Arbor Hills Care & Rehab Center
ARBOR HILLS CARE & REHAB CENTER in FERGUSON, MO — inspection on September 16, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of the
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
265883 09/16/2025
Arbor Hills Care & Rehab Center 800 Chambers Road Ferguson, MO 63135
Review of the resident's ePOS, dated 9/15/25, showed:-An order dated 8/20/25, wound care order to
right lateral (outer) foot, apply skin prep (protective barrier wipe) during day shift and as needed when
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], 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. 26029142604488
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.