The Arbor

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF851Mar 12, 2025

  Based on record review and staff interview, the facility failed to electronically submit direct care staffing information based on payroll data to the Centers for Medicare and Medicaid (CMS) as required for quarter 3 of federal fiscal year (FY) 2024 (April 1 through June 30, 2024). This failure occurred for 1 of 4 quarters reviewed. The findings included: Review of the Payroll Based Journal (PBJ) Staffing Data report from the Certification and Survey Provider Enhanced Reports (CASPER) database revealed the facility failed to submit the required PBJ Staffing Data for the third quarter of federal FY 2024. The PBJ Staffing Data for the third quarter of the federal FY 2024 was blank. […]

• No harm, potential for more than minimal, patternF760Jan 10, 2024

  Based on Medical Director, Psychiatrist, Director of Nursing, and Consultant Pharmacist interviews, and record reviews, the facility failed to identify the need to clarify a physician's medication order for crushing Bupropion HCl SR (a sustained release antidepressant) for 1 of 6 residents reviewed for significant medication errors (Resident #65). This resulted in Resident #65 receiving 11 crushed doses of the medication over a 6-day period. Findings included: Resident #65 was admitted to the facility on [DATE] with diagnoses which included major depressive disorder, vascular dementia, and cognitive communication deficit. […]

• No harm, potential for more than minimal, isolatedF695Jan 10, 2024

  Based on record reviews, observations, and staff resident interviews, the facility failed to administer oxygen at the prescribed rate for 1 of 1 resident reviewed for respiratory care (Residents #64). The findings included: Resident #64 was admitted to the facility on [DATE] with diagnoses which included acute respiratory failure with hypoxia, vascular dementia, and hypertension. Resident #64's admission summary dated 01/05/24 indicated he had cognitive impairment and was using oxygen. A review of the physician orders for Resident #64 indicated an order dated 01/05/24 to apply 2 liters of oxygen for shortness of breath or for oxygen saturations of 90% or less as needed for shortness of breath. […]

• No harm, potential for more than minimal, isolatedF761Jan 10, 2024

  Based on observations, record review and staff interviews, the facility failed to discard expired medications in 1 of 1 medication storage room (Juniper Hall Med Storage Room). Findings included: An observation was conducted on 01/08/24 at 10:11 AM of the Juniper Hall medication storage room in the presence of Nurse #1. The observation revealed 9 unopened bottles of aspirin Enteric Coated (EC) 81mg tablets with an expiration date of 12/2023 marked on each bottle. Nurse #1 verified the bottles of aspirin were expired, removed them from the cabinet and put them in a basket to return to pharmacy. Nurse #1 confirmed the medications should not have been in the medication storage room. An interview was conducted on 01/10/24 01:49 PM with the Director of Nursing (DON). […]

• No harm, potential for more than minimal, isolatedF887Jan 10, 2024

  Based on record review and interviews with the resident, the resident's representative and staff, the facility failed to educate and offer the COVID-19 vaccine on admission and failed to maintain a resident's record of COVID-19 vaccine history. This was for 1 of 5 residents reviewed for immunizations (Resident #2). Findings included: Review of the undated facility policy revealed in part: The facility will educate and offer the COVID-19 vaccine to residents, resident representative, or staff and maintain documentation of such. The resident's medical record will include documentation of the following: a. Education to the resident or resident representative regarding the risks, benefits, and potential side effects of the COVID-19 vaccine. b. […]