Health inspection·October 16, 2023

F 0584 of 15 indicating severely impaired cognition for daily decision making abilities. Level of Harm - Minimal harm or potential for actual harm Interview on 10/10/23 at 3:00 P.M. with Regional Director of Clinical Services #500 revealed when Resident #4 was admitted to the facility he displayed no inappropriate behaviors including sexual behaviors. The first incident was when Resident #74 claimed someone came into her room on 09/06/23 or 09/07/23 and was pleasuring themselves over top of her and leaving discharge on her. An investigation was started immediately. Resident #74 was noted to have vaginal discharge upon assessment and complained of a burning sensation with urination. Resident #74 ' s family was contacted and updated on the resident 's allegation and current symptoms who declined having the resident sent out to the hospital and requested for her to have a urinalysis completed to check for a urinary tract infection. During this time, one of the therapy staff members informed the Regional Director of Clinical Services #500 that there was another incident that occurred back on 08/24/23 involving Resident #74 and Resident #4. The therapy staff member claimed that they went to Resident #74 to take her to the therapy room and when they arrived at her room, they noticed the room door was closed. After knocking, they attempted to open the door and was not able to due to Resident #74 sitting in her wheelchair in front of the door. Since these rooms have joining bathrooms, the therapy staff member went into the room next to Resident #74 ' s room which was Resident #4 ' s room and noticed the bathroom door leading into Resident #74 ' s room was closed and appeared to be locked. After a couple attempts to open the door, housekeepers were contacted to assist with the bathroom door. Housekeeping was able to open the door without unlocking it and claimed some of the bathroom doors had been sticking and was difficult to open. The therapy staff member claimed when they entered Resident #74 ' s room through the bathroom door, Resident #74 was sitting in her wheelchair, fully dress, with no signs of distress noted and Resident #4 was sitting on the bed, fully dressed with no signs of distress. Resident #4 was observed jumping up off the bed and saying finally and exiting the room through the bathroom door back into his own room. The therapy staff member then claimed that Resident #74 told her that the male resident exposed himself and told her to kiss it or he would break her arm. The therapy staff member stayed with the resident until the Director of Nursing (DON) came to the room. Resident #74 appeared upset and refused therapy. This incident was not reported to the proper state agencies until 09/07/23. Residents Affected - Few Interview on 10/10/23 at 3:00 P.M. with Regional Director of Clinical Services #500 revealed she was not aware that Resident #4 had these prior behaviors before admitting to the facility and if so would not have been placed in a room that shared the bathroom with the opposite sex residents. This deficiency is based on incidental findings discovered during the course of this complaint investigation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365450 If continuation sheet Page 2 of 5 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 365450 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Pomeroy 36759 Rocksprings Road Pomeroy, OH 45769 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on medical record review, self-reported incident review, staff interview, and facilities policy review, the facility failed to report an allegation of sexual abuse in a timely manner and to the appropriate State agency. This affected one resident (#74) of three residents reviewed for reporting allegations of abuse. The facility census was 63. Findings include: Review of a facility self-reported incident, tracking number 238948 dated 09/07/23 revealed an allegation of sexual abuse was reported to the State agency. Time and location of occurrence was noted to be 08/24/23 in residents room. Narrative of the incident included, Allegation of sexual abuse. Resident #74 states that male resident, Resident #4 exposed himself and asked her to kiss it or he would break her arm. Staff reported both residents were in females' room, Resident #74's room with the door closed. Both residents were fully clothed during this time. Resident #4 was sitting on the bed and Resident #74 was next to the door in a wheelchair. No report of residents making contact just verbal remarks. Initially on 08/24/23 this incident was reported per Resident #74 to the Director of Nursing (DON) just that Resident #4 asked her to kiss him and there was no contact noted. On 09/07/23, therapy director brought an occupational therapy note from 08/24/23 reporting above incident. Per witness statements, Resident #74 was seen 15 minutes prior to incident up in her wheelchair in her room. Witness statement from Occupational Therapist (OT) #200 stated that around 1:00 P.M. or 2:00 P.M. she went to try to get Resident #74 for therapy after refusing twice earlier and that her door was shut when she attempted to open the it was stuck. On the third attempt she was able to get the door open enough to see Resident #4 sitting on Resident #74's bed. She attempted to try the adjoining bathroom door and the door was locked, housekeeping was able to get the door opened and the male resident was escorted to his room. Resident #74 then stated that the male resident exposed himself and told her to kiss it or her would break her arm. Therapy staff stayed with Resident #74 until the nurse and DON came. The nurse stayed 1:1 until another staff member could take over, Resident #74 seemed upset and refused therapy. Both residents were fully clothed. Denied witnessing the residents touch. Witness statement from State Tested Nursing Assistant (STNA) #131 stated that she was walking by and therapy staff stated that she could not open the door. Housekeeping opened the door and when I walked into the room, male resident stated Thank God! and got up and left the room and I followed him. She did not notice him having inappropriate sexual behaviors or contact with the female resident. STNA #131 denied that Resident #74 appeared upset. Interview on 10/10/23 at 3:00 P.M. with Regional Director of Clinical Services #500 revealed when Resident #4 was admitted to the facility he displayed no inappropriate behaviors including sexual behaviors. The first incident staff were aware of was when Resident #74 claimed someone came into her room on 09/06/23 or 09/07/23 and during this time, one of the therapy staff members informed the Regional Director of Clinical Services #500 that there was another incident that occurred back on 08/24/23 involving Resident #74 and Resident #4. The therapy staff member claimed that they went to Resident #74 to take her to the therapy room and when they arrived at her room, they noticed the room door (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365450 If continuation sheet Page 3 of 5 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 365450 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Pomeroy 36759 Rocksprings Road Pomeroy, OH 45769 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was closed. After knocking, they attempted to open the door and were not able to due to Resident #74 sitting in her wheelchair in front of the door. Since these rooms have joining bathrooms, the therapy staff member went into the room next to Resident #74's room which was Resident #4's room and noticed the bathroom door leading into Resident #74's room was closed and appeared to be locked. After a couple attempts to open the door, housekeepers were contacted to assist with the bathroom door. Housekeeping was able to open the door without unlocking it and claimed some of the bathroom doors had been sticking and were difficult to open. The therapy staff member claimed when they entered Resident #74's room through the bathroom door, Resident #74 was sitting in her wheelchair, fully dressed, with no signs of distress noted and Resident #4 was sitting on the bed, fully dressed with no signs of distress. Resident #4 was observed jumping up off the bed and saying finally and exiting the room through the bathroom door back into his own room. The therapy staff member then claimed that Resident #74 told her that the male resident exposed himself and told her to kiss it or he would break her arm. The therapy staff member stayed with the resident until the DON came to the room. Resident #74 appeared upset and refused therapy. This incident was not reported to the proper state agencies until 09/07/23. Review of the facility policy titled Abuse, Neglect and Exploitation, revised 10/24/22 revealed V. Investigation of Alleged Abuse, Neglect, and Exploitation. A. An immediate investigation is warranted when suspicion of abuse, neglect or expectoration, or reports of abuse, neglect or exploitation occur. VII. Reporting/Respond. 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other agencies within specified timeframe. a. Immediately but no later than 2 hours after the allegation is made. This deficiency represents non-compliance investigated under Complaint Number OH00147112. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365450 If continuation sheet Page 4 of 5 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 365450 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Pomeroy 36759 Rocksprings Road Pomeroy, OH 45769 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 medical record review and staff interview, this facility failed to develop a comprehensive person centered care plan to reflect behaviors including inappropriate sexual behaviors. This affected one resident (#4) of three residents reviewed for care planning. The facility census was 63. Findings include: Review of the medical record for Resident #4 revealed an initial admission date of 06/22/23 and a re-entry date of 09/29/23. Diagnoses included bipolar disorder current, dementia with behavioral disturbances and cognitive communication deficit. Review of Resident #4's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 10 out of 15 indicating a moderately impaired cognition for daily decision making abilities. Resident #4 was noted to be independent no set up assistance required for for bed mobility, walk in and out of room, locomotion on and off the unit. Resident #4 was noted to be free of any impairment to the bilateral upper or lower extremities and required no assistive devices for mobility. Review of the hospital discharge forms dated 06/09/23 for Resident #4 revealed Per family and emergency room assessment, patient with noted confusion, agitation, and sexually inappropriate behaviors per family for the past week. When caretaker came home from work yesterday patient was naked and had been incontinent. Patient had been intermittently confused and agitated throughout the week and was making inappropriate gestures/statements towards, daughter in-law, which was not his baseline. The caregiver has been locking her bedroom out of fear. Patient reportedly sleeps off and on during the day but is then up most of the night. Patient sees a physician and was recently started on medication two months ago, however caregiver reports that current medications aren't working. No physical aggression reported. Review of Resident #4's plan of care revealed no care plan developed to address residents behavior including the display of inappropriate sexual behaviors. Interview on 10/10/23 at 3:00 P.M. with Regional Director of Clinical Services #500 confirmed Resident #4 was seen at a hospital prior to admission to current skilled nursing facility due to increased sexual behaviors directed towards his care provider and confirmed a person centered care plan addressing this behavior was not developed upon admission to the facility. A facility policy was not provided regarding care planning. This deficiency is based on incidental findings discovered during the course of this complaint investigation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365450 If continuation sheet Page 5 of 5