Health inspection·May 9, 2023

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations of video, medical record reviews, policy review, Power of Attorney and staff interviews, the facility failed to ensure a resident was treated with dignity and respect. This affected one (#23) of three sampled residents for dignity and respect. The facility census was 81. Findings include: Review of Resident #23's medical record revealed an admission date of 06/15/20, with medical diagnoses including prostate cancer, atrial fibrillation, major depression, and constipation. Review of the comprehensive minimum data set assessment dated [DATE] identified mild impairment of cognition. Resident #23 identified assessed as needing one-person physical assistance with toileting and transferring. Review of Resident #23's written plan of care identified his power of attorney chooses to have a camera in resident room. The plan identified Resident #23 dignity will be maintained. The plan of care identified Resident #23 has short term memory issues and needs medication administration. Observation of video on 05/09/23 at 10:14 A.M., taken inside Resident #23's private room, with the facility Ombudsman and Resident #23's Power of Attorney (POA) revealed the video showed Resident #23 was observed to be sitting on the bed side table next to Resident #23's bed, facing the door. The video was time stamped for 05/03/23. State Tested Nursing Assistant (STNA) #40 was observed to enter Resident #23's room at 5:53 A.M., STNA #40 was observed to assist Resident #23 into the bathroom and partially shut the door to the bathroom. The bathroom is located directly across from the end of Resident #23's bed. STNA #40 was overheard stating people are 'expletive term' up a storm as he was removing bed linen from Resident #23's bed. The door was observed to be blocking Resident #23's view in the bathroom, so no reaction could be observed. The statement was observed to potentially be overheard by Resident #23. Interview on 05/09/23 at 10:17 A.M., with Resident #23's POA stated STNA #40's verbalization of people 'expletive term' up a storm would be offensive to Resident #23 for sure. Interview on 05/09/23 at 10:54 A.M., with the Director of Nursing confirmed STNA #40's statement is not professional and or dignified. Review of the policy titled Promoting/Maintaining Resident Dignity dated November 2017, revealed the practice of the facility to protect and promote resident right and treat each resident with respect and dignity, as well as care for resident in a manner and in an environment, which maintains of enhances resident quality of life by recognizing residents individuality. The policy identified when interacting with a resident, pay attention to the resident as an individual; conversations should be Page 1 of 4 365763 365763 05/09/2023 Arbors at Mifflin 1600 Crider Rd Mansfield, OH 44903

F 0557 resident focused, and resident centered. Level of Harm - Minimal harm or potential for actual harm This deficiency represents the noncompliance discovered during the investigation of Complaint Number OH00142666. Residents Affected - Few 365763 Page 2 of 4 365763 05/09/2023 Arbors at Mifflin 1600 Crider Rd Mansfield, OH 44903

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations of video, medical record review, self-report incident and investigation review, Power of Attorney and staff interviews, the facility failed to ensure adequate supervision was provided to prevent potential accidents. This affected one (#23) of three sampled residents for supervision. The facility census was 81. Findings include: Review of Resident #23's medical record revealed an admission date of 06/15/20, with medical diagnoses including prostate cancer, atrial fibrillation, major depression, and constipation. Review of the comprehensive minimum data set assessment dated [DATE] identified mild impairment of cognition. Resident #23 identified assessed as needing one-person physical assistance with toileting and transferring. Review of Resident #23's written plan of care identified his power of attorney chooses to have a camera in resident room. The plan identified Resident #23 dignity will be maintained. The plan of care identified Resident #23 has short term memory issues and needs medication administration. Observation of video on 05/09/23 at 10:14 A.M., taken inside Resident #23's private room, with the facility Ombudsman and Resident #23's Power of Attorney (POA) revealed the video showed Resident #23 was observed to be sitting on the bed side table next to Resident #23's bed, facing the door. The video was time stamped for 05/03/23. State Tested Nursing Assistant (STNA) #40 was observed to enter Resident #23's room at 5:53 A.M., STNA #40 was observed to assist Resident #23 into the bathroom and partially shut the door to the bathroom. The bathroom is located directly across from the end of Resident #23's bed. STNA #40 was then observed to leave the room at 5:56 A.M., with the bedding in his hands and did not return to the room. The video then shows as 6:16 A.M., Resident #23 is leaving the bathroom in his wheelchair and is naked. Resident #23 gets into bed at 6:20 A.M., he is unable to cover his naked body and is laying in the bed. Interview on 05/09/23 at 10:17 A.M., with Resident #23's POA, revealed the POA observed Resident #23 laying in his bed, uncovered and called the facility. The POA identified Medical Records Clerk (MRC) #49 as the person who answered the phone and went to Resident #23's room. Review of the facility self-reported incident (SRI) #234643 identified Resident #23 POA called the facility on 05/03/23, with concerns regarding his care and treatment that morning. The SRI included a written statement from STNA #40 that confirmed he had left Resident #23 in the bathroom at change of shift. The statement identified he told STNA #54 to check on Resident #23 first. Review of STNA #54's written statement dated 05/03/23, identified she remembers STNA #40 telling her in morning report that Resident #23 was toileted; however, not that he was still on the toilet. STNA #54 identified she was caring for another resident on 05/03/23 around 6:30 A.M., when MRC #49 notified her Resident #23 was in bed, naked and the concerns from the POA. Interview on 05/09/23 at 10:54 A.M., with the Director of Nursing confirmed staff should not have left Resident #23's bedroom, while he was in the bathroom. This deficiency represents the noncompliance discovered during the investigation of Complaint Number OH00142666. 365763 Page 3 of 4 365763 05/09/2023 Arbors at Mifflin 1600 Crider Rd Mansfield, OH 44903

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations of videos, medical record reviews, policy review and staff interview, the facility failed to ensure medications were not left unattended at bedside. This affected one (#23) of three sampled residents reviewed for medication administration. The facility census was 81. Findings include: Review of Resident #23's medical record revealed an admission date of 06/15/20, with medical diagnoses including prostate cancer, atrial fibrillation, major depression, and constipation. Review of the comprehensive minimum data set assessment dated [DATE] identified mild impairment of cognition. Resident #23 identified assessed as needing one-person physical assistance with toileting and transferring. Review of Resident #23's written plan of care identified his power of attorney chooses to have a camera in resident room. The plan identified Resident #23 dignity will be maintained. The plan of care identified Resident #23 has short term memory issues and needs medication administration. Observations of videos, dated 05/08/23 at 9:31 A.M., revealed Licensed Practical Nurse (LPN) #45 was observed to enter Resident #23's room and announced she had his medications. LPN #45 was observed to set the medications, inside a cup, down on his bedside stand. LPN #45 then immediately left the room and could no longer be seen on camera. LPN #45 left the door open. Resident #23 was observed to pick up the cup of medications with his left hand and pour the pills into his right hand. Resident #23 was then observed trying to lift his right hand to his mouth. Resident #23 was observed to struggle with this and was able to complete the task after several minutes. Observations of a video dated 04/21/23 identified LPN #45 entered Resident #23's room and set his medications on the bedside stand. LPN #45 was observed to leave the room immediately and without observation to ensure the medications were consumed. Interview on 05/09/23 at 10:34 A.M., with LPN #45, confirmed she was Resident #23's nurse on 05/08/23 and was to administer his morning medications. LPN #45 confirmed she should stay with residents until they consume the medications and not leave them at the bedside. Review of the policy titled Medication Administration dated 01/01/22 revealed the staff should observe resident consumption of medications. This deficiency represents the noncompliance discovered during the investigation of Complaint Number OH00142666. 365763 Page 4 of 4