Arbor Hills Nursing Center

Inspectors wroteBased on interview and record review, the facility failed to ensure completion of the Preadmission Screening and Resident Review (PASRR) Level II evaluation (a state-required process that determines whether an individual with indicators of serious mental illness is appropriate for nursing facility placement and requires specialized mental health services) was conducted for 1 of 2 residents reviewed for PASRR (3). As a result, the required Level II evaluation was not conducted, placing Resident 3 at risk of not receiving mental health and specialized services. Resident 3 was admitted to the facility on [DATE] and then readmitted on [DATE] following a hospitalization, with diagnoses of depression and unspecified psychosis. A record review of Resident 3's PASRR Level I, dated 11/18/25, indicated Resident 3 screened positive for serious mental illness and required a Level II evaluation. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a care plan related to the care of the intravenous (IV) access site (used to deliver medicines, fluids, blood products, or nutrition into a patient's bloodstream) for one of one resident reviewed for care planning (Resident 32). This failure had the potential for increased risk of infection and complications related to IV access site.

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor and assess the intravenous (IV) access site (used to deliver medicines, fluids, blood products, or nutrition into a patient's bloodstream) for one of one resident reviewed for IV hydration (Resident 32). This failure had the potential for increased risk of infection and complications related to the IV access site.

Inspectors wroteBased on interview and record review, the facility failed to do an annual performance evaluation to verify competency for one of five certified nursing assistants (CNAs) 1. This failure had the potential to affect clients' well-being, should the staff be unable to perform duties competently.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow guidelines for the facility's drying procedure when dietary food service trays and food covers were stacked wet and not allowed to completely air dry. This failure had the potential for resident illness from contamination and bacterial growth.

Inspectors wroteBased on observations, interview and record review, the facility did not ensure infections control practices were implemented for 3 of 24 sampled residents (1, 90,122) when:a) Linens soiled with an infectious bacteria, clostridium difficile (C.Diff, infection of the intestines that causes severe diarrhea), were not contained,b) Resident 1's urinary drainage bag was positioned above the level of the bladder, andc) A trash bag with dirty and used tissues and meal tray were placed next to each other. This failure had the potential to spread infections to Residents 1, 90 and 122. a) Resident 122 was admitted to the facility on [DATE] with a diagnosis of enterocolitis due to clostridium difficile (C.Diff, infection of the intestines that causes severe diarrhea) per the facility admission record. [...]

Inspectors wroteBased on interviews and record review, the facility failed to communicate among staff members to refer a resident (Resident 1) to a psychiatrist (psych, a medical doctor who can diagnose and treat mental health conditions) or psychologist (psych, scientific discipline that studies mental states and processes and behavior in humans) who had a behavioral manifestation for one of three sampled residents reviewed for behavioral assessment. This failure had the potential for Resident 1 to become aggressive to other residents and staff.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow Resident 1's plan of care of having two-person assistance when one-person assistance provided during care. As a result, Resident 1 had a witnessed fall and sustained a traumatic hematoma of the forehead (closed wound with blood collection following the fall.

Inspectors wroteBased on observation, interviews, and record review the facility failed to identify and address a decline in range of motion (ROM - how far a joint can move or stretch) for one of two residents (Resident 27) reviewed for limited range of motion. This failure resulted in a decline Resident 27's full movement potential of his hands (such as fully closing his hands to grasp or make a fist), which made it difficult for Resident 27 to cut up food items and fully grasp utensils during meals. In addition, this failure had the potential for Resident 27 to independently complete all other activities of daily living such as grooming, dressing and personal hygiene.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food served was in a palatable (pleasant and appealing), flavorful manner that maintained the nutritional value of the menu items served. This failure had the potential to decrease residents' meal intake and contribute to weight loss. The facility census was 86.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide food that accommodates resident's preferences for one of 20 residents (Resident 72) sampled. This failure had the potential for Resident 72 to experience poor meal intake and weight loss due to foods they do not like or tolerate.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food safety and sanitation practices in dietary services were maintained according to standards of practice when: 1. Two individual sized cereal containers were found on the floor under the food shelves of the dry pantry storage. 2. One large food can item was dented. 3. Food boxes stored above the red line (18 inch) mark from the ceiling from fire sprinkler clearance. 4. Five food seasonings was previously used without an opened date. 5. One dish machine did not have a proper air gap system to adequately prevent backflow of contaminated fluids. 6. A red sanitation bucket was placed on top of a food production table. These failures had the potential to cause widespread food borne illness among all 86 residents who receive food from the kitchen.

Inspectors wroteBased on observation, interviews, and record review, the facility did not develop and implement resident specific care plans related to PTSD (PTSD-an anxiety disorder that comes from a traumatic event) and limited range of motion (ROM) for 2 of 18 residents reviewed for care planning. (Resident 27 and Resident 294) Cross reference F688 and F699 As a result, Resident 27 did not receive care to address the decline in ROM in Resident 27's hands. In addition, Resident 294 had the potential to be retraumatized.

Inspectors wroteBased on interview and record review, the facility failed to ensure a comprehensive care plan was revised and updated for one of five residents (Resident 15) reviewed for nutrition. As a result, the resident had the potential for further weight loss and health decline.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide interventions (care) according to the comprehensive care plan to prevent foot injury for one of 12 residents (Resident 42) reviewed with diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). As a result, Resident 42 was hospitalized with a left foot swelling (buildup of fluid in the tissues caused by the body's defense response to injury or infection) due to abrasions with the potential for diabetic foot complications.

Inspectors wroteBased on interview and record review the facility failed to ensure one of three resident's (Resident 86) pain medication order was clarified to include parameters (how much medication to give based on the residents stated pain level on a 0-10 scale) and frequency of administration. This failure had the potential for Resident 86 to have uncontrolled pain or to be over medicated.

Inspectors wroteBased on interview and record review, the facility failed to provide trauma-informed care (care that involves recognizing and responding to the effects of all types of traumas) to one of six sampled residents (Resident 294). This deficient practice had the potential for Resident 294 to experience re-traumatization that could lead to severe psychosocial harm and affect the resident's quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure controlled medications (medications with high abuse potential) reconciled with the medication administration record (MAR) for one of three residents (Resident 86). This failure had the potential for drug diversion (the transfer of any legally prescribed controlled substance from the individual for whom it was prescribed to another person for any illicit use).

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident 68) who received a psychotropic medication (a medication that affects brain activity associated with mental processes and behavior) had accurate monitoring for use of the medication. As a result of inaccurate monitoring, there was a potential the facility would not be able to determine if the medicine was effective or if a gradual dose reduction was beneficial which put Resident 68 at risk for receiving unnecessary psychotropic medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure outdoor facility garbage and refuse (recyclable and non-recyclable trash) was not overflowing and was secure with the dumpster's lids closed, for one of three facility dumpsters located outside the kitchen by the parking lots. This had the potential for an unsafe environment for the residents and visitors due to possible pest infestation and spread of diseases in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five residents (Resident 15) reviewed for weight loss had a completed Interdisciplinary Note and SBAR (Situation, Background, Assessment, and Recommendations) Communication Form in the resident's electronic health record (EHR). This deficient practice had the potential for Resident 15's condition not to be communicated to all healthcare providers.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to assure the full understanding of an arbitration agreement was explained to three reviewed residents (Resident 68, Resident 72, and Resident 34) when: 1. Resident 68 entered into a legal agreement when they did not have the capacity to understand what they were signing. 2. Resident 72's family member who was not the responsible party (RP) or legal representative signed the agreement without explaining to Resident 72 what the agreement was about. 3. Resident 34 was not given a copy of the signed arbitration agreement and did not fully understand that they had 30 days from the date they signed to cancel the agreement. [...]

Inspectors wroteBased on interview and record review the facility's Quality Assessment and Assurance Committee (QAA-facility group that monitors concerning trends in a facility) failed to identify areas of improvement and include in the facility's Quality Assurance Performance Improvement plan (QAPI-plan developed by QAA to help improve conditions in the facility), complaints identified in resident council meetings and by surveyors during the recertification survey concerning food served to the residents. Cross reference F804 and F806 This failure resulted in unresolved issues affecting the residents' quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure infection control procedures were followed when: 1. Certified Nursing Assistant (CAN) 11 provided care to a resident, Resident 65, who was on Enhanced Barrier Precautions (EBP-stronger infection control requirements requiring gowns and masks in addition to gloves) without wearing appropriate personal protective equipment (PPE-clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments). 2. Licensed Nurse (LN) 4 did not perform hand hygiene (the practice of cleaning hands to remove germs, dirt, or other harmful substances) consistently after removing her gloves. In addition, LN 4 wore bandages on both hands and fingertips which prevented her hands from being fully cleaned. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete an admission Comprehensive Assessment according to the Minimum Data Set (MDS-A clinical assessment tool), a Federal requirement by Centers for Medicare and Medicaid Services (CMS) for one of 16 resident's (Resident 109) reviewed during a re-visit for Resident Assessments. This failure had the potential for Resident 109 not to be completely assessed for potential health issues and for CMS to be unaware of the resident current health status or location.

Inspectors wroteBased on interview and record review, the facility failed to clarify a physician ' s order for a medication for one of two residents reviewed for plan of care (Resident 1). This failure resulted in Resident 1 not receiving the medication for 12 days, with the potential for blood clots or other complications.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide communication in the native language of one resident, Resident 1, in his native Arabic dialect when: 1. The facility had a policy for communication which was not implemented A review of the facility policy entitled Facility Services - Translation and/ or Interpretation dated 7/1/20 indicated, This facility's language access program will ensure that individuals with limited English proficiency (LEP) shall have meaningful access to information and services provided by the facility.6. Competent oral translation of vital information that is not available in written translation, and non-vital information shall be provided in a timely manner and at no cost to the resident through the following means (as available to the facility): a. A staff member who is trained and competent in the skill of interpreting; b. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to implement their infection control program when two staff members did not wear proper full personal protective equipment (PPE- consisted of gown, gloves, N-95 [highly particulate-filtering facepiece] mask, and face shield/goggles) while providing care to residents who were tested with COVID-19 (highly infectious disease), and one staff member failed to properly discard used N95 mask. These failures had the potential for contamination of supplies and spread of infection among staff and residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who required assistance with toileting, were provided assistance when requested and in a timely manner for six residents (Residents 39, 163, 162, 20, 10 and 8) and for six out of seven confidential residents (CR). This failure had the potential for residents to not have their toileting needs met and to experience a health decline or to lose the ability to control bowel and or bladder.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 19 sampled resident's (Resident 13) Physician Orders for Life-Sustaining Treatment (POSLT- end of life medical care decisions) was consistent with other physician orders, and updated after a change of condition. This failure had the potential to cause confusion amongst the healthcare providers and may have resulted in end-of-life treatments that were against Resident 13's wishes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure written care plans were revised for two of 19 residents (Resident 18 and 26). This failure had the potential for residents' current care needs to not be accurately reflected in the written plan of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four residents (Resident 110) Peripheral Intravenous Catheter (PIVC- a catheter placed into a peripheral vein for venous access to administer intravenous therapy such as medication fluids) was dated in accordance to the facility's policy. As a result, Resident 110 was put at risk for infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement safe and/or effective pharmaceutical services procedures to meet the needs of a universe of 75 residents. This occurred when three of three expired medications were available for use. This failure had the potential for residents to receive ineffective or expired medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 27) was free from significant medication errors, when Resident 27's olanzapine (an antipsychotic medication used for psychosis; a condition that affects the way the brain processes the environment) was not administered in accordance with physician's orders for eight doses. This failure had the potential for Resident 27 to experience serious adverse health outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure improperly labeled medications/biologicals were not available for use. This occurred when four of four medications were observed without open dates in accordance with current standards of practice, expiration dates when applicable, and/or resident identification tags in accordance with facility policy for a universe of 75 residents. These failures placed residents at risk for receiving ineffective or expired medications and had the potential of exposing residents to infections due to cross contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 19 resident's (Resident 161) meal preferences (food likes/dislikes) were honored. This failure had the potential for Resident 161 to not eat food that she disliked which could contribute to inadequate food intake and possible weight loss.

Inspectors wroteBased on interview and record review, the facility failed to ensure a comprehensive care plan was developed for one of three sampled residents on hospice (Resident 13). This failure had the potential to affect the coordination and continuity of care for Resident 13.