Arbors at Stow

In the surveyor’s words

From the most serious findings on record at Arbors at Stow, in the surveyor’s own words.

• Immediate jeopardy, patternF600Sep 5, 2023

  Based on observation, open and closed medical record review, hospital medical record review, Self-Reported Incident (SRI) review, facility incident report review, staff schedule review, review of the facility Abuse policy and interviews, the facility failed to ensure Resident #119 was free from an incident of resident-to-resident physical abuse. This resulted in Immediate Jeopardy, serious life-threating injuries, and subsequent death beginning on [DATE] when Resident #119, who was cognitively impaired and had a history of wandering, wandered into Resident #40's room and Resident #40, who had a history of physical aggression toward other residents when entering her room, willfully pushed Resident #119 causing Resident #119 to fall to the ground. […]

• Immediate jeopardy, isolatedF760Sep 24, 2024

  Based on closed medical record review, hospital record review, pharmacy regimen review, policy review, resident representative interview and staff interviews, the facility failed to prevent a significant medication error for Resident #150. This resulted in Immediate Jeopardy and serious life-threatening harm when Resident #150, who had a known history of hypothyroidism and myxedema coma (a life-threatening condition caused when the level of thyroid hormones become very low or hypothyroidism which causes lethargy, confusion, weakness, and difficulty breathing) in 2021 and 2022, was not ordered or administered, Synthroid, used to treat hypothyroidism from admission on 09/07/23 through 04/20/24 when the resident was transferred to the hospital due to a deterioration in the resident's… […]

• Immediate jeopardy, isolatedF600May 2, 2023

  Based on observation, record review, review of a facility self-reported incident (SRI), review of a police report, review of the facility Abuse policy, and interviews with facility staff and Police Officer #642 the facility failed to ensure Resident #5 was free from an incident of staff to resident physical abuse. This resulted in Immediate Jeopardy on 04/22/23 at approximately 4:00 P.M. when Resident #5 was attempting to take the phone from the nurse's station to dial 911 and State tested Nursing Assistant (STNA) #576 attempted to remove the phone from Resident #5's hands. Resident #5 became combative with STNA #576 and STNA #576 physically pushed Resident #5 and the resident fell to the floor and hit his head. […]

• Actual harm, isolatedF692Jan 15, 2025

  Based on observation, record review, policy review and interview the facility failed to ensure residents received adequate fluids to prevent dehydration. This affected Resident #73 and had the potential to affect 17 residents (#19, #28, #36, #49, #59, #63, #67, #70, #71, #72, #81, #84, #87, #88, #91, #99, and #109) who resided on the C pod nursing unit and 19 residents (#5, #31, #33, #41, #44, #46, #64, #66, #73, #77, #90, #92, #94, #100, #101, #108, #112, #121 and #224) who resided on the D pod nursing unit. The facility also failed to ensure diets were followed as ordered. This affected one resident (Resident #93) of five reviewed for nutrition. The facility census was 125. […]

• Actual harm, isolatedF686Nov 21, 2024

  Based on observation, record review, facility policy and procedure review and interview, the facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention and treatment program for Resident #44 to prevent the development of in-house pressure ulcers within 30 days of admission. Actual harm occurred on 11/01/24 when Resident #44, who was cognitively impaired, had a history of skin impairment, was at risk pressure ulcer development, and dependent upon staff for bed mobility, was assessed by facility staff to have deep tissue injury (DTI) (persistent non-blanchable deep red, maroon or purple discoloration due to underlying damage to soft tissue) pressure ulcers to the left heel and sacrum. The resident reported pain associated with the pressure ulcers. […]