medications with their bare hands and then administer them to residents.
Missing Pneumococcal Immunization Documentation
Penalty
Summary
The facility failed to maintain documentation that pneumococcal immunization education was provided and that consent or declination was received for one resident. The resident was admitted with diagnoses including heart failure and atrial fibrillation, and the MDS with an ARD of 1/28/26 showed a BIMS score of 15 out of 15, indicating the resident was cognitively intact, and that the pneumococcal immunization was offered and declined. Review of the medical record found no documentation of pneumococcal immunization education, consent, or declination. The NHA reported the facility could not locate a consent or declination for the pneumococcal immunization, and the DON, who was also the Infection Preventionist, stated the facility had documentation of education and consent for influenza immunization and declination of COVID-19 immunization, but no documentation for pneumococcal immunization education and consent or declination.
Deficiencies in Food Service Equipment Maintenance and Cleanliness
Penalty
Summary
The facility failed to maintain cleanliness and proper maintenance of food service equipment, affecting 84 residents. During an initial tour of the food service area, several deficiencies were observed. Ice was found protruding from the Walk-In Freezer's Freon refrigerant inlet supply lines, and the ceiling surface of the freezer had accumulated ice droplets near the refrigeration fan unit. The can opener assembly was noted to be soiled with encrusted food residue. Additionally, the microwave oven door face plate was damaged, with a surface measuring approximately 0.5 inches wide by 4-6 inches long. These observations indicate a failure to adhere to the 2022 FDA Model Food Code, which requires equipment food-contact surfaces and utensils to be clean to sight and touch, and equipment to be maintained in a state of repair. Further observations included a leaking faucet assembly in the three-compartment sink rinse and sanitizer basin, and a soiled spray arm valve assembly in the dish machine room. The West Wing Dining Room's microwave oven was also found to be soiled with accumulated food residue. The facility's policies, dated 5/2014, state that all food service equipment should be clean, sanitary, and in proper working order, and that food preparation and service areas should be maintained in a clean and sanitary condition. However, the facility failed to ensure these policies were followed, leading to the noted deficiencies.
Frequent Loud Overhead Paging Disrupts Homelike Environment
Penalty
Summary
The facility failed to provide a homelike environment for up to 84 residents due to frequent and loud overhead paging announcements. Observations made on multiple occasions revealed that the announcements were pervasive throughout the facility, occurring at various times of the day. These announcements included calls for staff to report to different areas and notifications of wander risks, among others. The loudness of these announcements was noted to be disruptive, with one resident specifically mentioning that the noise was annoying and prompted her to keep her door closed. Interviews conducted with residents and their families further highlighted the impact of the loud announcements. A family member reported that a resident was startled by the noise, indicating the announcements were excessively loud. The facility's documentation provided to the survey team included instructions for making overhead pages, which were frequently used. The Nursing Home Administrator acknowledged the issue, noting that the facility's general maintenance policy included limiting overhead announcements to emergencies only, which was not being adhered to at the time of the survey.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure proper storage of medications in one of three medication carts and one medication room. During an observation, an LPN found an open Albuterol inhaler in the South 1 medication cart with a mismatched LOT number and an open date indicating it should have been discarded 12 months after opening. Additionally, an open bottle of Timolol Mateate eye drops was found without an open date label, and a Glucose Gel with an expiration date of 7/2024 was also present. The Director of Nursing confirmed that medications should be dated when opened and that pharmacy and unit managers routinely check for outdated items. In a separate observation, an RN found more than 20 Heparin syringes in the South 2 medication room with a manufacturer expiration date of 6/30/23. The RN was unsure of their use and planned to dispose of them. The Unit Manager verified that the Heparin syringes should have been discarded according to the expiration date.
Infection Control Deficiencies in PPE Use and Medication Administration
Penalty
Summary
The facility failed to ensure proper use of Personal Protective Equipment (PPE) and hand hygiene for a resident on Contact Precautions due to a multi-drug resistant organism (MDRO). Resident #4, who was cognitively intact and had a history of Carbapenem-resistant Acinetobacter baumannii, was observed to have PPE requirements posted on their door. However, a Certified Nurse Aide (CNA) entered the resident's room without wearing the required PPE and did not perform hand hygiene upon exiting. The CNA admitted to forgetting to don PPE before delivering a lunch tray and acknowledged the need to wear gloves due to the MDRO in the resident's urine. The Director of Nursing and Unit Manager confirmed that staff should wear a gown and gloves for any care involving the resident. Additionally, the facility failed to follow proper infection control procedures during medication administration. A Licensed Practical Nurse (LPN) was observed preparing to administer insulin without cleaning the rubber tip of the insulin pen with an alcohol wipe before attaching a new needle. The Director of Nursing stated that the expectation was for the nurse to clean the tip of the insulin pen prior to each use. These observations indicate lapses in adherence to infection prevention protocols, potentially compromising resident safety.
Failure to Provide Written Notice of Transfer/Discharge
Penalty
Summary
The facility failed to provide a written notice of transfer or discharge for a resident, identified as R92, who was admitted with diagnoses including dementia, anxiety, and multiple rib fractures. On December 31, 2024, R92 was transferred to the emergency room for evaluation due to behaviors and refusals of care and did not return to the facility. The Discharge Minimum Data Set (MDS) indicated an unplanned discharge with return not anticipated. However, the medical record lacked documentation of a written notice of transfer or discharge being provided. During an interview on March 5, 2025, the Director of Nursing (DON) confirmed the absence of a written notice for R92's transfer or discharge.
Failure to Provide Written Bed Hold Policy Notice
Penalty
Summary
The facility failed to provide a written notice of bed hold policy upon the transfer of a resident to a hospital. The resident, identified as R92, was admitted to the facility with diagnoses including dementia, anxiety, and multiple rib fractures. On December 31, 2024, R92 was transferred to the emergency room for evaluation due to behaviors and refusals of care and did not return to the facility. The medical record review revealed that there was no indication of a written notice of bed hold policy being provided upon this transfer. During an interview on March 5, 2025, the Director of Nursing (DON) reported that they were unable to locate a written notice of bed hold policy for R92's transfer. This oversight was identified as a deficiency in the facility's compliance with the requirement to notify residents or their representatives in writing about the bed hold policy in cases of transfer to a hospital or therapeutic leave.
Failure to Administer Enteral Nutrition and Monitor Weights
Penalty
Summary
The facility failed to ensure that enteral nutrition was administered as ordered and weights were monitored for two residents. Resident #33 was admitted with diagnoses including dysphagia and dementia, and had a physician's order for continuous tube feeding with Jevity 1.5 cal at 55 mL per hour. On a specific day, the resident was observed without the tube feeding running for over two hours, despite the presence of a new bottle of formula on the nightstand. Additionally, a significant weight gain was noted, but a re-weigh to confirm this gain was not conducted as expected. Resident #41, who had dysphagia and moderate protein-calorie malnutrition, was ordered to receive Jevity 1.5 cal at 70 mL per hour for 16 hours daily. Observations revealed discrepancies in the administration of the tube feeding, with the resident not receiving the full ordered amount of 1120 mL. The pump was not reset properly, leading to confusion about the total amount administered. Furthermore, the resident's weight was not monitored monthly as ordered, with the last documented weight being nearly two months prior. Interviews with staff, including a Registered Dietitian and a Licensed Practical Nurse, highlighted a lack of awareness and adherence to the prescribed feeding schedules and weight monitoring protocols. The facility's failure to provide the ordered nutrition and to monitor weights as required contributed to the deficiency, impacting the residents' nutritional management and care.
Failure to Monitor Psychotropic Medications as Ordered
Penalty
Summary
The facility failed to ensure proper monitoring of psychotropic medications for a resident diagnosed with bipolar disorder, schizophrenia, anxiety disorder, and other depressive disorders. The resident was cognitively intact and had a physician's order for monthly orthostatic blood pressure monitoring to assess the effects of psychotropic medications, including Buspirone, Venlafaxine, and Risperidone. However, the medical record did not reflect consistent orthostatic blood pressure monitoring for November 2024 and January 2025, as required by the physician's order. During an interview, the Director of Nursing (DON) acknowledged the lack of documentation for orthostatic blood pressures while the resident was lying, sitting, and standing. Although the resident was capable of standing, there was no documentation of any refusals to comply with the monitoring process. The DON was only able to locate records of orthostatic blood pressures for October and December 2024, indicating a failure to adhere to the prescribed monitoring schedule for the resident's psychotropic medication management.
Incomplete Medical Records and Treatment Administration
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who was admitted with diagnoses including atrial fibrillation, retention of urine, and a urinary tract infection. Upon admission, the resident was noted to have pressure ulcers on their bilateral buttocks. However, the medical records lacked documentation regarding the pressure ulcers, such as wound measurements, staging, or characteristics. A physician's order was in place for the treatment of these pressure ulcers, which included cleansing with normal saline, applying barrier cream, and covering with a sacral dressing every shift and as needed. During an interview, an LPN was unsure of the appearance of the resident's pressure ulcers and had not performed the treatment as scheduled. Despite this, the treatment was signed off as completed in the Treatment Administration Record and Medication Administration Audit Report. The Unit Manager reported assessing the resident's skin upon admission and noted the pressure ulcers as stage two, but the documentation was entered late. This lack of timely and accurate documentation and treatment administration led to the deficiency identified by the surveyors.
Improper Transfer with Assistive Device Leads to Resident Injury
Penalty
Summary
The facility failed to ensure a safe transfer for a resident using an assistive device, resulting in harm. The resident, who had been at the facility since 2013 and had diagnoses including multiple sclerosis and muscle weakness, experienced a fall during a transfer with a sit-to-stand lift. The resident was found on the floor with a fracture to the right femur, which required hospitalization and surgical intervention. The incident occurred when two nurse aides were transferring the resident from a wheelchair to a bed using the resident's personal sit-to-stand lift. During the transfer, the battery of the lift died, leaving the resident unsupported. One aide left to find a replacement battery, leaving the other aide unable to hold the resident up alone. Upon returning, the aides guided the resident to the floor as the resident's legs gave out. It was noted that the aides did not use a gait belt during the transfer, which was against protocol. Interviews revealed that the aides were unaware of the battery indicator on the lift and did not recognize the extra batteries in the resident's room. The care plan for the resident required three-person assistance for transfers, which was not followed. The lack of proper equipment use and adherence to the care plan led to the resident's fall and subsequent injury.
Failure to Prevent Falls and Update Care Plan
Penalty
Summary
The facility failed to implement new interventions to prevent falls for a resident with severe cognitive impairment, resulting in multiple falls and a hospitalization for a major injury. The resident, who had diagnoses including dementia and muscle weakness, required substantial assistance with personal care. Despite this, the facility did not update the care plan with new interventions following each of the eight falls that occurred between July and October. The resident's care plan, Kardex, and task sheet remained unchanged, and the facility did not document any new strategies to address the falls. Interviews with staff revealed a lack of adequate supervision and intervention for the resident. The LPN admitted that the facility did not have enough staff to provide one-on-one supervision as documented in the progress notes. The social worker and DON acknowledged that the facility did not have sufficient staff to monitor the resident continuously, and the interventions in place, such as alarms, were not effective in preventing falls. The DON also mentioned that care conferences with the resident's family were unproductive, and there was no documentation of family agreement or disagreement with suggested interventions. The incident reports documented eight separate falls, with the last fall resulting in a femur fracture. The facility's failure to update the care plan or implement effective interventions after each fall contributed to the resident's continued risk of injury. The lack of documentation and follow-through on care plan updates and interventions highlights a significant deficiency in the facility's approach to fall prevention and resident safety.
Failure to Update Care Plan Leads to Resident Falls and Injury
Penalty
Summary
The facility failed to implement, revise, and evaluate the effectiveness of the care plan for a resident, leading to multiple falls and a hospitalization with a major injury. The resident, who was initially admitted with severe cognitive impairment and required substantial assistance with personal care, experienced eight falls over a period of several months. Despite these incidents, the care plan was not updated with new interventions to prevent further falls. Interviews with facility staff revealed a lack of coordination and documentation regarding the resident's care. The social worker mentioned that the facility met weekly to review falls and interventions, but there was no evidence of one-on-one interactions for the resident in the activity log for the last 30 days. The Director of Nursing and Unit Manager were unable to provide documentation of family agreement or disagreement with suggested interventions, and the care conference notes were incomplete. The incident reports detailed the resident's falls, including one that resulted in a femur fracture. Despite the use of alarms and periodic checks, the facility did not update the care plan or Kardex with new strategies to prevent falls. The lack of documentation and follow-up on interventions contributed to the resident's repeated falls and eventual hospitalization.
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Illustrative
What surveyors actually found near you
We read the 181 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Spring Arbor
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Faith Haven Senior Care Centre | 3.6 mi | ★★★★★ | 14 | 0 |
| Cascade Senior Care Center | 4.9 mi | ★★★★★ | 10 | 0 |
| Mission Point Health Campus Of Jackson | 4.9 mi | ★★★★★ | 25 | 0 |
| Vista Grande Villa | 7.4 mi | ★★★★★ | 18 | 0 |
| Jackson County Medical Care Facility | 7.8 mi | ★★★★★ | 13 | 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 October 2026) and official state health department websites.