Arbors at Fairlawn the

In the surveyor’s words

From the most serious findings on record at Arbors at Fairlawn the, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Feb 6, 2023

  Based on medical record review, staff and resident interviews, physician interview, review of an emergency medical services (EMS) run report, review of hospital documentation including a surgical operative note, medication manufacture guidelines, review of Centers for Disease Control guidance on sepsis, and review of facility policies regarding abuse, change of condition, and sepsis protocol, the facility failed to prevent an incident of neglect involving Resident #2 following an acute change in condition when the change was not timely identified and medical treatment was not timely obtained. […]

• Actual harm, isolatedF689Oct 10, 2024

  Based 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 08/25/24 for treatment which included 21 sutures to the wound. […]

• Actual harm, isolatedF686Feb 6, 2023

  Based on observation, record review, facility policy and procedure review and interview, the facility failed to ensure interventions were implemented to prevent and timely identify the development of pressure ulcers and/or to ensure adequate treatments were in place to promote healing. This affected two residents (#25 and #40) of three residents reviewed for pressure ulcers. The facility census was 54. Actual Harm occurred on 12/06/22 when Resident #40, who required extensive assistance from two staff for bed mobility, developed a new, in-house acquired deep tissue injury to the sacrum without evidence of adequate preventative interventions including turning and repositioning. The facility failed to identify the pressure ulcer prior to it being identified as a deep tissue injury. […]

• Actual harm, isolatedF686Aug 15, 2022

  Based 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. […]

• No harm, potential for more than minimal, widespreadF725Mar 11, 2025

  Based 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. Findings include: 1. Record review for Resident #46 revealed an admitted [DATE]. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #46 was cognitively intact. Resident #46 required supervision or touch assistants with bathing and tub/shower transfers. […]