Health inspection·June 27, 2019

F 0578 Review of the resident's hard chart under the code status tab revealed it was blank. Level of Harm - Minimal harm or potential for actual harm Review of the plan of care revealed the resident was a do not resuscitate comfort care - arrest (DNRCCA). Review of Resident #15's electronic medical record revealed resident was an DNRCCA. Residents Affected - Few Interview on 06/25/19 at 1:30 P.M. with Registered Nurse (RN) #210 revealed Resident #15's hard copies medical chart did not have an advance directive placed under the code status tab. The RN said this would indicate Resident #15 was a full code. RN #210 confirmed Resident #15's plan of care, dated 05/30/19, and electronic medical record was marked for resident to be an DNRCCA. RN #210 confirmed Resident #15's electronic medical record and hard copy medical record did not match. RN #210 revealed when there was an emergence and a resident's code status was needed, staff would go to the resident's hard copy medical record to confirm their code status. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365426 If continuation sheet Page 2 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365426 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors West 375 West Main Street West Jefferson, OH 43162 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to complete an updated pre-admission screening and resident review (PASARR) following a significant change. This affected one (Resident #53) of twenty-four residents reviewed for PASARR. The facility census was 72. Findings include: Review of Resident #53's medical record revealed being admitted on [DATE] with diagnoses including adjustment disorder with mixed disturbances. Review of the Minimum Data Set (MDS) assessment, dated 04/03/19, revealed the resident was cognitively intact. Review of Resident #53's PASARR, dated 04/25/13, revealed the resident had a diagnosis of developmental disability. The PASARR did not identify Resident #53 had a diagnosis of Bipolar disorder. Review of Resident #53's medical record, dated 12/19/18, revealed the resident received a new diagnosis of Bipolar disorder. Interview on 06/25/19 at 12:55 P.M. with Corporate Social Service Director (SS) #300 confirmed Resident #53's PASARR, dated 04/25/13, revealed the resident had a diagnosis of developmental disability and did not identify the resident had a diagnosis of Bipolar disorder which was a diagnosis given to the resident on 12/19/18. SS #300 confirmed a significant change PASARR update should have occurred with the new diagnosis. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365426 If continuation sheet Page 3 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365426 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors West 375 West Main Street West Jefferson, OH 43162 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on observation, record review, and resident and staff interviews, the facility failed to accurately update the resident's plan of care to reflect any change of condition. This affected two (Resident #6 and #72) of the 24 residents reviewed for plan of cares. The facility's census was 72. Findings include: 1. Review of Resident #6's medical record revealed an admission date of 07/25/18. Diagnoses included delirium, anxiety, and muscle weakness. Review of Resident #6's Minimum Data Set (MDS) assessment, dated for 06/05/19, revealed the resident had intact cognition. Review of the resident's plan of care, dated 03/02/19, indicated resident was non-compliant with the facility's smoking policy including a history of smoking in his room and refusing to wear the recommended smoking apron for protection from dropped ashes or a dropped cigarette. Review of a smoking assessment, dated 06/21/19, revealed Resident #6 was no longer required to be supervised while smoking and no longer needed to wear a smoking apron. Observation on 06/27/19 at 9:00 A.M. of Resident #6 smoking outside in the designated smoking area revealed no staff members observing residents smoking nor was Resident #6 wearing a smoking apron. Interview on 06/27/19 at 11:39 A.M. with the Director of Nursing (DON) confirmed Resident #6 no longer required monitoring or a smoking apron while outside smoking. The DON verified Resident #6's plan of care had not been revised to reflect the most recent smoking assessment. 2. Review of Resident #72's medical chart revealed an admission date of 12/19/17. Diagnoses included dementia without behaviors, cognitive communication deficit and difficulty hearing in right ear. Review of the Minimum Data Set (MDS) assessment, dated 06/04/19, revealed the resident had no assistive devices related to her hearing deficit ordered for this resident. Resident #72's inventory list did not have hearing aids listed on it as items resident should have. Review of the plan of care, dated for 12/19/17, revealed the resident was at risk for a deficit related to a hearing deficit to her right ear. Interview on 06/24/19 at 11:00 A.M. with Resident #72 revealed she uses hearing aides in both ears, but has not had them in for awhile. Resident #72 could not verify why she did has not been wearing her hearing aides other than she thought they were broken. Interview on 06/26/19 at 10:52 A.M. with State Tested Nursing Assistant (STNA) #156 confirmed Resident #72 did have a pair of hearing aids and did normally have them in. STNA #156 confirmed Resident #72 did not have her hearing aids in at that moment. STNA #156 claimed that the other residents at that facility still tried to communicate with Resident #72 but without her hearing aides in, she was unable to hear them. Interview on 06/26/19 at 2:00 P.M. with the Director of Nursing (DON) confirmed the resident's plan of care was not revised to reflect the use of hearing aids. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365426 If continuation sheet Page 4 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365426 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors West 375 West Main Street West Jefferson, OH 43162 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 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm Based on record review, observation, and resident and staff interview, the facility failed to ensure resident's had their assistive hearing devices to maintain hearing abilities. This affected one (Resident #72) of one resident reviewed for hearing. The facility's census was 72. Residents Affected - Few Findings include: Review of Resident #72's medical chart revealed an admission date of 12/19/17 with the diagnoses of dementia without behaviors, cognitive communication deficit, difficulty hearing in right ear, and traumatic subdural hemorrhage without loss of consciousness. Review of the plan of care, dated 12/19/17, revealed the resident was at risk for a deficit related to hearing deficit to her right ear. There was no mention of hearing aids in the resident's plan of care. Review of the Minimum Data Set (MDS) assessment, dated 06/04/19, revealed the resident's cognition was intact and the resident had no assistive devices related to a hearing deficit ordered for this resident. Review of Resident #72's inventory list did not have hearing aids listed on it as items the resident should have. Interview and observation on 06/24/19 at 11:00 A.M. with Resident #72 revealed she uses hearing aids in both ears, but has not had them in for awhile. Resident #72 could not verify why she did has not been wearing her hearing aids other than she thought they were broken. Resident #72 continues to reveal she used to attend group activities everyday but has not attended them the last couple of weeks because all her friends stop talking to her and she felt unwanted. There were no hearing aids in her ears at this time of observation. Interview on 06/26/19 at 10:52 A.M. with State Tested Nursing Assistant (STNA) #156 confirmed Resident #72 did have a pair of hearing aids and did normally have them in. STNA #156 confirmed Resident #72 did not have her hearing aids in at that moment. STNA #156 claimed that the other residents at that facility still tried to communicate with Resident #72 but without her hearing aids in, she was unable to hear them. STNA #156 revealed she was unable to locate Resident #72's hearing aids. Interview on 06/26/19 at 11:15 A.M. with Registered Nurse (RN) #99 revealed she had no knowledge of Resident #72 having hearing aids. RN #99 confirmed Resident #72 was heard of hearing and would benefit from the use of hearing aids. After confirming that hearing aids were not identified on Resident #72's inventory list, RN #99 conducted a search of Resident #72's room. After searching for 45 minutes, RN #99 located Resident #72's hearing aids that were placed in a small box and placed at the bottom of her bedside dresser, where it was covered by other items, making it difficult for staff and resident to locate. RN #99 confirmed the hearing aids should have been indicated on Resident #72's inventory list and there needed to a care plan initiated for the use of hearing aids. Interview on 06/26/19 at 2:00 P.M. with the Director of Nursing (DON) confirmed Resident #72's plan of care was not revised to reflect the use of hearing aids. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365426 If continuation sheet Page 5 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365426 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors West 375 West Main Street West Jefferson, OH 43162 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on record review, observation, resident and staff interview, and review of the facility's smoking policy, the facility failed to ensure residents who smoked, returned their smoking items back to the nurse after each smoking incident and failed to ensure a resident was supervised during smoking. This affected three (Resident #6, #8 and #67) of the four residents reviewed for smoking. This facility also failed to ensure all ordered fall preventions were in place for the resident's safety. This affected one (Resident #72) of five residents reviewed for accidents. The facility's census was 72. Findings include: 1. Review of Resident #6's medical record revealed an admission date of 07/25/19 with the diagnoses of anxiety, delirium, type two diabetes mellitus, and cognitive communication deficit. The plan of care, dated 03/02/18, revealed the resident was a smoker. Review of the Smoking Assessment, dated 06/21/19, revealed the resident was not required to be monitored by facility staff while smoking. Interview on 06/27/19 at 10:00 A.M. with Resident #6 revealed residents who smoke were allowed to keep their lighters and cigarettes with them at all times. Resident #6 revealed they were not required or asked to give the nurses their smoking items. Observation on 06/27/19 at 10:05 A.M. of Resident #6's wheelchair reveled Resident #6 did in fact have all of his smoking items and held them under his leg while in the wheelchair to prevent them from falling out. 2. Review of Resident #67's medical record revealed as admission date of 06/19/18 with diagnoses of cerebral infarction, muscle weakness, difficulty in walking and acute and chronic respiratory failure. Review of the Smoking Assessment, dated 06/21/19, revealed the resident did not require monitoring from facility staff while smoking. Interview on 06/24/19 at 1:08 P.M. with Resident #67 revealed he held onto their own smoking items such as a lighter and cigarettes. Resident #67 revealed the facility will not take his lighter away from him. Observation on 06/24/18 at 1:10 P.M. of Resident #67's room revealed the resident was sitting in his wheelchair with his lighter and cigarettes placed in the breast pocket of his T-shirt. Interview on 06/27/19 at 4:00 P.M. with the Administrator confirmed residents who smoked were not permitted to hold onto their own smoking material while they were not smoking. All smoking material was to be returned to the nursing staff to be secured until the residents requested them to smoke outside. The Administrator also confirmed that Resident #6, Resident #67, and Resident #8 did not turn in their smoking material and the facility staff did not request their smoking material. 3. Review of Resident #8's medical record revealed an admission date of 01/17/17 with diagnoses (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365426 If continuation sheet Page 6 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365426 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors West 375 West Main Street West Jefferson, OH 43162 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few including subluxation of unspecified cervical vertebrae, chronic obstructive pulmonary disease and spinal instabilities. Review of the Minimum Data Set (MDS) assessment, dated 04/17/19, revealed the resident's cognition was intact. Review of the plan of care, dated 10/14/16, revealed the resident was required to have a smoking apron while smoking and was required to have supervision while smoking. The care plan additionally revealed smoking paraphernalia will be kept secured at the facility in a secured location. The care plan does reveal that the resident was non-compliant with the smoking apron. Review of the smoking assessment, dated 06/21/19, revealed the resident was to be supervised while smoking and was to wear a smoking apron. Observation on 06/25/19 at 2:00 P.M. revealed Resident #8 in his room and stated he was going to go smoke. The resident was observed with cigarettes and a lighter in his breast pocket. Resident #8 utilized a power wheelchair and has limited range of motion. Resident #8 had a drum stick which was modified by therapy so that he could push the keys on the secured panel. Resident independently wheeled himself to the smoke shack and removed his cigarettes and lighter from his pocket. Resident independently lit his cigarette. Resident did not wear a smoking apron and there was not a smoking apron visible in the smoking shack. Resident #8 denied that he ever wears a smoking apron. A staff was in the smoking shack initially, however left with another resident. Resident #8 continued to smoke without any supervision by staff. Resident #8's ashes from the cigarette dropped on the concrete floor of the smoking shack. Resident did not extinguish his cigarette and discarded it in a red metal partially-opened trash can. Resident then independently wheeled himself back into the building. Resident did return the lighter to the nurse prior to returning to his room. Interview with Administrator on 06/27/19 at 11:15 A.M. revealed he was unaware Resident #8 required supervision with smoking. The Administrator stated he thought Resident #8 was independent with smoking and was aware Resident #8 went out to the smoking area unsupervised. Review of Resident #8's smoking assessment and plan of care with the Administrator confirmed the plan of care and smoking assessment both identified the resident required supervision while smoking. Interview with Regional Director of Clinical Services (CRN) #200 on 06/27/19 at 12:35 P.M. confirmed the resident's smoking assessment, dated 06/21/19, was accurate. CRN #200 confirmed the resident should have had supervision while smoking. CRN #200 confirmed the resident was mentally alert, however due to his limited range of motion, there was potential for Resident #8 to drop his cigarette or possibly not be able to discard his cigarette safely. Review of the facility policy titled, Smoking Safety, dated 11/28/17, revealed each resident who smokes will be assessed for safety. Smoking items (cigarettes, lighters, etc.) will be kept in a designated area with limited staff access. 4. Review of Resident #72's medical record revealed an admission date of 12/19/17. Diagnoses included abnormalities of gait, depression, dementia, muscle weakness, and difficulty in walking. The record also revealed a history of falls without injury. Review of physician orders revealed the resident was to have a fall mat to be placed by the resident's bed at all times along with the resident's bed to be placed in the lowest position while the resident was in bed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365426 If continuation sheet Page 7 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365426 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors West 375 West Main Street West Jefferson, OH 43162 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 06/24/19 at 9:00 A.M., on 06/25/19 at 8:45 A.M. and on 06/26/19 at 10:22 A.M. of Resident #72 revealed the resident was in her bed with her eyes closed. The resident's bed was not in the lowest position and there was not a fall mat placed beside her bed. Interview on 06/26/19 at 11:00 A.M. with State Tested Nursing Assistant (STNA) #156 confirmed Resident #72 did not have a fall mat in her room and she had no knowledge of placing residents bed in lowest position while resident was in bed. Interview on 06/26/19 at 1:00 P.M. with Registered Nurse (RN) #99 confirmed the current doctor order for Resident #72 was to have fall mats placed beside her bed at all times and the current order for the resident's bed to be placed in the lowest positron. RN #99 confirmed that neither of these orders were in place. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365426 If continuation sheet Page 8 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365426 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors West 375 West Main Street West Jefferson, OH 43162 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, staff interview, medical record review, and facilities policy review, the facility failed to ensure oxygen tubing was dated for two residents (Residents #65 and #72) and failed to have current physician orders for use of oxygen for one resident (Resident #65). This affected two (Resident #65 and Resident #72) of 16 residents assessed for respiratory therapy. The facility census was 72. Residents Affected - Few Findings included: 1. Review of the medical record for Resident #65 revealed an admission date of 06/14/19 with diagnoses including congested heart failure, hypertension, and chronic atrial fibrillation. Review of the admission Minimum Data Set (MDS) assessment, dated 06/21/19, revealed he had no cognitive deficits. Review of the care plan revealed Resident #65 was on oxygen therapy related to congestive heart failure. Review of the physician orders, dated 06/2019, revealed there were no orders for oxygen therapy until after surveyor intervention. On 06/26/19, a new physician order revealed an oxygen saturation was to be obtained every shift and as needed, oxygen tubing and filter changed every week, and oxygen at two liters per minute via nasal cannula continuous and may titrate to keep oxygen saturation above 92 percent. Review of the nurse's note, dated 06/23/19, revealed Resident #65 complained of chest pain and oxygen was at 98 percent on two liters of oxygen. Review of the nurse's notes, dated 06/25/19, revealed Resident #65 had complained of not being able to breathe well and the nurse had noted he had on his oxygen wrong and fixed it. His oxygen saturation was 92 percent on two liters of oxygen. Observation on 06/24/19 at 2:12 P.M. of Resident #65 revealed he was wearing oxygen at two liters per nasal cannula. There was no date on the oxygen tubing. Interview on 06/24/19 at 2:13 P.M. with Registered Nurse (RN) #210 verified Resident #65 did not have his oxygen tubing dated. Review of the facilities Oxygen Administration Policy, dated July 2013, revealed the purpose of the policy was to provide guidelines for safe oxygen administration. Staff is to verify there is a physicians order for oxygen administration. 2. Review of Resident #72's medical record revealed an admission date of 12/19/17 with the diagnoses of seizures, dysphagia, apnea, and dementia without behaviors. Review of the admission Minimum Data Set (MDS) assessment, dated 06/04/19, revealed the resident had no cognitive deficits. Review of the care plan revealed the resident was on oxygen therapy related to shortness of breath and decreasing oxygen saturations. Observation on 06/24/19 at 11:20 A.M. revealed Resident #72 was sitting in her recliner wearing oxygen at two liters per nasal cannula. No date was noted on the oxygen tubing. Interview on 06/24/19 at 11:50 A.M. with Registered Nurse (RN) #210 confirmed there was no date on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365426 If continuation sheet Page 9 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365426 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors West 375 West Main Street West Jefferson, OH 43162 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 0695 Resident #72's oxygen tubing. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365426 If continuation sheet Page 10 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365426 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors West 375 West Main Street West Jefferson, OH 43162 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. Based on medical record review and staff interview, the facility failed to implement a gradual dose reduction for an antidepressant medication as ordered by physician for Resident #13, failed to follow up on pharmacy recommendations for Residents #46 and failed to ensure Resident #3 and #44 had a monthly medication regimen review. This affected four (Resident #3, #13, #44 and #46) of five residents reviewed for unnecessary medications. The facility census was 72. Findings include: 1. Review of the medical record for Resident #13 revealed an admission date of 11/30/18 with diagnoses including anxiety, depression, and post traumatic stress disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/09/19, revealed Resident #13 had no cognitive deficits and received antidepressant medications. Review of the care plan revealed Resident #13 had depression and used antidepressant medication. Intervention included to administer medications as ordered. Review of the physician orders, dated June 2019, revealed Resident #13 was on the following antidepressant medications: nortriptyline 75 milligrams (mg.) at bedtime, paxil 40 mg. one time a day, and Lexapro 20 mg. one time a day for depression. Review of pharmacy recommendation, dated 05/28/19, revealed Resident #13 was on paxil and Lexapro. Due to polypharmacy, the pharmacist recommended to discontinue medications. The physician addressed the recommendation on 06/05/19 to decrease paxil to 30 mg. Review of the medication administration record, dated June 2019, revealed Resident #13 was receiving paxil 40 mg. one time a day from 06/01/19 through 06/27/19. There was no evidence the facility implemented the physician's response to decrease paxil to 30 mg. Interview on 06/27/19 at 10:35 A.M. with the Director of Nursing verified the pharmacy recommendations, dated 05/28/19, addressed by the physician on 06/05/19 to decrease paxil to 30 mg. was not taking off by nursing and Resident #13 continued to receive paxil 40 mg. daily. 2. Review of the medical record for Resident #46 revealed an admission date of 04/05/19 with diagnoses including chronic congestive heart failure, hyperlipidemia, alcohol induced pancreatitis, hypertension, depression, seizures, diabetes mellitus, pseudobulbar affect, chronic kidney disease, and peripheral vascular disease. Review of the admission MDS assessment, dated 04/12/19, revealed Resident #46 had no cognitive deficits and received insulin injections, antidepressant, diuretic, opioids, and anticoagulant medications. Review of the nurses notes revealed pharmacy medication review progress notes dated 05/28/19 and 06/23/19 and revealed a monthly medication review was completed and to see reports. Review of the medical record was silent of any pharmacy recommendations for the listed dates of pharmacy reviews for 05/28/19 and 06/23/19. Interview on 06/27/19 at 4:17 P.M. with the Director of Nursing stated the facility could not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365426 If continuation sheet Page 11 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365426 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors West 375 West Main Street West Jefferson, OH 43162 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 locate the pharmacy recommendations made on 05/28/19 and 06/23/19 for Resident #46. Level of Harm - Minimal harm or potential for actual harm 3. Review of Resident #3's medical record revealed an admission date of 10/12/15. Diagnoses included muscular dystrophy, altered mental status, hyperlipidemia, vitamin d deficiency, tachycardia, acute and chronic respiratory failure, feeding difficulties, schizophrenia, neuromuscular dysfunction of bladder, sepsis, disorder of prostate, retention of urine, abnormal posture, muscle weakness, type two diabetes mellitus, hemiplegia and hemiparesis, depression and anxiety. Review of the quarterly MDS assessment, dated 05/20/19, revealed Resident #3's cognitive was moderately impaired and he required extensive assistance for activities of daily living (ADLs). Residents Affected - Some Review of Resident #3's medical record revealed there was no evidence a monthly pharmacy medication review was completed for May 2019. Interview on 06/27/19 at 4:19 P.M. with the Director of Nursing (DON) verified the facility could not provide a copy of the May 2019 monthly pharmacy medication review. 4. Review of Resident #44's medical record revealed an admission date of 01/16/16. Diagnoses included dementia, dysphagia oral phase, partial loss of teeth, difficulty in walking, muscle weakness, chronic obstructive pulmonary disorder, ataxia, neuropathy, Parkinson's, pacemaker, bipolar, depression, anxiety, hyperlipidemia, hyperglycemia, and cognitive communication deficit. Review of the quarterly MDS assessment, dated 04/08/19, revealed Resident #44's cognition was intact. Review of Resident #44's medical record revealed there was no evidence a monthly pharmacy medication review was completed for May 2019. Interview on 06/27/19 at 4:19 P.M. with the Director of Nursing (DON) verified the facility could not provide a copy of the May 2019 monthly pharmacy medication review. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365426 If continuation sheet Page 12 of 12