Arbor Post Acute

In the surveyor’s words

From the most serious findings on record at Arbor Post Acute, in the surveyor’s own words.

• Actual harm, isolatedF689Jul 14, 2025

  Based on interview and record review, the facility failed to ensure one of three residents sampled for falls with injury was provided with the necessary care to prevent an avoidable fall with injury (Resident 1) when the facility failed to;1.Take Resident 1 to the bathroom on 3/9/25, after her family member (FM) told staff that she needed to go. Subsequently, Resident 1 got up on her own to use the bathroom and fell. This failure to toilet Resident 1 resulted in Resident 1 falling and sustaining a broken right ankle, foot and toes which caused her severe pain, a transfer to the hospital, and delayed her discharge back home by 6 weeks. […]

• Actual harm, isolatedF689Jan 24, 2025

  Based on observation, interview, and record review, the facility failed to ensure resident's plan of care met their needs and provided supervision required to keep them free from accidents and hazards for two of five sampled residents (Resident 250 and 303) when: 1. Resident 250 was known to the facility to have restless/aggressive behaviors, active infection and had been evaluated to be at a high risk for falls. The facility failed to re-evaluate past interventions, identify the root cause of Resident 250's falls and develop resident specific individualized interventions to prevent accidents. This resulted in repeated falls for Resident 250 and subsequently, a bilateral head injury that required a 12-day hospitalization . 2. […]

• Actual harm, isolatedF697Jan 24, 2025

  Based on observation, interview, and record review, the facility failed to follow their pain management policy and identify causes of pain, implement pain management strategies, and monitor or modify approaches to ensure pain was adequately controlled for one out of 4 sampled residents (Resident 76) when: Resident 76 screamed out in pain when staff changed her brief (adult diaper), because staff forced her contractured legs (a permanent and irreversible deformity of a joint caused by the muscles and tendons shortening and stiffens the joint and causes an inability to move. […]

• Actual harm, isolatedF600Oct 9, 2023

  Based on interview, and record review, the facility failed to protect the resident's right to be free from physical abuse for one out of four sampled Residents (Resident 1), when Resident 1 was slapped on the face by Resident 2. As a result, Resident 1 had redness and swelling on her face, and she was crying. Findings: During a review of the facility's policy titled, Abuse and Neglect -Clinical Protocol , no revised date provided, the policy indicated: 1. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish . 2. […]

• No harm, potential for more than minimal, widespreadF801Jul 9, 2026

  Based on record review and interview, the facility failed to ensure the individual designated as the Dietary Manager met the qualifications required to direct food and nutrition services, including certification as a Dietary Manager or other qualifying credentials for one of one dietary managers.This failure had the potential to result in all residents receiving food and nutrition services that were not provided in accordance with professional standards.Findings:California Health and Safety Code, 1265.4 describes the staff qualifications for the day-to-day management of dietetic services in a skilled nursing facility. […]