Inspection·April 12, 2022

F 0553 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 04/06/22 at 11:20 A.M. with Social Worker (SW) #38 confirmed there was no evidence of care conference meetings being held for Resident #57. Interview with the Administrator on 04//07/22 at 9:58 A.M. confirmed the facility had not been inviting residents to care conference meetings. The Administrator stated an education to the staff would be provided about inviting residents to care conference meetings. Review of the facility's policy titled Comprehensive Care Plans, dated 10/19/20, revealed every effort will be made to schedule care plan meetings at the best time of day for the resident and family and a summary of the comprehensive care plan would be provided to the resident and resident rep/family. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365426 If continuation sheet Page 2 of 21 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 04/12/2022 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 0623 Level of Harm - Potential for minimal harm Residents Affected - Some Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of the facility policy, the facility failed to notify the Long-Term Care Ombudsman timely and failed to provide a transfer notice to the resident and/or resident's representative when Residents #36 and #59 were sent out to a local hospital. This affected two (#36 and #59) of four residents for hospitalization. The facility census was 61. Findings include: 1. Review of the medical record for Resident #36 revealed he was admitted to the facility 11/01/19. Diagnoses included osteomyelitis, Parkinson's Disease, cerebral infarction, peripheral vascular disease, and paroxysmal atrial fibrillation. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #36 has extensive cognitive impairment. Review of the progress notes dated 08/19/21 at 10:54 A.M. revealed Resident #36 was not feeling well and upon assessment, vital signs were stable with oxygen at 87 percent. Emergency oxygen started at two liters nasal cannula. Resident #36 verbalized not feeling well and physician notified. Resident #36 was sent out to hospital. Guardian made aware. There was no evidence the facility had sent a notice of transfer with the resident or provided one to the resident's representative. There was also no evidence the facility notified the Ombudsman of Resident #59's hospitalization. Review of the notice to the Ombudsman dated 04/03/22 revealed the notice had just been sent for 08/19/21 transfer to local hospital. Interview with the Business Office Manager (BOM) on 04/05/22 revealed she was not aware the transfer/discharge notice should be sent to the resident's representative. She also confirmed the Ombudsman notification was not done monthly. 2. Review of the closed medical record for Resident #59 revealed an admission date on 01/01/22 and a discharge date on 01/06/22. Diagnoses included sepsis due to other specified staphylococcus (a type of bacteria), peripheral vascular disease (PVD), stage III chronic kidney disease, and congestive heart failure. Review of the five-day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #59 had intact cognition. Review of the physician's orders for January 2022 revealed Resident #59 had an order to send to the emergency room for an evaluation dated 01/06/22. Review of the Situation, Background, Assessment, and Recommendation (SBAR) Communication Form dated 01/06/22 revealed Resident #59 had an identified change in condition. Resident #59 was being shocked via his pacemaker and the condition had worsened since it started on 01/06/22. Resident #59 was sent to the hospital for treatment. Resident #29's wife and physician were notified of the transfer to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365426 If continuation sheet Page 3 of 21 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 04/12/2022 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 0623 the hospital. Level of Harm - Potential for minimal harm Review of the progress note dated 01/06/22 revealed Resident #59 felt he was having a heart attack and was not feeling well. The nurse assessed Resident #59 and found the resident's defibrillator was firing. Emergency Medical Services (EMS) was called and Resident #59 was transferred to the hospital. Residents Affected - Some There was no evidence the facility had sent a notice of transfer with the resident or provided one to the resident's representative. There was also no evidence the facility notified the Ombudsman of Resident #59's hospitalization. Review of the notification to the Ombudsman revealed the facility had just sent an email to the Ombudsman on 04/05/22 at 5:59 P.M. to notify of transfers and discharges from December 2021 through March 2022. Interview with the Business Office Manager (BOM) on 04/05/22 confirmed notification to the Ombudsman of transfers and discharges were not completed monthly. Interview on 04/06/22 at 4:10 P.M. with the Administrator confirmed a Notice of Transfer was not completed, sent with the resident to the hospital, or provided to the resident's representative for Resident #59's hospitalization. Review of the facility policy titled, Involuntary Transfer and Discharge, dated 04/12/18 revealed a notice concerning the transfer or discharge shall be provided to the resident, residents representative, long-term care Ombudsman, state survey agency, and the physician. The facility shall provide a copy of the log to the long-term care ombudsman monthly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365426 If continuation sheet Page 4 of 21 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 04/12/2022 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the resident's Minimum Data Set (MDS) assessments were accurately completed. This affected two (Residents #8 and #30) of 20 residents reviewed for MDS assessments. The facility census was 61. Residents Affected - Few Findings include: 1. Review of Resident #30's medical record revealed an admission date of 09/19/19. Diagnoses included muscle weakness. Review of the quarterly MDS assessment dated [DATE] revealed Resident #30 was coded as having a wound infection. Further review of Resident #30's medical record from 10/01/21 through 04/07/22 revealed no documentation of any wound infections. Interview on 04/07/22 11:15 A.M. with Licensed Practical Nurse (LPN) #31 confirmed Resident #30's quarterly MDS assessment dated [DATE] was coded incorrectly for wound infection. LPN #31 confirmed there was no documentation of Resident #30 having a wound infection from 10/01/22 through 04/07/22. 2. Review of the medical record for Resident #8 revealed an admission date of 04/25/19. Diagnoses included dementia. Review of the therapy notes revealed on 10/25/19, Occupational Therapy (OT) began treatment to Resident #8's right and left hand contractures. The record further revealed that a restorative program was implemented on 11/07/19. Resident #8 required full assistance with all aspects of daily care and mobility. Review of section G0400A of the Minimum Data Set (MDS) assessment dated [DATE] for Resident #8 indicated he had no impairment to right or left upper extremities. Further reviews of section G0400A of the subsequent Minimum Data Set (MDS) assessments dated 02/05/20 through 01/06/22 for Resident #8 indicated that he had no impairment to right or left upper extremities. Review of the plan of care dated 03/16/20 for Resident #8 revealed no goals or interventions addressing the decline in range of motion or the addition of a restorative program. On 04/07/22 at 10:21 A.M., an interview with the MDS Nurse #31 was conducted. MDS Nurse #31 confirmed all prior MDS assessments were incorrectly coded and G0400A should reflect that Resident #8 has limited range of motion to both hands. MDS Nurse #31 also confirmed there was no care plan in place for Resident #8 addressing his decline in range of motion, the implementation of his restorative program, and the use of splints. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365426 If continuation sheet Page 5 of 21 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 04/12/2022 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #56 was admitted to the facility on [DATE]. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, left hand contracture, cerebral infarction, major depressive disorder, unspecified abnormalities of gait and mobility, contracture, left ankle, personal history of other mental and behavioral disorders. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #56 had no cognitive impairment. His functional status was listed as extensive one to two-person assist for all activities of daily living. Review of the care plan dated 09/20/21 revealed Resident #56 was at risk related to the resident has hemiplegia/hemiparesis related to stroke. Interventions included to assist with activities of daily living/Mobility as needed. Give medications as ordered. Monitor/document for side effects and effectiveness. Obtain and monitor lab/diagnostic work as ordered. Report results to physician and follow up as indicated. Pain management as needed. See physician orders. Provide alternative comfort measures as needed. Physical and Occupational Therapies to evaluate and treat as ordered. Review of the physician orders dated 09/02/20 revealed a Blue Hand and Extension Splint to be worn in the A.M. and off at bed time, may be removed for hygiene, one time a day for hand placement. Elevate left hand on pillow at bed time, every evening shift for left hand edema. Subsequent review of the medical record revealed there was no evidence the physician's order for a Blue Hand and Extension Split was implemented. Observation and interview on 04/07/22 at 10:30 A.M. revealed Resident #56 was not wearing a Blue Hand and Extension Splint. Interview with Resident #56 stated he was unaware of a splint being ordered for his hand. Interview with the Physical Therapist #200 on 04/07/22 at 11:15 A.M. revealed she was unaware of the physician's order for a Blue Hand and Extension splint for Resident #56. Interview with the Director of Nursing on 04/07/22 at 12:30 P.M. confirmed the Blue Hand and Extension Splint was never ordered for Resident #56. Review of the facility's policy titled, Restorative Nursing Programs dated 01/01/21 revealed the following types of residents could benefit from a restorative program but limited to contracture prevention and or management. 3. Review of Resident #33's medical record revealed an admission date of 02/06/22. Diagnoses included liver cell carcinoma and nonalcoholic steatohepatitis. Review of Resident #33's physician orders dated 02/06/22 revealed an active order for a half grab bar for bed mobility. Review of Resident #33's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition and required extensive assistance with one person physical assistance with bed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365426 If continuation sheet Page 6 of 21 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 04/12/2022 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 0688 mobility. Level of Harm - Minimal harm or potential for actual harm Observations of Resident #33 on 04/04/22 at 7:02 P.M., 04/05/22 at 7:16 A.M., 8:18 A.M., and 10:24 A.M., and 04/06/22 at 8:42 A.M. revealed Resident #33 lying in her bed without a half grab bar in place. Residents Affected - Some Interview on 04/06/22 at 9:25 A.M. with State Tested Nursing Aide (STNA) #57 revealed Resident #33 pulled on the mattress in order to turn herself. STNA #57 confirmed absence of a half grab bar on Resident #33's bed. Interview on 04/06/22 at 1:46 P.M. with Licensed Practical Nurse (LPN) #35 confirmed the absence of a half grab bar on Resident #33's bed. 4. Review of Resident #34's medical record revealed an admission date of 05/20/21. Diagnoses included dementia without behavioral disturbance and functional incontinence. Review of Resident #34's physician orders dated 05/20/21 revealed an active order for a half grab bar for bed mobility. Review of Resident #34's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition and required extensive assistance with one person physical assistance with bed mobility. Observations of Resident #34 on 04/04/22 at 7:00 P.M., 04/05/22 at 7:16 A.M., and 04/06/22 at 9:38 A.M. revealed Resident #34 in her bed without a half grab bar in place. Interview on 04/06/22 at 9:39 A.M. with STNA #57 confirmed the absence of a half grab bar on Resident #34's bed. Interview on 04/06/22 at 1:13 P.M. with LPN #35 confirmed the absence of a half grab bar on Resident #34's bed. Based on observations, medical record review, staff and resident interviews, and facility policy review, the facility failed to implement physician order for half grab bars for Residents #33 and #34, failed to implement physician order for a restorative program for Resident #8, and failed to implement physician order for a Blue Hand and Extension Splint for Resident #56. This affected four (Residents #8, #33, #34, and #56) of five residents reviewed for positioning/mobility. The facility identified 29 residents with contractures. The facility census was 61. Findings include: 1. Review of the medical record for Resident #8 revealed an admission date of 04/25/19. Diagnoses included dementia, depression, and left above the knee amputation. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 had severe cognitive impairments. Review of Resident #8's therapy notes revealed on 10/25/19, Occupational Therapy (OT) began treatment to Resident #8's right and left hand contractures. The record further revealed a restorative program was implemented on 11/07/19. The restorative program was to include range of motion (ROM) treatment and splints to both hands four hours per shift daily. Resident #8 required full assistance with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365426 If continuation sheet Page 7 of 21 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 04/12/2022 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 0688 all aspects of daily care and mobility. Level of Harm - Minimal harm or potential for actual harm Review of the physician's orders for Resident #8 revealed an order dated 10/23/19 for participation in restorative programs as needed. Residents Affected - Some Review of the restorative task documentation for March 2022 revealed Resident #8 did not receive restorative ROM or splint treatment 17 times on the following dates: 03/01/22, 03/06/22, 03/07/22, 03/09/22, 03/10/22, 03/11/22, 03/12/22, 03/13/22, 03/14/22, 03/15/22, 03/16/22, 03/17/22, 03/18/22, 03/20/22, 03/22/22, 03/25/22, and 03/27/22. Review of the plan of care for Resident #8 revealed the plan of care did not address or include the resident's need for a restorative ROM program. Observation on 04/04/22 at 8:08 A.M. revealed Resident #8 had contractures of both hands. Interview on 04/06/22 at 11:30 A.M with Occupational Therapist (OT) #85 revealed Resident #8's restorative ROM program was implemented on 11/07/19. OT #85 stated she was not aware Resident #8 refused to participate in wearing the splint or the restorative ROM program. Interview on 04/07/22 at 10:36 A.M. with the Director of Nursing (DON) confirmed there was no evidence Resident #8 received restorative ROM as ordered. The DON confirmed there was no documentation of the restorative ROM program for Resident #8 since 2019. The DON confirmed a restorative ROM program was not included in Resident #8's plan of care. The DON confirmed there was not a completed evaluation of the program for Resident #8. Interview on 04/07/22 at 10:40 A.M. with Restorative Aide (RA) #62 confirmed Resident #8 did not receive restorative ROM consistently due to being the only RA in the facility. RA #62 stated the restorative ROM program was not completed when she was unavailable. RA #62 denied Resident #8 refused to wear hand splints or participate in the restorative ROM program. Subsequent interview on 04/07/22 at 10:43 A.M. with the DON confirmed RA #62 was the only restorative aide for the facility. The DON stated there was not a plan for ensuring the restorative program was implemented on the days RA #62 was not available. Review of the facility policy, Restorative Programs, dated 01/01/2, revealed a restorative program would be led by the DON or designee, would have an established monitoring program to assure resident success, would document participation and refusals, determine resident goals, and review the program during the plan of care meeting with the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365426 If continuation sheet Page 8 of 21 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 04/12/2022 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, resident and staff interviews, review of fall reports, and review of facility policy, the facility failed to implement the appropriate fall procedure following Resident #40's fall and failed to implement fall interventions for Resident #34 who had a history of multiple falls. This affected two (Residents #34 and #40) of four residents reviewed for falls. The facility census was 61. Findings include: 1. Review of the medical record for Resident #40 revealed an original admission date on 03/16/18. Diagnoses included congestive heart failure, infarction (stroke), chronic pain, generalized muscle weakness, difficulty in walking, and seizures. Review of the physician orders dated 12/20/21 revealed Resident #40 had an order for a low bed when sleeping for fall precautions. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #40 had intact cognition. The resident required limited assistance to extensive assistance from one to two staff to complete Activities of Daily Living (ADLs). Resident #40 had two or more falls without injury since admission or readmission. Review of the Fall Risk assessment dated [DATE] revealed Resident #40 had one to two falls in the last 90 days. The resident most recent fall occurred on 02/22/22. The resident scored 24 on the assessment to show Resident #40 was at high risk for falling. Review of the progress notes dated 02/22/22 revealed Resident #40's fall was not documented in the medical record. Review of the Situation Background Assessment and Recommendation (SBAR) Communication Form dated 02/23/22 revealed Resident #40 had an unreported fall. Resident #40 was noted to have dry blood and an abrasion on his right eyebrow. Notes on the form stated walked into resident's room and found resident to have dry blood on right eyebrow. Resident #40 stated his bed broke last night causing him to fall and hit his head. Resident #40 denies any pain from fall and no other areas of concern from fall. Physician, hospice, Director of Nursing (DON), and resident's representative were notiifed. No report or documentation was provided from the previous nurse. Review of the progress note dated 02/23/22 at 10:39 A.M. revealed a nurse went into Resident #40's room to give morning medication and noticed dry blood on right eyebrow with some swelling. Resident #40 stated he fell last night and a nurse helped him to get up. The resident denied pain from the fall or bruised area. As needed pain medication was administered. The nurse attempted to clean the dry blood off but Resident #40 refused and stated, just leave me alone. Resident #40's blood pressure was elevated to 202/58. The resident's Nurse Practitioner, hospice, and resident's representative were notified. The nurse would continue to monitor Resident #44. Review of the progress note dated 02/23/22 at 7:22 P.M. revealed the date of Resident #40's fall was 02/22/22. Details included the resident had an abrasion to his right eyebrow with dried blood. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365426 If continuation sheet Page 9 of 21 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 04/12/2022 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 Assessments included neurological checks and a skin assessment. Environmental factors included Resident #40's bed was broken. Interventions included a new bed was ordered for Resident #40. The Nurse Practitioner, hospice provider, and resident representative were notified. Additional comments included Resident #40 had dried blood on his right eyebrow. Resident #40's bed broke causing him to fall last night and hit his head. Resident #40 denied any other pain from the fall. Pain medication was administered. Assessments were completed. Review of the Falls Investigation Worksheet dated 02/23/22 revealed the date of Resident #40's fall was 02/22/22 at an unknown time. The fall occurred in the resident's room and the resident was laying in bed when the fall occurred. Resident #40's bed was found to be broken. The fall was unwitnessed. Resident #40 sustained an abrasion to his right eyebrow. Review of the Neurological Evaluation Flow Sheet revealed neurological checks on Resident #40 were not completed until 02/23/22 at 10:05 A.M. The neurological checks scheduled for 2:40 P.M. and 3:40 P.M. were not completed. Interview on 04/07/22 at 1:21 P.M. with Resident #40 revealed he recalled the fall that occurred on 02/22/22. Resident #40 stated his bed broke causing him to fall out of bed during the night. Resident #40 stated Licensed Practical Nurse (LPN) #36 found him on the floor and was not able to assist him up without additional assistance from another staff person. Resident #40 denied having any major injuries from the fall and stated he did not experience any pain that he recalled. Resident #40 stated his bed was replaced immediately and was currently working at the time of the interview. Interview on 04/07/22 at 1:28 P.M. with LPN #34 revealed he was not working on 02/22/22 when Resident #40 fell. However, LPN #34 stated Resident #40 had a history of falls and did work on 02/23/22. LPN #34 recalled Resident #40 did have dried blood on his eyebrow. LPN #34 confirmed there was no documentation completed regarding the fall on 02/22/22 when the fall occurred. Interview via telephone on 04/07/22 at 2:03 P.M. with LPN #34 revealed he was working on night shift on 02/22/22 with another nurse, LPN #501. LPN #34 stated LPN #501 found Resident #40 on the floor on 02/22/22. LPN #34 stated the procedure following a resident fall included an immediate assessment and skin check of the resident before the resident was moved, as long as the assessment was within normal limits, the resident could be moved, a fall report should be completed and neurological checks should be started. LPN #34 confirmed LPN #501 did not complete the fall report or neurological checks for Resident #40's fall on 02/22/22 per the facility's protocol. Interview on 04/07/22 at 3:48 P.M. with the Director of Nursing (DON) confirmed LPN #501 did not complete a fall report, document neurological checks, or provide notifications to Resident #40's physician, hospice provider, or resident representative per facility protocol. The DON stated LPN #501 was a new nurse at the time of the incident and was orienting to the facility with LPN #34. DON stated education was provided to LPN #501 following the incident on the facility's fall procedures. Review of the facility's policy titled Falls-Clinical Protocol, dated 01/01/21, revealed the policy stated for a resident who has fallen, staff should define possible causes within 24 hours of the fall. Resident who have fallen and have been witnessed to hit head, suspected to have hit head, and all unwitnessed falls regardless of cognitive status should have neurochecks per physician orders or protocol. The physician and responsible party should be notified as soon as the resident is stabilized. Document findings in the resident's medical record or electronic health record (EHR) per protocol. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365426 If continuation sheet Page 10 of 21 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 04/12/2022 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 2. Review of Resident #34's medical record revealed an admission date of admission date of 05/20/21. Diagnoses included ataxia, dementia without behavioral disturbance, and functional incontinence. Review of Resident #34's progress notes dated 10/03/21 at 1:43 P.M. revealed Resident #34 was found on the floor in front of her wheelchair with wheel locks not engaged. Residents Affected - Few Further review of Resident #34's progress notes dated 12/17/21 at 3:26 P.M. revealed Resident #34 was found on floor in front of her wheelchair and Resident #34 stated she had slid out of her wheelchair. Further review of Resident #34's progress notes dated 03/26/22 at 11:41 P.M. revealed Resident #34 was found on the floor in front of her wheelchair and Resident #34 stated she had fallen from her wheelchair. A hospice nurse had visited Resident #34 after the fall and recommended dycem to wheelchair as fall intervention. Review of the Incident Report dated 03/26/22 revealed a note stating a dycem was recommended by the hospice nurse. Another notation on the report noted a new intervention of dycem (non-slip mat) to wheelchair. Observations of Resident #34 on 04/04/22 at 7:12 P.M. and 04/05/22 at 10:22 A.M. revealed Resident #34 transferring herself from her bed to her wheelchair without the wheelchair wheels being locked. The dycem was absent from wheelchair seat during the observations. Subsequent observation of Resident #34 on 04/05/22 at 3:14 P.M. in hallway in wheelchair and the dycem was absent from wheelchair seat. Interview with State Tested Nursing Aide (STNA) #57 on 04/06/22 at 9:39 A.M. confirmed the dycem was absent from wheelchair seat. Interview with Licensed Practical Nurse (LPN) #35 on 04/06/22 at 1:13 P.M. confirmed the dycem was absent from the wheelchair seat. Review of the facility's policy titled Falls-Clinical Protocol, dated 01/01/21, revealed the policy stated interventions should be developed and implemented per the assessed needs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365426 If continuation sheet Page 11 of 21 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 04/12/2022 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on medical record review, staff interview, observation, and review of the facility's policy, the facility failed to ensure a resident's enteral nutrition (tube feeding) was being administered as ordered. This affected one (Resident #30) of two residents reviewed for tube feeding. The facility identified two residents residing in the facility currently receiving tube feeding. The facility census was 61. Findings include: Review of Resident #30's medical record revealed an admission date of 09/19/19. Diagnoses listed included aphasia, dysphagia, muscle weakness. Resident #30 was assessed as being severely cognitively impaired, requiring extensive assistance with activities of daily living (ADLs), and had a feeding tube. Review of the physician orders dated 03/08/22 revealed an order for Jevity 1.5 (enteral nutrition) 75 milliliters per hour (ml/hr) times 18 hours from 4:00 P.M. until 10:00 A.M. This totaled to be 1,340 ml for the 18 hours. Provide an alternative when necessary. Observation of Resident #30's tube feeding on 04/04/22 at 8:23 P.M. revealed a tube feeding bottle of Jevity 1.5 running on a pump at 75 ml/hr. The bottle was marked as being hung on 04/04/22 at 4:00 P.M. A follow-up observation of Resident #30's tube feeding on 04/05/22 at 8:05 A.M. revealed Resident #30's Jevity 1.5 was not running. The same bottle marked as dated 04/04//2 at 4:00 P.M. was still hanging. The amount left in the bottle was approximately 450 ml. The bottle was 1,000 ml. Interview with Licensed Practical Nurse (LPN) #35 on 04/05/22 at 8:05 A.M. confirmed Resident #30's tube feeding was not running. LPN #35 confirmed the bottle was marked as dated 04/04/22 at 4:00 P.M. LPN #35 also confirmed that Resident #30's tube feeding bottle should have ran out during the night and new bottle should have been hung. Review of the facility's policy titled Feeding Tubes, dated 01/01/22, revealed the staff will ensure that the administration of enteral is consistent with and follows the practitioner's orders. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365426 If continuation sheet Page 12 of 21 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 04/12/2022 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. Review of the medical record for Resident #56 revealed the resident was admitted to the facility on [DATE]. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, cerebral infarction, major depressive disorder, unspecified abnormalities of gait and mobility, contracture, left ankle, personal history of other mental and behavioral disorders. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #56 had no cognitive impairment. Review of Resident #56's Medication Regimen Reviews dated 04/05/21, 06/06/21, 09/16/21, and 10/18/21 revealed a pharmacy recommendation that were not timely addressed by the facility physician for acid-suppressive therapy. This was addressed by the physician on 01/17/22 and changed to a different acid suppressive. Review of Resident #56's Medication Regimen Reviews dated 04/08/21 revealed it was for antidepressant Effexor 75 milligram (mg), twice a day since 09/20/20. The physician did not timely respond to the recommendation and the physician responded 01/19/22 and it was decreased to 100 mg one time a day for depression. Interview on 04/07/22 at 8:53 A.M. with the Director of Nursing (DON) confirmed the pharmacy recommendations for Resident #56 were not addressed timely or signed by a physician. Review of the facility's policy titled Unnecessary Drugs-Without Adequate Indication of Use, dated 01/01/21, revealed it was the facility's policy that each resident's drug regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being free from unnecessary drugs. The attending physician will assume leadership in medication management by developing, monitoring, and modifying the medication regimen in collaboration with residents and/or representatives, other professionals, and the interdisciplinary team. Each resident's drug regimen will be reviewed on an ongoing basis. Based on medical record review and staff interview, the facility failed to timely address pharmacy recommendations. This affected six (Residents #22, #25, #33, #34, #40, and #56) of six residents reviewed for unnecessary medications. The facility census was 61. Findings include: 1. Review of Resident #22's medical record revealed an admission dated of 01/30/20. Diagnoses included chronic kidney disease, type II diabetes mellitus, major depressive disorder, and morbid obesity. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 was cognitively intact. Review of Resident #22's pharmacy recommendations dated 10/18/21, 02/15/22,and 03/17/22 revealed a complete blood count (CBC), basic metabolic panel (BMP), and hemoglobin A1C laboratory tests were requested to be drawn every six months. The pharmacy recommendation was not signed by a physician nor was there evidence in the medical record this was addressed by a physician. Review of Resident #22's pharmacy recommendations dated 02/15/22 and 03/17/22 revealed a black box warning (safety related medication warning) was requested to be addressed for the use of Montelukast (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365426 If continuation sheet Page 13 of 21 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 04/12/2022 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 (allergy medication) 10 milligrams (mg). There was no documentation the pharmacy recommendations being addressed by a physician. Interview on 04/07/22 at 8:53 A.M. with the Director of Nursing (DON) confirmed the pharmacy recommendations for Resident #22 were not addressed timely or signed by a physician. Residents Affected - Some 2. Review of Resident #25's medical record revealed an admission date of 10/09/20. Diagnoses included vascular dementia, type II diabetes, schizoaffective disorders, hypertension, and dysphagia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 was severely cognitively impaired. Review of Resident #25's pharmacy recommendations dated 07/27/21, 09/18/21, and 10/18/21 revealed it was for a request to obtain a thyroid-stimulating hormone (TSH) level every six to twelve months for use of Amiodarone (antiarrhythmic medication). The pharmacy recommendation was not signed by a physician. There was no documentation of the pharmacy recommendations being addressed by a physician. Review of Resident #25's pharmacy recommendations dated 02/15/22 and 03/17/22 revealed it was for a gradual dose reduction (GDR) of Buspar (anxiety medication) 5.0 milligrams (mg) and Olanzapine (antipsychotic medication) 7.5 mg. The pharmacy recommendation was not signed by a physician. There was no documentation of the pharmacy recommendations being addressed by a physician. Review of Resident #25's pharmacy recommendations revealed on 03/17/22, a request to reconsider weaning Resident #25 off Nexium (acid reflux medication). Please consider Famotidine (acid reflux medication) if treatment needed. The pharmacy recommendation was not signed by a physician. There was no documentation of the pharmacy recommendations being addressed by a physician. Review of Resident #25's pharmacy recommendations dated 03/17/22 was for a GDR of Trazodone (antidepressant medication) 25 milligrams (mg). The pharmacy recommendation was not signed by a physician. There was no documentation of the pharmacy recommendations being addressed by a physician. Interview on 04/07/22 at 8:53 A.M. with the Director of Nursing (DON) confirmed the pharmacy recommendations for Resident #25 were not addressed timely or signed by a physician. 3. Review of Resident #40's medical record revealed an admission date of 02/12/21. Diagnoses included chronic kidney disease, hematuria, sciatica, hyperlipidemia, and pseudobulbar affect. Review of the quarterly Minimum Data Set (MDS) assessment date 02/14/22 revealed Resident #40 was cognitively intact. Review of Resident #40's pharmacy recommendation dated 04/05/21, 06/07/21, and 09/17/21 revealed a GDR request for Amitriptyline (antidepressant) 50 mg and Seroquel (antipsychotic) 100 mg. The pharmacy recommendation was not signed by a physician. There was no documentation of the pharmacy recommendations being addressed by a physician. Review of Resident #40's physician orders revealed an order dated 08/10/21 for Ativan (anxiety medication) 0.5 mg give one tablet by mouth every six hours (PRN) for agitation and give one tablet by mouth at bed time related to major depressive disorder. Review of Resident #40's pharmacy recommendation dated 09/17/21, 10/18/21, 01/18/22, and 02/15/22 revealed a request for a new order to use PRN Ativan 0.5 mg greater than 14 days was requested. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365426 If continuation sheet Page 14 of 21 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 04/12/2022 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 pharmacy recommendation was not signed by a physician. There was no documentation of the pharmacy recommendations being addressed by a physician. Interview on 04/07/22 at 8:53 A.M. with the Director of Nursing (DON) confirmed the pharmacy recommendations for Resident #40 were not addressed timely or signed by a physician. Residents Affected - Some 4. Review of Resident #33's medical record revealed an admission date of 02/06/22. Diagnoses included liver cell carcinoma, nonalcoholic steatohepatitis, history of healed physical injury and trauma, esophageal varices, insomnia, hypertension, and type two diabetes mellitus. Review of Resident #33's Medication Regimen Reviews dated 02/08/22 and 03/17/22 revealed Resident #33 was receiving Remeron 7.5 milligrams, two tablets by mouth daily at bedtime as needed for sleep. A recommendation was made to consider discontinuation due to as needed antipsychotic orders cannot exceed 14 days and require evaluation for continuation. The pharmacy recommendation was not signed by a physician. There was no documentation of the pharmacy recommendations being addressed by a physician. Review of Resident #33's Medication Regimen Review for 03/17/22 revealed a recommendation for changing the following medications to crushable medications: Tylenol Extended Release 500 milligrams, Metoprolol Extended Release 25 milligrams, and Klor-Con M20 20 milliequivalents. The pharmacy recommendation was not signed by a physician. There was no documentation of the pharmacy recommendations being addressed by a physician. Interview on 04/07/22 at 8:53 A.M. with the Director of Nursing (DON) confirmed the pharmacy recommendations for Resident #33 were not addressed timely or signed by a physician. 5. Review of Resident #34's medical record revealed an admission date of 05/20/21. Diagnoses included ataxia, dementia without behavioral disturbance, anxiety, major depressive disorder, hypertension, and functional incontinence. Review of Resident #34's Medication Regimen Reviews dated 06/07/21, 01/18/22, 02/15/22, and 03/17/22 revealed Resident #34 was prescribed a medication with a black box warning, Montelukast 10 milligrams by mouth every day. Recommendation to evaluate resident to determine if therapy can be continued, should be discontinued, or changed to different medication. The pharmacy recommendation was not signed by a physician. There was no documentation of the pharmacy recommendations being addressed by a physician. Review of Resident #34's Medication Regimen Reviews dated 06/07/21, 01/18/22, 02/15/22, and 03/17/22 revealed Resident #34 was receiving Metoprolol 50 milligrams by mouth every day. Recommendation to consider changing to improve efficacy and reduce potential adverse effects. The pharmacy recommendation was not signed by a physician. There was no documentation of the pharmacy recommendations being addressed by a physician. Review of Resident #34's Medication Regimen Reviews dated 06/07/21, 01/18/22, 02/15/22, and 03/17/22 revealed Resident #34 was receiving Prochlorperazine Suppository 25 milligrams by rectum every 12 hours as needed for nausea and vomiting. A recommendation was made to consider discontinuation due to as needed antipsychotic orders cannot exceed 14 days and require evaluation for continuation. The pharmacy recommendation was not signed by a physician. There was no documentation of the pharmacy recommendations being addressed by a physician. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365426 If continuation sheet Page 15 of 21 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 04/12/2022 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 Review of Resident #34's Medication Regimen Reviews dated 01/18/22, 02/15/22, and 03/17/22 revealed Resident # 34 was receiving Trazodone 50 milligrams by mouth daily at bedtime, Buspar 10 milligrams by mouth three times daily, Cymbalta 90 milligrams daily, and Seroquel 25 milligrams twice daily, and these medications were due for Gradual Dose Reduction review. Recommendation to evaluate current doses and consider whether a dose reduction of any of the medications would be appropriate. The pharmacy recommendation was not signed by a physician. There was no documentation of the pharmacy recommendations being addressed by a physician. Review of Resident #34's Medication Regimen Reviews dated 06/07/21, 01/18/22, 02/15/22, and 03/17/22 revealed Resident #34 was receiving Seroquel 25 milligrams by mouth twice daily. Recommendation for appropriate diagnosis for Seroquel use. The pharmacy recommendation was not signed by a physician. There was no documentation of the pharmacy recommendations being addressed by a physician. Review of Resident #34's Medication Regimen Review dated 10/18/22 revealed Resident #34 was receiving Seroquel 25 milligrams by mouth twice daily, Trazodone 50 milligrams by mouth every night, and two Ativan as needed orders. Recommended considering evaluation of current medications due to Resident #34's recent fall. The pharmacy recommendation was not signed by a physician. There was no documentation of the pharmacy recommendations being addressed by a physician. Interview on 04/07/22 at 8:53 A.M. with the Director of Nursing (DON) confirmed the pharmacy recommendations for Resident #34 were not addressed timely or signed by a physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365426 If continuation sheet Page 16 of 21 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 04/12/2022 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Review of the medical record for Resident #56 revealed the resident was admitted to the facility on [DATE]. Diagnoses included major depressive disorder and personal history of other mental and behavioral disorders. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #56 had no cognitive impairment. Review of Resident #56's Medication Regimen Reviews dated 04/08/21 revealed it was for antidepressant Effexor 75 milligram (mg), twice a day since 09/20/20. The physician did not timely respond to the recommendation and the physician responded 01/19/22 and it was decreased to 100 mg one time a day for depression. Interview on 04/07/22 at 8:53 A.M. with the Director of Nursing (DON) confirmed the pharmacy recommendations for Resident #56 was not addressed timely by the physician. Review of the facility's policy titled Unnecessary Drugs-Without Adequate Indication of Use, dated 01/01/21, revealed it was the facility's policy that each resident's drug regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being free from unnecessary drugs. The attending physician will assume leadership in medication management by developing, monitoring, and modifying the medication regimen in collaboration with residents and/or representatives, other professionals, and the interdisciplinary team. Each resident's drug regimen will be reviewed on an ongoing basis. Based on medical record review, staff interview, and review of the facility's policy, the facility failed to timely address pharmacy recommendations to address psychotropic medication use. This affected five (Resident #25, #33, #34, #40, and #56) of six reviewed for unnecessary medications. The facility census was 61. Findings include: 1. Review of Resident #25's medical record revealed an admission date of 10/09/20. Diagnoses included vascular dementia and schizoaffective disorders. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 was severely cognitively impaired. Review of Resident #25's pharmacy recommendations dated 03/17/22 was for a GDR of Trazodone (antidepressant medication) 25 milligrams (mg). The pharmacy recommendation was not signed by a physician. There was no documentation of the pharmacy recommendations being addressed by a physician. Review of Resident #25's pharmacy recommendations dated 02/15/22 and 03/17/22 revealed it was for a gradual dose reduction (GDR) of Buspar (anxiety medication) 5.0 milligrams (mg) and Olanzapine (antipsychotic medication) 7.5 mg. The pharmacy recommendation was not signed by a physician. There was no documentation of the pharmacy recommendations being addressed by a physician. Interview on 04/07/22 at 8:53 A.M. with the Director of Nursing (DON) confirmed the pharmacy recommendations for Resident #25 were not addressed timely or signed by a physician. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365426 If continuation sheet Page 17 of 21 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 04/12/2022 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2. Review of Resident #40's medical record revealed an admission date of 02/12/21. Diagnoses included major depressive disorder and pseudobulbar affect. Review of the quarterly Minimum Data Set (MDS) assessment date 02/14/22 revealed Resident #40 was cognitively intact. Review of the physician orders dated 08/10/21 revealed an order for Ativan 0.5 mg give one tablet by mouth every six hours as needed (PRN) for agitation and give one tablet by mouth at bedtime related to major depressive disorder. Review of Resident #40's pharmacy recommendation dated 04/05/21, 06/07/21, and 09/17/21 revealed a GDR request for Amitriptyline (antidepressant) 50 mg and Seroquel (antipsychotic) 100 mg. The pharmacy recommendation was not signed by a physician. There was no documentation of the pharmacy recommendations being addressed by a physician. Review of Resident #40's physician orders revealed an order dated 08/10/21 for Ativan (anxiety medication) 0.5 mg give one tablet by mouth every six hours PRN for agitation and give one tablet by mouth at bed time related to major depressive disorder. Review of Resident #40's pharmacy recommendation dated 09/17/21, 10/18/21, 01/18/22, and 02/15/22 revealed a request for a new order to use PRN Ativan 0.5 mg greater than 14 days was requested. The pharmacy recommendation was not signed by a physician. There was no documentation of the pharmacy recommendations being addressed by a physician. Interview on 04/07/22 at 8:53 A.M. with the Director of Nursing (DON) confirmed the pharmacy recommendations for Resident #40 were not addressed timely or signed by a physician. 3. Review of Resident #33's medical record revealed an admission date of 02/06/22. Diagnoses included insomnia. Review of Resident #33's Medication Regimen Reviews dated 02/08/22 and 03/17/22 revealed Resident #33 was receiving Remeron 7.5 milligrams, two tablets by mouth daily at bedtime as needed for sleep. A recommendation was made to consider discontinuation due to as needed antipsychotic orders cannot exceed 14 days and require evaluation for continuation. The pharmacy recommendation was not signed by a physician. There was no documentation of the pharmacy recommendations being addressed by a physician. Interview on 04/07/22 at 8:53 A.M. with the Director of Nursing (DON) confirmed the pharmacy recommendations for Resident #33 were not addressed timely or signed by a physician. 4. Review of Resident #34's medical record revealed an admission date of 05/20/21. Diagnoses included dementia without behavioral disturbance, anxiety, major depressive disorder. Review of Resident #34's Medication Regimen Reviews dated 01/18/22, 02/15/22, and 03/17/22 revealed Resident # 34 was receiving Trazodone 50 milligrams by mouth daily at bedtime, Buspar 10 milligrams by mouth three times daily, Cymbalta 90 milligrams daily, and Seroquel 25 milligrams twice daily, and these medications were due for Gradual Dose Reduction review. Recommendation to evaluate current doses and consider whether a dose reduction of any of the medications would be appropriate. The pharmacy recommendation was not signed by a physician. There was no documentation of the pharmacy recommendations being addressed by a physician. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365426 If continuation sheet Page 18 of 21 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 04/12/2022 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident #34's Medication Regimen Reviews dated 06/07/21, 01/18/22, 02/15/22, and 03/17/22 revealed Resident #34 was receiving Seroquel 25 milligrams by mouth twice daily. Recommendation for appropriate diagnosis for Seroquel use. The pharmacy recommendation was not signed by a physician. There was no documentation of the pharmacy recommendations being addressed by a physician. Review of Resident #34's Medication Regimen Review dated 10/18/22 revealed Resident #34 was receiving Seroquel 25 milligrams by mouth twice daily, Trazodone 50 milligrams by mouth every night, and two Ativan as needed orders. Recommended considering evaluation of current medications due to Resident #34's recent fall. The pharmacy recommendation was not signed by a physician. There was no documentation of the pharmacy recommendations being addressed by a physician. Interview on 04/07/22 at 8:53 A.M. with the Director of Nursing (DON) confirmed the pharmacy recommendations for Resident #34 were not addressed timely or signed by a physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365426 If continuation sheet Page 19 of 21 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 04/12/2022 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, review of a hospice contract, and facility policy review, the facility failed to ensure a hospice communication notes were kept on-site and were available to the facility staff for one resident (Resident #44). This affected one (Residents #44) of 20 residents reviewed for medical records. The facility census was 61. Findings include: Review of the medical record for Resident #44 revealed an admission date on 01/29/20. Diagnoses included Alzheimer's Disease, cerebral infarction (stroke), congestive heart failure, schizophrenia, and stage IV chronic kidney disease. Review of the care plan dated 01/29/20 revealed Resident #44 received hospice services and needed coordination of care related to end of life care. Interventions included the hospice provider to provide a schedule to the facility of their visits and care to be provided during visits and will notify facility of changes in the schedule or care to be provided. Review of the significant change Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #44 had severely impaired cognition. Resident #44 was rarely/never understood. Resident #44 required extensive assistance from one staff to complete Activities of Daily Living (ADLs). Resident #44 received hospice care. Review of the physician orders dated 02/22/22 revealed Resident #44 had an order to admit to hospice services. There was no evidence of any hospice communication notes in the resident's medical record. Review of the hospice contract on 04/05/22 at 4:22 P.M. revealed the facility shall allow access to medical records and shall allow hospice care plans and notes to be a part of the resident record. Interview on 04/06/22 at 10:18 A.M. with the Administrator confirmed hospice notes for Resident #44 were not kept on-site or in the resident's medical record. The Administrator stated the hospice provider was contacted and the notes requested were emailed to the facility. Review of the facility's policy titled Hospice, dated 01/01/21, revealed the policy stated the facility will communicate with hospice and identify, communicate, follow, and document all interventions put into place by hospice and the facility. When a resident chooses to receive hospice care and services, the facility will coordinate and provide care in cooperation with hospice staff in order to promote the resident's highest practicable physical, mental and psychosocial well-being. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365426 If continuation sheet Page 20 of 21 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 04/12/2022 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm Based on record review, staff interview, and policy review, the facility failed to offer residents pneumococcal immunization. This affected two (Resident #14 and #32) of five residents reviewed for immunizations. The facility census was 61. Residents Affected - Few Findings include: 1. Review of Resident #14's medical record revealed an admission date of 01/21/22. Diagnoses included type two diabetes mellitus, and heart failure. Further review of Resident #14's medical record revealed no evidence the resident received or was ever offered the pneumococcal vaccine. 2. Review of Resident #32's medical record revealed an admission date of 01/25/22. Diagnoses included malignant neoplasm of prostate and anxiety. Further review of Resident #32's medical record revealed no evidence the resident received or was ever offered the pneumococcal vaccine. Telephone interview with Director of Nursing on 04/14/22 at 3:55 P.M. confirmed Resident #14 and #32 did not receive the pneumonia vaccine and there was no documentation of the vaccine offered or refused in the resident's medical records. Review of the facilities Pneumococcal Vaccine policy, dated 01/01/21, revealed each resident will be assessed upon admission for immunization status and will be offered the pneumococcal immunization if it is not contraindicated. The policy also states the Residents' medical records shall include documentation of the pneumococcal immunization, contraindication, or refusal. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365426 If continuation sheet Page 21 of 21