Federal inspectors found the facility failed to complete required weekly skin assessments for residents with dementia and pressure ulcers during July, August and September. The lapses affected residents with Alzheimer's disease, severe cognitive impairment and active wounds.
Resident #6 had dementia, anxiety disorder and was at risk for pressure ulcers. Doctors ordered weekly skin assessments every Wednesday. But records showed no assessments completed on August 13, August 27 or September 3.
Resident #3 suffered from Alzheimer's, dementia and a pressure ulcer on the right ankle. This resident required protective gauze applied to the left hip twice weekly and skin prep to the right foot daily. No weekly skin assessments were documented for August 14 or August 21.
The facility missed four weekly assessments for Resident #7, who had Alzheimer's disease, heart failure and malnutrition. Records showed no skin checks on August 6, August 13, August 27 or September 3, despite doctor's orders for weekly Tuesday assessments.
During interviews on September 15, the administrator and director of nursing told inspectors that an "X or blank space" on treatment records meant orders weren't completed. They expected staff to mark treatments as finished once performed.
"If not marked completed, it has not been done," they said.
The administrator acknowledged being unaware of missing documentation for wound treatments during July and August. When pressed about the consequences, the administrator said incomplete treatments "could be detrimental to the resident's wound healing process."
The director of nursing attempted to explain the failures during a follow-up interview. She said weekly skin assessments should occur on all residents regardless of hospice status, typically during shower days. Nurses or wound care specialists usually performed the head-to-toe skin observations.
She distinguished between skin assessments and wound assessments, explaining that skin checks examine the entire body while wound assessments focus only on existing injuries. The wound nurse typically completed wound assessments during Thursday physician rounds.
But the director acknowledged she wasn't aware that weekly skin and wound assessments had been missed during the three-month period. She revealed that the wound nurse had been "let go during this time" and suggested this staffing change could explain the missing assessments.
The facility's own treatment records contradicted any suggestion that care was provided but simply not documented. The administrator and director of nursing both confirmed their documentation system: completed treatments get marked, incomplete ones remain blank.
For Resident #3, the stakes were particularly high. This resident already had an active pressure ulcer on the right ankle and required twice-weekly protective dressing changes to prevent another wound from opening on the left hip. The resident also needed daily skin prep applications to the right foot for wound care.
Missing four skin assessments over two months meant potential problems could go undetected for weeks at a time. Federal research shows that residents with cognitive impairment face higher risks of developing pressure ulcers, making regular monitoring critical.
The documentation gaps occurred during a period of staffing turnover. The wound care nurse's departure left regular nursing staff responsible for specialized assessments they may not have been trained to perform consistently.
Resident #7's case highlighted the compounding risks. This resident had Alzheimer's disease and moderate malnutrition, conditions that can slow healing and increase skin breakdown risks. Missing four weekly assessments over ten weeks meant extended periods without professional skin monitoring.
The administrator's admission that treatments "most likely" occurred but staff "forgot to mark as completed" contradicted the facility's own documentation standards. Both administrators had clearly stated that unmarked treatments meant undone care.
The inspection revealed a facility struggling to maintain basic preventive care documentation during a period of staff turnover. For residents with dementia who cannot advocate for themselves, consistent skin monitoring represents a critical safety net against pressure ulcer development and wound complications.
The missed assessments occurred despite clear physician orders and the facility's stated expectation that staff follow written treatment plans. The three-month pattern suggested systemic problems rather than isolated oversights.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Arbor Hills Care & Rehab Center from 2025-09-16 including all violations, facility responses, and corrective action plans.
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