Arbors At Springfield

F 0686 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

physician. On 06/23/25, the DON/designee audited all residents with splints for orders and skin assessed with no negative findings. On 06/23/25, the MDS nurse completed an audit of care plans for all residents with splints. On 06/23/25, the DON updated the Braden Scale (used to predict pressure injury risk) with a score of 14 indicating moderate risk. On 06/23/25, the DON/designee completed an audit of recent physician visits in the past two weeks for new orders with no negative findings. On 06/23/25, the DON placed an order for a soft air splint for FR #35. On 06/23/25, the DON/designee educated all nurses regarding after-visit summary for appointments and to clarify if devices are on the resident upon return from

the appointment. The DON/designee will audit all new residents with splints for orders, skin condition, and care plan updates weekly times four weeks. The DON/designee will audit after visit summary for all residents with outside appointments for new orders and visual check of residents for new devices weekly for four weeks. An AD HOC Quality Assurance and Performance Improvement (QAPI) committee meeting was completed on 06/23/25. Results of the audits will be reviewed in the QAPI Committee meeting for one month with revisions to the plan/change in monitoring as deemed by the QAPI committee. This deficiency represents noncompliance investigated under Complaint number 2642319.

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If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Arbors at Springfield

1600 Saint Paris Pike Springfield, OH 45504

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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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

record review, observation, interview, and policy review, the facility failed to ensure fall interventions were in place. This affected one (#33) of four residents reviewed for falls. The facility census was 34.Findings include:Review of the medical record for Resident #33 revealed an admission date of 07/02/25 with diagnoses including but not limited to anoxic brain damage, respiratory failure, cardiac arrest, and anxiety.Review of the minimum data set (MDS) dated [DATE REDACTED] revealed the resident had severe cognitive impairment. Resident #33 was dependent on staff for activities of daily living.Review of the care plan dated 10/07/25 revealed the resident was at risk for falls related to anoxic brain damage and muscle weakness.

Interventions included perimeter overlay to air mattress and low bed.Observation on 10/20/25 at 1:27 P.M. of Resident #33 revealed the resident was lying in bed with an air mattress and the bed was in high position approximately chest high to surveyor with no one in the room.Interview on 10/20/25 at 1:32 P.M. with Certified Nursing Assistant (CNA #118) verified the bed was in high position with no one in the room. CNA #118 stated the resident's husband was in the room prior and would raise the bed when he visited. CNA #118 verified the husband was no longer at the facility and the bed was not lowered per care plan.Review of policy titled, Fall Prevention Program, dated 10/26/23 revealed the nurse will indicate the resident's fall risk and initiate interventions on the resident's baseline care plan. Interventions will be monitored for effectiveness.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Arbors at Springfield

1600 Saint Paris Pike Springfield, OH 45504

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 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

record review, observation, interview, and policy review, the facility failed to ensure proper hand hygiene was completed during a dressing change. This affected one (#7) resident of one resident observed for wound care. The facility census was 34.Findings include:Review of the medical record for Resident #7 revealed an admission date of 07/09/25 with diagnoses including but not limited to chronic obstructive pulmonary disease (COPD), chronic kidney disease stage four, dependence on respirator (ventilator) status, anxiety, and need for assistance with personal care.Review of the minimum data set (MDS) dated [DATE REDACTED] revealed the resident was cognitively intact. The resident was dependent on staff for activities of daily living.Review of the physician order revealed right lower abdomen cleanse with normal saline, pat dry, apply moistened collagen and cover with foam dressing three times weekly and as needed.Observation on 10/20/25 at 2:16 P.M. of wound care with Licensed Practical Nurse (LPN #205) for Resident #7 revealed LPN #205 gathered supplies which included calcium alginate, scissors, normal saline vial, soft silicone foam dressing, and four by four dressings. LPN #205 cleaned scissors with an alcohol pad and placed them

on clean trash bag laid out on treatment cart along with the dressing supplies. LPN #205 knocked on door, entered room and explained to the resident what she was going to do. Resident agreeable to dressing change. LPN #205 then washed hands, donned a gown and placed a clean barrier to cover the bed table and arranged the supplies. LPN #205 donned gloves and removed the old dressing from the residents right lower abdomen. Wound appeared beefy red and peri wound was intact. No odor was noted. LPN #205 then removed her gloves and donned a new pair of gloves. LPN #205 then opened four by four gauze packages and cleansed the wound with normal saline. LPN #205 removed gloves and donned new gloves. LPN #205 placed calcium alginate in the wound and opened the silicone foam dressing. LPN #205 stated that she would date the dressing prior to applying it to the resident. LPN #205 removed her gloves and dated the dressing. LPN #205 donned new gloves and placed the foam dressing over the wound. LPN #205 was not observed to wash or sanitize hands after removing soiled gloves and donning clean gloves on four occasions. Interview on 10/20/25 at 2:42 P.M. with LPN #205 revealed the nurse verified she did not wash or sanitize hands between glove changes. LPN #205 verified she was supposed to wash hands or sanitize hands prior to donning new gloves. Review of policy titled, Clean Dressing Change, dated 12/28/23 revealed policy explanation and compliance guidelines: explain the procedure to the resident and screen for privacy, multi-use wound care supplies should be dated and initialed when opened, set up clean field with needed supplies for wound cleansing and dressing application, establish area for soiled products to be placed, wash hands and put on clean gloves, place a barrier cloth or pad next to the resident under the wound to protect the bed linen and other body sited, loosen the tape and remove the existing dressing, remove gloves, wash hands and put on clean gloves, cleanse the wound as ordered, measure wound, wash hands and put on clean gloves, apply topical ointments or creams and dress the wound as ordered, secure dressing mark with date and initials, discard disposable items and gloves into appropriate receptacle and wash hands.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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Facility ID:

If continuation sheet