Arbor Hills Care & Rehab Center

In the surveyor’s words

From the most serious findings on record at Arbor Hills Care & Rehab Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF678Jun 17, 2024

  Based on observation, interview and record review, the facility failed to provide timely basic life support, including cardiopulmonary resuscitation (CPR, a lifesaving technique that's used in emergencies in which someone's breathing or heartbeat has stopped) for one of four sampled residents, who was found by staff without a pulse (Resident #1). The resident expired. The facility also failed to have a code status for one resident (Resident #2), failed to have adequate supplies on the crash cart to allow staff to respond appropriately to an emergency situation, and failed to have a CPR certified staff member on each shift. The census was 82. The Administrator was notified on [DATE] at 3:02 P.M. of an Immediate Jeopardy (IJ) which began on [DATE]. […]

• Immediate jeopardy, isolatedF686Jul 22, 2022

  Based on observation, interview and record review, the facility failed to identify a Stage IV pressure ulcer (PU, Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color) may be present on some parts of the wound bed. Often includes undermining and tunneling) by not completing skin or wound assessments for one resident (Resident #1) and failed to treat and follow infection control measures per professional standards of care for one resident's wound (Resident #2) out of three sampled residents. The census was 43. The administrator was notified on 7/7/22 at 12:48 P.M., of an immediate jeopardy (IJ) which began on 6/18/22. The IJ was removed on 7/7/22. […]

• Immediate jeopardy, isolatedF689Jul 22, 2022

  Based on observation, interview and record review, the facility failed to provide protective oversight which prevented or minimized the risk of elopement (leaving the premises or a safe area without authorization and/or any necessary supervision to do so) for one of ten sampled residents (Resident #5) with a history of elopement. The cognitively impaired resident eloped from the facility twice, unbeknownst to staff. The facility did not implement interventions to address the resident's wandering and elopements. The census was 43. The administrator was notified on 7/21/22 at 1:15 P.M. of an immediate jeopardy (IJ) which began on 5/14/22. The IJ was removed on 7/21/22. […]

• Actual harm, isolatedF600Jan 28, 2025

  Based on observation, interview and record review, the facility failed to ensure two out of 17 sampled residents were free from abuse. Certified Nurse Aide (CNA) N yelled at Resident #6 in the dining room and pulled on the resident's arm- telling the resident he/she needed to leave and eat in their room, causing the resident to cry and be afraid. CNA G scolded Resident #7 when he/she yelled for assistance with continence care, due to not having a call light within reach. CNA G told the resident it was the last time he/she was going to care for the resident in bed, causing him/her to feel hurt and disrespected. During a later event, CNA G spoke disrespectfully towards the resident while walking past them. The census was 86. […]

• Actual harm, isolatedF686Jan 28, 2025

  Based on observation, interview and record review, the facility failed to notify the Primary Care Physician and obtain orders for pressure ulcers (ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) when they were first identified for two residents (Resident #2 and #5) out of three sampled residents. The facility also failed to administer treatments as ordered and failed to have consistent documentation of the wounds. […]