Health inspection·July 11, 2024

F 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Observation on 07/11/24 at 8:41 A.M. of the test tray was served after all other K Hall food trays were served. Observation of the test tray opened on 07/11/24 at 8:41 A.M. with Dietary Supervisor #421. Dietary Supervisor #421 checked the food on the tray and confirmed the food temperatures. The egg and cheddar bake was 123 degrees Fahrenheit, the donut was 94 degrees Fahrenheit, and the oatmeal was 143 degrees Fahrenheit. The food was tasted and the eggs were lukewarm. Interview on 07/11/24 at 09:03 A.M. with Dietary Supervisor #421 revealed the facility has hot plates but they were not currently using carriage pallet warmers under the plates. Dietary Supervisor #421 also revealed the pallet warmer wasn't working and it went down five or six days ago. She said they have to order more parts. Review of the Infection Control - Dietary/Food Handling policy dated March 2016 stated all potentially hazardous food, TCS must be maintained at 41 degrees or less, or at 135 degrees or above, except during preparation, cooking or cooling. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365440 If continuation sheet Page 2 of 4 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 07/11/2024 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 Based on observation, record review, staff interview and facility policy review, the facility failed to maintain appropriate infection control practices in the area of isolation and enhanced barrier precautions (EBP). This affected two residents (#77 and #84) of 24 residents on isolation and/or EBP. Additionally, the facility failed to ensure proper hand hygiene was completed in between contact with each resident while serving meal trays. This had the potential to all nine residents (Resident #198, #86, #30, #199, #200, #74, #72, #63, and #201) residing on the facility's C unit who received a meal tray. The facility census was 94. Residents Affected - Some Findings include: 1. Review of the medical record for Resident #77 revealed an initial admission date of 02/21/24 with the diagnoses including hydronephrosis with renal and ureteral calculous obstruction, artificial openings of urinary tract infection (UTI), and chronic kidney disease. Review of the admission assessment and baseline care plan dated 02/21/24 revealed Resident #77 had a right nephrostomy tube in place. Review of the plan of care dated 03/01/24 revealed Resident #77 was at risk for infection related to right nephrostomy tube. Interventions included to maintain EBP. Review of the resident's monthly physician orders for July 2024 revealed orders dated 02/21/24 to empty nephrostomy drainage bag every shift. On 04/08/24, the order was to maintain EBP every shift. On 07/09/24 at 2:19 P.M., observation of Licensed Practical Nurse (LPN) #324 provide the physician ordered treatment to Resident #77's nephrostomy tube revealed she washed her hands, donned a pair of gloves, removed the old dressing and washed her hands, donned gloves. LPN #324 then cleansed the insertion site with an alcohol pad in a circular motion from the insertion site out. LPN #324 then applied skin prep to the area around the nephrostomy tube insertion site. LPN #324 then placed a T drain sponge on the insertion site and then covered the tube with a 4X4. LPN #324 secured the dressing with a Tegaderm and then washed her hands. LPN #324 failed to wear a gown for personal protective equipment during the procedure for EBP as physician ordered. On 07/09/24 at 2:32 P.M., an interview with LPN #324 verified she did not wear a gown during the treatment of Resident #77's nephrostomy tube and verified a gown should have been worn per physician orders for the use of the EBP. 3. Observation completed on 07/08/24 from 11:20 A.M. to 11:51 A.M. revealed State Tested Nursing Assistant (STNA) #320 and #326 passed lunch meal trays to residents residing on the facility's C unit. STNAs #320 and #326 entered and exited multiple resident rooms to deliver their meal tray and helped residents set their meal tray up without the use of hand sanitizer nor were either staff member observed washing their hands. Interview on 07/08/24 at 11:52 A.M. with STNA #320 confirmed she did not complete hand hygiene between delivering lunch meal trays to the residents and claimed she thought hand hygiene only had to be completed after contact with so many residents. STNA #320 was not able to provide the number of residents she could come in contact with before hand hygiene needed to be completed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365440 If continuation sheet Page 3 of 4 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 07/11/2024 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 Interview on 07/08/24 at 11:56 A.M. with STNA #326 confirmed hand hygiene was not completed after delivering meal trays to different residents. STNA #326 stated she knew hand hygiene needed to be completed between contact with each resident, she just forgot to do it. Interview on 07/08/24 12:19 P.M. with the Director of Nursing (DON) revealed staff were to use hand sanitizer every time they enter a resident's room and when they leave a resident's room and to wash their hands when visibly soiled and as needed. Review of the facility policy titled Hand Hygiene dated 11/28/17 revealed staff should perform hand hygiene (even if gloves are used) in the following situations: which included before and after contact with the resident. 2. Review of the medical record for Resident #84 revealed an admission date of 12/03/23. Diagnoses included noninfective gastroenteritis and colitis. Review of Resident #84 physician orders dated 06/26/24 revealed to maintain contact precautions every shift for Methicillin-Resistant Staphyloccous aureus (MRSA) urinary tract infection (UTI). Observation on 07/08/24 at 12:23 P.M. with Licensed Practical Nurse (LPN) #381 revealed LPN #378 entered Resident 84's room with a medication cup and without donning any personal protective equipment (PPE) which included no gloves or gown was donned. Interview on 07/08/24 at 12:23 P.M. with LPN #381 confirmed LPN #378 should have been wearing PPE prior to entering Resident #84's room. LPN #381 said she would do education with LPN #378. Observation on 07/08/24 at 12:23 P.M. revealed there was contact precaution signage on Resident #84's door. The contact precaution sign on the door stated Contact Precautions Everyone Must: Clean their hands, including before entering and when leaving the room. Providers and staff must also: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person. [NAME] and Doff procedures were located to the left of the door as you enter. Lastly, PPE required supplies and directions were taped on top of the PPE supply cart that was located to the left of the door before you enter the room. Review of the Standard and Transmission-based Precautions policy dated 03/24/24 revealed the facility will use standard approaches, as defined by the Centers for Disease Control and Prevention (CDC) for transmission based precautions: airborne, contact, and droplet precautions. The category of transmission-based precautions will determine the type of PPE to be used. The category of and duration of transmission-based precaution (isolation) will depend upon the infectious agent or organism involved FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365440 If continuation sheet Page 4 of 4