Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Arbor Ridge Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
The facility failed to provide SNF ABN notices to two residents receiving Medicare Part A services, leaving them uninformed about coverage termination and potential financial liability. The issue was discovered during a Medicare audit, and the responsible social worker had left the facility.
A resident with severe cognitive impairment was kissed on the hand by another resident with no cognitive impairment, who admitted to the act but claimed it was a friendly gesture. The incident was reported by a family member but not documented by staff, and the facility concluded no abuse occurred despite the lack of consent.
A facility failed to timely report an alleged abuse incident where a resident with severe cognitive impairment was kissed on the hand by another resident. The incident was witnessed by a family member and reported to a recreation aide, but not to a supervisor. The facility delayed reporting the incident to the state until informed by the family member, despite the expectation for immediate reporting.
A facility failed to complete a resident's MDS assessment on time. The resident, admitted with major depressive disorder and anxiety, had an Annual MDS assessment pending past the completion deadline. The MDS Coordinator recognized the delay and cited a need for more assistance, while the DON expected timely completion of assessments.
A resident's significant change MDS assessment was not completed within the required timeframe after being readmitted and placed on hospice care. The delay occurred because the MDS Coordinator was on vacation, and the Regional MDS Coordinator was not promptly informed of the hospice order. The Director of Nursing expected timely assessments, but the oversight was acknowledged by the MDS Coordinator.
A facility failed to accurately code hospice care in a quarterly MDS assessment for a resident with a brain tumor, despite the resident being admitted to hospice services. The MDS Coordinator acknowledged the error, which placed the resident at risk of unmet care needs.
A facility failed to ensure a 14-day stop date for a PRN order of Alprazolam for a resident with cancer and pneumonia, who was cognitively intact. The resident's electronic medical record lacked the required stop date, and the Director of Nursing acknowledged the need for reassessment to determine the necessity of continued medication use.
A resident with Alzheimer's on hospice care was administered Lorazepam without a valid physician order, despite the medication being discontinued. The LPN involved failed to document the physician's verbal order or the resident's behavior and response, as confirmed by the DON.
A facility failed to update the label on an insulin pen to match a physician's order for a resident, leading to a risk of incorrect dosage. The insulin pen label showed 36 units, while the order had changed to 15 units. An LPN was unaware of the updated order during medication administration. The facility's policy requires notifying the pharmacy for a new label when orders change, but this was not done.
The facility failed to ensure kitchen staff properly air-dried pans before storage, potentially increasing the risk of foodborne illness for all 107 residents. Observations revealed that several pans were wet and had food particles on them, and the Food Service Director confirmed the oversight was due to the absence of the regular dishwasher.
The facility failed to maintain accurate medical records for two residents, risking unmet care needs. One resident with heart failure had missing daily weight entries, despite physician orders for daily monitoring. Another resident with muscle wasting and cancer had incomplete weekly weight documentation, with additional weights found on paper but not entered into the EMR. Staff interviews revealed weights were recorded on paper and reviewed by management, but only dietician-entered weights were documented in the EMR.
Failure to Provide SNF ABN Notices
Penalty
Summary
The facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) to two residents, R91 and R109, who were receiving Medicare Part A services. This notice is crucial as it informs residents about the termination of Medicare coverage and their potential financial liability if they choose to continue receiving services. The facility's policy, dated September 2022, mandates that residents be notified when Medicare Part A services are no longer covered, allowing them to make informed decisions about their care and financial responsibilities. The deficiency was identified during a review of the SNF Beneficiary Notification Review forms, which revealed that there was no documentation indicating that R91 and R109 received the SNF ABN forms. The Administrator acknowledged during an interview that a social worker had either lost or discarded the notices, and the issue was discovered during a Medicare audit. The social worker responsible for the oversight left the facility in July, and the facility has been unable to locate the missing notices.
Failure to Protect Resident from Non-Consensual Contact
Penalty
Summary
The facility failed to protect a resident's right to be free from sexual abuse when a resident with no cognitive impairment kissed the hand of another resident who was severely cognitively impaired and unable to give consent. The incident involved a resident with a BIMS score of zero, indicating severe cognitive impairment, and another resident with a BIMS score of 15, indicating no cognitive impairment. The incident was observed by a family member who reported it to a recreation aide, but the aide did not witness the act and did not report it to a supervisor. The Assistant Director of Nursing became aware of the incident three days later when the family member reported it. The facility conducted an investigation, during which the resident who kissed the hand admitted to the act but claimed it was a friendly gesture without sexual intent. The facility concluded that abuse did not occur, despite the inability of the cognitively impaired resident to consent. The incident was not documented in the nurse's notes, and the recreation aide did not report it due to not witnessing the act.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving two residents, one of whom was severely cognitively impaired and unable to give consent. Resident 39, who had diagnoses including dementia and schizophrenia, was kissed on the hand by Resident 32, who had no cognitive impairment. The incident was witnessed by a family member who reported it to a recreation aide, but the aide did not report it to a supervisor as she did not witness the act herself. The incident was not reported to the state until three days later, after the family member informed the Assistant Director of Nursing. The facility's investigation concluded that abuse did not occur, but the delay in reporting the incident was acknowledged by the Administrator. The Director of Nursing stated that staff are expected to report any allegations immediately. The failure to report the incident in a timely manner had the potential to affect all residents on the second floor who were at risk of abuse.
Failure to Complete MDS Assessment Timely
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment was completed in a timely manner for a resident, identified as R32. The resident was admitted with diagnoses including major depressive disorder and anxiety. Upon review, it was found that the resident's Annual MDS assessment, with an Assessment Reference Date (ARD) of 09/20/24, was still pending as of 10/14/24, despite the completion deadline being 10/15/24. The MDS Coordinator acknowledged the delay and mentioned the need for additional help to complete assessments on time. The Director of Nursing expected assessments to be completed within the required timeframes, which was not met in this instance.
Failure to Timely Complete Significant Change MDS Assessment
Penalty
Summary
The facility failed to complete a significant change Minimum Data Set (MDS) assessment in a timely manner for a resident who was readmitted to the facility and had an order for hospice care. The resident's Assessment Reference Date (ARD) was set for completion by a specific date, but the assessment was not completed within the required 14-day timeframe. This oversight was attributed to the MDS Coordinator being on vacation and the Regional MDS Coordinator not being notified promptly about the hospice order. During interviews, the MDS Coordinator acknowledged the delay, stating that per-diem staff were supposed to assist in her absence, but the assessment was missed. The Director of Nursing expressed an expectation for timely completion of assessments. The review of the Minimum Data Set Resident Assessment Instrument (RAI) guidelines indicated that an SCSA should be performed when a resident enrolls in hospice if there is a new onset of symptoms or a condition not part of the expected course of deterioration.
Inaccurate Quarterly Assessment for Hospice Care
Penalty
Summary
The facility failed to ensure an accurate quarterly assessment for a resident, identified as R83, who was admitted with a diagnosis of a brain tumor. The deficiency occurred when the quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date of June 28, 2024, did not accurately reflect that the resident was receiving hospice care, despite the resident being admitted to hospice services on March 27, 2024. This error was acknowledged by the MDS Coordinator during an interview, who admitted to missing the hospice indication in the assessment. The failure to accurately code hospice care placed the resident at risk of unmet care needs.
Failure to Implement 14-Day Stop Date for Psychotropic Medication
Penalty
Summary
The facility failed to ensure compliance with regulations regarding the administration of psychotropic medications, specifically concerning a resident identified as R106. The facility's policy mandates that psychotropic medications prescribed on a PRN (as needed) basis must have a 14-day stop date unless the medication is necessary to treat a diagnosis-specific condition documented in the clinical record. However, a review of the resident's electronic medical record revealed that an order for Alprazolam, an antianxiety medication, was issued without a stop date. This oversight was identified during a survey, which included interviews and record reviews. R106 was admitted to the facility with diagnoses of cancer and pneumonia and was noted to be cognitively intact with a Brief Interview of Mental Status (BIMS) score of 13 out of 15. During the observation period, the resident was administered an antianxiety medication. The Director of Nursing acknowledged during an interview that the resident should have been reassessed to determine the necessity of continuing the medication. This failure to reassess and appropriately document the need for continued medication use placed the resident at risk of unnecessary medication administration.
Failure to Obtain Valid Physician Order for Narcotic
Penalty
Summary
The facility failed to ensure a valid physician order for a narcotic was obtained for a resident, identified as R25, who was on hospice and had a diagnosis of Alzheimer's disease. The resident was severely impaired in cognition, as indicated by a Brief Interview of Mental Status (BIMS) score of zero out of 15. During a review of the narcotic book, it was found that the resident had been administered Lorazepam, an anti-anxiety medication, on two occasions in September, despite the medication order being discontinued in early August. There was no documentation of a physician's order for the administration of this medication, nor was there any record of symptoms justifying its use. The Licensed Practical Nurse (LPN) involved admitted to administering the medication without a current order and failing to document the physician's verbal order or the resident's behavior and response to the medication. The Director of Nursing (DON) confirmed that the medication should not have been administered after its discontinuation and that it was expected for a physician order to be entered into the electronic medical record (EMR) and a Nursing Progress Note to be written. The failure to document and follow proper procedures placed the resident at risk of receiving medication without proper authorization.
Insulin Pen Labeling Discrepancy
Penalty
Summary
The facility failed to ensure that the label on an insulin pen matched the physician's order for a resident during a medication pass observation. The insulin pen label indicated a dosage of 36 units of Glargine insulin, while the physician's order had been changed to 15 units on a previous date. This discrepancy was observed when an LPN was preparing to administer the insulin to the resident, and the LPN was unaware of the updated order. The facility's policy requires that medications be labeled in accordance with current orders, and any changes should be communicated to the pharmacy for a new label. During an interview, the Director of Nursing stated that staff are expected to verify the order with the physician and notify the pharmacy to send a corrected label when there is a change. The facility also has change stickers to use until the new label arrives. However, in this instance, the process was not followed, and the insulin pen label was not updated to reflect the new order, placing the resident at risk of receiving the incorrect dosage.
Improper Air-Drying of Kitchen Pans
Penalty
Summary
The facility failed to ensure that kitchen staff properly air-dried pans before storing them, which could potentially increase the risk of foodborne illness for all 107 residents receiving dietary services. During an observation, the Food Service Director (FSD) confirmed that several pans, which had been cleaned and stacked for use, were still wet and had food particles on them when unstacked. The FSD acknowledged that the pans should have been dry before being put away and attributed the oversight to the absence of the regular dishwasher, who was on vacation. Further observations revealed additional pans of various sizes that were also wet and improperly stacked without being allowed to air dry. The FSD confirmed these findings and stated that all the pans would need to be rewashed. The facility's policy on sanitization, dated November 2022, emphasizes that food preparation equipment and utensils should be allowed to air dry whenever practical to prevent cross-contamination, highlighting the deviation from established procedures.
Failure to Maintain Accurate Medical Records for Residents
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for two residents, which placed them at risk of unmet care needs. For one resident with a diagnosis of heart failure, the facility did not document daily weights as ordered by the physician. The resident's medical record showed missing daily weight entries over a period of several days, despite an order for daily weights to monitor potential weight gain, which could indicate worsening heart failure. Interviews with staff revealed that weights were recorded on paper and reviewed by the Unit Manager and Director of Nursing, but only weights entered by the dietician were documented in the electronic medical record. For another resident with diagnoses including muscle wasting and atrophy, and malignant neoplasm of the pancreas, the facility failed to document weekly weights in the electronic medical record as recommended by the Registered Dietician. The resident's medical record initially showed only three weight entries over a span of several weeks, but further investigation revealed additional weights recorded on paper in a binder at the nurse's station. These weights had not been entered into the electronic medical record, indicating a lapse in maintaining accurate and complete medical documentation.
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What surveyors actually found near you
We read the 1,242 citations issued within 25 miles in the last 12 months — including the 18 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.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Wayne
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Complete Care At Wayne Hills Rehab & Resp Center | 0.3 mi | ★★★★★ | 18 | 0 |
| Llanfair House Care & Rehabilitation Center | 1.3 mi | ★★★★★ | 0 | 0 |
| Oakland Rehabilitation And Healthcare Center | 1.5 mi | ★★★★★ | 0 | 0 |
| Phoenix Center For Rehabilitation And Pediatrics | 1.8 mi | ★★★★★ | 1 | 0 |
| Health Center At Bloomingdale | 2.4 mi | ★★★★★ | 16 | 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.