Inspection Reports for
Arbor Village at Hillcrest

.161.03 Unsupervised smoking: an unsampled resident was observed smoking a cigarette while wearing an oxygen nasal cannula with their oxygen tank on their walker; the nurse instructed the resident to not smoke with oxygen on.

.305.02.b Quarterly nursing assessments: the facility nurse did not ensure residents received medications as ordered; Resident #3 missed 33 doses of Rytary between 3/2/26 and 3/12/26 due to medication unavailability (previously cited 1/23/26).

.405.03 Telephone: the facility failed to maintain medical gas storage and handling per NFPA 99 Chapter 11; an oxygen cylinder was observed unsecured in the front office entry way.

.260.06 Toxic Chemicals: the facility was not maintained in a clean, safe, and orderly manner with issues such as low kitchen ambient temperature, stained hallway carpet, missing wall paint, and strong urine odors in multiple areas.

.305.02.b Quarterly Nursing Assessments: the facility failed to ensure residents' medications were available and given as ordered, with multiple residents missing numerous doses over a period of time.

.305.03 Change in Resident Health Status: the facility nurse did not assess residents after changes in health status, with seven of ten sampled residents lacking assessments after falls or other incidents.

.310.01.g Medication Distribution System: several residents did not have their as-needed medications available, and the facility nurse was working on a system to ensure availability (previously cited 11/1/2024).

.310.02.f Discontinued and Expired Prescriptions: the facility did not have a witness present for all medication destruction, with logs showing only one signature instead of two as required (previously cited 11/1/2024).

.330.04.c.xi Resident Care Records: the facility did not document incidents that occurred, including multiple falls by Resident #9, and incident reports were not completed by staff (previously cited 11/1/2024).

.330.06.b Additional Resident Records: the facility did not develop behavior plans with interventions for all sampled residents, missing plans for refusals of medications and cares.

.404 Fire and life safety standards: the facility did not conduct one of two required semi-annual hood cleaning inspections, with only one inspection completed.

.460.01 Food Preparation: the facility did not provide flavorful food due to cold temperatures, burned food, and improper cooking, including low hot holding temperatures and burned roasted cauliflower; the administrator was aware of these concerns.

.630 Training requirements for facilities admitting residents with dementia, mental illness, developmental disability, or traumatic brain injury: all fifteen staff reviewed lacked documentation of specialized training for residents with developmental disability or traumatic brain injury.

39-3321.2.e Qualifications and Requirements of Administrator: the administrator did not complete investigations and written reports within 30 days of each accident and incident, despite multiple resident falls and a medication error.

39-3321.4 Qualifications and Requirements of Administrator: the administrator did not immediately implement corrective actions to prevent recurrence of incidents and accidents involving multiple residents.

39-3321.5 Qualifications and Requirements of Administrator: the facility did not notify licensing and certification within one business day of resident falls resulting in hospital evaluation; the nurse was unclear on reporting requirements.

.250.09 Plumbing: the temperature of hot water at plumbing fixtures was 128 degrees, exceeding the required range of 105°F to 120°F.

.330.15.b Fire and Life Safety Records: facility could not provide documentation of semi-annual vane type waterflow alarm device testing in accordance with NFPA 25, Chapter 5, Section 5.3.2.2.

.402 Fire and life safety standards for new buildings housing seventeen or more residents and multi-story buildings: annual fire alarm documentation did not list locations of devices tested; documentation was not provided for a 5-year internal investigation of fire suppression pipes or pressure gauge recalibration; monthly inspection of pressure gauges was not conducted for multiple months; semi-annual UL hood suppression system testing and cleaning inspections were not documented; annual emergency light testing was last conducted in January 2024; monthly emergency light/exit signage testing was not conducted for several months; and several emergency light units were inoperable (previously cited 12/17/2021).

.405.03 Medical Gases: two E-size oxygen cylinders were sitting directly on the floor and one on top of a file cabinet; all oxygen cylinders must be stored in a proper cart or rack and secured from falling, tipping, or damage.

.405.04 Fuel-Fired Heating: facility could not provide documentation of annual inspection for roof top furnace units; documentation was provided only for the gas fireplace.

.410 Requirements for emergency actions and fire drills: facility failed to conduct at least six fire drills annually on a bi-monthly basis with two at night during normal sleeping hours; no drills were conducted between July 2024 and April 2025, and none were conducted during night hours.

F0641: The facility failed to ensure residents' Minimum Data Set (MDS) assessments included accurate PASRR Level II screening information for 4 of 16 residents reviewed.

F0684: The facility failed to provide appropriate treatment and care for bowel and bladder incontinence for Resident #12, resulting in potential bowel obstruction due to missed medication administration.

F0700: The facility failed to assess Resident #115 for safety risks prior to placement of bed rails, creating potential for entrapment or injury.

F0760: The facility failed to ensure residents were free from significant medication errors for Residents #116 and #117, including improper insulin administration and narcotic medication errors.

F0812: The facility failed to ensure proper cleaning and sanitation of kitchen cookware, which had crusted black residue, risking foodborne illness for 64 residents.

F0641: The facility failed to ensure residents' Minimum Data Set (MDS) Assessments included correct PASRR Level II screening information for 4 of 16 residents reviewed, risking inaccurate assessments.

F0684: The facility failed to provide appropriate bowel care treatment for Resident #12, not administering Milk of Magnesia suspension as ordered when no bowel movement occurred for 3 days.

F0700: The facility failed to assess Resident #115 for safety risks prior to placement of mobility bars, lacking documentation of assessment and informed consent.

F0760: The facility failed to prevent significant medication errors for 2 residents, including incorrect insulin administration and narcotic medication errors, with incomplete documentation of monitoring and error causes.

F0812: The facility failed to ensure cleaning and sanitation of kitchen cookware, with crusted black residue observed on baking sheets and frying pans, risking foodborne illness for 64 residents.

.009.01 Criminal History and Background Check: two of ten employees did not have a Department Criminal History and Background Check, and one employee with a pending background check was allowed to work unsupervised with residents.

.215.08.d Written Response to Complaint within Thirty Days: the facility did not provide written responses to complainants within 30 days despite several complaints being made to the administrator.

.305.02.c Current Medication Orders and Treatment Orders: the facility did not have current, signed orders in four of seven sampled residents' records, including missing orders for multiple medications.

.310.01.g Medication Distribution System: the facility did not ensure all residents' as-needed and scheduled medications were available, with multiple medications missing from the medication cart and delays attributed to issues with a new pharmacy.

.310.02.f Discontinued and Expired Prescriptions: the facility did not have a witness present for all resident medication destruction nor document the method of destruction, with only one signature recorded for medications destroyed over several months.

.320.01 Use of NSA: residents' Negotiated Service Agreements did not clearly reflect needs or describe services to be provided, lacking specific instructions for transfers, catheter care, wound care, and assistance with bathing.

.330.04.c.xi Resident Care Records: the administrator did not document investigations after incidents, including unwitnessed falls resulting in injuries and hospitalizations.

.460.02.d Frequency of Meals: residents were not consistently offered snacks and fluids between meals and at bedtime, with some residents unaware of snacks available in a downstairs refrigerator.

F 0561: The facility failed to promote and facilitate Resident #4's ability to make food choices, resulting in risk of weight loss and frustration.

F 0585: The facility failed to ensure residents could file grievances anonymously and receive written responses, impacting residents' ability to voice concerns.

F 0600: The facility failed to protect residents from abuse and neglect, including failure to provide communication aids and prevent verbal abuse among residents.

F 0609: The facility failed to timely report suspected abuse and misappropriation of resident property to proper authorities.

F 0610: The facility failed to investigate allegations of abuse, neglect, and misappropriation of resident property for Residents #8 and #35.

F 0641: The facility failed to ensure Resident #12's MDS assessment accurately reflected her pressure ulcers and their staging.

F 0656: The facility failed to include Resident #35's insomnia and related medication use in his care plan.

F 0657: The facility failed to revise and update care plans as residents' needs changed and failed to include residents' representatives in care planning.

F 0676: The facility failed to provide Resident #23 with appropriate treatment and services to maintain or improve communication ability.

F 0679: The facility failed to provide an ongoing activity program designed to meet the interests and support the well-being of residents #4, #23, and #24.

F 0684: The facility failed to follow professional standards of practice for medication administration for Residents #3, #10, #17, #33, and #35, including bowel care, pain management, insulin timing, and catheter care.

F 0756: The facility failed to ensure timely action was taken to address drug regimen review irregularities identified by the consultant pharmacist for Resident #35.

F 0806: The facility failed to accommodate Resident #8's gluten-free meal preference and provide appropriate meal alternatives.

F 0812: The facility failed to properly date, label, monitor, and discard food items in the kitchen and resident food refrigerators, risking food contamination.

F 0885: The facility failed to timely notify residents' representatives and families of new COVID-19 positive cases and cumulative updates as required.

F 0921: The facility failed to ensure a safe environment by allowing use of non-UL certified power strips and unsafe placement of power strips covered by pillows in Resident #39's room.

F578: The facility failed to ensure residents' records included an Advance Directive or documentation that one was discussed or offered for 5 of 24 residents reviewed.

F580: The facility failed to notify the physician of a resident's change of condition in a timely manner, resulting in actual harm to Resident #19 who was admitted to ICU for septic shock.

F623: The facility failed to provide timely written notification of transfer or discharge to residents, representatives, and the Ombudsman for 2 residents reviewed.

F625: The facility failed to provide written bed hold notices to residents or representatives upon transfer to hospital for 2 residents reviewed.

F657: The facility failed to develop and revise care plans accurately and hold quarterly care conferences for 3 of 16 residents reviewed.

F657: The facility failed to revise care plans to reflect current toileting status for 3 residents reviewed.

F677: The facility failed to provide bathing as needed for 2 of 16 residents reviewed, resulting in potential for skin breakdown and psychosocial harm.

F684: The facility failed to obtain emergent care timely for Resident #19, who was harmed by delayed physician notification of change of condition leading to septic shock.

F695: The facility failed to provide safe and appropriate respiratory care for 2 residents, including incorrect oxygen settings and inadequate CPAP mask cleaning.

F758: The facility failed to ensure appropriate monitoring of a resident receiving antidepressant medication for insomnia, lacking documentation of sleep monitoring.