Health inspection·February 26, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, interviews, policy review, and review of the investigation notes for self-reported incident (SRI) #243949 the facility failed to prevent staff to resident abuse. This affected one resident (#32) of three residents reviewed for abuse. The facility census was 56. Findings Include: Review of the medical record for Resident #32 revealed an admission date of 01/27/24 with diagnoses including chronic osteomyelitis (infection of bone) of the left thigh, local infection of the skin and subcutaneous tissue, unstageable pressure ulcer, Sjogren syndrome (an immune system illness that mainly causes dry eyes and dry mouth), major depression, and history of respiratory failure. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #32 had intact cognition and minimal signs of depression. Further review of the MDS assessment revealed Resident #32 was dependent for toileting, had a stage four pressure ulcer, and frequently suffered from severe pain during the five days prior to the assessment. Review of the progress note dated 02/08/24 revealed Resident #32 reported that State tested nurse aide (STNA) #351 left her on a bedpan too long and was too rough when turning her. The progress note further revealed an investigation was initiated, the STNA was suspended, the police were notified, and skin and pain assessments were completed on Resident #32 on 02/08/24 with no new findings. Review of the care plan dated 02/09/24 revealed Resident #32 had a self-care deficit in the performance of activities of daily living (ADLs) and required one-person assistance with toileting and bed mobility. Further review of the care plan revealed Resident #32 was at risk for impaired skin integrity and staff were to assist with repositioning as needed. Interview on 02/22/24 at 4:15 P.M. with Resident #32 revealed STNA #351 placed her on the bedpan wrong and when she asked to be repositioned, the STNA was rough when repositioning her and then she still felt poorly positioned and uncomfortable on the bedpan. Resident #32 stated she begged STNA #351 not to leave her like that and STNA #351 told her in an irritated tone that she would be fine as she proceeded to exit the room. Resident #32 further explained she was uncomfortable and felt she was not on the bedpan correctly, so she started yelling out for assistance when a nurse entered and helped her get better positioned on the bedpan. When STNA #351 came back, she would not remove the bedpan, telling Resident #32 she needed to get a second person to assist. Resident #32 reported STNA #351 Page 1 of 5 365689 365689 02/26/2024 Arbors at Fairlawn The 575 S Cleveland Massillon Road Fairlawn, OH 44333

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was gone so long, Resident #32 fell asleep on the bedpan. Once the STNA returned, she returned without another staff member. Resident #32 felt like her skin was adhered to the bedpan and was fearful it may have damaged her skin. STNA #351 instructed Resident #32 not to reach back there because she could cause her skin to bleed. Resident #32 denied new or worsening wounds related to the incident. Interview on 02/22/24 at 4:38 P.M. with the Administrator revealed STNA #351 was suspended immediately upon report of the incident on 02/08/24, and subsequently terminated on 02/13/24. The facility investigation substantiated abuse occurred on 02/07/24 during second shift when STNA left Resident #32 on the bedpan too long and was not responsive to Resident #32's requests to help reposition her appropriately and timely. The Administrator indicated Resident #32 was impacted at the time of the incident with no ongoing affects. Review of written statements dated 02/08/24 from Resident #32 and Social Worker #350, and the written statements dated 02/09/24 from Licensed practical nurse (LPN) #316, and STNA #353 revealed supportive statements by each that Resident #32 was placed on the bedpan by STNA #351 on 02/07/24. Further review of the statements revealed STNA #351 did not obtain assistance from another staff member with removing Resident #32 from the bedpan and Resident #32 reported increased pain when placed on the bedpan on the evening of 02/07/24 by STNA #351. Review of the facility policy and procedure titled Abuse, Neglect, and Exploitation revised on 01/10/24 revealed procedures to prevent all types of abuse, neglect, misappropriation, and exploitation. The deficient practice was corrected on 02/16/24 when the facility implemented the following corrective actions. • On 02/08/24, STNA #351 was suspended immediately upon report of the allegation. • On 02/08/24, the Director of Nursing (DON) performed a skin assessment and inspected Resident #32's wound with no new skin issues or deterioration in wound noted. • On 02/08/24, The DON conducted a pain assessment on Resident #32 with no increase in pain from baseline. • On 02/08/24, the Unit Manager reviewed Resident #32's medication administration record with no increased use of prescribed pain medication from time of incident to time of report. • On 02/08/24, Social Services Director #350 conducted a Patient Health Questionnaire-9 (PHQ-9), a depression screening tool, with no worsening depression noted, per the scale, from the score from the 365689 Page 2 of 5 365689 02/26/2024 Arbors at Fairlawn The 575 S Cleveland Massillon Road Fairlawn, OH 44333

F 0600 admission PHQ-9. Level of Harm - Minimal harm or potential for actual harm • Residents Affected - Few On 02/08/24, the Administrator spoke to Resident #32 regarding the alleged incident and to make sure Resident #32 felt safe at the facility; Resident #32 stated she did. • On 02/08/24, the Administrator called the police to have them speak to Resident #32. No charges were filed at that time. • On 02/08/24, the Administrator and Social Services Director #350 surveyed other interviewable residents in the facility to assess any other issues regarding staff and whether they felt safe at the facility. No new issues were noted, and all felt safe residing in the facility. • On 02/09/24, the Administrator spoke to nursing staff that were scheduled on same day on same shift about their involvement or recollection of the events on 02/07/24. Written statements were obtained from LPN #316 and STNA #353, who were assigned to the same unit as STNA #351. • Social Services Director #350 followed-up with Resident #32 for 72 hours post incident to make sure there was no residual emotional effects from the incident. Resident #32's mood was stable, and she was content during the 72 hour period. • On 02/13/24, the Administrator finalized the termination of STNA #351 at which time the DON reported STNA #351 to the Nurse Aide Registry. • On 02/14/24, The DON conducted a facility audit of all residents with bedpans which revealed Resident #32 was the only resident in the facility who used a bedpan. • On 02/14/24, an Ad hoc Quality Assurance Performance Improvement (QAPI) meeting took place to review quality concerns and plan of compliance for the incident. • By 02/16/24, the DON/designee completed skin assessments and pain assessments on all residents residing in the facility who were not interviewable with no identified concerns. 365689 Page 3 of 5 365689 02/26/2024 Arbors at Fairlawn The 575 S Cleveland Massillon Road Fairlawn, OH 44333

F 0600 • Level of Harm - Minimal harm or potential for actual harm By 02/16/24, the DON/designee educated all STNAs on bedpan etiquette. Bedpan placement competency training with checklists would be included in STNA new hire training indefinitely. Residents Affected - Few • By 02/16/24, the DON/designee educated all nursing staff on expectations to review the residents' [NAME] for resident needs. The [NAME] training would be included in new hire training indefinitely. • By 02/26/24, the DON/designee educated all nursing staff on the use of the communication board in Point Click Care (PCC). The PCC communication board training would be included in new hire training indefinitely. • The following audits commenced on or before 02/16/24: a. Visual rounds of bedpan placement and time resident spent on the bedpan on various shifts five days a week for four weeks completed by the DON/designee. b. Staff interviews of knowledge of [NAME] and communication board; two direct care staff on various shifts, five days a week for four weeks completed by the DON/designee. c. Interviews of five facility staff weekly for four weeks on the facility abuse/neglect policy with immediate education if discrepancies identified completed by the Administrator. d. Interview of five interviewable residents weekly for four weeks regarding the facility's abuse/neglect policy with any identified concerns reported to the facility abuse coordinator immediately completed by the Social Services Director. e. Completion of skin and pain assessments on five residents who were unable to be interviewed for abuse/neglect weekly for four weeks completed by the DON/designee. f. Results of the above audits to be reviewed in one month by the QAPI Committee and 365689 Page 4 of 5 365689 02/26/2024 Arbors at Fairlawn The 575 S Cleveland Massillon Road Fairlawn, OH 44333

F 0600 Level of Harm - Minimal harm or potential for actual harm revisions/changes would be made to compliance monitoring as deemed necessary by the QAPI Committee. This deficiency represents non-compliance investigated under Control Number OH00151147. Residents Affected - Few 365689 Page 5 of 5