Inspection·October 31, 2019

F 0684 room. Level of Harm - Minimal harm or potential for actual harm On 10/31/19 at 1:08 P.M., interview with the Director of Nursing verified physician orders including fluid restrictions were to be followed as ordered. Residents Affected - Few On 10/31/19 at 3:00 P.M., interview with unit manager Licensed Practical Nurse (LPN) #421 verified Resident #79 had an ordered fluid restriction and the facility was not monitoring how much the resident was drinking. LPN #421 stated the resident signed a risk and benefit due to non-compliance with the fluid restriction but verified the facility should still have been implementing the fluid restriction, monitoring intake, documenting refusals and non-compliance and contacting the physician as needed. Further interview revealed there was no breakdown of the amount of fluid nursing and dietary was allotted and dietary alone was offering (2360 ml) fluids with meals which exceeded the ordered daily fluid restriction. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365440 If continuation sheet Page 2 of 14 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 365440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arlington Care Center 98 South 30th Street Newark, OH 43055 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to implement interventions to restore or maintain bowel function. This affected one (Resident #75) of two residents reviewed for bladder and bowel incontinence. The facility census was 115. Findings include: Medical record review revealed Resident #75 was admitted on [DATE] with diagnoses including unspecified dementia without behavioral disturbance and psychosis. Review of the discharge assessment Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #75 was moderately impaired for daily decision-making and was continent of bowel. Review of the quarterly MDS assessments dated 09/20/19 and 10/02/19 revealed Resident #75 was frequently incontinent of bowel with no toileting program. Review of the readmission Bowel/Bladder assessment dated [DATE] revealed Resident #75 required limited assistance with ambulation and transfers and staff was to assist with incontinence as needed. Review of the care plan: Alteration in elimination revised 10/05/19 revealed Resident #75 was continent of bowel, required staff assist with toileting needs and was at risk for constipation. Interventions included to monitor bowel movements every shift, provide incontinence care as needed and monitor for a pattern if resident able to participate. On 10/31/19 at 3:39 P.M., interview with State Tested Nurse Aide (STNA) #218 stated she has noted a decline in the resident's continence status and has told the nurse. STNA #218 stated every couple hours the resident was asked if she needed to go to the bathroom but no specific times to her knowledge. STNA #218 also stated the resident is both continent and incontinent now and will sometimes let staff know when she needs to use the bathroom. On 10/31/19 at approximately 4:30 P.M., interview with the Director of Nursing verified Resident #75 had a decline in bowel continence with no intervention and the care plan was not accurate for the resident's continence status. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365440 If continuation sheet Page 3 of 14 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 365440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arlington Care Center 98 South 30th Street Newark, OH 43055 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** Residents Affected - Few Based on review of the medical record and staff interview the facility failed to monitor and document the status of the resident's dialysis access cite. This affected one resident (#216) of one resident reviewed for dialysis. Facility census was 115. Findings include Review of the medical record revealed Resident #216 was admitted to the facility on [DATE]. Diagnoses included compression fracture of a lumbar vertebra, Alzheimer's disease, diabetes type two with anemia and requiring dialysis, and hypertension. Review of the comprehensive assessment dated [DATE] revealed the resident had severe cognitive impairment. Resident # 216 required extensive assistance for activities of daily living. No swallowing disorders were identified. Review of the care plan revealed a focus areas for dialysis with appropriate interventions including to monitor the dialysis fistula every shift. Interview on 10/31/19 at 11:30 A.M. with Registered Nurse (RN) #165 revealed staff checked Resident #216's fistula dressing when returning to the facility following dialysis. The dressing remained in place for one day. Staff checked the thrill and bruit of the fistula each shift and documented the check on the resident's treatment administration record (TAR). A physician order should be in place in the medical record and populated on the TAR. RN #165 verified no order was in place to check the bruit and thrill every shift. Review of the facility's policy titled Dialysis Management, dated 10/11/18, revealed physician orders include dialysis access care. The care plan included assessment and care of the access site. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365440 If continuation sheet Page 4 of 14 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 365440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arlington Care Center 98 South 30th Street Newark, OH 43055 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 - Few 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** Based on record review and interview the facility failed to ensure the monthly drug regimen reviews were addressed in a timely manner for Resident #30 and #97. This affected two residents (#30 and #97) out of five residents reviewed for unnecessary medications. Facility census was 115. Findings include: 1. Review of the medical record revealed Resident #30 was admitted on [DATE] with diagnosis that included mood disorder, generalized anxiety disorder, and psychosis. Review of physician orders revealed on 04/06/19 Resident #30 was ordered Seroquel (antipsychotic) 25 milligrams at bedtime. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #30 was cognitively intact and no behaviors were noted. Review of the plan of care dated 08/06/19 revealed Resident #30 was at risk for adverse effects related to psychoactive medication used for depression, anxiety, and insomnia. Interventions included to monitor for medication side effects such as extrapyramidal symptoms (serious side-effects of antipsychotic and other drugs). Review of the the pharmacy recommendation printed 04/11/19 revealed Resident #30 was ordered Seroquel on 04/06/19. The medication required an abnormal involuntary movement scale (AIMS) assessment at baseline and every six months. The pharmacy recommendation was not signed by the physician and an AIMS assessment was not completed until 05/03/19. Interview on 10/31/19 at 12:05 P.M. Director of Nursing (DON) verified the pharmacy recommendation had no documentation of being reviewed by the physician. DON stated an AIMS test was completed on 05/03/19 but could not verify when the physician addressed the the pharmacy recommendation. Interview on 10/31/19 at 4:28 P.M. Manager of Clinical Services #500 verified a baseline AIMS had not been completed when Seroquel was ordered on 04/06/19, and the pharmacy recommendation had not been addressed for 22 days. 2. Review of the medical record revealed Resident #97 was admitted to the facility on [DATE]. Diagnoses included unspecified dementia with behavioral disturbance, insomnia, anxiety disorder, unspecified psychosis, other symbolic dysfunctions, and major depressive disorder. Review of the comprehensive assessment dated [DATE] revealed the mental status interview was not conducted as the resident was rarely or never understood. Resident #97 was assessed by staff as having both short term and long term memory loss. The resident's mood assessment score was 13, indicating moderate depression. Resident #97 experienced hallucinations and delusions but did not exhibit behaviors. Extensive assistance was required for all activities of daily living. The resident received antipsychotic and antianxiety medications. Review of the care plan revealed focus areas for alteration in mood and behavior and risk for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365440 If continuation sheet Page 5 of 14 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 365440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arlington Care Center 98 South 30th Street Newark, OH 43055 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 adverse effects related to use of psychoactive medications with appropriate interventions. Level of Harm - Minimal harm or potential for actual harm Review of pharmacy medication regimen reviews revealed reviews were completed monthly from 10/29/18 through 10/22/19. A recommendation was made to the physician on the 06/18/19 review. Residents Affected - Few Review of Pharmacy Recommendation dated 06/18/19 revealed a recommendation for a gradual dose reduction (GDR) for an antipsychotic medication as the medication had been used for greater than six months without an attempt to reduce the dose or a documented contraindication to a GDR. The form requested the physician to consider a dose reduction if appropriate or document the reason a GDR would be contraindicated. Interview on 10/30/19 at 5:30 P.M. with the Director of Nursing (DON) revealed the facility had not been able to find the pharmacy recommendation in the resident's chart. Interview on 0/31/19 at 12:41 P.M. with the DON verified the physician did not respond to the GDR recommendation dated 06/18/19. Review of the facility's policyMedication Monitoring, dated 10/01/18, revealed the facility's medical director and the director of nursing must act upon in a manner that meets regulatory requirements. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365440 If continuation sheet Page 6 of 14 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 365440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arlington Care Center 98 South 30th Street Newark, OH 43055 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 record review and interview the facility failed to implement an order to decrease Resident #87's Buspar (antianxiety medication) as ordered. This affected one Resident (#87) out of five residents reviewed for unnecessary medications. Facility census was 115. Findings include: Review of the medical record revealed Resident #87 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included chronic kidney disease, major depressive disorder, and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #87 was cognitively intact. Review of gradual dose reduction (GDR) recommendations dated 10/08/19 revealed Resident #87's Buspar was to be decreased from 10 milligrams (mg) twice a day to 10 mg once a day. Review of the medication administration record revealed Resident #87 continued to receive Buspar 10 mg twice a day. Interview on 10/31/19 at 8:55 A.M. Director of Nursing (DON) verified the GDR to decrease Resident #87's Buspar had not been implemented. On 10/31/19 at 9:27 A.M. DON provided a physician and nurse practitioner note dated 10/08/19 that revealed Resident #87's international normalized ratio (INR) was within normal range and no medication change was noted. The nurse practitioner would rechecked in one week and other medications were to be continued. DON stated no medication change could refer to not only to the residents order for Coumadin (anticoagulant) but to no changes in any of the residents medication. DON verified if there was an order to change a residents medication and a note that contradicted the change, a clarification should have been made. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365440 If continuation sheet Page 7 of 14 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 365440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arlington Care Center 98 South 30th Street Newark, OH 43055 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 0772 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure laboratory anemia monitoring was completed as ordered. This affected one (Resident #79) of five residents reviewed for unnecessary medications. The facility census was 115. Findings include: Medical record review revealed Resident #79 was admitted on [DATE] with diagnoses including anemia (lack enough healthy red blood cells to carry adequate oxygen to your body's tissues) and Stage III (moderate) chronic kidney disease. Review of the hospital Hematology/Oncology report dated 08/07/19 revealed Resident #79 received a monthly procrit (medication to help the body produce more red blood cells) injection of 10,000 units for anemia when needed. New orders included to obtain a CBC (complete blood count that measures the cells that make up your blood including red blood cells, white blood cells, and platelets) in two weeks and monthly labs. The plan was for procrit to be administered every two weeks. Review of the hospital laboratory Test Form prescriptions dated 08/07/19 revealed to obtain the a CBC with differential on 09/18/19 and 10/21/19 for anemia. Review of the Physician Orders dated 08/07/19 revealed to obtain a CBC monthly on Tuesday and fax to physician and a renal panel every Tuesday. Review of the medical record revealed ordered blood work was not completed as ordered after 08/20/19. Review of the care plan: Altered Health Maintenance dated 06/20/19 revealed interventions including to monitor labs as ordered. On 10/31/19 at 10:50 A.M., interview with the Director of Nursing (DON) verified the resident had a physician order to obtain a weekly renal panel, fax the results to the hematology physician and obtain a monthly CBC. The DON verified there was no evidence this had been done since 08/20/19. On 10/31/19 at 1:08 P.M., interview with the DON verified physician orders including laboratory blood work should be completed as ordered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365440 If continuation sheet Page 8 of 14 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 365440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arlington Care Center 98 South 30th Street Newark, OH 43055 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 0791 Provide or obtain dental services for each resident. 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 interview the facility failed to provide dental services for Resident (#70 and #87). This affected two Residents (#70 and #87) out of three residents reviewed for dental services. Facility census was 115. Residents Affected - Few Findings include: 1. Review of the medical record revealed Resident #70 was admitted on [DATE] and readmitted on [DATE] with diagnosis that included cerebral infarction, endocarditis, bactermia, and inflammatory conditions of the jaws. Review of an oral exam dated 06/25/19 revealed Resident #70 had one to three decayed or broken teeth. Review of hospital progress note dated 09/01/19 revealed Resident #70 was treated for methicillin-susceptible Staphylococcus aureus (MSSA) bacterimina/urinary tract infection and was transferred to tertiary center for a dental abscess. Resident #70 had a dental abscess and multiple cavities. Review of the doctor of dental surgery consult note dated 09/02/19 revealed a computed tomography (CT) scan revealed Resident #70 had a jaw abscess which showed apical abscess of front incision, upper alveloar ridge with several dental cavities. There was no need for extraction and the resident should follow up with the dentist. Review of an oral exam dated 09/20/19 revealed Resident #70 had four or more decayed or broken teeth. The resident was missing several teeth and the noted teeth were discolored/decayed. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #70 was cognitively intact. Resident #70 was not on the list of residents that was seen by the facility dentist on 09/30/19. Interview on 10/29/19 at 10:35 A.M. Resident #70 stated he had an abscessed tooth. Resident #70 stated the tooth hurt for a while but the tooth has not hurt since the antibiotics were started. Interview on 10/31/19 at 12:50 P.M. Director of Nursing (DON) verified Resident #70 did not see the dentist on 09/30/19 and there was no documentation of the resident seeing a dentist since 02/16/18. 2. Review of the medical record revealed Resident #87 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included chronic kidney disease and dysphagia. Review of the quarterly oral exam dated 04/18/19 revealed Resident #87 had no decayed or broken teeth. Review of the plan of care dated 06/07/19 revealed Resident #87 has impaired dentition and was at risk for oral problems (i.e pain, infection, difficulty chewing/swallowing, poor self image). The resident had one to three broken or decayed teeth. Interventions included to complete an oral (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365440 If continuation sheet Page 9 of 14 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 365440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arlington Care Center 98 South 30th Street Newark, OH 43055 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 0791 assessment as scheduled and refer to the dentist as needed. Level of Harm - Minimal harm or potential for actual harm Review of the quarterly MDS dated [DATE] revealed Resident #87 was cognitively intact. Residents Affected - Few Review of the quarterly oral exam dated 10/16/19 revealed Resident #87 had one to three decayed or broken teeth. Interview on 10/28/19 at 1:43 P.M. Resident #87 stated that her teeth ached at times and she had not seen a dentist for probably a year. Interview on 10/31/19 at 12:50 P.M. DON verified Resident #87 had not seen a dentist since 2017. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365440 If continuation sheet Page 10 of 14 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 365440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arlington Care Center 98 South 30th Street Newark, OH 43055 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 Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure food/beverage containers were stored correctly, the dishwasher functioned according to manufactures guidelines, and food/beverage were dated and labeled. This had the potential to affect all 115 residents who receive meals from the kitchen. The census was 115. Findings Include: 1. Observation of the kitchen dry storage room on 10/28/19 at 8:45 A.M. revealed three bowls and four beverage pitchers stored face up and uncovered. Interview with Dietary Director #432 on 10/28/19 at 8:45 A.M. verified the three bowls and four beverage pitchers were stored incorrectly. Observation of the kitchen dry storage room on 10/30/19 at 9:13 A.M. revealed two coffee containers and a clear pitcher stored face up and uncovered. Interview with Dietary Supervisor #40 on 10/30/19 at 9:13 A.M. verified the two coffee containers and clear pitcher were stored incorrectly. 2. Observation of the dishwasher on 10/28/19 at 8:55 A.M. revealed the dishwasher wash tank temperature was 131 degrees Fahrenheit, the rinse tank temperature was 140 degrees Fahrenheit, and the final rinse temperature was 184 degrees Fahrenheit. Interview with Dietary Director #432 on 10/28/19 at 8:55 A.M. verified the dishwasher was a hot water sanitizing dishwasher and the wash tank temperature did not reach 150 degrees Fahrenheit and the rinse tank temperature did not reach 160 degrees Fahrenheit. Observation of the dishwasher on 10/28/19 at 10:40 A.M. revealed the dishwasher wash tank temperature was 148 degrees Fahrenheit, the rinse tank temperature was 148 degrees Fahrenheit, and the final rinse temperature was 191 degrees Fahrenheit. Interview with Dietary Supervisor #40 on 10/28/19 at 10:40 A.M. verified the dishwasher was a hot water sanitizing dishwasher and the wash tank temperature did not reach 150 degrees Fahrenheit and the rinse tank temperature did not reach 160 degrees Fahrenheit. Observation of the dishwasher on 10/30/19 at 10:39 A.M. revealed the dishwasher wash tank temperature was 139 degrees Fahrenheit. Interview with Registered Dietitian (RD) #320 on 10/30/19 at 10:39 A.M. revealed the dishwasher was switched to a chemical sanitizing dishwasher and verified the dishwasher was tank temperature did not reach 140 degrees Fahrenheit. Review of the dishwasher manufacture guidelines dated 10/07/13 revealed when the dishwasher is set up for hot water sanitizing, the wash tank temperature minimum temperature is 150 degrees Fahrenheit, the minimum pumped rinse tank temperature is 160 degrees Fahrenheit, and the minimum final sanitizing rinse temperature is 180 degrees Fahrenheit. Further review of the dishwasher manufacture (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365440 If continuation sheet Page 11 of 14 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 365440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arlington Care Center 98 South 30th Street Newark, OH 43055 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 Residents Affected - Many guidelines revealed when the dishwasher is set up for chemical sanitizing, the wash tank temperature minimum temperature is 140 degrees Fahrenheit, the pumped rinse tank temperature is 120 degrees Fahrenheit, the final rinse minimum temperature is 120 degrees Fahrenheit, and the sanitizer required is 50 parts per million of available chlorine. 3. Observation of the unit one refrigerator on 10/30/19 at 2:15 P.M. revealed an undated open container of nectar thick lemon flavored water. Interview with Unit Manager #165 on 10/30/19 at 2:15 P.M. verified the nectar thick lemon flavored water was not dated as to when it was opened. Observation of the unit two refrigerator on 10/30/19 at 2:18 P.M. revealed resident salsa that was undated and not labeled with the residents name. Interview with RD #130 on 10/30/19 at 2:18 P.M. verified the salsa was a residents and was not dated or labeled with the residents name. Observation of the unit three freezer on 10/30/19 at 2:20 P.M. revealed frozen beef and peppers that was not labeled with the residents name. Interview with RD #130 on 10/30/19 at 2:20 P.M. verified the frozen beef and peppers was a residents and was not labeled with the residents name. Observation of the unit four freezer on 10/30/19 at 2:24 P.M. revealed a pint of vanilla ice cream that was not labeled with the residents name. Interview with RD #130 on 10/30/19 at 2:24 P.M. verified the pint of vanilla ice cream was a residents and was not labeled with the residents name. Review of the policy titled Food Storage- Labeling and Dating last revised August 2017 revealed all food must has a date that includes the month/day/year on the package indicating the date in which it entered the facility, items must be dated after opening with an Open date and a Use by Date, and pre-thickened water's use by date is 10 days after opening. Review of the policy titled Use and Storage of Food Brought in by Family and Visitors last revised 04/16/18 revealed food items that are already prepared by families or visitors brought in must be labeled and dated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365440 If continuation sheet Page 12 of 14 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 365440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arlington Care Center 98 South 30th Street Newark, OH 43055 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, tuberculosis exposure control plan review, infection control log review, manufacturer guidelines review, policy review and interview, the facility failed to ensure residents received tuberculosis testing upon admission and failed to ensure a sanitary environment. This affected one (Resident #79) of five residents reviewed for immunizations and two of four units within the facility. The facility was 115. Residents Affected - Some Findings include: 1. Medical record review revealed Resident #79 was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease. Review of the Medication Administration Review (MAR) dated June 2019 revealed no evidence a mantoux tuberculin skin test was given upon admission. Review of the undated Tuberculosis Exposure Control Plan revealed due to the increasing incidence of tuberculosis and the potential for nosocomial (facility acquired) transmission of the disease to residents and employees, the facility adopted a tuberculosis exposure control plan. This plan included to administer a mantoux tuberculin skin test to every resident upon admission. Review of the electronic Immunization record revealed no evidence the resident was administered a mantoux upon admission. Review of the immunization history revealed the last mantoux administered to Resident #79 was on 03/15/14. On 10/30/19 at approximately 3:30 P.M., interview with the Director of Nursing (DON) stated the facility was notified of a limited availability of tubersol sometime in June 2019 and it was determined at that time that residents deemed at low risk were to be checked for symptoms of tuberculosis. The DON stated it was unknown when the shortage began or resolved itself, and verified there was no evidence a mantoux was administered to Resident #79 upon admission on [DATE]. Review of the pharmacy email dated 10/30/19 at 3:38 P.M. revealed the availability of tubersol (mantoux) and aplisol (diluted tuberculin) would be limited between the dates of 06/14/19 to 09/17/19. On 10/31/19 at 8:09 A.M., interview with the DON verified the pharmacy did not notify the facility of the limited availability of tubersol or aplisol until 06/14/19, the resident was admitted on [DATE] and should have been administered a mantoux upon admission. The DON further stated Resident #79's nurse did not administer the mantoux upon admission because she did not realize this was the facility policy. 2. Review of the undated policy: Housekeeping Guidelines revealed routine cleaning of horizontal surfaces including floors were to be cleaned daily with an acceptable hospital grade disinfectant/germicide. Review of the Infection Control Logs dated August 2019 to October 2019 revealed no increased incidence of gastrointestinal or skin infections. On 10/30/19 at 12:34 P.M., interview with Housekeeper (HSKP) #264 revealed resident rooms and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365440 If continuation sheet Page 13 of 14 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 365440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arlington Care Center 98 South 30th Street Newark, OH 43055 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some common area floors were mopped with a mixture of a neutral floor cleaner and water on Monday, Wednesday and Friday. HSKP #264 stated on Sunday, Tuesday, Thursday and Saturday the rooms and common area floors were mopped with only water. At the time of the interview, HSKP #264 showed the surveyor a posting in the Unit 1 Housekeeping Room revealing which days staff was to clean the floors with only water. HSKP #264 stated if the floor was visibly dirty she would use bleach spray on the soiled area prior to mopping the area. HSKP #264 stated isolation rooms including the floors were cleaned with bleach products. On 10/30/19 at 1:57 P.M., observation with Laundry and Housekeeping Supervisor (LHS) #176 verified Unit 1 and Unit 2 housekeeping rooms had a posted floor cleaning schedule to use water only to mop the floors on Sunday, Tuesday, Thursday and Saturday. LHS #176 removed the postings during the observation, verified the floors were to be washed with floor cleaner daily and stated last year the facility practice of using only water to clean the floors was discontinued. On 10/30/19 at 2:42 P.M., interview with the DON stated there were no known trends or patterns of infections on Unit 1 or Unit 2. On 10/31/19 at 2:55 P.M., interview with the Administrator verified the State Scentastic Neutral Cleaner was a general cleaner and deodorizer only. Review of the State Scentastic Neutral Cleaner dated 2016 revealed the neutral cleaner was safe for use on finished floors, dilute product according to existing floor soils and apply using traditional mopping equipment. There was no evidence the cleaner was a hospital grade disinfectant/germicide. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365440 If continuation sheet Page 14 of 14