Health inspection·May 22, 2024

F 0689 Level of Harm - Actual harm Review of Resident #200's progress note dated 05/14/24 at 9:16 P.M. revealed the resident's x-ray results identified a displaced fracture of the right distal humerus. There was no evidence this was a chronic/old injury or that the fracture appeared pathological in nature (evidence of osteoporosis). The NP and POA were notified of the x-ray results. Residents Affected - Few Record review revealed the facility submitted a self-reported incident (SRI), dated 05/14/24 and coded as unusual source involving Resident #200. The SRI noted Resident #200 was treated in house for a distal humerus fracture and continued under hospice care. The investigation revealed the resident was removed from the bed via a mechanical lift by STNA #702 at approximately 4:00 A.M. on 05/14/24. STNA #702 admitted to self-transferring the resident, who was slightly resistive to morning care. Evidence collected was inconclusive in determining a definitive cause of injury. However, the SRI noted it was suspected Resident #200 bumped her arm on the mechanical lift bar during the morning care. Review of Resident #200's Statement of Witness form dated 05/14/24 authored by STNA #702 indicated he was doing the last round and was preparing Resident #200 to get her ready for the Hoyer mechanical lift when the resident grabbed the Hoyer strap bar and hit herself above the right eye. The resident was resistant to care. Review of Resident #200's progress note dated 05/15/24 at 12:27 P.M. revealed new orders were obtained from the NP for a sling to the right arm for comfort measures. Interview on 05/21/24 at 8:35 A.M. with Licensed Practical Nurse (LPN) #813 revealed LPN #920 had reported to her during the shift report that Resident #200 sustained an injury to her right eyebrow during a Hoyer mechanical lift transfer. The nurse stated at around 3:30 P.M., STNA #703 told her that the resident complained of right arm pain. She said the resident's right arm was flaccid (different from baseline) and she called and obtained an x-ray which showed evidence of a fracture. Telephone interview on 05/21/24 at 9:10 A.M. with STNA #703 revealed she worked day shift on 05/14/24 and was told in report Resident #200 had bumped her face on the Hoyer mechanical lift bar and caused an injury. Interview on 05/21/24 at 9:29 A.M. with NP #807 revealed she was aware of Resident #200's right arm fracture and felt it was pathological in nature due to a diagnosis of osteoporosis. The NP indicated the osteoporosis diagnosis was within her NP records, but the facility did not provide evidence of this diagnosis upon request. Interview on 05/21/24 at 9:31 A.M. with STNA #702 indicated on 05/14/24 before the end of his shift, Resident #200 was in bed and he provided incontinence care to the resident. The Hoyer mechanical lift was over the resident. He stated that he had turned to throw the soiled incontinence brief into the trash when the resident had become antsy and had grabbed the bottom of the Hoyer mechanical lift and hit herself in the head with the lift causing an injury to the face above the right eye. He stated he proceeded to transfer the resident by himself using the Hoyer mechanical lift from the bed to the Broda chair. When questioned, he stated it was common practice to use a Hoyer mechanical lift with only one staff member even though he was provided education that Hoyer mechanical lifts required two staff members. He stated STNA #843 worked on the unit with him and was in the process of using a Hoyer mechanical lift to transfer his own people and he did not think to ask for assistance. Interview on 05/21/24 at 10:11 A.M. with STNA #843 stated he could not remember if he worked with STNA #702 on 05/14/24 but verified he did not assist STNA #702 in transferring Resident #200 from the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365720 If continuation sheet Page 2 of 3 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 365720 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Stow 2910 L'Ermitage Pl Stow, OH 44224 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 0689 bed to a wheelchair on this date. Level of Harm - Actual harm Telephone interview on 05/21/24 at 1:34 P.M. with LPN #920 indicated he was doing his morning medication administration when STNA #702 reported Resident #200 had an injury with a Hoyer mechanical lift bar. He stated he cleansed the resident's right eye but was unaware of a fracture to the right arm. He stated he was unaware STNA #702 had transferred the resident by himself using a Hoyer mechanical lift. Residents Affected - Few During the onsite complaint investigation, the faciltiy was unable to provide any other explanation as to the cause of the resident's fracture that occurred on 05/14/24. The facility investigation/SRI documentation reflected while being transferred by only one staff member (instead of two as per care plan and policy) it was suspected Resident #200 bumped her arm on the mechanical lift bar during the morning care. The resident's injury/fracture was identified following this resident care interaction. Review of the Safe Lifting and Movement of Residents policy, revised 01/01/22 revealed each resident was assessed to determine lifting and movement assistance needs. At times, it was necessary to include the use of mechanical lifts to protect the safety and well-being of staff and residents, and to promote quality of care. Two staff shall be present to assist during all patient lifts utilizing a mechanical lift. This deficiency represents non-compliance investigated under Complaint Number OH00154089 and Complaint Number OH00154066. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365720 If continuation sheet Page 3 of 3