Health inspection·December 8, 2025

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review and interview, the facility failed to ensure resident safety during facility provided transportation to prevent injury. In addition, the facility failed to ensure fall interventions were in place for residents at risk for falls. This affected two residents (#1 and #15) of three residents reviewed for falls. The facility census was 117. Actual Harm occurred on 10/27/25 when Resident #1, a resident dependent on staff for transportation, was on her way back to the facility from an appointment at a local hospital when Transport Aide (TA) #118 failed to ensure the wheel straps on the left side of Resident #1's wheelchair were secured appropriately. This resulted in Resident #1 being dislodged from her wheelchair as the bus turned, falling and hitting her head. Resident #1 was transported to the local hospital emergency room where she required medical treatment including 10 staples to a head laceration. Findings include:1. Record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including cerebral infarction, paroxysmal atrial fibrillation and hypothyroidism.Review of a care plan revised on 08/18/25 revealed Resident #1 was at risk for falls related to cerebral vascular incident, generalized weakness, medications, pain, and need for assistance with activities of daily living. The goal was to reduce Resident #1's risk of injury through the next review. Interventions included but were not limited to anti-tippers to wheelchair, non-skid footwear, use call light, and ensure resident's room will be free from hazards.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1's cognition was intact. The assessment revealed the resident had no behaviors and used a wheelchair for mobility.Review of the physician's orders revealed an order dated 10/03/25 for Resident #1 to receive Eliquis (a blood thinning medication) five milligrams (mg) by mouth every morning and at bedtime related to cardiomyopathy.There was no evidence Resident #1 had a care plan in place related to her use of a blood thinning medication that would include monitoring for abnormal signs or symptoms related to the resident's medical condition and use of a blood thinning medication.Review of a nursing note and corresponding incident report both dated 10/27/25 at 12:40 P.M. by the Director of Nursing (DON) revealed Resident #1 was on her way to an appointment with TA #118. TA #118 noticed a strap came loose and Resident #1 started to move backwards which caused the resident's wheelchair to upset. Resident #1 hit her head causing a laceration. The transportation assistant applied pressure with first aide gauze on the bus, and the driver got the bus pulled to safety, removed the wheelchair and assisted Resident #1 back into the wheelchair. Resident #1 maintained pressure on the wound until the driver arrived at a local emergency room per Medical Director (MD) #500. The note included Resident #1's family was updated with no concerns. TA #118 was with Resident #1, Resident #1 remained alert and oriented to person, place, and time with complaints of a mild headache and wanted to go home. Resident #1 was interviewed via phone and stated she slid back and the chair upset.Review of a nursing note dated 10/27/25 at 6:10 P.M. authored by Licensed Practical Nurse (LPN) #101 revealed Resident #1 Page 1 of 4 365687 365687 12/08/2025 Arbors at Marietta 400 Seventh Street Marietta, OH 45750

F 0689 Level of Harm - Actual harm Residents Affected - Few returned to the facility from the emergency department with 10 staples to her posterior head, to remain (in place for 10-14 days). The area was clean, staples intact, some scant bleeding was noted when assessed. Instructions included, do not get the area wet for 24 hours, no other skin issues noted upon skin assessment. Vitals were obtained and no new orders.Review of a social service progress note dated 10/28/25 at 12:05 P.M. by Social Worker (SW) #131 revealed Resident #1 had been speaking to the unit manager when SW #131 approached. The note included Resident #1 stated she had some pain between her shoulders rating at a three out of 10 (this pain was a result of the resident's fall out of her wheelchair on 10/27/25). Nursing was made aware and planned to apply Biofreeze to the area. Review of a nursing note dated 10/28/25 at 5:20 P.M. by Social Worker (SW) #131 revealed Resident #1 refused a shower due to not feeling well, this nurse spoke with the resident who stated she was having head and neck pain (the pain was related to the resident's fall out of her wheelchair on 10/27/25) and would like to wait. MD #500 and representative were aware.Review of a social services note dated 10/29/25 at 11:13 A.M. by SW #131 revealed Resident #1 had an appointment later in the day. The note included when asked if she had reservations attending appointments, she denied any and stated she trusted the bus driver and was in good hands. Resident #1 stated she had some pain between her shoulders rating at a two, reported the day prior Biofreeze was applied and alleviated the pain, nursing was made aware and planned to put Biofreeze on the area. Review of a performance improvement form dated 10/30/25 revealed TA #118 was terminated from the facility. Interview on 12/03/25 at 4:00 P.M. with the DON revealed Resident #1 was in the transport van when it was noticed a strap was coming loose. Resident #1 tipped over in her wheelchair and hit her head, causing a laceration which required ten staples from the ER. The DON stated the facility had the bus inspected to determine the cause of the loose straps, the inspection came back with no concerns. The DON stated due to no concerns with the bus, it was determined user error must have been the cause when strapping the wheelchair down to the bus. The DON revealed the transport staff (TA #118) was terminated as a result of the incident.Interview on 12/03/25 at 4:41 P.M. with TA #126 revealed on 10/27/25 she and TA #118 had picked two residents up from the facility and were taking them to the hospital for their appointments. Upon arriving to the hospital, both residents were assisted off the bus, and Resident #1 was placed on the lift to the bus because she was being picked up from an appointment at the hospital. TA #126 stated she was unable to say what exactly happened with the four-point straps on the bus to hold Resident #1's wheelchair in place because once Resident #1 was in the van off the lift, TA #118 strapped her in while TA #126 took the other two residents to their appointments. TA #126 stated she was headed back downstairs from dropping off the residents when she received a phone call from TA #118 telling her to come to the ER for an emergency regarding Resident #1. TA #126 emphasized she was not on the bus with Resident #1 at the time of the incident. TA #126 stated she met Resident #1 at the ER, and the resident was holding paper towels to her head to apply pressure. When the incident statement dated 10/27/25 (that was included in the facility investigation and completed by the DON) was read to TA #126, she stated it was confusing because there was not a first aid kit on the bus and it sounded like there were two transport aides, TA #118 and an additional one but that wasn't accurate. At the time of the incident with Resident #1, there was only one transport aide present, TA #118.Interview on 12/03/25 at 5:50 P.M. with Resident #1 revealed she recalled the incident that had occurred on 10/27/25. The resident revealed TA #118 had strapped one side in then moved on to the other, but then TA #118 didn't lock both sides, only the right side. Resident #1 stated she recalled asking TA #118 if she was forgetting something to which TA #118 replied no. Resident #1 stated she did not question TA #118 any further. Resident #1 stated when they left the hospital going down the hill she was 365687 Page 2 of 4 365687 12/08/2025 Arbors at Marietta 400 Seventh Street Marietta, OH 45750

F 0689 Level of Harm - Actual harm Residents Affected - Few okay. At the bottom of the hill there was a stop sign, and they were turning left but TA #118 gunned it a little too hard and she (the resident) came out of her wheelchair. Resident #1 stated the wheelchair completely folded up and went to the right side of the van and she was on her back on the floor of the van. Resident #1 stated she hit her head and was bleeding. Resident #1 stated she felt TA #118 messed up because she did not call for an ambulance and someone had stopped to offer help, which TA #118 declined. Resident #1 stated TA #118 was panicking trying to figure out what to do and Resident #1 had to tell her to get it together because she needed help. Resident #1 stated she received paper towels from TA #118 and was helped back up into her chair. Once the chair was locked in, she was taken to the ER and she (Resident #1) applied pressure to her wound. Resident #1 stated the ER was concerned because she does take a blood thinner and was bleeding. Her representative was called because they were concerned about a potential brain bleed, but all the tests came back ok. Resident #1 reported getting nine staples in her head and being afraid to get in a vehicle to go back to the facility. Resident #1 reported having a hard time going to the first few appointments and stated she would only let TA #126 drive her now. Resident #1 stated even with TA #126 driving, she felt scared and when they go around a curve, she would still find herself reaching out to grab on to something.2. Record review revealed Resident #15 was admitted to the facility on [DATE] with diagnoses including hypertension, type II diabetes, and end stage renal disease.Review of an incident log revealed Resident #15 had two falls on 09/28/25.Review of a care plan revised on 10/09/25 revealed Resident #15 was at risk for falls/injury related to decreased strength and endurance. The goal was to reduce the risk of injury through the next review. Interventions included but were not limited to 15 minutes checks, keep frequently used items within reach, traction strips to the floor on left of bed, visual reminder to call for assistance, apply side rails to bed to aid in repositioning, encourage resident to use call light, and place call light in reach.Review of an order dated 10/10/25 revealed Resident #15 had an order in place for traction strips to the left side of bed for fall intervention.Review of the MDS assessment dated [DATE] revealed Resident #15 had moderately impaired cognition, no behaviors, required maximum assistance for transfers, had one fall with no injury since admission, one fall with injury other than major injury since admission, and took an anticoagulant (blood thinning) medication.On 12/03/25 at 2:24 P.M. Resident #15 was observed in bed. Interview with the resident at the time of the observation revealed the resident stated she could not find her call light, but if she needed anything she could just call out to her roommate and ask her to put on her call light. During the observation of the room, the call light was not within reach to the resident and there were no traction strips observed to the left of Resident #15's bed.Interview and observation on 12/03/25 at 4:15 P.M. with the DON confirmed there were no traction strips to the left of Resident #15's bed and the resident's call light was not within reach.Review of policy titled Fall Prevention Program dated 10/26/23 revealed each resident would be assessed for the risks of falling and will receive care and services in accordance with the level of risk to minimize the likelihood of falls. A fall was an event in which an individual unintentionally comes to rest on the ground, floor or other level but not as a result of an overwhelming external force. The event may be witnessed, reported, or presumed when a resident is found on the floor or ground, and can occur anywhere. After risk assessment, a nurse would indicate the resident's fall risk and initiate interventions on the resident's baseline care plan in accordance with the resident's level of risk. Each resident's risk factors and environmental hazards would be evaluated when developing the resident's comprehensive plan of care. When a resident experienced a fall, the facility would assess the resident, complete a post-fall assessment, complete an incident report, notify physician and family, review the resident's care plan 365687 Page 3 of 4 365687 12/08/2025 Arbors at Marietta 400 Seventh Street Marietta, OH 45750

F 0689 and update as indicated, document all assessments and actions, and obtain witness statements in the case of injury.This deficiency represents non-compliance investigated under Complaint Number 2656047. Level of Harm - Actual harm Residents Affected - Few 365687 Page 4 of 4