Arbors At Oregon
ARBORS AT OREGON in OREGON, OH — inspection on August 27, 2025.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
(#64) of three residents reviewed for wound care.
The facility census was 66.
Findings
included diabetes mellitus, portal hypertension, transient ischemic attack (TIA), congestive heart failure, end stage renal disease, and dependence on renal dialysis.
Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/15/25, revealed Resident #64 had a diabetic foot ulcer.Review of the current physician orders for August 2025 revealed Resident #64 had a treatment order for a diabetic foot ulcer to the right plantar foot to cleanse the wound with wound cleaner, apply medihoney to the wound bed, then apply adaptic (non-stick moist dressing), and cover with abdominal pad and wrap in kerlix daily.
Review of the care plan, revised July 2025, revealed Resident #64 had a diabetic foot ulcer with interventions in place to complete wound treatment as prescribed.
Review of the skin and wound assessments from 06/16/25 through 07/28/25 revealed no measurements of Resident #64's diabetic wound.
Interview on 08/13/25 at 10:44 A.M. with Registered Nurse (RN) #551 verified Resident #64's wound was not measured from 06/16/25 through 07/28/25.
Review of the facility policy titled, Wound Treatment Management, revised October 2023, revealed to promote the healing of various types of wounds, it was the policy of the facility to provide evidence-based treatments in accordance with current wound standards of practice and physician orders.
The effectiveness of treatments would be monitored through ongoing assessment of the wound and considerations for needed modifications.This deficiency represents non-compliance investigated under Complaint Number 2568913.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
365523 08/27/2025
Arbors at Oregon 904 Isaac Streets Drive Oregon, OH 43616
supervisors to report the incident.
Review of the LPD report, dated 08/10/25 at 4:48 A.M., revealed
jeopardy to resident health or A.M., the facility notified the LPD that on 08/09/25, a resident (Resident #23) with dementia had left safety the facility and did not return.
The facility staff could not confirm the last time the resident was seen at the facility and LPN #505 stated she believed Resident #23 left the facility during daylight hours,
Further review of the police supplemental report, dated 08/11/25 at 4:02 P.M., revealed Resident #23 had been located at a public bus hub and was safely returned to the facility by PD #600.
Review of the local weather conditions from 08/09/25 through 08/11/25, located at https://wunderground.com/history/monthly/us/, revealed on 08/09/25, the high temperature in the area of the facility was 90 degrees F and on 08/10/25 and 08/11/25, the high temperature reached 91 degrees F.
Review of the facility policy titled, Unsafe Wandering and Elopement Prevention, revised January 2022, revealed every effort would be made to prevent wandering and elopement episodes while maintaining the least restrictive environment for residents who were at risk for elopement.
All residents who are at risk for harm because of unsafe wandering would be assessed by the interdisciplinary care planning team.
The resident's care plan would be modified to indicate the resident was at risk for elopement episodes and staff would be informed at shift change of the modifications to the resident's care plan.This deficiency represents noncompliance investigated under Complaint Number 2588449.
365523 08/27/2025
Arbors at Oregon 904 Isaac Streets Drive Oregon, OH 43616
Based on observation, staff interview, and review of the facility policy, the facility failed to ensure
syringes used for the administration of medication.
This had the potential to affect seven (#22, #23, #28, #31, #34,#35, and #44) residents identified by the facility as being cognitively impaired, independently mobile, and resided on the C and D Halls.
The facility census was 66.
Findings include:Observation on 08/06/25 at 7:00 A.M., upon entry into the facility, revealed an unattended and unlocked medication cart near the beginning of the C and D Halls. On top of the medication cart was a clear plastic drinking cup that contained two small oral syringes (no needle attached), resembling the type of syringe that was used to administer liquid oral medications.
Small droplets of an unknown clear substance were observed on the syringes and on the inside of the drinking cup. No facility staff were observed in the area.
Continuous observation revealed at 7:05 A.M., Licensed Practical Nurse (LPN) #505 exited a resident's room, from behind a closed door, at the very end of the D Hall.
Further observation revealed the D Hall had 13 resident rooms, a shower room, a soiled linen utility room, and other office type rooms.
Interview on 08/06/25 at 7:05 A.M. with LPN #505 verified the medication cart was left unlocked and unattended. LPN #505 further confirmed the two syringes in the clear drinking cup on top of the medication cart had been used to administer morphine sulphate. LPN #505 stated this was not her medication cart and she was trying to clean up the mess left by night shift.
LPN #505 verified shift change was at 6:00 A.M. (approximately one hour prior).
Review of the facility policy titled, Medication Storage, revised January 2024, revealed it was the policy of the facility to ensure all medications housed on the premises would be stored according to the manufacturer's recommendations and ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security.
During a medication pass, medications would be under direct observation of the person administering medications or locked in the medication storage area or cart.
This deficiency was an incidental finding discovered during the complaint investigation.
365523 08/27/2025
Arbors at Oregon 904 Isaac Streets Drive Oregon, OH 43616
Observation on 08/06/25 at 8:25 A.M. of the east pantry (where the refrigerator was located to hold foods brought in by residents and/or family and visitors) revealed a bag containing food from a fast-food restaurant that was not labeled with a name and was dated 07/25/25; a container of potato salad, unlabeled with a name and dated 06/17/25; and food debris of cheese, lettuce, and croutons on the floor in front of the refrigerator.
Concurrent interview with Licensed Practical Nurse (LPN) #506 verified the findings.Interview on 08/06/25 at 8:25 A.M. with DM #541 revealed dietary staff maintained the temperature logs for the pantry refrigerator and cleaned the refrigerator maybe two to three times per month but all staff were responsible for maintaining the refrigerator.Observation on 08/06/25 at 8:30 A.M. of the west pantry revealed an unlabeled plastic grocery bag of unknown food dated 07/04/25, one plastic grocery bag of unknown food unlabeled and undated, two different restaurant boxes that contained food that were undated, and an expired carton of milk that was dated 08/03/25.
Concurrent interview with Medical Records Clerk (MRC) #561 verified the findings.
Review of the facility policy title, Food Receiving and Storage revised July 2025, revealed foods should be received and stored in a manner that complied with safe food handling practices.
All dry foods were labeled, dated, and rotated by using the first in-first out system.
All foods stored in the refrigerator would be covered, labeled and dated.
Review of the facility policy titled, Use and Storage of Food Brought in by Family or Visitor, revised July 2025, revealed family members and visitors may bring the resident food of their choosing.
All food items that were already prepared by the family or visitor must be labeled with the contents and dated.
The facility may refrigerate labeled and dated prepared items in the nourishment refrigerator.
Food must be consumed by the resident within three days and, if not consumed within three days, the food would be thrown away by the facility staff.
This deficiency represents non-compliance investigated under Complaint Number 1260630 and Complaint Number 1260631.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.