Health inspection·June 13, 2024

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and facility policy review, the facility failed to ensure appropriate orders and monitoring were in place regarding a urinary catheter. This affected one resident (#112) of two residents reviewed for urinary catheters. The facility census was 59. Findings include: Review of Resident #112's record revealed an admission date of 05/22/24 and diagnoses including Parkinson's disease without dyskinesia, ulcerative colitis, hypertension, iron deficiency anemia, anxiety, insomnia, constipation, depression and bipolar disorder. Review of Resident #112's admission minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #112 was moderately cognitively intact and had an indwelling catheter. Review of Resident #112's current physician's orders revealed there were no orders to change the urinary catheter bag monthly or as needed, to monitor urine from the indwelling catheter or to change the catheter as needed prior to 06/10/24. Interview on 06/10/24 at 10:10 A.M. with the Director of Nursing (DON) revealed Resident #112 was on enhanced barrier precautions due to an indwelling catheter. Interview on 06/10/24 at 10:36 A.M. with Resident #112 revealed staff did not clean the catheter where it entered her body. Resident #112 indicated since she had been at the facility, the collection bag and the catheter tubing had not needed to be changed. Observation during the interview revealed Resident #112 was nude from the waist down and had a urinary catheter draining into a collection bag located to her left and attached to her bed frame. Interview on 06/12/24 at 9:03 A.M. with Stated Tested Nursing Assistant (STNA) #339 revealed Resident #112 had her urinary catheter since admission and staff just had to empty the catheter bag as Resident #112 would clean her perineal area herself. Interview on 06/12/24 at 9:20 A.M. with Licensed Practical Nurse (LPN) #315 revealed Resident #112 had a urinary catheter upon admission to the facility. LPN #314 indicated nurses were to check the color and qualities of the urine in the collection bag and STNAs were to clean the tubing where it entered the body and empty the bag each shift. When asked if there were any orders regarding Resident #112's catheter including changing the tubing or collection bag if needed, LPN #315 verified there were no orders relative to Resident #112's catheter present in the medical record prior to 06/10/24. Revised policy, Catheterization, revised 01/01/22 revealed indwelling urinary catheters will be utilized in accordance with current standards of practice with interventions to prevent complications to the extent possible. The plan of care will address the use of an indwelling urinary catheter including strategies to prevent complications. Review of the facility policy, Catheter Irrigation, revised 12/28/23 revealed orders shall include the frequency, type, and amount of irrigating solution or medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365689 If continuation sheet Page 2 of 8 Printed: 05/15/2026 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 365689 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Fairlawn The 575 S Cleveland Massillon Road Fairlawn, OH 44333 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and review of the facility policy, the facility failed to ensure respiratory equipment was dated and monitored for routine replacement. This affected three residents (#19, #35 and #113) of four residents reviewed for respiratory care. The facility census was 59. Residents Affected - Few Findings include: 1. Review of Resident #35's medical record revealed an admission date of 06/25/23 and diagnoses including depression, acute and chronic respiratory failure, malignant neoplasm of lower lobe, right bronchus or lung, chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea. Review of Resident #35's annual minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #35 was cognitively intact and used oxygen. Review of Resident #35's physician's orders as of 06/10/24 revealed an order dated 06/25/23 for oxygen at three liters/minute via nasal cannula continuous every day and night shift for COPD. No orders for replacing oxygen tubing on a routine basis were available in the medical record prior to 06/10/24. Observation on 06/11/24 at 8:25 A.M. revealed Resident #35's oxygen tubing did not have a date on it. Interview on 06/11/24 at 8:26 A.M. with Licensed Practical Nurse (LPN) #338 revealed oxygen tubing was supposed to be changed weekly and dated at that time. Observation of Resident #35's oxygen tubing with LPN #338 during the interview confirmed no date was present and should have been. 2. Review of Resident #113's medical record revealed an admission date of 05/24/24 and diagnoses including type two diabetes, chronic obstructive pulmonary disease (COPD), acute respiratory failure with hypoxia, chronic congestive heart failure, depression, insomnia and hyperlipidemia. Review of Resident #113's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #113 was cognitively intact but did not code him as utilizing oxygen. Review of Resident #113's physician's orders as of 06/10/24 revealed an order dated 05/28/24 for two liters of oxygen as needed at night for shortness of breath every 12 hours. No orders for replacing oxygen tubing on a routine basis were available in the medical record prior to 06/10/24. Observation of 06/10/24 at 10:15 A.M. revealed Resident #113's oxygen tubing did not have a date on it. Interview on 06/10/24 at 10:18 A.M. with Registered Nurse (RN) #331 revealed oxygen tubing was to be dated. Observation of Resident #331's oxygen tubing with RN #331 during the interview confirmed no date was present and should have been.3. A review of medical records for Resident #19 revealed a date of admission of 02/28/24 with diagnoses including chronic obstructive pulmonary disease, hypertension and severe protein calorie malnutrition. Resident #19's physician orders included oxygen at four liters per minute via nasal cannula (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365689 If continuation sheet Page 3 of 8 Printed: 05/15/2026 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 365689 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Fairlawn The 575 S Cleveland Massillon Road Fairlawn, OH 44333 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 0695 continuously, change oxygen tubing every week and date and initial oxygen tubing. Level of Harm - Minimal harm or potential for actual harm Review of Resident #19's admission minimum data set assessment (MDS) revealed a BIMS of 15 (cognitively intact). Residents Affected - Few A care plan dated 02/29/24 revealed Resident #19 has impaired pulmonary/respiratory status. Interventions included observe for signs and symptoms of respiratory distress (increased respiration rate, low oxygen saturation levels, cyanosis (a bluing of the skin due to low oxygen), increased heart rate, restlessness, diaphoresis, headaches, increased lethargy, increased confusion) report to physician and administer oxygen as ordered. A review of the medication administration record and treatment administration record for May 2024 revealed no documented oxygen tubing changes for the entire month of May 2024. A review of the medication administration record and treatment administration record for June 2024 revealed no documented oxygen tubing change for month of June 2024 until 06/10/24. On 06/10/24 at 9:37 A.M. an observation of Resident #19 revealed an oxygen tubing with no date. An interview with LPN #308 at the time of the observation verified the oxygen tubing for Resident #19 was not dated. LPN #308 stated oxygen tubing was to be changed weekly. A review of the policy titled, Oxygen Administration dated 10/26/23 stated on page one, point five, subsection b to change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365689 If continuation sheet Page 4 of 8 Printed: 05/15/2026 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 365689 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Fairlawn The 575 S Cleveland Massillon Road Fairlawn, OH 44333 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review the facility failed to monitor residents using anticoagulant and psychotropic medications. This affected one resident (#113) out of five residents reviewed for unnecessary medications. The facility census was 59. Residents Affected - Few Findings include: Review of Resident #113's medical record revealed an admission date of 05/24/24 and diagnoses including type two diabetes, chronic obstructive pulmonary disease, acute respiratory failure with hypoxia, chronic congestive heart failure, depression, insomnia and hyperlipidemia. Review of Resident #113's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #113 was cognitively intact and was coded as taking an antidepressant, a hypnotic medication, an anticoagulant, an antibiotic, a diuretic, an opioid and a hypoglycemic medication. Review of Resident #113's physician's orders as of 06/10/24 revealed an order dated 05/24/24 for Eliquis (anticoagulant) oral tablet five milligrams (mg) and an order dated 05/24/24 for Sertraline hydrochloride (antidepressant) oral tablet 100 mg. Further review of Resident #113's physician's orders revealed no evidence of monitoring for side effects relative to his anticoagulant and antidepressant medications. Review of Resident #113's Medication Administration Records (MARs) and Treatment Administration Records (TARs) for May 2024 and June 2024 revealed no evidence of monitoring for side effects relative to his anticoagulant and antidepressant medications. Review of Resident #113's plan of care dated 05/26/24 for risk for abnormal bleeding or hemorrhage related to anticoagulant therapy and recent surgery had the following interventions included: • Observe for and report to physician as needed any signs and symptoms of abnormal bleeding: blood-tinged or frank blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, shortness of breath, loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs. • Report to nurse any signs or symptoms of bleeding such as black tarry stool, bruising, bleeding gums, blood-tinged urine, excessive bleeding when shaving. Review of an additional plan of care dated 06/10/24 for Resident #113's impaired mood/psychiatric status related to depression, anxiety, insomnia, antidepressant medication use and Melatonin use had the following interventions included: • (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365689 If continuation sheet Page 5 of 8 Printed: 05/15/2026 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 365689 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Fairlawn The 575 S Cleveland Massillon Road Fairlawn, OH 44333 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 0757 Level of Harm - Minimal harm or potential for actual harm Observe for and report to physician any signs/symptoms for change in mood/acute psychosis from resident's baseline (hallucinations, delusions, inability to concentrate, depression, sleeping too much or too less, feelings of worthlessness or guilt, loss of pleasure or interest in activities, change in psychomotor skills, anxiety, suicidal thoughts, paranoia). Residents Affected - Few • Observe for and report to physician any signs of mania or hypomania, racing thoughts or euphoria, increased irritability, frequent mood changes, pressured speech, flight of ideas, marked changes in agitation or hyperactivity. Interview on 06/12/24 at 8:49 A.M. with State Tested Nursing Assistant (STNA) #332 revealed their point-of-care charting did not include monitoring medication side effects. Interview on 06/12/24 at 9:03 A.M. with STNA #339 revealed the STNAs did not document anything relative to medications or their side effects. Interview on 06/12/24 at 9:20 A.M. with Licensed Practical Nurse (LPN) #315 revealed usually there was an order on the MAR or the TAR to check for signs of bleeding, mood changes and side effects for anticoagulant and antidepressant medications respectively. LPN #315 verified Resident #113's record lacked such orders for monitoring these medications during the interview. Interview on 06/12/24 at 9:58 A.M. with the DON revealed the expectation for medication monitoring included monitoring for signs and symptoms of bleeding as well as side effects for anticoagulants and antidepressants respectively. The DON verified Resident #113's ancillary orders were not done yet which included medication monitoring and should have been completed already as the Unit Manager would put these orders in within five days of the resident's admission. Review of the facility policy, Medication-Psychotropic, revised on 10/30/23 revealed the effects of the psychotropic medications on a resident's physical, mental and psychosocial well-being will be evaluated on an on-going basis, including in accordance with nurse assessments and medication monitoring parameters consistent with clinical standards of practice, manufacturer's specifications and the resident's comprehensive plan of care. Review of the facility policy, Medication-Adverse Drug Consequence or Event, revised 01/17/24 revealed the facility would establish a mechanism to ensure that adverse drug reactions are systematically reported, monitored, evaluated and documented in order to prevent future recurrences. All medications have the potential to cause an adverse drug event and all residents will be monitored appropriately. Care plan interventions will be documented for residents receiving high risk medications for monitoring of and preventing adverse drug events. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365689 If continuation sheet Page 6 of 8 Printed: 05/15/2026 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 365689 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Fairlawn The 575 S Cleveland Massillon Road Fairlawn, OH 44333 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, review of the facility policy and review of guidance from the Centers for Disease Control (CDC), the facility failed to ensure adequate signage was posted to instruct staff and visitors of proper precautions to take for a resident on enhanced-barrier precautions (EBP). This affected one resident (#112) of three residents reviewed for transmission-based precautions. The facility census was 59. Residents Affected - Few Findings include: Review of Resident #112's record revealed an admission date of 05/22/24 and diagnoses including Parkinson's disease without dyskinesia, ulcerative colitis, hypertension, iron deficiency anemia, anxiety, insomnia, constipation, depression and bipolar disorder. Review of Resident #112's physician's orders on 06/10/24 revealed an order dated 05/24/24 for enhanced barriers while performing high-contact activity with the resident. No rationale for enhanced barrier precautions (EBP) was specified in the order. Observation on 06/10/24 at 9:52 A.M. revealed Resident #112's door had a yellow personal protective equipment (PPE) hanger over the door with respirator masks, disposable gowns, red trash bags and gloves. No sign was noted on the door or near the door to communicate why PPE was on Resident #112's door and what PPE was needed to enter the room. Observation on 06/10/24 at 10:10 A.M. with the Director of Nursing (DON) revealed Resident #112 did not have any signage on her door or near the PPE hanger. Interview with the DON at the time of observation verified signage should have been present as Resident #112 was on EBP due to an indwelling catheter. Interview on 06/12/24 at 8:49 A.M. with State Tested Nursing Assistant (STNA) #332 revealed Resident #112 had her catheter since admission and for any room with the yellow PPE hanger the nurse would tell them why the resident was on isolation and what PPE was needed to enter the room. Interview on 06/12/24 at 9:03 A.M. with STNA #339 revealed Resident #112 had been on EBP since admission and shared care staff found out about which residents were on transmission-based precautions and what PPE was required based on review of the [NAME] (care card) or through a verbal report from the nurse. Interview on 06/12/24 at 9:20 A.M. with Licensed Practical Nurse (LPN) #315 revealed Resident #112 had been on EBP since admission and shared staff would verbally ask the nurse about a PPE hanger to obtain further information on why a resident was on transmission-based precautions and what PPE was needed. Follow-up interview on 06/12/24 at 9:58 A.M. with the DON revealed while the facility would put information about a resident's isolation status in the [NAME], a sign should still be present to give direction to anyone who entered the resident's room regarding what PPE was required. The DON was made aware the facility policy on EBP provided lacked guidance on signage during the interview. Review of the facility policy, Enhanced Barrier Precautions (EBP), revised 03/26/24 defined EBP as (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365689 If continuation sheet Page 7 of 8 Printed: 05/15/2026 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 365689 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Fairlawn The 575 S Cleveland Massillon Road Fairlawn, OH 44333 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete infection control interventions designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves during high-contact resident care activities. No guidance on signage was provided in the policy. Review of the CDC guidance, Frequently Asked Questions (FAQs) about Enhanced Barrier Precautions in Nursing Homes, dated 05/20/24 revealed signs were intended to signal to individuals entering the room the specific actions they should take to protect themselves and the resident. To do this effectively, the sign must contain information about the type of precautions and the recommended PPE to be worn when caring for the resident. Event ID: Facility ID: 365689 If continuation sheet Page 8 of 8