Health inspection·December 7, 2023

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record reviews, and staff interviews, the facility failed to ensure a resident had geri-sleeves applied as ordered. This affected one (Resident #2) of one resident observed for use of Geri-sleeves. Additionally, the facility failed to complete daily weights as ordered. This affected one (Resident #9) of one resident reviewed for weight monitoring. The facility census was 79. Residents Affected - Few Findings include: 1. Review of Resident #2's medical record identified admission to the facility occurred on 01/15/13 with diagnoses including stroke, high blood pressure, dementia and anemia. Review of Resident #2's most recent Minimum Data Set (MDS) assessment dated [DATE] revealed he had fragile skin with no current skin tears. Resident #2 was dependent upon staff for dressing. Review of Resident #2's December physician orders identified an order dated 04/06/23 for Resident #2 to have Geri-sleeves (sleeves that provide protection to sensitive skin) on at all times. Observation of Resident #2 on 12/05/23 at 7:14 A.M. revealed he was sitting in his wheelchair near the main nursing station and did not have any Geri-sleeves applied at this time. Observation on 12/05/23 at 7:41 A.M. Resident #2 was in the main dining room, in his wheelchair, and remains without Geri-sleeves on. Observation of Resident #2 on 12/06/23 at 7:03 A.M. revealed the resident sitting in the television room, next to the nursing station. Resident #2 did not have any Geri-sleeves on at this time. Interview and observation with the Director of Nursing (DON) on 12/06/23 at 7:05 A.M. confirmed Resident #2 did not have Geri-sleeves on, and he had a current physician order for Geri-sleeves to be applied at all times. The DON further verified Resident #2's skin was fragile and Geri-sleeves were used in an attempt to prevent skin tears. Observation of Resident #2 on 12/07/23 at 8:15 A.M. and again at 8:44 A.M. revealed Resident #2 did not have Geri-sleeves on. Interview and observation with the DON on 12/07/23 at 8:44 A.M. verified Resident #2 did not have Geri-sleeves on. 2. Review of Resident #9's medical record identified admission to the facility occurred on 08/30/23 with medical diagnoses including heart disease, aortic stenosis, chronic obstructive pulmonary disease (COPD), mood disorder, Alzheimer's, Herpes viral infection, anxiety, and major depression. Review of Resident #9's physician orders revealed an order dated 10/12/23 to obtain a daily weight, with instructions to call the cardiologist if weight gain greater than three pounds overnight or five pounds in a week. Review of Resident #9's weights listed in her medical record revealed only four weights taken from October 2023 to November 2023. On 10/18/23, Resident #9 weighed 165.5 pounds (lbs.). On 10/28/23, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365408 If continuation sheet Page 2 of 17 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 365408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Delaware 2270 Warrensburg Road Delaware, OH 43015 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 0684 Level of Harm - Minimal harm or potential for actual harm Resident #9 weighed 163.7 lbs. On 11/01/23, Resident #9 weighed 163.8 lbs. On 11/10/23, Resident #9 weighed 164.6 lbs. Daily weights were not documented. Interview on 12/06/23 at 1:37 P.M. with Unit Manager (UM) #75 verified Resident #9's daily weight was not being obtained as ordered. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365408 If continuation sheet Page 3 of 17 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 365408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Delaware 2270 Warrensburg Road Delaware, OH 43015 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 - Some 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 medical record review and staff interview, the facility failed to complete thorough root cause analysis following falls. This affected three (Residents #16, #19, and #181) of five residents reviewed for falls. Additionally, the facility failed to have fall interventions in place as ordered. This affected three (Residents #16, #181, and #37) of five residents reviewed for falls. The facility census was 79. Findings include: 1. Review of Resident #19's medical record identified admission to the facility on [DATE] with medical diagnoses including high blood pressure, anemia, trouble swallowing, muscle weakness and reduced mobility. Review of Resident #19's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. Further review of Resident #19's medical record revealed he suffered a fall with femur fracture on 06/08/23 and was at high risk for further falls. Review of Resident #19's December 2023 physician orders for fall interventions revealed orders for non-skid strips in front of the commode, 1/4 left side assist bar to bed frame, fall mat on floor to left side of the bed, raised toilet seat, and nonskid strips near bed. Review of Resident #19's care plan revealed interventions in place to prevent falls including apply side rails to aide in repositioning and scoop mattress. Review of Resident #19's SOC meeting-fall dated 09/17/23 revealed the resident had a fall and there was no time documented for when the fall occurred. The section identified as 'Review' which identified the who, what, when, why, and root cause analysis of the fall revealed resident room was listed. There were no other details or a root cause analysis documented. Review of Resident #19's SOC meeting-fall dated 09/29/23 revealed the resident had a fall and there was no time documented for when the fall occurred. The section identified as 'Review' which identified the who, what, when, why, and root cause analysis of the fall revealed resident room was listed. There were no other details or a root cause analysis documented. Review of Resident #19's SOC meeting-fall dated 10/07/23 revealed the resident had a fall and there was no time documented for when the fall occurred. The section identified as 'Review' which identified the who, what, when, why, and root cause analysis of the fall revealed resident room was listed. There were no other details or a root cause analysis documented. Review of the nursing note dated 10/07/23 at 7:30 P.M. revealed Resident #19 was found sitting on the floor with a mat beside the bed. Resident #19 was unable to explain what happened. The resident had no visible injuries and voiced no complaints of pain. The bed was in the low position and the call light was in the resident's bed. A perimeter (scoop) mattress was added to the care plan and ordered, and would be delivered that evening. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365408 If continuation sheet Page 4 of 17 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 365408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Delaware 2270 Warrensburg Road Delaware, OH 43015 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 - Some Further review of the medical record revealed the resident did not have injuries documented with any of the falls. Observation of Resident #19 and his room on 12/04/23 at 11:50 A.M. revealed there was no raised toilet seat or non-skid strips in the bathroom. Further observation revealed Resident #19's bed did not have assistive bars and there were no non-skid strips near the bed. Observation on 12/06/23 at 7:06 A.M. with the Director of Nursing (DON) verified Resident #19 did not have a raised toilet seat, non-skid strips in the bathroom or near the bed, and no assistive bars applied to the bed. The bed was observed with an air mattress and not a scoop mattress as ordered. Interview with the DON on 12/06/23 at 7:06 A.M. confirmed the root cause analysis for Resident #19's falls on 09/17/23, 09/29/23, and 10/07/23 was not completed. The DON also confirmed there was no time documented for each fall and no effective information to help determine proper interventions to put into place to potentially prevent future falls. 2. Review of Resident #16's medical record identified admission to the facility on [DATE] with medical diagnoses including cerebral atherosclerosis, multiple sclerosis, asthma, cerebral infarction, and dementia. Review of Resident #16's MDS assessment dated [DATE] revealed the resident had severe cognitive impairment. Further review of Resident #16's medical record revealed she had a fall on 11/26/23. Review of Resident #16's SOC meeting-fall dated 11/28/23 revealed the section identified as 'Review' which identified the who, what, when, why, and root cause analysis of the fall revealed resident room was listed. There were no other details or a root cause analysis documented. Interview with the DON on 12/07/23 at 11:30 A.M. verified the root cause analysis was not completed for Resident #16's fall on 11/28/23. 3. Review of Resident #181's medical record identified admission to the facility on [DATE] with medical diagnoses including displaced avulsion fracture of the right ilium, dementia, psychotic disturbances, major depression disorder, and repeated falls. Review of Resident #181's MDS assessment dated [DATE] revealed the resident had severe cognitive impairment. Resident #181 had a fall on 11/27/23 and was diagnosed with a right ilium fracture. Review of Resident #181's care plan updated 09/25/23 revealed Resident #181 was to have anti-tippers to her wheelchair. After her fall on 11/27/23, she was to wear hipsters while in her wheelchair. Review of Resident #181's SOC meeting-fall- V2 dated 11/28/23 revealed the resident had a fall and there was no time documented for when the fall occurred. The section identified as 'Review' which identified the who, what, when, why, and root cause analysis of the fall revealed resident room was listed. There were no other details or a root cause analysis documented. Observation on 12/06/23 at 11:46 A.M. with Registered Nurse (RN) #82 revealed Resident #181 was sitting in her wheelchair with no anti-tippers applies to the wheelchair and the resident was not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365408 If continuation sheet Page 5 of 17 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 365408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Delaware 2270 Warrensburg Road Delaware, OH 43015 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 wearing hipsters. RN #82 verified fall interventions were not in place for Resident #181. Level of Harm - Minimal harm or potential for actual harm Observation on 12/07/23 at 9:28 A.M. with Unit Manager (UM) #75 revealed Resident #181 seated in her wheelchair with no anti-tippers and the resident was not wearing hipsters. UM #75 verified Resident #181's fall interventions were not in place. Residents Affected - Some Interview on 12/07/23 at 11:30 A.M. with the DON confirmed the root cause analysis for Resident #181's fall on 11/28/23 was not completed. The DON also confirmed there was no time documented for the fall and no effective information to help determine proper interventions to put into place to potentially prevent future falls. Review of the Fall-Clinical Protocol Policy dated 11/02/23 revealed a fall re-evaluation should be completed in the medical record, to determine if there are new additional risk factors and address as appropriate. Analysis of the causative factors and rationale for interventions developed and implemented should be documented in the standards of care notes. Further review revealed as part of an initial and ongoing resident assessment, the staff will help identify individuals with history of falls and risk factors for subsequent falling. Interventions should be developed and implemented per the assessed needs , and monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. 4. Review of Resident #37's medical record identified admission to the facility occurred on 01/13/19 with medical diagnoses including fractured femur (04/08/23), diabetes, chronic pain, insomnia, and asthma. Review of Resident #37's care plan revealed interventions in place for falls including apply side rails to the bed to aide in repositioning, self-releasing seatbelt, and transfer assist device 1/4 bilateral assist bars to bed. Review of Resident #37's December 2023 physician orders revealed an order dated 08/29/23 for bilateral 1/4 assist rails and an order dated 04/17/23 for a trapeze for bed mobility. Review of the nursing note dated 10/15/23 at 4:30 A.M. revealed Resident #37 was yelling out for help in the morning after he slid out of bed. He was trying to get into his wheelchair. The resident hit his face and had a small laceration on the inside nasal area near his eye resulting in a black eye and a wound that seeped and needed cleaned frequently until it scabbed over. The resident also had a scratch on his right shoulder blade. Resident #37 was weak and needed assistance with getting in and out of his chair and was reminded to use his call light. Review of the nursing note dated 10/25/23 at 5:30 A.M. revealed Resident #37 was found on the floor beside his bed. The resident was lying on right side with left arm extended and holding on to mattress. Resident stated he was attempting to sit up on the side of the bed and slid off the edge to the floor. The resident had a laceration to his interior eye at bridge of nose. Review of Resident #37's Interdisciplinary Progress Note (IDT) dated 11/21/23 at 2:00 P.M. revealed the care plan was updated to reflect the resident was at high risk for falls with a history of falls and self-transfers with impaired cognition and decreased safety awareness. Observation and interview with Resident #37 on 12/07/23 at 10:38 A.M. revealed Resident #37 did not have assistance bars applies to his bed. Resident #37 reported he would use assistive bars to help (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365408 If continuation sheet Page 6 of 17 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 365408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Delaware 2270 Warrensburg Road Delaware, OH 43015 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 - Some reposition himself if they were available. Resident #37 further verified his wheelchair had a seat belt, which he did not use, and his bed did not have a trapeze bar, which he felt he wouldn't use. Observation and interview on 12/07/23 at 11:11 A.M. with Assistance Director or Nursing (ADON) #75 verified Resident #37's bed did not have assistive bars applied and there was no trapeze bar above the bed as ordered. ADON #75 was unaware Resident #37 did not utilize the wheelchair seatbelt and that it was listed as an intervention on his care plan. This deficiency represents non-compliance investigated under Complaint Number OH00148339. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365408 If continuation sheet Page 7 of 17 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 365408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Delaware 2270 Warrensburg Road Delaware, OH 43015 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on medical record review and staff interview, the facility failed to gain clarification on a medication order. This affected one (Resident #235) of five residents observed for medication administration. The facility census was 79. Findings include: Observation on 12/06/23 at 7:30 A.M. of Licensed Practical Nurse (LPN) #26 gathering medications for Resident #235 revealed a total of six pills were pulled for administration. LPN#26 administered the six pills to Resident #235, which included one Guaifenesin Mucinex 400 milligrams (mg) tablet. Review of Resident #235's physician order dated 11/24/23 identified Guaifenesin Oral Liquid (Guaifenesin) Give 1200 ml by mouth two times a day for productive cough. Interview on 12/06/23 at 7:37 A.M. with Licensed Practical Nurse (LPN) #235 confirmed the physician's order for Guaifenesin 1200 ml (over a liter of fluid) was a large amount of fluid and verified no one had clarified the physicians order. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365408 If continuation sheet Page 8 of 17 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 365408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Delaware 2270 Warrensburg Road Delaware, OH 43015 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 - Some 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** Based on medical record review and staff interviews, the facility failed to ensure pharmacy recommendations approved by the Certified Nurse Practitioner (CNP) were acted upon in a timely manner. This affected two (Residents #19 and #37) of five reviewed for unnecessary medications. The facility census was 79. Findings include: 1. Review of Resident #19's medical record identified admission to the facility on [DATE] with medical diagnoses including high blood pressure, anemia, trouble swallowing, muscle weakness, and reduced mobility. Review of Resident #19's most recent Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. Review of the Pharmacy Medication Regimen Review dated 08/11/23 revealed a recommendation to change Resident #19's Namenda (medication to slow progression of Alzheimer's) from 10 milligrams (mg) to 5 mg, because the manufacturer's guidelines identified any doses greater than 5 mg should be divided into two doses. The pharmacy recommendation was reviewed by CNP #300 on 08/14/23, at which time she agreed with the pharmacy recommendation to change the order to Namenda 5 mg twice a day. Review of Resident #19's Medication Administration Records (MAR) and physician orders for 08/23, 09/23, 10/23 and 11/23 confirmed the pharmacy recommendation was not put into place until 11/20/23. Interview with the Director of Nursing (DON) on 12/07/23 at 1:05 P.M. verified the pharmacy recommendation from 08/14/23 to change Namenda to 5 mg was not put into place until 11/20/23. 2. Review of Resident #37's medical record identified admission to the facility occurred on 01/13/19 with medical diagnoses including fractured femur, diabetes, chronic pain, insomnia, and asthma. Review of the Pharmacy Medication Regimen Review dated 08/11/23 revealed Resident #37 had been receiving Trazodone (anti-depressant) 25 mg since 05/17/23 and that a quarterly dose reduction trial must be attempted to minimize or discontinue medications that are unnecessary. CNP #300 reviewed the recommendation and agree to discontinue the Trazodone on 08/14/23. Review of Resident #37's MAR and physician orders for 08/23, 09/23, 10/23 and 11/23 revealed Resident #37 remained on the Trazodone until 11/19/23, when it was discontinued. Interview with the DON on 12/07/23 at 11:58 A.M. verified CNP #300 agreed to discontinue Resident #37's Trazodone on 08/14/23 and it was not discontinued until 11/19/23. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365408 If continuation sheet Page 9 of 17 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 365408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Delaware 2270 Warrensburg Road Delaware, OH 43015 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on medication administration observations, staff interviews, and review of facility policy, the facility failed to ensure medications were administered as ordered resulting in three medication errors out of 26 opportunities or a 11.5 percent (%) medication error rate. This affected three (Resident #18, #82, #79) of five residents observed for medication administration. The facility census was 79. Residents Affected - Some Findings include: 1. Observation on 12/06/23 at 7:56 A.M. revealed Licensed Practical Nurse (LPN) #18 gathering medications for Resident #54. LPN #18 gathered Paxlovid 150 milligrams (mg) and Zinc 50 mg and headed to Resident #54's room. LPN #18 was stopped before entering the room and asked to re-check the physician orders. LPN #18 confirmed the order for Resident #54's Zinc was 220 mg and confirmed she had a 50 mg tablet. LPN #18 confirmed she does not have Zinc available to administer the ordered 220 mg. LPN #18 would have to get the order clarified to be able to give the medication to Resident #54. 2. Observation on 12/06/23 at 8:23 A.M. revealed Registered Nurse (RN) #82 gathered six tablets of medication to give to Resident #63. RN #82 administered the six medications to Resident #82, which included Aspirin 81 mg. Review of Resident #82's physician orders identified Aspirin 325 mg twice a day for heart disease. Interview with RN #82 on 12/06/23 at 8:34 A.M. upon returning to the medication cart, confirmed Resident #82's physician order was for Aspirin 325 mg and she gave 81 mg. RN #82 confirmed she was not paying close enough attention to the medication administration record and physician ordered dose of the Aspirin. 3. Observation on 12/06/23 at 9:24 A.M. revealed RN #79 gathered seven pills and a Lidocaine 4 percent (%) pain patch for Resident #74. RN #79 was observed to administer Resident #74's pills without incident. RN #79 went to place the Lidocaine patch on Resident #74's back. RN #79 removed the previous patch, which was dated 12/03/23 with the initials of Medication Technician #67. The observation identified there were no other pain patches applied to Resident #74's back. Review of Resident #74's Medication Administration Record (MAR) revealed Medication Technician #67 worked on 12/03/23. The MAR identified LPN #30 worked on 12/04/23 and 12/05/23 and signed off that he placed the Lidocaine Patch on Resident #74. There was a discrepancy between the MAR and the pain patch observed on Resident #74's back dated 12/03/23, indicating LPN #30 did not apply the pain patches as documented. Interview on 12/06/23 with RN #79 verified the pain patch she removed from Resident #74 was dated 12/03/23, and the pain patch was ordered to be changed daily. RN #79 verified a new pain patch was not applied on 12/04/23 and 12/05/23 as ordered. RN #79 reported LPN #30 worked on 12/04/23 and 12/05/23 and initialed he applied the pain back, but he had not. RN #69 further verified the pain patch should be removed within 23 hours of application, and it had not been removed. Review of the facility's Medication Administration policy dated 01/01/22 revealed staff are to review the MAR to identify medications to be administered. The policy identified compare medication source with MAR to verify resident name, medication name, dose, route, and time of administration. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365408 If continuation sheet Page 10 of 17 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 365408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Delaware 2270 Warrensburg Road Delaware, OH 43015 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 0759 policy identified to sign the MAR after administration of the medications. Level of Harm - Minimal harm or potential for actual harm This deficiency represents non-compliance investigated under Complaint Number OH00148419. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365408 If continuation sheet Page 11 of 17 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 365408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Delaware 2270 Warrensburg Road Delaware, OH 43015 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 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. Based on medical record review, observation, staff interview, and review of policy, the facility failed to ensure medications were appropriately stored and secured. This affected one (Resident #14) of one observed with medications unattended at the bedside. The facility census was 79. Findings include: Review of the medical record revealed Resident #14 had an admission date of 12/27/18. Diagnoses included quadriplegia, cerebrovascular disease, benign, prostatic hyperplasia, contracture of muscle, chronic pain syndrome, idiopathic progressive neuropathy, and dysphagia. Observation on 12/04/23 at 12:10 P.M. in Resident #14's room revealed there was one small clear plastic cup containing five pills next to the resident on a tray table. Interview with Resident #14 verified staff sometimes leave his pills for him. Interview on 12/04/23 at 12:57 P.M. with Assistant Director of Nursing (ADON) #75 verified medications were left at Resident #14's bedside. ADON #75 verified leaving pills at bedside is not part of their protocol. Review of the policy, Medication Administration, dated 01/01/22, stated staff would observe resident consumption of medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365408 If continuation sheet Page 12 of 17 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 365408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Delaware 2270 Warrensburg Road Delaware, OH 43015 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 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, staff interview and review of facility policy, the facility failed to obtain physician ordered laboratory (lab) testing for one (#19) of five residents reviewed for unnecessary medications. The facility census was 79. Residents Affected - Few Findings include: Review of Resident #19's medical record revealed an admission date of 10/23/14. Diagnoses included seizures, high blood pressure, anemia, trouble swallowing, muscle weakness and reduced mobility. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/08/23, revealed Resident #19 was severely cognitively impaired. Review of a physician order dated 10/02/23 revealed Resident #19 was to have lab testing every six months, in April and October, to include basic metabolic panel (BMP - used to evaluate kidney function, body fluid balance and electrolyte levels), Keppra level (medication used to treat seizures), lipid panel (measures cholesterol and other fats in the blood), and HgBA1C (measures average blood sugar levels over the previous three months). Additional review of the medical record revealed no evidence of lab testing for Resident #19 in October 2023. Interview on 12/07/23 at 10:02 A.M. with the Assistant Director of Nursing (ADON) #75 verified lab testing had not been completed as ordered for Resident #19. Additionally, ADON #75, after reviewing the medical record and online lab system, confirmed no lab testing had been completed since June 2023, when the resident was in the hospital. At that time, only a BMP was completed. ADON #75 verified the physician ordered lab testing was not completed in October 2023 and the last full set of labs were done in April 2023. Review of facility policy titled Laboratory and Diagnostic Guidelines, revised 10/26/23, revealed routine laboratory or diagnostic test may be placed on a calendar or schedule, or other mechanism. The mechanism should allow for ease of the facility staff to recognize upcoming lab and diagnostic tests. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365408 If continuation sheet Page 13 of 17 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 365408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Delaware 2270 Warrensburg Road Delaware, OH 43015 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 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure timely physician notification of laboratory (lab) results for Resident #33, which required a change in treatment, and critical lab results for Resident #37. This affected two (#33 and #37) of five residents reviewed for unnecessary medications. The facility census was 79. Findings include: 1. Review of Resident #33's medical record revealed an admission date of 03/13/23. Diagnoses included depression, Alzheimer's disease and chronic obstructive pulmonary disease (COPD). Review of a nursing note dated 11/30/23 at 10:38 A.M. revealed Resident #33 had a low grade fever, increased incontinence episodes and confusion. Certified Nurse Practitioner (CNP) #300 was notified regarding the change in condition and ordered Augmentin 875 milligrams (mg) twice daily for five days and a urine swab test. Review of a lab report, dated 11/30/23, revealed Resident #33's urine sample was received by the lab on 12/01/23 and resulted on 12/02/23. Further review revealed Resident #33 had a urinary tract infection (UTI) due to Escherichia coli (E.coli) and Bactrim should be the antibiotic used to treat the infection. Further review of Resident #33's medical record revealed no evidence the physician or CNP were notified of the lab results until 12/04/23 (two days following receipt of the results). Review of a progress note dated 12/04/23 revealed CNP #300 reviewed Resident #33's lab results and changed the antibiotic treatment from Augmentin to Bactrim due to the urine culture sensitivity. Interview on 12/07/23 at 2:24 P.M. with Assistant Director of Nursing (ADON) #75 confirmed Resident #33's lab results were noted as received by the facility on 12/02/23 and not reported to CNP #300 until 12/04/23. ADON #75 verified Resident #33's lab results required a change in the antibiotic treatment due to the bacteria identified in the lab results and staff should have notified the physician/CNP on 12/02/23 and not waited until 12/04/23. 2. Review of Resident #37's medical record revealed an admission date of 01/13/19. Diagnoses included diabetes, chronic pain, high cholesterol, insomnia and asthma. Review of physician orders revealed Resident #37 was ordered atorvastatin (cholesterol lowering medication) 40 milligrams (mg). Additionally, Resident #37 had an order for a lipid panel (measures cholesterol and other fats in the blood) every six months. Review of Resident #37's lab results, dated 10/19/23, revealed a critical result for triglycerides. Further review revealed Resident #37's triglyceride result was 563 and a normal level was less than 150. Review of Resident #37's nursing notes, dated 10/20/23 at 12:21 A.M., revealed laboratory results were received, no critical values noted, and the results were left on the clipboard for the Certified Nurse Practitioner (CNP)/physician to review. The note was silent for CNP or physician notification (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365408 If continuation sheet Page 14 of 17 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 365408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Delaware 2270 Warrensburg Road Delaware, OH 43015 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 0773 of critical lab values at the time the lab results were received. Level of Harm - Minimal harm or potential for actual harm Interview on 12/07/23 at 12:48 P.M., via telephone, with CNP #300 revealed the facility should immediately call the CNP or physician with any critical lab values. CNP #300 verified she was not immediately notified of Resident #37's critical triglyceride levels. Residents Affected - Few Review of facility policy titled Laboratory and Diagnostic Guidelines, revised 10/26/23, revealed critical lab results and urgent diagnostic should be called to the physician upon receipt. Non-critical or non-urgent test results that are abnormal should have physician notification within 24 hours unless the physician has provided specific notification parameters. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365408 If continuation sheet Page 15 of 17 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 365408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Delaware 2270 Warrensburg Road Delaware, OH 43015 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, resident interview, staff interview and review of facility policy, the facility failed to ensure foods were maintained at preferred temperatures during serving. This had the potential to affect all 79 residents of the facility. The facility census was 79. Residents Affected - Many Findings include: Interview on 12/04/23 at 10:18 A.M. with Resident #25 revealed the facility food was cold when served and breakfast was exceptionally bad. Interview on 12/04/23 at 2:23 P.M. with Resident #37 revealed the facility food was cold when served. Observation on 12/07/23 at 8:06 A.M. with District Manager (DM) #94 and Food Director (FD) #95 of the breakfast tray line revealed all hot breakfast foods, including sausage, biscuits and gravy, and eggs, were of an appropriate temperature of 135 degrees Fahrenheit (F) or warmer. Continued observation on 12/07/23 at 8:28 A.M. of the breakfast tray line revealed the 400 Hall tray cart left the kitchen for distribution to residents. Additional observation at 8:46 A.M., with DM #94 and FD #95, revealed the last tray removed from the 400 Hall cart was a test tray. Observation of the test tray revealed the temperature of each of the food items was as follows: sausage was 90 degrees F, biscuits and gravy was 99 F, and the eggs were 96 F. FD #95 verified the food temperatures at the time of the observation. Further observation of the test tray revealed each of the food items were cold when tasted. Interview on 12/07/23 at 8:53 A.M. with DM #94 revealed 135 F was the ideal temperature for food to be served to residents; however, 100 F would be acceptable based on taste. DM #94 confirmed the temperatures from the breakfast test tray were not of an acceptable temperature for serving to residents. Review of facility policy titled Meal Distribution, dated 09/01/21, revealed all food items would be transported promptly for appropriate temperature maintenance. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365408 If continuation sheet Page 16 of 17 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 365408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Delaware 2270 Warrensburg Road Delaware, OH 43015 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and staff interview, the facility failed to maintain the activity room refrigerator and freezer in a clean and sanitary manner. This had the potential to affect all 79 residents of the facility. The facility census was 79. Findings include: Observation on 12/05/23 at 12:27 P.M. of the activity room refrigerator and freezer combination unit revealed the refrigerator compartment was dirty, with food debris and a black and brown substance in the corners. Beverages, assorted syrups, and sprinkles were stored in the refrigerator. The freezer compartment had an abundance of ice growing on the top and sides. Ice cream was stored in the freezer. Interview on 12/05/23 at 12:27 P.M. with Activities Director (AD) #54 verified the items stored in the refrigerator/freezer unit were for resident use. Additionally, AD #54 confirmed the unit needed cleaned, including defrosting the freezer. AD #54 stated she had been employed by the facility for nearly a year and the refrigerator and freezer had not been cleaned in that time. Interview on 12/07/23 at 2:35 P.M. with the Administrator revealed that the facility did not have a policy related to cleaning the activity room refrigerator and freezer. This deficiency represents non-compliance investigated under Complaint Number OH00148419. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365408 If continuation sheet Page 17 of 17