Arbor Hills Care & Rehab: Wound Care Gaps Found - MO
A September 2025 inspection of Arbor Hills Care & Rehab Center found that staff repeatedly failed to complete required wound treatments and weekly skin assessments on residents already identified as high risk for pressure ulcers, with gaps stretching across July, August, and into September. The administrator and director of nursing told inspectors they were unaware any of it had happened.
The inspection, conducted September 15 and 16, focused on two residents whose records showed a pattern of missed care that neither manager had caught.
One resident, identified in the report as Resident 6, had two active wound care orders. A physician had ordered staff to apply a protective border gauze to the resident's left hip every Monday and Thursday during the day shift, specifically to protect a bony prominence and prevent the area from opening. A separate order required staff to apply a skin prep barrier wipe to the resident's right outer foot during the day shift, and any time the dressing became soiled or dislodged. A review of the resident's treatment records for July and August 2025 showed those wound treatments were not documented as completed on multiple dates across both months.
The administrator and director of nursing, interviewed together on the afternoon of September 15, explained how the facility's treatment records work: an X or a blank space means the order was not done. If a treatment is completed, staff are supposed to mark it as such. "If not marked completed, it has not been done," they told inspectors. They said they expected nursing staff to follow physician orders as written.
They also said they had no idea Resident 6's wound treatment documentation was missing for two months. Their explanation: "Orders were most likely completed and nursing staff forgot to mark as completed." They acknowledged that if the treatments were not actually performed, it "could be detrimental to the resident's wound healing process."
The second resident, Resident 7, had a more acute risk profile. Their records showed diagnoses of Alzheimer's disease, heart failure, and moderate-protein calorie malnutrition, and they were flagged on admission as at risk for pressure ulcers with moderately impaired cognition. A physician order from January 2025 required weekly skin assessments every Tuesday during the day shift. A review of assessments from July 1 through September 11, 2025 found four Tuesdays where the assessment simply did not happen: August 6, August 13, August 27, and September 3.
Resident 6's records showed the same problem. Weekly skin assessments were not completed on August 14 or August 21.
The director of nursing, speaking separately the following morning, drew a distinction between two types of monitoring that had both broken down. A skin assessment, she explained, is a head-to-toe observation of a resident's entire skin. A wound assessment focuses only on the wound itself, and is supposed to be completed by the wound nurse during physician rounds every Thursday. The two are different documents and should be recorded separately. Both had gaps.
Her explanation for why: the wound nurse had been let go during this period. "This could be the reason the assessments were missed," she said. She told inspectors she was not aware that weekly skin and wound assessments had been missed across July, August, and September 2025.
A resident with Alzheimer's disease, heart failure, and documented malnutrition cannot flag a missed assessment. Cannot report that no one checked the skin over their bony prominences this week, or last week, or the week before. The order was there, written in January, sitting in the chart every Tuesday. The nurse was supposed to come. The record shows, on at least four occasions over nine weeks, no one did.
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.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 23, 2026 · Our methodology
ARBOR HILLS CARE & REHAB CENTER in FERGUSON, MO was cited for violations during a health inspection on September 16, 2025.
The administrator and director of nursing told inspectors they were unaware any of it had happened.
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.