Inspection·February 12, 2022

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few This resident was assessed to require extensive assistance from two staff members for bed mobility and toileting, extensive assistance from one staff member for transfers, and physical help from one staff member for bathing. Review of the care plan, dated 01/11/22, revealed this resident needed Activities of Daily Living (ADL) assistance. Interventions included to provide extensive assistance with personal hygiene. Review of the facility Preferences for Customary Routine and Activities-Section F Assessment, dated 07/12/21, revealed this resident preferred to have a shower three times a week in the evening and it was very important for the resident to choose her schedule. Review of the State Tested Nursing Assistant (STNA) task bar revealed this resident was scheduled to receive a shower on Monday and Thursday on day shift. Review of the STNA documentation of showers provided from 12/10/21 through 02/10/22 revealed this resident received a shower on Friday 12/10/21, received a shower on Monday 12/13/21, refused a shower on Wednesday 12/15/21, received a shower on Monday 12/20/21, received a shower on Wednesday 12/22/21, received a shower on Wednesday 12/29/21, received a shower on Thursday 01/13/22, received a shower on Wednesday 01/19/22, and received a shower on Wednesday 02/02/22. Interview with Resident #4 on 02/07/22 at 12:20 P.M. revealed the resident was not receiving showers according to her preferred schedule. Interview with the Director of Nursing on 02/10/22 at 2:45 P.M. verified the shower preference for Resident #4 had been documented on 07/12/21 as three times a week in the evening on the Preferences for Customary Routine and Activities-Section F Assessment but the resident was scheduled to receive showers on Mondays and Thursdays during day shift. Interview with Resident #4 on 02/10/22 at 3:00 P.M. verified she had been interviewed regarding her preferences shortly after admission to the facility and had verbalized she wished to receive showers three times a week in the evenings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365474 If continuation sheet Page 2 of 43 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 365474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Carroll 3680 Dolson Court NW Carroll, OH 43112 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 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the medical record for Resident #52 revealed an admission date of 11/05/21 with diagnoses including Alzheimer's disease, adult failure to thrive, chronic obstructive pulmonary disorder, weakness, lack of coordination, anxiety, schizoaffective disorder, Parkinson's disease and need for assistance with personal care. Residents Affected - Few Review of the quarterly MDS dated [DATE] revealed Resident #52 had cognitive impairment with no behaviors. Resident #52 required extensive physical assistance of one person for bed mobility, dressing, toileting and personal hygiene. Resident #52 required limited assistance of one person for transfers. The resident was not coded for a personal alarm. Review of the fall risk assessment dated [DATE] indicated Resident #52 was at high risk for falls. Review of the incident report for Resident #52 fall on 02/05/22 revealed the nurse found Resident #52 seated on the floor beside her bed. There was no injury noted, neurological assessments were initiated and the nurse put a mat to the floor at bedside while in the bed. Review of the nursing progress notes from 02/05/22 through 02/08/22 indicated follow up on Resident #52 post fall revealed no concerns or injury. A progress note dated 02/05/22 at 3:45 P.M. of the initial assessment of the resident fall indicated the intervention was a pull tab alarm to the resident's wheelchair. Review of the physician orders for 02/22 revealed no order for a tab alarm to Resident #52 wheelchair. Review of the medical record of Resident #52 revealed no restraint assessment for the use of a pull tab alarm to her wheelchair. Review of the plan of care for at risk for falls was also silent on the use of a pull tab alarm to Resident #52 wheelchair. An observation on 02/08/22 at 1:42 P.M. and on 02/08/22 at 4:30 P.M. revealed Resident #52 had a pull tab alarm to wheelchair. This was confirmed with STNA #122. An observation on 02/09/22 at 8:53 A.M. revealed the pull tab alarm to Resident #52 wheelchair was removed. An interview on 02/09/22 at 8:56 A.M. with LPN #128 revealed the pull tab alarm to Resident #52 was discontinued on 02/08/22. An interview on 02/09/22 at 9:05 A.M. with the DON confirmed the pull tab alarm to Resident #52 wheelchair was placed on the wheelchair as an intervention to the fall on 02/05/22. Also confirmed there was not a restraint assessment completed on Resident #52 or a physician order written. However, the Interdisciplinary Team (IDT) discussed the alarm and decided it was not an appropriate intervention for the resident's fall and the alarm was discontinued and removed. An interview on 02/09/22 at 2:12 P.M. with the DON revealed the facility did not have a policy on alarms or restraints. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365474 If continuation sheet Page 3 of 43 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 365474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Carroll 3680 Dolson Court NW Carroll, OH 43112 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 0604 Level of Harm - Minimal harm or potential for actual harm Based on staff interview, observations, medical record review, facility policy review, and review of the Centers for Medicare & Medicaid Services, the facility failed to assess, obtain Physician orders, and care plan personal alarms. This affected three Residents (#5, #52, #30) of seven residents reviewed for alarms. The facility census was 76. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #5 revealed an admission date of 11/03/21. Diagnoses included palliative care, muscle weakness, unspecified fall, abnormalities of gait and mobility, cognitive communication deficit, unsteady on his feet, and Dementia without behavioral disturbance. Review of the physician orders revealed an order dated 11/03/21 for a bed and chair alarm to be in place for 14 days and then to reevaluate the resident. The order was discontinued on 11/16/21. Review of the physician orders revealed an order for a pressure sensor alarm to his wheelchair to alert staff if the resident attempts to transfer unassisted and staff was to check placement and functioning every shift. The order date was 11/04/21, the start date was 02/09/22, and the discontinue date was 02/09/22. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 11/10/21, revealed the resident had impaired cognition with a Brief Interview of Mental Status (BIMS) score of four out of 15 indicating severe cognitive impairment. He required limited to extensive assistance of one to two staff members for Activities of Daily Living (ADL's). His behaviors included inattention, disorganized thinking, and other behavioral symptoms not directed towards others. Review of the physician orders revealed an order dated 11/16/21 for a bed and chair alarm in place starting 11/16/21. The order was discontinued on 11/29/21 with the reasoning being the resident was not compliant with alarm and therapy agreed the residents safety not at risk in his room. Review of the progress notes for November 2021, December 2021, January 2022, and February 2022 revealed the resident suffered numerous falls but had no noted behaviors. Review of the physician orders revealed an order for a chair alarm to be in place. The start and order dates were 11/29/21 and the discontinue date was 12/21/21. Review of the plan of care dated 01/23/22 revealed the resident was at risk for falls related to history of falls, weakness, poor safety awareness, and unsteady gait. Interventions included fall interventions but did not mention any bed or chair alarms. Interview on 02/09/22 at 10:01 A.M. with Licensed Practical Nurse (LPN) #129 revealed the resident had a chair alarm over the weekend (Saturday and Sunday) but upon her arrival for her shift today, he did not have an alarm. Interview on 02/09/22 at 10:31 A.M. with the Director of Nursing (DON) revealed she was unsure if assessments were completed prior to initiating an alarm. She also stated she knew after 14 days with an alarm the resident was reevaluated in the facility's morning meeting but did not know if it was documented any where. She stated she would provide the facility's policy for review. She also confirmed Resident #5 had a chair alarm intact and functioning on 02/07/22 and 02/08/22. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365474 If continuation sheet Page 4 of 43 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 365474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Carroll 3680 Dolson Court NW Carroll, OH 43112 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 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 02/07/22 at approximately 11:00 A.M. the resident was observed transferring himself from the bed to the wheelchair and then going to the bathroom and setting off his chair alarm. Staff entered the room to assist the resident and turn the alarm off. There were no assessments regarding the need for restraints/alarms. Assessments of the resident's need for the alarms were requested from the DON on 02/09/22 at 3:14 P.M. Interviews on 02/09/22 at 2:12 P.M. and 3:14 P.M. with the DON revealed the facility does not have an alarm policy. She also confirmed she would have to check with corporate to figure out how a resident need for an alarm was assessed. She confirmed she would obtain the appropriate assessments needed prior to the initiation of an alarm. Interview on 02/10/22 at 4:10 P.M. with Regional Nurse #8000 and the DON confirmed there were no assessments completed for Resident #5 prior to initiating the alarm. Review of the webpage titled Restraint/seclusion Interpretive Guidelines and Updated SOM Appendix A on CMS.gov, website for the Centers for Medicare & Medicaid Services, bed and chair alarms, or any position change alarms which make an audible noise near the resident, as a restraint. 2. Review of the medical record for Resident #30 revealed an admission date of 12/29/21 and discharge date of 02/07/22. Diagnoses included unspecified fall, major depressive disorder, anxiety disorder, disorientation, unsteadiness on his feet, cognitive communication deficit, weakness, reduced mobility, muscle weakness, lack of coordination, and insomnia. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 01/05/22, revealed the resident had intact cognition with a Brief Interview of Mental Status (BIMS) score of 13 out of 15 (cognitively intact). He required extensive assistance of one to two or more staff for Activities of Daily Living (ADL's) and he exhibited other behavioral symptoms not directed towards others. Review of the assessments from 12/01/21 through 02/07/22 revealed there were no assessments regarding the need for a restraint or alarm. Assessments of the resident's need for the alarms were requested from the DON on 02/09/22 at 3:14 P.M. Review of the progress notes for December 2021, January 2022, and February 2022 revealed the resident suffered numerous falls but had no noted behaviors. Review of physician orders dated 12/29/21 revealed an order for a bed alarm to alert staff of unassisted transfers. Review of the plan of care dated 12/29/21 revealed the resident was at risk for falls related to history of falls, weakness, and confusion. Interventions included the resident should wear nonskid footwear when in bed for safety should the resident get out of bed without assistance, the resident uses a bed alarm, and mat to the bedside floor at night. Further review of the care plan revealed the resident used bed and chair alarms. The interventions included discuss and document the risks and benefits, when the personal alarm will be used, routine modifications, and any other concerns or issues related to personal alarm use with the resident/resident representative. Observation and interview on 02/07/22 at 10:22 A.M. revealed Resident #30 was sitting up on the edge of the bed with bilateral bare feet on the floor and an alarm to his motorized wheelchair. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365474 If continuation sheet Page 5 of 43 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 365474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Carroll 3680 Dolson Court NW Carroll, OH 43112 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 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the physician orders for February 2022 revealed an order for a bed alarm to the resident bed to alert staff of unassisted transfers every day and night shift for safety starting 12/29/2021. The order was discontinued on 02/07/22 which was also the day the resident was discharged to the community. Review of the Electronic Medical Record/Treatment Administration Record (EMAR/ETAR) for February 2022 revealed all physician's order for a bed alarm to the resident bed to alert staff of unassisted transfers every day and night shift for safety was signed off per orders. Interview on 02/09/22 at 10:01 A.M. with Licensed Practical Nurse (LPN) #129 revealed the resident had a chair alarm over the weekend (Saturday and Sunday) but upon her arrival for her shift today, he did not have an alarm. Interview on 02/09/22 at 10:31 A.M. with the DON revealed she confirmed Resident #30 had a bed alarm intact and functioning on 02/07/22. Interviews on 02/09/22 at 2:12 P.M. and 3:14 P.M. with the DON revealed the facility does not have an alarm policy policy. She also confirmed she would have to check with cooperate to figure out how a resident need for an alarm was assessed. She confirmed she would obtain the appropriate assessments needed prior to the initiation of an alarm. Interview on 02/10/22 at 4:10 P.M. with Regional Nurse #8000 and the DON confirmed there were no assessments completed for Resident #30 prior to initiating the alarm. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365474 If continuation sheet Page 6 of 43 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 365474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Carroll 3680 Dolson Court NW Carroll, OH 43112 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide a written Notice of Transfer for one former resident's (Resident #69) hospitalization. The deficient practice affected one resident (Resident #69) out of one reviewed for hospitalization. The facility census was 76. Findings Include: Review of the medical record for former Resident #69 revealed an admission date of 10/28/21 and discharge date of 11/30/21. Medical diagnoses included methicillin resistant staphylococcus aureus infection (MRSA), stage four pressure ulcer of sacral region, cellulitis, presence of left artificial hip joint, and chronic pain. Review of the five day Medicare Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #69 had mildly impaired cognition and scored a 13 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. The resident required extensive assistance from one to two staff to complete Activities of Daily Living (ADLs). Review of the discharge MDS 3.0 assessment dated [DATE] revealed Resident #69 was discharged on 11/30/21 to the hospital with return not anticipated. Review of the nurse's note dated 11/30/21 revealed Resident #69 became unresponsive to verbal commands during a therapy session. The resident also was not able to follow with eyes and was looking off to the right side. Resident #69 became reactive to verbal and tactile stimuli after one to two minutes. The resident's smile was drooping to the left side. Resident #69's husband and the physician were notified. Emergency Medical Services (EMS) was called immediately and the resident was transported to a local hospital. Report was called in to the hospital. There was no evidence in the medical record that a written notice of transfer was provided to Resident #69 or the resident's representative. Interview via email on 02/10/22 at 3:42 P.M. with the Administrator confirmed a written notice of transfer was not completed or provided to Resident #69 or the resident's representative. The Administrator confirmed this was a deficient area that was identified by the facility's corporate team prior to the annual survey but a new process had not been implemented yet. Review of the facility policy, Transfer and Discharge, revised 02/28/20, stated, for emergency transfers, the facility will complete and send with the resident (or provide as soon as practicable) a Transfer Form which documents the resident's status, current diagnoses, allergies, reasons for transfer, contact information of the practitioner responsible for the care of the resident, resident representative information including contact information, current medications, treatments, most recent relevant lab and/or radiological findings, recent immunizations, special instructions or precautions for ongoing care to include precautions such as isolation or contact, special risks such as risk of falls, comprehensive care plan goals, and any other documentation as applicable to ensure a safe and effective transition of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365474 If continuation sheet Page 7 of 43 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 365474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Carroll 3680 Dolson Court NW Carroll, OH 43112 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 interview, record review and review of the facility policy the facility failed to complete an accurate Preadmission Screening and Resident Review (PASRR) including all mental health diagnoses. This affected two of two residents reviewed for PASRR (Resident #21 and #39). The facility census was 76. Findings include: 1. Review of the medical record for Resident #39 revealed an admission date of 09/29/16 with diagnoses type two diabetes mellitus, morbid obesity, acquired absence of left leg above the knee, depression, anxiety and seizure disorder. On 03/29/17 the diagnosis of personality disorder was added, on 05/08/17 the diagnosis of mood disorder was added and on 05/27/21 the diagnosis of schizophrenia was added. Review of the quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #39 was cognitively intact with no behaviors noted. Resident #39 expressed symptoms of depression including feeling down, trouble sleeping, feeling tired, feeling bad about self and trouble concentrating. The resident had the following diagnoses; anxiety, depression, schizophrenia and mood disorder. Review of the physician orders for 02/22 revealed Resident #39 received the following medications; Venlafaxine Hydrochloride (HCL) extended release (ER) an antidepressant, Perphenazine an antipsychotic and Bupropion HCL ER an antidepressant. Review of the initial PASRR for Resident #39 dated 06/13/17 revealed no mental health diagnoses and level two assessment was not applicable. On 05/27/21 Resident #39 received the diagnoses of schizophrenia. There was not a new PASRR completed for Resident #39. An interview on 02/09/22 at 3:43 P.M. with the admission Director confirmed the facility did not complete a new PASRR on Resident #39 with new mental health diagnoses. The facility did not provide a policy related to PASRR. 2. Review of the medical record for Resident #21 revealed an initial admission date of 08/04/20 and a re-admission date of 04/07/21. Diagnoses included anxiety disorder, Dementia with Behavioral disturbances, bipolar disorder, schizoaffective bipolar disorder, and major depressive disorder. Review of the PASRR dated 08/04/20 revealed it was from the hospital. Review of the PASRR dated 09/09/20 revealed it was completed upon the resident's admission. Review of the plan of care dated 08/05/20 revealed she had the potential to be verbally aggressive, rude, and belligerent. Interventions included administration of medications per orders, monitor/document for side effects and effectiveness, and allow the resident time to express herself and feelings towards the situation. Review of the plan of care dated 08/05/20 revealed the resident was resistive to care and medications at times related to Dementia. Interventions included psychiatric evaluation as needed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365474 If continuation sheet Page 8 of 43 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 365474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Carroll 3680 Dolson Court NW Carroll, OH 43112 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 Review of the plan of care dated 08/05/20 revealed the resident uses antianxiety medications. Interventions included administration of anti-anxiety medications per orders and monitor/document for side effects and effectiveness. Review of the plan of care dated 08/05/20 revealed the resident used antidepressant medication. Interventions included administration of antidepressant medications as ordered and monitor/document for side effects and effectiveness. Review of the plan of care dated 08/05/20 revealed the resident received antipsychotic medication related to dementia with behavioral disturbances, wandering, crawling on the floor, refusing care, delusions, hallucinations and paranoia. interventions included administration of medications as ordered and monitor/document for side effects and effectiveness. Review of the plan of care dated 08/05/20 revealed the resident used psychotic medications. Interventions included administration of psychotropic medications as ordered by the physician, monitor for side effects/effectiveness every shift, discuss with the Medical Director (MD) and family the ongoing need for the use of the medication, review behaviors/interventions and alternate therapies attempted and their effectiveness as per the facility policy. Review of the medical diagnoses revealed the diagnosis schizoaffective Bipolar disorder was added on 08/06/21. There was no PASRR completed after 09/09/20. Review of a physician order dated 08/06/21 revealed the resident began taking an extended release Brupropion hydrochloride 300 milligram (tablet) by mouth in the morning for depression. She was already ordered to take one 30 mg tablet of abilify (antipsychotic) every morning for dementia with behavioral disturbance and Xanax 0.25 mg tablet three times per day for anxiety disorder prior to the new diagnosis on 08/06/21. Review of the quarterly Minimum Data Set (MDS) assessment, dated 12/13/21, revealed the resident had impaired cognition with a Brief Interview of Mental Status (BIMS) score of three out of 15 indicating severe cognitive impairment and no documented behaviors. She required limited to extensive assistance of one to two staff members for Activities of Daily Living (ADL's). Review of the careplan dated 01/12/22 revealed the resident had the potential to be verbally aggressive, rude, and had belligerent vocalizations. Interventions included administration of medications as ordered, assess and anticipate the resident's needs, assess the resident's understanding of the situation, and allow time for the resident to express herself and her feelings towards the situation. Further review of the careplan revealed the resident was resistive to care/medications at time due to Dementia. Interventions included education, encouragement to participate in her own care, providing opportunities for the resident to self choose, and psychiatric evaluations as needed. Interview on 02/09/22 at 3:06 P.M. with admission Director #7000, revealed she was completing Preadmission Screening and Resident Reviews (PASRR) while the facility did not have a Social Worker. She confirmed Resident #21 should have had completed a new PASRR/trigger a level two when diagnosed with schizoaffective bipolar disorder on 08/06/21. Review of the facility policy titled, PASRR Preadmission Screen and Resident Review dated 10/18/20 revealed a PASRR should be completed with a new diagnosis. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365474 If continuation sheet Page 9 of 43 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 365474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Carroll 3680 Dolson Court NW Carroll, OH 43112 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 observation, record review, interview and facility policy review, the facility failed to develop a comprehensive plan of care for three residents (Residents #12, #55 and #60) in the areas of fluid restriction, behaviors and oxygen. This affected three of 24 sampled residents reviewed. Findings Include: 1. Review of Resident #12's medical record revealed an admission date of 11/21/21. Diagnoses included disruption of wound, right above knee amputation, diabetes mellitus, end stage renal failure with dependence on renal dialysis, atrial fibrillation, history of COVID-19, major depressive disorder, ischemic cardiomyopathy, peripheral vascular disease, hypertension, hyperlipidemia, congestive heart failure and anemia. Review of the resident's comprehensive MDS 3.0 assessment dated [DATE] revealed the resident had clear speech, understood others, made himself understood and had no cognitive deficit as indicated by a BIMS score of 14. The resident requires supervision with ADL. The assessment indicated the resident received dialysis services. Review of the resident's February 2022 physician's orders identified orders dated 11/26/21 for a 1,000 milliliter (ml) fluid restriction daily with the special instructions for nursing to give 400 ml every shift. Review of the resident's comprehensive plan of cares failed to identify a plan of care addressing the physician ordered fluid restriction. On 02/10/22 at 11:05 A.M. interview with the Director of Nursing (DON) verified the resident lacked of a plan of care addressing the fluid restriction. 2. Review of Resident #60's medical record revealed an initial admission date of 01/07/21 with the latest readmission of 03/21/21. Diagnoses included dementia with behavioral disturbances, anxiety disorders, mood disorder, hypertension, major depressive disorder with psychotic symptoms, pain, restlessness and agitation, history of COVID-19, gastro-esophageal reflux disease, lactose intolerance and insomnia. Review of the resident's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had clear speech, understood others, makes herself understood and had a moderate cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of seven. Review of the mood and behavior revealed the resident had indicators of depression and wandered daily. The assessment indicated the resident received antipsychotic, antianxiety and hypnotic medications on a routine basis. Review of the resident' physician's orders for February 2022 identified an order dated 01/15/22 Zyprexa (a medication used to treat behaviors) 2.5 mg by mouth every day for dementia with behavioral disturbances and 01/19/22 for Zyprexa 5 mg by mouth at bedtime for dementia with behavior disturbances. Review of the resident's comprehensive plan of care failed to identify a plan of care addressing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365474 If continuation sheet Page 10 of 43 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 365474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Carroll 3680 Dolson Court NW Carroll, OH 43112 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 the resident's behavior to support the use of the medication Zyprexa. Level of Harm - Minimal harm or potential for actual harm On 02/10/22 at 11:05 A.M. interview with the Director of Nursing (DON) verified the resident lacked of a plan of care addressing the resident's behavior to support the use of the medication Zyprexa. Residents Affected - Few 3. Record review for Resident #55 revealed this resident was admitted to the facility on [DATE] and had diagnoses including schizophrenia, depression, anxiety, and COVID-19. Review of the quarterly MDS assessment, dated 01/07/22, revealed this resident had mildly impaired cognition evidenced by a BIMS assessment score of 12. This resident was assessed to require supervision for bed mobility, transfers, and toileting. This resident was assessed to have not received oxygen therapy. Review of the active care plans for this resident revealed an absence of a care plan for respiratory care or oxygen use. Review of the active physician's order for Resident #55 revealed an order, dated 02/07/22, for oxygen to be administered at two liters a minute as needed. Observation on 02/07/22 at 10:17 A.M. revealed Resident #55 had an oxygen concentrator in place at bedside. The nasal cannula tubing was observed to be dated 02/01/22. Interview with State Tested Nursing Aide (STNA) #165 on 02/07/22 at 10:17 A.M. verified the oxygen concentrator and tubing belonged to Resident #55 and the resident used oxygen at times. Interview with Resident #55 on 02/07/22 at 10:21 A.M. verified she used the oxygen at times when she was having difficulty breathing. Interview with the Director Of Nursing on 02/10/22 at 3:45 P.M. verified Resident #55 did not have a care plan in place regarding respiratory care or the use of oxygen. Review of the facility policy titled Oxygen Administration, revised on 06/02/21, revealed the resident's care plan should identify the interventions for oxygen therapy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365474 If continuation sheet Page 11 of 43 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 365474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Carroll 3680 Dolson Court NW Carroll, OH 43112 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** 2. Review of the medical record for Resident #52 revealed an admission date of 11/05/21 with diagnoses including Alzheimer's disease, adult failure to thrive, chronic obstructive pulmonary disorder, schizoaffective disorder and Parkinson's disease. Review of the quarterly MDS dated [DATE] revealed Resident #52 had cognitive impairment with no behaviors. The resident required extensive assistance of one person for bed mobility, dressing, toileting and personal hygiene. The resident required limited assistance of one person for transfers and supervision for walking in her room. The resident had no recent falls or skin impairments. Review of the physician orders for 02/22 revealed Resident #52 did not have an order to monitor the bruise noted to her left eyebrow and forehead. Review of the fall assessment dated [DATE] indicated Resident #52 was found sitting on the floor beside her bed. The nurse completed an assessment and found no injury. Review of the nursing progress notes from 02/05/22 through 02/08/22 revealed no documentation of the bruise to Resident #52 left eyebrow and forehead. Review of the plan of care revealed the fall and skin care plans were silent on the injury/bruise to Resident #52 left eyebrow/forehead from the fall on 02/05/22. Observations of Resident #52 from 02/07/22 through 02/09/22 revealed the resident had a purple with brown edges bruise to the left eyebrow/forehead area. An interview on 02/09/22 at 8:56 A.M. with Licensed Practical Nurse (LPN) #128 revealed the bruise was being monitored however failed to provide any documentation of the monitoring. An interview on 02/09/22 at 2:12 P.M. with the Director of Nursing (DON) confirmed the bruise to Resident #52 left eyebrow and forehead area was not being monitored and there was no mention of the bruise in the resident's plan of care. Based on staff interview, medical record review, and facility policy review, the facility failed to revise care plans in the areas of bruising following a fall and alarms. This affected two Residents (#5 and #52) of 24 residents reviewed for care plans. The facility census was 76. Findings include: 1. Review of the medical record for Resident #5 revealed an admission date of 11/03/21. Diagnoses included palliative care, muscle weakness, unspecified fall, abnormalities of gait and mobility, cognitive communication deficit, unsteady on his feet, and Dementia without behavioral disturbance. Review of the physician orders revealed an order dated 11/03/21 for a bed and chair alarm to be in place for 14 days and then to reevaluate the resident. The order was discontinued on 11/16/21. Review of the physician orders revealed an order for a pressure sensor alarm to his wheelchair to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365474 If continuation sheet Page 12 of 43 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 365474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Carroll 3680 Dolson Court NW Carroll, OH 43112 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 alert staff if the resident attempts to transfer unassisted and staff was to check placement and functioning every shift. The order date was 11/04/21, the start date was 02/09/22, and the discontinue date was 02/09/22. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 11/10/21, revealed the resident had impaired cognition with a Brief Interview of Mental Status (BIMS) score of four out of 15 indicating severe cognitive impairment. He required limited to extensive assistance of one to two staff members for Activities of Daily Living (ADL's). His behaviors included inattention, disorganized thinking, and other behavioral symptoms not directed towards others. Review of the physician orders revealed an order dated 11/16/21 for a bed and chair alarm in place starting 11/16/21. The order was discontinued on 11/29/21 with the reasoning being the resident was not compliant with alarm and therapy agreed the resident's safety not at risk in his room. Review of the physician orders revealed an order for a chair alarm to be in place. The start and order dates were 11/29/21 and the discontinue date was 12/21/21. Review of the Skin assessment dated [DATE] revealed the resident had deep purple bruising on the left hip. The assessment did not have measurements but indicated x-rays were ordered. Review of the progress note dated 12/07/21 at 2:15 P.M. by Registered Nurse (RN) #159 revealed the resident suffered a fall and had deep purple bruising and swelling. Review of the progress note dated 12/07/21 at 9:15 P.M. by Unit Manager (UM) RN #119 revealed the resident's hip was without changes. Review of the progress note dated 12/08/21 at 10:32 A.M. MDS Licensed Practical Nurse (LPN) #999 revealed monitoring of the bruising to the resident's left hip was to occur. Review of the progress note dated 12/08/21 at 5:31 P.M. by RN #159 revealed the resident's daughter was updated on the resident's hip being bruised and swollen. Review of the physician orders revealed an order to monitor bruising to left hip every shift until healed was ordered on 12/08/21. The order was discontinued on 12/26/21. Review of the progress note dated 12/14/21 at 5:08 P.M. revealed the resident's Xarelto was discontinued due to the resident being a fall risk to help with bruising and the hip remained with a quite a bit of bruising. Review of the Skin Assessments dated 12/14/21, 12/25/21, 01/03/22, 01/12/22, 01/19/22, and 01/26/22 revealed the resident did not have any new or existing abnormal skin conditions. Review of the plan of care dated 01/23/22 revealed the resident was at risk for falls related to history of falls, weakness, poor safety awareness, and unsteady gait. Interventions included fall interventions but did not mention any bed or chair alarms or bruise monitoring. Review of the Skin assessment dated [DATE] revealed the resident did not have any new or continued skin conditions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365474 If continuation sheet Page 13 of 43 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 365474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Carroll 3680 Dolson Court NW Carroll, OH 43112 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 Interview on 02/09/22 at 10:31 A.M. with the DON confirmed Resident #5 had a chair alarm intact and functioning on 02/07/22 and 02/08/22 and a bruise that was to be monitored on his hip following a fall. Interviews on 02/09/22 at 2:12 P.M. and 3:14 P.M. with the DON confirmed Resident #5 did not have an updated careplan to reflect his alarms or bruise monitoring. Residents Affected - Few Review of the facility policy titled, Care Plan Process undated, revealed care plans should be revised with any changes affecting the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365474 If continuation sheet Page 14 of 43 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 365474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Carroll 3680 Dolson Court NW Carroll, OH 43112 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of the medical record for Resident #52 revealed an admission date of 11/05/21 with diagnoses including Alzheimer's disease, adult failure to thrive, chronic obstructive pulmonary disorder, schizoaffective disorder and Parkinson's disease. Residents Affected - Some Review of the quarterly MDS dated [DATE] revealed Resident #52 had cognitive impairment with no behaviors. The resident required extensive assistance of one person for bed mobility, dressing, toileting and personal hygiene. The resident required limited assistance of one person for transfers and supervision for walking in her room. The resident had no recent falls or skin impairments. Review of the physician orders for 02/22 revealed Resident #52 did not have an order to monitor the bruise noted to her left eyebrow and forehead. Review of the fall assessment dated [DATE] indicated Resident #52 was found sitting on the floor beside her bed. The nurse completed an assessment and found no injury. Review of the nursing progress notes from 02/05/22 through 02/08/22 revealed no documentation of the bruise to Resident #52 left eyebrow and forehead. Review of the plan of care revealed the fall and skin care plans were silent on the injury/bruise to Resident #52 left eyebrow/forehead from the fall on 02/05/22. Observations of Resident #52 from 02/07/22 through 02/09/22 revealed the resident had a purple with brown edges bruise to the left eyebrow/forehead area. An interview on 02/09/22 at 8:56 A.M. with Licensed Practical Nurse (LPN) #128 revealed the bruise was being monitored, however failed to provide any documentation of the monitoring. An interview on 02/09/22 at 2:12 P.M. with the Director of Nursing (DON) confirmed the bruise to Resident #52 left eyebrow/forehead was not being monitored or documented in the nursing notes. The DON also stated the facility did not have a policy on monitoring of bruises. 3. Review of the medical record for Resident #320 revealed an admission date of 01/25/22. Medical diagnoses included intrahepatic bile duct carcinoma, secondary malignant neoplasm of liver and intrahepatic bile duct, chronic obstructive pulmonary disorder (COPD), and encounter for palliative care. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had mildly impaired cognition and scored a 12 out of 15 on the Brief Interview for Mental Status (BIMS). The resident required supervision from one staff to complete Activities of Daily Living (ADLs). The resident received hospice care. Review of the current physician's orders for February 2022 revealed Resident #320 had an order to admit to hospice with a start date of 01/25/22. Review of the nurse's notes from admission to current revealed there were not any notes related to hospice services provided to Resident #320. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365474 If continuation sheet Page 15 of 43 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 365474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Carroll 3680 Dolson Court NW Carroll, OH 43112 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the plan of care dated 01/26/22 revealed Resident #320 was a Do Not Resuscitate Comfort Care (DNRCC) code status. Interventions included hospice services with a contracted hospice agency. Interview on 02/08/22 at 5:59 P.M. with the Administrator confirmed hospice communication notes were not included as a part of Resident #320's electronic medical record and were not kept onsite. The facility contacted the hospice agency when needed to have communication notes faxed to the facility. Review of the facility hospice agreement dated 01/17/17 revealed the facility shall prepare and maintain complete and detailed records concerning each hospice patient receiving facility services under this agreement in accordance with prudent record-keeping procedures and as required by applicable federal and state laws and regulations and Medicare and Medicaid program guidelines. The facility shall retain such records for a minimum of six years from the date of discharge of each hospice patient or such other time period as required by applicable federal and state law. Review of the facility policy, Hospice Services Facility Agreement, revised 07/28/20, stated, it is the policy of this facility to provide and/or arrange for hospice services in order to protect a resident's right to dignified existence, self-determination, and communication with, and access to, persons and services inside and outside the facility. Based on staff interview, medical record review, and facility policy review, the facility failed to monitor bruising following a fall affecting three Residents (#5, #30, and #52) and failed to ensure the hospice notes were available onsite or in the resident's medical record affecting Resident #320 of four residents reviewed for hospice. The facility census was 76. Findings include: 1. Review of the medical record for Resident #5 revealed an admission date of 11/03/21. Diagnoses included palliative care, muscle weakness, unspecified fall, abnormalities of gait and mobility, cognitive communication deficit, unsteady on his feet, and Dementia without behavioral disturbance. Review of the physician orders for December, 2021 revealed no orders to monitor bruising. The resident was ordered Xarelto Tablet 20 MG on 11/03/21 for his atrial fibrillation. The Xarelto was discontinued on 12/14/2021. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 11/10/21, revealed the resident had impaired cognition with a Brief Interview of Mental Status (BIMS) score of four out of 15 indicating severe cognitive impairment. He required limited to extensive assistance of one to two staff members for Activities of Daily Living (ADL's). His behaviors included inattention, disorganized thinking, and other behavioral symptoms not directed towards others. Review of the Electronic Medication Administration Record (EMAR) for November and December, 2021 revealed the resident was administered Xarelto as ordered. Review of the Skin assessment dated [DATE] revealed the resident had deep purple bruising on the left hip. The assessment did not have measurements of the bruising but indicated x-rays were ordered. Review of the progress note dated 12/07/21 at 2:15 P.M. by Registered Nurse (RN) #159 revealed the resident suffered a fall and had deep purple bruising and swelling. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365474 If continuation sheet Page 16 of 43 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 365474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Carroll 3680 Dolson Court NW Carroll, OH 43112 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 0684 Level of Harm - Minimal harm or potential for actual harm Review of the progress note dated 12/07/21 at 9:15 P.M. by Unit Manager (UM) RN #119 revealed the resident's hip was without changes. Review of the progress note dated 12/08/21 at 10:32 A.M. MDS Licensed Practical Nurse (LPN) #999 revealed monitoring of the bruising to the resident's left hip was to occur. Residents Affected - Some Review of the progress note dated 12/08/21 at 5:31 P.M. by RN #159 revealed the resident's daughter was updated on the resident's hip being bruised and swollen. Review of the Skin Assessments dated 12/14/21, 12/25/21, 01/03/22, 01/12/22, 01/19/22, and 01/26/22 revealed the resident did not have any new or existing abnormal skin conditions. Review of the progress note dated 12/14/21 at 5:08 P.M. revealed the resident's Xarelto was discontinued due to the resident being a fall risk to help with bruising and the hip remained with a quite a bit of bruising. Review of the plan of care dated 01/23/22 revealed the resident did not have any care plans related to bruising. Review of the Skin assessment dated [DATE] revealed the resident did not have any new or continued skin conditions. Interview on 02/08/22 at 5:57 P.M. with the Director of Nursing (DON) confirmed bruising should be monitored, an order to monitor bruising should have been placed, and documentation of bruise monitoring should be in the medical record. Interview on 02/09/22 at 10:01 A.M. with LPN #129 revealed the resident had bruising in December following a fall but did not recall an order to monitor the bruising. Interview on 02/09/22 at 10:31 A.M. with the Director of Nursing (DON) confirmed bruising was to be monitored for healing or worsening. Interview on 02/09/22 at 2:12 P.M. with the DON revealed the facility does not have a bruise monitoring policy. She stated the facility's procedure was to monitor bruising each shift and document the findings, and there should have been an order in place to monitor the bruising. Interview on 02/09/22 3:14 P.M. with the DON confirmed there was no documentation of bruise monitoring for the resident. 2. Review of the medical record for Resident #30 revealed an admission date of 12/29/21 and discharge date of 02/07/22. Diagnoses included unspecified fall, major depressive disorder, anxiety disorder, disorientation, unsteadiness on his feet, cognitive communication deficit, weakness, reduced mobility, muscle weakness, lack of coordination, and insomnia. Review of the plan of care dated 12/29/21 revealed the resident did not have any bruise monitoring plan. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 01/05/22, revealed the resident had intact cognition with a Brief Interview of Mental Status (BIMS) score of 13 out of 15 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365474 If continuation sheet Page 17 of 43 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 365474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Carroll 3680 Dolson Court NW Carroll, OH 43112 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 0684 Level of Harm - Minimal harm or potential for actual harm (cognitively intact). He required extensive assistance of one to two or more staff for Activities of Daily Living (ADL's) and he exhibited other behavioral symptoms not directed towards others. Interview on 02/07/22 at 10:22 A.M. with Resident #30 revealed he fell last week and his ankle, hip, and knee were painful. He stated he believed the pain was due to the bruising and being sore. Residents Affected - Some Interview on 02/07/22 11:55 A.M. with Registered Nurse (RN) #159 confirmed the resident fell last week but did not suffer from any injuries outside of bruising on his hip/leg. Upon entering the residents room the RN confirmed with the resident that he was experiencing ongoing left side hip pain felt like bruising pain. Interview on 02/09/22 at 2:12 P.M. with the Director of Nursing (DON) revealed the facility does not have an alarm policy or bruise monitoring policy. She stated the facility's procedure was to monitor bruising each shift and document the findings, and there should be an order in place to monitor the bruising. Interview on 02/09/22 at 3:14 P.M. with the DON confirmed there was no documentation of bruise monitoring for the resident. Review of the fall risk assessment dated [DATE] and 02/05/22 revealed the resident was a fall risk and required fall interventions. According to the assessments, the resident's last known fall was 02/05/22. Review of the falls initial charting dated 02/05/22 revealed the resident suffered an unwitnessed fall. The documentation revealed the only noted injury was a laceration to the left outer knee where the resident stated he hit his knee against the toilet paper dispenser. Review of the physician orders for February, 2022 revealed no orders for bruise monitoring. Review of the nurses notes dated 02/05/22 at 7:40 P.M. by Licensed Practical Nurse (LPN) #9000 revealed the resident suffered an unwitnessed fall as a result of increased confusion. He was on an antibiotic for a Urinary Tract Infection (UTI). One laceration was noted to the left knee, but no additional injuries were noted. A sign was placed on the bathroom door to remind the resident to ask for assistance. Review of the nurses notes dated 02/06/22 at 7:40 A.M. by LPN #129 revealed the resident had multiple bruises on his bilateral lower extremities (BLE) and bilateral upper extremities (BUE), as needed (PRN) medication was administered for soreness from his fall on 02/05/22. Review of the nurses notes dated 02/07/22 at 11:58 A.M. by Registered Nurse (RN) #159 revealed the resident reported new left hip pain related to his fall on 02/05/22 to the surveyor. Further review of the progress note revealed the resident described the pain as oh left hip kinda bruise like and he denied left foot pain. The Medical Director (MD) was updated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365474 If continuation sheet Page 18 of 43 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 365474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Carroll 3680 Dolson Court NW Carroll, OH 43112 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, interviews and facility policy review, the facility failed to maintain one resident (#12) dialysis fluid restriction. This affected one of one resident received for dialysis. Additionally, the facility failed to monitor one resident's (#21) supplement intake used to prevent further weight loss. This affected one of four reviewed for nutrition. Residents Affected - Few Findings Include: 1. Review of Resident #12's medical record revealed an admission date of 11/21/21. Diagnoses included disruption of wound, right above knee amputation, diabetes mellitus, end stage renal failure with dependence on renal dialysis, atrial fibrillation, history of COVID-19, major depressive disorder, ischemic cardiomyopathy, peripheral vascular disease, hypertension, hyperlipidemia, congestive heart failure and anemia. Review of the resident's comprehensive MDS 3.0 assessment dated [DATE] revealed the resident had clear speech, understood others, made himself understood and had no cognitive deficit as indicated by a BIMS score of 14. The resident requires supervision with ADL. The assessment indicated the resident received dialysis services. Review of the resident's February 2022 physician's orders identified orders dated 11/26/21 for a 1,000 milliliters (ml) fluid restriction daily with the special instructions nursing to give 400 ml every shift. Review of the January 2022 Medication Administration Record (MAR) revealed the resident was scheduled to receive 400 ml of fluid every shift (days, evenings and nights) which exceeded the physician ordered 1,000 ml fluid restriction daily. On 02/10/22 at 10:11 A.M. interview with Dietary Aide #145 revealed the resident receives 240 ml of water for breakfast, lunch and supper. On 02/10/22 at 11:05 A.M. interview with the Director of Nursing (DON) verified the resident was scheduled to receive 1,920 ml of fluid which exceeded the resident's physician ordered 1,000 ml fluid restriction daily. 2. Review of the medical record for Resident #21 revealed an re-admission date of 04/07/21. Diagnoses included cognitive communication deficit, Dementia with behavioral disturbance, schizoaffective bipolar disorder, major depressive disorder, and type two diabetes. Review of the quarterly Minimum Data Set (MDS) assessment, dated 12/13/21, revealed Resident #21 had impaired cognition with a Brief Interview of Mental Status (BIMS) score of three out of 15 indicating severe cognitive impairment. She required limited to extensive assistance of one to two staff members for Activities of Daily Living (ADL's). Review of the plan of care dated 08/05/20 revealed she had the potential for nutritional deficits related to Dementia, history of variable feeding assistance needed at times with meals, nutritional supplements, and weight gain in one month. Interventions included provide and serve supplements as ordered (Magic cup twice a day and Med Plus 1.7 every day). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365474 If continuation sheet Page 19 of 43 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 365474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Carroll 3680 Dolson Court NW Carroll, OH 43112 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the resident's weights were as follows: on 09/27/21 she weighed 144.2 lbs, on 10/06/21 she weighed 136.6 lbs, on 11/09/21 she weighed 142.8, on 12/09/21 she weighed 131.8 lbs, on 01/21/22 she weighed 134.4, on 01/28/22 she weighed 137.0 lbs, on 02/04/22 she weighed 137.8 lbs. There were no documentation of any reweights completed. Review of the Nutrition assessment dated [DATE] revealed the resident was on thin liquids, regular diet, and received a magic cup (600 kcal's,18 gm/pro) supplement twice daily. Further review of the assessment revealed the resident had a 5.3 percent weight loss in the past 30 days and a 15.5 percent decrease in the last 180 days. She usually consumed 50 percent or more of her meals but occasionally ate less. She usually ate 100 percent of her supplements and refused additional supplements. Review of the progress note dated 12/10/21 at 12:18 P.M. revealed a significant weight loss of 5.0% change. She had an average intake of meals 65%, supplement average intake 76%. Interventions included a magic cup twice a day (BID) (600 kcal's, 18 gm/pro). It was recommended that the resident be reweighed to verify weight loss but no reweigh was obtained. It was recommended the resident start Med Plus 1.7 every day to help stabilize her weight. Review of the physician orders for December 2021, January 2022, and February 2022 revealed the resident was ordered to be weighed weekly starting 01/21/22, a Magic Cup (nutritional supplement) twice daily for supplement starting 08/24/21, she was ordered a regular diet, Level 3 texture, regular fluid, and thin consistency starting 09/20/21, and Med Plus Sugar free 1.7 for supplement in the afternoon (there was no amount specified) starting on 12/14/21. Review of the Nutrition assessment dated [DATE] revealed the resident was on thin liquids, regular diet, received a magic cup (600 kcal's,18 gm/pro) supplement twice daily, and Med Plus 1.7 (200 kcal's, 10 gm/pro) 120 milliliters (ml) daily. She had a weight gain of 14 percent (18.4 pounds (lbs)). She usually consumed 50 percent or more of her meals but occasionally ate less. She usually ate 50 percent of her supplements. Interview on 02/08/22 at 5:57 P.M. with the Director of Nursing (DON) confirmed if a resident had significant weight loss then the dietician would make recommendations. If a reweigh was ordered then the weight should have been entered in the resident's medical record. She confirmed a supplement order should have an amount ordered to administer. Interview on 02/09/22 at 3:14 P.M. with the DON confirmed it would be impossible to calculate the amount of Med plus the resident was receiving since the order did not specify the amount to be administered. Review of the Electronic Medication Administration Record (EMAR) for February 2022 revealed the resident was administered the ordered med plus every day in February except 02/03/22 when nothing was documented. It was documented that she drank between 25 and 50 percent of an unknown amount that was administered. It did not reveal the amount of supplement provided to the resident on each administration. Review of the January 2022 EMAR revealed the resident drank between 50 and 100 percent of her med plus supplement every day in January except on 01/20/22 when there was nothing documented. It did not reveal the amount of supplement provided to the resident. Review of the progress note dated 11/30/21 at 2:08 P.M. revealed the resident had a ten percent (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365474 If continuation sheet Page 20 of 43 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 365474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Carroll 3680 Dolson Court NW Carroll, OH 43112 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few weight loss (16.9 lbs) from 159.7 lbs on 05/25/21 to 142.9 lbs. Resident #21 consumes 50% or greater of most meals, often 75-100%. She also receives Magic cup BID, which she consumes 100% of on most occasions. She has had a weight loss trend over the past 6 months. This could be related to decreased snacking in between meals. She recently started going to the dining room for meals which appears to be helping intakes as evidenced by a 6 pound weight gain over 1 month. Her current weight is 142.8# and she is 68. Her BMI is 21.7, indicating she is appropriate weight for height. Her needs are 1625-1950 kcal's, 65 gm/pro and ~1950 ml fluid. Continue current diet and supplements as ordered. RD to continue to monitor and make recommendations as needed. Review of the facility policy titled, Medication Administration dated 01/01/21 revealed medication source was to be verified with the Electronic Medication Administration Record (EMAR) to verify the dose. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365474 If continuation sheet Page 21 of 43 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 365474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Carroll 3680 Dolson Court NW Carroll, OH 43112 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, interviews, and record reviews, the facility failed to obtain physicians orders for the administration of oxygen therapy. This affected the one resident (#55) reviewed for respiratory care. The facility census was 76. Residents Affected - Few Findings include: Record review for Resident #55 revealed this resident was admitted to the facility on [DATE] and had diagnoses including schizophrenia, depression, anxiety, and COVID-19. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/07/22, revealed this resident had mildly impaired cognition evidenced by a BIMS assessment score of 12. This resident was assessed to require supervision for bed mobility, transfers, and toileting. This resident was assessed to have not received oxygen therapy. Review of the active care plans for this resident revealed an absence of a care plan for respiratory care or oxygen use. Review of the active physicians order for Resident #55 revealed an order, dated 02/07/22 and timed 10:47 A.M., for oxygen to administered at two liters a minute as needed. Observation on 02/07/22 at 10:17 A.M. revealed Resident #55 had an oxygen concentrator in place at bedside. The nasal cannula tubing was observed to be dated 02/01/22. Interview with State Tested Nursing Assistant (STNA) #165 on 02/07/22 at 10:17 A.M. verified the oxygen concentrator and tubing belonged to Resident #55 and the resident used oxygen at times. Interview with Resident #55 on 02/07/22 at 10:21 A.M. verified she used the oxygen at times when she was having difficulty breathing. Interview with the DON on 02/10/22 at 3:45 P.M. verified Resident #55 had been receiving oxygen therapy prior to 02/07/22 but could not confirm when it was initiated. The DON verified there had not been a physician's order for the administration of oxygen in place for Resident #55 until 02/07/22 at 10:47 A.M. Review of the facility policy titled Oxygen Administration, revised on 06/02/21, revealed oxygen was to be administered under orders of a physician, except in the case of an emergency. In such case, the oxygen was to be administered and orders for the oxygen were to be obtained as soon as practicable when the situation was under control. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365474 If continuation sheet Page 22 of 43 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 365474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Carroll 3680 Dolson Court NW Carroll, OH 43112 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on staff interview, observations, medical record review, facility policy review, shift change controlled substance accountability sheets review, procedure review, the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and the facility failed to remove and dispose of an opioid pain patch. This affected one Residents (#31) of three residents reviewed for medications and had the potential to affect additional residents in the facility who had orders for controlled drugs. The facility census was 76. Findings include: 1. Review of the medical record for Resident #31 revealed an admission date of 12/18/18. Diagnoses included rheumatoid polyneuropathy with rheumatoid arthritis of multiple sites and age-related osteoporosis without current pathological fracture. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/14/22, revealed the resident had intact cognition with a Brief Interview of Mental Status (BIMS) score of 15 out of 15 (no cognitive impairment) and no behaviors. The resident required supervision of one staff member for all Activities of Daily Living (ADL's) except personal hygiene where she required the extensive assistance of one staff member. Review of the plan of care dated 07/14/20 revealed the resident was at risk for acute/chronic pain related to arthritis, low back pain, compression fracture, and a history of shingles. Interventions included administration of medications as ordered, evaluate the effectiveness of pain interventions every shift, review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. Further review of the plan of care dated 07/14/20 revealed the resident was at risk for side effects related to Opioid medication use. Interventions included administration of Opioid medication as ordered by the physician and monitor for side effects and effectiveness every shift. Review of the physician orders revealed an order with a start date of 12/13/21 for Buprenorphine (Butrans) patch (opioid pain patch) five micrograms (mcg) per hour with the instructions to apply one patch every seven days, cover with tegaderm (transparent dressing), and avoid chest where patient may accidentally rub off. A second order with a start date of 10/08/21 revealed an order to check the placement of the residents Butrans patch by examining the resident every shift for proper placement. Review of the progress notes dated 12/27/21 through 02/09/22 revealed no progress note related to the removal of a Butrans patch. Review of the progress note dated 02/09/22 at 5:06 P.M. by Licensed Practical Nurse (LPN) #129 revealed she informed the Physician Assistant (PA) #777 regarding the butrans pain patch found on residents blanket. There were no changes or new orders, the Director of Nursing (DON) was informed and verification of the most recent pain patch was in place was confirmed. Review of the Electronic Medication Administration Record (EMAR) for December 2021 revealed the Butrans patch was placed on 12/20/21 by Registered Nurse (RN) #119 and was replaced on 12/27/21 by RN #159. Further review of the EMAR revealed an order with a start date of 04/19/21 to document the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365474 If continuation sheet Page 23 of 43 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 365474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Carroll 3680 Dolson Court NW Carroll, OH 43112 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 0755 removal and application of the Butrans patch. The order was discontinued on 12/08/21. Level of Harm - Minimal harm or potential for actual harm Observation on 02/09/22 at approximately 4:28 P.M. revealed a labeled Butrans patch dated 12/20 and initialed AS, stuck to the residents blanket. LPN #129 removed the patch from the blanket, informed the Director of Nursing (DON), placed the used patch into a disposal sleeve, and discarded the patch in the sharps/biohazard container. Residents Affected - Few Interview on 02/09/22 at 5:04 P.M. with the DON confirmed she spoke with the nurse who was supposed to have removed the butran patch but she stated there was no patch to remove despite searching the residents body and bedding. The DON confirmed the nurse signed off the order stating she removed the patch but did not document the patch was actually unfound. Interview on 02/10/22 at 4:10 P.M. with the DON confirmed there was no documentation of the Butrans patch removal after 12/08/21. Review of the facility policy titled, Medication-Narcotic Pain Patch revised 06/30/21 revealed patches will be checked for placement by the nurse every shift and documented in the medication administration record and upon the placement of a new patch the old patch will be removed and discarded in a safe and secure method and verified as such by the nurse removing and the nurse verifying the discard of the patch. 2. Review of the Shift Change Controlled Substance Accountability sheet for the controlled substance Emergency Drug Kit (EDK) revealed on 12/27/21 at 7:00 P.M. there was no signature for the oncoming nurse. There was no count documented 12/28/21 or 12/29/21. On 12/30/21 at 7:00 P.M. there was no signature for the off going nurse. There was no count documented on 01/01/22 through 01/12/22. On 01/13/22 at 7:00 P.M. there was no signature for the oncoming nurse. There was no count documented on 01/14/22. On 01/16/22 at 7:00 P.M. there was no signature for the outgoing nurse. There was no count documented on 01/17/22 through 01/23/22. On 01/24/22 at 7:00 A.M. there was no signature for the outgoing nurse. On 01/26/22 at 7:00 A.M. there was no signature for the oncoming nurse. There was no count documented on 01/26/22 evening shift through 02/06/22. On 02/07/22 at 7:00 P.M. there was no oncoming or outgoing nurse signatures indicating the count was completed. There was no count documented on 02/08/22 in the morning or evening and no count completed on 02/09/22 in the morning. On 02/09/22 at 7:00 P.M. there was no signature for the off going nurse. On 02/10/22 at 7:00 A.M. there was no signature for the on coming nurse and no documentation that the count occurred on 02/10/21 evening shift. Interview on 02/10/22 at 11:20 A.M. with Licensed Practical Nurse (LPN) #128 revealed controlled medications were to be counted and documented at the beginning of every shift. Review of the Shift Change Controlled Substance Accountability sheets for the North Long Unit revealed there were no count documented on 01/12/22 night shift through 01/30/22. There was no signature for the on coming nurse on 02/05/22 at 7:00 P.M., 02/06/22 at 7:00 P.M. Interview on 02/10/22 at 3:30 with the Regional Nurse #8000 confirmed the nurses were to count/verify tag numbers and sign the Shift Change Controlled Substance Accountability sheet for the EDK any time a new on coming nurse was starting their shift and every shift for each units medication cart controlled substances. Interview on 02/10/22 at 4:10 P.M. with the Director of Nursing (DON) confirmed the missing counts, missing signatures, and documentation on the Shift Change Controlled Substance Accountability sheets for the North Long Unit and the controlled substance EDK. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365474 If continuation sheet Page 24 of 43 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 365474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Carroll 3680 Dolson Court NW Carroll, OH 43112 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 0755 Level of Harm - Minimal harm or potential for actual harm Review of the facility provided drug information titled, Buprenorphine dated 01/14/22 revealed this drug was a strong pain drug that can increase the risk for addiction, abuse, and misuse, do not take more than what the doctor ordered, taking more than ordered can increase the chances of very bad side effects, take off the old patch prior to placing a new patch, and do not place more than one patch at the same time unless the doctor ordered it. Residents Affected - Few Review of the facility policy titled, Controlled Substance Administration and Accountability dated 10/20/20 revealed nursing staff must count controlled drugs at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the DON or his/her designee immediately and documentation should be made on the shift verification sheet. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365474 If continuation sheet Page 25 of 43 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 365474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Carroll 3680 Dolson Court NW Carroll, OH 43112 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #60's medical record revealed an initial admission date of 01/07/21 with the latest readmission of 03/21/21. Diagnoses included dementia with behavioral disturbances, anxiety disorders, mood disorder, hypertension, major depressive disorder with psychotic symptoms, pain, restlessness and agitation, history of COVID-19, gastro-esophageal reflux disease, lactose intolerance and insomnia. Review of the resident's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had clear speech, understood others, makes herself understood and had a moderate cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of seven. Review of the mood and behavior revealed the resident had indicators of depression and wandered daily. The resident required supervision with activities of daily living (ADL). The assessment indicated the resident received antipsychotic, antianxiety, hypnotic medications on a routine basis. The assessment indicated a gradual dose reduction (GDR) had not been attempted and the physician had not documented the GDR was clinically contraindicated. Review of the plan of care dated 01/27/21 revealed the resident receives antipsychotic medications as ordered by physician. Haldol GDR on 02/09/21. Interventions included administer medications as ordered, observe for adverse drug effects and notify MD as needed, observe resident for underlying causes of distress behavior. Review of the resident' physician's orders for February 2022 identified an order dated 01/15/22 Zyprexa 2.5 mg by mouth every day for dementia with behavioral disturbances and 01/19/22 for Zyprexa 5 mg by mouth at bedtime for dementia with behavior disturbances. Review of the pharmacy recommendation dated 03/05/21 revealed the pharmacist recommended an appropriate diagnoses for Zyprexa. The physician addressed the recommendation on 05/05/21. On 02/09/22 at 9:03 A.M. interview with the Director of Nursing (DON) verified the pharmacy recommendation was not addressed in a timely manner. 2. Review of the medical record for Resident #67 revealed an admission date of 06/08/21 with diagnosis including schizoaffective disorder, mood disorder, unspecified psychosis not due to substance abuse or physiological, major depressive disorder, anxiety and personality disorder. Review of the quarterly MDS dated [DATE] for Resident #67 revealed the resident was cognitively intact with no behaviors. The resident received no psychological treatment and received antidepressant, antianxiety, and sedative/hypnotic medications. Review of the physician orders for 02/22 revealed Resident #67 received Ativan (antianxiety), Buspirone (antianxiety), Hydroxizine (antianxiety), Fluoxetine (antidepressant), Zolpidem (sedative) and Roxerem (sedative). Review of the pharmacy recommendations for Resident #67 dated 06/09/21 revealed the pharmacist recommended discontinuing the Zolpidem because the resident was taking multiple medications for insomnia. Review of the physician progress notes revealed no documentation addressing the recommendations. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365474 If continuation sheet Page 26 of 43 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 365474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Carroll 3680 Dolson Court NW Carroll, OH 43112 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 02/10/22 at 9:22 A.M. with the DON confirmed Resident #67 was receiving three medications for sleep, and two were sedative/hypnotics. The DON confirmed the were no gradual dose reductions attempted or physician notes to support the continuation of the medications. Review of the facility policy titled Behavior Management Program dated 01/01/21 indicated the Interdisciplinary team (IDT) would review all residents with behaviors or on psychoactive medications quarterly and assess for a possible gradual dose reduction. Based on record review, staff interview, review of pharmacy recommendations, and review of facility policy, the facility failed to implement pharmacy recommendations timely upon approval by the physician for two residents (Resident #3 and Resident #60). The facility also failed to document appropriate justifications for declining a gradual dose reduction (GDR) for two residents (Resident #60 and Resident #67). The deficient practice affected three residents (Residents #3, #60, and #67) out of eight reviewed for unnecessary medications. The facility census was 76. Findings include: 1. Review of the medical record for Resident #3 revealed an admission date on 05/13/21. Medical diagnoses included unspecified mood (affective) disorder, adjustment disorder with mixed anxiety and depressed mood, insomnia, and schizoaffective disorder (Bipolar type). Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #3 had intact cognition and scored 14 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. The resident required supervision with set up help only for most Activities of Daily Living (ADLs). The resident required supervision with one staff assist for bed mobility, dressing, toileting and hygiene. The resident took daily antipsychotics, antianxiety, and antidepressant medications. Review of the physician's orders for February 2022 revealed Resident #3 had an order for Bupropion HCL ER (XL) tablet Extended Release 24 hour 150 milligrams (mg) with instructions to give one tablet by mouth daily for depression for one week and give two tablets daily for depression. The order had a start date of 08/07/21. Resident #3 also had an order for Vilazodone HCL 40 mg with instructions to give one tablet in the morning for depression. The order had a start date of 05/29/21. Review of the plan of care dated 03/30/21 revealed Resident #3 had depression. Interventions included administer medications as ordered and to monitor and document for side effects and effectiveness. Review of the pharmacy recommendation dated 11/17/21 for Resident #3 revealed the resident was prescribed two different antidepressants, Wellbutrin XL (generic brand Bupropion HCL) 300 milligrams (mg) daily and Viibryd (generic brand Vilazodone HCL) 40 mg daily. A trial dose reduction of Wellbutrin from 300 mg to 150 mg daily was recommended. The physician agreed to the trial dose reduction on 12/02/21. Review of the Medication Administration Record (MAR) for December 2021 revealed the only order for Bupropion HCL ER (XL) 150 mg had instructions to give two tablets by mouth one time a day for depression (a total of 300 mg) with a start date of 08/15/21. The medication was administered daily as ordered. Resident #3 also continued to receive Vilazodone HCL 40 mg tablet daily in the morning for depression. Review of the nurse's notes from 11/01/21 to current revealed there was no documentation related to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365474 If continuation sheet Page 27 of 43 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 365474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Carroll 3680 Dolson Court NW Carroll, OH 43112 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 the pharmacy recommendation being implemented. Level of Harm - Minimal harm or potential for actual harm Interview on 02/09/22 at 5:04 PM with the Director of Nursing (DON) confirmed the pharmacy recommendation had not been implemented as indicated by the physician. Residents Affected - Few Review of the facility policy, Unnecessary Drugs-Without Adequate Indication for Use, revised 10/30/20, stated, it is the facility's policy that each resident's drug regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being free from unnecessary drugs. Documentation will be provided in the resident's medical record to show adequate indications for medication's use and the diagnosed condition for which it was prescribed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365474 If continuation sheet Page 28 of 43 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 365474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Carroll 3680 Dolson Court NW Carroll, OH 43112 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and review of the facility policy, the facility failed to administer opioid pain medication according to the ordered pain level for one resident (Resident #3). The deficient practice affected one resident (Resident #3) of eight residents reviewed for unnecessary medications. The facility census was 76. Residents Affected - Few Findings Include: Review of the medical record for Resident #3 revealed an original admission date on 03/30/21 and a readmission date of 05/13/21. Medical diagnoses included unspecified fractures of unspecified shaft of the radius and patella, Type II Diabetes Mellitus with diabetic neuropathy, mood (affective) disorder, adjustment disorder with mixed anxiety and depressed mood, insomnia, and schizoaffective disorder (Bipolar type). Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #3 had intact cognition and scored 14 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. The resident required supervision with set up help only for most Activities of Daily Living (ADLs). The resident required supervision with one staff assist for bed mobility, dressing, toileting and hygiene. The resident took daily antipsychotics, antianxiety, and antidepressant medications. Review of the physician's orders for February 2022 revealed Resident #3 had an order for Oxycodone HCL (an opioid pain medication) capsule 5 milligrams (mg) with instructions to give one capsule by mouth every four hours as needed for moderate pain. The order had a start date of 05/13/21. Review of the pain evaluation dated 06/29/21 revealed Resident #3 had frequent pain in the last five days that limited her day to day activities and affected the resident's mood. The resident reported her pain management regimen was effective. The resident stated she had moderate pain at a level of five on a pain scale from 0 to 10. Resident #3 stated the pain was aching and throbbing. Resident #3 received as needed pain medication. Review of additional pain evaluations dated 08/23/21 and 08/28/21 revealed Resident #3 reported not having any pain. There were no additional pain evaluations since 08/28/21. Review of the plan of care dated 03/30/21 revealed Resident #3 had chronic pain related to comorbidities and a diagnosis of fracture. Interventions included administer pain medications as ordered. Review of the Medication Administration Record (MAR) for November 2021 revealed Resident #3 was administered Oxycodone HCL on the following dates with the following documented pain levels: 11/02/21 with a pain level of two, 11/01/21, 11/09/21, 11/10/21, and 11/13/21 for a pain level of three, 11/08/21, 11/10/21, 11/11/21, and 11/14/21 for a pain level of four, and 11/04/21, 11/15/21, and 11/16/21 for a pain level of five. Review of the MAR for December 2021 revealed Resident #3 was administered Oxycodone HCL on the following dates with the following documented pain levels: 12/08/21 for a pain level of zero, 12/01/21 for a pain level of five, and 12/02/21, 12/11/21, and 12/12/21 for a pain level of four. Review of the MAR for January 2022 revealed Resident #3 was administered Oxycodone HCL on the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365474 If continuation sheet Page 29 of 43 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 365474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Carroll 3680 Dolson Court NW Carroll, OH 43112 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 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few following dates for the following pain levels: 01/10/22, 01/11/22, 01/24/22, and 01/27/22 for a pain level of zero, 01/01/22 for a pain level of three, 01/07/22, 01/09/22, and 01/10/22 for a pain level of four, and 01/07/22, 01/14/22, and 01/21/22 for a pain level of five. Review of the MAR for February 2022 revealed Resident #3 was administered Oxycodone HCL on the following dates for the following pain levels: 02/01/22 and 02/09/22 for a pain level of zero, 02/06/22 for a pain level of one, 02/06/22 for a pain level of two, 02/06/22 for a pain level of three, 02/05/22 and 02/06/22 for a pain level of four, and 02/05/22, 02/08/22, and 02/10/22 for a pain level of five. Interviews on 02/09/22 at 3:03 P.M. and 02/10/22 at 2:07 P.M. with the Director of Nursing (DON) confirmed Resident #3 was administered Oxycodone HCL with pain levels not indicative of moderate pain. The DON stated the physician order should have included the pain scale or the nurse should have called the physician to clarify the order. Based on nursing judgement, an order for moderate pain would be considered a pain level of six or higher on a pain scale from zero to ten where ten is the greatest level of pain. Review of the facility policy, Unnecessary Drugs-Without Adequate Indication for Use, revised 10/30/20, stated, it is the facility's policy that each resident's drug regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being free from unnecessary drugs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365474 If continuation sheet Page 30 of 43 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 365474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Carroll 3680 Dolson Court NW Carroll, OH 43112 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** 3. Review of Resident #60's medical record revealed an initial admission date of 01/07/21 with the latest readmission of 03/21/21. Diagnoses included dementia with behavioral disturbances, anxiety disorders, mood disorder, hypertension, major depressive disorder with psychotic symptoms, pain, restlessness and agitation, history of COVID-19, gastro-esophageal reflux disease, lactose intolerance and insomnia. Review of the resident's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had clear speech, understood others, makes herself understood and had a moderate cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of seven. Review of the mood and behavior revealed the resident had indicators of depression and wandered daily. The resident required supervision with activities of daily living (ADL). The assessment indicated the resident received antipsychotic, antianxiety, hypnotic medications on a routine basis. The assessment indicated a gradual dose reduction (GDR) had not been attempted and the physician had not documented the GDR was clinically contraindicated. Review of the plan of care dated 01/08/21 revealed the resident uses anti-anxiety medications related to anxiety. Interventions included administer anti--anxiety medication as order and monitor for side effects and effectiveness every shift. Review of the plan of care dated 01/27/21 revealed the resident receives antipsychotic medications as ordered by physician. Haldol GDR on 02/09/21. Interventions included administer medications as ordered, observe for adverse drug effects and notify MD as needed, observe resident for underlying causes of distress behavior. Review of the plan of care dated 07/27/21 revealed the resident is on sedative/hypnotic therapy related to insomnia. Interventions included to maximize daily activities, encourage socialization, administer sedative/hypnotic medications as ordered by physician, monitor/document/report to nurse/MD/as needed for adverse effects. Review of the resident' physician's orders for February 2022 identified an order dated 01/15/22 for Ambien 5 milligrams (mg) by mouth at bedtime, Zyprexa 2.5 mg by mouth every day for dementia with behavioral disturbances and 01/19/22 for Zyprexa 5 mg by mouth at bedtime for dementia with behavior disturbances. Review of the medical record failed to identify and appropriate diagnoses and identified behaviors to support the use of the medication Zyprexa. Review of the Medication Administration Record (MAR) for January and February 2022 revealed the resident received Ambien 5 mg by mouth daily at bedtime. On 02/08/22 at 3:48 P.M. interview with the Director of Nursing (DON) verified the resident lacked an appropriate diagnosis for the use of the Zyprexa. She also verified the resident received the Ambien for more than 14 days and was not reevaluated for continued use. On 02/09/22 at 9:03 A.M. interview with the DON verified the care plans contained no identified (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365474 If continuation sheet Page 31 of 43 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 365474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Carroll 3680 Dolson Court NW Carroll, OH 43112 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 behaviors, no documented behaviors to support the use of the antipsychotropic medications Level of Harm - Minimal harm or potential for actual harm Based on interview, record review, and review of facility policy the facility failed to monitor behaviors, ensure appropriate diagnosis for antipsychotic medication use, hypnotic/sedative medication in place over 14 days, and monitor for side effects of antipsychotic and antianxiety medications for Resident #3, #52, #60 and #67. This affected four of eight residents reviewed for unnecessary medications. The facility census was 76. Residents Affected - Few Finding include: 1. Review of the medical record for Resident #52 revealed an admission date of 11/05/21 with diagnoses including Alzheimer's disease, anxiety, schizoaffective disorder and Parkinson's disease. Review of the quarterly MDS dated [DATE] for Resident #52 revealed the resident had moderate cognitive impairment with no behaviors. Review of the physician orders for 02/22 revealed Resident #52 received Risperidone three mg by mouth two times daily for Mood disorder. Review of the Medication Administration Record and the Treatment Administration Record revealed the facility did not monitor or document resident behaviors or interventions. Review of the plan of care for Resident #52 revealed a plan for the inappropriate social behavior of garbled, non sensical repetitive speech. The interventions included offer calm reassuring touch, provide medications as ordered and document efficacy. An interview with the Director of Nursing (DON) on 02/09/22 at 3:13 P.M. confirmed that Mood disorder was not an appropriate diagnosis for the use of Risperidone. The facility did not provide a policy for use of anti psychotic medications. 2. Review of the medical record for Resident #67 revealed an admission date of 06/08/21 with diagnoses including schizoaffective disorder, mood disorder, unspecified psychosis not due to substance abuse or physiological, major depressive disorder, anxiety and personality disorder. Review of the quarterly MDS dated [DATE] for Resident #67 revealed the resident was cognitively intact with no behaviors. The resident received no psychological treatment and received antidepressant, antianxiety, and sedative/hypnotic medications. Review of the physician orders for 02/22 revealed Resident #67 received Zolpidem (sedative) and Roxerem (sedative) with start dates of 06/08/21. Review of the pharmacy recommendations for Resident #67 dated 06/09/21 revealed the pharmacist recommended discontinuing the Zolpidem because the resident was taking multiple medications for insomnia. Review of the physician progress notes revealed no documentation addressing the continued use of a sedative/hypnotic for longer than 14 days. Interview on 02/10/22 at 9:22 A.M. with the DON confirmed Resident #67 was receiving three medications for sleep, and two were sedative/hypnotics. The DON confirmed the were no gradual dose (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365474 If continuation sheet Page 32 of 43 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 365474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Carroll 3680 Dolson Court NW Carroll, OH 43112 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 reductions attempted or physician notes to support the continuation of the medications past 14 days, Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled Behavior Management Program dated 01/01/21 indicated the Interdisciplinary team (IDT) would review all residents with behaviors or on psychoactive medications quarterly and assess for a possible gradual dose reduction. Residents Affected - Few 4. Review of the medical record for Resident #3 revealed an original admission date on 03/30/21 and a readmission date of 05/13/21. Medical diagnoses included unspecified fractures of unspecified shaft of the radius and patella, Type II Diabetes Mellitus with diabetic neuropathy, mood (affective) disorder, adjustment disorder with mixed anxiety and depressed mood, insomnia, and schizoaffective disorder (Bipolar type). Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #3 had intact cognition and scored 14 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. The resident required supervision with set up help only for most Activities of Daily Living (ADLs). The resident required supervision with one staff assist for bed mobility, dressing, toileting and hygiene. The resident took daily antipsychotics, antianxiety, and antidepressant medications. Review of the physician's orders for February 2022 revealed Resident #3 had an order for Buspirone Hydrochloride (HCL) (an antianxiety medication) 5 milligrams (mg) with instructions to give two tablets three times a day related to adjustment disorder with mixed anxiety and depressed mood. The order had a start date of 11/29/21. Resident #3 had an order for Olanzapine (an antipsychotic medication) 2.5 mg with instructions to give one tablet daily related to schizoaffective disorder, Bipolar type. The order had a start date of 09/25/21. Resident #3 had an order for Hydroxyzine Pamoate (an antianxiety medication) 25 mg with instructions to give one capsule by mouth daily for anxiety and give two capsules by mouth at bedtime for anxiety. The order had a start date of 08/06/21. In addition, Resident #3 had an order to monitor for side effects of antidepressant medications with a start date of 05/14/21. There were no orders to monitor for side effects of Resident #3's antipsychotic or antianxiety medications. Review of the Medication Administration Records (MAR) from November 2021 through current revealed side effects of Resident #3's antipsychotic and antianxiety medications were not documented as being monitored. Review of the nurse's notes dated from 11/01/21 through current revealed there were no notes related to monitoring side effects of Resident #3's antipsychotic or antianxiety medications. Review of the plan of care dated 03/30/21 revealed Resident #3 received antipsychotic medication. Interventions included administer medications as ordered and observe for adverse drug effects and notify the physician as needed. In addition, Resident #3 used antianxiety medications. Interventions included administer antianxiety medications as ordered by physician and monitor for side effects and effectiveness every shift. Interview on 02/09/22 at 3:03 P.M. with the Director of Nursing (DON) confirmed there were no physician orders to monitor side effects of Resident #3's antipsychotic or antianxiety medications. Therefore, there was no documentation Resident #3 was being monitored for any side effects of the medications. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365474 If continuation sheet Page 33 of 43 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 365474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Carroll 3680 Dolson Court NW Carroll, OH 43112 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 FORM CMS-2567 (02/99) Previous Versions Obsolete Review of the facility policy, Unnecessary Drugs-Without Adequate Indication for Use, revised 10/30/20, stated, it is the facility's policy that each resident's drug regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical and psychosocial well-being free from unnecessary drugs. Furthermore, the attending physician will assume leadership in medication management by developing, monitoring, and modifying the medication regimen in collaboration with residents and/or representatives, other professionals, and the interdisciplinary team. Each resident's drug regimen will be reviewed on an ongoing basis, taking into consideration the following elements: adequate monitoring for efficacy and adverse consequences. Event ID: Facility ID: 365474 If continuation sheet Page 34 of 43 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 365474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Carroll 3680 Dolson Court NW Carroll, OH 43112 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, observations, medical record review, facility policy review, the facility failed to maintain a medication error rate less than five percent. There were six medication errors out of 26 opportunities, resulting in a 23.08 percent medication error rate. This affected three Residents (#67, #56, #60) of seven residents reviewed for medication administration. The facility census was 76. Residents Affected - Few Findings include: 1. Review of the medical record for the Resident #56 revealed an admission date of [DATE]. Diagnoses included Urinary Tract Infection (UTI) and Dementia. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #56 was cognitively impaired with a Brief Interview of Mental Status (BIMS) score of two out of 15 (severe cognitive impairment). She required extensive assistance of one to two or more staff members for Activities of Daily Living (ADL's). Review of physician orders for [DATE] identified orders for Cranberry 450 milligram (mg) two tablets by mouth in the morning for supplementation to equal 900 mg. The order was stated on [DATE] and changed on [DATE]. She was also ordered Potassium Chloride Extended Release (ER) 20 milliequivalents (MEQ) tablet for supplementation on [DATE]. Observation on [DATE] at 8:36 A.M. with Registered Nurse (RN) #159 revealed she administered two cranberry 425 mg tablets instead of the ordered two tablets of 450 mg of cranberry. RN #159 also crushed the resident's potassium ER and administered it with the other ordered crushed and opened capsule medications in chocolate pudding. Interview on [DATE] at 8:58 A.M. with RN #159 confirmed potassium chloride ER was crushed and the administered cranberry was 425 mg instead of the ordered 450 mg. Review of the facility provided drug information titled, Cranberry dated [DATE] revealed cranberry tablets were available to administer in divided doses. Review of the facility provided drug information titled, Potassium Chloride dated [DATE] revealed tablets were to be swallowed whole, not chewed, crushed, or broken. 2. Review of the medical record for the Resident #67 revealed an admission date of [DATE]. Diagnoses included Allergic Rhinitis and intervertebral disc degeneration. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #67 was not assessed cognitively with a Brief Interview of Mental Status (BIMS) and required extensive assistance of one to two staff members. Review of the BIMS dated [DATE] revealed the resident was cognitively intact with a score of 13 out of 15 (intact cognition). Review of physician orders for [DATE] identified orders to apply a Salonpas Pain Relieving Patch 4% topically to the resident's back one time a day for intervertebral disc degeneration with a start date of [DATE]. The resident also had an order for one spray to each nostril of Fluticasone 50 mcg daily for nasal congestion with a start date of [DATE]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365474 If continuation sheet Page 35 of 43 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 365474 B. Wing (X3) DATE SURVEY COMPLETED A. Building 02/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Carroll 3680 Dolson Court NW Carroll, OH 43112 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 0759 Level of Harm - Minimal harm or potential for actual harm Observation on [DATE] at 9:08 A.M. of the medication administration with Licensed Practical Nurse (LPN) #128 revealed she instructed the resident to spray two sprays of the fluticasone 50 mcg into each nostril. She also did not apply the Salonpas Pain Relieving patch due to the resident's request to apply it at a later date. LPN #128 removed the pain patch from the room and placed in in the medication cart after the medication administration. Residents Affected - Few Interview on [DATE] at 9:15 A.M. with LPN #128 confirmed the pain patch was not applied and was placed back into the medication cart. She also confirmed she instructed the resident to administer two sprays nasally of the fluticasone despite the order stating one spray to each nostril. Interview on [DATE] at 3:47 P.M. with Resident #67 revealed her lidocaine pain patch was never applied. Observation and interview on [DATE] at 3:51 P.M. with the Director of Nursing (DON) and Resident #67 confirmed the resident did not have a pain patch in place per her orders and the application of the pain patch was signed off in the Electronic Medication Administration Record (EMAR). Review of the facility provided drug information titled, Fluticasone dated [DATE] revealed the drug was to be used as ordered by the doctor. Review of the facility provided drug information titled, Lidocaine dated [DATE] revealed the patch was to be placed topically at the same time every day. 3. Review of the medical record for the Resident #60 revealed an initial admission date of [DATE] and a readmission date of [DATE]. Diagnoses included Urinary Tract Infection (UTI) and Dementia. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #60 was cognitively impaired with a Brief Interview of Mental Status (BIMS) score of seven out of 15 (severe cognitive impairment). She required supervision and set up for all Activities of Daily Living (ADL's). Review of physician orders dated [DATE] identified orders to administer two 125 milligram (mg) capsules of Divalproex Sodium Delayed Release (DR) Sprinkle for Dementia with behavioral disturbances. A second order dated [DATE] revealed the resident was to be administered one tablet of Senna plus 8.6-50 mg (stool softener) for constipation. Review of the care plan dated [DATE] revealed the resident had a mood problem related to disease process of anxiety and depression. Interventions included administration of medications per physician orders. There was no care plan for constipation. Observation on [DATE] at 4:35 P.M. of Licensed Practical Nurse (LPN) #129 administering medications to Resident #60 revealed one Senna plus (stool softener) tablet was crushed. Further observation revealed two capsules of divalproex sodium delayed release (DR) 125 milligrams (mg) were opened and the capsule contents were added to the other crushed medications with pudding. Interview on [DATE] at 4:45 P.M. with LPN #129 confirmed the observations. Review of the facility provided drug information titled, Docusate and Senna dated [DATE] revealed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365474 If continuation sheet Page 36 of 43 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 365474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Carroll 3680 Dolson Court NW Carroll, OH 43112 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 0759 other drugs should not be taken within two hours of this drug. Level of Harm - Minimal harm or potential for actual harm Review of the facility provided drug information titled, Valproic Acid and Derivative dated [DATE] revealed the capsules were to be swallowed whole, not chewed, crushed, or broken. Residents Affected - Few Review of the facility policy titled, Medication Administration dated [DATE] revealed medication source was to be verified with the EMAR to verify dose, identify expiration dates and notify the nurse manager if medication was expired, administer medication as ordered in accordance with manufacturer instructions such as do not crush medication with do not crush instructions, sign EMAR after the medication was administered, and correct any discrepancies and report to the nurse manager. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365474 If continuation sheet Page 37 of 43 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 365474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Carroll 3680 Dolson Court NW Carroll, OH 43112 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on staff interview, observations, facility policy review, the facility failed to ensure expired medications and open medications that were undated were removed from the medication cart. This specifically affected two residents (#370 and #372) but had the potential to affect all residents on the north long hall. The facility census was 76. Findings include: Observation on 02/10/22 at 10:50 A.M. and 1:40 P.M. with Agency Registered Nurse (RN) #3000 of medication storage on the medication cart revealed facility stock medications vitamin B complex with electrolytes dietary supplement, melatonin 5 milligrams (mg), Calcium Carbonate chewable antacid, Cranberry 450 mg extract, Fish oil 1000 mg (300 mg omega-3), Sodium chloride tablets 1 gram, and oyster shell calcium 500 mg plus vitamin D were opened but undated. Further Review of the medication cart revealed Novolog mix 70-30 flex pen (Insulin) for Resident #370 was opened and undated and Flonase for Resident #372 was opened and undated. Further Review of the medication cart revealed Mucus relief guaifenesin 400 mg had an expiration date of 01/22. Interview on 02/10/22 at 11:00 A.M. and 1:49 P.M. with RN #3000 confirmed the findings. After confirming the findings, she then placed the medication back onto the Medication Cart. Observation on 02/10/22 at 11:20 A.M. revealed a sterile water for injection vial with 20 milliliters (ml), opened, but undated in the north medication room. Licensed Practical Nurse (LPN) #160 confirmed the findings at 11:30 A.M. Review of the facility policy titled, Medication Administration dated 01/01/21 revealed medication source was to be verified with the Electronic Medication Administration Record (EMAR) to identify expiration dates and notify the nurse manager if medication was expired and correct any discrepancies and report to the nurse manager. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365474 If continuation sheet Page 38 of 43 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 365474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Carroll 3680 Dolson Court NW Carroll, OH 43112 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 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #60's medical record revealed an initial admission date of 01/07/21 with the latest readmission of 03/21/21. Diagnoses included dementia with behavioral disturbances, anxiety disorders, mood disorder, hypertension, major depressive disorder with psychotic symptoms, pain, restlessness and agitation, history of COVID-19, gastro-esophageal reflux disease, lactose intolerance and insomnia. Residents Affected - Few Review of the resident's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had clear speech, understood others, makes herself understood and had a moderate cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of seven. Review of the resident' physician's orders for February 2022 identified an order dated 10/28/21 for a Basic Metabolic Panel (BMP) every six months in October and April. Review of the medical record contained no results for the 10/28/21 BMP. On 02/09/22 at 2:16 P.M. interview with Director of Nursing (DON) verified the 10/28/21 ordered BMP was not completed. Based on medical record review, staff interview, and policy review the facility failed to provide ordered laboratory services for residents. This affected two of four sampled residents reviewed for laboratory services (Residents #3 and #60). Findings Include: 1. Review of the medical record for Resident #3 revealed an original admission date on 03/30/21 and a readmission date of 05/13/21. Medical diagnoses included unspecified fractures of unspecified shaft of the radius and patella, Type II Diabetes Mellitus with diabetic neuropathy, mood (affective) disorder, adjustment disorder with mixed anxiety and depressed mood, insomnia, and schizoaffective disorder (Bipolar type). Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #3 had intact cognition and scored 14 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. The resident required supervision with set up help only for most Activities of Daily Living (ADLs). The resident required supervision with one staff assist for bed mobility, dressing, toileting and hygiene. Review of the physician's orders for February 2022 revealed Resident #3 had an order to obtain a hemoglobin A1c (HgbA1c) blood test every three months. The order had a start date on 10/05/21. Review of the Medication Administration Records (MAR) dated from October 2021 and January 2022 revealed on 10/05/21 there was a code of see nurse notes entered. The rest of the month was marked as administered. On 01/05/22, the lab order was marked as administered. Review of the electronic medical record for Resident #3 revealed there were no HgbA1c lab results included in the record. Review of nurse's notes dated from 10/01/21 through current revealed there were no notes related to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365474 If continuation sheet Page 39 of 43 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 365474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Carroll 3680 Dolson Court NW Carroll, OH 43112 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 0770 completion of the HgbA1c lab. Level of Harm - Minimal harm or potential for actual harm Review of the plan of care dated 03/30/21 revealed Resident #3 had Diabetes Mellitus with a history of being non-compliant with taking medications and insulin. Interventions included administer diabetes medication as ordered by physician, monitor and document side effects and effectiveness, and obtain fasting serum blood sugar as ordered by physician. The care plan did not address obtaining labs as ordered by the physician. Residents Affected - Few Interview on 02/09/22 at 2:13 P.M. with the Director of Nursing (DON) confirmed Resident #3 did not have HgbA1c lab drawn as ordered by the physician. The DON stated the staff would be educated related to proper documentation in Resident #3's MAR related to lab orders. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365474 If continuation sheet Page 40 of 43 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 365474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Carroll 3680 Dolson Court NW Carroll, OH 43112 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to provide mechanically altered foods in the form prescribed by the physician. This affected one resident (#17) of the five residents reviewed for nutrition. The facility census was 76. Findings include: Record review for Resident #17 revealed this resident was admitted to the facility on [DATE] and had diagnoses including epilepsy, Alzheimer's disease, anxiety disorder, and dysphagia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/25/22, revealed this resident had severely impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 00. This resident was assessed to require extensive assistance from two staff members for bed mobility, transfers, and toileting and to require extensive assistance from one staff member for eating. This resident was assessed to have received a mechanically altered diet. Review of the care plan, dated 02/01/22, revealed this resident had the potential for nutritional deficits and received an altered texture diet. Interventions included to assist with meals as needed and provide and serve diet as ordered. Review of the active physicians order, dated 01/25/22, revealed this resident had orders to receive a pureed texture diet with nectar/mildly thick consistency fluids. Observation on 02/07/22 at 12:22 P.M. revealed Resident #17 was being assisted to consume her lunch meal by Activity Director #200. The residents lunch meal tray consisted of a pork chop which had been ground into small chunks and not pureed, mashed potatoes, and spinach was was chopped and also not pureed. The meal ticket lying on the residents tray revealed the resident was to have received pureed pork chops, mashed potatoes, and pureed brussel sprouts. Interview with Activity Director #200 on 02/07/22 at 12:24 P.M. verified the meal ticket for Resident #17 stated the resident was to receive a pureed pork chop, mashed potatoes, and pureed spinach. Activity Worker #200 verified the pork chop and the spinach the resident received had not been pureed. Observation and interview with Licensed Practical Nurse (LPN) #110 on 02/07/22 at 12:28 P.M. verified Resident #17 was ordered to receive pureed foods and the pork chop and spinach on the residents meal tray were ground and not pureed. Review of the facility policy titled Therapeutic Diet Orders, revised 07/31/20, revealed a mechanically altered diet was one in which the texture or consistency of food is altered to facilitate oral intake and dietary and nursing staff were responsible for providing therapeutic diets in the appropriate form as prescribed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365474 If continuation sheet Page 41 of 43 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 365474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Carroll 3680 Dolson Court NW Carroll, OH 43112 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to maintain a complete record in the area of psychiatric consults for one resident (#60). This affected one of 24 sampled residents. Findings Include: Review of Resident #60's medical record revealed an initial admission date of 01/07/21 with the latest readmission of 03/21/21. Diagnoses included dementia with behavioral disturbances, anxiety disorders, mood disorder, hypertension, major depressive disorder with psychotic symptoms, pain, restlessness and agitation, history of COVID-19, gastro-esophageal reflux disease, lactose intolerance and insomnia. Review of the resident's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had clear speech, understood others, makes herself understood and had a moderate cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of seven. Review of the resident' physician's orders for February 2022 identified an order dated 01/15/22 for Ambien 5 milligrams (mg) by mouth at bedtime, Zyprexa 2.5 mg by mouth every day for dementia with behavioral disturbances and 01/19/22 for Zyprexa 5 mg by mouth at bedtime for dementia with behavior disturbances. On 02/09/22 at 9:35 A.M. interview with the Director of Nursing (DON) revealed the resident is seen by psychiatry, however the psychiatric consult notes were not available. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365474 If continuation sheet Page 42 of 43 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 365474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Carroll 3680 Dolson Court NW Carroll, OH 43112 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to provide a clean and sanitary environment in residents rooms. This affected the two residents (#29 and #55). The facility census was 76. Findings include: Observation on 02/07/22 at 10:15 A.M. revealed the trash can in room [ROOM NUMBER] was observed to be filled with garbage which was overflowing onto the floor. The floor, recliner,trash can, and the bottom legs of the bedside stand located in the room were observed to have an excessive amount of a dried, brown, sticky substance covering them. Observation and interview with State Tested Nursing Assistant (STNA) #165 on 02/07/22 at 10:24 A.M. revealed one of the residents in the room had a behavior which included spitting on the floor and items in the room. STNA #165 verified the floor, recliner, and bottom legs of the bedside stand in the room were covered with an excessive amount of a dried, brown, sticky substance which most likely was spit. Observation on 02/08/22 at 7:58 A.M. revealed the trash can and bottom legs of the bedside table in room [ROOM NUMBER] continue to be covered with a dried, brown, sticky substance. Observation and interview with Licensed Practical Nurse (LPN) #110 on 02/08/22 at 8:05 A.M. verified the trash can and bottom legs of the bedside table in room [ROOM NUMBER] were covered in a dried, brown, sticky substance. Observation on 02/09/22 at 3:45 P.M. revealed the trash can and bottom legs of the bedside table in room [ROOM NUMBER] continued to be covered with a dried, brown, sticky substance. Observation and interview with Assistant Director of Nursing (ADON) #700 on 02/09/22 at 3:45 P.M. verified the trash can and bottom legs of the bedside table in room [ROOM NUMBER] were covered in a dried, brown, sticky substance which needed to be cleaned. Review of the facility policy titled Routine Cleaning and Disinfection, revised on 10/17/20, revealed cleaning referred to the removal of visible soil from objects and surfaces and consistent surface cleaning and disinfection would be conducted with a detailed focus on high touch areas to include resident chairs and tray tables. This deficiency substantiates Complaint Number OH00130055. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365474 If continuation sheet Page 43 of 43