Inspection·August 18, 2022

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 08/16/22 at 8:35 A.M. Resident #24's fingernails were observed to appear very dirty, with an unknown dark brown/black substance around the fingernail beds and underneath the resident's fingernails. On 08/16/22 at 8:40 A.M. interview with Licensed Practical Nurse (LPN) #404 confirmed Resident #24's fingernails had an unknown dark brown substance around the nail beds and what appeared to be dried food under the fingernails. 2. Review of the medical record for Resident #58 revealed an admission date of 01/12/21 with diagnoses including dementia, diabetes, heart failure, chronic obstructive pulmonary disease and cataract in the right eye. Review of the quarterly MDS 3.0 assessment, dated 07/21/22 revealed Resident #58 was severely cognitively impaired, required extensive assistance from one staff for hygiene and bathing and was independent with eating. Review of the plan of care, dated 07/22/22 revealed the resident had a need for assistance with functional abilities including bathing and hygiene. Interventions included staff to assist with activities of daily living (ADL) care as needed. On 08/15/22 at 10:30 A.M. Resident #58 was observed sitting in her wheelchair in her room. Resident #58's fingernails were observed to be long, polished with the nail polish peeling off the tips and nails beds. The fingernails were observed to be light brown with some staining and what appeared to be dirt under the fingernails. On 08/15/22 at 3:31 P.M. Resident #58 was observed in the dining room where fingernail polishing was being completed for residents. Interview at the time of the observation with Activities Aide #490 confirmed the presence of what appeared to be a build-up of dirt underneath Resident #58's fingernails, in addition to the staining. On 08/18/22 at 10:22 A.M. interview with State Tested Nursing Assistant (STNA) #494 revealed STNA staff can trim resident fingernails unless the resident was diabetic, then the nurse should do it. STNA #494 revealed there were one or two residents on the unit who request a wet wash cloth each morning to wash up, otherwise they get a bath on scheduled bath days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365440 If continuation sheet Page 2 of 6 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 08/18/2022 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure Resident #37 was provided timely and adequate assistance with eating, a nutritional diet was provided as ordered and meal intakes were documented for Resident #37 who was identified to have a significant weight loss in one month. This affected one resident (#37) of five residents reviewed for nutrition. Residents Affected - Few Findings include: Review of the medical record revealed Resident #37 was admitted to the facility on [DATE] with diagnoses including pressure ulcer to the sacral area, chronic obstructive pulmonary disease, dementia, sleep apnea and depression. Review of the dietary assessment, dated 07/06/22 at 1:06 P.M. revealed Resident #37 was on a regular diet with finger foods because she would not use silverware. The assessment revealed the meal should provide approximately 2473 calories and 95 grams of protein daily. The resident feeds herself with poor intakes of approximately 25-50 percent of most meals documented. Her current body weight was 140 pounds (lbs) with a body mass index of 21.9, which was her normal weight status. Resident #37 was at high risk for nutritional decline per the nutritional risk assessment tool. The dietitian recommends offering 120 milliliters (ml) house supplement twice daily to provide an additional 480 calories and 20 grams of protein. Also add 60 ml of house liquid protein supplement daily to provide 202 calories and 30 grams protein for wound healing and provide diet as ordered with the goal of greater than 50 percent of meals consumed. Monitor intakes, supplement acceptance, weight and skin integrity. Review of the plan of care, dated 07/06/22 revealed Resident #37 had a potential for alteration in nutrition and hydration related to finger foods (she refused all silverware), supplements related to poor intakes and pressure wounds. Interventions included to provide assistance with meals as needed, encourage family to bring in favorite foods from home, honor food preferences, medications as ordered, monitor consistency of diet ordered, obtain food preferences, provide diet as ordered, provide supplement as ordered, weights as ordered, and dietitian referral as needed. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 07/07/22 revealed Resident #37 had severely impaired cognition, required total assistance from one staff member for dressing and personal hygiene, extensive assistance from two staff members for bed mobility and extensive assistance from one staff member for eating. The assessment revealed the resident weighed 140 lbs. Review of July 2022 meal intake records for Resident #37 revealed there was no documentation of her meal intakes for breakfast on 07/08/22, 07/09/22, 07/10/22, 07/11/22, 07/17/22, 07/19/22, 07/21/22, 07/23/22, 07/26/22 or 07/31/22. There was no documentation of her meal intakes for lunch on 07/07/22, 07/08/22, 07/09/22, 07/10/22, 07/11/22, 07/17/22, 07/19/22, 07/21/22, 07/23/22, 07/26/22 or 07/31/22. There was no documentation of her meal intakes for dinner on 07/02/22, 07/06/22, 07/07/22, 07/08/22, 07/09/22, 07/10/22, 07/11/22, 07/12/22, 07/13/22 07/14/22, 07/16/22, 7/17/22, 07/19/22, 07/21/22, 07/23/22, 07/25/22, 07/26/22, 07/27/22, 07/29/22, 07/30/22 or 07/31/22. Review of the weights in the electronic medical record (in Point Click Care) revealed Resident #37 weighed 140 lbs on 07/06/22. There was not an admission [DATE]) weight documented. She weighed 131.6 lbs on 07/14/22, 135.5 lbs on 07/21/22, 134.9 lbs on 07/27/22, 133.4 lbs on 08/04/22 and 131.7 lbs (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365440 If continuation sheet Page 3 of 6 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 08/18/2022 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 0692 on 08/16/22 which reflected a 5.6 percent weight loss. Level of Harm - Minimal harm or potential for actual harm Review of the August 2022 physician's orders revealed Resident #37 was on a regular diet with finger foods. Residents Affected - Few Review of August 2022 meal intake records for Resident #37 revealed there was no documentation of meal intakes for breakfast on 08/04/22 or 08/06/22. There was no documentation of meal intakes for lunch on 08/04/22, 08/05/22, 08/06/22 or 08/07/22. There was no documentation of meal intakes for dinner on 08/03/22, 08/04/22, 08/05/22, 08/06/22, 08/07/22, 08/12/22 or 08/13/22. Review of the breakfast diet slip, dated 08/17/22 revealed resident's slip documented a regular diet, finger foods and four ounces health shake. On 08/17/22 at 8:35 A.M. State Tested Nursing Assistant (STNA) #406 was observed to hand Resident #37's breakfast tray to Licensed Practical Nurse (LPN) #405 who was in the resident's room. LPN #405 set the tray on the round table in the corner of the room. The resident was in bed. LPN #405 left the resident's room and closed the door. Continued observation from 8:35 A.M. to 9:39 A.M. revealed no staff member had gone into the room of Resident #37 to provide assistance to her with the meal and the meal tray was not positioned in front of her to eat. At 9:39 A.M. STNA #406 was observed to enter the resident's room to assist with the meal. At 10:10 A.M. STNA #406 came out of the room with Resident #37's meal tray and indicated she had only eaten her donut. The tray had scrambled eggs, bacon, toast, a donut, a carton of milk, which was unopened, a bowl of fruit loops, a four-ounce glass of orange juice, which was half gone, and a four-ounce glass of heath shake which still had the lid on it. STNA #406 indicated the resident does not like eggs and stated she had told the kitchen, but they kept sending her eggs. In addition, STNA #406 verified scrambled eggs were not a finger food. Review of the week two menu (dated 08/15/22) revealed on Wednesday for lunch the residents who were to get finger foods were to receive three ounces of veal bites, four ounces of pasta, four ounces of the Key [NAME] vegetable blend, four ounces carton of milk, and eight ounces of water. On Wednesday 08/17/22 at 12:05 P.M. observation of the lunch trays revealed they arrived to the unit at this time. STNA #406, who was passing trays, left the tray for Resident #37 on the meal cart in the hallway. Continuous observation from 12:05 P.M. to 12:58 P.M. revealed the lunch tray for Resident #37 remained on the meal cart in the hallway. At 12:58 P.M. STNA #406 took the meal tray for Resident #37 into the resident's room. The meal tray had a ground meat sandwich, green beans, Cheetos puffs, a four ounces carton of milk and a four-ounce glass of water. On 08/17/22 at 12:58 P.M. interview with STNA #406 revealed it was taking her a little longer to feed the four residents on the unit because the other nursing assistant had gone home at 12:00 P.M. and it was just her on the unit. On 08/17/22 at 1:40 P.M. interview with Dietitian #481 revealed the facility does give scrambled eggs as a finger food so the resident would have a variety of options for breakfast. Also, they wound give green beans instead of the Key [NAME] blend because they believe the green beans were easier to hold on to then the Key [NAME] blend which tends to get mushy when cooked. She indicated the cook gave the Cheetos puffs in place of the pasta and verified this was not an appropriate substitution. She indicated the alternate sandwich was a chicken patty and the resident does not like chicken, so the cook put ground meat on a bun for her. She did not know why she did not get the veal patty because she was a regular diet not a mechanical soft. She stated she did not do the menus, so she did not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365440 If continuation sheet Page 4 of 6 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 08/18/2022 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 0692 know why they gave Cheetos instead of pasta. Level of Harm - Minimal harm or potential for actual harm On 08/17/22 at 2:55 P.M. interview with Dietary Manager #462 revealed Resident #37 should not have gotten the ground meat sandwich. She stated the cook must have put it on the wrong tray. She stated Resident #37 could have had the veil and pasta. The Cheetos puffs should not have been a replacement for the pasta but an extra on her tray. Residents Affected - Few On 08/18/22 at 1:45 P.M. interview with Dietitian #481 revealed meal intakes were an important part of her nutritional assessment and determined what intervention she initiated. She stated if no meal intakes were documented she would have to go talk to the staff to know how much the resident was consuming at meals. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365440 If continuation sheet Page 5 of 6 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 08/18/2022 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure Resident #37 had oxygen on to maintain her oxygen saturation above 90 percent as ordered. This affected one resident (#37) of eight residents who were ordered oxygen on unit one. Residents Affected - Few Finding include: Review of the medical record revealed Resident #37 was admitted to the facility on [DATE] with diagnoses including pressure ulcer to the sacral area, chronic obstructive pulmonary disease, dementia, sleep apnea and depression. Review of the Minimum data Set (MDS) 3.0 assessment, dated 07/07/22 revealed Resident #37 had severely impaired cognition, required total assist from one staff member for dressing and personal hygiene, extensive assistance from two staff members for bed mobility and extensive assistance from one staff member for eating. Review of the August 2022 physician's orders revealed Resident #37 had an order for oxygen at two liters via nasal cannula continuously to maintain oxygen saturation (above 90%) and to check oxygen saturation every shift while on oxygen. On 08/15/22 at 11:58 A.M. Resident #37 was observed without oxygen on as ordered. Interview with State Tested Nursing Assistant #401 at the time of the observation verified Resident #37 did not have her oxygen on as ordered. On 08/16/22 at 1:33 P.M. and 4:32 P.M. and on 08/17/22 at 8:35 A.M. Resident #37 was observed without oxygen in place. On 08/17/22 at 8:35 A.M. interview with Licensed Practical Nurse (LPN) #405 verified Resident #37 did not have her oxygen on as ordered. LPN #405 obtained an oxygen saturation from Resident #37 at this time and the resident's oxygen saturation level was 89 percent on room air. LPN #405 placed oxygen Resident #37 and her oxygen saturation came up to 91 percent. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365440 If continuation sheet Page 6 of 6