Inspection·May 12, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **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 record reviews and interviews with staff the facility failed to notify Resident #90's physician and daughter of notification of changes. This affected one resident of three reviewed for notifications of change. The census was 80. Findings include: Review of the closed medical record for Resident #90 revealed an initial admission date of 08/23/24 and re-admission date of 04/05/25 with diagnoses including chronic obstructive pulmonary disorder, diabetes and congestive heart failure. Resident #90 was discharged on 04/18/25. Review of the profile tab in the electronic medical record revealed Resident #90 was listed first as his own responsible party then his daughter as the second contact. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #90 was cognitively intact. He was independent with chair to chair transfers. Review of Resident #90's progress note on 02/05/25 at 8:30 P.M. revealed Resident #90 wanted to go to the hospital. The resident was sent to the emergency room (ER). Resident was his own responsible party. There was no evidence his daughter was notified. Review of Resident #90's progress note on 03/16/25 at 9:06 A.M., 03/17/25 at 8:52 A.M., 03/18/25 at 9:38 A.M. and 12:38 P.M. and 03/19/25 at 7:41 A.M. revealed Resident #90 refused either treatments such as dialysis or vitals signs, and/or medications. There was no evidence Resident #90's physician or daughter was notified of the refusals. Review of Resident #90's progress note on 03/21/25 at 2:58 P.M. revealed Resident #90 was sent to the ER. There was no evidence Resident #90's daughter was notified. Review of Resident #90's progress notes dated 04/18/25 at 11:49 P.M. and authored by Licensed Practical Nurse (LPN) #265 revealed the day nurse reported Resident #90 signed himself out on an LOA. The resident had not returned yet. Resident #90's note dated 04/19/25 at 4:03 A.M. authored by LPN #265 indicated LOA. There was no evidence Resident 90's physician or daughter were notified of the resident not returning from LOA. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 5 Event ID: 365689 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 05/12/2025 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)