Arbors at Delaware

Inspectors wroteBased on observation, staff interviews and policy review, the facility failed to ensure safe and sanitary storage of food items. The facility also failed to ensure proper hand hygiene during food service. This had the potential to affect all facility residents except two residents (#24 and #80) who the facility identified to be NPO (had no oral intake). The facility census was 90.

Inspectors wroteBased on observations, interview, record review, review of facility audits, and review of facility policy, the facility failed to ensure resident room temperatures were maintained at a comfortable level above at least 71 degrees Fahrenheit (F). This affected five Residents (#18, #60, #71, #74, and #102). Additionally, the facility failed to maintain a clean environment of common area furniture in the memory care unit affecting 19 Residents (#11, #15, #28, #29, #32, #40, #45, #47, #48, #50, #56, #60, #66, #69, #71, #72, #79, #82, and #83) who resided in memory care. Facility census was 90.

Inspectors wroteBased on observations, interviews, record review, review of activities calendars, and policy review, the facility failed to ensure a variety of activities of interest were planned throughout the day including weekends as well as age-appropriate activities. This affected one resident (#5) of one reviewed for activities and had the potential to affect 19 residents in memory care (#11, #15, #28, #29, #32, #40, #45, #47, #48, #50, #56, #60, #66, #69, #71, #72, #79, #82, and #83).

Inspectors wroteBased on staff interview, and review of personnel files, the facility failed to ensure an appropriate staff member was employed who was certified and had adequate experience to plan and execute activities in the facility. This had potential to affect all residents except the 19 residents residing in the memory care unit (#11, #15, #28, #29, #32, #40, #45, #47, #48, #50, #56, #60, #66, #69, #71, #72, #79, #82, and #83). Facility census was 90.

Inspectors wroteBased on observation, staff interviews, record review and policy review, the facility failed to ensure puree food was made to the proper consistency by following facility recipes. The facility also failed to maintain the nutritional value of the food item. This affected four Residents (#22, #30, #69 and #82) identified by the facility as receiving puree diets. The facility census was 90.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure that resident dignity was maintained for Resident #80. This affected one resident (#80) of two residents reviewed for dignity. The facility census was 90. Findings Include: Review of Resident #80's medical record revealed an admission date of 07/09/25. Further review revealed the following medical diagnoses: aphasia, hemiplegia and hemiparesis, chronic respiratory failure, hyperlipidemia, nontraumatic intracranial hemorrhage, other seizures, communication deficits, dysphagia, unspecified mood disorder, muscle weakness, anxiety disorder, anemia, and encephalopathy. Review of Resident #80's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) was not conducted due to the resident never/rarely being understood. Observation on 01/20/26 at 10:41 A.M. [...]

Inspectors wroteBased on medical record review, review of hospital records, interview, review of the facility transfer and discharge log, and review of facility policy, the facility failed to ensure a safe discharge when on 11/29/25, Resident #99 was sent to the hospital and on 12/01/25 the facility was aware the resident would be receiving an involuntary discharge, but his representative was not made aware until 12/16/25 when the facility dropped off Resident #99 at the residents representatives home. This affected one (#99) of three residents reviewed for discharge. The facility census was 90. Findings Include: Review of medical record for Resident #99 revealed an admission date of 07/11/25 with diagnoses including dementia, diabetes mellitus type two, and encephalopathy. The record indicated the residents wife was his responsible party. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the Preadmission and Resident Review (PASRR) was completed accurately. This affected one resident (#3) of two reviewed for PASRR. Facility census was 90.

Inspectors wroteBased on interviews, record review, and review of facility policy, the facility failed to ensure Resident #76 had a care plan to address post-traumatic stress disorder triggers. This affected one resident (#76) of 24 residents reviewed in the sample. Census was 90.

Inspectors wroteBased on observation, record review, interview, and policy review, the facility failed to ensure dependent residents received assistance with activities of daily living (ADL). This affected one (Resident #72) of five residents reviewed for ADL assistance. The facility census was 90.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure appropriate care and services to treat a residents new non-pressure related wounds. This deficient practice affected one resident (#2) of one resident reviewed for non-pressure related wounds. The facility census was 90.

Inspectors wroteBased on interview, observation, record review, and review of the restorative nursing program, the facility failed to ensure a restorative splinting program was implemented. This affected one (Resident #49) out of one resident reviewed for mobility and limited range of motion. The facility identified 10 residents as receiving range of motion programming. The facility census is 90.

Inspectors wroteBased on interview, record review, observation, and policy review, the facility failed to ensure catheters were maintained in a sanitary manner for Resident #7. This affected one resident (Resident #7) out of three residents reviewed for bladder and bowel services. The facility census was 90.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to implement dietary orders for Resident #75. This affected one resident (Resident #75) out of five residents reviewed for nutrition services. The facility census was 90.

Inspectors wroteBased on record reviews and staff interviews, the facility failed to ensure residents with a history of trauma received trauma-informed care by identifying and addressing trauma-related triggers. This affected three residents (Resident #49, Resident #76, and Resident #99) out of twelve residents identified with post-traumatic stress disorder. The facility census was 90.

Inspectors wroteBased on resident interview, staff interview, and record review, the facility failed to ensure that a binding arbitration agreement was explained to the resident in a form and manner the resident understood and failed to ensure the resident acknowledged understanding of the agreement prior to execution. This deficient practice affected one resident (Resident #81) out of twenty-four residents reviewed, with a facility census of 90.

Inspectors wroteBased on record review, observation, staff interview and facility policy review, the facility failed to ensure Enhanced Barrier Precautions (EBP) were implemented in accordance with national infection control standards for a resident with risk factors indicating the need for such precautions. Specifically, the facility failed to post required signage or provide visual cues to alert staff to use EBP during high-contact care activities for Resident #6, despite the resident having open, draining skin lesions and other conditions placing the resident at increased risk for transmission of infectious organisms. This affected one resident (#6) of one resident reviewed for EBP. [...]

Inspectors wroteBased on record review, observation, resident interview, staff interview, and policy review, the facility failed to maintain a clean, safe, comfortable homelike environment. This affected 25 (#5, #6, #8, #13, #14, #15, #16, #19, #22, #23, #25 #28, #29, #30, #34, #46, #50, #54, #55, #56, #70, #72, #82, #83 and #91) residents residing on hall 300 and 16 (#2, #12, #20, #21, #24, #31, #32, #37, #39, #40, #42, #48, #62, #71, #76 and #78) residents residing on the on the Memory Care Unit. The facility census was 89. Observation during the initial tour on 11/24/25 from 8:51 A.M. to 9:07 A.M. revealed a black substance on the ceiling in the shower room on the hall 300. [...]

Inspectors wroteBased on record review, observation, resident interview, staff interview, and policy review, the facility failed to maintain a clean, safe, comfortable homelike environment. This affected one (#68) of three residents reviewed for environment. The facility census was 89. Review of Resident #68 ' s medical record revealed an admission date of 12/28/22. Diagnoses included heart failure, type two diabetes mellitus, hypertension, and bipolar disorder. Review of Resident #68 ' s quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #68 had intact cognition. Observation on 11/24/25 at 11:44 A.M. of Resident #68 ' s room revealed an air conditioner that was not functioning, a large puddle of water on the bathroom floor under the sink, and a hole in the tile near the bathroom door. Interview on 11/24/25 at 11:45 A.M. [...]

Inspectors wroteBased on record review, pharmacy delivery slips, pharmacy return slips, staff interviews, and policy review the facility failed to ensure residents were discharged with adequate amount of medications. This affected one (#93) of two residents reviewed for discharge. The facility census was 89. Review of medical record for Resident #93 revealed an admission date of 01/04/25 and discharge date of 02/27/25 with diagnoses including but not limited to epilepsy intractable with status epilepticus, severe intellectual disabilities, post-traumatic stress disorder, bipolar disorder, and conversion disorder with seizures or convulsions. Review of discharge Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact with no behaviors. Review of care plan dated 01/05/25 revealed the resident plans to discharge to home with family after completion of stay. [...]

Inspectors wroteBased on record review, staff interview, and policy review the facility failed to ensure a complete and thorough resident assessment was completed for a resident with a change in condition. This affected one (#92) of five residents reviewed for change in condition. The facility census was 89. Review of medical record for Resident #92 revealed an admission date of 03/29/25 and discharge date of 04/23/25 with diagnoses including but not limited to wedge compression fracture of second lumbar vertebra, nondisplaced fracture of lateral end of right clavicle, rotator cuff tear or rupture of right shoulder, Alzheimer's disease, and age-related osteoporosis with current pathological fracture vertebrae. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderately impaired cognition with no behaviors. [...]

Inspectors wroteBased on record review, review of a Self-Reported Incident (SRI), review of facility video, staff and resident interview, and facility policy review, the facility failed to ensure Resident #10 was free from abuse from Resident #20. This resulted in Actual Harm on 10/18/25 at 2:34 P.M. when Resident #20 walked up to Resident #10 in the hallway. Resident #20 pushed Resident #10, resulting in Resident #10 suffering nondisplaced fractures of the left superior and inferior pubic rami. This affected one, (Resident #10) of three residents reviewed for abuse. The facility census was 90. Findings Include: Review of the medical record for Resident #10 revealed an admission date of 08/27/25. Diagnoses included vascular dementia with behavior problems, encephalopathy, cerebrovascular accident (CVA), Type II Diabetes and depression. She resided in the secured memory care unit. [...]

Inspectors wroteBased on medical record review, review of facility investigation, review of personnel files, review of inservice logs, resident and family interiews, and staff interview, the facility failed to ensure residents were treated with dignity and respect. This affected two (#83 and #75) residents of six residents reviewed for respect and dignity. The facility census was 84.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to notify a physician of change in resident's status. This affected one (#88) out of three residents reviewed for catheter care. The facility census was 85.

Inspectors wroteBased on observations, staff and resident interviews, and policy review, the facility failed to maintain a clean and homelike environment. This affected three (#24, #4, and #8) of three residents reviewed for the physical environment. The facility census was 85.

Inspectors wroteBased on medical record review, staff interviews, Hospice nurse interview, and review of the Resident Assessment Instrument (RAI) manual 3.0, the facility failed to ensure care plan was updated to include accurate Activities of Daily Living (ADL) information. This affected one (#88) out of the three residents reviewed for feeding assistance. The facility census was 85.

Inspectors wroteBased on medical record review, staff interviews, Hospice nurse interview, and policy review, the facility failed to ensure activity of daily living (ADL) assistance was provided for dependent resident. This affected one (#88) out of the three residents reviewed for feeding assistance. The facility census was 85.

Inspectors wroteBased on medical record review, staff interviews, Hospice nurse interview, and policy review, the facility failed to properly assess and treat a resident's skin breakdown. This affected one (#88) out of three residents reviewed for skin breakdown. The facility census was 85.

Inspectors wroteBased on medical record reviews, staff interviews, and policy review, the facility failed to ensure residents were from significant med errors. This affected two (#20 and #85) residents out of the six residents reviewed for medication administration. The facility census was 85.

Inspectors wroteBased on medical record review, staff interview, Hospice nurse interview, and policy review, the facility failed to ensure coordination of care and services with the Hospice provider. This affected one (#88) out of the three residents reviewed for catheter care. The facility census was 85.

Inspectors wroteBased on observations, staff and resident interviews, and policy review, the facility failed to maintain pest control in hallways and resident rooms. This affected two (#4 and #24) of three residents reviewed for the effective pest control. The facility census was 85.

Inspectors wroteBased on observations, staff interviews, resident interview, family interview, medical record reviews, and policy reviews, the facility failed to ensure residents were free from significant medication errors. This affected two (#85 and #14) of six residents reviewed for medication administration. The facility census was 86.

Inspectors wroteBased on observation, record review, resident and staff interview, and policy review, the facility failed to provide comprehensive urostomy care for one (#40) of four residents reviewed for indwelling urinary drainage device. The facility identified one resident (#40) who had a urostomy used in his care. The facility census was 85. Findings Include: Review of the medical record for Resident # 40, revealed the resident was admitted to the facility on [DATE]. Diagnoses included unspecified hydronephrosis, perinephric abscess and diabetes mellitus type two. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #40 was cognitively intact and was to have an indwelling catheter for his urinary elimination. Observation of Resident #40 on 06/24/24 at 2:40 P.M. [...]

Inspectors wroteBased on record review, observation, staff interview, and policy review the facility failed to ensure residents were free from significant medication errors. This affected one (#29) of the six residents observed for medication administration. The facility census was 85. Findings Include: Review of the medical record for Resident #29's revealed the resident was admitted on [DATE]. Diagnoses included diabetes mellitus, dementia, cerebrovascular accident (CVA/stroke) and coronary artery disease. Review of the Minimum Data Set (MDS) assessment dated [DATE], Revealed Resident #29 was cognitively intact. Review of a physician's order dated [DATE], revealed Resident #29 was ordered to receive Regular Insulin (short acting insulin) 100 units/milliliter (mL) per sliding scale subcutaneously before meals and at bedtime for diabetes. [...]

Inspectors wroteBased on observations, medical record review, activity calendar review, resident interview, family interview, staff interview, and review of policy, the facility failed to ensure residents were provided with activities to meet the needs and interests of the residents. This affected five (#100, #300, #400, #500, and #600) of five residents reviewed for activities. The census was 82.

Inspectors wroteBased on observations, resident interviews, and staff interviews, the facility failed to provide an environment free from potential hazards of unsecured chemicals and sharps in a construction area. This had potential to affect 21 confused and independently mobile resident (#112, #113, #114, #300, #115, #116, #117, #118, #119, #120, #121, #122, #124, #125, #126, #127, #128, #129, #130, #131 and #400) of 23 residents who resided on the memory care unit. The facility census was 82.

Inspectors wroteBased on record review, resident interview, staff interview, and policy review, the facility failed to ensure resident complaints and concerns were documented and followed up on in a timely manner. This affected two (Residents #103 and #222) of three residents reviewed for follow up on resident concerns. The census was 82.

Inspectors wroteBased on record review, resident interview, staff interviews, and interview with Oncology Social Services staff, the facility failed to ensure a resident was provided assistance to and arrange transportation to medical appointments, when the resident required supplement oxygen, resulting in the resident missing physician appointments a medical treatments and not having supplemental oxygen available. This affected one (#200) of three residents reviewed for assistance with outside medical services. The facility census was 82.

Inspectors wroteBased on observation, resident interview, staff interview and review of facility policy, the facility failed to ensure foods were maintained at preferred temperatures during serving. This had the potential to affect all 79 residents of the facility. The facility census was 79.

Inspectors wroteBased on observation and staff interview, the facility failed to maintain the activity room refrigerator and freezer in a clean and sanitary manner. This had the potential to affect all 79 residents of the facility. The facility census was 79.

Inspectors wroteBased on medical record review and staff interview, the facility failed to complete thorough root cause analysis following falls. This affected three (Residents #16, #19, and #181) of five residents reviewed for falls. Additionally, the facility failed to have fall interventions in place as ordered. This affected three (Residents #16, #181, and #37) of five residents reviewed for falls. The facility census was 79.

Inspectors wroteBased on medical record review and staff interviews, the facility failed to ensure pharmacy recommendations approved by the Certified Nurse Practitioner (CNP) were acted upon in a timely manner. This affected two (Residents #19 and #37) of five reviewed for unnecessary medications. The facility census was 79.

Inspectors wroteBased on medication administration observations, staff interviews, and review of facility policy, the facility failed to ensure medications were administered as ordered resulting in three medication errors out of 26 opportunities or a 11.5 percent (%) medication error rate. This affected three (Resident #18, #82, #79) of five residents observed for medication administration. The facility census was 79.

Inspectors wroteBased on medical record review, facility policy, and staff interviews, the facility failed to notify a resident's representative of weight loss and start of a medication. This affected one (#25) of three residents reviewed for notification of change in condition. The facility census 79.

Inspectors wroteBased on observations, medical record reviews, and staff interviews, the facility failed to ensure a resident had geri-sleeves applied as ordered. This affected one (Resident #2) of one resident observed for use of Geri-sleeves. Additionally, the facility failed to complete daily weights as ordered. This affected one (Resident #9) of one resident reviewed for weight monitoring. The facility census was 79.

Inspectors wroteBased on medical record review and staff interview, the facility failed to gain clarification on a medication order. This affected one (Resident #235) of five residents observed for medication administration. The facility census was 79.

Inspectors wroteBased on medical record review, observation, staff interview, and review of policy, the facility failed to ensure medications were appropriately stored and secured. This affected one (Resident #14) of one observed with medications unattended at the bedside. The facility census was 79.

Inspectors wroteBased on medical record review, staff interview and review of facility policy, the facility failed to obtain physician ordered laboratory (lab) testing for one (#19) of five residents reviewed for unnecessary medications. The facility census was 79.

Inspectors wroteBased on medical record review, staff interview, and review of facility policy, the facility failed to ensure timely physician notification of laboratory (lab) results for Resident #33, which required a change in treatment, and critical lab results for Resident #37. This affected two (#33 and #37) of five residents reviewed for unnecessary medications. The facility census was 79.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure the 300-hall central bath, 400-hall central bath, common areas, and resident rooms were maintained in a clean and safe manner. This affected Resident #60 and had the potential to affect all 84 residents. The facility census was 84.

Inspectors wroteBased on medical record review, staff and resident interviews, facility assessment review, licensure staffing tool, and facility policy review, the facility failed to ensure sufficient staffing was in place to meet resident needs. This had the potential to affect all 73 residents that resided in the facility.

Inspectors wroteBased on medical record review, observation, staff interview and facility policy and procedure, the facility failed to appropriately store and dispense medications. This affected eight residents (Resident #11, #12, #30, #31, #43, #47, #57, and #523) of eight residents reviewed for medication storage.

Inspectors wroteBased on observation, staff interviews, and policy and procedure review, the facility failed to prepare pureed foods per the recipe. This had the potential to affect seven residents (Resident #25, Resident #34, Resident #41, Resident #58, Resident #60, Resident #66,and Resident #69) out of seven resident who were on a pureed diet.

Inspectors wroteBased on observation, resident and staff interviews, and facility policy review, the facility failed to ensure Resident #43's dignity was maintained at all times. This affected one resident (Resident #43) of one resident reviewed for respect and dignity.

Inspectors wroteBased on record review, staff and resident interviews, and facility policy review, the facility failed to ensure Resident #16 received showers per his preference. This affected one resident (Resident #16) of three residents reviewed for showers.

Inspectors wroteBased on review of facility Self-Reported Incidents, review of facility investigations, staff interviews, and facility policy review, the facility failed to report potential crimes to law enforcement. This affected four residents (Residents #75, #76, #77, and #78) of 20 residents reviewed for allegations of abuse, neglect, misappropriation, and exploitation. Findings Include: Review of facility Self-Reported Incident (SRI) history revealed the following: Review of SRI number 189760, dated 03/09/20, revealed Resident #75 family made an allegation that he had $100 taken from his wallet while it was in the facility. Review of SRI number 173478, dated 05/14/19, revealed Resident #76 made a sexual abuse allegation against a facility staff member. Review of SRI number 196649, dated 09/10/20, revealed Resident #77 made a sexual abuse allegation against an unknown male while in the facility. [...]

Inspectors wroteBased on medical record review and staff interview, the facility failed to provide Resident #73 a bed hold notification. This affected one resident (Resident #73) of two residents reviewed for bed hold notifications when discharged to the hospital.

Inspectors wroteBased on medical record review and staff interviews, the facility failed to provide Resident #130 assistance with transportation when discharging to home, when they were leaving against medical advice (AMA). This affected one resident (Resident #130) of four residents reviewed for discharge.

Inspectors wroteBased on medical record review, interview, and policy and procedures review, the facility failed to provide Resident #19 constipation treatment when not having bowel movements. This affected one resident (Resident #19) out of one resident reviewed for constipation.

Inspectors wroteBased on medical record review, staff interview, and review of facility policy, the facility failed to ensure physician orders were obtained to provide appropriate care and services to manage Resident #42's Intravenous (IV) Peripherally Inserted Central Catheter (PICC). This affected one resident (Resident #42) of two residents reviewed for management of PICC lines. Findings Include: Review of Resident #42's medical record revealed an admission date of 01/03/19 with diagnoses including urinary tract infection (UTI), obstructive and reflux uropathy, urethral fistula, chronic kidney disease. [...]

Inspectors wroteBased on interview, medical record review, and facility policy review of the facility policy, the facility failed to ensure Resident #30 received lunch on scheduled dialysis treatment days. The affected one resident (Resident #30) out of one resident reviewed for dialysis.

Inspectors wroteBased on medical record review, observation, staff interview, and facility policy and procedure, the facility failed to administer medications routinely. This affected one resident (Resident #11) out of 19 residents observed in the survey sample.