Arbors At Oregon

F 0684

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or potential for actual harm

Based on medical record review, staff interview, and review of the facility policy the facility failed to ensure wound measurements were completed for ongoing assessment of wounds. This affected one (#64) of three residents reviewed for wound care. The facility census was 66. Findings include:Review of Resident #64's medical record revealed an admission date of 12/28/23. Diagnoses 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

1. 2568913. Residents Affected - Few

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 REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/27/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Arbors at Oregon

904 Isaac Streets Drive Oregon, OH 43616

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

8:01 A.M. with CNA #558 verified she worked on 08/09/25 and was assigned to provide care for Resident #23 from 6:00 P.M. to 10:00 P.M. CNA #558 stated she arrived on the unit and began answering call lights and on her rounds identified that Resident #23's dinner tray remained in his room, untouched. CNA #23 stated she asked LPN #505 about his whereabouts and learned Resident #23 went to a local festival (within walking distance) with family. CNA #558 stated that at 10:00 P.M., her assignment changed, and she was no longer assigned to Resident #23. CNA #558 stated when Resident #23 was identified as missing, at approximately 2:00 A.M. on 08/10/25, she assisted with conducting a head count of all residents, a search of the inside and outside of the facility, and provided a photograph of Resident #23 to other residents and

the LPD when they arrived to take a report.A telephone interview on 08/13/25 at 9:07 A.M. with LPN #505 revealed she worked on 08/09/25 and was assigned to Resident #23. LPN #505 stated she received in report at shift change that Resident #23 went to a local festival with family. LPN #505 stated she did not recall if any of the staff reported Resident #23 did not eat his dinner and further stated if he was at the festival, she would have expected him to eat dinner with his family at the festival. LPN #505 stated that at approximately 2:00 A.M. on 08/10/25 she went to see if Resident #23 wanted his nighttime medications, even though they were late, and that was when she discovered he was not in his room and immediately began searching for him. LPN #505 stated she called the LPD and her supervisors to report the incident.Review of the LPD report, dated 08/10/25 at 4:48 A.M., revealed the facility filed a missing adult report for Resident #23. Further review revealed on 08/10/25 at 3:32 A.M., the facility notified the LPD that

on 08/09/25, a resident (Resident #23) with dementia had left 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, along with other residents, to attend Boomfest (local festival) and all other residents returned. 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.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/27/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Arbors at Oregon

904 Isaac Streets Drive Oregon, OH 43616

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Based on observation, staff interview, and review of the facility policy, the facility failed to ensure medication carts were secured when left unattended and further failed to appropriately dispose of oral 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.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/27/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Arbors at Oregon

904 Isaac Streets Drive Oregon, OH 43616

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Based on observation, staff interview, and review of the facility policy the facility failed to ensure foods were appropriately stored and further failed to ensure foods were discarded of past the use by dates. This had

the potential to affect all residents residing in the facility, except for 13 (#3, #5, #6, #8, #12, #13, #15, #16, #17, #19, #20, #21, and #33) residents identified by the facility as receiving no food by mouth. The facility census was 66.Findings include:Observations on 08/06/25 from 7:20 A.M. to 7:42 A.M. of the kitchen revealed the milk cooler contained a crate holding 38 individual cartons of one percent milk with a stamped expiration date of 08/05/25, two unopened thickened orange juice containers with an expiration date of February 2024, and one unopened thickened apple juice with an expiration date of July 2025. Interview on 08/06/25 at 8:22 A.M. with Dietary Manager (DM) #541 verified the expired thickened orange juice, apple juice, and one percent milk. 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

1. 1260631. Event ID:

Facility ID:

If continuation sheet