Arbor Hills Rehabilitation and Healthcare Center

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 (Residents #8 and #18) of 17 residents reviewed for infection control. The facility failed to ensure CNA I and CNA N used the required PPE for Resident #8, who was on enhanced barrier precautions during incontinent care on [DATE]. The facility failed to label and store Resident #18's personal care items at sink area of a semi-private shared room. CNA I changed gloves during incontinent care without performing hand hygiene. These failures placed residents, staff and visitors at risk for cross contamination, unwanted infections, and decease in quality of life. 1. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one of three residents (Resident #18) reviewed for quality of care. The facility failed to ensure Resident #18 was accurately Care Planned as a smoker. This failure placed residents at risk for not receiving appropriate care and interventions to meet their needs. Record review of Resident #18's Facesheet, dated 08/15/2025, reflected the resident was a [AGE] year-old male with an admission date of 07/02/2025 and diagnoses which included but not limited to: bipolar disorder, Parkinsonism, recurring depression disorder, cognitive communication deficit, and lack of coordination. Record review of Resident #18's MDS dated [DATE] reflected his BIMS was 15, which indicated intact cognition. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who are unable to carry out activities of daily living receives the necessary services 1 of 3 residents (Resident #8) reviewed for ADLs.1. The facility failed to ensure CNA I cleaned Resident #8 properly during incontinent care on 8/14/25. These failures could place residents at risk for pain, infection and hospitalization. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain medical records on each resident that are complete and accurately documented for 1 (Resident #68) of 5 residents reviewed for accurate records.-The facility failed to document neuro checks neurological assessments (neurochecks) according to facility policy when Resident #68 was found on the floor in her room on 07/30/2025. Failure to not accurately document residents' health status in real time could put them at risk of changes in condition not being detected after an unwitnessed fall or injury. Record review of Resident #68's face sheet dated 08/15/2025, indicated she was a [AGE] year-old female originally admitted on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living (ADL's) received the necessary services to maintain nutrition, grooming and personal and oral hygiene for 3 of 11 residents (Resident #170, Resident #6, and Resident #223) reviewed for ADLs. 1. The facility did not provide Resident #170 with showers after the resident reported asking for a shower on his scheduled shower day of 06/11/2024. 2. The facility failed to ensure Resident #6 was provided grooming (toenails care). 3. The facility failed to ensure Resident #223 was provided grooming (shower). These failures could place residents who were dependent on staff for showering at risk of not receiving care and services to meet their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services to prevent complications for 1 of 8 residents (Resident# 1) reviewed for enteral nutrition, in that: -CNA S lowered the head of bed on Resident #1 while the resident was receiving continuous gastrostomy feedings on 06/13/24. -CNA T entered Resident #1's room on 06/13/24 while the resident was receiving continuous gastrostomy feedings with the head of bed flat and did not elevate the head of bed instead, left the room to get the nurse. -LVN U flushed Resident #1's gastrostomy tube by pushing the water in instead of letting the water go in by gravity. The failures placed resident at risk for unwanted abdominal discomfort, aspiration (when food, drink, or foreign objects are breathed into the lungs) pneumonia, hospitalization, and decrease in quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care and services, including breathing treatment administration was provided such care, consistent with professional standards of practice for 1 of 8 residents (Resident #1) reviewed for respiratory therapy in that: The facility failed to change Resident #1's respiratory equipment in a timely manner. This failure could place residents at risk for respiratory infections.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 11% based on 4 errors out of 34 opportunities, which involved 2 of 7 residents (Resident #223, and Resident #1) reviewed for medication errors. 1-LVN U left a substantial amount of albuterol sulfate inhalation solution 0.083% (2.5MG/3ML) in the mask chamber after the medication was administrated through a nebulizer machine to Resident #223. 2-LVN U poured away a substantial amount of miralax power17mg, and poured away all pink medication (metoprolol 50 mg) during medication administration through g tube. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure that drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles for 1 Station 1 nurse's cart) of 2 nurse medication cart and 1(Station 1 medication room) of 2 medication room reviewed for medications. -1 of 2 nurse medication cart (station 1) had 1 expired medication, breathing treatment opened and not dated opened breathing treatments with expired open dates. -1 of 2 medication rooms (medication room) had breathing treatments stored in a temperature above manufacturer's required temperature. These failures could affect residents, placing them at risk for altered effectiveness of the medication and worsening of the resident's symptoms, requiring medical intervention.

Inspectors wroteBased on observation, interview and record review, the facility failed to care for resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 of 8 residents (Resident 63), reviewed for resident rights, in that: -LVN U was standing while feeding Resident #63 her lunch in the Dining Room. This failure placed residents at risk for feeling disrespected and diminished quality of life. Record review of Resident #63's face sheet dated 06/13/24 revealed a [AGE] year-old female admitted to the NF on 11/01/2023 and readmitted on [DATE]. Resident #63's diagnoses included the following; [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one of three residents (Resident #7) reviewed for quality of care. The facility failed to ensure Resident #7 was assessed by LVN A for injuries after her fall on 06/11/2024. This failure placed residents at risk for potential injuries, pain, and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 residents (Resident #222) reviewed for incontinent care. 1. The facility failed to ensure CNA Z and CNA E followed proper Foley bag placement during Hoyer lift transfer on Resident #222. This failure could place residents at risk for pain, infection, injury, and hospitalization.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an Infection Control Program designed to help prevent the development and transmission of disease and infection for 1 of 8 residents (Resident #120) reviewed for infection control during care in that: -The NF failed to label and store resident personal care items that were in the bathroom of a semi-private room. -The NF failed to keep Resident #120's Foley catheter off the floor. These failures placed residents at risk for cross contamination, infections, and decease in quality of life.