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 Hills Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
The facility failed to provide necessary hygiene and grooming services to three residents, leading to deficiencies in their care. A resident with multiple health conditions was not given a shower or basic hygiene supplies despite requests. Another resident with dementia had long, calcified toenails due to a lack of communication about podiatry needs. A third resident was not showered upon request, violating her dignity and facility policy. These issues were due to poor communication and documentation among staff.
A resident receiving continuous gastrostomy feedings was placed at risk when a CNA lowered the head of the bed, contrary to care plan instructions. Another CNA failed to elevate the bed immediately upon noticing the issue, and an LVN improperly flushed the gastrostomy tube by pushing water through instead of using gravity. Interviews revealed staff were aware of proper procedures but did not follow them, risking aspiration and discomfort for the resident.
A resident with a history of heart failure and pneumonia did not receive timely changes of respiratory equipment, as required by facility policy. Observations showed equipment dated over three weeks old, and interviews revealed staff confusion about the frequency of changes. The Infection Control Nurse stated equipment should be changed weekly, but the LVN and ambassador were unsure of the protocol, highlighting a gap in training and adherence to infection control practices.
A facility reported an 11% medication error rate due to improper administration by an LVN. One resident with COPD did not receive the full dose of albuterol via nebulizer, while another resident with a gastrostomy had medications spilled during administration. The errors were confirmed by the DON and ADON, indicating non-compliance with medication administration procedures.
The facility failed to properly store and label medications, with expired drugs found on a nurse's cart and breathing treatments stored at incorrect temperatures in a medication room. Staff interviews revealed a lack of adherence to protocols, and the facility was unaware of an ongoing air conditioning failure affecting medication storage conditions.
A facility failed to maintain a resident's dignity during meal assistance when an LVN was observed standing while feeding a resident with severe cognitive impairment and other medical conditions. The resident required supervision and assistance with eating, as outlined in her care plan. Interviews with the LVN and DON confirmed that standing while feeding does not provide dignity, violating the facility's policies on resident rights and meal assistance.
A resident with severe cognitive impairment fell while playing a game, but the incident was not immediately documented or assessed by the LVN on duty. The DON was unaware of the fall until the next day, and the LVN only conducted a complete assessment after being informed by the DON. This delay in assessment and documentation did not align with the facility's Fall Prevention Program Policy, placing the resident at risk for potential injuries.
A resident with an indwelling catheter was improperly handled during a transfer, leading to a potential risk of infection. The Foley bag fell on the floor and was placed on the resident's lap and hung on a Hoyer lift, contrary to facility policy. The CNAs involved did not report the incident to the LVN, and the bag was not changed, increasing the risk of urinary tract infection.
A facility failed to maintain an effective Infection Control Program, leading to deficiencies in resident care. Personal care items were not labeled or stored properly, risking cross-contamination. Additionally, a resident's Foley catheter bag was found on the floor, increasing infection risk. Staff acknowledged awareness of proper procedures, yet these were not followed.
Deficiencies in Resident Hygiene and Grooming Care
Penalty
Summary
The facility failed to provide necessary services for activities of daily living (ADLs) to three residents, leading to deficiencies in maintaining their hygiene and grooming. Resident #170, a male with multiple health conditions including gangrene and diabetes, was not provided with a shower or even basic hygiene supplies like wipes or towels despite his requests. He had been admitted for short-term care and had a surgical wound on his foot, which required careful management. Despite his repeated requests for a shower or a wipe down, the staff did not provide the necessary assistance, and there was a lack of communication among the staff regarding his needs. Resident #6, a male with cerebral infarction, dementia, and other health issues, was dependent on staff for all ADLs. His toenails were observed to be long and calcified, which could potentially cause discomfort or injury. The facility's process for ensuring residents received podiatry care was not followed, as the resident's need for toenail care was not communicated to the appropriate staff, and he was not included on the podiatrist's list. This oversight was due to a breakdown in communication between the nursing staff and the social worker responsible for coordinating podiatry visits. Resident #223, a female with chronic obstructive pulmonary disease and heart failure, was not provided with a shower upon her request when she was admitted. She was told that showers were not given on weekends, and despite her requests, she was not showered until several days later. The staff failed to document her requests or provide the necessary care, which was a violation of her dignity and the facility's policy on maintaining resident hygiene. The lack of documentation and communication among staff members contributed to the failure to meet her needs.
Failure to Follow Enteral Nutrition Protocols
Penalty
Summary
The facility failed to provide adequate care and services to prevent complications for a resident receiving enteral nutrition. The resident, an elderly female with a history of cerebral infarction, heart failure, gastro-esophageal reflux disease, and Alzheimer's Disease, was receiving continuous gastrostomy feedings. The care plan required the head of the bed to be elevated at all times to prevent aspiration. However, on the day of the incident, a CNA lowered the head of the bed while the resident was receiving feedings, contrary to the care plan and the sign above the bed instructing to keep the head elevated. Another CNA entered the room and found the resident with the head of the bed flat but did not elevate it immediately. Instead, the CNA left the room to get a nurse, leaving the resident at risk. When the nurse arrived, the head of the bed was raised, and the feedings were stopped. The nurse then flushed the gastrostomy tube by pushing water through it instead of allowing it to flow by gravity, which is against the facility's policy and could introduce air into the stomach, causing discomfort. Interviews with the CNAs and the LVN revealed that they were aware of the correct procedures for handling residents with gastrostomy tubes but failed to follow them. The Director of Nursing confirmed that the procedures were not followed correctly, which placed the resident at risk for aspiration and discomfort. The facility's policy on enteral nutrition emphasized the importance of head elevation and proper flushing techniques to prevent complications.
Failure to Timely Change Respiratory Equipment
Penalty
Summary
The facility failed to provide timely respiratory care for a resident, specifically in changing respiratory equipment, which is crucial for infection control. The resident, an elderly female with a history of cerebral infarction, heart failure, and pneumonia, among other conditions, was observed with respiratory equipment that had not been changed since 05/20/24, despite the facility's policy requiring weekly changes. This included a breathing mask and an oral yankauer suction tip, both of which were dated over three weeks prior to the observation. Interviews with facility staff revealed a lack of awareness and adherence to the facility's infection control policies. The Infection Control Nurse/ADON stated that respiratory equipment should be changed weekly, but the LVN responsible for administering breathing treatments was unsure of the frequency, estimating changes to occur once or twice every two weeks. The DON confirmed the weekly change policy but was uncertain if nonclinical staff had been adequately trained on their responsibilities as ambassadors, who are supposed to check on residents and ensure equipment is properly dated and maintained. The ambassador assigned to the resident admitted to checking for dates on equipment but was not familiar with the specific requirements for changing respiratory equipment, as she was not a clinical staff member. This lack of knowledge and oversight contributed to the failure to maintain proper infection control practices, potentially placing the resident at risk for respiratory infections.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in an 11% error rate. This was based on four errors out of 34 opportunities, involving two residents. The first incident involved a resident with chronic obstructive pulmonary disease, hypertension, and heart failure, who did not receive the full dose of albuterol sulfate inhalation solution through a nebulizer. The LVN administering the medication left 95% of the solution in the mask chamber and disposed of it, acknowledging that the resident did not receive the correct dosage. In the second incident, another resident with hypertension, a gastrostomy, heart failure, and cerebral infarction did not receive the full dose of medications administered through a gastric tube. The LVN spilled a significant amount of Miralax and metoprolol during administration, and a substantial amount of white medication was left in the portion cup. The ADON confirmed that the resident did not receive the medications as ordered, constituting a medication error. Interviews with the LVN and DON revealed that the medication administration process was not followed correctly, leading to the errors. The facility's policies and procedures for medication administration, including those for nebulizer use and enteral tube administration, were not adhered to, resulting in the residents not receiving their prescribed medications effectively.
Improper Storage and Labeling of Medications
Penalty
Summary
The facility failed to ensure proper storage and labeling of drugs and biologicals, as observed in one of the two nurse medication carts and one of the two medication rooms. During an inspection, it was found that the nurse medication cart contained expired medications, including a blister packet of ondansetron HCL and opened breathing treatments that were not dated. The Assistant Director of Nursing (ADON) acknowledged that nurses are responsible for removing expired medications to prevent their administration, but this was not done, leading to a risk of reduced potency and effectiveness of the medications. Additionally, the medication room was found to have breathing treatments stored at a temperature above the manufacturer's recommended range. The Maintenance Director confirmed that the room temperature was 81 degrees, which exceeded the storage requirements for medications such as albuterol and Advair Diskus. The Director of Nursing (DON) stated that medications not stored at the correct temperature would not be effective, indicating a failure in maintaining the appropriate storage conditions. Interviews with staff revealed a lack of awareness and adherence to proper medication storage protocols. The Administrator was unaware of the air conditioning failure in the medication room, which had been ongoing for about three weeks, according to the Maintenance Director. This oversight contributed to the improper storage conditions, as the facility had not taken timely action to address the temperature issue, further compromising the effectiveness of the medications stored in the room.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to uphold the resident's right to a dignified existence and self-determination by not providing care in a manner that promotes the maintenance or enhancement of quality of life. Specifically, a Licensed Vocational Nurse (LVN) was observed standing while feeding a resident, which is against the facility's policy that emphasizes feeding residents with attention to safety, comfort, and dignity. This action was noted during an observation in the dining room, where the LVN was feeding a resident who required supervision or touching assistance with eating due to severe cognitive impairment and other medical conditions. The resident involved was an elderly female with a history of heart failure, type 2 diabetes, hemiplegia, hemiparesis, hypertension, dysphagia, and cognitive communication deficit. Her care plan indicated the need for staff assistance with eating, including setup, cueing, and supervision. Interviews with the LVN and the Director of Nursing (DON) confirmed that staff should not stand while feeding residents, as it does not provide the resident with dignity. The facility's policies on resident rights and assistance with meals were not adhered to, leading to this deficiency.
Failure to Assess and Document Resident Fall
Penalty
Summary
The facility failed to ensure that a resident received appropriate treatment and care following a fall, as per professional standards of practice. The incident involved a resident with severe cognitive impairment, who was observed falling while playing a game. Despite the fall being witnessed by a CNA, the incident was not immediately documented or assessed by the LVN on duty. The resident's fall was not recorded in the progress notes or evaluations, and no immediate head-to-toe assessment was conducted to check for injuries. The Director of Nursing (DON) was unaware of the fall until the following day, and upon learning of the incident, instructed the LVN to assess the resident. The LVN admitted to not performing a thorough assessment immediately after the fall, as she was not informed of the severity of the incident. The LVN only conducted a complete assessment after being informed by the DON, which was not documented until the next day. This delay in assessment and documentation did not align with the facility's Fall Prevention Program Policy, which requires immediate assessment and documentation of falls. The facility's policy mandates that all falls be assessed, documented, and reported promptly, with a thorough evaluation to prevent further incidents. However, in this case, the lack of immediate action and documentation placed the resident at risk for potential injuries. The incident report was only completed two days after the fall, indicating a lapse in following the established procedures for fall management and documentation.
Improper Foley Bag Handling During Transfer
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling catheter, leading to a potential risk of urinary tract infection. The resident, a male with a history of obstructive and reflux uropathy, dementia, hypertension, and kidney disorder, was observed being transferred from a wheelchair to a bed using a Hoyer lift by two CNAs. During the transfer, the Foley bag, which is supposed to be kept below the bladder to ensure proper drainage and prevent backflow, fell on the floor. One of the CNAs picked it up and placed it on the resident's lap, and later hung it on the Hoyer lift, which was against the facility's policy. The CNAs involved did not inform the LVN about the incident, which could have led to the Foley bag being changed to prevent infection. The LVN, upon being interviewed, confirmed that the CNAs should have reported the incident and that the Foley bag should have been kept below the bladder during the transfer. The Director of Nursing (DON) and the Assistant Director of Nursing (ADON) also confirmed that the actions taken by the CNAs were inappropriate and could lead to infection due to the Foley bag being placed on a dirty surface and hung above the bladder. The facility's policy on catheter care, revised in March 2024, clearly states that the urinary drainage bag must be held or positioned lower than the bladder at all times to prevent backflow and infection. The CNAs involved had been checked off on their skills for Foley care, indicating they should have been aware of the proper procedures. However, the failure to follow these procedures and the lack of communication with the nursing staff resulted in a deficiency in the care provided to the resident.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain an effective Infection Control Program, which resulted in deficiencies in the care of a resident. Specifically, the facility did not properly label and store personal care items in the bathroom of a semi-private room, which could lead to cross-contamination. During an observation, it was noted that several personal care items, including toothpaste, shampoo, deodorant, and shaving cream, were left unlabeled on the bathroom counter. The resident in the room confirmed that these items did not belong to her, indicating a lack of proper labeling and storage procedures. Additionally, the facility failed to ensure that a resident's Foley catheter was properly managed. The catheter bag was observed on the floor, which poses a risk for infection. The CNA responsible for the resident acknowledged that the catheter should not be on the floor and that personal care items should be labeled and stored in plastic bags to prevent cross-contamination. The Director of Nursing confirmed that staff were aware of these procedures, yet the deficiencies were still present, indicating a lapse in adherence to the facility's Infection Prevention and Control Program.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Eagle Lake
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Columbus Oaks Healthcare Community | 14.5 mi | ★★★★★ | 3 | 0 |
| Trucare Living Centers-columbus | 14.9 mi | ★★★★★ | 1 | 0 |
| Avir At Sealy | 16.5 mi | ★★★★★ | 1 | 0 |
| Paradigm At The Creek | 22.8 mi | ★★★★★ | 3 | 0 |
| Wharton Nursing And Rehabilitation Center | 24.3 mi | ★★★★★ | 8 | 4 |
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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.