Health inspection·November 6, 2025

F 0600 Level of Harm - Actual harm Residents Affected - Few The task documentation indicated the resident was redirected after each episode of aggression. Review of the facility video of the secured memory care unit hallway on 10/29/25 at 10:55 A.M. with the Administrator and Director of Nursing (DON) revealed on 10/18/25 at 2:34 PM, Resident #20 was standing at the end of the hallway facing the camera near the exit door. No staff were seen in the hallway. Resident #10 was walking down the hallway towards the exit door alone with her back to the video camera; Resident #10 stopped when Registered Nurse (RN) #149 stepped out of a resident room and handed her a baby doll. Resident #10 proceeded to walk down the hall carrying the baby doll towards the exit doors. Resident #20 walked towards Resident #10 clapping his hands and stood directly in front of Resident #10. Resident #10 turned away from Resident #20. Resident #20 pushed Resident #10 and she fell to the floor. Staff exited a resident room and went to Resident #10, who was laying on the floor on her left side. Review of Resident #10's nurses progress notes revealed on 10/18/25, RN #149 heard a strange sound from the hallway. Upon checking, Resident #10 was lying on the floor. Resident #10 could not say what happened. Neuromuscular and skin assessments initiated, resident ambulated to her room with assistance. Resident holding left arm during assessments. Physician ordered to send Resident #10 to the emergency room for evaluation. Resident #10 left the facility at 3:45 P.M. Resident #10 returned to the facility on [DATE] at 2:03 A.M. with a diagnosis of a urinary tract infection with antibiotics ordered. On 10/21/25 at 11:38 A.M. Resident #10 was complaining of pain and discomfort of her left leg and hip area. The physician was notified and ordered mobile X-rays as soon as possible. At 3:32 P.M. X-ray results received and questioned left pubic ring fractures on one view and recommend Computed Tomography (CAT) Scan (CT). At 4:00 P.M. Resident #10 was transferred to Emergency Room. On 10/22/25 at 10:00 P.M. Resident #10 returned to the facility with a diagnosis of fracture of pubic rami. Review of Incident Report #1111 dated 10/18/25 at 2:00 P.M. documented Nurse #149 heard a strange sound from hallway. Upon checking, Resident #10 was lying on the floor. Skin assessment initiated and resident ambulated to her room with assistance and a full body assessment was completed. No visible injuries. Resident #10 was holding her left arm. Resident #10's Physician and Power of Attorney were notified on 10/18/25 at 4:23 P.M. The report documented Resident #20's description of the incident revealed he was standing close to the door when Resident #10 came to his face and grabbed his shirt. Resident #20 said he removed Resident #10's hands and pushed her away. Resident #20's Physician and Power of Attorney were notified on 10/18/25 at 4:55 P.M. Review of the facility SRI #266676 submitted on 10/18/25 at 4:00 P.M. documented RN #149 reported the incident to the Director of Nursing. The description of the incident was Resident #20 pushed another resident, Resident #10, on the floor. The Administrator was notified, and an investigation was initiated. The summary of the incident and investigation documented: According to Resident #20 he was standing close to the door in the hallway when Resident #10 came up to him and grabbed his shirt. Resident #20 stated he removed her hands to hold her off then she tripped over her own feet causing her to fall. According to Resident #10, she was unable to recall the alleged incident. There were no staff present at the time of the alleged incident, however there was one resident, Resident #50 present. According to Resident #50, Resident #10 walked up to Resident #20 and grabbed his shirt. Resident #20 pushed her hands off his shirt, causing Resident #10 to fall in the hallway. Staff immediately responded to the sound of Resident #10 falling. According to RN #149, he heard a sound from the hallway and immediately responded. Upon checking, Resident #10 was lying on the floor. While obtaining vital signs and checking range of motion on Resident #10, Resident #50 informed the nurse Resident #20 pushed Resident #10 causing her to fall. Both residents were immediately separated. Skin and pain assessments were completed on Resident #20 and Resident #10 with no injuries, pain or distress noted at the time. Both (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365408 If continuation sheet Page 2 of 4 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 11/06/2025 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 0600 Level of Harm - Actual harm Residents Affected - Few residents were placed on 15-minute checks. Resident #10's physician and family were notified, and neurological checks were initiated on Resident #10. Shortly after, Resident #10 was holding her left arm during 15-minute check, so RN #149 contacted the physician and obtained new orders to administer Tylenol (analgesic) Lidocaine patch (topical analgesic) and to send Resident #10 to the Emergency Department for further evaluation. Resident #10 returned from the hospital on [DATE] with no concerns. Imaging was completed at hospital. Medication review was completed on Resident #20 by medical director on 10/20/25 and gave a new order for Depakote (medication used for mood stabilization) to 1000 milligrams (mg) every morning and 1250 mg every evening. On 10/21/25, Resident #10 called out with left leg and hip pain. The physician was notified and new orders received for X-ray two views and increase Meloxicam (non-steroidal anti-inflammatory) 7.5 mg to twice daily as needed for pain and discomfort. Resident #10's POA was notified of reported pain and new orders on 10/21/25. On 10/21/25 X-rays were completed and results received with conclusion: No acute fracture or dislocation. The osseous structures appear intact. Modest joint space narrowing. Soft tissues are unremarkable. Addendum: Question left pubic ring fractures on one view, recommend CT. The physician was notified of X-ray results and new orders received to send Resident #10 to the emergency department for evaluation. On 10/22/25, facility was notified Resident #10 had a pelvic ring fracture and was returning to the facility on [DATE]. Although no injuries, pain or distress was noted at the time of the incident, it was determined the fracture resulted from the resident-to-resident altercation on 10/18/25. Review of Director of Nursing's statement not dated, or timed, revealed RN #149 notified her on 10/18/25, no time indicated, and reported Resident #10 had fallen and he was still investigating the circumstances and there was another resident involved. No injuries were visible. She received another call from RN #149 no time indicated, revealing a third resident on the dementia unit witnessed the incident and stated, Resident #10 had walked up to Resident #20 and put her hand on his shirt, and he pushed her hand away and she fell. DON advised RN #149 to notify the Administrator and update her because the incident was a resident-to-resident altercation. Review of statement from Resident #50 no date and or time indicated, revealed she was at the end of the hall waiting to go outside on smoke break. Resident #20 was across from her and Miss orange and orange, white stripes came over, and Resident #20 crossed his fist and slugged her to the floor. Review of the Nurse Practitioner visit notes for Resident #10 on 10/23/25 confirmed nonoperative management for fracture and gave no new orders for pain. During an interview on 10/28/25 at 9:50 A.M., Resident #10 resident was not interviewable and could not recall falling on 10/18/25. During an interview on 10/29/25 at 4:30 P.M. Resident #20 stated Resident #10 walked up to him, and he pushed Resident #10 away from touching his shirt. During an interview on 10/30/25 at 11:00 A.M., Certified Nursing Assistant (CNA) #167 stated when Resident #20 displays aggressive behavior, it is towards other residents and not the staff. CNA #167 stated the process when a resident has a behavior is to document it in the electronic record under the Task section of in the electronic record and let the nurse know of the resident's behaviors. During an interview on 11/05/25 at 5:10 P.M. to 5:25 P.M. CN #131 and #146 stated Resident #20 does become very agitated and paces, screams and yells mean things to residents and to the staff. When it is time to smoke Resident #20 will stand by the exit door and pace. If the staff is late getting him for his smoke break his anxiousness, agitation and pacing intensifies. CNA #131 and #146 stated after they record the behavior in the task section of the medical record, they inform the nurse, and it is the nurse's responsibility to document the behavior in the Resident's #20 nursing notes. When Resident #20's behaviors are displayed, they try to redirect the resident, talk softly and walk away and approach him later. CNA #131 can remember an incident when a resident went into Resident #20's room and Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365408 If continuation sheet Page 3 of 4 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 11/06/2025 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 0600 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete #20 started screaming. She went in and removed the intruder to avoid an altercation. During an interview on 11/06/25 at 8:38 A.M. to 8:50 A.M. with LPN #124 and #170 stated when a resident displays behaviors, they are to document it in the resident's medical record. If only the CNA witnesses the behavior, they are to record it in the task sheet and report to the nurse to place it in the resident's medical record. When the behaviors are present it is the responsibility of the staff to try non-pharmacological interventions to diffuse the behaviors. During an interview on 11/06/25 at 8:55 A.M., LPN #110 stated when residents exhibit behaviors the nurse is to document the behavior in the medical record. LPN #110 also stated staff are to attempt non-pharmacological interventions to diffuse behaviors and those should be documented as well. LPN #110 stated she had been working at the facility for four months. Resident #20's behaviors were less when she started here. LPN #110 stated he was not as anxious and less threatening. When he started smoking in September 2025, his behavior increased and he started to refuse care, be demanding, and if the staff were late taking him for his break his anxiousness increased. He screamed and yelled out to anyone in the unit and he is less tolerable and very territorial During an interview on 11/06/25 at 12:36 P.M., the DON said psychiatric services were contacted today and they were waiting for a call back. She said psychiatric services were not consulted before because he hasn't had any behaviors until now. During a subsequent interview at 1:56 P.M. with the DON confirmed from 10/14/25 to 10/29/25 Resident #20 had nine episodes of having aggressive behavior documented in electronic health record under Target Behavior Task section and confirmed there was no nursing progress note that correlated to the behavior. Review of the facility policy titled Abuse, Neglect, and Exploitation, dated 01/10/24, revealed the facility is to provide protections for the health, welfare, and rights of each resident by implementing policies and procedures that prohibit and prevent abuse and neglect. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse and mental abuse. This deficiency represents non-compliance investigated under Complaint Number 2650764 and 2651377. Event ID: Facility ID: 365408 If continuation sheet Page 4 of 4