Arbor Ridge Rehabilitation and Healthcare Center

In the surveyor’s words

From the most serious findings on record at Arbor Ridge Rehabilitation and Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Jun 5, 2026

  Complaint Intake ID #408686Based on interviews, record reviews and reviews of pertinent facility documents, it was determined that the facility failed to ensure care and treatment were provided timely to Resident #121, to prevent further change in condition. This failure delayed care for Resident #121 who was admitted to the intensive care unit at an acute care hospital with a diagnosis of septic shock (the most severe, life-threatening stage of sepsis [body's extreme response to an infection], which is a critical medical emergency requiring immediate hospitalization.) This deficient practice was identified for 1 of 3 residents (Resident #121) reviewed for hospitalization.On 12/28/24 at 8:00 PM, Resident #121 had a change in condition with rapid, shallow breathing and difficulty breathing… […]

• No harm, potential for more than minimal, patternF755Nov 23, 2022

  Based on observation, interview, and record review, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure that a.) an expired narcotic medication was removed from active inventory that resulted in repeated administration of an expired medication to Resident #93 for three months and b.) discontinued biologicals were removed from active inventory for 3 of 3 unsampled residents (Resident #6, #32, and #34). This deficient practice was identified during 1 of 1 medication rooms inspected (First-floor) and evidenced by the following: 1. On 11/16/22 at 10:23 AM, the surveyor inspected the First-floor medication room in the presence of Licensed Practical Nurse/Unit Manager (LPN/UM). […]

• No harm, potential for more than minimal, isolatedF640Jun 5, 2026

  Based on record review, interview, and review of the Resident Assessment Instrument (RAI manual), the facility failed to ensure that one resident (Resident (R) 95) out of 15 sampled residents' Minimum Data Set (MDS) assessments were transmitted in a timely manner. Findings include: Review of the Center for Medicare and Medicaid Services (CMS) Long-term Care Facility Assessment Instrument 3.0 User's Manual, version 1.20.1, dated 10/25 revealed, Chapter 2: Assessments for the Resident Assessment Instrument, 2.6: Required OBRA Assessments for the MDS.RAI OBRA-required assessment summary for Entry tracking record.MDS completion date (Z0400) no later than entry date + 7 calendar days.Transmission date no later than entry date + 14 calendar days. […]

• No harm, potential for more than minimal, isolatedF655Jun 5, 2026

  Based on interviews, record reviews, and review of facility policy, the facility failed to ensure a baseline care plan was given to the residents or their representatives for two Residents (R's), R150 and R121) of 25 sampled residents. These failures had the potential to cause the residents and/or their representatives not to be informed of or are included in the development of the plan of care. Findings include: 1.On 06/01/26 at 1:17 PM, R150 was observed sitting in a wheelchair in his/her room. During a concurrent interview, the resident was unable to state how long he/she had been in the facility and if the facility had provided him/her with a written baseline care plan. On 06/02/26 at 10:45 AM, an interview was conducted with R150's representative. […]

• No harm, potential for more than minimal, isolatedF656Jun 5, 2026

  Based on interviews, record reviews and review of facility policy, the facility failed to develop a comprehensive care plan for one resident, Resident (R) 121, when he/she was readmitted to the facility. This failure had the potential to cause R121 to receive a less effective plan of care which could affect the quality of care and services provided.Findings include: Review of R121's record revealed R121 was readmitted to the facility on [DATE] with diagnoses of metabolic encephalopathy (brain dysfunction caused by chemical imbalances, systemic illness or organ failure other than direct physical injury), pneumonitis (inflammation of the lungs), chronic kidney disease stage three, catatonia (a complex neuropsychiatric syndrome characterized by profound abnormalities in movement, speech, and… […]