Below average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Arbor Care Centers - Ord, Llc during CMS and state inspections, most recent first.
The facility did not notify the State Agency within the required timeframe after changes in the Administrator position, as confirmed by record review and interviews with the administrator and owner. Notification forms for two separate administrator changes were submitted late, potentially affecting all 39 residents.
Dirty Bath House, Dining Room, and Vent Covers: The facility failed to keep the dining room windowsills clean, and multiple hallway, room, and bath house ventilation covers were observed with dusty, fuzzy buildup. In the 400-hallway bath house, the exhaust vent had gray particulates and the tub handles had a white buildup that looked like soap scum or hard water deposits. The admin and maintenance staff confirmed the conditions, and the dining room windowsills also had dead bugs and an oily residue.
Missing Required Employee Screening Checks: Record review showed an active MA had no evidence of a criminal background check or [NAME] (Sex Offender Registry) check in the personnel file. The Admin confirmed the checks had not been completed before the MA was hired and/or worked with residents, despite the facility policy requiring screening and documentation of background checks for potential employees.
The facility failed to employ a Director of Food and Nutrition Services who met the required educational standards. Records showed the Dietary Manager lacked the required education, and the RD was not employed full time but instead visited monthly for resident reviews. This affected all residents receiving meals from the kitchen.
Food Storage and Hand Hygiene Deficiencies: A freezer in the dry storage area had a 3-4-inch frost buildup, and packaged items inside were covered with frost. During meal prep, a cook handled frozen raw chicken, removed gloves, touched the same wax paper where the scoop had been placed, and did not perform hand hygiene before continuing food prep. The cook later washed hands with soap and water for only 10 seconds, which the cook and DM confirmed did not meet the required 20-second technique.
Failure to Provide SNF ABN When Medicare A Coverage Ended: The facility did not provide written SNF ABNs for 3 residents when Medicare A skilled coverage ended. Record review showed the residents still had Med A days left, and the missing notices were documented as a facility error. One resident remained in the facility after coverage ended, while two residents discharged to home.
Nonworking Bathroom Exhaust Fans on 400 Hallway: Exhaust fans in resident room bathrooms on the 400 hallway were found not to be working, as each observed vent failed to pull up a 1-ply square of toilet paper. The Maint Supervisor and Administrator both stated they were unaware the fans were not working as required, and the issue affected all sampled residents in those rooms.
A resident with multiple myeloma did not consistently receive their prescribed chemotherapy medication, lenalidomide, due to repeated lapses in ordering, availability, and administration. The medication was not given according to the required 28-day cycle, with missed and delayed doses documented over several months. Staff and pharmacy interviews confirmed gaps in ordering and delivery, and there was no evidence that the prescribing oncologist was notified of these medication errors.
The facility failed to report an incident involving a cognitively intact resident with quadriplegia who sustained a self-inflicted burn to the right hand after falling asleep with a blow dryer on. Although an incident report was completed and the Administrator confirmed the event, it was not reported to the required regulatory agencies per facility policy.
Activities Not Provided in Accordance With Resident Preferences: A resident with intact cognition, wheelchair dependence, and a care plan noting religious services as very important stated the facility only offered Catholic Mass/Communion and Bible Study, while the resident wanted other church services. Review of activity calendars for multiple months showed only those religious offerings, and the Admin confirmed they were the only services provided.
A nebulizer used for a resident’s medication treatment was observed sitting on top of the machine without a label, without being cleaned, and without being placed in a plastic bag. Facility policy required reusable respiratory equipment and oxygen tubing to be labeled and dated, cleaned after use, and stored properly, and both the IP and Admin confirmed the expected process.
Medication Administration Error Rate Exceeded Limit: Surveyors found a 52% med error rate after reviewing 25 administration opportunities. An LPN gave a resident’s scheduled meds late and at the wrong time, and a med aide applied Voltaren cream without using the measuring card, so the ordered 4-gram dose could not be verified and was confirmed as a wrong-dose error.
A resident with multiple myeloma had repeated significant med errors with lenalidomide, a cycle-based chemo med ordered for 21 days on and 7 days off. The MAR repeatedly failed to restart the med on time, resulting in missed doses and prolonged gaps, and the oncologist was not notified of the errors.
The facility failed to maintain sanitary conditions in food storage areas, with rodent droppings observed in multiple locations. The Food Services Supervisor acknowledged the issue and the need for more cleaning. This deficiency had the potential to affect all 32 residents.
The facility failed to maintain an effective pest control program, as evidenced by rodent droppings in food storage areas. The Food Services Supervisor acknowledged the issue, noting a lack of live mouse traps in the kitchen. The Facility Administrator was unaware of the problem, despite the facility's policy requiring an ongoing pest control program.
The facility failed to maintain a safe and clean environment, with stained carpets and ceiling tiles, a deceased bug in a light fixture, and loose flooring creating trip hazards in multiple hallways. The Maintenance Manager confirmed these issues, noting that carpets were only cleaned biannually and ceiling tiles had not been replaced after a water leak repair.
The facility failed to complete pre-employment health screenings for staff and did not adhere to hand hygiene protocols during medication administration. Additionally, staff did not follow Enhanced Barrier Precautions for residents with multidrug-resistant organisms, failing to wear gowns and gloves during high-contact care activities. These deficiencies were confirmed by facility management and observed during resident care.
The facility failed to ensure proper bathroom ventilation in three rooms, as the ventilation systems were unable to pull up a single ply of tissue, indicating inadequate ventilation. This was confirmed by the Maintenance Manager, who acknowledged the malfunction.
The facility failed to notify physicians of abnormal lab results for a resident with diabetes and out-of-range blood pressure readings for two residents with Parkinson's Disease and hypertensive heart disease. Despite having orders to notify physicians of these conditions, there was no documentation of such notifications, as confirmed by interviews with facility staff.
A resident with a history of falls and severe cognitive impairment experienced multiple falls due to inadequate fall prevention interventions. Despite the facility's policy, no new interventions were developed after a fall, and the resident was frequently left in a wheelchair instead of a regular chair as per the care plan. Additionally, the resident's mattress was not secured to the bedframe, posing a safety risk. Staff interviews revealed that fall prevention measures were not effectively communicated or implemented.
The facility failed to manage pain effectively for two residents, both experiencing chronic pain conditions. Despite receiving routine and as-needed pain medications, their pain was not adequately controlled, with frequent moderate to severe pain ratings. Staff did not notify providers about the frequent use of as-needed medications, which could have led to adjustments in pain management plans. Interviews confirmed the deficiency in communication and pain management strategies.
A facility failed to limit a PRN psychotropic medication order for a resident to 14 days as required. The resident received Lorazepam beyond the 14-day limit without a documented rationale from a physician. The oversight was noted by a consultant pharmacist, but the facility's Infection Control Coordinator was unaware of the issue until later, and a necessary note to the attending physician was not sent for review.
The facility failed to ensure clear and accurate medication labeling for two residents. One resident's insulin pen label was illegible, obscuring administration directions, while another resident's medication label did not match the physician's order. These issues were confirmed by nursing staff and the Director of Nursing.
Failure to Timely Notify State Agency of Administrator Changes
Penalty
Summary
The facility failed to notify the State Agency within the required five working days following changes in the Administrator position, as mandated by licensure regulations. Record review showed that the Change of Administrator Notification Form for an administrator change occurring between 11/19/2025 and 11/20/2024 was not submitted to the State Agency until 12/16/2025. Similarly, for another administrator change between 6/10/2025 and 6/11/2025, the notification form was not sent until 7/12/2025. Interviews with the administrator and facility owner confirmed that both notifications were submitted outside the required timeframe. This deficiency had the potential to affect all 39 residents in the facility.
Dirty Bath House, Dining Room, and Ventilation Covers
Penalty
Summary
The facility failed to ensure cleanliness in the dining room, room wall fans and ventilation covers, and the bath house. In the 400-hallway bath house, the exhaust vent was observed covered with fuzzy, gray-colored particulates, and the bathtub knobs had a white buildup that looked like soap scum or hard water deposits and could be easily scraped off. The bath aide confirmed the bath house was cleaned between residents and terminally cleaned daily by housekeeping, and agreed the exhaust fan had fuzzy particles and the tub handles had white buildup. The administrator and maintenance staff later confirmed the same conditions in the bath house. In the dining room, the windowsills were observed to have a dusty, oily-feeling buildup with dead bugs present, and the same condition remained on a later observation. The administrator confirmed the dining area windowsills had dusty residue and dead bugs. In the hallway and multiple resident rooms, ventilation fan covers and bathroom exhaust vents were observed with dusty, fuzzy buildup, including near the north and south outside emergency exits beside a room and in several rooms' bathroom ventilation covers.
Missing Required Employee Screening Checks
Penalty
Summary
Develop and implement policies and procedures to prevent abuse, neglect, and theft was cited after record review and interview showed the facility did not follow its policy for screening personnel. A review of an active employee roster dated 09/12/2025 showed Medication Aide (MA)-A was listed as active, and personnel records showed MA-A had a hire date of 10/28/2024. The personnel file contained no evidence of a criminal background check or [NAME] (Sex Offender Registry) check for MA-A. During interviews, the Administrator stated on 9/23/2025 that the criminal background check and [NAME] check for MA-A had not been completed. On 9/24/2025, the Administrator stated corporate staff had not completed the background check or [NAME] checks for MA-A prior to hire and/or working with facility residents. The facility policy titled Abuse-Neglect-and-Exploitation Policy, dated September 2024, stated potential employees will be screened for history of abuse, neglect, exploitation, or misappropriation of resident property, and that background, reference, and credential checks shall be conducted on potential employees and documentation of proof that the screening occurred will be maintained.
Unqualified Dietary Manager and No Full-Time Dietitian
Penalty
Summary
The facility failed to employ a Director of Food and Nutrition Services who met the regulatory educational requirements. A record review of a facility-supplied document titled Department Heads listed an employee as the Dietary Manager, but facility records showed no evidence that the Dietary Manager had completed the required education and no evidence that a qualified dietitian was employed full time. During an interview, the Dietary Manager confirmed they had not completed an educational program that met regulatory requirements and confirmed that the Registered Dietitian was not employed full time and instead completed facility visits and resident reviews on a monthly basis. The facility census was 39, and the deficiency had the potential to affect all residents receiving meals from the kitchen.
Food Storage and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to store and prepare food in safe and sanitary conditions. During observation of the dry food storage area, an upright single-door standard freezer had a 3-4-inch layer of frost on the inner top of the freezer, and all visible items inside were covered with a thin opaque white layer of frost on their exposed packaging. The Dietary Manager confirmed the frost buildup and stated it had not been defrosted and cleaned because items could not be stored elsewhere while it was being defrosted. The manager also confirmed there should not have been frost buildup on the freezer interior or on the packaged items stored inside. During meal preparation, a cook placed a white piece of wax paper on a stainless-steel table and used a scoop to handle solid/frozen peach-colored cubes that were later identified as frozen raw chicken pieces. After placing the scoop opening down on the wax paper, the cook removed gloves, disposed of them, and then placed an unwashed bare hand on the same wax paper where the scoop had been resting. The cook then emptied the chicken pieces into a baking pan and placed it in the convection oven. The cook later washed hands with soap and water for 10 seconds, and both the cook and Dietary Manager confirmed hand hygiene was not performed after glove removal or after touching the wax paper contaminated by the scoop used on raw chicken, and that the soap-and-water hand hygiene did not include rubbing hands for at least 20 seconds.
Failure to Provide SNF ABN When Medicare A Coverage Ended
Penalty
Summary
The facility failed to provide written SNF ABN documentation for 3 sampled residents when their Medicare Part A services ended. Record review showed that Resident 25 had a Medicare Part A skilled services episode that began on 02/28/2025, with the last covered day of Part A service on 3/31/2025, and the termination was listed as facility/provider initiated discharge from Medicare Part A services when benefit days were not exhausted. The SNF ABN was not provided, with the reason documented as the resident had Med A days left and it was a facility error. Resident 25 remained in the facility after Medicare A services ended. Resident 28 had a Medicare Part A skilled services episode that began on 06/03/2025, with the last covered day of Part A service on 07/25/2025, and the termination was listed as facility/provider initiated discharge from Medicare Part A services when benefit days were not exhausted. The SNF ABN was not provided, with the reason documented as the resident had Med A days left and it was a facility error; this resident discharged from the facility to home when Medicare A services ended. Resident 46 had a Medicare Part A skilled services episode that began on 05/07/2025, with the last covered day of Part A service on 06/20/2025, and the termination was listed as resident initiated discharge from Medicare Part A services when benefit days were not exhausted. The SNF ABN was not provided, with the reason documented as the resident had Med A days left and it was a facility error; this resident discharged from the facility to home after Medicare A services ended. The Administrator confirmed this was a facility error and that the SNF ABNs had not been issued to Residents 25, 28, and 46.
Nonworking Bathroom Exhaust Fans on 400 Hallway
Penalty
Summary
The facility failed to ensure that exhaust fans in resident rooms on the 400 hallway were in working order, affecting 12 of 12 sampled residents: Residents 3, 5, 10, 14, 17, 18, 19, 30, 31, 39, 40, and 45. The cited requirement was to have enough outside ventilation via a window or mechanical ventilation, or both, under 175 NAC 12-007.04(D). During observations on 09/22/2025, the bathroom exhaust vent in each of the observed resident rooms would not pull up a 1-ply square of toilet paper, indicating the vents were not functioning as expected. During interview on 09/23/2025, the Maintenance Supervisor stated they were not aware that the vents in these rooms were not working as required. The Facility Administrator also confirmed not knowing that the ventilation fans were not working in the 400 hallway. The report documents that the exhaust fans in the resident rooms on that hallway were not in working order and that facility leadership and maintenance were unaware of the issue at the time of the survey.
Failure to Ensure Timely Administration and Availability of Prescribed Chemotherapy Medication
Penalty
Summary
The facility failed to ensure that a resident with multiple myeloma received their prescribed medication, lenalidomide, according to the physician's orders. The medication was to be administered in a 28-day cycle, with 21 days on and 7 days off, but there were multiple documented instances where the medication was not available or not administered as ordered. Review of the Medication Administration Records (MAR) over several months revealed repeated gaps in administration, with cycles starting late, not restarting on time, or being missed entirely. There was no physician order to stop the medication at any point, and the MARs did not reflect any authorized changes to the regimen. Interviews with facility staff and the infection preventionist (IP) confirmed that the medication was only available through a specialty pharmacy, which required the facility to order the medication for each cycle individually. The IP acknowledged that the medication order would fall off the electronic system after a few months and had to be manually re-entered, which contributed to the missed doses. The pharmacy representative corroborated that there were months when no medication was ordered or delivered, and staff interviews confirmed that there were times when the medication was not available for administration. There was also a lack of documentation or receipts to show that the medication was obtained from any other source during the periods when the pharmacy did not deliver it. Additionally, there was no evidence that the resident's oncologist was notified of the medication errors, despite the ongoing issues with medication availability and administration. Staff interviews indicated inconsistent practices regarding the storage and tracking of the medication, with reports of extra medication being kept in the medication cart at times, but no clear process for ensuring continuous supply. The facility's failure to maintain a consistent supply and administration of the prescribed medication led to significant lapses in care for the resident.
Failure to Report Resident Burn Incident
Penalty
Summary
The facility failed to report an incident involving Resident 38 to the required regulatory agencies as required by its policies and 175 NAC 12-006.02(H). Resident 38 was admitted with quadriplegia and had a quarterly MDS showing a BIMS score of 15/15, indicating the resident was cognitively intact. The resident was dependent on staff for bed mobility, transfers, and toilet use. Record review showed that on 09/17/2025 the resident was observed with a red raised area on the dorsal surface of the right hand and stated that the burn occurred after falling asleep with a blow dryer on. A facility incident report was completed for the event, and the Administrator later confirmed in interview that the resident had a self-inflicted burn to the right hand. The Administrator also confirmed that the incident was not reported to the necessary regulatory agencies as required by the facility abuse policy.
Activities Not Provided in Accordance With Resident Preferences
Penalty
Summary
The facility failed to provide activities in accordance with a resident’s expressed interests. The resident was admitted with diagnoses of Type 2 diabetes mellitus, hypertension, and generalized muscle weakness, and the quarterly MDS dated 08/28/2025 showed a BIMS score of 15/15, indicating the resident was cognitively intact. The resident used a wheelchair for mobility and was dependent on staff assistance to propel the wheelchair throughout the facility. The care plan identified participation in religious services as very important to the resident. During interview, the resident stated they wished the facility offered religious services other than Catholic Mass and said they really missed going to church and would enjoy attending church services. Review of the facility activity calendars for July, August, and September 2025 showed only Catholic Communion or Catholic Mass offered weekly, along with Bible Study on limited dates. In interview, the Administrator confirmed the only religious services offered in the facility for the last 3 months were Catholic Mass or Communion and Bible Study.
Respiratory Equipment Not Properly Cleaned or Stored
Penalty
Summary
Reusable respiratory equipment was not labeled, cleaned, or stored according to facility policy after use for Resident 5. Record review showed the facility’s Infection Prevention and Control Program required reusable items and equipment needing special cleaning, disinfection, or sterilization to be cleaned per procedure, and reusable items potentially contaminated with infectious materials to be placed in an impervious clear plastic bag. During observation in Resident 5’s room, a nebulizer that had been used for a medication treatment was found sitting on top of the nebulizer machine; it was not labeled, was not clean, and was not in a plastic bag. The Infection Control Preventionist and the Facility Administrator both confirmed that nebulizers and oxygen equipment and tubing were to be labeled and dated, cleaned after use, and then stored per facility policy.
Medication Administration Error Rate Exceeded Limit
Penalty
Summary
The facility failed to ensure the medication administration error rate was 5% or less. Surveyors reviewed 25 medication administration opportunities and identified 13 errors, resulting in a 52% error rate. The deficiency affected 2 of 4 sampled residents in a facility census of 39. For one resident, medications scheduled for 8:00 AM, including aspirin, Qulipta, baclofen, vitamin B-12, ferrous sulfate, fluoxetine, gabapentin, lamotrigine, pantoprazole, Xarelto, senna docusate, and vitamin D3, were observed being prepared and administered at 9:43 AM by an LPN, and the LPN confirmed the medications were given late and at the wrong time. For another resident, Voltaren cream was ordered as 4 grams twice daily topically and 4 grams twice daily as needed, but a medication aide applied a quarter-sized amount to the back of the resident’s neck without using the measuring card; the aide stated it was unknown whether 4 grams had been administered and confirmed it was a medication error due to the wrong dose being given.
Significant Medication Errors With Cycle-Based Lenalidomide
Penalty
Summary
The facility failed to ensure that a resident with multiple myeloma, not yet in remission, received lenalidomide in the ordered 28-day cycle without significant interruptions. The resident’s oncology telemedicine record showed the medication was intended to be given as 10 mg orally daily for 21 days, followed by 7 days with no medication before the next cycle began. The MAR reflected this same cycle-based order, with no evidence of an order to stop the medication. Record review showed repeated failures to restart the medication on time after the 7-day breaks. In October 2024, the medication did not restart until 13 days after it should have resumed. In November 2024, the medication ended on the 21-day schedule and was not restarted at all during that month. In December 2024, the resident did not receive any lenalidomide. In January 2025, the medication again was not restarted when due and instead resumed later than ordered. In February 2025, the medication was restarted after the scheduled date. The April 2025 medication error report documented that the errors began in October 2024 and continued through December 2024, and the resident’s records did not show that the oncologist was notified of the medication errors. The April 2025 MAR also showed missed doses when the medication was unavailable during part of the cycle. During interview, the Infection Control and Preventionist confirmed the resident was supposed to take the medication for 21 days, then have 7 days off, and that the facility made a mistake by not getting lenalidomide back on the MAR when it fell off the system. The IP stated the medication had to be manually entered back into the system and ordered from one source for each cycle, and confirmed that several doses were missed during November and December 2024 and that significant medication errors occurred with the administration of lenalidomide.
Rodent Droppings Found in Food Storage Areas
Penalty
Summary
The facility failed to store food under sanitary conditions, as evidenced by the presence of rodent droppings in and around the food storage areas. During an observation, the Food Services Supervisor (FSS) directed the surveyor to the kitchen's dry storage area, where food items were stored off the floor. However, there was a 4-inch gap between the shelving and the floor, where individual food packs and wooden snap mouse traps were visible. In the main storage area, which contained a refrigerator, freezers, and dry food shelving units, the floors were observed to have dried pasta, corn kernels, and a buildup of dark soiling. Mouse droppings were littered all over the floor, with a concentration in specific areas, and sticky mouse traps were present by the delivery entryway. The FSS acknowledged awareness of the mouse droppings and stated that live mouse traps were not available in the kitchen. Additionally, the FSS admitted that more cleaning was needed. The facility's policy on dietary sanitation requires that all kitchen and dining areas be kept clean and free from rodents and other pests. The failure to adhere to these standards had the potential to affect all 32 residents of the facility.
Pest Control Deficiency in Food Storage Areas
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of rodent droppings in and around the food storage areas. During an observation, the Food Services Supervisor (FSS) directed the surveyor to a kitchen area with a dry storage section where a 4-inch gap was found under the storage, containing food items and four wooden snap mouse traps. In the main storage area, which included a refrigerator, freezers, and shelving units for dry and canned food items, the floors were observed to have dried pasta, corn kernels, and a buildup of dark soiling. Mouse droppings were littered across the floor, with a concentration in specific areas, and sticky mouse traps with dead bugs were found near the delivery entryway, along with additional mouse droppings. The FSS acknowledged awareness of the mouse droppings and admitted that live mouse traps were not available in the kitchen as they were in other facility areas. The FSS mentioned that some cleaning had been done, but more was needed. The Facility Administrator (FA) was interviewed and revealed they were unaware of the rodent droppings in the dry food storage area. The facility's policy on pest control, which was undated, indicated that an ongoing pest control program should be maintained to keep the building free of insects and rodents, but this was not effectively implemented.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for its residents, as evidenced by several deficiencies observed in multiple hallways. In the 300 Hall, the carpet was stained and discolored, with a large dark ring extending into the hallway. The commons area near the nurse's station also had discolored areas. In the 400 Hall, ceiling tiles were stained and warped, and a deceased bug was found in a light fixture. The carpet and laminate flooring in several rooms were loose, creating trip hazards. The 500 Hall had stained ceiling tiles, and the 700 Hall had loose carpet and cracked tiles at the thresholds, with a buildup of a black, thick brown substance. The Maintenance Manager confirmed the issues, acknowledging that the ceiling tiles were warped and stained due to a previous water leak that had been repaired, but the tiles had not yet been replaced. The carpets were only cleaned twice a year by an outside company, with no interim cleaning, leading to varying degrees of staining throughout the facility. The Maintenance Manager also confirmed the presence of the bug in the light fixture and the loose and cracked flooring at the door thresholds.
Infection Control and Staff Health Screening Deficiencies
Penalty
Summary
The facility failed to complete and review pre-employment health histories for four sampled staff members, which is a critical step in ensuring that employees are free of communicable diseases before working with residents. The Business Office Manager confirmed that the Employee Health History Screen forms for the housekeeper, medication aide, dietary aide, and maintenance manager were incomplete and not reviewed by facility staff. This oversight could potentially expose residents to health risks from staff who may carry communicable diseases. During medication administration, a registered nurse failed to perform hand hygiene between resident contacts, which is a violation of the facility's hand hygiene policy. The nurse did not sanitize hands after administering medications to two residents and before preparing medications for another. Additionally, the nurse did not sanitize hands after removing gloves post-procedure when obtaining a resident's blood sugar. This lack of adherence to hand hygiene protocols increases the risk of cross-contamination and infection among residents. The facility also failed to follow Enhanced Barrier Precautions for residents known to be colonized or infected with multidrug-resistant organisms. Staff did not wear gowns and gloves during high-contact care activities for two residents, despite clear signage and policy requirements. This non-compliance was observed during transfers, toileting, and wound care, where staff had direct contact with residents without the necessary protective equipment. The Director of Nursing Services acknowledged the need for revised training to ensure staff are educated on these precautions.
Inadequate Bathroom Ventilation in Three Rooms
Penalty
Summary
The facility failed to ensure proper bathroom ventilation in three rooms, as required by licensure reference number 175NAC 12-007.04(D). During observations conducted on August 22, 2024, it was noted that the ventilation systems in the bathrooms of three specific rooms were unable to pull up a single ply of tissue, indicating inadequate ventilation. This deficiency was confirmed through an interview with the Maintenance Manager, who acknowledged that the ventilation systems in these rooms were not functioning correctly and should have been able to perform the tissue test successfully.
Failure to Notify Physicians of Abnormal Lab Results and Blood Pressure Readings
Penalty
Summary
The facility failed to notify the provider of abnormal laboratory results for Resident 21, who was admitted with type two diabetes. The resident had a Hemoglobin A1C (HbA1C) test result of 9.10, which was significantly higher than the normal range of 4.80-6.00. Despite the abnormal result, there was no documentation indicating that the provider was notified or had reviewed the abnormal value. Interviews with the facility's Medical Records staff and the Director of Nursing confirmed the lack of notification and review. Additionally, the facility did not notify the physician of out-of-range blood pressure readings for Resident 24 and Resident 4. Resident 24, who was admitted with Parkinson's Disease, had several instances of systolic blood pressure readings below 100, which required physician notification according to the care plan. However, there was no documentation of such notifications. Similarly, Resident 4, who had a diagnosis of cervical spinal cord injury and hypertensive heart disease, also had multiple instances of systolic blood pressure readings below 100, with no evidence of physician notification. Interviews with the facility's Registered Nurse and Director of Nursing confirmed the absence of documentation for physician notifications regarding the out-of-range blood pressure readings for both residents. The expectation was for the nurse or charge nurse on duty to contact the physician's office and document the information in the progress notes, which was not done in these cases.
Failure to Implement Fall Prevention and Secure Mattress
Penalty
Summary
The facility failed to implement adequate fall prevention interventions for a resident, identified as Resident 25, who had a history of falls, anxiety, unsteadiness on feet, and muscle weakness. Despite the facility's policy requiring a Fall Incident and Investigation report and interdisciplinary review after a fall, no new interventions were developed following a fall on March 20, 2024, where Resident 25 and their spouse/roommate, Resident 28, fell while attempting a bathroom transfer. On August 19, 2024, Resident 25 experienced another fall under similar circumstances, yet the care plan only included an intervention to have staff assist Resident 25 back to their room from meals, which was not implemented as observed on August 21, 2024. Observations revealed that Resident 25 was frequently left in a wheelchair at the dining room table, contrary to the care plan's intervention to place them in a regular chair to prevent falls. Staff interviews confirmed that new or revised fall prevention interventions were expected but not effectively communicated or implemented. The Medication Aide-G indicated that staff often did not have time to read updates on the computer dashboard, which lacked information about Resident 25's fall and updated prevention measures. Additionally, the facility failed to ensure the mattress on Resident 25's bed was secured to the bedframe, creating a potential entrapment and fall hazard. The Maintenance Manager confirmed that the facility did not check if mattresses were secured and was unaware of devices to secure them. This oversight further compromised the safety of Resident 25, who had severe cognitive impairment and was at increased risk of falls.
Inadequate Pain Management for Two Residents
Penalty
Summary
The facility failed to manage pain effectively for two residents, Resident 18 and Resident 21, as identified during a survey. Resident 18, admitted with multiple chronic pain-related diagnoses, frequently experienced moderate to severe pain that interfered with daily activities. Despite receiving both routine and as-needed pain medications, the resident's pain was not adequately controlled, as evidenced by frequent high pain ratings. The facility's staff did not notify the resident's provider about the frequent use of as-needed pain medication, which could have led to adjustments in the resident's pain management plan. Similarly, Resident 21, who also had chronic pain conditions, reported frequent pain that disrupted sleep and daily activities. The resident's pain was consistently rated at moderate to severe levels, and the resident often required as-needed pain medication during early morning hours. The staff did not inform the resident's provider about the frequent need for additional pain relief, which might have prompted a review and adjustment of the resident's pain management regimen. Interviews with the facility's nursing staff and the Director of Nursing confirmed that both residents' pain was not adequately controlled and that the providers had not been notified to consider changes in the pain management plans. This lack of communication and failure to adjust pain management strategies contributed to the deficiency in providing appropriate pain management for the residents.
Failure to Limit PRN Psychotropic Medication to 14 Days
Penalty
Summary
The facility failed to ensure compliance with the regulation that PRN psychotropic medications are limited to 14 days unless re-evaluated and re-ordered by a physician. This deficiency was identified for one resident, who had an order for Lorazepam, a psychotropic medication, to be administered every 12 hours as needed for anxiety or agitation. The order, which started on 8/5/24, did not have an end date, and the medication was administered beyond the 14-day limit, specifically on the 15th day. The facility's policy requires that PRN orders for psychotropic drugs be limited to 14 days unless a physician documents a rationale for extending the order. However, the consultant pharmacist noted the absence of a 14-day stop date in their review, and the facility's Infection Control Coordinator was unaware of this note until it was brought to their attention. Additionally, a note to the attending physician regarding the 14-day limit was not sent for review, which contributed to the oversight.
Medication Labeling Deficiencies
Penalty
Summary
The facility failed to ensure medications were labeled clearly and accurately for two residents, leading to deficiencies in medication administration. Resident 18, who was admitted with type two diabetes mellitus, received Humalog Insulin injections per a sliding scale schedule. During a medication administration observation, it was noted that the insulin pen label was illegible due to smeared ink, obscuring the resident's name and administration directions. This issue was confirmed by both the administering nurse and the Director of Nursing, indicating a failure to adhere to the facility's policy on medication labeling. Similarly, Resident 29, admitted with hypertensive heart disease, had a discrepancy between the medication label and the physician's order. The medication card label indicated Potassium Chloride 20 MEQ, while the Medication Administration Record specified Potassium Chloride ER 20 MEQ. This inconsistency was observed during medication administration and confirmed by the nurse and the Director of Nursing. The mismatch between the medication label and the physician's order highlights a failure in ensuring accurate medication labeling and administration.
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 10 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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 Ord
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Community Memorial Health Center | 16.1 mi | ★★★★★ | 10 | 0 |
| Rose Lane Home | 22.4 mi | — | 0 | 0 |
| Brookefield Park | 36 mi | ★★★★★ | 7 | 0 |
| Brookestone View | 38.7 mi | ★★★★★ | 8 | 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.