Arbor Hills Care & Rehab Center

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

shift for pain monitoring. Review of the resident's progress notes showed:-Order administration note dated 8/14/25 at 12:17 P.M., Hydrocodone-Acetaminophen oral tablet 5-325 mg, give one tablet by mouth one time a day for moderate/severed pain;- Nursing progress note dated 8/15/25 at 1:11 P.M., nurse spoke with Hospice nurse regarding the Hydrocodone medication order. Hospice nurse confirmed that the order has been entered and is awaiting pharmacy delivery. Resident will continue to be monitored for comfort and safety until medication is received and administered as ordered;-Nursing progress note dated 8/15/25 at 1:55 P.M, Primary Care Physician (PCP) currently in facility made aware that resident was out of hydrocodone medication and came off hospice a couple of days ago. PCP stated he would contact the pharmacy to send a three-day supply to facility and would have his office to take care of the script order on Monday (8/18/25). Also, placed call to responsible party and made him/her aware resident's condition and Hydrocodone 5/235 mg medication was out for a few days due to hospice nurse not recording medication.

Resident has an order for Acetaminophen, which will be offered until medication arrives to facility. Review of

the Resident's MAR, dated 8/2025 and 9/2025 showed:-On 8/16/25 Norco once a day dose, scheduled for 9:00 A.M., had been discontinued with no physician order;-On 8/16/25 Norco as needed every four hours dose, had been discontinued with no physician order;-On 8/17/25 through 9/1/25 the resident did not receive his/her Norco, once a day dose;-On 8/17/25 through 9/1/25 the resident did not receive his/her Norco, as needed every four hours dose. Review of the Resident's Treatment Administration Record (TAR), dated 8/2025 and 9/2025 showed:-On 8/11/25, evening shift, the resident was not assessed for pain;-On 8/20/25, night shift, the resident was not assessed for pain;-On 8/21/25, evening shift, the resident was not assessed for pain;-On 8/25/25, evening shift, the resident was not assessed for pain;-On 8/27/25, evening shift, the resident was not assessed for pain; During an interview on 9/16/25 at 10:06 A.M., the DON said

she was not aware the resident's Norco was out and then was discontinued by a nurse without physician order. After reviewing nursing progress note dated 8/15/25, she said the physician's intention clearly states continue resident on Norco and follow up with script on Monday. She would have expected nursing staff to follow up on the resident's Norco script, and it is unacceptable for a nurse to change or discontinue medication without a physician's order. 260291426044882602553

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/16/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Arbor Hills Care & Rehab Center

800 Chambers Road Ferguson, MO 63135

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

for pressure ulcers;-Diagnoses included dementia, generalized anxiety disorder and cognitive communication deficit. Review of the resident's ePOS, dated 9/15/25, showed an order dated 10/8/24, for weekly skin assessment, on every Wednesday dayshift. Review of resident's weekly skin assessments reviewed for the dates of 7/1/25 through 9/11/25, showed weekly skin assessments not completed on 8/13/25, 8/27/25 and 9/3/25. 3. Review of Resident #3's quarterly MDS, dated [DATE REDACTED], showed:-Severe impaired cognition;-At risk for pressure ulcers;-Diagnoses included Alzheimer's, dementia and pressure ulcer to right ankle. Review of the resident's ePOS, dated 9/15/25, showed:-An order dated 8/20/25, wound care order to left hip, apply protective border gauze to left hip to protect bony prominence weekly on Monday and Thursday every dayshift to prevent area from opening;-An order last updated 8/28/25, wound care to right lateral (outer) foot, apply skin prep (protective barrier wipe) during day shift and as needed when soiled or dislodged for wound care;-No order for weekly skin assessments. Review of resident's weekly skin assessments reviewed for the dates of 7/1/25 through 9/11/25, showed weekly skin assessments not completed on 8/14/25 and 8/21/25. 4. Review of Resident #7's entry MDS, dated [DATE REDACTED], showed:-Moderately impaired cognition;-At risk for pressure ulcers;-Diagnoses included Alzheimer's disease, heart failure and moderate-protein calorie malnutrition. Review of the resident's ePOS showed an order dated 1/28/25, for weekly skin assessment perform weekly on every Tuesday dayshift for preventative.

Review of the resident's weekly skin assessments reviewed for the dates of 7/1/25 through 9/11/25, showed weekly skin assessments not completed on 8/6/25, 8/13/25, 8/27/25 and 9/3/25. 5. During an interview on 9/15/25 at 2:20 P.M., the Administrator and Director of Nursing (DON) said, an X or blank space on the TAR indicates the order was not completed. They expected nursing staff to follow physician orders as they are written. They also expected nursing staff to mark a treatment as completed on the TAR once it has been completed. If not marked completed, it has not been done. They were not aware of Resident #6's missing documentation for wound treatments for the months of July and August 2025. If the treatments were not performed, this could be detrimental to the resident's wound healing process. Orders were most likely completed and nursing staff forgot to mark as completed. During an interview on 9/16/26 at 8:43 A.M., the DON said weekly skin assessments are to be completed every week on all residents in the facility regardless of whether the resident is on hospice. The weekly skin assessments usually occur on one of the resident's shower days during the week. The weekly skin assessments are usually done by the nurse and sometimes the wound nurse. Weekly wound assessments are different than the weekly skin assessments and should be documented separately. Weekly wound assessments are to be completed by the wound nurse during the wound physician rounds on Thursdays of every week, unless the wound nurse is not available and then the nursing staff should complete wound assessment. The difference between a skin assessment and wound assessment is that the skin assessment is a head-to-toe observation of the resident skin, and the wound assessment is only focused on the wound. She was not aware weekly skin, and wound assessments were not completed during July 2025, August 2025 and September 2025. The wound nurse was let go during this time and this could be the reason the assessments were missed.

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