Health inspection·March 30, 2023

F 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff and resident interview, and policy review, the facility failed to ensure residents were free from physical restraint. This affected one resident (#68) of one resident reviewed for a physical restraint. The facility census was 79. Residents Affected - Few Findings include: Review of Resident #68's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, hypertensive chronic kidney disease, malignant neoplasm of the colon, personal history of transient ischemic attack, peripheral vascular disease, chronic pain, and anorexia. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #68 was severely cognitively impaired, had physical behaviors, verbal behaviors and rejection of care one to three days of the review period. The resident required extensive assist with bed mobility, transfers, dressing, toilet use and personal hygiene. Resident #68 utilized a walker and a wheelchair for mobility. Resident was coded as not steady only able to stabilize with human assistance for moving from seated to standing position, surface to surface transfer, and walking. The resident was coded not for trunk restraint and chair that prevents rising. Review of Resident #68's physician orders revealed the resident had a gel cushion to a Broda chair (a chair which can be positioned to recline) ordered on 02/16/23 and admit to hospice services on 11/11/22 for a diagnosis of chronic obstructive pulmonary disease. Review of the safety device data collection and evaluation dated 03/11/23 revealed Resident #68 had a safety device, a seatbelt implemented on a non emergency basis. The device was noted to be used due to resident weakness and to maintain proper body alignment while in the Broda chair. The evaluation had no documentation any other devices were attempted prior to the initiation of a seatbelt. The assessment indicated the device was able to be removed easily by the resident, had not restricted freedom of movement or normal access to one's body or caused the resident to avoid moving. No further device evaluations were present after 03/11/23. Observation and interview on 03/28/23 at 8:57 A.M. revealed Resident #68 was sitting in a Broda chair with a seatbelt in place across her hips. The resident was asked if she could remove the seat belt and she grabbed the locking mechanism and stated she could not unlatch the belt. Observation of Resident #68 on 03/29/23 at 12:10 P. M. revealed the resident was sitting in a Broda Page 1 of 11 365763 365763 03/30/2023 Arbors at Mifflin 1600 Crider Rd Mansfield, OH 44903

F 0604 chair with the seatbelt in place over her hips in the common area. Level of Harm - Minimal harm or potential for actual harm Observation of Resident #68 on 03/30/23 at 8:10 A.M. revealed the resident was sitting in a Broda Chair with the seat belt in place over her hips in her room with staff present assisting the resident. Residents Affected - Few Interview with the State Tested Nursing Assistant (STNA) #349 on 03/29/23 at 6:15 A.M., revealed Resident #68 could stand and ambulate to the toilet with extensive staff assistance, the STNA confirmed the resident could be active and was currently using the Broda chair provided by hospice. Interview with the Director of Nursing and the Corporate Nurse #400 on 03/29/23 at 10:00 A.M., verified Resident #68 had a seatbelt on her Broda chair. The DON stated the Broda chair was provided by hospice for the resident and stated all Broda chairs come with a seat belt. The DON stated the facility had a device assessment completed for the Broda chair that indicated the seatbelt was for positioning. The DON verified the medical record had no order for the seatbelt and the order was added on this date. The resident's ability to stand and ambulate with staff assistance and her inability to unlock the seatbelt was discussed and the DON stated she was unaware the resident could not remove the seatbelt. The Corporate Nurse #400 stated the facility would reassess the resident for the use of the Broda chair with the seatbelt. Review of the policy titled Restraints, dated 10/30/22 last revised 01/01/22 revealed : Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Policy Explanation and Compliance Guidelines: 1. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor). An evaluation will be completed to determine the medical symptom requiring the device and to determine the least restrictive device to treat the symptom. 2. Restraints with locking devices shall not be used. 6. Physical restraints shall only be used on the signed order of a physician, except in an emergency which threatens to bring immediate injury to the resident or others. In such an emergency an order may be received by telephone, and shall be signed by the physician within forty-eight (48) hours. Full documentation of the episode leading to the use of the physical restraint, the type of the physical restraint used, the length of effectiveness of the restraint time, and the name of the individual applying such measures shall be entered in the resident's medical record. 365763 Page 2 of 11 365763 03/30/2023 Arbors at Mifflin 1600 Crider Rd Mansfield, OH 44903

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record, observation, and staff and resident interview, the facility failed to ensure a resident who required assistance was provided with nail care. This affected one resident (#57) of two residents reviewed for activities of daily living care. The facility census was 79. Residents Affected - Few Findings include: Review of the medical record for Resident #57 revealed admission date of 10/01/19. Diagnoses included traumatic subarachnoid hemorrhage with loss of consciousness, left sided hemiplegia, contractures of right knee and hip, contractures of left hand, elbow, wrist, forearm, shoulder, hip, and knee, unsteadiness on feet, and muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #57 had intact cognition and required extensive two staff assistance with personal hygiene and dependent on two staff assistance for bathing. Review of the plan of care dated 07/26/22 revealed Resident #57 refused care at times and preferred certain staff to care for him. Interventions included allow the resident to make choices about treatment, encourage participation in care, give clear explanations of all care, negotiate time for care and return upon agreed time, and reapproach if the resident refuses. Review of the current physician's orders dated 03/29/23 revealed Resident #57 should be bathed daily on the evening shift and left hand hygiene provided daily to prevent skin breakdown. Interview and observation on 03/27/23 at 4:14 P.M., with Resident #57 revealed he wanted his fingernails trimmed. Resident #57 had long nails extending past the tips of his fingers of his right hand. Follow-up interview on 03/29/23 at 4:02 P.M., with Resident #57 revealed he had not yet received assistance with cleaning or trimming nails. Resident #57 indicated he wanted the beautician to trim his nails. Observation and interview on 03/29/23 at 4:12 P.M. with the Director of Nursing (DON) of Resident #57's nails on his right hand. Resident #57's nails were long and extended past the tips of his fingers and the nails were discolored. Interview at the time of the observation the DON verified Resident #57's nails were long and discolored. The DON indicated the beautician was also a state tested nursing assistant (STNA) at the facility. Interview on 03/30/23 at 8:53 A.M. with Registered Nurse (RN) #335 revealed Resident #57 was known to refuse care at times. RN #355 indicated Resident #57's refusals depended on which staff were attempting to provide the care. Review of facility policy titled Nail Care dated 01/01/22 revealed routine cleaning and inspection of nails would be provided during activities of daily living (ADL) care on an ongoing basis. Nail care would include trimming and filing. 365763 Page 3 of 11 365763 03/30/2023 Arbors at Mifflin 1600 Crider Rd Mansfield, OH 44903

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, review of the dialysis communication record, and policy review, the facility failed to ensure residents who received dialysis treatments were monitored per physician orders. This affected one resident (#239) of one resident reviewed for dialysis. The facility census was 79. Residents Affected - Few Findings include: Review of the medical record for Resident #239 revealed an admission date of 03/07/23. Diagnoses included stage III chronic renal disease, dependence upon renal dialysis, pneumonia, type II diabetes mellitus with hyperglycemia, chronic obstructive pulmonary disease, morbid obesity, atherosclerotic heart disease and depression. Review of the physician's order dated 03/08/23 revealed Resident #239 had an order for pre and post dialysis assessments to be completed two times a day every Monday, Wednesday, and Friday for dialysis treatments. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] for Resident #239 revealed he was on dialysis treatments. Review of the dialysis communication assessment records for Resident #239 revealed the records were not being filled out for pre and post dialysis treatments consistently per the physician orders. Review of the medical record for Resident #239 revealed the facility completed both the pre and post dialysis assessments on one day 03/15/23 out of 10 days 03/08/23, 03/10/23, 03/13/23, 03/17/23, 03/20/23, 03/22/23, 03/24/23, 03/27/23, and 03/29/23 since starting dialysis while residing at the facility. Interview on 3/29/23 at 9:35 A.M., with the Director of Nursing (DON) #365 verified Resident #239's documentation of pre and post dialysis assessments were not completed per the physician orders. Review of the policy titled Special Needs, revised dated 01/01/22 revealed Registered Nurses (RNs) and Licensed Practical Nurses (LPNs) will participate in the management of medical conditions by following physician orders, assessment of resident and reporting changes in condition to the resident's physicians. 365763 Page 4 of 11 365763 03/30/2023 Arbors at Mifflin 1600 Crider Rd Mansfield, OH 44903

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 medical record review, physician and staff interview, and policy review, the facility failed to ensure residents prescribed antibiotics had an adequate indication for use. This affected two residents (#10 and #80) out of eight residents reviewed. The facility census was 79. Residents Affected - Few Findings include: 1. Review of Resident #10's medical record identified admission to the facility occurred on 12/31/15. Diagnoses included right femur fractures, anxiety, constipation, neuromuscular dysfunction of the bladder with urinary catheter and contracture's. Review of the minimum data set (MDS) assessment dated [DATE] revealed Resident #10 cognitively intact and required the use of an indwelling urinary catheter. Review of the physician orders dated 03/25/23 revealed Resident #10 was ordered Amoxicillin 500 milligram (mg) three times a day for seven days. Review of Resident #10's progress notes and vital signs were completed from 03/15/23 through 03/21/23. The notes identified no evidence of any changes in Resident #10's mental status and no evidence of pain or concerns regarding the urine and/or catheter. Review of a Certified Nurse Practitioner (CNP) #410 notes dated 03/21/23 identified she visited Resident #10 and completed an assessment. The note documented Resident #10's urinary catheter was noted with increased sediment and dark urine and a urinalysis with a culture and sensitivity test was ordered. Review of the laboratory urinalysis test dated 03/22/23 identified the color of the urine was documented as yellow. The completed urinalysis and culture and sensitivity dated 03/25/23 identified the culture grew greater than 100,000 colony forming unit per milliliter (CFU/ml) Providencia Stuartii (a common uropathogen in people with long-term indwelling urinary catheters). Interview with the Infection Preventionist, Licensed Practical Nurse (LPN) #340 on 03/29/23 at 10:14 A.M., verified Resident #10 had not met the criteria for antibiotic treatment. LPN #390 said the facility used McGeer criteria for signs/symptoms of urinary tract infection (UTI) with an indwelling urinary catheter. Resident #10 had not met the diagnostic criteria for UTI with an indwelling catheter. Interview with Resident #10's Medical Physician #400 on 03/29/23 at 11:09 A.M., verified there should be adequate symptoms before ordering urinalysis testing. Medical Physician #400 said there was criteria to start antibiotics for residents with UTIs, including with or without urinary catheters. The physician verified Resident #10 should have not had an order to test the urine on 03/21/23 as the only issue documented was dark urine in the urinary drainage bag. Review of the policy titled Antibiotic Stewardship Program, dated 10/24/22 revealed it is the policy of this facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. The policy identified 365763 Page 5 of 11 365763 03/30/2023 Arbors at Mifflin 1600 Crider Rd Mansfield, OH 44903

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few attending physician's -prescribe appropriate antibiotics in accordance with standards of practice and facility protocols. The facility identified they utilize the McGreer criteria to define infections and Loeb Minimum Criteria may be used to determine whether to treat and infection with antibiotics. 2. Review of Resident #80's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included metabolic encephalopathy, pancreatitis, breast cancer, hypertension, acute candidiasis of vulva and vagina, and altered mental status. Review of the quarterly MDS dated [DATE] revealed Resident #80 was severely cognitively impaired, had verbal behaviors and rejection of care, one to three days of the review period, required limited assist for bed mobility, transfers, extensive assistance with toilet use, dressing and personal hygiene. The resident was frequently incontinent of both bowel and bladder. Review of Resident #80's physician orders revealed Cephalexin (antibiotic) 500 mg three times a day for seven days for disorder of the urinary system dated 03/20/23 and Augmentin (antibiotic) 875-125 mg every 12 hours for seven days for tooth pain related to periapical abscess without sinus dated 03/24/23. Review of Resident #80's urine analysis completed on 03/20/23 revealed a positive result with greater than 100,000 streptococcus B bacteria present in the urine sample. Review of Resident #80's nurses notes from 03/19/23 through 03/29/23 revealed there was no indication why the resident had a urinalysis culture and sensitivity completed and the medical record had no order for the laboratory test. Review of the Certified Nurse Practitioner (CNP) # 410's progress note dated 03/20/23 at 2:26 P.M. revealed Resident #80 was tearful stating her mother just passed away, and she did not want to be at the facility. The note documented the resident's mother passed away 10 years prior. The note had no documentation of the genitourinary system or concerns of the resident having a urinary tract infection. Review of the CNP # 410's progress note dated 03/24/23 revealed the staff reported the resident had complaints of tooth pain. The CNP documented the resident was a very poor historian but had stated her tooth hurt but was only able to say the pain was somewhere on the bottom. Resident #80's diagnoses were listed as acid reflux, breast cancer, chronic obstructive pulmonary disease, hiatal hernia, hypertension, obesity and thrush. The physical exam indicated the mouth mucous membranes were moist, no other description was included. The note identified the problem addressed by the visit was a tooth ache, with antibiotics ordered and an acute visit to the dentist. Interview with the Infection Preventionist, Licensed Practical Nurse (LPN) #340 on 03/29/23 at 10:14 A.M., revealed Resident #80 had not met the criteria for antibiotic treatment for either the urinary tract infection or the mucosal infection. LPN #340 said the facility used McGeer criteria for signs/symptoms of UTI was completed and no criteria was present for a mucosal infection. LPN #340 verified Resident #80 had not met the diagnostic criteria for a UTI or a mucosal infection. Review of the policy titled Antibiotic Stewardship Program, policy dated 10/24/22 revealed it is the policy of this facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The purpose of the program is to optimize the 365763 Page 6 of 11 365763 03/30/2023 Arbors at Mifflin 1600 Crider Rd Mansfield, OH 44903

F 0757 Level of Harm - Minimal harm or potential for actual harm treatment of infections while reducing the adverse events associated with antibiotic use. The policy identified attending physician's -prescribe appropriate antibiotics in accordance with standards of practice and facility protocols. The facility identified they utilize the McGreer criteria to define infections and Loeb Minimum Criteria may be used to determine whether to treat and infection with antibiotics. Residents Affected - Few 365763 Page 7 of 11 365763 03/30/2023 Arbors at Mifflin 1600 Crider Rd Mansfield, OH 44903

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, and policy review, the facility failed to maintain appropriate infection control measures during resident personal care. This affected one resident (#22) of two residents observed for personal care. The facility census was 79. Residents Affected - Few Findings include: Resident #22 was admitted to the facility on [DATE] with diagnoses including atrial fibrillation, Schizophrenia, hypertension, depression, dissection of unspecified site of aorta, diabetes type II, neuromuscular bladder, acquired absence of left leg below knee, sacral stage three pressure ulcer, stage two left buttock pressure ulcer; and congestive heart failure. Review of the Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #22 had mild cognitive impairment. Resident #22 required extensive assistance with bed mobility, dressing, toilet use, personal hygiene, and bathing with assistance from one to two staff persons. Review of the care plan for Resident #22 dated 02/10/23 revealed a need for assistance with Activities of Daily Living (ADL) interventions included to provide assistance with bathing/showering, and provide extensive assistance of one staff member for bed mobility. On 03/29/23 at 9:40 A.M. an observation of peri-care, dressing, and a mechanical lift transfer of Resident #22 was performed by State Tested Nurse Aide (STNA) #321 and STNA #354 . The observation had not initiated until after the STNAs had already entered the resident's room and had already donned gloves prior to beginning resident care. STNA #321 and #354 were observed removing Resident #22's clothing. STNAs #321 and #354 performed washing of Resident # 22's upper body, allowing Resident #22 to perform self-care when possible. STNA #354 then performed peri area care, assisted Resident #22 to turn onto his right side and performed anal care. With the same gloved hands, STNA #354 assisted Resident #22 onto his back. STNA #321 was observed to then place barrier cream onto Resident #22's peri area, was observed removing her gloves, and observed to immediately don new gloves which she retrieved from her pockets without performing hand hygiene. STNA #354, using the original pair of gloves, then performed catheter care for Resident #22, cleaning the catheter tubing from the insertion point at the body to the drainage tubing. STNAs #321 and #354 proceeded to complete care for Resident #22 including dressing, emptying of the urinary drainage bag, transferring Resident #22 to the wheelchair using a mechanical lift, and straightening up the covers on Resident #22's bed, with the same pair of gloves used throughout the resident care process. STNA #321 doffed her gloves just before exiting the resident's room and had not performed hand hygiene upon exiting the room. STNA #354 doffed gloves while in the resident's room, retrieved Resident #22's personal cell phone at the resident's request, and then exited the resident's room without performing hand hygiene. During an interview with STNA #321 on 03/29/23 at 9:58 A.M., verified hand hygiene was not performed between changing gloves during resident care, and hand hygiene was not performed upon exit of the resident's room. During an interview with STNA #354 on 03/29/23 at 10:01 A.M., verified the same pair of gloves was used throughout the entire care process for Resident #22 and no hand hygiene was performed upon exit of the resident's room. 365763 Page 8 of 11 365763 03/30/2023 Arbors at Mifflin 1600 Crider Rd Mansfield, OH 44903

F 0880 Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled Personal Protective Equipment, dated 07/28/20 showed the facility Policy Explanation and Compliance Guidelines Section 4(a)(iii) stated to perform hand hygiene before donning gloves and after doffing gloves. This policy, Section 4(a)(v) also stated to change gloves and perform hand hygiene between clean and dirty tasks, and when moving from one part of the body to another part of the body. Residents Affected - Few 365763 Page 9 of 11 365763 03/30/2023 Arbors at Mifflin 1600 Crider Rd Mansfield, OH 44903

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff and resident interview, and policy review, the facility failed to ensure call lights within resident's reach. This affected one resident (#42) of two residents reviewed for the accessibility of call lights. The facility census was 79. Residents Affected - Few Findings include: Review of the medical record revealed Resident #42 was admitted to the facility on [DATE]. Diagnoses included hypertension, diabetes type II, Post-Traumatic Stress Disorder, major depressive disorder, pain disorder with psychological factors, repeated falls, and unsteadiness on feet. Diagnoses after admission included vascular dementia, transient ischemic attack, cerebral infarct, hemiplegia and hemiparesis affecting left side, and dysphagia. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #42 had moderate cognitive impairment. The assessment also revealed the resident required extensive assistance with bed mobility, transfers, dressing, personal hygiene, and bathing with physical assistance by one staff person. The assessment revealed the resident required limited assistance for locomotion on the unit, and required supervision for locomotion off from the unit and with eating. Review of the care plan dated 02/28/23 showed Resident #42 was at risk for falls with interventions which included to ensure the call light was within reach and to encourage the resident to use the call light for assistance as needed. The care plan also lists the intervention of ensuring the call light within the resident's reach for the care areas of use for a safety alarm, and the care area related to pain. During an observation on 03/27/23 at 10:47 A.M., revealed Resident #42 in his room and was seated in his wheelchair in front of the television, positioned approximately two feet away from the open side of his bed which was pushed against the wall. The call light was observed hanging from the wall down to the floor on the wall side of the bed. During an interview with Resident #42 on 03/27/23 at 10:47 A.M., a determination was made Resident #42 was able to identify and describe the purpose of the call light. Resident #42 was asked about the location of the call light not being within his reach and stated he did not want the call light because he said he would not get a response from using the call light he guessed they came whenever they were not busy with anybody else. During an observation on 03/28/23 at 1:45 P.M. revealed Resident #42 was sitting in his wheelchair positioned in front of the television approximately two feet away from the open side of the bed. The call light was observed hanging from the wall to the floor on the wall side of the bed. The resident was sitting with his head down, chin near to chest, and responded to his name called after the third try. Resident #42 was asked if he was tired and stated he wanted to go to bed. Resident #42 was asked how he could call for assistance from staff to help him get into the bed. Resident #42 looked around the room, looked briefly at the call light, then looked back to this surveyor and reached out his hand towards this surveyor. During an interview with State Tested Nurse Aide (STNA) #354 on 03/28/23 at 1:49 P.M., verified the call light for Resident #42 was located hanging from the wall to the floor on the wall side of the 365763 Page 10 of 11 365763 03/30/2023 Arbors at Mifflin 1600 Crider Rd Mansfield, OH 44903

F 0919 Level of Harm - Minimal harm or potential for actual harm bed, and not within reach of Resident #42 who was seated in a wheelchair two feet away from the open side of the bed. Review of the facility policy titled Call Lights: Accessibility and Timely Response, dated 10/19/20 described the staff responsibility of ensuring call lights were accessible to residents. Residents Affected - Few 365763 Page 11 of 11