Arbor Acres United Methodist Retirement Community

In the surveyor’s words

From the most serious findings on record at Arbor Acres United Methodist Retirement Community, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF851Mar 17, 2026

  Based on record review and staff interviews, the facility failed to submit accurate payroll data on the Payroll Based Journal (PBJ) report to the Centers for Medicare and Medicaid Services (CMS) related to Registered Nurse (RN) hours and licensed nursing coverage 24-hours per day. This was reviewed for 1 of 3 Federal Fiscal quarters for sufficient nurse staffing (Quarter 1 which ranged from October 1, 2025 through December 31, 2025). Findings included:Review of the PBJ for Federal Fiscal Year Quarter 1 2025 (October 1st through December 31st) revealed system triggers for no Registered Nurse (RN) hours from October 16th 2025 through December 31st 2025, as well as no licensed nursing coverage on October 5, 2025, October 11, 2025 and October 16, 2025 through December 31, 2025. […]

• No harm, potential for more than minimal, isolatedF883Nov 9, 2022

  Based on staff interviews and record review, the facility failed to ensure the residents' medical record included pneumococcal immunization status for 2 of 5 residents (Resident #3 and #56) reviewed for pneumococcal immunization status. The findings included: A review of the facility policy (revised 9/22) Immunization Policy, read: upon admission nursing staff will document in the Immunization Record the resident's history of immunization with the pneumococcal vaccine, influenza vaccine, and COVID-19 vaccine. 1) Resident #3 was admitted to the facility on [DATE] with diagnoses that included a pelvic fracture and Alzheimer's disease. The Admission Minimum Data Set (MDS), dated [DATE], for Resident #3 was reviewed for the immunization section. […]

• No harm, potential for more than minimal, isolatedF609Jan 22, 2021

  Based on record review and resident and staff interviews, the facility failed to submit an initial resident abuse allegation to the state agency within the 2 hour time frame to for 2 allegations of abuse for 1 of 1 resident reviewed (Resident #1). The findings included: Review of the facility ' s Abuse, neglect or Sexual Assault, Protection of Residents policy included, a thorough investigation is to be completed on all reports of any type of abuse and submitted to the state for further Investigation if warranted. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had moderately impaired cognition. […]

• No harm, potential for more than minimal, isolatedF610Jan 22, 2021

  Based on record review and staff and resident interviews, the facility failed to ensure an allegation of staff to resident abuse was thoroughly investigated for 1 of 1 resident reviewed for abuse (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had moderately impaired cognition. Resident #1 required assistance with her activities of daily living and had behaviors not directed toward others 1-3 days during the look back period. A review of the facility ' s grievance log from June 2020 to December 2020 revealed a grievance submitted on 9/23/20 by Resident #1 ' s family regarding concerns about a staff member. […]