Every finding on record at Arbor Acres United Methodist Retirement Community

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. Detailed review with the Assistant Director of Nursing (ADON) of the Posted Daily Nursing Staffing Forms, Daily Staffing Sheets, and the nursing staff time detail reports for October 5th through October 31st, for each day of November 2025 and for each day of December 2025 revealed there was an RN on site for at least 8 hours every 24 hours and there was licensed nursing coverage at the facility 24 hours a day for all aforementioned dates.On 3/17/26 at 11:00 AM, a joint interview with the Administrator and the Assistant Director of Nursing (ADON) was conducted. The Administrator said she became aware of a potential PBJ issue when she learned of a 1 star staffing rating on 2/17/26. The Administrator said the 1 star rating on 2/17/26 was the first they knew they had a problem with the PBJ report submissions for Quarter 1. The ADON said she did the scheduling and staffing and she always ensured there was RN and licensed nurse coverage every day but she did not do the final PBJ submissions to CMS. The Administrator said the final submission of the PBJ staffing data was done by the facility's Controller. The Administrator said they ensured they have RN coverage and nurse coverage every day. An interview with the facility's Controller was conducted on 3/17/26 12:33 PM. The Controller confirmed he had worked at the facility for 8 years and he had been doing the PBJ submissions for that duration. The Controller said he received all nurse staffing information from the online staffing computer system used by the facility, after staffing was entered and completed by the ADON. The Controller said he put all staffing information onto a computer spreadsheet and uploaded the spreadsheet into the staffing computer system, which system then converted the data from the spreadsheet file into a different type of file acceptable to CMS. The Controller added CMS did not accept spreadsheet files for PBJ submissions so this file conversion step had to be done. The Controller said he verified all actual nursing hours from the facility's payroll system to ensure he had all necessary nursing hour coverage for submission. The Controller confirmed, I don't prorate hours down for only the 6 skilled beds specifically, I credit the RN for the actual hours required only. The Controller said he had to log into the CMS site where he submits payroll data in order to see CMS validation messages. The Controller said any validation message not only confirms the submission but also flags a potential issue. The Controller said he logs into the CMS system once every quarter when he submits the payroll data. The Controller said he did not receive CMS alerts directly to his email. The Controller said he had not reached out to CMS specifically about this issue because he did not know about it, and said the Administrator also checked for issues and kept up with it. The Controller said he was at a loss to understand what was happening because he had all the data supporting required nursing coverage and he submitted it as he had it and the first he knew there was a problem with quarter 1 was at this interview. In a follow up interview with the Administrator on 3/17/26 at 2:20 PM, the Administrator said she did not reach out to CMS after 2/17/26 because she only knew they had dropped to a 1 star staffing rating but did not know why, as they had received no specific alert messages indicating a problem. The Administrator said the facility had therefore obtained a consultant to get assistance on ascertaining the reason for the drop and how to correct the issue as soon as possible to ensure their PBJ staffing data was submitted correctly but she did not know that RN and licensed nurse coverage was the issue until this survey.

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. The pneumococcal vaccine questions had documentation that read: the vaccine was not up to date and had not been offered. A review of Resident #3's medical record revealed there was no documentation to indicate whether the Resident received or refused a pneumococcal vaccine. An interview was conducted with the Director of Nursing (DON) on 11/09/2022 at 1:39 p.m. She reviewed the medical record for Resident #3 and revealed she had been unable to locate a consent for the Pneumococcal vaccine or a record of her pneumococcal vaccination history. She stated it was her expectation that the information be obtained by the admission nurse and entered into the chart within 48 hours of admission. 2) Resident #56 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation and heart failure. The Admission MDS dated [DATE], for Resident #56 was reviewed for the immunization section. The pneumococcal vaccine questions had documentation that read: the vaccine was not up to date and had not been offered. A review of Resident #56's medical record revealed there was no documentation to indicate whether the Resident received or refused a pneumococcal vaccine. An interview was conducted with the DON on 11/09/2022 at 1:39 p.m. She reviewed the medical record for Resident #56 and revealed she had been unable to locate a consent for the Pneumococcal vaccine or a record of his pneumococcal vaccination history. She stated it was her expectation that the information be obtained by the admission nurse and entered into the chart within 48 hours of admission.

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. 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. The facility ' s grievance log from June 2020 to December 2020 was reviewed. A grievance submitted on 9/23/20 by Resident #1 ' s family members to the facility social worker revealed Resident #1 was expressing a concern about a staff member. The social worker informed the family she would talk to Resident #1 over the next three days to see what she reported to her. On 9/23/20, the social worker interviewed Resident #1. Resident #1 expressed concerns about one staff member and stated the staff member told her she was going crazy and might have to go to a mental institution and pounced on her stomach one night. A grievance submitted on 12/31/20 by Resident #1 ' s family member to the facility ' s social worker and Director of Nursing (DON) revealed an incident regarding Nurse #1 jumping all over her and trying to force a spoon in her mouth. Review of the facility reported incidents from June 2020 to December 2020 revealed no allegations submitted to the State Agency for Resident #1. On 1/15/21 at 8:15 AM, Resident #1 was interviewed. She stated most of the staff were nice to her, but there was one who yelled and screamed at her that she was busy and didn ' t do as she asked. She stated she did not know her name. There was also a heavyset nurse who shoved medication down her throat one time and jumped on her. She was unsure when the incidents occurred but did report it to the nurse. On 1/15/21 at 10:14 AM, the DON was interviewed. She stated the facility did investigate Resident #1 ' s allegations of abuse but didn ' t report the allegations to the State Agency because they did not substantiate it and, per their policy, they only reported allegations that were substantiated. On 1/15/21 at approximately 11:00 AM, the social worker was interviewed. She stated she was the one Resident #1 ' s family reported her concerns to in September and in December. She stated she reported both incidents to the DON, but she wasn ' t the one responsible for sending allegations of abuse to the State Agency. On 1/22/21 at 10:23 AM, the Administrator was interviewed. She stated when Resident #1 ' s family submitted the grievances about the staff member, the social worker interviewed Resident #1. The Administrator added the allegations were not substantiated so they did not report the allegations to the State Agency.

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. The grievance was received by the facility ' s social worker who informed the family she would visit and interview Resident #1 for three days to see what she reported. On 9/23/20, the social worker interviewed Resident #1. Resident #1 expressed concerns about one staff member and stated the staff member told her she was going crazy and might have to go to a mental institution and pounced on her stomach one night. On 1/15/21 at 8:15 AM, Resident #1 was interviewed. She stated most of the staff were nice to her, but there was one who yelled and screamed at her that she was busy and didn ' t do as she asked. She stated she did not know her name and there was a heavyset nurse that jumped on her one time. She was unsure when the incidents occurred but did report it to the nurse. A review of facility reported incidents revealed none found for Resident #1 ' s allegations of abuse. There was no evidence the facility interviewed staff or other residents regarding the allegation of abuse which was reported by Resident #1 ' s family on 9/23/20. On 1/15/21 at approximately 11:00 AM, the social worker was interviewed. She stated she interviewed Resident #1 in September 2020 after the Resident #1 ' s family submitted the grievance. She stated she visited Resident #1 on 3 consecutive days; the first day on 9/23/20, Resident #1 stated, when asked if she had any concerns about staff members, she had concerns about one staff member, sometimes. The SW asked Resident #1 to describe the staff member and Resident #1 did so. Resident #1 added the staff member told her she was going crazy and might have to go to a mental institute and she pounced on her stomach one night. The SW visited Resident #1 the following day, 9/24/20 and asked if Resident #1 had the same staff member again and Resident #1 stated she had and had no problems. On the third day, Resident #1 stated she didn ' t think she had the same staff person. The SW determined Resident #1 did have the same staff member assigned to her all three nights and who the staff member was. She concluded the allegation was unsubstantiated because Resident #1 was unclear about who was taking care of her and she did have the same staff member all three nights. She stated she spoke with the family and told her the staff member responsible was Nurse #1. The family told the SW they really liked Nurse #1 and they had a good relationship with her. The SW suggested the facility monitor the situation and the family would let her know if they had any additional concerns. On 1/22/21 at 11:44 AM, Nurse #1 was interviewed. She stated she was not interviewed in September 2020 about abuse allegations about Resident #1. On 1/22/21 at 10:23 AM, the Administrator was interviewed. She stated she was aware of the allegations submitted by Resident #1. The interview with the Administrator validated that the facility investigation consisted only of talking to the resident and the family. She added after the SW spoke with the resident and the family, they unsubstantiated the allegation due to Resident #1 ' s cognitive status.

Based on observation and staff interviews the facility failed to seal, label and date food that had been opened in 2 different kitchen areas (the main kitchen and the(NAME)Kitchen), remove a dented can from the cooking area, maintain clean cooking equipment and ensure the chemical sanitizer was at the required level in the 3-compartment sink. This was evident in 3 of 3 kitchen observations. Findings included: The initial tour of the main kitchen area on 5-29-19 at 10:00am with the dietary manager revealed the following: 1. Half a black ham shank, a log of bologna, sliced turkey, tortia flats, half a red onion, half a yellow onion, a pan of macaroni and cheese, a container of gravy, a bag of cheddar cheese, a bag of swiss cheese and a bag of pepper [NAME] cheese was noted to be in the walk-in cooler open without being dated. 2. 2 bags of frozen meatballs, a bag of imitation lobster, chicken breasts and a pan of crab cakes was noted to be in the walk-in freezer open and not dated. 3. The dry storage room was noted to have a bar of white chocolate and a bag of coconut flakes open, not sealed and not dated. 4. The cooking area had a large rack of canned goods that were ready to be used and it was noted there was a 6 pound can of pizza sauce that was dented. 5. During the observation of the kitchen equipment it was noted the convection oven had a brown sticky and slippery substance on the doors, windows and frame of the oven as well as a white substance down the left side of the oven. Both the brown and white substances were noted to have dripped onto the floor below the convection oven. During an interview with the dietary manager on 5-29-19 at 10:30am, the manager stated he had just started working at the facility and had provided training with the kitchen staff about a month ago the importance of dating items when they are opened. The manager stated he did not know why the items found had not been dated or why there was a dented can in the cooking area staff will usually put the dented cans in my office. The manager also stated he could not recall the last time the convection oven had been cleaned on the outside but stated someone must have spilt something and needs to clean it up. The initial tour of the(NAME)Kitchen area with the dietician on 5-30-19 at 11:45am revealed the following: 1. The reach in freezer was noted to have a bag of waffle sticks and approximately 15 turkey burgers that were open and not dated. During an interview with the dietician on 5-30-19 at 11:50am, the dietician stated she checked for items to be dated daily and did not know how the items in the freezer were not dated. During a return visit to the main kitchen on 5-30-19 at 12:50pm, a chemical test was performed on the sanitized water in the rinse sink with a dietary manager. The sanitized water was noted to have a cutting board in it. The dishwasher stated he had just placed it in the sink after I washed it. The chemical test for the sanitized water did not pass. The dishwasher stated the water had been in the sink since he had washed the breakfast dishes. He also denied changing the sanitized water between meals No it usually stays in there all day because it does not need to be at a certain temperature. The dietary manager had the dishwasher drain the current water and refill the sink with fresh water and sanitizer. A second chemical test was performed and was found to be within satisfactory range. The interim Administrator was interviewed on 5-30-19 at 4:22pm. The Administrator stated she expected policies and procedures to be followed and that she would review the policy and procedures with the kitchen staff and determine what needed to change or improve.

Based on record review and staff interviews the facility failed to accurately code the skin section of a minimum data set (MDS) assessment for 1 of 2 residents reviewed for skin condition (Resident #4). Findings Included: Resident #4 was admitted to the facility on [DATE] and [DIAGNOSES REDACTED]. Review of the nursing admission assessment dated [DATE] for Resident #5 revealed the resident had a surgical incision. An admission MDS assessment dated [DATE] for Resident #4 revealed section M1040 had not been checked for surgical wounds. An interview on 5/30/19 at 2:41 pm with the MDS Nurse revealed she had completed the admission MDS dated [DATE] for Resident #5. She stated she wasn ' t sure if a surgical incision would be coded as a surgical wound on the assessment. The Resident Assessment Instrument (RAI) manual was reviewed with the MDS nurse and she confirmed the definition of a surgical wound did include a surgical incision. She stated Resident #5 was receiving a treatment to a surgical wound during the look-back period for the admission assessment and she should have coded yes for surgical wound. An interview on 5/30/19 at 4:18 pm with the Administrator revealed it was here expectation that the MDS Coordinator coded the MDS assessments accurately.

Based on observations, record review, resident and staff interviews the facility failed to complete a smoking assessment on a resident prior to allowing her to smoke independently at the facility and failed to provide a fire extinguisher in the designated smoking area. This was evident for 1 of 1 resident reviewed for smoking (Resident #4). Findings Included: Resident #4 was admitted to the facility on [DATE] and [DIAGNOSES REDACTED]. An admission minimum data set ((MDS) dated [DATE] for Resident #4 revealed she used tobacco products and her cognition was intact. A care plan dated 5/25/19 for Resident #4 stated the resident had chosen to continue smoking. Interventions included to observe for safe smoking techniques that included ability to hold securely, ash without loosing the tip, extinguishing appropriately and disposing of butt. An observation on 5/25/19 at 10:51 am of Resident #4 revealed she was outside on the porch smoking a cigarette. The resident was accompanied by her private sitter. The resident had a pack of cigarettes and lighter with her. The private sitter was observed lighting a cigarette for the resident. The resident was observed holding and ashing the cigarette without difficulty. The private sitter was observed to extinguish the cigarette for the resident. An interview on 5/25/19 at 10:51 am with Resident #4 and her private sitter revealed the resident was able to smoke independently and she kept her cigarettes and lighter in her room. The sitter stated she typically came outside with the resident when she wanted to smoke, but she could come out on her own. Review of a smoking assessment dated [DATE] at 11:30 am for Resident #4 stated the assessment was to be completed for residents that wished to smoke on admission, quarterly, annually, with a significant change and if an incident of unsafe smoking was observed. The summary of evaluation indicated Resident #4 could smoke independently or with set-up. An observation on 5/30/19 at 10:56 am revealed Resident #4 was outside on the porch smoking accompanied by her private sitter. The porch which was a facility designated smoking area had a smoking blanket and an appropriate receptacle for extinguishing cigarettes. There was no fire extinguisher present in the smoking area. An interview on 5/30/19 at 10:56 am with Resident #4 revealed a nurse had completed a smoking assessment with her yesterday. The resident added she didn ' t recall this being done prior to yesterday. An interview on 5/30/19 at 11:00 am with Nursing Assistant (NA) #5 revealed she provided care for Resident #4. She stated the resident did smoke and could go out and smoke on her own whenever she wanted. NA #5 added the resident usually had a private sitter with her, but she didn ' t have to be attended by a staff member. She stated the resident kept her cigarettes in her room, but she wasn ' t sure where her lighter was kept. An interview on 5/30/19 at 11:22 am with Nurse #5 revealed she had checked the smoking porch and she did not see a fire extinguisher present. An interview on 5/30/19 at 11:24 am with the Administrator revealed the facility had done some remodeling in that area and it appeared the fire extinguisher hadn ' t been reinstalled on the smoking porch. An interview on 5/30/19 at 11:34 am with the Director of Nursing (DON) revealed the smoking assessment for Resident #5 had not been completed until 5/29/19. She stated the smoking assessment should have been done on day the resident was admitted . An interview on 5/30/19 at 4:21 pm with the Administrator revealed it was her expectation that smoking assessments would be completed on the day of admission for residents that smoked. She stated all required safety equipment should be present in designated smoking areas.