Inspection·December 4, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, facility failed to maintain a homelike environment in resident rooms. This affected two residents (#18 and #55) of four residents reviewed for homelike environment. The census was 65. Findings include: 1. Record review revealed Resident #18 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction, chronic obstructive pulmonary disease, hypertension, gastro-esophageal reflux disease, dysphagia, schizoaffective disorder, major depression, and acute kidney failure. Observation on 11/29/23 at 10:44 A.M. revealed Resident #18 in his room. The bathroom door in his room had three holes on the bottom, each approximately the size of a golf ball. Interview on 11/29/23 at 10:46 A.M. with Registered Nurse (RN) #145 confirmed the holes in Resident #18's bathroom door. During the course of the annual survey, Resident #18 was not available for interview. 2. Record review revealed Resident #55 was admitted to the facility on [DATE] with diagnoses including type II diabetes, hypertension, hyperlipidemia, dysphagia, and cognitive communication disorder. Resident #55 was cognitively impaired and was not able to be interviewed. Observation on 11/29/23 at 10:42 A.M. revealed Resident #55 was resting in her room. The walls did not have any decorations, very few personal items were noted in the room, paint was peeling off the walls in areas, and multiple nail or screw holes were scattered across the wall to the right of the residents' bed. Observation of her bathroom revealed a dirty toilet with bowel movement in it, a putrid smell, and a rattling exhaust fan. Interview on 11/29/23 at 10:46 A.M. with RN #145 confirmed the findings in Resident #55's room and bathroom. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365450 If continuation sheet Page 2 of 16 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 12/04/2023 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 0641 Ensure each resident receives an accurate assessment. 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 interview, the facility failed to ensure Minimum Data Set (MDS) assessments were completed accurately in the area of gradual dose reduction attempts being completed when on an antipsychotic medication and the use of personal alarms and wander guards. This affected two residents (#18 and #36) of 23 residents reviewed for assessments. Residents Affected - Few Findings include: 1. A review of Resident #18's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included schizo-affective disorder and major depressive disorder. A review of a pharmacy recommendation for Resident #18 dated 06/27/23 revealed the pharmacist had recommended a gradual dose reduction (GDR) attempt for the use of Seroquel (an antipsychotic medication). The pharmacist indicated the resident had been on 25 milligrams (mg) twice a day since October 2021. The nurse practitioner responding to the recommendation agreed to the recommendation and reduced the dose of the Seroquel from 25 mg twice a day to 12.5 mg twice a day on 06/28/23. A review of Resident #18's medication administration record (MAR) revealed the resident was receiving Seroquel 12.5 mg by mouth (po) twice a day for schizo-affective disorder. That order had been in place since 07/02/23. A review of Resident #18's quarterly MDS assessment dated [DATE] revealed the resident was identified as being on an antipsychotic medication under Section (N.) Medications on the MDS. Section (N.) also asked if the resident has had a GDR attempted for the use of the antipsychotic medication. The assessor indicated on the MDS assessment that a GDR had not been attempted despite the resident's Seroquel dose being reduced from 25 mg twice a day to 12.5 mg twice a day on 06/28/23, as was ordered in response to the pharmacy recommendation made on 06/27/23. On 11/22/23 at 9:07 A.M., an interview with the facility's Director of Nursing confirmed Resident #18 did have a GDR attempt for his Seroquel in response to a GDR recommendation from their pharmacy on 06/27/23. She confirmed the nurse practitioner agreed to the recommendation and the dosage of the Seroquel was reduced from 25 mg to 12.5 mg twice a day on 06/28/23. She further confirmed the resident's quarterly MDS assessment that was completed on 10/04/23 was not coded accurately, as it did not reflect the GDR that had been attempted on the resident's Seroquel that occurred prior to the quarterly MDS assessment being completed. She stated Section (N.) should have been coded to reflect a GDR for the antipsychotic had been done. 2. Review of the medical record for Resident #36 revealed an initial admission date of 10/29/21 and a re-entry date of 10/12/23. Diagnoses included vascular dementia without behavioral disturbances, a history of falling, muscle weakness, and repeated falls. Review of Resident #36's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 05 indicating a severely impaired cognition for daily decision making abilities. Resident #36 was noted to be inattentive with disorganized thinking and displaying physical behaviors directed towards others. No restraints or alarms were noted to be used during this assessment review. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365450 If continuation sheet Page 3 of 16 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 12/04/2023 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the care plan dated 09/22/23 and revised 10/14/23 revealed Resident #36 was at risk for elopement related to exit seeking behaviors. Interventions included the use of a wander guard placed on the resident's right ankle. Review of the care plan dated 09/22/23 revealed Resident #36 was at risk for falls/injuries related to a bed alarm, bladder incontinence, bowel incontinence, cerebral vascular accident, chair alarm, a history of falls, and generalized weakness. Interventions included to place a tab alarm to the bed and wheelchair. Review of Resident #36's orders revealed an order for a tab alarm to be placed on the resident's wheelchair and to the resident's bed to alert staff of unassisted transfers ordered on 07/30/23. Also noted was an order for a wander guard to be placed on Resident #36's right ankle due to a history of exit seeking behaviors with the order date of 07/24/23. Review of Resident #36's quarterly risk of elopement/wandering review assessment dated [DATE] revealed the resident was at a risk for an elopement and a wander guard was in place. Interview on 11/29/23 at 2:30 P.M. with the Administrator and the Director of Nursing verified Resident #36 had a tab alarm placed on her bed and wheelchair as well as a wander guard placed to the right ankle for safety needs. The DON confirmed the MDS dated [DATE] should have reflected the use of the tab alarm and wander guard and confirmed these items were not noted in this assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365450 If continuation sheet Page 4 of 16 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 12/04/2023 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and policy review, the facility failed to ensure residents had a new resident review completed after a newly diagnosed mental illness was added to their diagnoses. This affected two residents (#12 and #43) of two residents reviewed for Preadmission Screening and Resident Review (PASARR) assessments. Findings include: 1. A review of Resident #43's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included generalized anxiety disorder and depression at the time of his admission. His diagnoses list was updated to reflect an added diagnosis of schizo-affective disorder (type of schizophrenia that also included a mood disorder component) on 12/14/21. A review of Resident #43's PASARR Identification Screen dated 10/26/21 that was completed within 30 days of his admission revealed it was being completed as part of his pre-admission screen (PAS) and was an out of state PAS. Section (E.) Indications of Serious Mental Illness documented any known mental disorders the resident was known to have at the time the assessment was completed. Seven specific mental disorders were listed to include schizophrenia, mood disorder, delusional disorder, panic or other severe anxiety disorder, somatic symptom disorder, personality disorder, and other psychotic disorders. The assessor was to check all that applied. The resident was marked as having a panic or other severe anxiety disorder. There were none of the other diagnoses marked as having been known at that time. As a result of that PASARR screen, the resident was not indicated to have had any indications of serious mental illness and/ or developmental disability. Resident #43's medical record was absent for any evidence of a new resident review assessment being completed on or after 12/14/21, when he was diagnosed with a new mental illness diagnosis of schizo-affective disorder. Findings were verified by the Director of Nursing (DON). On 11/21/23 at 11:05 A.M., an interview with the DON revealed she reviewed Resident #43's electronic medical record (EMR) and did not see evidence of a new resident review being completed after his admission to the facility on [DATE]. She confirmed a new resident review should have been completed when he was given the new mental illness diagnosis of schizo-affective disorder. A review of the facility's policy on Pre-admission Screen and Resident Review revised 10/30/23 revealed the facility must coordinate assessments with the pre-admission screening and resident review program under Medicaid in part 483, subpart C to the maximum extent practicable to avoid duplicative testing and efforts. If a resident was admitted with a level diagnosis as indicated in the policy above, review was required upon change in the resident's condition. A review and determination must be conducted promptly after a nursing facility has notified the State mental health authority or State developmental disability authority, as applicable, with respect to a mentally ill resident that there had been a significant change in the resident's physical or mental condition. The facility was responsible for notifying the State agency which governs PASARR of a resident's change in condition. 2. A review of Resident #12's medical record revealed the resident was admitted to the facility on [DATE]. His diagnoses included major depressive disorder, anxiety disorder, and schizo-affective disorder. Schizo-affective disorder was included in his diagnoses at the time he was admitted to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365450 If continuation sheet Page 5 of 16 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 12/04/2023 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few facility on [DATE]. Anxiety disorder was added on 04/19/21 and major depressive disorder was added on 05/06/21. A review of Resident #12's Preadmission Screening and Resident Review (PASARR) Identification Screen dated 05/06/22 revealed the assessment was being completed for a resident review for a significant change in his condition. Section (E.) Indications of Serious Mental Illness was marked to reflect the resident had a mood disorder. Schizophrenia and anxiety disorder was not marked as being one of the diagnoses the resident was known to have despite his diagnoses including schizo-affective disorder and anxiety disorder. The PAS Determination dated 05/06/22 revealed the resident did not have any indications of a serious mental illness and/ or developmental disability. On 11/21/23 at 11:05 A.M., an interview with the DON confirmed Resident #12's Resident Review completed on 05/06/22 was not completed accurately, as schizophrenia and anxiety disorder were not checked as being two of the diagnoses the resident was known to have. She stated the Resident Review completed on 05/06/22 was the last screen that had been completed for the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365450 If continuation sheet Page 6 of 16 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 12/04/2023 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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** Based on medical record review, staff interview, policy review, the facility failed to ensure a residents care plan properly reflected a resident's code status. This affected one resident (#67) of the 23 residents reviewed for accurate care planning. The facility census was 65. Findings include: Review of the medical record for Resident #67 revealed an initial admission date of [DATE]. Diagnoses included COVID-19, chronic obstructive pulmonary disease, cerebral infarction and vascular dementia. Review of Resident #67's code status document dated [DATE] revealed a completed and signed document indicating Resident #67 wished to be a Do-Not-Resuscitate (DNR), Comfort Care, Arrest (CCA) DNR-CCA indicating the provider will treat resident as any other without a DNR order until the point of cardiac or respiratory arrest at which point all interventions will cease and the DNR Comfort Care protocol will be implemented. Review of Resident #67's orders for [DATE] revealed a code status order for DNR-CCA with an original order date being [DATE]. Review of the care plan dated [DATE] revealed Resident #67 was a full code indicating if the resident is found to be without pulse or breathing immediately call 911 and begin cardiopulmonary resuscitation (CPR), notify the medical director (MD) and family immediately of change of condition, once CPR has been initiated continue until Emergency Medical Services (EMS) arrives and takes over. Interview on [DATE] at 3:30 P.M. with the Director of Nursing confirmed Resident #67 had a signed DNR-CCA code status in his medical record and the care plan did not accurately reflect this DNR-CCA code status. Review of the facility's policy titled Residents' Rights Regarding Treatment and Advanced Directives. dated [DATE] revealed under section Policy Explanation and Compliance Guidelines: 7. During the care planning process, the facility will identify, clarify, and review with the resident or legal representative whether they desire to make any changes related to any advance directives. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365450 If continuation sheet Page 7 of 16 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 12/04/2023 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 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of the facility's fall investigation, staff interview, and policy review, the facility failed to ensure Resident #55 was provided the assistance needed to prevent an avoidable fall from occurring that resulted in major injury to the resident and failed to ensure Resident #44's room was free of a safety hazard (an electrical heated curling iron). This affected two residents (#55 and #44) of three residents reviewed for accidents. The facility census was 65. Actual harm occurred on 09/26/23 when Resident #55, who was severely cognitively impaired was observed ambulating in the hall, without the use of her walker, and was only educated by a staff member that she needed her assistive device when ambulating. At the time of the incident, Resident #55 was encouraged to return to her room, without being provided the appropriate staff assistance needed and fell fracturing her left hip requiring surgical repair Findings include: 1. A review of Resident #55's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included unspecified dementia, muscle weakness, unsteadiness on her feet, lack of coordination, and need for assistance with personal care. Her diagnoses list was updated to reflect she had a displaced fracture of the base of the left femur that was added on 10/02/23. A review of Resident #55's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognition was assessed as being severely impaired. She was sometimes able to understand others and was sometimes able to make herself understood. She required supervision with the physical assist of one for ambulation in her room and in the corridor. Balance issues were indicated to be present with transfers and ambulation but the resident was able to stabilize herself without the assistance of staff. A walker was listed as the only mobility device being used at that time. A review of Resident #55's care plans revealed she was at risk for falls related to unsteadiness on her feet, lack of coordination, and a closed fracture of the left femur. Interventions included visual cues in room to remind the resident to use call light, educate resident on safety interventions, encourage the resident to keep needed items within reach, encourage the resident to use her call light, and to place call light in reach. A review of Resident #55's progress notes revealed a nurse's note dated 09/26/23 at 10:06 P.M. by Registered Nurse (RN) #120 that indicated she was walking up from the back hall of B unit to go answer a phone call. On her way up, she saw Resident #55 fall. Resident #55 landed on her left hip. The resident was ambulating without the use of her walker. She was sent out to the emergency room for an evaluation and was transported to another local hospital with the diagnosis of a left hip fracture. She remained in the hospital until her return to the facility on [DATE]. A review of the facility's fall investigation for Resident #55's fall that occurred on 09/26/23 revealed the fall occurred on 09/26/23 at 8:05 P.M. She resided on the front hall of the B unit at the time the fall occurred. The nurse's description of the fall revealed the same information the nurse documented in her progress note on 09/26/23 at 10:06 P.M. In addition, the nurse further indicated an aide was present speaking to another resident when Resident #55 walked up. The aide gave Resident #55 a verbal cue and encouraged the resident that she needed to have her walker. Resident #55 walked (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365450 If continuation sheet Page 8 of 16 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 12/04/2023 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 0689 Level of Harm - Actual harm Residents Affected - Few off while the aide's back was turned towards her as the aide continued to speak with the other resident. Resident #55 then fell. When assessed for injuries, Resident #55 complained of left hip pain. The physician was notified and an order was received to send the resident to the emergency room. Injuries observed at the time of the incident was a fracture of the left hip. Predisposing factors of the fall included confusion, impaired memory, gait imbalance, and weakness. Predisposing situational factors included ambulating without assistance. Witnesses to the incident included RN #120 and State Tested Nurse Aide (STNA) #125. STNA #125's statement regarding the fall revealed Resident #55 had walked up to her while she was talking to another resident. She reminded the resident that she needed her walker. The resident then went walking towards her room. She turned around from talking to the other resident and observed Resident #55 on the floor by the nurse's station. She further indicated on a statement given on 09/29/23 that Resident #55 brought her bowl from her snack while she was talking with another resident. She asked the resident where her walker was because she needed to use it. She told the resident she needed to have it. The aide then reported she turned around to finish with the other resident for maybe two seconds and turned back around seeing Resident #55 on the floor. A review of Resident #55's hospital records for her hospital stay between 09/26/23 and 10/02/23 revealed a history and physical from the hospitalist revealed the resident presented to the emergency room for complaints of a fall. She was noted to have fallen from a standing position onto the floor and complained of left hip pain that was worse with movement. A CT scan of her left hip revealed a left femoral neck fracture with superior and anterior displacement of the distal components with compaction. Morphine had been given twice in the ER for pain. Her diagnosis was as indicated on the CT scan. An orthopedic follow up was ordered. The plan was for her to have a left hemiarthroplasty performed on 09/27/23 pending medical clearance and surgical risks were acceptable. On 11/22/23 at 3:00 P.M., an interview with STNA #125 confirmed she was on duty 09/26/23 when Resident #55 had her fall. She reported the resident resided on the front hall of B unit at the time the fall occurred. They had passed her a snack and the resident came walking out of her room to take the bowl back to the snack cart. The snack cart was on the back hall of B unit just past the nurse's station (approximately 65 feet from the resident's room). The aide was on the back hall of B unit talking to another resident when she observed Resident #55 walking without a walker. She reminded the resident she needed to have her walker when ambulating. The resident fell while she was walking back to her room. The aide had her back to the resident when she fell as she continued to talk to the other resident she had previously been engaged in a conversation with. She denied she stopped talking with the other resident to immediately assist Resident #55, after she observed her walking without her walker. She received education from the facility's administrative staff (after the incident occurred) informing her she should have intervened and assisted the resident when she noted her to be walking without her assistive device. The facility's administrative staff also told her she should not have continued talking with the other resident while failing to assist Resident #55 with returning safely to her room. On 11/22/23 at 3:25 P.M., an interview with the Director of Nursing (DON) confirmed Resident #55 did have a fall on 09/26/23 that resulted in a hip fracture. The fall investigation showed Resident #55 fell while ambulating without the use of her walker. STNA #125 observed the resident ambulating without her walker and did not provide the immediate assistance needed to prevent the fall from occurring. They provided education to the aide, as well as all other staff. The education provided included the following: If they see a resident ambulating without an assistive device that was needed, they were to wait with the resident while someone else went to get the assistive device. They were not to tell the resident that they needed to go get the assistive device and leave them (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365450 If continuation sheet Page 9 of 16 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 12/04/2023 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 0689 unattended. Safety was to come first. Level of Harm - Actual harm A review of the facility's Fall Prevention Program policy (revised 10/26/23) revealed each resident would be assessed for the risks of falling and would receive care and services in accordance with the level of risk to minimize the likelihood of falls. Each resident's risk factors and environmental hazards would be evaluated when developing the resident's comprehensive plan of care. Residents Affected - Few 2. Review of the medical record for Resident #44 revealed an initial admission date of 12/27/21 and a re-entry date of 07/16/23. Diagnoses included Bipolar disorder with current episode manic severe with psychotic features, schizoaffective disorder, bipolar type, dementia with other behavioral disturbance, psychotic disorder with delusions, lack of coordination, and need for assistance with personal care. Review of the plan of care (dated 09/14/23) revealed Resident #44 was at risk for falls and/or injuries related to a lack of coordination. Interventions included to encourage to allow staff to carry items when walking, the use of a call light, and to ensure room is free from accident hazards. Review of Resident #44's quarterly Minimum Data Set (MDS) 3.0 assessment (dated 10/16/23) revealed a Brief Interview for Mental Status (BIMS) score of 04 indicating a severely impaired cognition for daily decision making abilities. Resident #44 was also noted to experience hallucinations. Observation of Resident #44 on 11/20/23 at 10:45 A.M. revealed the resident was using an electrical curling iron in private room to curl her own hair with no assistance from facility staff. Continued observation revealed STNA #300 entering Resident #44's room, observing resident in bathroom using electrical curing iron to curl her hair, telling the resident her hair looked nice, and exiting the resident's room. Interview with STNA #300 on 11/20/23 at 10:50 A.M. revealed she didn't know Resident #44 had a curling iron but she thinks one of her family members brought it in for her to use. Interview on 11/20/23 at 11:00 A.M. with the DON revealed no knowledge of the resident having a curling iron but someone would check on this. Observation on 11/20/23 at 11:05 A.M. revealed STNA #302 entering Resident #44's room and shortly after wards exiting the resident's room with the electrical curling iron in his hand. Review of the progress note dated 11/20/23 at 5:06 P.M. created by the DON revealed, Resident noted to have curling iron in room this morning and curling hair. Removed curling iron from room and educated resident we would leave at nurses station and she can come get it daily to curl hair and to have staff help her with this task to prevent any injury. Resident feels she can curl her hair by self and appropriately. Resident did agree to letting us keep the curling iron. Resident was assessed and no injury or anything noted from having curling iron. Medical Director (MD) and responsible party made aware. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365450 If continuation sheet Page 10 of 16 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 12/04/2023 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 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 medical record review and staff interview, the facility failed to obtain ordered weekly weights for nutritional support monitoring. This affected one resident (#15) of the two residents reviewed for nutrition. The facility census was 65. Residents Affected - Few Findings include: Review of the medical record for Resident #15 revealed an initial admission date of 08/09/11 and a re-entry date of 05/26/23. Diagnoses included dementia, dysphasia, muscle weakness, and impaired renal tubular function. Review of Resident #15's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 01 indicating a severely impaired cognition for daily decision making abilities. Resident #15 was noted to be independent with set up only for eating and was noted to weigh 157 pounds. Review of Resident #15's dietary progress note dated 11/08/23 at 12:27 P.M. created by Dietitian #500 revealed a recommendation for weekly weights due to weight decline. Review of Resident #15's orders for November 2023 revealed an order for the resident weight to be obtained weekly. Review of Resident #15's Treatment Administration Record (TAR) for November 2023 revealed the resident's weight had not been obtained on 11/20/23. Interview on 11/25/23 at 2:10 P.M. with the Director of Nursing (DON) confirmed Resident #15 had an order to have her weight obtained weekly and this had not been completed on 11/20/23. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365450 If continuation sheet Page 11 of 16 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 12/04/2023 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 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 record review, observation, staff interview, and policy review, the facility failed to ensure a resident receiving supplemental oxygen had a physician's order to administer oxygen and a physician's order to specify the flow rate in which it was to be received. This affected one resident (#16) of two residents reviewed for respiratory care. Residents Affected - Few Findings include: A review of Resident #16's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included chronic obstructive pulmonary disease (COPD), unspecified asthma, and personal history of Covid-19. A review of Resident #16's active care plans revealed he had impaired pulmonary/ respiratory status related to COPD. The care plan was initiated on 09/26/23. Interventions included administering medications and treatments as ordered. The care plan did not specifically indicate the use of supplemental oxygen as one of the interventions implemented. A review of Resident #16's physician's orders revealed the resident did not have an order to receive supplemental oxygen. The physician's orders reviewed reflected all active orders as of 11/21/23. A review of Resident #16's progress notes revealed there was no documentation indicating he had the use of supplemental oxygen. Progress notes were reviewed from 10/22/23 through 11/21/23. On 11/20/23 at 10:59 A.M., an observation of Resident #16 noted him to be lying in bed in a supine position with his head of the bed (HOB) up. He was noted to be wearing oxygen at 3 liters per minute (LPM) per nasal cannula. On 11/21/23 at 10:06 A.M., further observation of Resident #16 noted him to be lying in bed in a supine position with the HOB up. He continued to wear oxygen at 3 LPM per nasal cannula despite no physician order being in place for the use of supplemental oxygen. On 11/21/23 at 10:08 A.M., an interview with Licensed Practical Nurse (LPN) #100 revealed she was not all that familiar with Resident #16, as she did not work his unit that often. She was not assigned to work with him that day, but the nurse assigned to that unit (Registered Nurse (RN) #110) was not real familiar with him either as she had only recently started working there. She indicated the nurses would be the ones to apply oxygen when it was needed. She was asked what flow rate of oxygen was typically used for someone with COPD. She stated they would start them at 2 LPM and then would see how they did. She acknowledged Resident #16 had oxygen running at 3 LPM without an active physician's order directing the use of supplemental oxygen. On 11/21/23 at 10:09 A.M., an interview with State Tested Nursing Assistant (STNA) #115 revealed Resident #16 always had oxygen on. She indicated he would wear it on and off when his sats (oxygen saturation levels) would go down. On 11/21/23 at 10:10 A.M., an interview with RN #110 revealed she was not really that familiar with Resident #16, as she just started working there not to long ago. She stated the resident had oxygen on when she came on duty that morning. She was not aware of how long he had been wearing oxygen. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365450 If continuation sheet Page 12 of 16 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 12/04/2023 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few She too acknowledged there was not an active physician's order that directed the use of his supplemental oxygen. On 11/21/23 at 10:13 A.M., an interview with the Director of Nursing (DON) revealed residents should have an order for the use of supplemental oxygen. She stated the nurses could apply it (using their own judgement), but they were then to write an order for the use of oxygen. She acknowledged Resident #16's physician's orders did not include an order to apply supplemental oxygen and he had been observed receiving oxygen at 3 LPM per nasal cannula the past couple of days. A review of the facility's Oxygen Administration policy (revised 10/26/23) revealed oxygen was to be administered to residents who needed it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the residents' goals and preferences. Oxygen was to be administered under orders of a physician, except in the case of an emergency. In such a case, oxygen was administered and orders for oxygen were obtained as soon as practicable when the situation was under control. Staff should document the initial and ongoing assessment of the resident's condition warranting oxygen and the response to oxygen therapy. The resident's care plan should identify the interventions for oxygen therapy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365450 If continuation sheet Page 13 of 16 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 12/04/2023 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 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 interviews, the facility failed to ensure as needed antipsychotic medication had an appropriate diagnosis for use and was not administered to residents prior to attempting nonpharmacologic interventions. This affected one resident (#36) of six residents reviewed for unnecessary medications. The facility census was 65. Findings included: Record review revealed Resident #36 was admitted to the facility on [DATE] with diagnoses including stroke, type II diabetes, Crohn's disease, depression, hypertension, dementia, aortic valve stenosis, anxiety disorder, dementia with behaviors, dysphagia, insomnia, atherosclerotic heart disease without angina, fibromyalgia, and gastroesophageal reflux disease. Review of orders revealed Resident #36 had orders in place for a mood stabilizer, depakote 250 milligrams (mg), and an anti-anxiety medication, ativan 0.5 mg. Review of quarterly minimum data set (MDS) from 10/11/23 revealed Resident #36 had impaired cognition and physical behaviors four to six days a week. Review of the care plan revealed Resident #36 had behaviors of anxiety, tearful, difficulty sleeping, exit seeking, verbally and physically aggressive behaviors, false allegations against staff, and interventions included offer calm reassuring touch, offer food or fluids, provide activities which were care planned on 11/02/22. The care plan also revealed the resident had behaviors of refusals of care with interventions including approaching resident in a calm manner to avoid frustration and behavior escalation, and if resident becomes agitated and shows sign of escalation to re-approach later which was care planned on 08/08/23. Review of nursing note dated 08/03/23 at 5:03 P.M. by Licensed Practical Nurse (LPN) #135 revealed Resident #36 was exit seeking in the lobby, staff redirected her back to her room. Once Resident #36 was back in her room, she began to wander again. Staff informed resident the facility was her home which agitated Resident #36 and she began swinging at staff and trying to kick. Staff continued to talk to resident causing further agitation. Staff notified the Medical Director (MD) of Resident #36's behaviors. An order was given for an antipsychotic, Haldol, five milligrams (mg) intramuscular (IM) one dose. Review of nursing note dated 08/17/23 at 5:33 P.M. by LPN #140 revealed Resident #36 was exit seeking and stated she wanted to go home. Once staff redirected resident back to her room, she began exhibiting combative behaviors. Staff provided one to one intervention, offered food, and attempted redirection which agitated Resident #36 more. The MD was notified and a new order was given for Haldol five mg IM one dose. Review of nursing note dated 09/12/23 at 4:45 P.M. by LPN #100 revealed Resident #36 was self-propelling throughout the facility in her wheelchair. Resident #36 was sitting in front of the administrator's office and made comments directed towards him. Resident #36 then switched to exit seeking. The MD was notified and a new order was received for Haldol five mg IM. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365450 If continuation sheet Page 14 of 16 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 12/04/2023 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of nursing note from 09/16/23 at 12:17 P.M. by LPN #135 revealed Resident #36 left her room so she could go home, staff took resident back to her room and attempted to redirect her which was unsuccessful. Staff attempted to get Resident #36 to talk about why she was upset and resident threw a remote control and had verbal behaviors toward staff. An STNA entered Resident #36's room to deliver a lunch tray, the resident knocked the lid off the tray and when staff went to retrieve the lid, resident hit the aide. Staff attempted redirection which was unsuccessful. MD was notified and staff received a new order to administer Haldol five mg IM. Review of nursing note from 09/19/23 at 11:25 P.M. by Registered Nurse (RN) #120 revealed Resident #36 was exit seeking with increased aggression, was very restless, and refusing care from staff. MD was notified and a new order was received for 20 mg IM of Geodon (antipsychotic). Interview on 11/21/23 at 1:04 PM with LPN #140 revealed if a resident is being combative, staff is to remove them from the area, offer food and fluids, a distraction, and if they are not in an area which would be of harm to themselves or others to leave them alone and allow them to calm down. If Resident #36 states she wants to go home, LPN #140 tries to distract her or offer her a sweet snack. Staff notify the MD if there are behaviors because it could be a clinical issue such as a urinary tract infection. LPN #140 stated it is rare to use IM medications unless behaviors create a risk for the resident or others. LPN #140 stated regarding the incident with Resident #36 it does not appear other nonpharmacologic interventions were attempted prior to the administration of the antipsychotic, but Resident #36 was on droplet precautions due to suspected case of COVID-19 and if she would have been working and a resident on precautions was wandering and exhibiting behaviors, she would administer the medication because she would be a danger to others. Regarding the 09/12/23 incident, LPN #140 stated Resident #36 had been kicking but she forgot to document it. Interview on 11/21/23 at 2:34 PM with the Director of Nursing (DON) revealed she did not believe the nursing notes documenting administration of antipsychotic medications to Resident #36 did provide enough information to show the need of use for antipsychotic medications. Interview on 11/22/23 at 10:22 AM with the DON revealed new interventions regarding behaviors were not added to plan of care for each incident and the staff did not attempt all care planned interventions prior to administration of antipsychotic medications for Resident #36. Interview on 11/29/23 at 9:59 A.M. with the Medical Director (MD) revealed if a resident is wandering, it depends on the situation but it could be appropriate for them to receive an injection of an antipsychotic for wandering if they could escape or wander into resident rooms. If a resident is agitated, MD stated he will try to tell the staff to leave them alone and let them cool down if they aren't a harm to themselves, then re-evaluate. MD stated he has to assume if he is being asked for an injection, it is the last resort since he is not present, and he never offers injections unless the facility specifically requests them because it should be a last resort. MD stated he educated staff regarding injection use and how they should not be used if a resident is having verbal behaviors, is wandering or going to the door constantly because that happens daily in a nursing facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365450 If continuation sheet Page 15 of 16 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 12/04/2023 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 0881 Implement a program that monitors antibiotic use. 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, facility failed to ensure a resident received an antibiotic for an appropriate diagnosis. This affected one resident (#223) of six residents reviewed for antibiotic stewardship. The facility census was 65. Residents Affected - Few Findings included: Record review revealed Resident #223 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), paraplegia, chronic kidney disease stage 3, type II diabetes, gastro-esophageal reflux disease, hypertension, dysphagia, insomnia, flaccid neuropathic bladder, emphysema, and atrial fibrillation. Review of progress notes revealed Resident #223 was seen by Medical Director (MD) on 06/26/23 for a regulatory visit. MD stated Resident #223 had complaints of being short of breath with movement, is oxygen dependent at baseline, and has a diagnosis of chronic obstructive pulmonary disease. During the visit, Resident #223's vitals were stable, had no congestion, and respiratory system was diminished to bilateral lower lobes. MD ordered 250 milligrams of zythromax, an antibiotic, and did not specify the reason for the order. Review of McGeer's criteria for antibiotic stewardship completed on 06/27/23 stated Resident #223 was receiving an antibiotic prophylactically, and comment stated, prophylactic use due to resident co-morbidities and advanced COPD, benefits outweigh the risks. Interview on 11/29/23 at 3:42 P.M. with Interim Director of Nursing revealed there was no further documentation to support the need for antibiotic use for Resident #223. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365450 If continuation sheet Page 16 of 16