Health inspection·April 4, 2024

F 0585 Level of Harm - Minimal harm or potential for actual harm Interview on 04/02/24 at approximately 10:30 A.M., with Resident #222 confirmed she had reported to staff on multiple occasions personal clothing missing and not being returned from laundry. Resident #222 confirmed personal items including four Playtex bras, jeans, tee shirts, a dress and pants were still missing. Resident #222 confirmed no communication was provided to her by staff on the status of her missing personal clothing items and items were still not returned to her. Residents Affected - Few Review of document titled Quality Assistance Form dated 03/15/24, documented Resident #222 communicated to the Administrator missing 4 Playtex bras (50DD white), 4 pair jeans (size 24-26), wine leggings (3x), yellow tee shirt dress (3x), 1 plaid (red/black) men' pajama pants (4x), black sweatpants (3x), tee shirts different colors (4x) and socks with different characters. Further revealing a documented resolution was provided in person to Resident #222 from staff on 04/01/24 (first day of summary), as all items were found, returned to Resident #222 and Resident #222 is happy to have clothing back. Interview on 04/02/24 approximately 11:00 A.M., with Laundry Staff #784 confirmed Resident #222 has on multiple occasions complained about missing personal clothing items and was unaware if any items were located. with Laundry Staff #784 stated many residents' pieces of clothing go missing because of not being appropriately labeled by staff with each resident's name. Interview on 04/03/24 at approximately 9:20 A.M., with Social Services #14, confirmed the facility had multiple complaints of missing clothing items not being returned from laundry. Social Service #14 stated Resident #222 had voiced on different occasions complaints about missing personal items of clothing. 2. Review of the medical record for Resident #103 revealed an admission date of 12/11/23 with diagnosis including but not limited to Chronic obstructive pulmonary disease, diabetes mellitus type 2, obesity, hypothyroid, major depressive disorder, Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #103 had a Brief Interview Mental Status (BIMS) score of 13. She requires Supervision or touching assistance for eating, oral hygiene, toilet hygiene, shower/bathe, upper body dressing and personal hygiene. Review of the March 2024 grievance log revealed a documented concern from Resident #103, on 03/18/24 for missing clothes, dress pants, stretchy pants, and diabetic socks. Documentation of resolution revealed, ongoing some items found and returned, others still being searched for, and date complaint notified was blank. Review of document titled Quality Assistance Form dated 03/18/24, documented Resident #103 communicated to the Director of Nursing missing 2 black dress pants, 1 pair of stretch black pants, 1 pair of gray stretchy pants, 1 pair of blue stretchy pants and 7 pair of diabetic socks. Further revealing a documented resolution was provided in person to Resident #103 from staff on 04/01/24 (first day of survey), as all items were found except diabetic socks and administration to purchase. Interview on 04/01/24 at approximately 3:30 P.M., with Administrator confirmed that all complaints and concerns were documented on the grievance form and should be addressed promptly. Further revealing that complaints of missing personal clothing items were completed on 04/01/24 (first day of survey) with all items documented as returned to Resident #103 except for diabetic socks. Interview on 04/02/24 approximately 11:00 A.M., with Laundry Staff #784, confirmed Resident #103 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365408 If continuation sheet Page 2 of 13 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 04/04/2024 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few complained about missing personal clothing items and was unaware if any items were located. Laundry Staff #784 stated many residents' pieces of clothing go missing because of not being appropriately labeled by staff with each resident's name. Further gesturing to a container of socks located under the folding area containing many socks that were unmatched and or missing matches and were yet to be gone though. Interview on 04/02/24 at approximately 11:30 A.M., with Resident #103 confirmed she had reported to staff on multiple occasions personal clothing missing and not being returned from laundry. Resident #103 confirmed dissatisfaction with the length of the time that had taken place since she had filed the grievance and the lack of communication regarding the resolution to the complaint. Further detailing the high-risk nature of being diabetic and not having appropriate fitting socks that could lead to diabetic foot issues confirming she was still missing items and diabetic socks had not been replaced by the facility. Interview on 04/03/24 at approximately 9:20 A.M., with Social Services #14, confirmed the facility had received multiple complaints of missing clothing items not being returned from laundry promptly. Confirming Resident #103 had voiced complaints about missing personal items of clothing. Review of the policy titled, Quality Assistance Procedure revised date of 10/30/23, revealed the resident or person filing the quality assistance form on behalf of the resident, will be informed of the findings of the investigation and the actions that will be taken to correct any identified problems. This deficiency represents non-compliance investigated under Complaint Number OH00152122 and OH00152055. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365408 If continuation sheet Page 3 of 13 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 04/04/2024 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 0679 Provide activities to meet all resident's needs. 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 review, activity calendar review, resident interview, family interview, staff interview, and review of policy, the facility failed to ensure residents were provided with activities to meet the needs and interests of the residents. This affected five (#100, #300, #400, #500, and #600) of five residents reviewed for activities. The census was 82. Residents Affected - Some Findings: Review of the April 2024 activity calendar provided by the facility revealed there was a lack of variety of activities scheduled. The daily calendar included: 9:00 A.M. Daily Chronicle (IR), 10:00 A.M. Exercise (A), 10:30 A.M. Hit 21 (A), 1:30 P.M. UNO (A), 3:00 P.M. Bingo (DR), and 6:30 P.M. Resident Led Cards (A). Observation on 04/01/24 at 8:10 A.M., on the locked memory care unit, in the common area/dining room found 7 Residents of which 5 of which were sitting in wheelchairs, and 2 in a strait back chair all faced towards a large wall of plastic with holes and a zipper open to an area under construction, with no music or television or active interaction from staff. Further observation of a stack of approximately 7 boxes labeled puzzles stacked on top of and in a small side table. In a small corner of the room was table that had pieces of wood missing from the edges, a green felt like material with numerous holes with puzzle pieces partially sticking out of the holes in the material and a broken portion of the table laying partially off to the side of the table. Interview on 04/01/24 at approximately 8:20 A.M., with State Tested Nurse Aid, (STNA) #35 confirmed the lack of individualized interventions on the associated task/[NAME] information for area of psychosocial/ activities. STNA #35 stated the scheduled activities are the same for everyone in the locked memory care unit. Observation on 04/01/24 at approximately 8:25 A.M., observed Resident #500 sitting at dining table with other residents. The all-dining tables were clear of any objects or decor. The dining room had one large happy easter flag attached to one wall, all other walls were clear of décor, no music, no menus were observed. Resident #500 sat at the table with eyes closed and her head back position. Interview on 04/01/24 at approximately 8:30 A.M., with Resident #500, while sitting at a table, Resident stated she had been waiting for breakfast and was tired of waiting. Observation on 04/01/24 at approximately 8:45 A.M., observed Resident #400 sitting at dining table with other residents. The all-dining tables were clear of any objects or decor. The dining room had one large happy easter flag attached to one wall, all other walls were clear of décor, no music, no menus were observed. On 04/01/24 at approximately 8:50 A.M., an attempt to interview Resident #400, while sitting at a table but was unable or unwilling to communicate needs or verbalize understanding of questions. Observation on 04/01/24 from approximately 9:00 A.M. to 10:00 A.M., on memory care unit found no calendar of activity or events posted in common area and no planned activity taking place, no television program being displayed and no music playing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365408 If continuation sheet Page 4 of 13 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 04/04/2024 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 04/01/24, at approximately 10:00 A.M., with License Practical Nurse (LPN) #11 confirmed that no planned activity was provided to the residents from 9:00 A.M. to 10:00 A.M., as per the activity schedule and was unable to find a posted activity calendar in common areas. Observation on 04/02/24 at approximately 2:35 P.M., observed Resident #500 to be sleeping in a chair in the common area along with 3 other residents. The common area was free from music, television, décor, or psychosocial stimulation. Interview on 04/02/24 at approximately 2:40 P.M., with STNA #44, confirmed that no planned activities had taken place on the memory care unit for that day. Interview on 04/03/24 at approximately 2:50 P.M., with Activities Director #71, confirmed no formal activities were provided as per the calendar schedule on the memory care unit on 04/01/24 or 04/02/24. 1. Review of medical record for Resident #100 revealed admission date of 08/30/23. Medical diagnoses included hypertensive heart disease, chronic obstructive pulmonary disease, mood disorder, Alzheimer's, adjustment disorder with mixed disturbance of emotional conduct, anxiety, cognitive communication deficit, mental and behavioral disorders, chronic pain, bipolar disorder, major depressive disorder recurrent with severe with psychotic symptoms and insomnia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed for Resident #100 a Brief Interview Mental Status (BIMS) score of 11 indicating mild cognitive impairment. She required supervision or touching assistance for eating, toilet hygiene, shower/bathe, upper and lower body dressing, and personal hygiene. Indicated hallucinations and delusions with physical, verbal, and other behavioral symptoms occurring one to three days. Further indicating rejection of care and wandering occurring one to three days. Review of Resident #100's quarterly activity assessment date 11/21/23 revealed there was no interest listed for the resident. The assessment indicated the resident's interest and participation were unchanged. Review of the care plan dated 09/20/23 for Resident #100 revealed a relative to at risk for altered activity patterns/pursuits related to anxiety, confusion, depression, and disinterest interventions of: allow and encourage hallway activities, encourage resident to participate in small group to promote a sense of ease/belonging and to decrease the potential for anxiety encourage to participate in leisure interest throughout the day. Provide, when possible based on interest (internet access, preferred radio programs audiobooks, library books, word puzzles, magazines) for in room use with measurable goals maintain their current level of activity and socialization though next review. Review of Resident #100 record of planned activities attendance from 03/02/24-04/01/24 was silent for attendance or refusals of any planned activities. Interview and observation on 04/01/24 at approximately 1:15 P.M., revealed Resident #100 in room lying in bed, Resident #100 stated there was nothing to do at the facility and that the activities staff did not interact with her. Resident #100 gestures to the activities calendar on the wall, stating the activities are the same thing every day. Interview on 04/02/24 at 8:50 A.M., with Resident #100's family states Resident #100 has not been (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365408 If continuation sheet Page 5 of 13 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 04/04/2024 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 0679 Level of Harm - Minimal harm or potential for actual harm provided with activities, 1 on 1 activities, invited to group activities she just sits in her bed. Further stating that Resident #100 has behaviors but many of them could be controlled, or not even happen if she something to do throughout the day, evening and at night. Further stated suggestions, ideas and insight have been provided to multiple different staff on what activities Resident #100 would like to do or had previously enjoyed but none have been provided. Residents Affected - Some Interview on 04/03/24 at approximately 2:50 P.M., with Activities Director #71 confirmed the documentation of Resident #100's attendance or refusal of planned activities was blank indicating no evidence of activities being provided from 03/02/24-04/01/24. 2. Review of medical record for Resident #600 revealed admission date of 05/08/20. Medical diagnoses included transient cerebral ischemic attack, cerebral arteritis, essential primary hypertension, vascular dementia, psoriasis, weakness, pain, muscle weakness. Review of the quarterly MDS assessment dated [DATE] revealed for Resident #600 a Brief Interview Mental Status (BIMS) score of 13. She required substantial/maximal assistance for lower body dressing, personal hygiene, shower/bathe, and toileting. Partial/moderate assistance for upper body dressing and oral hygiene. Resident #600's MDS indicated no behavior symptoms, no rejection of care, no wandering and utilization of a wheelchair and or walker for mobility. Further indicated frequently incontinent of bowel and always incontinent of bladder. Review of Resident #600's quarterly activity assessment date 03/26/24, revealed there was no interest listed for the resident. The assessment stated Resident #600 will gather with friends thorough out the day. The assessment indicated the resident's interest and participation were unchanged. Review of Resident #600 care plan dated 08/16/2023 relative to at risk for altered activity patterns/ pursuits related to anxiety depression and disinterest revealed interventions in place of: allow and encourage hallway activities as able, encourage resident to participate in small group to promote a sense of ease/belonging and to decrease the potential for anxiety encourage to participate in leisure interest throughout the day. Provide, when possible based on interest (internet access, preferred radio programs audiobooks, library books, word puzzles, magazines) for in room use. with measurable goals. Review of Resident #600's record of planned activities attendance from 03/02/24-04/01/24 was silent for attendance or refusals of any planned activities. Interview on 04/02/24 at approximately 1:50 P.M., with Resident #600 stated she was bored, she had never been invited to any scheduled activities, staff did not bring her 1 on 1 activities or crafts to complete. Interview on 04/02/24 at 11:49 A.M., with Resident #600 family revealed they have voiced concerns regarding Resident #600's lack of social interactions or being provided with psychosocial activities throughout the day. Further stating, Resident #600 has mental health issues, that were worse because of not having activities/psychosocial interactions to help reduce or control them. Interview on 04/03/24 at approximately 2:50 P.M., with Activities Director #71 confirmed that documentation of Resident #600's attendance or refusal of planned activities was blank indicating activities had not been provided from 03/02/24-04/01/24. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365408 If continuation sheet Page 6 of 13 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 04/04/2024 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 3. Review of medical record for Resident #300 revealed admission date of 11/16/22. Medical diagnoses included moderate dementia with other behavioral disturbances, post-traumatic stress disorder, diabetes mellitus, insomnia, major depressive disorder, dysphagia, and amnesia. Review of the quarterly MDS dated [DATE] revealed for Resident #300 a Brief Interview Mental Status (BIMS) score of 09 indicating cognitive impairment. He required supervision or touching assistance for eating and oral care, substantial or maximal assistance for toileting, shower/bathe, personal hygiene, and lower body dressing. Review of activities annual evaluation dated 11/20/23 for Resident #300 revealed he enjoyed exercise or sports, cooking or baking, family or friend visits, pet visits, found strength in faith or religion and preferred activities in own room or 1 on 1. Review of Resident #300 plan of care dated 09/09/2023, at risk for altered activity patterns/pursuits related to confusion, dementia, depression and disinterest with interventions of: allow and encourage hallway activities, encourage resident to participate in small group to promote a sense of ease/belonging and to decrease the potential for anxiety, encourage to participate in leisure interest throughout the day, provide, when possible based on interest (internet access, preferred radio programs audiobooks, library books, word puzzles, magazines) for in room use with measurable goals maintain their current level of activity and socialization though next review. Review of Resident #300's record of planned activities attendance from 03/02/24-04/01/24 was silent for attendance or refusals of any planned activities. Interview on 04/03/24 at approximately 2:50 P.M., with Activities Director #71 confirmed that documentation of Resident #300's attendance or refusal of planned activities was blank indicating activities had not been provided from 03/02/24-04/01/24. 4. Review of medical record for Resident #400 revealed admission date of 05/30/19. Medical diagnoses included traumatic subdural hemorrhage, age related osteoporosis, general anxiety, edema, hypertension, chronic obstructive pulmonary disease, severe dementia with anxiety, cognitive communication deficit, dysphagia, and abnormalities of gait and mobility. Review of the significant change MDS dated [DATE] revealed for Resident #400 a Brief Interview Mental Status (BIMS) score of 05 indicating severe cognitive impairment. She required supervision or touch assistance for eating partial/moderate assistance oral hygiene, dependent for personal hygiene, shower/bathe, toileting, substantial/maximal assistance lower body dressing. Further review of MDS revealed very important to be around animals, somewhat important to do favorite activities, and very important to go outside and get fresh air. No behaviors or rejection of care with indications of wandered 1 to 3 days. Review of the activities evaluation dated 01/11/24 for Resident #400 revealed the resident enjoys art and crafts, beauty shop, computer, cooking/baking, exercise/sports, family/friend visits, community outings or shopping, religious activities, walking, pet visits, parties, or social events. In small groups in the day or activity room. Review of the care plan dated 08/09/23 for Resident #400 revealed a relative to at risk for altered activity patterns/pursuits related to anxiety, dementia, and depression with interventions of: allow and encourage hallway activities, encourage resident to participate in small group to promote a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365408 If continuation sheet Page 7 of 13 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 04/04/2024 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some sense of ease/belonging and to decrease the potential for anxiety encourage to participate in leisure interest throughout the day. Provide, when possible based on interest (internet access, preferred radio programs audiobooks, library books, word puzzles, magazines) for in room use with measurable goals maintain their current level of activity and socialization though next review. Review of Resident #400's record of planned activities attendance from 03/02/24-04/01/24 was silent for attendance or refusals of any planned activities. Interview on 04/03/24 at approximately 2:50 P.M., with Activities Director #71 confirmed that documentation of Resident #400's attendance or refusal of planned activities was blank indicating activities had not been provided from 03/02/24-04/01/24. 5. Review of medical record for Resident #500 revealed admission date of 03/13/23. Medical diagnoses included Alzheimer disease, chronic obstructive pulmonary disease, major depressive disorder, bilateral primary osteoarthritis, repeated falls, bilateral hearing loss, bladder disorder, sciatica, abnormalities of gait and mobility, and cognitive communication deficit. The annual Minimum Data Set (MDS) dated [DATE] for Resident #500 a Brief Interview Mental Status (BIMS) score of 08 indicating cognitive impairment. She required supervision or touch assistance for eating and oral hygiene and partial/moderate assistance for toileting hygiene, shower/bathing, upper body dressing and personal hygiene. Resident #500 MDS further indicated somewhat important to do things with groups of people and to go outside to get fresh air when weather is good. Review of the 03/13/24 activities evaluation Resident #500 revealed, enjoys community outing/shopping, computer, exercise/sports, family/friend visits, walking, volunteering/ helping others, pet visits, reading/writing, preferred activity setting of small groups and one on one. Review of the care plan dated 08/09/23 for Resident #500 revealed a relative to at risk for altered activity patterns/pursuits related to dementia with interventions of: allow and encourage hallway activities, encourage resident to participate in small group to promote a sense of ease/belonging and to decrease the potential for anxiety encourage to participate in leisure interest throughout the day. Provide, when possible based on interest (internet access, preferred radio programs audiobooks, library books, word puzzles, magazines) for in room use with measurable goals maintain their current level of activity and socialization though next review. Review of Resident #500 record of planned activities attendance from 03/02/24-04/01/24 identified attendance on 03/12/24 and 03/18/24, with no further documented refusals of any planned activities or attendance. Interview on 04/03/24 at approximately 2:50 P.M., with Activities Director #71 confirmed that documentation of Resident #500's attendance was correct and there was no refusal of planned activities was blank indicating activities had not been provided from 03/02/24-04/01/24. Review of the policy titled, Activities with a revision date of 10/30/23, states activities will be designed with the intent to enhance the resident's sense of wellbeing, belonging and usefulness, promote or enhance physical activity, cognition, emotional health, self-esteem, dignity, pleasure, comfort, education, creativity, success, and independence. Special consideration will be made for developing meaningful activities for residents with dementia including residents who exhibit unusual amounts of energy or walking without a purpose, who engage in behaviors not conductive with therapeutic (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365408 If continuation sheet Page 8 of 13 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 04/04/2024 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 0679 Level of Harm - Minimal harm or potential for actual harm home like environment and who lack awareness of personal safety. Scheduled activities are posted in the resident room and in prominent place in the facility. This deficiency represents non-compliance investigated under Complaint Number OH00152385. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365408 If continuation sheet Page 9 of 13 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 04/04/2024 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. Based on observations, resident interviews, and staff interviews, the facility failed to provide an environment free from potential hazards of unsecured chemicals and sharps in a construction area. This had potential to affect 21 confused and independently mobile resident (#112, #113, #114, #300, #115, #116, #117, #118, #119, #120, #121, #122, #124, #125, #126, #127, #128, #129, #130, #131 and #400) of 23 residents who resided on the memory care unit. The facility census was 82. Findings include: Observation on 04/01/24 at 8:02 A.M., on the locked memory care unit, revealed a doorway that opened to a common area with a doorway that connected to a dining room. Seven residents, of which five were sitting in wheelchairs, on the left side of the common area. The five residents were facing a falling down piece of clear plastic that was attempting to cover the entire wall. The large piece of plastic was taped with blue tape on the fluorescent ceiling lights at the left side of the zipper. The bottom portion of the plastic was taped into the walking path of the common area into the entry of the dining room. The bottom of the plastic was taped to the floor and had multiple rips/holes and shoe prints where people walked across the plastic. The clear plastic had an open red zipper about halfway down the sheet of plastic creating an open doorway into the kitchenette area. Then after the zippered area the sheet of plastic hung down off the ceiling causing the plastic to bunch up onto the floor into the walking path to the dining room. The partially hanging plastic allowed a view and access to the construction area of the kitchenette. Staff were randomly observed to be walking in and out of the common areas as they were getting residents up for the day. Observation from the opening of the hanging plastic, looking into the kitchenette, revealed a large black wheeled trash can with a piece of drywall on top and screws coming out of the drywall; two spray bottle sitting on the counter; a large blower fan; electrical cords across the floor, an open ladder, a wet floor sign, different tools, rolls of tape, a drop cloth, screws laying on the floor, 6 long pieces of metal, a black banana peel, wrappers and a fine white powdery residue covering the entire area. Upon walking though, the accessible unzipped portion of the plastic, the spray bottles. One was labeled: Hard surface sanitizer, with the precautionary label of danger causes severe skin burns and eye damage, harmful if inhaled, harmful if swallowed. The other spray bottle was labeled: Peroxide multi surface cleaner and disinfectant with a precautionary label stating keep out of reach of children. Further observations revealed 6 electrical outlet covers laying on the floor along with sharp metal pieces of laying against the wall protruding out of the left side of the plastic, a fire extinguisher, and a large metal drywall taping knife laying on the floor near the trash can. Walking though the open zippered area into the common area revealed no observable signs, caution, or hazardous storage signs were observed. Further observation revealed more residents in wheelchairs beginning to gather in the common area, one wheeled over the falling bunched plastic causing it to get caught on her wheelchair, while others attempted to avoid the plastic, while others walked or wheeled though. Observation of Resident #116 attempting to maneuver his wheelchair though 5 stacked large boxes labeled: 4 foot led high output lights led, and Resident #116 was noted to hit the boxes several times attempting to find an area to sit at the table. Interview on 04/01/24 at 8:07 A.M., with Resident #116, stated the boxes made it difficult to get to his seat for breakfast. Resident #116 stated the boxes had been stored there for a long time. Interview on 04/01/24 at 8:15 A.M., with Resident #121, revealed she gestured to the large piece of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365408 If continuation sheet Page 10 of 13 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 04/04/2024 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 plastic and stated she had about fell the other day on the plastic. Further gesturing to the area, stating, construction had been going on for a long time and was not sure when it would be done, but would be happy when it was completed. Resident #121 pointed to the cabinets and fridge, then requested a boost drink located in the fridge. Interview on 04/01/24 at 8:17 A.M., with State Tested Nurse Aid (STNA) #81 stated the plastic on the floor was a dangerous trip hazard, referencing the resident who was wheeling into the dining room and plastic getting caught on her wheelchair. Further stated that residents pull on the plastic all the time or wheel over the plastic causing it to fall. STNA #81 verbalizing the difficulty to keep cognitively impaired residents safe during weeks of slow construction with equipment, noise, and drywall dust that has disrupted their home. Interview on 04/01/24 at 8:20 A.M., with STNA #35 confirmed the difficulty Resident #116 was having getting to the table and hazards of having 5 stacked 4-foot boxes of lights in the dining area with severely cognitively impaired mobile residents. Interview on 04/01/24 at 8:38 A.M., with License Practical Nurse (LPN) #11, stated residents pull on the plastic causing it to fall. LPN #11 confirmed the open zipper in the plastic was supposed to be closed so residents would not enter the construction hazardous area. LPN #11 verified the two spray bottles of cleaner needed to be stored in a locked area and the large drywall knife, needed to be removed from the area because of the potential risk associated with cognitively impaired residents. Interview on 04/01/24 approximately 3:30 P.M., with Administrator stated the memory care unit had been undergoing some renovations for several weeks and would be completed soon. The Administrator verified the memory care unit provided care for residents with impaired cognition increases the need for safety precautions. Interview on 04/04/24 at approximately 9:00 A.M., with Administrator provided a list or resident on the memory care unit consisting of two residents who were unable to propel self, confirming all other 21 residents were independently mobile and cognitively impaired. This deficiency represents non-compliance investigated under Complaint Number OH00152122. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365408 If continuation sheet Page 11 of 13 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 04/04/2024 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 0745 Provide medically-related social services to help each resident achieve the highest possible quality of life. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, staff interviews, and interview with Oncology Social Services staff, the facility failed to ensure a resident was provided assistance to and arrange transportation to medical appointments, when the resident required supplement oxygen, resulting in the resident missing physician appointments a medical treatments and not having supplemental oxygen available. This affected one (#200) of three residents reviewed for assistance with outside medical services. The facility census was 82. Residents Affected - Few Finding include: Review of medical record for Resident #200 revealed admission date of 02/01/24. Medical diagnoses included chronic obstructive pulmonary disease, secondary malignant neoplasm of lung, atrial fibrillation, hypothyroidism, pulmonary hypertension, major depression, weakness, need for assistance with personal care, abnormalities of gait and mobility, muscle weakness, low back pain, bipolar disorder, and alcohol abuse. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed for Resident #200 a Brief Interview Mental Status (BIMS) score of 14 indicating intact cognition. He required supervision or touch assistance for toileting, shower/bathe, putting on or taking off footwear, and setup or clean up assistance with upper body and lower body dressing and oral hygiene. Further revealing, no behaviors, rejection of care or wandering and continence of bowel and bladder was indicated on MDS. Review of Resident #200's plan of care dated 02/02/24, revealed the resident was relative risk of episodes of bladder/bowel incontinence related to cancer, depression, and pain to revealed individualized interventions to assist resident with toileting needs with measurable goals. Resident #200 identified risk of impaired pulmonary/respiratory status related to having emphysema and chronic obstructive pulmonary disease with interventions of activity level as tolerated, observe for increase anxiety associated with shortness of breath; provide reassurance, and observer for signs/symptoms of respiratory distress and report to physician. Review of the physician orders dated 02/02/24 for Resident #200 revealed 4 liters of oxygen per nasal cannula continuous. Review of Resident #200's assessment for physician certification of medical necessity for oxygen dated 02/02/24 documented oxygen saturation of 88% on room air, with oxygen needs of 4 liters of oxygen 24 hours a day for lifetime. Interview on 04/01/24 at 9:20 A.M. with Scheduling Staff (SS) #87 revealed Resident #200, was homeless prior to coming into the facility and had managed transportation and appointment on his own. Resident #200 has also done that on occasion at the facility. SS #87 stated Resident #200 had oxygen and could manage the oxygen per self. SS #87 was unaware if any education on the instruction on utilization of oxygen had been provided. SS #87 was unaware if there was a policy for the public transport system assistance level with oxygen during the transport. SS #87 revealed the facility utilizes the public transport though the county for many of the residents' appointments. The Delaware County transportation will take residents anywhere in the county, including physician appointments and drop them off. Further stated the Delaware County transportation bus is wheelchair accessible, and they (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365408 If continuation sheet Page 12 of 13 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 04/04/2024 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 0745 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few will only pick up in the front entry and drop off at the front entry, they do not accompany residents to an office, or push them inside of the building, or make sure they arrived at the correct office or make sure they are at the correct location. Interview on 04/01/24 at 10:30 A.M., with SS #2 stated anyone who is independent with activities of daily living goes to appointments by themselves. Further revealing that no staff was scheduled to go to any appointment with Resident #200. Interview on 04/02/24 at 8:56 A.M., with Oncology Social Services ([NAME]) #1 at Ohio Health Delaware Health Center revealed Resident #200 had appointments on 02/29/24 for MRI, 03/07/24, 03/08/24, 03/14/24 for chemotherapy and physician appointments and were documented as no shows to those appointments. [NAME] #1 stated when Resident #200 does come to scheduled appointments, for example on 03/22/24, he came alone with no personal assistance, he was soiled with urine, was out of oxygen and very short of breath and required nursing assistance was required to assist with oxygen saturation levels. [NAME] #1 stated Resident #200 needs personal care assistance during their visits and during his visits been placed on supplemental oxygen during the appointments, so he does not run out of oxygen in his tank. [NAME] #1 stated the staff have communicated their concerns to the facility with no avail. Interview with on 04/02/24 at approximately 9:15 A.M., with SS #87 revealed that anyone who requires assistance with activities of daily living, needs assistance when going to outside appointments, with pushing wheelchair, medical equipment, toileting assistance and or information gathering will be provided assistance to their appointment. SS #87 stated Resident #200 has never had assistance when going on his appointment including appointments on 02/06/24 and 03/22/24. SS #87 stated Resident #200 is transported to appointments in Delaware County by public transportation including Delaware County Transit. SS #87 confirmed Resident #200 had missed appointments and had been rescheduled. Interview and observation on 04/02/24 at approximately 10:20 A.M., with Resident #200 stated he wears 4 liters of oxygen continuously. Further confirming he gets short of breath when propelling in a wheelchair for distances out of his room. Resident #200 stated that on multiple occasions he has run out of oxygen when attending appointments because the portable oxygen tanks do not last long enough when he has to wait for public transportation. Resident #200 further revealed that he has had accidents of urine because of needing personal assistance when he is out of breath and not having it available. Observations revealed Resident #200 became winded during the interview from talking. Resident #200 revealed that he has missed appointments because of transportation not being available. Appointments he missed that had to be rescheduled included an MRI, cancer doctor and or chemotherapy appointment visits because the facility refused to believe he had an appointment and was told they could not get transportation. Resident #200 stated they refused to call the physician office to verify even after explaining or having documents containing the appointment information. Interview on 04/03/24 at approximately 2:30 P.M., with Director of Nursing confirmed staff had to bring an oxygen tank to Resident #200 during an appointment after he had run out. This deficiency represents non-compliance investigated under Complaint Number OH00152301. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365408 If continuation sheet Page 13 of 13