Arbors at Stow

Inspectors wroteBased on observation, interview and review of the facility policy, the facility failed to discard expired food timely. This had the potential to affect all 131 residents receiving food from the kitchen. Facility census was 131.

Inspectors wroteBased on record review, interview and review of the facility policy, the facility failed to implement their abuse policy to timely report allegations of abuse. This affected five residents (#8, #77, #131, #155 and #157) out of 21 residents reviewed for abuse. Facility census was 131.

Inspectors wroteBased on record review, interview and review of the facility policy, the facility failed to timely report allegations of abuse to the State Agency (SA) as required. This affected five residents (#8, #77, #131, #155 and #157) out of 21 residents reviewed for abuse. Facility census was 131.

Inspectors wroteBased on observation, review of medical record, review of facility fall investigation, review of hospital records, review of facility policy and interview, the facility failed to provide comprehensive interdisciplinary monitoring (including input from hospice and Resident #71's son) following an incident on 02/07/26 when the resident was lowered to the floor resulting in a delay in identification and treatment of a left femur fracture, failed to ensure medication parameters were followed per the physician's orders and physician was notified medication was being held for Resident #131, failed to ensure the dressing was changed for Resident #75 per the physician's order, and failed to have a perimeter mattress in place for Resident #12 and #75 per the physician's order. [...]

Inspectors wroteBased on observation, interview, recipe review and review of the facility policy, the facility failed to ensure pureed foods were prepared appropriately. This affected 22 residents (#13, #14, #18, #21, #30, #31, #32, #37, #38, #45, #54, #57, #60, #61, #63, #65, #72, #91, #103, #107, #153 and #154) that received pureed cabbage during the lunch meal on 03/17/26. Facility census was 131.

Inspectors wroteBased on observation, interview and review of the facility policy, the facility failed to ensure call lights were functional as required. This affected four residents (#20, #47, #49 and #52) reviewed out of 16 resident rooms observed for call light functionality. Facility census was 131.

Inspectors wroteBased on observation, interview, record review and review of the facility policy the facility failed to ensure air temperatures remained in required ranges and failed to maintain wheelchairs in a clean and sanitary manner. This affected 48 residents (Resident #5, #18, #27, #47 and #52), all 21 residents on D pod (Residents #2, #8, #14, #15, #17, #22, #25, #33, #38, #44, #58, #61, #78, #83, #84, #88, #92, #97, #115, #149 and #150), and all 22 residents on E pod (Residents #10, #24, #35, #41, #43, #48, #53, #54, #56, #63, #66, #71, #72, #81, #86, #87, #89, #93, #95, #96, #114, #118 and #148). Facility census was 131.

Inspectors wroteBased on record review, interview and review of the facility policy, the facility failed to notify residents when their resident funds accounts were within $200.00 of the Medicaid resource limit as required. This affected three residents (#17, #38 and #49) of five residents reviewed for personal funds. Facility census was 131.

Inspectors wroteBased on review of the medical record review, facility incident report review, interview with staff, and review of the facility's abuse policy the facility failed to provide adequate supervision to prevent physical abuse of a cognitively impaired resident (Resident #131) by another resident identified by the staff to have aggressive behaviors. This affected one resident ( Resident #131) of 21 residents reviewed for abuse.

Inspectors wroteBased on observation, interview, record review and review of the facility policy the facility failed to ensure Resident's #7 care planned fall interventions were implemented. This affected one resident (Resident's #7) out of three residents reviewed for falls. The facility census was 131.

Inspectors wroteBased on record review and interview the facility failed to adequately manage Resident #6's pain following a fall. This affected one resident (#6) of three reviewed for pain management. The facility census was 131.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on record review and staff interview, the facility failed to ensure individualized behavioral health interventions were implemented to meet Resident #77's mental health needs tp prevent suicidal ideation with suicidal attempt. This deficient practice affected one (Resident #77) of two residents reviewed for mood and behavior. The facility census was 131.

Inspectors wroteBased on review of the medical record, review of the Self-Reported Incident and interview with the staff the facility failed to ensure an incident of potential abuse was documented in the medical record of Resident #31. This affected one resident (Resident #31) of 21 residents reviewed for abuse.

Inspectors wroteBased on observation, interview and record review the facility failed to follow proper infection control techniques for residents on Enhanced Barrier Precautions (EBP). This affected one resident (#75) of three observed for EBP. The facility failed to maintain hand hygiene during medication administration and disinfect a glucometer meter after use. This affected one resident (#9) of four observed for infection control techniques during medication administration. The facility census was 131.1. Review of Resident #75's medical records revealed an admission date 11/24/25. Diagnoses included surgical amputation of the right toes, muscle weakness and dementia. Review of care plan dated 12/29/25 revealed Resident #75 required EBP related to diabetic foot ulcer. [...]

Inspectors wroteBased on review of the personnel files and staff interviews, the facility failed to ensure its Certified Nursing Assistants (CNAs) had regular performance evaluations at least annually as required. This affected two of four CNA personnel files reviewed and had the potential to affect all residents. The facility census was 131. Findings Include:Review of the personnel record for CNA #999 revealed the last yearly performance evaluation was completed on 10/18/16. Review of the personnel record for CNA # 514 revealed the last yearly performance evaluation was completed on 04/25/22. Human Resources Director (HRD) # 998 verified the above lack of evaluations in an interview on 03/20/26 at 12:45 P.M.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, review of completed cleaning schedules, and review of facility policies, the facility failed to ensure the kitchen was clean and sanitary and food items were properly stored, which had the potential to affect all residents who received food from the kitchen. The facility identified no residents as receiving nothing by mouth. The facility census was 125.

Inspectors wroteBased on observation, review of the facility policy, and interview with staff the facility failed to ensure the water temperature on the 200 unit was maintained at a comfortable temperature. This affected seven residents (Resident #17, #29, #40, #51, #74, #83, and #110) who resided on the 200 hall and had the potential to affect all 23 residents on the 200 unit ( #17, #29, #30, #34, #35, #40, #45, #47, #50, #51, #54, #58, #65, #74, #79, #83, #93, #86 #97, #98, #103, #110, #117). The facility census was 125.

Inspectors wroteBased on observation, record review and interview the facility failed to maintain acceptable infection control practices to prevent the spread of infection during wound care for Resident #37 and failed to ensure staff performed hand hygiene to prevent cross contamination of germs during Resident #2's, Resident #9's, Resident #87's and Resident #120's medication administration. This affected one resident (#37) out of three residents (Resident #37,#27,#49) reviewed for wound care and four out of ten residents observed for medication administration. The facility census was 125 residents.

Inspectors wroteBased on observation, review of the medical record, review of the facility policy and interview with staff the facility failed to ensure hair care was provided to Resident #35 and Resident #40. This affected two residents ( Resident #35 and #40) out of five reviewed for activities of daily living (ADL). The facility census was 125.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review and interview the facility failed to provide adequate supervision to Resident #7 to prevent Resident #7 from obtaining an over-the-counter medication and possible ingestion of the medication. This affected one out of three residents reviewed for accidents.

Inspectors wroteBased on review of the medical record, review of pharmacy recommendation, and interview the facility failed to address pharmacy recommendation timely for Residents #7, #35, and #90. This affected three residents (#7, #35, and #90) of five reviewed for unnecessary medications. The facility census was 125.

Inspectors wroteBased on observation, staff interview, and record review, the facility failed to ensure expired medications and supplies were discarded appropriately. This affected one resident (Resident #3) of eight residents reviewed for medication administration. The census was 125.

Inspectors wroteBased on observation, review of the medical record and interview the facility failed to ensure Resident #34 received speech therapy as ordered. This affected one resident ( Resident #34) of one reviewed for therapy services.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure documentation was complete and accurate for two residents (Residents #106 and #123) of 28 residents reviewed for accuracy of documentation. The facility census was 125.

Inspectors wroteBased 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. [...]

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on review of the medical record, review of the facility's investigation, interviews with facility staff, and review of the facility policy on elopement, the facility failed to ensure staff provided adequate supervision to prevent Resident #33 from leaving the facility unsupervised. This affected one resident (#33) of three residents reviewed for elopement/exit seeking behaviors.

Inspectors wroteBased on record review, review of a facility self-reported incident (SRI), facility policy review, and interview the facility failed to ensure a resident was free from an incident of resident to resident abuse. This affected one resident (#113) of three residents reviewed for abuse. The facility census was 131.

Inspectors wroteBased on record review, policy review, and interview the facility failed to provide timely discharge notice as required related to a resident's transfer and discharge. This affected one resident (#133) of three residents reviewed for transfer/discharge. The facility census was 131.

Inspectors wroteBased on record review and interview the facility failed to provide a resident and the resident's guardian of the resident's bed hold. This affected one resident (#133) of three residents reviewed for transfer/discharge. The facility census was 131.

Inspectors wroteBased 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 [DATE] through 04/20/24 when the resident was transferred to the hospital due to a deterioration in the resident's condition. [...]

Inspectors wroteBased on record review and interview, and facility policy review the facility failed to ensure background checks were completed on all employees, specifically volunteers. This had the potential to affect all 130 residents residing in the facility.

Inspectors wroteBased on record review, facility Self-Reported Incident (SRI) review, policy review, and interview, the facility failed to ensure Resident #200 was transferred safely using a Hoyer mechanical lift to prevent an injury. Actual harm occurred on 05/14/24 when Resident #200, who required assistance of two people during transfers, was transferred with one staff member using a Hoyer mechanical lift and sustained a displaced fracture of the right distal humerus. This affected one resident (#200) of three residents reviewed for falls and accidents. The facility census was 129.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, review of a self-reported incident (SRI), facility investigation, review of an employee personnel file, review of a police report, facility policy review and interview, the facility failed to timely report an allegation of staff to resident abuse. This affected one resident (#92) of three residents reviewed for abuse. The facility census was 127 residents.

Inspectors wroteBased 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 08/15/23 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. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure the resident's environment was kept clean, neat, well lit, and homelike. This affected Resident #83 and had the potential to affect all the 59 residents (#1, #3, #6, #10, #12, #15, #16, #18, #19, #24, #25, #26, #27, #29, #31, #35, #37, #39, #41, #42, #43, #44, #45, #47, #49, #51, #53, #55, #57, #61, #63, #67, #71, #72, #74, #77, #81, #82, #83, #85, #87, #89, #91, #93, #94, #95, #98, #100, #101, #102, #106, #107, #112, #114, #116, #273, #274, #322 and #323) on the 300, 500, and 600 pods. The census was 124.

Inspectors wroteBased on observation, record review, and interview the facility failed to ensure Resident #110's urinary catheter bag had been covered. This affected one resident (#110) of one resident observed for urinary catheters. In addition, the facility failed to ensure staff knocked on a common bathroom door prior to entering. This affected Resident #88. The facility census was 124.

Inspectors wroteBased on medical record review and interview, the facility failed to ensure resident wishes regarding end-of-life measures were clearly identified in the medical record. This affected three residents (#19, #37 and #116) of three residents reviewed for Advanced Directives. The facility census was 124.

Inspectors wroteBased on observation, interview, record review, and facility policy review the facility failed to report an incident of elopement to the state agency as required. This affected one resident (#272) of one resident reviewed for elopement and Self-Reported Incidents (SRI). The facility census was 124.

Inspectors wroteBased on observation, interview, and record review the facility failed to prevent an elopement of Resident #272. This affected one resident (#272) of one resident reviewed for elopement. The facility census was 124.

Inspectors wroteBased on interview, observation, and record review the facility failed to ensure proper positioning of Resident #110's urinary catheter bag. This affected one resident (#110) of one resident observed for urinary catheters. The facility census was 124.

Inspectors wroteBased on interview, observation, and record review the facility failed to provide adequate pain management to Resident #110. This affected one resident (#110) of one resident reviewed for pain management. The facility census was 124.

Inspectors wroteBased on observation and interview the facility failed to ensure adequate amounts of staff to provide timely and adequate resident care. This affected two residents (#14 and #46) of eight residents reviewed for staffing and had the potential to affect all 124 residents residing in the facility.