Arbors at Fairlawn the

Inspectors wroteTHE 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.

Inspectors wroteBased on record reviews and interview, the facility failed to ensure Resident #90's safety after not returning timely after a leave of absence (LOA). This affected one resident (Resident #90) of three residents reviewed for LOA's. The census was 80.

Inspectors wroteBased on observation, resident and staff interview, record review, and review of the facility policy, the facility failed to provide sufficient staff to ensure the residents received timely assistance with showers/bathing, incontinence care, dressing, personal hygiene, and changing of soiled sheets. This affected six of six residents (Resident #9, #13, #38, #46, #49, and #56) reviewed for sufficient staffing and had the potential to affect all residents residing at the facility. The facility census was 73.

Inspectors wroteBased on observation, resident and staff interview, record review, and review of the facility policy, the facility failed to ensure residents who were dependent on staff for activities of daily living (ADL) received assistance with bathing/showers. This affected four (Resident #9, #13, #38, and #46) of five residents reviewed for ADLs. The facility census was 73.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy, the facility failed to ensure fall interventions were in place for a resident with a history of falls and was a fall risk. This affected one (Resident #68) of three residents reviewed for falls. The facility census was 73.

Inspectors wroteBased on observation, resident and staff interview, record review, and review of the facility policy, the facility failed to ensure the residents received timely incontinence care. This affected three (Residents #9, #49, and #56) of three residents reviewed for incontinence care. The facility census was 73.

Inspectors wroteBased on record review and interview, the facility failed to ensure Resident #74 and resident representatives were properly notified in writing of an emergency discharge for Resident #74. This affected one resident (Resident #74) of three residents reviewed for discharges. The facility census was 72.

Inspectors wroteBased on record review, interview and review of facility policy, the facility failed to collaborate with the hospital to ascertain an accurate status of Resident #74's condition before refusing to allow Resident #74 to return to the facility after hospitalization. This affected one resident (Resident #74) of three residents reviewed for discharges. The facility census was 72.

Inspectors wroteBased on medical record review, review of the ambulance run report, review of hospital documents, review of the facility Self-Reported Incident (SRI) investigation, and interviews, the facility failed to ensure Resident #73 was provided a transfer to bed in a safe manner to prevent an incident/accident with major injury. Actual harm occurred on 08/25/24 when Resident #73, who was severely cognitively impaired and dependent on two staff with maximal assistance needed for transfers, sustained a 10-centimeter laceration that went to the bone with profuse bleeding to her right calf during a staff assisted transfer. As a result of the incident/injury, Resident #73 was emergently transferred to the local hospital on [DATE] for treatment which included 21 sutures to the wound. [...]

Inspectors wroteBased on observation, record review, and interviews the facility failed to ensure all treatments were completed per physician orders for Resident #39. This affected one resident (Resident #39) of four residents reviewed for treatment administration. The facility census was 69.

Inspectors wroteBased on observation and staff interview the facility failed to ensure the security and confidentiality of resident medical records. This affected thirteen (Residents #5, #10, #12, #16, #18, #20 #36,#42 #262, #263, #264, #265 #266) of thirty six sampled residents. The facility census was 59. Findings Include: Observation on 06/10/24 at 5:15 P.M. of the facilities information board on the wall after the main entrance area noted information such as contact information for advocacy agencies (i.e local social security office, local area agency on aging and local ombudsman office), resident rights, state agency contact information and numerous other important information for residents. On the wall was also a plastic file holder. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, interviews, policy review, and review of the investigation notes for self-reported incident (SRI) #243949 the facility failed to prevent staff to resident abuse. This affected one resident (#32) of three residents reviewed for abuse. The facility census was 56. Findings Include: Review of the medical record for Resident #32 revealed an admission date of 01/27/24 with diagnoses including chronic osteomyelitis (infection of bone) of the left thigh, local infection of the skin and subcutaneous tissue, unstageable pressure ulcer, Sjogren syndrome (an immune system illness that mainly causes dry eyes and dry mouth), major depression, and history of respiratory failure. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to timely provide care and treatment to ensure one resident (Resident #50) did not develop a pressure injury of the sacrum. Actual harm occurred when Resident #50 developed a Stage 4 (Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible on some parts of the wound bed. Epibole [rolled edges], undermining and/or tunneling often occur. Depth varies by anatomical location.) of the sacrum. The facility also failed to ensure pressure injuries of a lower stage did not develop for Resident #47. This affected two of three residents (#47, #50, and #57) reviewed for pressure injuries. The facility identified five resident with pressure ulcers. The census was 58.

Inspectors wroteBased on observations, interview, and record review, the facility failed to maintain a clean and sanitary kitchen and nursing unit refrigerator and ensure proper food storage. This had the potential to affect all residents. The facility census was 58.

Inspectors wroteBased on observation and interview, the facility failed to ensure the residents' environment was maintained in a clean, sanitary, homelike condition and in good repair. This had the potential to all residents. The facility census was 58.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection control and infection prevention guidelines for community equipment. This affected one resident (Resident #3) out of 15 residents (Residents #3, #14, #18, #20, #21, #24, #28, #33, #37, #45, #48, #49, #50, #57) with an active physician order to monitor blood sugar. The facility failed to ensure proper hand hygiene during medication administration. This affected one resident (Resident #3) and had the potential to affect all facility residents. The facility failed to ensure staff donned proper personal protective equipment (PPE). This affected one Resident (Resident #49) and had the potential to affect all facility residents. The facility census was 58.

Inspectors wroteBased on observation, interview, record review and review of the facility policy the facility failed to ensure Residents #47 and #56 were treated with respect by facility staff. This affected two of three residents reviewed for respect and dignity, Resident's #47 and #56. The facility census was 58.

Inspectors wroteBased on record review and interview, the facility failed to ensure Resident #211 transfer notice contained the accurate state's information under the appeal rights. This affected one resident (#211) of two residents (#210 and #211) reviewed for hospitalizations. The facility census was 58.

Inspectors wroteBased on record review and interview, the facility failed to ensure a bed hold notice was provided to Resident #211 upon hospitalization. This affected one resident (#211) of two residents (#210 and #211) reviewed for hospitalizations. The facility census was 58.

Inspectors wroteBased on observation, interview, medical record review, review of manufacturer instructions, and review of the facility policy, the facility failed to provide a safe mechanical lift transfer for Resident #24, ensure Resident #210 was provided appropriate assistance with bed mobility during incontinence care, and ensure vaping supplies were kept secured. This affected one resident (Resident #24) of 16 residents (Resident #1, #3, #4, #11, #13, #19, #22, #26, #41, #48, #49, #50, #51, #52, and #58) reviewed who required a mechanical lift for transfers, one resident (Resident #210) out of three residents reviewed for falls, and one resident (Resident #28) out of nine residents reviewed for smoking. The facility census was 58.

Inspectors wroteBased on observation, interview, record review and review of the facility policy the facility failed to ensure one resident (Resident #300) known for wandering did not walk out of the facility unaccompanied by a staff member. This affected one resident (Resident #300) out of six residents (Resident's #5, #6, #7, #17, #21, #23) reviewed who were at risk for elopement. The facility census was 58.

Inspectors wroteBased on record review and interview, the facility failed to ensure an antipsychotic as needed medication was not ordered beyond 14 days without first re-evaluating the resident, and ensure all psychotropic medications were reviewed to ensure the appropriateness of their use. This affected one resident (Resident #44) of five residents reviewed for unnecessary medications. The facility census was 58.

Inspectors wroteBased on record review and interview, the facility failed to provide adequate supervision for Resident #24 during toileting. Actual harm occurred when Resident #24 was left unsupervised in the bathroom, fell and hit her head causing a laceration requiring an emergency room visit and a staple was needed to close her head/scalp laceration. This affected one of six residents reviewed for accidents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare, store and distribute food in a sanitary kitchen environment. This affected 80 of 81 residents receiving meals from the kitchen. The facility identified Resident #52 as not receiving food by mouth.

Inspectors wroteBased on observation, interview and menu spreadsheet review the facility failed to ensure meals were provided as planned on the menus. This affected three residents (Resident #43, Resident #62 and Resident #85) of three residents on a pureed diet and one resident (Resident #6) of one resident on a level-II mechanically altered diet. The facility census was 81 residents.

Inspectors wroteBased on observation and interview the facility failed to maintain clean, functional and sanitary shower rooms. This affected Resident #41, Resident #56 and Resident #61 and affected four of four facility shower rooms, which had the potential to affect all residents residing in the facility, except for 13 residents receiving only bed baths (Residents #8, 9, 15, 29, 35, 40, 43, 48, 50, 52, 62, 70 and 80).

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician was notified of abnormal glucose levels for Resident #33. This affected one of five residents reviewed for medications.

Inspectors wroteBased on observation, record review and interview, the facility failed to provide treatment to Resident #52's pressure ulcer per the physician orders. This affected one of one resident reviewed for pressure ulcers.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure Resident #52's medical record contained a physician order for oxygen therapy. This affected one of two residents reviewed for respiratory care.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure Resident #50's medications and renal diet were provided as ordered by the physician. This affected one resident of one resident reviewed for dialysis services.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. The facility error rate was 18.51%, with 5 errors in 27 opportunities. This affected two of four residents observed for medication pass (Resident #'s 2 and 52).

Inspectors wroteBased on observation, interview and record review the facility failed to ensure Resident #50's medications were appropriately stored and labeled. This affected one resident of one resident reviewed for dialysis.