Arbor Rehabilitation & Nursing Center

In the surveyor’s words

From the most serious findings on record at Arbor Rehabilitation & Nursing Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Jan 9, 2026

  Based on observation, interview, and record review the facility failed to store, prepare, and serve food in accordance with professional standards for food safety when:1. There was no air gap or back flow prevention device installed for the food prep sink or the three compartment sink (a commercial kitchen essential with three basins for washing, rinsing, and sanitizing dishes), 2. Dietary staff (DS) 1 and DS 2 did not wear hygienic hair gear/hair net in the food preparation area,3. Food items for residents were stored inside the utility room. These failures had the potential to affect the flavor and palatability of the food and to lead to food borne illness (nausea, vomiting, diarrhea) for the 123 residents receiving facility prepared food. […]

• No harm, potential for more than minimal, patternF887Jan 9, 2026

  Based on interview, and record review, the facility failed to provide the COVID-19 vaccine, for four out of five sampled residents (for immunization review) when Resident 58, Resident 36, Resident 29 and Resident 86's electronic health record (EHR) did not contain documented evidence that the COVID-19 vaccine was administered after obtaining consent.This deficient practice placed Resident 58, Resident 36, Resident 29 and Resident 86 at risk to be infected with COVID-19 virus that could lead to severe illness, hospitalization, and/or death.Findings:A review of Resident 58's admission RECORD, indicated Resident 58 was admitted early October 2025.A review of Resident 36's admission RECORD, indicated Resident 36 was admitted early December 2025.A review of Resident 29's admission RECORD,… […]

• No harm, potential for more than minimal, patternF689May 15, 2025

  Based on observation, interview, and record review, the facility failed to maintain a safe and supervised environment to prevent accidents and hazards for three of three sampled residents (Resident 1, Resident 2, and Resident 3) when: 1a. Resident 1 was moved, prior to being assessed, following Resident 1's fall on 3/16/25; b. Resident 1's physician was not notified of Resident 1's blurred vision, on 3/17/25, following a fall on 3/16/25, resulting in a 5-day delay in treatment; 2. Resident 2's clinical documentation was incomplete for a fall on 3/23/25; 3a. Resident 3's clinical documentation was incomplete for a fall on 3/31/25; and, b. […]

• No harm, potential for more than minimal, patternF697May 15, 2025

  Based on interview and record review the facility failed to ensure one of three sampled residents (Resident 1)'s, management and administration of pain relieving medication, (including a narcotic [a drug that could have induced sleep, stupor, or a state of insensitivity to pain]), was done according to professional standards of practice and the narcotic pain medication did not have pain level parameters in place (pain level parameter are assessed using the numeric pain assessment tool: 0=no pain and 10=the worst pain) associated with the narcotic medication order. These failures resulted in Resident 1 not receiving the appropriate type of pain medication for the assessed pain level. […]

• No harm, potential for more than minimal, patternF761Aug 22, 2024

  Based on observation, interview and documentation review, the facility failed to ensure: 1. Expired medical supplies were removed from the medication storage room, and 2. Medication carts were maintained clean and in an orderly manner. These failures had the potential for accidental use of expired supplies and for drug diversion for a census of 124. Findings: 1. During the medication storage room check on [DATE] starting at 2:35 p.m. in the North Station with the Licensed Nurse (LN 4), an expired Mic-Key continuous feed extension set (a feeding tube extension) was stored in the medication room available for use. The expiration date was [DATE]. There were Covid-19/Flu test kits also stored in the bag with the expiration date of [DATE]. […]