Health inspection·March 27, 2025

F 0569 Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and facility policy review, the facility failed to ensure residents were provided spenddown notifications when their accounts balances exceeded $1800.00. This affected two Residents (#17 and #43) of two reviewed with account balances over $1800.00. Facility identified 41 Residents (#1, #2, #4, #5, #6, #7, #10, #11, #12, #13, #15, #17, #18, #19, #21, #22, #24, #27, #28, #29, #30, #31, #33, #36, #41, #43, #44, #45, #46, #47, 49, #50, #53, #54, #55, #58, #62, #64, #66, #137, and #232) with Resident fund accounts. Facility census was 82. Residents Affected - Few Findings include 1. Review of the medical record for Resident #17 revealed an admission date of 02/14/23. Diagnoses included respiratory failure, dementia, vascular disease, and dysphagia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 was cognitively impaired with a Brief Interview of Mental Status (BIMS) score of 4. Review of Resident #17's personal fund balance statements dated 01/02/24 revealed a balance of $2263.55. Review of Resident #17's personal fund balance statements dated 02/01/24 revealed a balance of $2260.32. Review of Resident #17's personal fund balance statements dated 03/01/24 revealed a balance of $2197.20. Review of Resident #17's personal fund balance statements dated 04/01/24 revealed a balance of $2198.11. Review of Resident #17's personal fund balance statements dated 05/01/24 revealed a balance of $2115.88. Review of Resident #17's personal fund balance statements dated 06/03/24 revealed a balance of $2143.77. Review of Resident #17's personal fund balance statements dated 07/01/24 revealed a balance of $2124.63. Review of Resident #17's personal fund balance statements dated 08/01/24 revealed a balance of $2075.49. Review of Resident #17's personal fund balance statements dated 09/03/24 revealed a balance of $2086.32. Review of spend-down letter for Resident #17 dated 09/17/24 revealed resident was within $200 or over the allowable limit under Medical Assistance. The letter instructed resident to contact Social Services with one week to discuss. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365426 If continuation sheet Page 2 of 22 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 03/27/2025 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 0569 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #17's personal fund balance statements dated 10/01/24 revealed a balance of $2102.01. Review of spend-down letter for Resident #17 dated 10/22/24 revealed resident was within $200 or over the allowable limit under Medical Assistance. The letter instructed resident to contact Social Services with one week to discuss. Review of Resident #17's personal fund balance statements dated 11/01/24 revealed a balance of $1991.82. Review of spend-down letter for Resident #17 dated 11/11/24 revealed resident was within $200 or over the allowable limit under Medical Assistance. The letter instructed resident to contact Social Services with one week to discuss. Review of Resident #17's personal fund balance statements dated 12/02/24 revealed a balance of $1799.57. Review of Resident #17's personal fund balance statements dated 01/02/25 revealed a balance of $3604.52. Review of Resident #17's personal fund balance statements dated 02/03/25 revealed a balance of $3655.99. Review of Resident #17's personal fund balance statements dated 03/03/25 revealed a balance of $3707.29. 2. Review of the medical record for Resident #43 revealed an admission date of 03/22/22. Diagnoses included Wernicke Encephalopathy, alcohol abuse, asperger's syndrome, psychotic disorder, cognitive communication deficit, and depression. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #43 was cognitively impaired with a BIMS of 00 for resident was rarely if ever understood. Review of Resident #43's personal fund balance statements dated 01/02/24 revealed a balance of $19,150.55. Review of Resident #43's personal fund balance statements dated 02/01/24 revealed a balance of $19,207.06. Review of Resident #43's personal fund balance statements dated 03/01/24 revealed a balance of $19,114.34. Review of Resident #43's personal fund balance statements dated 04/01/24 revealed a balance of $19,076.27. Review of Resident #43's personal fund balance statements dated 05/01/24 revealed a balance of $19,083.12. Review of Resident #43's personal fund balance statements dated 06/03/24 revealed a balance of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365426 If continuation sheet Page 3 of 22 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 03/27/2025 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 0569 $19,141.09. Level of Harm - Minimal harm or potential for actual harm Review of Resident #43's personal fund balance statements dated 07/01/24 revealed a balance of $19,088.78. Residents Affected - Few Review of Resident #43's personal fund balance statements dated 08/01/24 revealed a balance of $18,296.36. Review of Resident #43's personal fund balance statements dated 09/03/24 revealed a balance of $1906.46. Review of Resident #43's personal fund balance statements dated 10/01/24 revealed a balance of $1926.46. Review of Resident #43's personal fund balance statements dated 11/01/24 revealed a balance of $1872.84. Review of spend-down letter for Resident #43 dated 11/11/24 revealed resident was within $200 or over the allowable limit under Medical Assistance. The letter instructed resident to contact Social Services with one week to discuss. Review of Resident #43's personal fund balance statements dated 12/02/24 revealed a balance of $1923.61. Review of Resident #43's personal fund balance statements dated 01/02/25 revealed a balance of $1813.83. Review of spend-down letter for Resident #43 dated 01/18/25 revealed resident was within $200 or over the allowable limit under Medical Assistance. The letter instructed resident to contact Social Services with one week to discuss. Review of Resident #43's personal fund balance statements dated 02/03/25 revealed a balance of $1864.58. Review of Resident #43's personal fund balance statements dated 03/03/25 revealed a balance of $1875.24. Review of spend-down letter for Resident #43 dated 03/24/25 revealed resident was within $200 or over the allowable limit under Medical Assistance. The letter instructed resident to contact Social Services with one week to discuss. Interview on 03/25/25 at 5:20 P.M. with Business Office Manager (BOM) #110 confirmed spenddown letters were not provided monthly for residents who were over resourced and confirmed the facility had no additional spend down letters to provide. Review of facility policy titled, Resident trust Fund Policies and Procedures, dated 02/01/18, revealed the facility would identify account balances each month at or exceeding the state asset limit. For Ohio the limit was $2000 and Residents shall be notified when the account balance reaches $1800. Resident/Representatives shall be sent a asset limit notification letter when they have reached the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365426 If continuation sheet Page 4 of 22 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 03/27/2025 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 0569 $200 threshold. 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 5 of 22 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 03/27/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility staff interview, and facility policy review, the facility failed to develop an accurate and comprehensive care plan for one (Resident #55) with Post Traumatic Stress Disorder (PTSD), of one reviewed for PTSD. The facility census was 82. Findings include: Resident #55 was admitted on [DATE] with diagnoses that included cerebral infarction, hemiplegia and hemiparesis affecting left non-dominant side, type two diabetes mellitus, fibromyalgia, dementia, depression, and PTSD. Review of the annual minimum data set (MDS) 3.0 dated 01/10/25 revealed Resident #55 was severely cognitively impaired with a brief interview for mental status (BIMS) score of 05/15. Resident #55 was noted to have delusions but no behaviors. Resident #55 had psychiatric/mood disorders of depression and post-traumatic stress disorder (PTSD) noted. Resident #55 received antidepressants and anticonvulsant medications with indication present. Review of the care plan for Resident #55 revealed no documentation of monitoring or interventions for post-traumatic stress disorder (PTSD) or potential triggers. Interview on 03/27/25 at 8:10 A.M. with the Director of Nursing (DON) revealed the DON was not aware there was no care plan for Resident #55's diagnoses of PTSD. Interview on 03/27/25 at 9:12 A.M. with Social Worker #106 confirmed the facility did not complete a care plan for PTSD. The residents with PTSD are referred to psychiatric services. Review of the facility's policy titled Comprehensive Care Plans dated 06/30/22 revealed it is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment (MDS). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365426 If continuation sheet Page 6 of 22 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 03/27/2025 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 - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of Resident #51's closed medical record revealed an admission date of 11/02/24. Diagnoses listed included atrial fibrillation, obstructive sleep apnea, hypertension, prosthetic heart valve, embolism and thrombosis of thoracic aorta, and major depressive disorder. Resident #51 was discharged from the facility on 02/26/25 and did not return. Review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #51 was not understood by staff, was assessed as having severe cognitive impairment, and was receiving an anticoagulant medication. Review of physician orders revealed an order dated 01/07/25 for Eliquis (anticoagulant) five milligrams (mg) tablet, give 10 mg by mouth two times daily related to embolism and thrombosis of thoracic aorta. Eliquis was changed to five mg tablet, give one tablet by mouth two times daily related to embolism and thrombosis of thoracic aorta on 01/14/25. Review of Resident #51's care plan dated initiated 11/02/24 and last revised on 03/08/25 revealed no focus, goals, or interventions for the use of an anticoagulant medication. Interview with the Director of Nursing (DON) confirmed Resident #51 had received an anticoagulant medication. The DON confirmed Resident #51's care plan did not include focus, goals, or interventions for the use of an anticoagulant medication. Review of the facility's policy titled Comprehensive Care Plans dated 06/30/22 revealed it is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment (MDS). The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. Based on record review, resident and family interview, facility staff interviews, and facility policy review, the facility failed to ensure interdispinary quarterly care conferences were completed for Residents #7, #9 and #36. This affected three residents of six reviewed for care conferences. The facility also failed to update a care plan for an anticoagulant for former Resident #51. This affected one resident of 18 resident care plans reviewed. Facility census was 82. Findings include 1. Review of the medical record for Resident #7 revealed an admission date of 10/05/23. Diagnoses included cerebral infarction, cerebellar stroke, diabetes mellitus, and seizures. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 was cognitively intact with a Brief Interview of Mental Status (BIMS) score of 14. Review of the medical record found an interdisciplinary care conferences form dated 05/30/24 revealed a quarterly care conference was held and staff discussed care with resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365426 If continuation sheet Page 7 of 22 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 03/27/2025 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 Interview on 03/24/25 at 4:17 P.M. with Resident #7 revealed she had not been invited to any care conferences in the previous year. 2. Review of the medical record for Resident #9 revealed an admission date of 02/16/21. Diagnoses included Parkinson's disease, cerebral infarct, vascular disease and vascular dementia. Residents Affected - Some Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 was cognitively impaired with a BIMS of 4. Review of the medical record found an interdisciplinary(IDT) care conferences form dated 04/22/24 revealed a quarterly care conference was held and staff discussed care with resident representative. Interview on 03/24/25 at 6:01 P.M. with Resident #9's family revealed they had only been invited to a care conference about once in the last year. The family revealed she would like to be invited and attend care conferences to ensure good communication and care. Interview on 03/25/25 at 5:58 P.M. with Regional Staff #300 and Regional Staff #400 confirmed the facility identified care conferences were not being completed and confirmed facility had no additional evidence of IDT care conferences for Resident #7 and #9. 3. Resident #36 was admitted on [DATE] with diagnoses that included congestive heart failure, ulcerative colitis, atrial fibrillation, dementia, dysphagia, cognitive communication deficit, major depressive disorder, psychoactive substance abuse, anxiety disorder, and arthritis. Review of the annual minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #36 was moderately cognitively impaired with a brief interview for mental status (BIMS) score of 12 out of 15. Resident #36 had no indications of psychosis or behaviors noted and received antianxiety and antidepressant medications with indications present. Review of the medical record for Resident #36 revealed there was no care conference summary documentation, only documentation of a quarterly mood evaluation by the social worker. The documentation reflected the resident participated in care discussions with no summary of the discussions or who was present to participate. Interview on 03/24/25 at 10:57 A.M. with Resident #36 revealed Resident #36 has had no care conferences with the facility staff but would like to have one. Resident #36 stated I am just now coming out of my shell and would like to be more involved in my care. Interview on 03/27/25 at 12:00 PM with Social Worker #106 confirmed there were no quarterly care plan meetings documented for Resident #36. Resident #36 does not get out of bed so each discipline the resident wishes to speak with goes in and discusses her concerns when requested. Review of facility policy titled, Comprehensive Care Plans, dated 06/30/22, revealed facility shall create a comprehensive care plan quarterly and shall include members of the team including resident and representative, attending Physician, registered nurse and nurse aide and other appropriate staff. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365426 If continuation sheet Page 8 of 22 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 03/27/2025 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to ensure they communicated with the dialysis center. This affected one Resident (#69) of one reviewed for dialysis. The facility identified two residents receiving care from dialysis centers (#69 and #132). Facility census was 82. Residents Affected - Few Findings include Review of the medical record for Resident #69 revealed an admission date of 09/26/24. Diagnoses included end stage renal disease, diabetes, heart failure, and cognitive communication deficit. Review of pre dialysis communication assessment dated [DATE] revealed The following vital signs which were obtained on the morning of 03/21/25: Blood pressure of 131/68, Pulse of 61, Respirations of 16, Temperature of 97.9. The resident weight was 166.2 from 03/20/25 at 10:43 A.M. Review of post dialysis communication assessment dated [DATE] revealed: Blood pressure of 128/64 and Pulse of 62 obtained on 03/21/25 at 9:29 P.M. Respirations of 16 obtained on 03/21/25 at 8:31 A.M., Temperature of 97.9 obtained on 03/21/25 at 8:32 A.M. and Weight of 166.2 lbs from 03/20/25 at 10:43 A.M. Interview on 03/26/25 at 5:10 P.M. with Licensed Practical Nurse #137 revealed the facility did not have a dialysis communication binder and all documentation was located in the electronic medical record. LPN #137 revealed the facility did not send any documentation to dialysis and did not believe they had access to the facility medical record. Interview on 03/26/25 at 5:40 P.M. with Director of Nursing confirmed the facility had no evidence of communication with dialysis center from the medical team and nursing. DON revealed the dialysis center would never complete their part of the form so they stopped sending it a few years ago. DON confirmed the vitals on the electronic form titled pre and post dialysis assessment were just flowing from the last vitals taken and not specific to dialysis as they were done every 12 hours and not shortly before and after his four-hour dialysis sessions. Review of facility policy titled, Care Planning Special Needs - Dialysis, dated 12/28/23, revealed facility shall provide the necessary care and treatment consistent with professional standards of practice. The care plan will reflect the coordination between the facility and the dialysis provider. Nursing staff shall provide a report to dialysis provider regarding residents condition and treatment provided each dialysis treatment day. If no report is received back from dialysis provider facility staff shall call to receive a report. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365426 If continuation sheet Page 9 of 22 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 03/27/2025 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 0699 Provide care or services that was trauma informed and/or culturally competent. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and facility staff interviews the facility failed to ensure individualized trauma informed care was implemented for one resident (Resident #55) of one reviewed for Post Traumatic Stress Disorder (PTSD). The facility census was 82. Residents Affected - Few Findings include: Resident #55 was admitted on [DATE] with diagnoses that included cerebral infarction, hemiplegia and hemiparesis affecting left non-dominant side, type two diabetes mellitus, fibromyalgia, dementia, depression, and post-traumatic stress disorder. Review of the annual minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #55 was severely cognitively impaired with a brief interview for mental status (BIMS) score of five out of a possible 15. Resident #55 was noted to have delusions but no behaviors. Resident #55 had psychiatric/mood disorders of depression and post-traumatic stress disorder (PTSD) noted. Resident #55 received antidepressants and anticonvulsant medications with indication present. Review of the medical record for Resident #55 revealed there were no documented preferences, trauma triggers or interventions staff should take to minimize re-traumatization of the resident. Review of consult notes for Resident #55 revealed psychiatric services evaluated and saw Resident #55 on 04/24/24, 05/22/24, 08/26/24, 09/24/24, 10/22/24, 11/26/24, 01/07/25, 02/11/25 and 03/18/25. Interview on 03/27/25 at 8:10 A.M. with the Director of Nursing (DON) revealed the DON was not aware there was no assessment for Resident #55's diagnoses of PTSD. Interview on 03/27/25 at 9:12 A.M. with Social Worker #106 confirmed the facility did not do an independent assessment for PTSD. The residents with PTSD are referred to psychiatric services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365426 If continuation sheet Page 10 of 22 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 03/27/2025 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** 4. Review of Resident #32's medical record revealed an admission date of 01/21/25. Diagnoses listed included malnutrition, Alzheimer's disease, heart failure, muscle weakness, and atrial fibrillation. Review of an admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #4 had severe cognitive impairment and did not have a psychotic disorder. Review of physician orders revealed an order dated 03/10/25 for Quetiapine Fumarate (antipsychotic medication Seroquel) 25 milligrams (mg) give one tablet by mouth at bedtime. Further review of physician orders revealed Seroquel 25 mg at bedtime for insomnia was originally ordered on 01/21/25 and continued with orders dated 02/02/25, and 03/08/25. Seroquel was discontinued on 03/25/25. Review of a medication regime review (MRR) dated 02/05/25 revealed a pharmacist had communicated that Seroquel was being used for sleep per hospital discharge and recommended to please evaluate change in diagnosis and consider discontinuing Seroquel in the [AGE] year old patient with dementia. The physician signed to agree discontinue Seroquel on 03/18/25. Review of a MRR dated 03/09/25 revealed a pharmacist had communicated Seroquel 25 mg at bedtime instructions were antipsychotics must be evaluated by the prescriber upon admission or soon after to assess if reduction or discontinuation is appropriate and antipsychotics are not approved for sleep, also receiving Melatonin. Please evaluate Seroquel for discontinuation. The MMR was dated with a verbal order from a nurse practitioner (NP) on 03/26/25. Review of medication administration records (MAR) revealed Resident #32 was administered Seroquel from 01/21/25 until a last dose documented as being given on 03/24/25. Interview with the Director of Nursing (DON) on 03/26/25 at 7:50 A.M. confirmed Resident #32 received Seroquel until 03/24/25. The DON confirmed Resident #32's MRR dated 02/05/25 had a physician order to discontinue Seroquel on 03/18/25. The DON confirmed the MMR for Resident #32 was not acted on and reviewed timely. Review of the facility's policy titled Addressing Medication Regimen Review Irregularities dated 12/28/23 revealed it is the policy of this facility to provide a MRR for each resident to identify irregularities and respond in a timely manner to prevent the occurrence of an adverse drug event. The pharmacist must report any irregularities to the attending physician, the facility's medical director, and DON, and the reports must be acted upon. The report should be submitted to the DON within 10 working days of the review. Based on record review, interviews, and facility policy review, the facility failed to timely respond to monthly medication regimen reviews (MRR) for four residents (Resident #32, #53, #62, and #73) out of five residents reviewed for unnecessary medications. The facility census was 82. Findings include: 1. Resident #53 was admitted on [DATE] with diagnoses that included non-traumatic chronic subdural hemorrhage, type two diabetes mellitus, anxiety, dementia, hypertension, polyosteoarthritis, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365426 If continuation sheet Page 11 of 22 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 03/27/2025 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 atherosclerotic heart disease, peripheral vascular disease, chronic kidney disease stage three, mood disorder, neurocognitive disorder with lewy bodies, and aneurysm of carotid artery. Review of the annual minimum data set (MDS) 3.0 assessment dated [DATE] revealed the resident was unable to be interviewed because her responses were rarely understood. The staff reported Resident #53 had short-term and long-term memory problems. Resident #53 received scheduled pain medications. Resident #53 also received antipsychotic and antianxiety medications with indications present. Review of the medication administration record (MAR) for March 2025 revealed pain was monitored every shift. Side effects of pain medications, side effects of antipsychotic and antidepressant medications were also monitored every shift. Medications were administered as ordered. Review of the Monthly Medication Regimen Reviews conducted revealed on 02/05/25 the pharmacists documented please consider obtaining a thyroid stimulating hormone (TSH) level and on 03/18/25 the provider documented check TSH. A TSH level was ordered 03/25/25. Interview on 03/26/25 at 7:58 A.M. with the Director of Nursing confirmed the pharmacy recommendations dated 02/05/25 were addressed by the provider 03/18/25. The DON also confirmed the expectation is the recommendations are addressed by the provider on the next provider visit and a provider visits at least once a week. 2. Resident #62 was admitted on [DATE] with diagnoses that included cerebral infarction, hemiplegia and hemiparesis affecting the left non-dominant side, dysphagia, type two diabetes mellitus, chronic obstructive pulmonary disease (COPD), cerebral edema, mood disorder, opioid dependence, anxiety disorder, depression, abscess of liver, and heart disease. Review of the quarterly minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #62 was cognitively intact with a brief interview for mental status (BIMS) score of 13 with no signs of psychosis or behaviors noted. Resident #62 received insulin, antianxiety, antidepressant, anticoagulant, opioid, anticonvulsant, and hypoglycemic medications with indications present. Review of the monthly medication regimen reviews revealed recommendations on 02/05/25 included a recommendation to discontinue Lorazepam (antianxiety) 0.5 mg every eight hours as needed. On 02/05/25 currently receiving Zoloft (antidepressant) 100 mg and Trazodone (antidepressant) 100 mg and recommended a gradual dose reduction be attempted. On 03/18/25 the practitioner agreed to discontinue the Lorazepam 0.5 mg every eight hours as needed. The provider also agreed Resident #62's condition was stable and recommended a dose reduction of Zoloft to 50 mg daily and Trazodone to 50 mg at bedtime. Review of the progress notes revealed the interdisciplinary team did not meet until 03/25/25 at 3:28 P.M. to review pharmacy recommendations. The order to reduce the Zoloft 50 mg daily and Trazodone 50 mg at once a day at bedtime was not entered into Resident #62's record until 03/25/25 at 3:30 P.M. Interview on 03/26/25 at 7:58 A.M. with the Director of Nursing confirmed the pharmacy recommendations dated 02/05/25 were addressed by the provider 03/18/25. The DON confirmed the expectation is the recommendations are addressed by the provider on the next provider visit and a provider visits at least once a week. The DON also confirmed the orders were not acted upon until 03/25/25. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365426 If continuation sheet Page 12 of 22 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 03/27/2025 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 3. Resident #73 was admitted on [DATE], hospitalized on [DATE] and readmitted to the facility on [DATE] with diagnoses that included a fractured right femur, laceration of the scalp, chronic obstructive pulmonary disease, intrarenal abdominal aortic aneurysm, depression, acute embolism and thrombosis of deep veins of the right lower extremity, atherosclerotic heart disease, fibromyalgia, and osteoporosis. Review of the admission minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #73 was significantly cognitively impaired with a brief interview for mental status (BIMS) score of six. Resident #72 received antidepressant, anticoagulant, and antibiotic medications with indications present. Review of the monthly medication regimen reviews revealed recommendations on 02/05/25 to discontinue Megace (megestrol acetate) 40 mg given orally before meals for appetite stimulation because this is not an appetite stimulation dose, Resident #73's weight is above the minimum ideal weight, and Megace is known to increase the risk of a deep vein thrombosis and Resident #73 is known to have a history of deep vein thrombosis. The provider responded on 03/18/25 to discontinue the Megace 40 mg before meals. The medication was not discontinued until 03/25/25. Interview on 03/26/25 at 7:58 A.M. with the Director of Nursing confirmed the pharmacy recommendations dated 02/05/25 were addressed by the provider 03/18/25. The DON confirmed the expectation is the recommendations are addressed by the provider on the next provider visit and a provider visits at least once a week. The DON also confirmed the orders were not acted upon until 03/25/25. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365426 If continuation sheet Page 13 of 22 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 03/27/2025 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm Based on medication administration observations, staff interview, record review, and facility policy review, the facility failed to follow ordered parameters for blood pressure medication administration for one (Resident #240) of three residents observed for medication administration. The facility census was 82. Residents Affected - Few Findings include: Observation on 03/26/25 at 8:17 A.M. revealed Registered nurse (RN) #136 prepared seven medications for Resident #240 including Lisinopril (used to decrease blood pressure) 5 milligram (mg) tablet and Propranolol (used to decrease blood pressure) 10 mg tablet. After preparing the medications RN #136 entered the resident's room and obtained a blood pressure and pulse for Resident #240. Blood pressure was 105/69 and pulse was 80 beats per minutes. RN #136 continued to administer medications. Review of medication orders for Resident #240 revealed the orders read Lisinopril 5 mg once a day hold for a systolic blood pressure less than 110 millimeters of mercury (mmHg) and Propranolol 10 mg once a day hold for a systolic blood pressure less than 110 mmHg. Interview on 03/26/25 at 8:36 A.M. with RN #136 confirmed Lisinopril and Propranolol were given this morning. Blood pressure was 105/69 and the order reads to hold Lisinopril and Propranolol for systolic blood pressure less than 110 mmHg. Nurse #136 stated she was not aware of the parameters to hold the medication. Review of the policy Medication Administration last date reviewed 01/17/23 confirmed the person administering medications is to obtain and record vital signs, when applicable per physician's order, when applicable, hold medication for those vital signs outside the physician's prescribed parameters. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365426 If continuation sheet Page 14 of 22 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 03/27/2025 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 - Few 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** Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure a resident had an appropriate diagnosis for the use on an antipsychotic medication. This affected one (#32) of five reviewed for unnecessary medications. The census was 82. Findings include: Review of Resident #32's medical record revealed an admission date of 01/21/25. Diagnoses listed included malnutrition, Alzheimer's disease, heart failure, muscle weakness, and atrial fibrillation. Review of an admission Minimum Data Set (MDS) dated [DATE] revealed Resident #4 had severe cognitive impairment and did not have a psychotic disorder. Review of physician orders revealed an order dated 03/10/25 for Quetiapine Fumarate (antipsychotic medication Seroquel) 25 milligrams (mg) give one tablet by mouth at bedtime. Further review of physician orders revealed Seroquel 25 mg at bedtime for insomnia was originally ordered on 01/21/25 and continued with orders dated 02/02/25, and 03/08/25. Seroquel was discontinued on 03/25/25. Review of a medication regime review (MRR) dated 02/05/25 revealed a pharmacist had communicated that Seroquel was being used for sleep per hospital discharge and recommended to please evaluate change in diagnosis and consider discontinuing Seroquel in the [AGE] year old patient with dementia. The physician signed to agree discontinue Seroquel on 03/18/25. Review of a MRR dated 03/09/25 revealed a pharmacist had communicated Seroquel 25 mg at bedtime instructions were antipsychotics must be evaluated by the prescriber upon admission or soon after to assess if reduction or discontinuation is appropriate and antipsychotics are not approved for sleep, also receiving Melatonin. Please evaluate Seroquel for discontinuation. The MMR was dated with a verbal order from a nurse practitioner (NP) on 03/26/25. Review of medication administration records (MAR) revealed Resident #32 was administered Seroquel from 01/21/25 until a last dose documented as being given on 03/24/25. Interview with the Director of Nursing (DON) on 03/26/25 at 7:50 A.M. confirmed Resident #32 received Seroquel until 03/24/25. The DON confirmed Resident #32 MRR dated 02/05/25 had a physician order to discontinue Seroquel on 03/18/25. The DON confirmed the MMR for Resident #32 was not acted on and reviewed timely. The DON confirmed Resident #32 did not have a diagnosis that would warrant the use of the ordered antipsychotic medication. Review of the facility's policy titled Medication - Psychotropic dated 10/30/23 revealed residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include, but are not limited to the following categories: antipsychotics, antidepressants, anti-anxiety, and hypnotics. For new admissions the facility shall identify the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365426 If continuation sheet Page 15 of 22 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 03/27/2025 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 indication for use, as possible, using pre-admission screening and other pre-admission data. The physician in collaboration with the consultant pharmacist shall re-evaluate the use of the medication and consider whether or not the medication can be reduced or discontinued upon admission or soon after admission. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365426 If continuation sheet Page 16 of 22 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 03/27/2025 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on medication administration observations, staff interview, record review, and facility policy review, the facility failed to ensure medications were administered as ordered resulting in a medication errors rate of 6.45 percent (%). This affected one resident (Resident #240) out of three residents observed for medication administration. The facility census was 82. Residents Affected - Few Findings include: Observation on 03/26/25 at 8:17 A.M. revealed Registered nurse (RN) #136 prepared seven medications for Resident #240 including Lisinopril (used to decrease blood pressure) 5 milligram (mg) tablet and Propranolol (used to decrease blood pressure) 10 mg tablet. After preparing the medications RN #136 entered the resident's room and obtained a blood pressure and pulse for Resident #240. Blood pressure was 105/69 and pulse was 80 beats per minutes. RN #136 continued to administer medications. Review of medication orders for Resident #240 revealed the orders read Lisinopril 5mg once a day hold for a systolic blood pressure less than 110 millimeters of mercury (mmHg) and Propranolol 10 mg once a day hold for a systolic blood pressure less than 110 mmHg. Interview on 03/26/25 at 8:36 A.M. with RN #136 confirmed Lisinopril and Propranolol were given this morning. Blood pressure was 105/69 and the order reads to hold Lisinopril and Propranolol for systolic blood pressure less than 110 mmHg. Nurse #136 stated she was not aware of the parameters to hold the medication. Review of the policy Medication Administration last date reviewed 01/17/23 confirmed the person administering medications is to obtain and record vital signs, when applicable per physician's order, when applicable, hold medication for those vital signs outside the physician's prescribed parameters. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365426 If continuation sheet Page 17 of 22 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 03/27/2025 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observations, record review, and staff interviews, facility failed to ensure puree was made to the proper consistency. This had potential to affect 11 Residents (#7, #16, #17, 31, #32, #39, #43, #45, #59, #77, and #236) identified by facility to have orders for puree food. Facility census was 82. Findings include Observation on 03/26/25 at 11:12 A.M. revealed [NAME] #177 made puree peas by placing eight heaping scoops with a slotted spoon into the roboku. Then one after another added eight teaspoons of broth into the mixture. Then Regional Dietary Contractor #220 tasted and instructed [NAME] #177 to add more broth 1/4 cup. [NAME] added the broth and continued to mix and added another 1/8 cup of broth. About every 30 seconds the blending was stopped and [NAME] #177 tried the mixture to test for consistency. [NAME] scraped the sides of the roboku but left significant amounts of food on the sides including visible lumps and pieces of peas. Interview and observation on 03/26/25 at 11:20 A.M. revealed [NAME] #177 reported she had finished making the pureed peas and was starting to put them in a dish for the warmer and tray line. The mixture was tasted and several chunks and full skins of peas was tasted and verified by Regional Dietary Contractor #220. The peas were placed back in the roboku blender and mixed to a full puree consistency after surveyor intervention. Review of facility policy titled, Dysphagia Puree How To, undated, revealed facility shall ensure puree foods are made to a pudding mousse-like consistency. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365426 If continuation sheet Page 18 of 22 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 03/27/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, record review, and staff interviews, facility failed to maintain proper hand hygiene during food service. This had potential to affect all facility residents. Facility census was 82. Residents Affected - Many Findings include 1. Observation and interview on 03/26/25 at 12:04 P.M. revealed [NAME] #177 was taking temperatures of the food items. [NAME] placed thermometer in the mashed potatoes getting a quarter size piece of potato on her thumb and pointer finger. The thermometer was wiped off and was then placed in the gravy by submerging [NAME] #177's thumb and pointer finger into the gravy while their hand was also still covered in mashed potato pieces. [NAME] #177 verified she put her soiled/dirty glove in the gravy mixture. 2. Interview and observation on 03/26/25 from 12:15 P.M. to 12:24 P.M. revealed [NAME] #177 was scooping augratin potatoes on tray line when the scooper fell into the pan and became soiled with cheesy augratin potato residue. Regional Dietary Contractor #222 picked up the soiled scoop and continued tray line service while grabbing all other food items scoops. [NAME] #177 revealed if a scoop or service item falls into the food, it should be placed in the dish area and a clean scoop should be put in its place. Review of facility policy titled, Meal distribution: infection control, dated 02/2023, revealed facility shall ensure meal service and ware washing for residents/patients with infectious conditions will follow federal guidelines or as directed by state or local officials. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365426 If continuation sheet Page 19 of 22 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 03/27/2025 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 record review and facility staff interview the facility failed to maintain an accurate and complete record for one (Resident #53) who received hospice services. This affected one of one reviewed for hospice services. The facility census was 82. Findings include: Resident #53 was admitted on [DATE] with diagnoses that included non-traumatic chronic subdural hemorrhage, type two diabetes mellitus, anxiety, dementia, hypertension, polyosteoarthritis, atherosclerotic heart disease, peripheral vascular disease, chronic kidney disease stage III, mood disorder, neurocognitive disorder with lewy bodies, and aneurysm of carotid artery. Review of the annual minimum data set (MDS) 3.0 assessment dated [DATE] revealed the resident was unable to be interviewed because her responses were rarely understood. The staff reported Resident #53 had short-term and long-term memory problems. Resident #53 was also receiving hospice care. Review of the electronic medical record revealed the last hospice note scanned into the record was the hospice interdisciplinary team meeting dated 02/26/25 at 9:30 A.M. Review of the hospice communication notebook at the nurses' station revealed no visit documentation was present for Resident #53. The notebook contained an admission face sheet for Resident #53 and sections for the hospice team to document visit communication information but all sections were blank. Interview on 03/26/25 at 4:20 P.M. with Registered Nurse (RN) #138 confirmed there was no communication notes from the hospice provider in the hospice binder for Resident #53. Interview on 03/26/25 at 4:34 P.M. with the Director of Nursing (DON) confirmed there were no hospice notes in the hospice binder. The DON also confirmed the nursing staff would look for communication from the hospice team in the binder. The DON explained hospice notes are uploaded in the electronic medical record and verified the last note in the chart was the care team meeting on 02/26/25. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365426 If continuation sheet Page 20 of 22 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 03/27/2025 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on medication administration observations, staff interview, and facility policy review, the facility failed to ensure medications were administered in a manner to prevent contamination or infection. This affected one resident (Resident #240) out of three residents observed during medication administration observations. The facility census was 82. Residents Affected - Few Findings include: Observation on 03/26/25 at 8:17 A.M. revealed Registered Nurse (RN) #136 prepared seven medications for Resident #240. The individual medications were stored in a unit dose dispensing system. Each individual medication was removed from the package and placed in the medication cup. RN #136 removed each medication from the package into her ungloved hand. Then dropped the medication into the medicine cup. Interview on 03/26/25 at 8:22 A.M. with RN #136 confirmed medications were removed from pharmacy unit dose packs into her bare hand. RN #136 stated she was not aware she should not touch the pills and should either place the pills directly into the cup or wear gloves. Review of the policy Medication Administration last reviewed 01/17/23 confirmed medications are to be administered as prescribed by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365426 If continuation sheet Page 21 of 22 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 03/27/2025 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observations, record review, and resident and staff interviews, facility failed to maintain the grounds in a clean and safe manner regarding cigarette butts on the property. This had potential to affect all facility residents. Facility census was 82. Findings include Observation on 03/25/25 at 8:48 A.M. revealed the sidewalk from the east hall exit of the facility to the designated smoking area had significant litter of cigarette butts along the fence and walkway. A second observation at 4:00 P.M. found hundreds of visualized cigarette butts. Interviews and observation on 03/26/25 at 1:40 P.M. with Residents #18 and #52 confirmed smoking area, sidewalk and grass area on the outside of the fence had tons of cigarette butts as people do not pick up after themselves. Residents reported they were supposed to use the dispensing devices and residents just tossed their cigarette butts anywhere. Observation and interview on 03/26/25 at 1:45 P.M. with Licensed Practical Nurse (LPN) #137 confirmed the sidewalk and back of fence were littered with hundred of cigarette butts. He confirmed it was better than it used to be and the yard company was responsible for picking up trash and cigarette butts. LPN confirmed dinner size piles of dead plant debris leaves, pine needles and dead grass with dozens of cigarette butts could become kindling and create a fire hazard next to the wooden fence. LPN confirmed facility was responsible to maintain clean and safe facility and grounds. Review of facility policy titled, Preventative Maintenance, dated 03/12/22, revealed maintenance was responsible for maintaining a schedule of services to ensure building and grounds were maintained in a safe and operable manner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365426 If continuation sheet Page 22 of 22