Inspection·October 24, 2023

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was. LPN #22 then said she was too busy and for her to go back to her room. When LPN #22 asked the resident to go to her room, the resident replied that she would not because she wanted cough medicine and would wait at the cart. LPN #22 then told the resident not to stare at her and that the resident was harassing her. She then allegedly said What the F***, stop being rude to me. The resident told the nurse again that she was not leaving. Resident #46 then heard LPN #22 tell LPN #45 that she (the resident) was being a B****. The resident was asked how that made her feel overhearing the nurse calling her a B**** or being told she was harassing the the nurse. The resident reported she was angry at the time, but had prayed and now felt fine. She denied being angry or sad. She denied feeling fearful of staff when she was interviewed by the DON for her witness statement. A witness statement from LPN #22 for the incident occurring on 10/10/23 at 8:00 A.M. revealed the nurse came on duty at 7:00 A.M. and at 7:30 A.M. Resident #46 came to the medication cart during report. LPN #22 told the resident that she would assist her when they were done with report. The nurse asked the resident to wait in her room because the resident was standing directly over them when she was trying to take report. When the report was finished, the nurse was stocking her medication cart and checking the narcotic supplies. Resident #46 returned and was standing over the nurse. The resident told her that she wanted her pills. The nurse asked her to give her some time, as she did not know her medications, and needed to look them up. The resident then stomped her foot and said she was not moving until the nurse gave her her stuff. The nurse replied that she asked her nicely to please go to her room while she got the resident her stuff. The nurse then indicated in her statement she was carrying a bag of trash to take it to the soiled utility room and walked by LPN #45. LPN #22 thought she was out of earshot of the resident as she was by the soiled utility room at that time. The nurse indicated she said to LPN #45 (under her breath) she's being a B****. When the nurse came out of the soiled utility room, the resident was following the other nurse down the back hallway. At that time the resident was screaming at her (LPN #22) and she was yelling back at the resident. At that time the DON came around the corner and intervened. A witness statement by LPN #45 for the incident occurring on 10/10/23 at 8:00 A.M. revealed she was starting her morning routine and overheard yelling on the South side. Resident #46 was asking for cough medicine and the other nurse (LPN #22) repeated Give me a few minutes, I have this whole side for the love of God! The nurse (LPN #45) told the other nurse (LPN #22) to give her the keys. She would hold them and start the medication pass for the South Short unit. LPN #22 replied no I told you I got this side, she can wait, she needs to stop being a F****** B****, it's a bit much. The resident then asked LPN #22 what did you call me, a F****** B****? The resident told LPN #45 not to let her talk to her like that. At that time, the DON was on the unit. The resident went to her room and LPN #22 went to the medication room. LPN #45 was then asked to take over the South Short unit as LPN #22 was sent home for the day. The witness statement by the DON for the incident occurring on 10/10/23 at 8:00 A.M. revealed she heard Resident #46 and LPN #22 yelling at each other. She could not determine what they were yelling about at the time, but was told LPN #22 called Resident #46 a F****** B****. She approached the nurse as she was gathering her things and reported she was leaving. The DON told LPN #22 that she needed to come to her office. The nurse was crying and was telling her that it was all too much. The DON obtained a statement from LPN #22 before walking her to the time clock before the nurse exited the building through the side door. As a result of the facility's investigation into the allegation of emotional/ verbal abuse that occurred on 10/10/23 at 8:00 A.M. between Resident #46 and LPN #22, the facility substantiated the abuse allegation. LPN #22 was terminated from her employment with the facility as a result of that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365474 If continuation sheet Page 2 of 11 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 10/24/2023 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 0600 incident. Level of Harm - Minimal harm or potential for actual harm On 10/23/23 at 11:05 A.M., an interview with the DON confirmed LPN #22 was terminated as a result of the incident that occurred between Resident #46 and LPN #22. The facility substantiated the allegation of abuse based on their investigation. She confirmed Resident #46 did overhear LPN call her a derogatory name and it was upsetting to the resident to hear that, which is why they felt it met the definition of abuse. Residents Affected - Few A review of the facility's abuse policy (revised 10/24/22) revealed it was the policy of the facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse. Abuse was defined as a willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, which could include staff to resident abuse. Verbal abuse was defined as the use of oral, written, or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within hearing distance regardless of their age, ability to comprehend, or disability. As a result of the incident, the facility took the following actions to correct the deficient practice by 10/16/23: • Immediately following the incident on 10/10/23, skin and pain assessments were completed on Resident #46 and the resident was seen by psychiatric services that same day. • Psychosocial assessments were completed on Resident #46 on 10/11/23 and 10/12/23 to ensure no negative effects occurred related to the abuse. • LPN #22 was immediately suspended pending the outcome of the investigation. Her employment with the facility was terminated on 10/11/23, as a result of the outcome of the investigation. • On 10/10/23, all alert and oriented residents were interviewed to ensure no abuse had occurred involving those residents. Non-alert and oriented residents had skin sweeps conducted to ensure no evidence of abuse existed for those residents. • On 10/10/23 and by 10/11/23, all facility staff were educated on the facility's abuse policy and procedure with reporting. Education was also provided on how to deal with difficult behaviors. Ongoing training to be provided through Relias on how to deal with residents with difficult behaviors. A post test to be completed to ensure staff competency on the facility's abuse policy and dealing with difficult residents related to behaviors. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365474 If continuation sheet Page 3 of 11 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 10/24/2023 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 0600 • Level of Harm - Minimal harm or potential for actual harm Audits to be completed with five residents weekly x 4, then monthly x 1 to ensure residents were free from abuse and felt safe in the facility. Skin sweeps were to be completed on five non-alert and oriented residents weekly x 4, then monthly x 1 to ensure those residents were free of abuse. Five employees weekly x 4, then monthly x 1 would be interviewed to ensure they could identify signs and symptoms of abuse and how to respond appropriately to residents with difficult behaviors. Residents Affected - Few • Results of audits to be reviewed in Ad Hoc QAPI meetings to ensure the plan was appropriate and effective x 2 months. This deficiency is cited as an incidental finding to Complaint Number OH00146747. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365474 If continuation sheet Page 4 of 11 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 10/24/2023 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 0602 Protect each resident from the wrongful use of the resident's belongings or money. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Residents Affected - Some Based on review of a self reporting incident (SRI), review of the facility's related investigation, staff interview, and policy review, the facility failed to ensure residents were free from misappropriation when residents' controlled narcotic pain medication was not misappropriated. This affected 18 residents (#10, #17, #22, #26, #29, #42, #47, #53, #67, #89, #90, #91, #92, #93, #94, #95, #96, and #97) identified by the facility during their investigation into an allegation of misappropriation as having had their controlled narcotic pain medications misappropriated. Findings include: A review of SRI #240119 revealed an allegation of misappropriation was made known to the facility on [DATE]. The initial source of the allegation was a facility nurse and the alleged perpetrator was identified as Licensed Practical Nurse (LPN) #100. The initial resident/ victim was identified as Resident #53. As a result of the facility's investigation, 17 other residents (Resident #10, #17, #22, #26, #29, #42, #47, #67, #89, #90, #91, #92, #93, #94, #95, #96, and #97) were identified and included as resident/ victims. A brief description of the allegation revealed LPN #107 noted Resident #53 was out of her Oxycodone. LPN #107 called the facility's contracted pharmacy for a refill and was told Resident #53 had a quantity of 60 Oxycodone tablets delivered to the facility on [DATE] and should have had enough to last her through 10/14/23. LPN #107 notified the facility's Director of Nursing (DON) and the facility staff began searching for the drug cards and the narcotic count sheet that should have been sent with the controlled narcotic pain medication. It was discovered the drug cards for Resident #53's Oxycodone and it's narcotic count sheet were missing. An investigation began for the misappropriation of the resident's medication. The last nurse in question was identified as the day shift nurse from 10/11/23 (LPN #100). The facility's DON contacted her by phone and LPN #100 confirmed she called the pharmacy to get a refill for Resident #53's Oxycodone. She claimed she placed the empty drug card and the completed narcotic count sheet in the unit manager's box. Those were not found. LPN #100 was suspended pending further investigation. The local law enforcement was notified and a report was opened. A review of the facility's investigation into the allegation of misappropriation was reviewed with the DON. Each of the 18 residents that were identified as being a resident/ victim involved in the misappropriation was reviewed. 1 a.) Resident #89 had the use of Norco (narcotic pain medication) 5/325 milligrams (mg) tablets. The DON reported her investigation determined 30 tablets were suspected as having been misappropriated by LPN #100. The nurse was noted to have documented on the shift to shift sheet that the card containing the Norco tablets and the narcotic count sheet for that controlled medication had been removed from the medication cart and the narcotic count book by LPN #100 on 10/09/23. 1 b.) Resident #10 had the use of Percocet (narcotic pain medication) 5-325 mg tablets. Up to 30 tablets were suspected as having been misappropriated by LPN #100 as a result of the facility's investigation. The DON determined the facility received 30 tablets of Percocet for the resident on 09/26/23. The medication administration record (MAR) did not reflect any doses had been received by the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365474 If continuation sheet Page 5 of 11 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 10/24/2023 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 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some resident. LPN #100 documented on the shift change controlled substance accountability sheet that the resident's card of Percocet and it's narcotic count sheet had been removed on 09/28/23. 1 c.) Resident #90 had the use of Norco 5/325 mg tablets. The DON determined through her investigation that the facility received 30 tablets of Norco from their pharmacy on 07/13/23. The resident's MAR showed five tablets had been given to the resident. 25 tablets of the Norco was believed to have been misappropriated. The card containing the Norco and the narcotic count sheet had been removed by LPN #100 on 07/20/23, after the resident's discharge on [DATE]. The DON stated the resident's discharge was unexpected as his brother just showed up to take him home. The DON denied that the resident would have been given any of the Norco to take home with him, since his discharge was not planned. 1 d.) Resident #17 had the use of Oxycodone (narcotic pain medication) 5 mg tablets. The DON reported the facility received a card of 26 Oxycodone on 09/26/23 from the pharmacy. The card containing the Oxycodone was documented as having been removed from the medication cart along with the narcotic sheet by LPN #100 on 09/28/23, as was indicated on the controlled substance accountability sheet. The DON stated the resident would have had another card of Oxycodone available for use and did not go without any pain medication. 1 e.) Resident #22 had the use of Percocet 5/325 mg tablets. The DON reported the facility had received 30 tablets from their pharmacy for the resident's use on 10/05/23. The facility's investigation determined that medication was not added to the the controlled substance accountability sheet when it was received and the card that contained the controlled narcotic pain medication was not placed in the medication cart. The narcotic count sheet that was to track the use of that controlled medication was not placed in the narcotic control book by LPN #100. The DON reported the nurse was the one that was working when that medication was received. She stated that resident had a previous card that the nurses were pulling from and the resident continued to receive the pain medication when she needed it for pain. 1 f.) Resident #26 had the use of Norco 5/325 mg tablets. A count of 84 Norco's were received by the facility from the pharmacy on 10/06/23. The DON was able to determine the resident had used 10 of those tablets. LPN #100 documented on the controlled substance accountability sheet that she removed three cards containing the Norco from the medication cart and removed one narcotic sheet from their narcotic count book on 10/10/23. The DON stated one card could hold up to 30 tablets and they would have had only one sheet that was supposed to be used to document the 84 doses administered. She could not account for 74 of the 84 tablets and suspected LPN #100 had misappropriated them when the controlled medication was removed from the medication cart. She denied the other nurses would have questioned that nurse removing the card and the narcotic count sheet, as that medication was discontinued it was likely assumed LPN #100 gave the discontinued medication to the DON for destruction as was their policy. 1 g.) Resident #91 had the use of Norco 5/325 mg tablets. The DON reported the facility received 30 tablets from their pharmacy on 08/18/23. The card containing Norco and the narcotic sheet had been removed from their medication cart and the controlled narcotic count book by LPN #100 on 10/06/23. She was able to determine by reviewing the resident's MAR that three doses of the Norco had been used from that 30 tablet supply. She could not account for the 27 tablets of Norco that were missing. She reported the resident was discharged to an assisted living facility, so any remaining balance of the Norco would not have been sent to the assisted living facility with the resident. 1 h.) Resident #29 had the use of Percocet 5-325 mg tablets. A refill was requested from their (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365474 If continuation sheet Page 6 of 11 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 10/24/2023 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 0602 Level of Harm - Minimal harm or potential for actual harm contracted pharmacy by LPN #100 on 10/09/23. It was determined by the DON that the pharmacy had delivered 12 tablets on that same day. LPN #100 was suspected as having kept the card of Percocet and the narcotic sheet when it was delivered failing to add it to the controlled substance accountability sheet or in the narcotic count book as it should have been. She reported the resident had previous supply of that medication on hand and the medication was available for use if needed. Residents Affected - Some 1 i.) Resident #92 had the use of Percocet 5-325 mg tablets. The DON reported a supply of that medication had been provided by their pharmacy on 09/26/23 to include 30 tablets. The resident used 17 tablets while in the facility per her MAR and was sent home on [DATE] with 12 tablets, as was indicated in her progress notes. She could not account for one of the doses that should have been remaining. She stated it was possible the resident was given the full remaining 13 count, but she could not rule out that LPN #100 took that medication as it was not documented as having been sent with the resident. 1 j.) Resident #93 had the use of Norco 5/325 mg tablets. The DON reported the facility received 30 tablets from their pharmacy on 06/23/23. The resident was discharged home on [DATE]. LPN #100 documented she pulled the card of Norco from the cart and removed the narcotic sheet for that medication from the narcotic count book on 07/20/23. The DON was able to show 19 of the 30 tablets had been signed out for the resident's use, but she could not account for the remaining 11 tablets not accounted for. She suspected LPN #100 had misappropriated those 11 remaining Norco tablets, as they were not turned in to her, after the resident's discharge from the facility, as they should have been. 1 k.) Resident #42 had the use of Tramadol 50 mg tablets. A supply of 30 had been sent from their pharmacy on 05/13/23 according to the DON and her investigation. The resident's MAR showed he received one tablet from that supply. The card containing the medication and the narcotic sheet was removed by LPN #100 on 07/27/23. She determined that 29 tablets could not be accounted for and it was thought the nurse that removed the medication and narcotic sheet misappropriated them. 1 l.) Resident #94 had the use of Norco 5/ 325 mg tablets. The DON reported the pharmacy had delivered 60 tablets of Norco on 07/17/23. The order for Norco was discontinued on 07/31/23. LPN #100 documented on the controlled substance accountability sheet that she removed the card containing the Norco and narcotic count sheet on 08/03/23. The DON was able to show the resident received 24 of those 60 tablets, as was indicated on the MAR's, but 36 tablets could not be accounted for. 1 m.) Resident #47 had the use of Percocet 5/325 mg tablets. The DON stated they received a 30 count from the pharmacy on 07/11/23. She was able to determine that the resident used 16 doses from that 30 count according to doses signed out on the MAR. LPN #100 documented on the controlled substance accountability sheet that she removed the card containing the Percocet and the narcotic sheet on 07/20/23. The DON could not account for the 14 tablets that should have been remaining when the LPN removed them from the cart/ count. She further stated the resident was transferred to the hospital on [DATE] and his return was anticipated. She stated the nurse should have left the Percocet in the cart for him to have upon his return. Resident #47 also had the use of Oxycodone 5 mg tablets. The DON reported the facility received 30 Oxycodone tablets from their pharmacy on 07/31/23. She was able to account for 12 of those 30 tablets being given to the resident based on what was documented on the MAR. LPN #100 documented she removed the card containing the Oxycodone and the narcotic count sheet from their medication cart and count on 08/25/23, as was documented on the controlled substance accountability sheet. She could not account for 18 of the 30 tablets. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365474 If continuation sheet Page 7 of 11 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 10/24/2023 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 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A further review of the facility's investigation revealed Resident #47 also had a 30 count of Oxycodone 5 mg tablets (30 count) delivered by their pharmacy on 08/25/23. She was able to determine by reviewing the MAR that six of those tablets had been signed out as having been given to the resident. LPN #100 removed the card containing the remaining Oxycodone 5 mg tablets and the narcotic count sheet on 09/14/23, as was documented on the controlled substance accountability sheet. 24 of those 30 tablets could not be accounted for. LPN #100 had also ordered Oxycodone for the resident from their pharmacy on 09/13/23. The nurse signed for receipt of the medication when it was delivered that same day. 30 tablets were reported to have been sent by the pharmacy. The DON indicated the nurse must have taken that card containing the Oxycodone and the narcotic count sheet as it could not be found after it was delivered. 1 n.) Resident #95 had the use of Oxycodone 5 mg tablets. The DON reported the pharmacy delivered 20 tablets on 10/07/23. The order for Oxycodone was given on 10/05/23 before being discontinued on 10/07/23. She reviewed the MAR's and determined the resident was not documented as having received any doses of that medication. LPN #100 documented on the controlled substance accountability sheet that she removed the card and the sheet from their count on 10/09/23. The DON was not able to account for any of the 20 tablets of Oxycodone that was missing. 1 o.) Resident #53 had the use of Oxycodone 10 mg tablets. The DON reported the the facility received a 60 count of Oxycodone from the pharmacy on 10/05/23. The DON was able to account for 35 of the 60 tablets, as that was what was signed out on the MAR. LPN #100 removed the card containing the Oxycodone and the narcotic count sheet on 10/11/23, as was documented on the controlled substance accountability sheet. The DON could not account for the 25 tablets that should have been remaining when the card was removed from the cart on 10/11/23. 1 p.) Resident #96 had the use of Norco 5/325 mg tablets. The DON stated they received 24 tablets from the pharmacy on 09/17/23. The Norco card was not placed in the medication cart and the medication was not added to their shift to shift controlled substance accountability sheet. She reported LPN #100 was the nurse that was working that day and would have been the one to receive the Norco from the pharmacy. She suspected all 24 tablets of the Norco had been diverted by LPN #100 upon their arrival to the facility. The resident also had the use of Percocet 5/ 325 mg tablets. The DON reported they received 30 tablets of Percocet from the pharmacy on 08/21/23. She denied the resident was noted to use any when she looked at the MAR. LPN #100 removed the card and the narcotic sheet on 09/04/23, as was documented on the controlled substance accountability sheet. All 30 tablets of the Percocet was thought to have been misappropriated. The DON indicated her investigation determined another six tablets of Norco had been received by the facility on 07/14/23 for Resident #96. The order was discontinued on 07/17/23 and it was not noted that the resident received any of the 6 doses according to the MAR. LPN #100 had documented on the controlled substance accountability sheet that she removed the card containing the six Norco tablets and the narcotic count sheet from the cart/ count on 07/20/23. All six tablets were thought to have been misappropriated. 1 q.) Resident #97 had the use of Norco 5/325 mg tablets. The DON reported they received 82 tablets of Norco from their pharmacy on 06/11/23. Her investigation showed the resident received 15 of those tablets. LPN #100 documented that she had removed the card containing the Norco and the narcotic count sheet from the medication cart and their count on 06/26/23. She indicated three cards and one (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365474 If continuation sheet Page 8 of 11 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 10/24/2023 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 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some sheet had been removed, which the three cards should have still contained 67 tablets of Norco at the time it was removed. 1 r.) Resident #67 had the use of Norco 5/325 mg tablets. The DON reported the facility received 30 tablets from their pharmacy on 10/07/23. She was able to show by reviewing the MAR that six tablets was documented as having been given to the resident since 10/07/23. LPN #100 documented she removed one card and one narcotic sheet from their cart/ count on 10/09/23, as was documented on the controlled substance accountability sheet. The DON could not account for 24 of the 30 Norco tablets and it was suspected that the remaining 24 had been misappropriated by LPN #100. In all, out of the 18 residents that had medications misappropriated, there were 324 tablets of Norco, 117 tablets of Percocet, 143 tablets of Oxycodone, and 29 tablets of Tramadol that the facility could not account for. LPN #100 was directly involved with the ordering, receipt and/ or removal of those controlled medications. As a result of the facility's investigation they substantiated the allegation of misappropriation of residents' medications. LPN #100's employment with the facility had been terminated and she was reported to the local law enforcement agency and the Ohio Board of Nursing. On 10/23/23 at 1:45 P.M., an interview with the DON revealed she did substantiate the allegation of misappropriation of resident medication based on the findings of her investigation. She confirmed 18 residents medications were found to have been misappropriated by LPN #100. The misappropriation had occurred between June 2023 and October 2023 before it was reported on 10/12/23. They were alerted to the possibility of the medication misappropriation when LPN #107 had attempted to get a controlled narcotic pain medication refilled for Resident #53. The pharmacy reported the controlled narcotic pain medication had recently been filled, which the medication and the narcotic count sheet could not be found. They identified the nurse (LPN #100) who was working that day when the controlled narcotic medication had been received. That prompted an investigation that identified 17 other residents to have had their narcotic pain medication misappropriated by LPN #100. She stated the nurse would pull the cards containing to controlled medications from the cart and would remove the count sheet from their controlled medication count book when a resident was discharged or the controlled medications were discontinued. The nurse would also call in for a refill and keep the controlled medication and the count sheets when she received them from the pharmacy. She reported the residents cards/ sheets for controlled medications that were empty and had been used up were to go to the unit managers. If the cards had controlled medication remaining in them, such as at the time of the resident's discharge or when the controlled medication had been discontinued, the cards containing the controlled medication and the narcotic count sheet were supposed to be given to her. If she was not there, they were to remain in their controlled medication storage box and continued to be reconciled every shift until they could be given to her. Her investigation determined concerns with how the facility was keeping track of the controlled medications, as the staff nurses were not completing the shift to shift count correctly. She gave them examples on how the shift to shift count sheet should be completed and how they should look. The count sheets were not being completed neatly and were sloppy. That made it hard to track the controlled medications with how the count sheets/ shift to shift accountability sheets were being filled out. The DON also stated during her investigation, she found pharmacy receipts and narcotic count sheets disposed of in the facility's shredder box for controlled medications LPN #100 received from the pharmacy or pulled from the cart/ count. A review of the facility's policy on policy on Abuse, Neglect, and Exploitation (revised 10/24/22) revealed it was the facility's policy to provide protections for the health, welfare, and rights of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365474 If continuation sheet Page 9 of 11 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 10/24/2023 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 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Misappropriation of resident property meant the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of resident's belongings without the resident's consent. A review of the facility's policy on Controlled Substance Administration and Accountability (revised 01/01/22) revealed it was the policy of the facility to promote a safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. The facility would have safeguards in place in order to prevent loss, diversion, or accidental exposure. Controlled medications must be counted upon delivery. The nurse receiving the delivery, along with the person delivering the medication order, must count the controlled substances together. Both individuals must sign the designated narcotic record. If the count was correct on delivery, the medication would be placed in the controlled substance binder for the designated medication cart. Each time a controlled substance and control count sheet was received, it should be added to the shift verification sheet column for the number of control count sheets present. Nursing staff must count controlled drugs at the end of each shift. They must document and report any discrepancies to the DON immediately. When a resident with a controlled substance was discharged from the facility, or the controlled substance was discontinued, the remaining controlled substance and control count sheet would be delivered to the DON as soon as possible. As a result of the incident, the facility took the following actions to correct the deficient practice by 10/16/23: • An investigation into the allegation was initiated by the facility's DON on 10/12/23. A total of 18 residents were identified as having had controlled narcotic pain medication misappropriated by LPN #100 through the facility's investigation. LPN #100 was suspended immediately pending the outcome of the investigation. Her employment with the facility was terminated as a result of the investigation, with local law enforcement and the Ohio Board of Nursing notified of the misappropriation/ diversion of controlled medication. • A whole house audit was completed with a 30 day look back by the DON showing that narcotics have been delivered and added to the narcotic drawer/ count sheet appropriately. A whole house audit was completed of medication carts for the storage of narcotic medications to ensure the counts were correct and the shift to shift sheets were filled out appropriately. The DON completed a review of all narcotics LPN #100 had removed from the cart to ensure they were removed appropriately and either given to the resident at discharge or placed on the destruction log for the DON to destroy. Pain assessments were completed on all residents by the DON/ Designee on 10/12/23 and 10/13/23. Alert and oriented residents were interviewed by 10/13/23 to ensure they were receiving their pain medications as ordered. • All nurses were educated by the DON by 10/15/23 on Controlled Substance Policy to include appropriate narcotic count, ensuring MAR's and narcotic logs would be signed off with all narcotic medication administration and ensure they were counting the narcotics appropriately. All nurses were also (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365474 If continuation sheet Page 10 of 11 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 10/24/2023 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 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some educated by the DON/ Designee on the removal of narcotics in a timely manner and to be given to the DON to be added to the destruction log or if given to the residents at discharge must be witnessed by two nurses. When narcotic cards had been emptied, the narcotic card, count sheet, and copy of the shift to shift count would be put in the unit manager's mail box. Unit managers were to compare delivery manifest with the narcotic log daily. When narcotics were discontinued, the floor nurse would alert the DON and the narcotics would be removed from the medication cart at that time during regular business hours for destruction. During off hours, the nurse receiving the order for the narcotics being discontinued, would notify the DON/ on call nurse that the narcotic would need removed from the cart for destruction next business day. Narcotics received would be verified by two nurses at the time of arrival. • DON/ Designee would complete audits on five residents weekly x 4 weeks to ensure MAR's matched the narcotic logs. Any variances would be addressed immediately. The DON/ designee would audit the delivery of narcotics weekly x 4 to ensure narcotics were delivered and added to the medication cart appropriately. The DON/ Designee would audit three nurses weekly x 4 weeks to ensure counting of narcotics were conducted appropriately to include the shift to shift sheet being filled out correctly. The DON/ Designee would audit weekly x 4 the narcotic shift to shift count sheets to ensure any removal of narcotics was removed timely and documented appropriately. • Results of audits to be reviewed in the Ad Hoc QAPI meetings weekly x 4 to ensure the facility's plan was effective. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365474 If continuation sheet Page 11 of 11