Inspection·June 8, 2021

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and policy review, the facility failed to ensure the physician was notified of a resident's weight gain of two or more pounds in 24 hours in accordance to his plan of care. This affected one (Resident #63) of one residents reviewed for dialysis. Findings include: A review of Resident #63's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included end stage renal disease, dependence on renal dialysis and congestive heart failure. A review of Resident #63's physician's orders revealed he was to be weighed daily. The order had been in place since 05/11/21. A review of Resident #63's care plans revealed he had a care plan in place chronic renal failure related to end stage renal disease requiring dialysis. The care plan was initiated on 05/11/21. One of the goals included the resident would not have any signs or symptoms of any complications related to fluid overload. The interventions included the need to monitor/ document/ report to the physician signs and symptoms of fluid overload to include a weight gain of over two pounds a day. A review of Resident #63's treatment administration record (TAR) for May 2021 revealed the resident's daily weights were to be recorded on the TAR. The start date for obtaining the daily weights was 05/12/21. Weights obtained on 05/13/21 and 05/14/21 reflected a weight gain of two or more pounds as the resident weighed 286.2 pounds on 05/13/21 and was 290.6 pounds on 05/14/21 (4.4 pounds). Weights obtained on 05/27/21 and 05/28/21, again showed a weight gain of greater than two pounds as the resident weighed 291.6 pounds on 05/27/21 and was 297.8 pounds on 05/28/21 reflecting a 6.2 pound weight gain. A review of Resident #63's nurse's progress notes from 05/13/21 through 05/27/21 revealed no evidence of the physician being notified of the resident's weight gains of two or more pounds between 05/13/21 to 05/14/21 and again 05/27/21 to 05/28/21. Findings were verified by Registered Nurse (RN) #100. On 06/03/21 at 10:42 A.M., an interview with RN #100 confirmed they did not have any evidence of Resident #63's physician being notified of the resident's weight gain of two or more pounds in 24 hours occurring on 05/14/21 and 05/28/21 as per his physician's orders and plan of care. A review of the facility's policy on notification of changes revised 10/20/20 revealed the purpose of the policy was to ensure the facility promptly consults the resident's physician when there was a change requiring notification. Circumstances requiring notification included a significant change in the resident's physical condition that may include clinical complications. They were also to notify the physician for circumstances that require the resident's treatment to be altered. A review of the facility's policy on care planning special needs for dialysis revised 10/30/20 revealed it was the facility's policy that they would provide the necessary care and treatment, consistent with the physician's orders and the comprehensive person centered care plan to meet special (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365348 If continuation sheet Page 2 of 12 Printed: 05/15/2026 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 365348 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Gallipolis 170 Pinecrest Drive Gallipolis, OH 45631 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 0580 Level of Harm - Minimal harm or potential for actual harm medical and nursing needs of residents receiving dialysis. Comprehensive care plans would be developed based on resident assessments, goals, and preferences in accordance with assessment and care plan procedures. Interventions would include documentation and monitoring of complications. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365348 If continuation sheet Page 3 of 12 Printed: 05/15/2026 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 365348 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Gallipolis 170 Pinecrest Drive Gallipolis, OH 45631 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview and facility policy and procedure review, the facility failed to consistently and adequately assess one resident's Stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough or bruising. May also present as an intact or open/ ruptured blister.) pressure ulcer. This affected one of one resident (Resident #59) reviewed for pressure ulcers. The facility identified two residents with pressure ulcers. Residents Affected - Few Findings Include: Review of Resident #59's medical record revealed an original admission date of 07/28/20 with the latest readmission of 02/21/21. Diagnoses included congestive heart failure, chronic obstructive pulmonary disease, chronic kidney disease, anemia, cardiomyopathy, atrial fibrillation, history of COVID-19, chronic pain, major depressive disorder, overactive bladder and insomnia. Review of the resident's quarterly MDS 3.0 assessment dated [DATE] revealed the resident had clear speech, sometimes understood others, sometimes made herself understood and had a severe cognitive deficit as indicated by a BIMS score of six. The resident required extensive assistance of two staff for bed mobility, transfers and toilet use. The resident was assessed as being at risk for skin breakdown and had an unhealed Stage II pressure ulcer. The facility implemented a pressure reducing device for bed, pressure ulcer care, application of non-surgical dressing and application of ointment/medications. Review of the resident's pressure ulcer scale dated 08/31/20 revealed a score of 16 indicating the resident was a low risk for skin breakdown. Review of the plan of care dated 07/28/20 revealed the resident had an actual skin impairment related to a pressure ulcer to coccyx and skin teat to left shin. Interventions included air mattress to bed, keep fingernails short, encourage geri-sleeves, encourage good nutrition and hydration. Follow facility protocols for treatment of pressure injury, keep skin clean and dry, use a draw sheet or lifting device to move resident and use caution during transfers and bed mobility to prevent striking hands against any sharp or hard surface. Review of the resident's monthly physician's orders for June 2021 identified orders dated 03/01/21 to monitor dressing to coccyx and ensure dressing is intact with the instructions to change as needed per order, cleanse area to coccyx with wound cleanser, pat dry, apply hydrogel with AG, and cover with hydrocolliod dressing every three days and as needed until resolved and 03/23/21 for an air mattress to bed with the special instructions to check placement weekly. Review of the skin and wound assessment dated [DATE] revealed the facility identified the resident had a Stage II pressure ulcer to her coccyx measuring 3.0 centimeters (cm) by 2.0 cm by 0.1 cm. The wound was described as being 100% granulation tissue. The facility implemented the treatment to cleanse the coccyx wound with wound cleanser, pat dry, apply hydrogel with alginate and cover with hydrocolloid dressing every three days and as needed until healed. Review of the skin and wound assessment dated [DATE] revealed the Stage II pressure ulcer measured 2.0 cm by 1.5 cm by 0.1 cm and was 100% granulation tissue with serous drainage. The treatment was unchanged. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365348 If continuation sheet Page 4 of 12 Printed: 05/15/2026 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 365348 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Gallipolis 170 Pinecrest Drive Gallipolis, OH 45631 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the skin and wound assessment dated [DATE] revealed the Stage II pressure ulcer measured 1.2 cm by 0.8 cm by 0.1 cm and was 100% granulation tissue with serous drainage. The treatment was unchanged. Review of the skin and wound assessment dated [DATE] revealed the Stage II pressure ulcer measured 0.8 cm by 0.8 cm by 0.1 cm and was 100% granulation tissue with serous drainage. The treatment was unchanged. Review of the skin and wound assessment dated [DATE] revealed the Stage II pressure ulcer measured 0.8 cm by 0.8 cm by 0.1 cm and was 100% granulation tissue with serous drainage. The treatment was unchanged. Review of the medical record failed to provide a weekly skin assessment for the facility acquired Stage II pressure ulcer to the resident's coccyx. Review of the skin and wound assessment dated [DATE] revealed the Stage II pressure ulcer measured 0.8 cm by 0.6 cm by 0.1 cm and was 80% granulation tissue with serous drainage. The assessment did not specify what the remaining 20% of wound bed was comprised of. There was no change to the treatment although the assessment indicated the wound had stalled in healing. Review of the skin and wound assessment dated [DATE] revealed the Stage II pressure ulcer measured 0.3 cm by 0.7 cm with no depth. The assessment lacked a description of the wound, current treatment or the progress of the wound. Review of the skin and wound assessment dated [DATE] revealed the Stage II pressure ulcer measured 0.2 cm by 0.5 cm with no depth measurement and was 100% granulation tissue and 10% slough. The wound was assessed as having a light amount of serous drainage. The assessment again indicated the wound had stalled in the healing process. Review of the skin and wound assessment dated [DATE] revealed the Stage II pressure ulcer measured 0.6 cm by 0.4 cm with no recorded depth and was 100% granulation tissue with light serous drainage. The treatment was unchanged. The wound was assessed as being stable. Review of the skin and wound assessment dated [DATE] revealed the Stage II pressure ulcer measured 0.2 cm by 0.1 cm by 0.1 cm and was 100% granulation tissue with light serous drainage. The treatment was unchanged. The wound was assessed as improving. Review of the skin and wound assessment dated [DATE] revealed the Stage II pressure ulcer measured 0.5 cm by 0.4 cm by 0.1 cm and had granulation tissue with light serous drainage. The treatment was unchanged. The wound was assessed as being stalled. Review of the skin and wound assessment dated [DATE] revealed the Stage II pressure ulcer measured 0.2 cm by 0.2 cm with no depth measurement and had granulation tissue with light serous drainage. The treatment was unchanged. The wound was not assessed for progress. Review of the skin and wound assessment dated [DATE] revealed the Stage II pressure ulcer measured 0.3 cm by 0.3 cm with no depth measurement and had granulation tissue with light serous drainage. The treatment was unchanged. The wound was assessed as being stable. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365348 If continuation sheet Page 5 of 12 Printed: 05/15/2026 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 365348 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Gallipolis 170 Pinecrest Drive Gallipolis, OH 45631 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 06/03/21 at 2:15 P.M. observation of Registered Nurse (RN) #11 and Licensed Practical Nurses (LPN) #6 and #48 provide the physician ordered treatment to the resident's Stage II pressure ulcer to her coccyx revealed upon entry to the room the required supplies were set up on a barrier on the resident's bedside table. The staff washed their hands and donned disposable gloves. RN #11 and LPN #6 positioned the resident on her left side. LPN #48 removed the soiled dressing dated 06/02/21 and disposed of it in the trash. She washed her hands and donned a clean pair of gloves. She then cleansed the wound with wound cleanser and a 4X4, pat dry. She measured the wound with a single use paper wound measure at 0.5 cm by 0.3 cm by 0.1 cm. The wound was 100% granulation. She then washed her hands donned a clean pair of gloves applied the dermagel/AG with a sterile Q-tip and covered the wound with a hydrocolloid dressing. On 06/03/21 at 3:15 P.M. interview with RN #11 verified the lack of a weekly assessment for 04/06/21 and the lack of accuracy of the assessments. Review of the facility policy titled, Pressure Injury Prevention and Management, dated 10/30/20 revealed the facility is committed to the prevention of avoidable pressure injuries and the promotion of healing of existing pressure injuries. Assessments of pressure injuries will be performed by a licensed nurse and documented in the medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365348 If continuation sheet Page 6 of 12 Printed: 05/15/2026 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 365348 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Gallipolis 170 Pinecrest Drive Gallipolis, OH 45631 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 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 record review, staff interview, and policy review, the facility failed to ensure a resident receiving dialysis, who had an order to be weighed daily, was weighed in accordance to his orders and plan of care and failed to follow the parameters included with the daily weight order by not notifying the physician when the resident had a weight gain of two or more pounds in 24 hours. They also failed to ensure the dialysis center completed the dialysis communication record to include a pre and post assessment of the resident's weights/ vital signs, medications received during his treatment and any other pertinent problems or complications that may have occurred during his dialysis treatment. This affected one (Resident #63) of one residents reviewed for dialysis. Residents Affected - Few Findings include: A review of Resident #63's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included end stage renal disease, dependence on renal dialysis, and congestive heart failure. A review of Resident #63's physician's orders revealed the resident had an order to be a daily weight. The order had been in place since 05/11/21. A review of Resident #63's care plans revealed he had a care plan in place for chronic renal failure related to end stage renal disease requiring dialysis. The care plan was initiated on 05/11/21. One of the goals included the resident would not have signs or symptoms of any complications related to fluid overload. The interventions included the need to monitor/ document/ report to the physician and signs or symptoms of a weight gain of over two pounds a day. The intervention was initiated on 05/11/21 as well. A review of Resident #63's treatment administration record (TAR) for May 2021 revealed the resident's daily weights were to be recorded on the TAR. The start date for the daily weights was 05/12/21. There was no evidence of a daily weight being obtained on the resident on 05/16/21, 05/18/21, 05/22/21, 05/23/21, 05/25/21 or on 05/26/21. Weights obtained on 05/13/21 and 05/14/21 reflected a weight gain of two or more pounds as the resident weighed 286.2 pounds on 05/13/21 and was 290.6 pounds on 05/14/21 (4.4 pounds). Weights again obtained on 05/27/21 and 05/28/21 showed a weight gain of greater than two pounds as the resident weighed 291.6 pounds on 05/27/21 and was 297.8 pounds on 05/28/21 reflecting a 6.2 pound weight gain. A review of Resident #63's weights recorded in his electronic health record under the vital signs tab confirmed weights were not obtained on the dates missing above. Weights reflecting a weight gain of two or more pounds was confirmed for 05/13/21 to 05/14/21 and again on 05/27/21 to 05/28/21. A review of Resident #63's nurse's progress notes from 05/13/21 through 05/27/21 revealed no evidence of the resident refusing to be weighed on the dates where his daily weights were not recorded. There was also no evidence of the physician being notified of the resident's weight gains of two or more pounds between 05/13/21 to 05/14/21 and again 05/27/21 to 05/28/21. A review of Resident #63's dialysis communication records scanned into the electronic health record revealed there were several dialysis communication records that were not completed by the dialysis center when the resident received his dialysis treatments on 05/19/21, 05/24/21, 05/28/21, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365348 If continuation sheet Page 7 of 12 Printed: 05/15/2026 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 365348 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Gallipolis 170 Pinecrest Drive Gallipolis, OH 45631 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 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 05/31/21. The dialysis communication records for 05/19/21 and 05/24/21 did not include any documentation from the dialysis center pertaining to the resident's vital signs or weights pre and post dialysis treatments, the start and stop time of his dialysis treatments, an assessment of his shunt site, any pain or problems during his treatment or whether or not new orders were received and returned with the resident. The dialysis communication records for 05/28/21 and 05/31/21 only included pre and post vital signs and weights. Findings were verified by Registered Nurse (RN) #100. On 06/03/21 at 10:42 A.M., an interview with RN #100 confirmed they did not have any evidence of Resident #63's daily weights being obtained on the dates missing above. She also could not provide any documented evidence of the physician being notified of the resident's weight gain of two or more pounds in 24 hours occurring on 05/14/21 and 05/28/21 as per his physician's orders and plan of care. She confirmed the dialysis center did not complete and/ or include all the relevant information on the dialysis communication records that they should have when the resident received dialysis treatments. She denied anyone had reached out to the dialysis center to obtain that information when the resident returned to the facility with the incomplete dialysis communication records. A review of the facility's policy on care planning special needs for dialysis revised 10/30/20 revealed the facility would provide the necessary care and treatment, consistent with professional standards of practice, physician's orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet the special medical and nursing needs of residents receiving dialysis. Comprehensive care plans would be developed based on resident assessments, goals, and preferences in accordance with assessment and care plan procedures. The care plan would reflect the coordination between the facility and the dialysis provider and would identify nursing home and dialysis responsibilities. Interventions would include documentation and monitoring of any complications, pre and post weights, assessing/ observing/ documenting care of access sites, lab tests, vital signs and the provisions of medications on dialysis treatment days, such as which medications were administered during dialysis, held prior to dialysis, given prior to dialysis or administered by dialysis staff. Nursing staff was to provide a report to the dialysis provider regarding the resident's condition and treatment provisions each dialysis treatment day. If no written report was received upon return from dialysis, nursing staff would call the dialysis provider to receive a report. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365348 If continuation sheet Page 8 of 12 Printed: 05/15/2026 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 365348 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Gallipolis 170 Pinecrest Drive Gallipolis, OH 45631 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #57 revealed an admission date of 10/05/18. Diagnoses included dementia with behavioral disturbances, cognitive communication deficit, and aneurysm of the carotid artery. Review of Resident #57's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 08 indicating a moderately impaired cognition for decision making abilities. Resident #57 was noted to express verbal behaviors directed towards others. Resident #57 required extensive assistance from two staff members for bed mobility, transfers, dressing, and toilet use. Review of Resident #57's physician orders for May 2021 revealed: -Protonix (proton pump inhibitor to treat reflux disease) 40 milligram (mg) tablet, give daily for heartburn, -Tagament (antacid to reduce acis in the stomach) 200 mg tablet, give one tablet, twice a day for sexual behaviors. Review of the pharmacy recommendation dated 07/16/20 revealed, This resident has been taking Tagament 200 mg, three times a day for behaviors since August 2019. Please evaluate the current dose and consider a dose reduction. Continued review of this pharmacy recommendation revealed no evidence of the physician reviewing or addressing the recommendations for this medication. Review of the pharmacy recommendation dated 09/17/20 revealed, The use of acid-suppressive therapy, particularly Proton Pump Inhibitor (PPI) is associated with an increased risk of community-acquired clostridium difficile colitis (C-Difficile). There is also an association in risk with non-steroidal anti-inflammatory drug use. The incidence of C-difficile for residents on PPIs was shown to be three time normal. Please evaluate continued need for therapy and consider discontinuing Protonix. (Note-resident is also taking Tagament for increased sexual behaviors.) Continued review of this recommendation revealed no evidence of the physician reviewing or addressing the recommendation for this medication. Interview on 06/03/21 at 2:30 P.M. with Registered Nurse (RN) #11 revealed a Pharmacist will review all of the residents medication orders and if there is a concern with their current medication, then the pharmacist will make recommendation of possible changed to be make to that medication. RN #11 stated the facility will receive a print out of all the residents who were reviewed along with a list of residents who did not have any recommendations for that months. For the resident who did have recommendations, there is a sheet called, :Consultant Pharmacist's Medication Regimen Review. This paper will have the residents information on it and the exact medication that the recommendations is pertaining to. The medication order is listed followed by what the new recommended order should be or if the medication should be discontinued. The facility physician will review all of the recommendations for that current month which is normally within 10 days. The physician can either agree, disagree, or suggest other, to the medication recommendations. The physician will them either write a new order for the medications or comments why a change was not made. RN #11 confirmed Resident #57 was still currently taking the medication, Tagament, and Protonix. RN #11 also confirmed there was no evidence of the physician addressing or making any charges to Resident #57's orders in regards to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365348 If continuation sheet Page 9 of 12 Printed: 05/15/2026 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 365348 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Gallipolis 170 Pinecrest Drive Gallipolis, OH 45631 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 0756 medications Tagament or Protonix. Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled, Addressing Medication Regimen Review Irregularities,: dated 01/01/21 revealed , It is the policy of the facility to provide a Medication Regimen Review (MRR) for each resident in order to identify irregularities and respond to those irregularities in a timely manner to prevent the occurrence of an adverse drug event. Residents Affected - Few Based on medical record review and staff interview, the facility failed to ensure pharmacy recommendations for one resident contraindicated gradual dose reduction (GDR) contained a clinical rationale and one resident's pharmacy recommendation was addressed by the physician. This affected two of five residents (Residents #28 and #57) reviewed for unnecessary medications. Findings Include: 1. Review of Resident #28's medical record revealed an admission date of 03/06/19. Diagnoses included dementia with lewy bodies, diabetes mellitus, atrophy of thyroid, early onset cerebellar ataxia, white matter disease, lupus anticoagulant syndrome, hypertension, mood disorder, major depressive disorder, anxiety disorder, dementia with behavioral disturbances and personality change due to known physiological condition. Review of the resident's comprehensive MDS 3.0 assessment dated [DATE] revealed the resident had clear speech, sometimes understood others, sometimes made herself understood and had a severe cognitive deficit. Review of the mood and behavior revealed the resident displayed physical and verbal behaviors towards others and wandered. The assessment indicated the resident received antipsychotic, antianxiety and antidepressant medications. The resident received the medications on a regular basis and the last GDR was attempted on 10/17/19. Review of the monthly physician's orders for June 2021 identified orders dated 03/06/19 for Remeron 15 milligrams (mg) by mouth one time a day for depression, Pristiq 50 mg by mouth one time a day for depression, 06/29/19 Xanax 0.5 mg by mouth two times a day for anxiety and give 1 mg two tablets by mouth at bedtime for depression, 09/30/19 Trazadone 125 mg by mouth at bedtime for insomnia and 10/02/20 Risperdal 0.5 mg by mouth two times a day for mood disorder. Review of the pharmacy recommendation dated 03/18/20 revealed the pharmacist recommended to decrease the medication Trazadone 125 mg by mouth due to receiving the medication since 09/19. The physician addressed the recommendation on 03/20/20 and disagreed documenting, the family refuses. Review of the pharmacy recommendation dated 06/25/20 revealed the pharmacist recommended a gradual dose reduction for the medication Trazadone 125 mg. The physician addressed the recommendation documented, the resident was doing well and daughter refused the reduction. Review of the pharmacy recommendation dated 09/17/20 revealed the pharmacist recommended to decrease the medication Remeron used for an appetite stimulant since 03/19. The physician addressed the recommendation on 09/22/20 and documented uses for appetite, would do more harm than good. Review of the recommendation dated 02/28/21 revealed the pharmacist recommended a GDR for the medication Pristiq 50 mg daily. The physician addressed the recommendation on 03/02/21 and declined the recommendation and documented, behaviors improved, family doesn't want this discontinued. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365348 If continuation sheet Page 10 of 12 Printed: 05/15/2026 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 365348 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Gallipolis 170 Pinecrest Drive Gallipolis, OH 45631 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the recommendation dated 02/28/21 revealed the pharmacist recommended a GDR on the medication Risperdal 0.5 mg by mouth twice daily. The physician addressed the recommendation on 03/02/21 and documented, would do more harm then good. Review of the pharmacy recommendation dated 05/27/21 revealed the pharmacist recommended a GDR on the medication Xanax 0.5 mg by mouth twice a day. The physician addressed the recommendation on 06/03/21 and declined the recommendation documenting, patient currently stable, no changes at this time. On 06/07/21 at 3:00 P.M. interview with Registered Nurse (RN) verified the physician had not provided a rationale for the decline for the pharmacy recommended GDR for the medications antipsychotropic medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365348 If continuation sheet Page 11 of 12 Printed: 05/15/2026 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 365348 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Gallipolis 170 Pinecrest Drive Gallipolis, OH 45631 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, staff interview, review of Food and Drug Administration (FDA) information, review of a Health Day News Study, and facility policy and review, the facility failed to provide adequate justification for the use of antibiotics for COVID-19 positive residents. This affected 17 residents (Residents #1, #2, #3, #4, #10, #20, #22, #24, #27, #32, #49, #50, #53, #55, #56, #60 and #61) of 56 residents who were COVID-19 positive. Residents Affected - Some Findings Include: Review of medical records of Residents #1, #2, #3, #4, #10, #20, #22, #24, #27, #32, #49, #50, #53, #55, #56, #60 and #61 from 01/18/21 to 02/28/21 revealed the residents received the antibiotic Azithromycin prior to the results of a positive COVID-19 test result. There was also no documentation or evidence to support McGeer's criteria or any other assessment was utilized to determine if an antibiotic should be prescribed and administered; it was simply used for the symptoms of COVID-19. On 06/08/21 at 2:58 P.M. interview with Registered Nurse (RN) #53 verified the facility treated residents who were COVID-19 positive with the antibiotic Azithromycin. Additionally she confirmed the course of Azithromycin was completed when the positive COVID-19 results were received. Review of information on the FDA website (https://www.fda.gov) revealed the following FDA response to the question, Are antibiotics effective in preventing or treating COVID-19? No. Antibiotics do not work against viruses; they only work on bacterial infections. Antibiotics do not prevent or treat COVID-19, because COVID-19 is caused by a virus, not bacteria. Some patients with COVID-19 may also develop a bacterial infection, such as pneumonia. In that case, a health care professional may treat the bacterial infection with an antibiotic. In addition, an article from HealthDay News, dated 08/04/20 revealed the following: Early in the U.S. coronavirus pandemic, many people landing in the hospital may have been given unnecessary antibiotics, a new study suggests. The findings come from one of the hard-hit hospitals in New York City, the initial epicenter of the U.S. pandemic. Researchers there found that of COVID-19 patients admitted between March and May, just over 70% were given antibiotics. That's despite the fact that COVID-19 is caused by a virus, and very few of those patients actually had a coexisting bacterial infection. Antibiotics kill bacteria, but are useless against viral infections such as the common cold, the flu and COVID-19. Review of the facility Antibiotic Stewardship Infection Control Program, dated 11/28/17 revealed the program promotes the appropriate use of antimicrobials, including antibiotics, improves outcomes, reduces microbial resistance and decreases the spread of infections by multidrug-resistant organisms. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365348 If continuation sheet Page 12 of 12