Arbor Hills Rehabilitation and Healthcare Center

In the surveyor’s words

From the most serious findings on record at Arbor Hills Rehabilitation and Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Jan 10, 2022

  Based on observation, interview, and record review, the facility failed to identify and provide needed care and services that are resident centered, in accordance with the resident's preferences, goals for care and professional standards of practice for one of five residents reviewed for quality of care. (CR #1) The facility failed to ensure CR# 1 was monitored for choking while she ate in her room on [DATE] as outlined in her plan of care. The facility failed to ensure CR# 1 received ordered mechanically altered texture diet but instead was served regular diet -Chicken nugget and green beans for dinner which she ate unsupervised in her room. […]

• Immediate jeopardy, isolatedF805Jan 10, 2022

  Based on observation, interview and record review, the facility failed to ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs for 1 of 20 residents (CR#1) reviewed for food form. The facility failed to ensure CR# 1 received ordered mechanically altered texture diet but instead was served regular diet (Chicken nugget and green beans) for dinner on [DATE] which she ate unsupervised in her room. As a result, CR#1 was heard coughing a few minutes later, was found unresponsive few minutes later with signs of vomiting and some food in her mouth. […]

• No harm, potential for more than minimal, patternF880Aug 15, 2025

  Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 (Residents #8 and #18) of 17 residents reviewed for infection control. The facility failed to ensure CNA I and CNA N used the required PPE for Resident #8, who was on enhanced barrier precautions during incontinent care on [DATE].The facility failed to label and store Resident #18's personal care items at sink area of a semi-private shared room.CNA I changed gloves during incontinent care without performing hand hygiene.These failures placed residents, staff and visitors at risk for cross contamination,… […]

• No harm, potential for more than minimal, patternF677Jun 13, 2024

  Based on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living (ADL's) received the necessary services to maintain nutrition, grooming and personal and oral hygiene for 3 of 11 residents (Resident #170, Resident #6, and Resident #223) reviewed for ADLs. 1. The facility did not provide Resident #170 with showers after the resident reported asking for a shower on his scheduled shower day of 06/11/2024. 2. The facility failed to ensure Resident #6 was provided grooming (toenails care). 3. […]

• No harm, potential for more than minimal, patternF693Jun 13, 2024

  Based on observation, interview, and record review, the facility failed to provide care and services to prevent complications for 1 of 8 residents (Resident# 1) reviewed for enteral nutrition, in that: -CNA S lowered the head of bed on Resident #1 while the resident was receiving continuous gastrostomy feedings on 06/13/24. -CNA T entered Resident #1's room on 06/13/24 while the resident was receiving continuous gastrostomy feedings with the head of bed flat and did not elevate the head of bed instead, left the room to get the nurse. -LVN U flushed Resident #1's gastrostomy tube by pushing the water in instead of letting the water go in by gravity. […]