Arbor Hills Care & Rehab: Pain Meds Withheld From Hospice Patient - MO
The resident had an order for Norco, the brand name for hydrocodone-acetaminophen, prescribed for moderate to severe pain. The medication ran out around August 14. What followed was a cascade of missed steps that left the resident without pain relief through the end of the month.
A nursing progress note from August 15 documented the shortage and recorded that the primary care physician, who was physically present in the facility that day, said he would contact the pharmacy to send a three-day supply and have his office handle the prescription order by Monday, August 18. The physician's intent was clear: keep the resident on Norco.
Nobody followed up.
Instead, on August 16, a nurse discontinued both the once-daily scheduled Norco dose and the as-needed every-four-hours dose in the medication administration record. There was no physician order authorizing either discontinuation. From August 17 through September 1, the resident received neither dose on any day.
That is 16 consecutive days without the pain medication a doctor had ordered for a person on hospice care.
The gaps in pain monitoring compounded the medication failure. The treatment administration record showed the resident was not assessed for pain during the evening shift on August 11, the night shift on August 20, the evening shift on August 21, the evening shift on August 25, and the evening shift on August 27. Five separate shifts across the month when no one documented checking whether the resident was in pain.
The director of nursing said during an interview with inspectors on September 16 that she had no idea the Norco had run out or that a nurse had then discontinued it without authorization. After inspectors walked her through the August 15 progress note, she said the physician's intention was plain: continue the resident on Norco and follow up on the prescription Monday morning. She said she would have expected nursing staff to chase down that script. She called it unacceptable for a nurse to alter or stop a medication without a physician's order.
The inspection report categorized the deficiency as causing minimal harm or potential for actual harm, affecting a few residents.
What the record shows is a hospice patient, already at the end of life and prescribed opioid pain medication for a reason, going more than two weeks without it while staff on five separate shifts did not document checking whether that person was comfortable.
The facility is located at 800 Chambers Road in Ferguson.
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.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 27, 2026 · Our methodology
ARBOR HILLS CARE & REHAB CENTER in FERGUSON, MO was cited for violations during a health inspection on September 16, 2025.
The resident had an order for Norco, the brand name for hydrocodone-acetaminophen, prescribed for moderate to severe pain.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.