Health inspection·February 14, 2024

F 0636 A.M. revealed she thought Resident #84 had her own teeth and did not require dentures. Level of Harm - Minimal harm or potential for actual harm Interview with MDS LPN #414 on 02/07/24 at 9:56 A.M. confirmed the nutrition assessments, nursing assessment, and MDS assessments were not accurate since Resident #84 did not have all of her own teeth and had dentures on top, which the resident said were broken. She confirmed a comprehensive assessment of Resident #84's dental status was not completed. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365474 If continuation sheet Page 2 of 29 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 02/14/2024 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interviews, and facility policy review, the facility failed to provide showers as scheduled to Resident #46. The deficient practice affected one resident (#46) of two residents reviewed for activities of daily living (ADL). The facility census was 88. Residents Affected - Few Findings Include: Review of the medical record for Resident #46 revealed an admission date on 11/18/23. Medical diagnoses included heart failure, acute and chronic respiratory failure, type II diabetes mellitus, chronic obstructive pulmonary disease (COPD), asthma, morbid obesity, anxiety disorder, and depression. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #46 had intact cognition and scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #46 required partial to moderate assistance from staff for showering or bathing and for tub or shower transfers. Review of shower documentation dated December 2023 revealed Resident #46 was scheduled to receive showers on Mondays and Thursdays during the 2:00 P.M. to 10:00 P.M. shift. Resident #46 did not receive scheduled showers on Monday, 12/11/23, Thursday, 12/14/23, Thursday 12/21/23, or Thursday 12/28/23. Review of shower documentation dated January 2024 revealed Resident #46 did not receive scheduled showers on Monday 01/08/24, Thursday 01/18/24, or Thursday 01/25/24. Review of shower documentation dated February 2024 revealed Resident #46 received showers on 02/01/24 and 02/08/24. Resident #46 was marked as refusing a shower on Monday, 02/05/24. Interview and observation on 02/05/24 at 12:55 P.M. with Resident #46 revealed she did not always receive showers as scheduled. Resident #46 reported she was supposed to receive showers on Mondays and Thursdays. Resident #46 stated she had not been offered a shower yet today, 02/05/24 but typically received showers in the evenings. Resident #46 also reported she had not received a shower for an entire week in January 2024. Resident #46 stated the facility staff may report the resident refused showers, but the resident adamantly denied she had refused any showers at the facility. Interview and observation on 02/07/24 at 10:10 A.M. with Resident #46 revealed she did not receive a shower or bed bath as scheduled on 02/05/24. Again, the resident denied she refused a shower and stated the facility staff had not offered to take her to the shower. Resident #46 stated she was able to complete most of her shower by herself but needed assistance with washing her back and feet and needed staff to stay in the shower room with her for safety. Resident #46 stated her last shower was on Thursday, 02/01/24 (nearly one week ago). Resident #46 stated her next scheduled shower was tomorrow, 02/08/24. Interview and observation on 02/12/24 at 2:37 P.M. with Resident #46 revealed she did not receive a shower on Monday, 02/05/24 or Thursday, 02/08/24. The resident stated she did receive a shower on Saturday, 02/10/24. Resident #46 denied again she had refused any showers. Interview on 02/12/24 at 3:11 P.M. with the Director of Nursing (DON) #533 confirmed Resident #46 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365474 If continuation sheet Page 3 of 29 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 02/14/2024 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 0677 did not receive scheduled showers as indicated above in December 2023 or January 2024. Level of Harm - Minimal harm or potential for actual harm Review of the facility policy, Activities of Daily Living (ADL), revised 12/28/23, revealed the policy stated, a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365474 If continuation sheet Page 4 of 29 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 02/14/2024 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** Based on medical record review, interview, and facility policy review the facility failed to ensure timely treatment was initiated urinary tract infections. This affected two residents (#43 and #84) of six residents reviewed for antibiotic use/urinary tract infections. The facility census was 88. Residents Affected - Few Findings Include: 1. Review of the medical record for Resident #84 revealed an admission date of 08/04/23 with diagnoses including diabetes, chronic kidney disease, and urinary retention. Review of nursing progress notes on 11/13/23 at 11:10 A.M. revealed Resident #84 received the last dose of an antibiotic and stated she feels a little better but not all the way. The resident continued to be slightly confused at times. The nurse updated the nurse practitioner who said it was okay to get another urine culture if needed in the morning. On 11/14/23 at 11:37 P.M. a urine specimen was collected. Review of urine culture results reported on 11/18/23 revealed greater than 100,000 Proteus Mirabilis. The bacteria was not sensitive to any oral antibiotics (only intravenous or intramuscular medications). Resident #84 was started on an antibiotic (Amoxicillin-potassium clavulanate 875-125 milligrams) twice daily for seven days on 11/20/23. This antibiotic was not listed on the urine culture for the bacteria being sensitive to it. Review of the medication administration record revealed the resident received the Amoxicillin-potassium clavulanate from 11/20/23 to 11/27/23 for a total of 14 doses. There was nothing documented to indicate why the antibiotic was not started for two days after the urine culture results were reported. Interview with the Director of Nursing (DON) on 02/07/24 at 2:45 P.M. confirmed Resident #84 was still confused, so another urine culture was obtained on 11/14/23. She confirmed the bacteria was not listed as sensitive to the antibiotic that was used. She stated she did not know why the antibiotic was not started after the results were reported on 11/18/23. She confirmed the antibiotic did not start until 11/20/23 and could have started 11/19/23 in the morning. 2. Review of the medical record for Resident #43 revealed an admission date on 10/27/23 with medical diagnoses including Alzheimer's disease, type II diabetes mellitus with diabetic chronic kidney disease, chronic kidney disease stage three, urinary tract infection, generalized anxiety disorder, psychosis, major depressive disorder, and cognitive communication deficit. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #43 had impaired cognition and scored seven out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #43 required partial to moderate assistance with toileting and toilet transfers. Resident #43 was frequently incontinent of bowel and bladder. Review of the laboratory results from a urinalysis culture and sensitivity (UA C&S) test reported to the facility on [DATE] at 1:36 P.M. revealed Resident #43 had a positive urinalysis with the culture showing an organism of Escherichia coli (e-coli) bacteria growth greater than 100,000 colony-forming units per milliliter (CFU/mL) (a unit which estimates the number of cells viable enough to proliferate and form small colonies). Review of the Medication Administration Record (MAR) dated November 2023 revealed an order for Cephalexin (an antibiotic) 500 milligrams with instructions to give one capsule by mouth three times (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365474 If continuation sheet Page 5 of 29 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 02/14/2024 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 - Few daily for infection for seven days was ordered to start on 11/28/23 at 1:00 P.M. (two days after the positive urinalysis results were reported to the facility). Review of the laboratory results from a UA C&S test reported to the facility on [DATE] at 3:54 P.M. revealed Resident #43 had a positive urinalysis with the culture showing organisms of e-coli bacteria between 70-99,000 CFU/mL and proteus mirabilis bacteria growth greater than 100,000 CFU/mL. Review of the MAR dated December 2023 revealed an order for Cefdinir (an antibiotic) 300 mg with instructions to give one capsule by mouth every morning and at bedtime for urinary tract infection (UTI) for seven days was ordered to start on 12/17/23 at 8:00 P.M. (approximately 28 hours after results had been reported to the facility.) Review of the laboratory results from a UA C&S test reported to the facility on [DATE] at 4:31 P.M. revealed Resident #43 had a positive urinalysis with the culture showing an organism of e-coli bacteria growth greater than 100,000 CFU/mL. Review of the MAR dated January 2024 revealed there were not any orders for an antibiotic to be started for Resident #43. Review of the MAR dated February 2024 revealed an order for Cephalexin 500 mg with instructions to give one capsule by mouth three times daily for an infection for five days was ordered to start on 02/01/24 at 6:00 A.M. (approximately three and a half days after the results had been reported to the facility). Interview on 02/07/24 at 3:17 P.M. with the DON #533 confirmed there was a delay in starting antibiotic treatment for Resident #43 after positive UA C&S results were reported to the facility on [DATE], 12/16/23, and 01/28/24. DON #533 stated treatment orders should be received immediately after positive lab results were reported. DON #533 stated if results were reported late into the night, the following day would be acceptable but there should not be a longer delay than that to obtain and implement treatment orders. Review of the facility policy, Antibiotic Stewardship Program, revised 12/13/23, revealed the facility would monitor laboratory results when available to determine if an antibiotic was indicated. Review of the facility policy, Antibiotic Prescribing Practices, revised 10/26/23, revealed the purpose of the policy was to implement antibiotic use protocols, including prescribing practices, to optimize the treatment of the infections. The decision to prescribe an antibiotic would be guided by medical knowledge, best practices, and professional guidelines. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365474 If continuation sheet Page 6 of 29 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 02/14/2024 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 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm Based on observations, resident interview, staff interview, and medical record review, the facility failed to ensure Resident #39 received treatment to maintain vision abilities. This affected one resident (#39) of one resident reviewed for communication/sensory abilities. The facility census was 88. Residents Affected - Few Findings Include: Review of the medical record for Resident #39 revealed an admission date of 03/10/23 with diagnoses including end stage renal disease, diabetes, and psychosis. Record review revealed the resident went out of the facility three times weekly for dialysis. Review of an annual Minimum Data Set (MDS) assessment completed 01/01/24 revealed Resident #39 had a Brief Interview for Mental Status score of 12, indicating moderately impaired cognition (a score of 8-12 = moderately impaired cognition and a score of 13-15 = intact cognition). It stated the resident had impaired vision with no corrective lenses. A quarterly MDS on 10/01/23 also indicated impaired vision with no corrective lenses. Review of a vision consult report dated 04/27/23 revealed Resident #39 was scheduled to be treated, but was out of the building. (The resident had dialysis three days per week outside of the facility). Will attempt to see at next visit. There was no evidence the resident had received a vision exam since admission to the facility. Interview with Resident #39 on 02/05/24 at 9:21 A.M. revealed someone took her glasses a couple months ago. She stated she needed new glasses but had not seen the eye doctor. Observations on 02/05/24 at 9:21 A.M. revealed Resident #39 was not wearing glasses. Interview with Social Service Assistant #551 on 02/08/24 at 1:40 P.M. confirmed Resident #39 could not be seen by the eye doctor on 04/27/23 as she was out of the facility for dialysis. She stated the resident had cataract surgery on 11/20/23 so her daughter took her glasses, so she won't wear them. She stated the resident would need a new eyeglass prescription since having the cataract surgery. She confirmed the facility eye doctor had been to the facility again on 01/08/24 but the resident was at dialysis again. She confirmed a vision exam had not been arranged for Resident #39. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365474 If continuation sheet Page 7 of 29 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 02/14/2024 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, resident interview, staff interview, and facility policy review, the facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program to prevent the development of a pressure ulcer to Resident #19's nose caused by his glasses. This affected one resident (#19) of four residents reviewed for pressure ulcers. The census was 88. Residents Affected - Few Findings Include: Record review revealed Resident #19 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis, cerebral infarction, anxiety disorder, diverticulitis, major depressive disorder, cognitive communication deficit, hyperlipidemia, contracture of left hand, and peripheral vascular disease. Review of the Minimum Data Set (MDS) assessment, dated 01/01/24, revealed Resident #19 was cognitively intact. The assessment noted the resident was at risk for pressure ulcer development. Review of Resident #19's physician orders, dated 11/27/23, revealed an order for staff to cut about a 2.0-centimeter (cm) strip of DermaFilm Thin hydrocolloid dressing (maintains a moist wound environment) and place across the bridge of Resident #19's nose to protect the corners of the resident's nose from skin irritation/breakdown from resident's glasses. The dressing was to be changed every three days. Within the order, it noted the resident would refuse to take off his glasses to give the areas a rest. Record review revealed this order appeared to be preventative in nature and not as a result of skin breakdown at that time. Review of Resident #19's care plans dated 11/27/23 through 02/06/24 revealed no care plan related to risk of skin breakdown caused by the resident's glasses. Review of Resident #19's Treatment Administration Records (TAR) dated 11/27/23 through 02/06/24 revealed the DermaFilm treatment was not documented as being completed as ordered on 01/05/24 and 01/17/24. On 02/05/24 at 10:00 A.M., 11:44 A.M., and 2:13 P.M., and 02/06/24 at 7:38 A.M., 8:15 A.M., and 2:45 P.M. Resident #19 was observed in his room in bed wearing glasses. The resident was observed to have an open pressure ulcer to the right side of his nose. The nose pad of the glasses was observed to be embedded into the wound. The left side of his nose had a strip of DermaFilm on it. Review of Resident #19's physician orders, dated 02/06/24, revealed the facility obtained an order to cleanse right side of the nose with normal saline and pat dry. Cut about small tear drop shaped DermaFilm Thin hydrocolloid dressing for both sides of the nose, to place under nose pieces of glasses. The treatment order was to be completed every three days and as needed if it comes off. Review of Resident #19's skin assessment, dated 02/06/24, revealed a pressure ulcer to the right and lateral side of the resident's nose measuring 0.85 cm by 0.55 cm with 100% eschar, eschar/scabbed area dark red/black. The pressure ulcer was documented as being in-house acquired. The resident's care plan was updated on 02/07/24 to reflect the development of the pressure ulcer. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365474 If continuation sheet Page 8 of 29 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 02/14/2024 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview with Resident #19 on 02/07/24 at 2:43 P.M. and 2:50 P.M. confirmed he had an open area to the right side of his nose. The resident indicated the area was very tender and painful with his glasses on. He indicated he liked to wear his glasses the vast majority of each day because he wanted to be able to see all the time, but stated there were times when the preventative DermaFilm was not across both sides of his nose. The resident denied reporting this to staff for follow-up or to ensure the areas of his nose were being protected to decrease the risk of skin breakdown. Interview with the Administrator on 02/07/24 at 2:50 P.M. confirmed the resident did not have any treatment or barrier across the right side of his nose at the time the ulcer developed. She confirmed there was an open area to the right side of his nose, and the nose piece to the resident's glasses was embedded in the wound. Review of facility Pressure Injury Prevention and Management policy, dated 01/01/22, revealed the facility was committed to the prevention of avoidable pressure injuries and the promotion of healing of existing pressure injuries. The facility shall establish and utilize a systematic approach for pressure injury prevention and management including prompt assessment and treatment; intervening to stabilize, reduce, or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate. Licensed nurses will conduct a full body skin assessment on all residents upon admission/re-admission, weekly, and after any newly identified pressure injury. Interventions would be documented in the care plan and communicated to all relevant staff. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365474 If continuation sheet Page 9 of 29 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 02/14/2024 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Based on observations, resident interview, staff interview, and medical record review, the facility failed to ensure Resident #85 received services to prevent decrease in range of motion and to maintain or improve mobility. This affected one resident (#85) of three residents reviewed for positioning/mobility. The facility census was 88. Findings Include: Review of the medical record for Resident #85 revealed an admission date of 06/07/23 with diagnoses including cerebral infarction (stroke) with hemiplegia and hemiparesis (muscle weakness/paralysis). Review of a quarterly Minimum Data Set (MDS) assessment completed 12/12/23 revealed a Brief Interview for Mental Status score of 15, indicating intact cognition. Resident #85 had impairment in range of motion on one side, upper and lower. The resident was dependent upon staff for transfers. Review of a physical therapy discharge summary revealed Resident #85 received physical therapy from 10/26/23 to 01/16/24. It stated the resident had significant mobility deficits with increased weakness. The resident had resided at home prior to admission and had been able to drive. Physical therapy goals had included walking five to ten feet with left leg brace and walker. Upon discharge from physical therapy, the resident was able to walk 15 feet with brace, rail, and moderate/maximum assistance. Recommendations were made for a restorative nursing program for walking five to ten feet with braces and to use exercise equipment in the therapy gym. Review of an occupational therapy discharge summary revealed Resident #85 received occupational therapy from 11/17/23 to 01/16/24. Occupational therapy goals included tolerating left upper extremity range of motion exercises for 15 minutes for contracture management and to be independent with self-range of motion for left upper extremity to prevent contractures and reduce pain caused by muscle tightening. The goal for tolerating range of motion was met on 01/05/24, and the goal for independence with self-range of motion stated on 01/16/24, the resident was able to complete self-range of motion for affected left hand and wrist but required assistance with left shoulder range of motion. Recommendations were made for a functional maintenance program for staff to assist with range of motion of the left upper extremity with focus on the left shoulder. Review of the plan of care for Resident #85 revealed on 01/31/24 it stated the resident would benefit from a restorative ambulation program related to decreased endurance. The goal was for the resident to ambulate ten-15 feet with hemi walker and bracing daily. The intervention listed was to provide ambulation program daily as tolerated. The plan of care dated 01/31/24 also stated the resident would benefit from a restorative range of motion program related to decreased strength in lower extremities. (The plan of care did not specify the need for range of motion for the left upper extremity). The goal was to use therapy equipment for passive range of motion 15 minutes daily and maintain current level of range of motion. The interventions included to provide range of motion program daily for 15 minutes or as tolerated. Review of the restorative nursing program documentation revealed walking with a hemi walker with assistance of two staff for ten-15 feet and range of motion for 15 minutes using therapy equipment were started on 01/26/24 (10 days after therapy discontinued). Documentation for ambulating revealed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365474 If continuation sheet Page 10 of 29 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 02/14/2024 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 0688 Level of Harm - Minimal harm or potential for actual harm between 01/26/24 and 02/10/24 (16 days) the resident walked five times. On nine days it was documented ambulating did not occur (no reason) and on two days the resident was not available. Documentation for therapy equipment for range of motion revealed between 01/26/24 and 02/10/23 (16 days) the resident did range of motion on nine days. On five days it was documented use of therapy equipment did not occur (no reason) and on two days the resident was not available. Residents Affected - Few Interview with Resident #85 on 02/05/24 at 10:35 A.M. revealed she had experienced a stroke and had left sided weakness in her arm and leg. She stated she had been discharged from therapy in mid-January 2024. She stated she was supposed to be assisted to walk in a restorative nursing program but had only been assisted maybe once. She also stated she had weakness in her left arm/hand but did not receive any type of range of motion for this. She stated she wished the staff would assist with this. Observations, at that time, revealed the resident to be seated in a wheelchair and wearing a sling on her left arm. Interview with Rehab Director #611 on 02/12/24 at 9:30 A.M. confirmed Resident #85 was discharged from physical and occupational therapies on 01/16/24. She stated the resident had left sided weakness but met her maximum potential for skilled therapies. She stated the resident was willing to participate in her therapies. She stated upon discharge from therapy the resident was walking ten feet with moderate assistance and a hemi walker. She stated the resident's left arm was flaccid and she used a sling. She stated recommendations were made by physical therapy for a restorative nursing program for walking and use of a leg bike to stretch legs. Interview with Restorative Aide #405 on 02/12/24 at 12:00 P.M. revealed she worked with Resident #85. She stated the resident's restorative programs consisted of taking her to therapy room to use an omni cycle to exercise her legs and to assist the resident to walk when the other restorative aide was available as the resident required two staff to walk. She stated did not occur was documented as there were not enough restorative staff to complete all the programs they are scheduled to do. She stated there are typically two restorative aides during the week unless they got pulled from providing restorative therapy. She stated there were no restorative staff scheduled on Sundays and only one on Saturdays. She stated not available means the resident may have been out for an appointment, etc. She confirmed on those days, there was only one time that restorative therapy was attempted. She confirmed there was no further specific documentation to explain why the restorative programs were not completed daily as per the plan of care. She further confirmed Resident #85 was not provided with any range of motion for her left upper extremity. Interview with the Director of Nursing on 02/12/24 at 12:08 P.M. revealed she did not know why it took ten days to initiate the restorative nursing programs for Resident #85 after her physical and occupational therapies were discontinued. She confirmed the plan of care stated the restorative programs were to be done daily and that they were not being done daily. She confirmed Resident #85 should be receiving range of motion for her left upper extremity and was not. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365474 If continuation sheet Page 11 of 29 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 02/14/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, review of fall investigations, and facility policy review, the facility failed to complete neurological checks following unwitnessed falls for Resident #17. The deficient practice affected one resident (#17) of two residents reviewed for falls. The facility census was 88. Findings Include: Review of the medical record for Resident #17 revealed an initial admission date of 08/07/23 and a readmission date of 09/21/23. Medical diagnoses included Alzheimer's disease, history of falling, and type II diabetes mellitus with diabetic chronic kidney disease. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #17 was rarely or never understood. Per staff assessment, Resident #17 had moderately impaired cognition. Resident #17 required partial to moderate assistance from staff with transfers and used a walker or a wheelchair for mobility. Review of the fall investigations for Resident #17 revealed the resident had unwitnessed falls on 08/25/23 at 6:10 P.M., 11/20/23 at 3:36 P.M., 12/04/23 at 2:37 P.M., 12/07/23 at 10:45 A.M., and 02/03/24 at 7:49 P.M. Interview on 02/12/24 at 2:24 P.M. with Registered Nurse (RN) #511 revealed neurological checks were to be completed after an unwitnessed fall on every shift for three days. RN #511 stated the neurological checks were documented in the Fall-Follow-up assessments in the medical record. Review of the Fall-Follow-up assessments completed for Resident #17 revealed neurological checks were completed one time on 08/27/23 and 08/28/23, one time on 11/21/23 and 11/22/23, one time on 12/05/23, 12/06/23, and 12/07/23, one time on 12/08/23, not completed at all on 02/04/24, and one time on 02/06/24 following the resident's unwitnessed falls. Interview on 02/12/24 at 3:13 P.M. with the Director of Nursing (DON) #533 confirmed neurological checks should be completed on each shift (twice a day) for three days following an unwitnessed fall. The neurological checks should be documented in the Fall-Follow-up assessment. DON #533 confirmed neurological checks were not completed as required following unwitnessed falls for Resident #17 on 08/25/23, 11/20/23, 12/04/23, 12/07/23, or 02/03/24. Review of the facility policy, Falls-Clinical Protocol, revised 11/02/23, revealed the policy stated, residents who have fallen and have been witnessed to hit their head, suspected to have hit their head, and all un-witnessed falls regardless of the resident's cognitive status should have neurochecks per physician orders or protocol. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365474 If continuation sheet Page 12 of 29 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 02/14/2024 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, medical record review, review of facility policy and staff interviews, the facility did not ensure all physician ordered nutritional interventions to prevent weight loss were consistently implemented for Resident #53. This affected one resident (Resident #53) of five residents reviewed for nutrition. The facility census was 88. Residents Affected - Few Findings Include: Review of the medical record revealed Resident #53 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), emphysema, acute respiratory failure, cardiomyopathy, dysphagia, muscle weakness, hypertension, polyneuropathy, anxiety disorder, depression, and hypotension. Review of Resident #53's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 12/05/23, revealed she had no cognitive impairment, was dependent on staff for eating, had no significant weight changes and received nutrition by mouth with a mechanically altered diet and nutrition through a feeding tube. Review of Resident #53's current care plan revealed she was at risk for altered nutritional status due to COPD, congestive heart failure, anxiety, depression, dysphagia with gastroparesis requiring PEG (percutaneous endoscopic gastrostomy) tube feeding. Interventions included texture modified diet and reliance on enteral nutrition to meet her needs. Review of the physician orders for February 2024 revealed Resident #53 was receiving Remeron 15 milligrams every day for appetite stimulant, Med Pass 2.0 (a liquid, high calorie, high protein supplement) twice a day by mouth and her diet was regular diet, level two texture. Additional diet orders included an order dated 12/19/23 for bolus enteral feeding of 240 milliliters Osmolite 1.5 via PEG tube if the resident consumed less than 50% of lunch or dinner. Review of Resident #53's meal intake logs, dated January 2024 to February 2024, revealed a total of 21 meal entries for lunch and dinner that were left blank. Also, there were 13 entries in which her meal intake for lunch and dinner was less than 50% or she refused her meal. Review of Resident #53's Medication Administration Records (MAR) dated January 2024 to February 2024 revealed good acceptance of the Med Pass 2.0 supplement but varied acceptance and lack of consistent administration of the enteral bolus of Osmolite 1.5. if Resident #53 refused or ate less than 50% of her lunch and dinner. The MAR revealed 16 entries in which she ate less than 50% of her lunch or dinner, or refused either meal, yet her enteral feeding was not offered/provided to her. Review of Resident #53's weights, dated 11/15/23 to 02/07/24, revealed the following weights: 11/15/23 (104.6 pounds), 11/19/23 (106.9 pounds), 11/26/23 (105 pounds), 12/06/23 (101.2 pounds), 12/10/23 (106.4 pounds), 12/11/23 (106.2 pounds), 12/17/24 (101.8 pounds), 01/05/24 (98.8 pounds), 01/22/24 (95.4 pounds), 01/23/24 (96.3 pounds), 01/30/24 (100.6 pounds), 02/07/24 (101.6 pounds). From 12/17/23 to 01/23/24 Resident #53's weight declined 5.5 pounds or 5.4 percent which was a significant weight loss. From 01/23/24 to 02/07/24 Resident #53's weight increased 5.3 pounds for a significant gain of 5.5 percent. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365474 If continuation sheet Page 13 of 29 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 02/14/2024 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 Interview was attempted with Resident #53 on 02/07/24 at 2:30 P.M. in her room. Resident #53 presented with a petite stature, weight appropriate for her frame and no observed signs of weakness or malnutrition. When greeted and asked questions, Resident #53 was alert but would not participate in the interview. Interview with Dietitian #500 and Director of Nursing (DON) on 02/12/24 at 2:05 P.M. revealed the facility staff was to offer her the enteral feeding as ordered. Dietitian #500 confirmed she implemented the enteral feeding order to help maintain and stabilize her weight so she would expect this order to be followed. Both confirmed there were both blanks on the MAR and meal intake logs as well as refusals of the enteral bolus. The DON confirmed if Resident #53 was refusing her enteral feeding, the staff should be documenting refusals so Dietitian #500 would have an accurate account of how many times she refused and potentially put another nutritional intervention in place. The DON also confirmed that on the MAR there were multiple NA documented and if the enteral feeding was documented as NA, that would indicate it was not offered. The DON confirmed the number of instances on Resident #53's MAR that were documented as NA and verified the enteral bolus was not being given to Resident #53 according to the physician orders. Review of facility Weight Monitoring policy, dated 10/26/23, revealed interventions will be identified, implemented, monitored, and modified (as appropriate), consistent with the resident's assessed needs, choices, preferences, goals, and current professional standards to maintain acceptable parameters of nutritional status. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365474 If continuation sheet Page 14 of 29 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 02/14/2024 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 Based on observations, medical record review, staff interview, and review of the facility list of medications not to be crushed, the facility failed to maintain a medication error rate of less than five percent (%). The medication error rate was calculated to be 15% and included four medication errors of 26 medication administration opportunities. This affected one resident (Resident #39) of six residents observed for medication administration. The facility census was 88. Residents Affected - Few Findings include: Review of the medical record for Resident #39 revealed an admission date of 03/10/23 and diagnoses including end stage renal disease and diabetes. The resident received hemodialysis three times weekly. There was no evidence of any physician's orders to crush medications. Observation of medication administration on 02/12/24 at 8:45 A.M. revealed Registered Nurse (RN) #528 preparing medications to administer to Resident #39. The following medications were crushed in applesauce together: Sevelamer 800 milligrams (used to lower phosphorus in the blood of patients receiving kidney dialysis), Ropinirole two milligrams (used for restless leg syndrome), Tamiflu 75 milligrams (used to prevent flu), and Colestipol one gram (used to lower cholesterol). The medications were taken in the room to give to Resident #39. (Crushing and combining medications may result in physical and chemical incompatibilities leading to an altered therapeutic response). On 02/12/24 the Director of Nursing provided a list of medications not to be crushed and included Sevelamer, Ropinirole, and Colestipol. Interview with RN #516 on 02/12/24 at 11:35 A.M. confirmed Tamiflu should not be crushed. Interview with RN #528 on 02/12/24 at 11:35 A.M. confirmed the medications were crushed to give to Resident #39. She stated she thought they were crushed per the resident's preference because some of the pills were big. However, she stated she crushed all of the resident's medications. She confirmed there was no physician's order to crush the medications and no documentation from the physician or pharmacist that it was acceptable to crush the medications that were on the not to be crushed list. A total of 26 opportunities for error were observed during medication administration with a total of four errors (four medications crushed that are not to be crushed) resulting in a 15% medication error rate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365474 If continuation sheet Page 15 of 29 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 02/14/2024 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #46 revealed an admission date on 11/18/23. Medical diagnoses included heart failure, acute and chronic respiratory failure, type two diabetes mellitus, Chronic Obstructive Pulmonary Disease (COPD), asthma, morbid obesity, anxiety disorder, and depression. Residents Affected - Few Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #46 had intact cognition and scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #46 required assistance from staff which ranged from set up help to maximal assistance to complete Activities of Daily Living (ADLs). Review of progress notes for Resident #46 revealed on 01/19/24 at 11:15 A.M., a new order to discontinue Flovent due to not being available at pharmacy and start Resident #46 on Fluticasone HFA 110 mcg one puff twice daily. On 01/22/24 at 9:33 P.M., Fluticasone Propionate HFA order was noted to be waiting on the pharmacy to deliver the inhaler. On 01/30/24 at 8:59 P.M., Fluticasone Propionate HFA was still waiting to be delivered. On 02/07/24 at 8:57 P.M., Fluticasone Propionate HFA was still waiting for the pharmacy to deliver the medication. Review of physician orders for Resident #46 revealed an order dated 01/22/24 for Levalbuterol Tartrate Inhalation Aerosol 45 mcg/act with instructions to take two puffs inhale orally every four hours as needed for shortness of breath. Review of the MAR dated January 2024 revealed Resident #46 was administered Fluticasone Propionate HFA inhaler at bedtime on 01/19/24, in the morning on 01/20/24, in the morning on 01/22/24, at bedtime on 01/30/24, and both in the morning and at bedtime on 01/23/24, 01/24/24, 01/25/24, 01/26/24, 01/27/24, 01/28/24, 01/29/24, and 01/31/24. Resident #46 was not administered the Levalbuterol Tartrate Inhaler at all in the month of January. Review of the Medication Administration Record (MAR) dated February 2024 revealed Resident #46 had the following orders: Fluticasone Propionate Hydrofluoroalkane (HFA) Inhalation Aerosol 110 micrograms/actuation (mcg/act) with instructions to give one puff inhale orally every morning and at bedtime and rinse and spit after each use with a start date on 01/30/24. Resident #46 was administered Fluticasone Propionate HFA twice daily as ordered and was only administered the Levalbuterol Tartrate Inhaler one time on 02/08/24 and the medication was marked effective. Interview on 02/05/24 at 12:50 P.M. with Resident #46 revealed the resident was not receiving her inhaler in the morning and at night as ordered. Resident #46 stated she discussed her concerns with a nurse (was unsure which nurse) who indicated the inhaler could not be found. Interview on 02/07/24 at 10:10 A.M. with Resident #46 revealed she had been told by a nurse the inhaler should be delivered today, 02/07/24. Observations of the medication cart on 02/08/24 at 9:45 A.M. and 12:21 P.M. with Licensed Practical Nurse (LPN) #543 LPN #543 confirmed the only inhaler available to administer to Resident #46 was the Levalbuterol HFA inhaler. LPN #543 confirmed she had been administering the Levalbuterol HFA inhaler (which was ordered every four hours as needed for shortness of breath) to Resident #46 twice a day and had not been administering the Fluticasone Propionate HFA inhaler (which was ordered to be administered twice daily) to Resident #46 at all due to the inhaler was never received from the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365474 If continuation sheet Page 16 of 29 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 02/14/2024 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few pharmacy after several attempts. LPN #543 confirmed the MAR indicated the Fluticasone Propionate HFA inhaler was the one being signed off as administered even though what was actually being given in place of it was the Levalbuterol HFA inhaler which was not being signed off as administered to Resident #46. Interviews on 02/08/24 at 9:45 A.M. and 12:21 P.M. with LPN #543 revealed she discussed Resident #46's medications with Medical Director (MD) #532 this morning and the Fluticasone Propionate HFA inhaler was discontinued effective 02/08/24. LPN #543 confirmed the nursing staff, including herself, marked the wrong inhaler (the Fluticasone Propionate HFA inhaler) as administered in error. LPN #543 stated she thinks she marked the wrong inhaler as being administered because Resident #46 also had an order for scheduled Fluticasone Propionate nasal spray and when she was in a hurry thought she was marking the nasal spray as administered, not the inhaler. LPN #543 could not explain why the Levalbuterol inhaler was not being marked as administered to Resident #46. Review of the Levalbuterol HFA inhaler medication insert revealed the inhaler should not be administered more frequently then the recommended dose which was two inhalations repeated every four to six hours. More frequent administration or a larger number of inhalations is not routinely recommended. Use exactly as your doctor tells you to. Do not change your dose without talking to your doctor first. Review of the facility policy, Medication Administration, revised 01/17/23, revealed the policy stated, medications are administered as ordered by the physician. Review MAR to identify medication to be administered. Compare medication source with MAR to verify resident name, medication name, form, dose, route, and time of administration. Administer medication as ordered in accordance with manufacturer specifications. Sign MAR after administered. Based on observations, resident and staff interviews, record review, and facility policy review, the facility failed to ensure residents were administered medication in accordance with physician orders and prescribing instructions for use of the medications. This affected two residents (Residents #46 and #297) of six residents reviewed for medication administration. The facility census was 88. Findings include: 1. Review of the medical record revealed Resident #297 was admitted to the facility on [DATE] with diagnoses that included arthritis due to other bacteria and left knee bacteremia. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #297 was cognitively intact, required moderate assistance for activities of daily living and was receiving intravenous (IV) antibiotics. Review of the discharge information from the hospital dated 12/29/23 for Resident #297 revealed a primary diagnosis of blood stream infection and was ordered to receive intravenous (IV) Vancomycin (medication for infection) every 12 hours until 02/16/24. Review of Resident #297's clinical summary revealed septic shock due to Methicillin-resistant Staphylococcus aureus (MRSA) (a bacteria that causes severe and sometimes life-threatening complications) bacterium resulting in elevated creatinine levels indicating kidney damage. Review of infectious disease sign-off from the hospital for Resident #297 revealed the resident was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365474 If continuation sheet Page 17 of 29 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 02/14/2024 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to receive IV Vancomycin for six weeks with an end date of 02/16/24 due to bacteremia, septic arthritis, MRSA, and left septic knee. Review of the physician orders for January 2024 revealed Resident #297 was ordered Vancomycin 1000 milligrams (mg) to be administered IV every 12 hours for infection related to arthritis due to other bacteria with a start date on 01/29/24 at 9:00 P.M. and end date on 02/16/24. Review of the Medication Administration Record (MAR) for dates 01/30/24 to 02/12/24 revealed the following administration times for Vancomycin HCL IV Solution 1000 MG/200 ML: On 01/30/24 Resident #297 received his 9:00 A.M. dose at 10:29 A.M. On 01/31/24 Resident #297 received his 9:00 A.M. dose at 2:05 P.M. On 02/02/24 Resident #297 received his 9:00 A.M. dose at 11:21 A.M., and his 9:00 P.M. dose at 11:36 P.M. On 02/04/24 Resident #297 received his 9:00 A.M. dose at 10:38 A.M. On 02/08/24 Resident #297 received his 9:00 P.M. dose at 11:22 P.M. On 02/10/24 Resident #297 received his 9:00 P.M. dose at 11:27 P.M. On 02/12/24 Resident #297 received his 9:00 A.M. dose at 11:16 A.M. Review of Resident #297's progress note dated 01/31/24 at 12:12 P.M. revealed Vancomycin 1000 mg was not available for administration. Interview on 02/08/24 at 5:36 P.M. with Licensed Practical Nurse (LPN) #427 confirmed she was unable to administer the antibiotic due to a shortage of essential fluids to combine the drug. Observation of the emergency drug kit on 02/08/24 at 5:36 P.M. with LPN #427 revealed appropriate fluids were not available for mixing Resident #297's antibiotic if needed. Interview on 02/12/24 at 7:55 A.M. with Director of Nursing (DON) #533 confirmed knowledge of late dose on 01/31/24. DON #533 confirmed medications on 01/30/24, 01/31/24, 02/01/24, 02/02/24, and 02/08/24 were not administered 60 minutes prior to or after scheduled time. Review of the prescribing information for Vancomycin Hydrochloride revised July 2018 revealed Vancomycin Hydrochloride should be taken as directed and skipping doses or not completing the full course of therapy may (1) decrease the effectiveness of the immediate treatment and (2) increase the likelihood that bacteria will develop resistance and will not be treatable. Review of the facility policy, Medication Administration, revised on 01/17/23, revealed medication was to be administered within 60 minutes prior to or after scheduled time. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365474 If continuation sheet Page 18 of 29 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 02/14/2024 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 0791 Provide or obtain dental services for each resident. 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, and resident and staff interviews, the facility failed to provide timely dental care and services for one resident (Resident #46). This affected one resident (Resident #46) of one reviewed for dental services. The facility census was 88. Residents Affected - Few Findings Include: Review of the medical record for Resident #46 revealed an admission date on 11/18/23. Medical diagnoses included heart failure, acute and chronic respiratory failure, type two diabetes mellitus, Chronic Obstructive Pulmonary Disease (COPD), asthma, morbid obesity, anxiety disorder, and depression. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #46 had intact cognition and scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #46 required assistance from staff which ranged from set up help to maximal assistance to complete Activities of Daily Living (ADLs). Resident #46 had missing or broken teeth. Review of the plan of care revised 12/01/23 revealed Resident #46 was at risk for dental problems related to having natural teeth, some in poor condition. Interventions included notify nurse/physician of any pain, open areas, white patches, and/or changes in nutritional status and refer to dental services as needed. Review of the HealthDrive Request for Services dated 01/02/24 revealed Resident #46 requested the HealthDrive Dental Provider examine her for sharp edges or fractured teeth or root tips. The consent was signed by Medical Director (MD) #532, Director of Nursing (DON) #533, and Resident #46. Review of progress notes for Resident #46 revealed on 01/05/24 at 3:43 P.M., the nurse notified Social Service Assistant (SSA) #551 the resident's front tooth fell out. SSA #551 emailed the dentist to let them know and set up a possible course of action. On 01/05/24 at 3:53 P.M., Resident #46 notified the nurse her front left tooth fell out. Upon assessment, the nurse noted front left lateral incisor tooth was missing with some tooth still noted in gum. No bleeding noted. No signs of infection noted. Gums were pink and not swollen. Resident #46 denied pain or discomfort. The physician was notified and no new orders were given. Review of Doctor's Orders for Tooth Concerns, dated 01/09/24, from Dentist #705 for Resident #46 revealed the resident's symptoms included front tooth fell out and two upper front teeth were broken. Please follow the orders below: for tooth pain, request physician prescribe a pain medication for five to seven days and request physician prescribe an antibiotic for seven to ten days. For broken/sharp teeth: apply ortho wax as needed over broken tooth to cover sharp edge until patient is seen by dentist. For gum symptoms (bleeding, swelling, extraction site pain, etc): peridex periodontal solution. Upon authorizing the Doctor Orders listed above: we recommend general observation of the patient's condition. Review of the progress notes dated 01/09/24 at 3:35 P.M., new orders received from Nurse Practitioner #700 for Keflex (an antibiotic) 500 milligrams (mg) twice daily for seven days for tooth and to continue as needed Tramadol order for 50 mg twice daily as needed. Resident #46 was notified. Review of the Medication Administration Record (MAR) dated January 2024 revealed Resident #46 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365474 If continuation sheet Page 19 of 29 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 02/14/2024 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 0791 Level of Harm - Minimal harm or potential for actual harm received Cephalexin (an antibiotic) 500 milligrams (mg) every 12 hours for possible tooth infection for 14 administrations. The medication as administered as ordered from 01/09/24 to 01/16/24. On 01/09/24 at 5:01 P.M., a Pertinent Charting-Infections/signs symptoms note revealed Resident #46 was on a preventative antibiotic for broken tooth per the dentist's recommendation. Residents Affected - Few On 01/10/24 at 7:38 A.M., the interdisciplinary team (IDT) met to review the new order for Keflex for possible tooth infection. Resident #46 did not have any redness or edema noted in gums surrounding tooth that fell out. Dentist was contacted by Social Services. Resident #46's pain was currently controlled with current plan of care. On 01/10/24 at 9:14 A.M., no signs or symptoms of an infection were noted for Resident #46. Prophylactic antibiotic for the resident's broken tooth was in place. No pain or discomfort was reported by Resident #46. On 01/12/24 at 5:15 P.M., Resident #46 continued on prophylactic antibiotic for broken front tooth as recommended by the dentist. No signs or symptoms of infection were noted and no complaints of pain or discomfort were reported by Resident #46. On 01/18/24 at 3:09 P.M., antibiotic was completed for Resident #46's front broken tooth. Review of Doctor's Orders for Tooth Concerns, dated 01/23/24, from Dentist #705 for Resident #46 revealed the resident's symptoms included front tooth fell out and two upper front teeth were broken. Please follow the orders below: for tooth pain, request physician prescribe a pain medication for five to seven days and request physician prescribe an antibiotic for seven to ten days. For broken/sharp teeth: apply ortho wax as needed over broken tooth to cover sharp edge until patient is seen by dentist. For gum symptoms (bleeding, swelling, extraction site pain, etc): peridex periodontal solution. Upon authorizing the Doctor Orders listed above: we recommend general observation of the patient's condition. The instructions also stated the office would request Resident #46 complete the Treatment Authorization form for services to be performed. Review of the Treatment Authorization form dated 01/23/24 from Dentist #705 revealed the recommended treatment for Resident #46's tooth concerns was to fill or extract any symptomatic teeth. Resident #46 signed the authorization form. Additional review of the progress notes for Resident #46 revealed there was no evidence of any additional follow up to schedule Resident #46 to be seen by a dentist until 02/01/24 at 12:27 P.M. (two weeks after Resident #46 completed antibiotic treatment for a broken tooth) when Resident #46 signed off agreement to be seen at the next dental visit. On 02/09/24 at 1:43 P.M. (after surveyor had already started questioning about the resident's dental services), Resident #46 notified Social Service Director (SSD) #518 she was experiencing tooth pain. SSD #518 followed up with dentist to request Resident #46 be seen. On 02/12/24 at 1:01 P.M., Resident #46 was seen by the dentist. Interview on 02/05/24 at 1:04 P.M. with Resident #46 revealed she had two broken front teeth and a piece of one of the teeth was still left in the resident's gum. Resident #46 reported it caused pain at times, but not constantly. Resident #46 stated she had requested to see a dentist but was not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365474 If continuation sheet Page 20 of 29 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 02/14/2024 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 0791 sure when she would be seen. Level of Harm - Minimal harm or potential for actual harm Interview on 02/06/24 at 9:20 A.M. with the Director of Nursing (DON) #533 revealed a date had not been scheduled for the dentist to visit yet because Social Services Director (SSD) #518 was still gathering consents for treatment from residents and developing a comprehensive list of residents who needed to be seen. Residents Affected - Few Interview on 02/12/24 at 9:56 A.M. with DON #533 confirmed Resident #46 had not been seen by a dentist yet. DON #533 confirmed a referral was sent for the resident to be seen on 01/09/24 (over one month ago) due to broken teeth. A facility policy related to dental care and services was requested at the time of the survey but a policy was not provided. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365474 If continuation sheet Page 21 of 29 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 02/14/2024 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, staff interview, and facility policy review, the facility failed to ensure dietary spreadsheets were followed and all food items on the spreadsheets were offered to the residents according to their needs on a level three dysphagia diet. This affected 14 residents, (Residents #6, #10, #14, #17, #31, #33, #48, #59, #61, #64, #66, #72, #85, and #89) the facility identified as having physician orders for a level three dysphagia diet, out of 87 residents receiving meals from the kitchen. Resident #68 was identified by the facility as receiving nothing by mouth. The facility census was 88. Findings Include: Review of the lunch menu dated 02/07/24 revealed ham steak, rice pilaf, broccoli and cheese sauce, assorted cookies, and a beverage was the scheduled meal. Review of the dietary spreadsheets dated 02/07/24 revealed residents with an a level three dysphagia diet should receive ground ham steak with gravy, soft rice pilaf with gravy, chopped soft broccoli and cheese sauce, and pudding. Observation of tray line for the lunch meal on 02/07/24 at 11:55 A.M. with [NAME] #712 revealed the chopped broccoli for the residents on an ordered level three dysphagia diet was plain in water and did not have a cheese sauce. Continuous observation on 02/07/24 from 11:55 A.M. to 12:25 P.M. of lunch tray line service revealed the plain chopped broccoli was served to all residents without a cheese sauce. Interview on 02/07/24 at 12:25 P.M. with Dietary Manager (DM) #710 confirmed the chopped broccoli did not have a cheese sauce. DM #710 confirmed according to the dietary spreadsheet, the chopped broccoli should have had a cheese sauce. Review of the facility policy, Therapeutic Diets, dated 09/01/21, revealed the policy stated, diets are prepared in accordance with the guidelines in the approved diet manual and the individualized plan of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365474 If continuation sheet Page 22 of 29 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 02/14/2024 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 - Some Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation, staff interview, review of the pureed ham recipe and facility policy, the facility failed to ensure pureed foods were prepared to the appropriate pureed consistency. This affected nine residents, (Residents #2, #22, #27, #29, #41, #49, #50, #76, and #297) the facility identified as having physician orders for pureed diets, out of 87 residents receiving meals from the kitchen. Resident #68 was identified by the facility as receiving nothing by mouth. The facility census was 88. Findings Include: Review of the lunch menu dated 02/07/24 revealed ham steak, rice pilaf, broccoli and cheese sauce, assorted cookies, and a beverage was the scheduled meal. Review of the dietary spreadsheets dated 02/07/24 revealed residents with an ordered pureed textured diet should receive pureed ham steak, pureed rice pilaf, pureed broccoli with cheese sauce, pureed cookies, and a beverage. Review of the recipe, Pureed Ham Steak, revealed for preparation, combine chicken base and water to make chicken broth. Place prepared meat in a washed and sanitized food processor. Gradually add broth and blend until smooth. If the product needed thinning, gradually add an appropriate amount of liquid (not water) to achieve a smooth, pudding or soft mashed potato consistency. If the product needed thickening, gradually add a commercial or natural food thickener (potato flakes or baby rice cereal) to achieve a smooth, pudding or soft mashed potato consistency. Observation of the pureed ham steak preparation on 02/07/24 at 10:30 A.M. with [NAME] #712 revealed the cook used tongs to place several ham steaks into the food processor, added a small amount of chicken broth and proceeded to process the ham. At 10:40 A.M. [NAME] #712 checked the contents of the food processor multiple times. At 10:45 A.M. Corporate Food Manager (CFM) #715 instructed [NAME] #712 to remove some of the pureed ham steaks from the food processor in order to obtain the desired consistency quicker. [NAME] #712 transferred some of the ham from the processor into a container and then continued to process the remaining ham still in the food processor. At 10:53 A.M. CFM #715 stated looks good to [NAME] #712 who then stopped the food processor and proceeded to transfer all of the pureed ham from the food processor into a metal container. The pureed ham appeared lumpy. At 10:55 A.M. [NAME] #712 confirmed she was ready to place the pureed ham on the steam table to be served to residents and had not sampled the texture of the pureed ham. The surveyor intervened due to seeing lumps in the ham and requested to taste the pureed ham. Upon looking into the container, several intact pieces of the ham skin were present in the pureed ham. The surveyor tasted a spoonful of the pureed ham and felt two intact pieces of the skin or rind on the tongue which required chewing to safely swallow it. [NAME] #712 verified the pureed ham was not a smooth, pudding or mashed potato like consistency. At 10:57 A.M. during the observation, interviews conducted with [NAME] #712 and Dietary Manager #710 confirmed the pureed ham was not a safe consistency for residents in need of a pureed diet. Review of the facility policy, Therapeutic Diets, dated 09/01/21, revealed the policy stated, diets are prepared in accordance with the guidelines in the approved diet manual and the individualized plan of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365474 If continuation sheet Page 23 of 29 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 02/14/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, staff interview, and facility policy review, the facility failed to follow proper hand hygiene protocols during pureed food preparation. This had the potential to affect all nine residents, (Residents #2, #22, #27, #29, #41, #49, #50, #76, and #297) the facility identified as having physician orders for pureed diets, out of 87 residents receiving meals from the kitchen. Resident #68 was identified by the facility as receiving nothing by mouth. The facility census was 88. Findings Include: Review of the lunch menu dated 02/07/24 revealed ham steak, rice pilaf, broccoli and cheese sauce, assorted cookies, and a beverage was the scheduled meal. Review of the dietary spreadsheets dated 02/07/24 revealed residents with an ordered pureed textured diet should receive pureed ham steak, pureed rice pilaf, pureed broccoli with cheese sauce, pureed cookies, and a beverage. Review of the recipe, Pureed Ham Steak, revealed for preparation, combine chicken base and water to make chicken broth. Place prepared meat in a washed and sanitized food processor. Gradually add broth and blend until smooth. If product needs thinning, gradually add an appropriate amount of liquid (not water) to achieve a smooth, pudding or soft mashed potato consistency. If the product needs thickening, gradually add a commercial or natural food thickener (potato flakes or baby rice cereal) to achieve a smooth, pudding or soft mashed potato consistency. Observation of the pureed ham steak preparation on 02/07/24 at 10:30 A.M. with [NAME] #712 revealed the cook washed her hands at the sink and put on clean gloves. [NAME] #712 turned around to the steamer and grabbed two oven mitts from the top of the steamer and proceeded to put both of them on over her clean gloves. With the oven mitts on, [NAME] #712 retrieved a large covered pan from the steamer and placed it on the preparation counter. [NAME] #712 removed the oven mitts and placed them back on the top of the steamer. Without changing gloves or completing hand hygiene, [NAME] #712 used tongs to remove several ham steaks from the pan and placed them in the food processor. [NAME] #712 added a small amount of chicken broth and turned on the processor. [NAME] #712's glove on her left hand had a hole in the tip of the middle finger which exposed her finger outside of the glove. At 10:40 A.M., [NAME] #712 was observed touching the inside of the food processor lid and bowl with contaminated gloves on. After checking the ham three or four times, at 10:45 A.M., Corporate Food Manager (CFM) #715 instructed [NAME] #712 to remove some of the pureed ham steaks from the food processor in order to obtain the desired consistency quicker. [NAME] #712 grabbed a small metal container already lined with a plastic wrap with the contaminated gloves on. [NAME] #712 used her right gloved hand to press the inside of the plastic wrap down inside the container and then proceeded to transfer some of the ham from the processor into the container on top of the plastic wrap. [NAME] #712 continued processing the remaining ham in the processor. At 10:49 A.M., Dietary Manager (DM) #710 was observed handing [NAME] #712 a clean glove. [NAME] #712 removed her left glove (that had a hole in the middle finger) and donned the clean glove without washing her hands. At 10:50 A.M., [NAME] #712 was observed placing her contaminated gloved fingers inside the food processor and inside the plastic lining of the metal container which held some of the pureed ham mixture. At 10:53 A.M., CFM #715 stated, looks good to [NAME] #712. At that time, [NAME] #712 stopped the processor and proceeded to transfer all of the pureed ham into the metal container. The pureed ham appeared lumpy during the transfer. At 10:55 A.M., [NAME] #712 confirmed she was prepared to place the pureed ham on the steam table to be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365474 If continuation sheet Page 24 of 29 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 02/14/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some served to residents. [NAME] #712 removed both gloves and discarded them in a covered trashcan then washed her hands at the sink with soap and water. Interview on 02/07/24 at 10:57 A.M. with [NAME] #712 confirmed she did not change gloves or wash her hands after placing oven mitts over clean gloves and had touched the inside of the food processor lid, bowl, and the plasic wrap on the inside of the metal container with contaminated gloves on. [NAME] #712 also confirmed she did not complete hand hygiene after removing the compromised glove from her left hand and donning a clean glove. Review of the facility policy, Hand Washing, dated 09/01/21, revealed the policy stated, wash your hands as often as possible. It is important to wash your hands: before putting on gloves, after handling soiled utensils or equipment, as often as needed during food preparation and when changing tasks. Gloves, wet-wipes, or hand antiseptics are not substitutes for hand washing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365474 If continuation sheet Page 25 of 29 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 02/14/2024 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the medical record for Resident #84 revealed an admission date of 08/04/23 and diagnoses of diabetes, chronic kidney disease, and urinary retention. Residents Affected - Some Review of nursing progress notes revealed on 09/12/23 at 1:14 A.M. it was documented that a urine specimen was collected for urinalysis and culture and sensitivity. There was nothing documented to indicate why the urine specimen was collected and no symptoms of a urinary tract infection documented. Review of a laboratory report revealed a urine specimen was collected on 09/12/23 and results on 09/15/23 showed >100,000 Proteus Mirabilis and Escherichia Coli. The nurse practitioner was notified on 09/15/23 at 6:09 P.M. and an order was received for an antibiotic (Bactrim DS 800-160 milligrams) twice daily for seven days for a urinary tract infection. Review of the medication administration record revealed the Bactrim was administered from 09/16/23 to 09/22/23 for a total of 13 doses. Review of the facility infection record (McGeer criteria) revealed a resident must meet criteria 1 and 2 for it to be considered a urinary tract infection. (Criteria 1 includes symptoms and Criteria 2 is a urine culture with >100,000 bacteria). The infection record indicated an onset date of 09/11/23 but did not include any symptoms of a urinary tract infection under Criteria 1. Interview with the Director of Nursing on 02/07/24 at 2:45 P.M. confirmed there were no symptoms of a urinary tract infection documented for Resident #84 on 09/12/23 when a urine specimen was collected. She confirmed the resident was treated with an antibiotic without meeting the facility guidelines/McGeer criteria for a urinary tract infection. Review of nursing progress notes on 10/31/23 at 1:27 P.M. revealed Resident #84 had a suspected urinary tract infection as the resident was complaining of frequency with episodes of confusion. The note stated a urine sample was to be collected and sent out in the morning and an antibiotic (Cipro 500 milligrams) was ordered twice daily for seven days. The note stated once the final results were received, will have to ensure appropriate antibiotic in place. Review of the medication administration record revealed the resident received Cipro 500 milligrams twice daily from 11/01/23 to 11/05/23 (10 doses). Review of urine culture results reported on 11/05/23 revealed >100,000 Escherichia Coli that was not sensitive to Cipro. Review of nursing progress notes on 11/06/23 at 6:28 A.M. revealed final urine culture sent to physician. New order to discontinue Cipro and start a different antibiotic (Nitrofurantoin) 100 milligrams twice daily for seven days. Review of the medication administration record revealed Nitrofurantoin was administered from 11/06/23 to 11/12/23 for a total of 14 doses. Review of the facility infection record (McGeers criteria) revealed an onset date of 10/30/23 and did not document that any criteria had been met to indicate a urinary tract infection. Interview with the Director of Nursing on 02/07/24 at 2:45 P.M. confirmed an antibiotic was started prior to a urinary tract infection being confirmed. She confirmed that the antibiotic the resident received (Cipro) 10 doses of was not an antibiotic that the bacteria was sensitive to so the antibiotic had to be changed. She further confirmed the McGeers form did not indicate criteria was met for a urinary tract infection. Review of nursing progress notes on 11/13/23 at 11:10 A.M. revealed the resident received the last dose of antibiotic and states she feels a little better but not all the way. Continues at times to be slightly confused. Updated nurse practitioner who said ok to get another urine culture if needed in morning. On 11/14/23 at 11:37 P.M. a urine specimen was collected. Review of urine culture results reported on 11/18/23 revealed >100,000 Proteus Mirabilis. The bacteria was not sensitive to any (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365474 If continuation sheet Page 26 of 29 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 02/14/2024 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 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some oral antibiotics (only intravenous or intramuscular medications). The resident was started on an antibiotic (Amoxicillin-potassium clavulanate 875-125 milligrams) twice daily for seven days on 11/20/23. This antibiotic was not listed on the urine culture for the bacteria being sensitive to it. Review of the medication administration record revealed the resident received the Amoxicillin-potassium clavulanate from 11/20/23 to 11/27/23 for a total of 14 doses. There was nothing documented to indicate why the antibiotic was not started for two days after the urine culture results were reported. Interview with the Director of Nursing on 02/07/24 at 2:45 P.M. confirmed the resident was still confused so another urine culture was obtained on 11/14/23. She confirmed the bacteria was not listed as sensitive to the antibiotic that was used. She stated she did not know why the antibiotic was not started after the results were reported on 11/18/23. She confirmed the antibiotic did not start until 11/20/23 and could have started 11/19/23 in the morning. Review of a text message from the physician on 02/07/24 at 3:21 P.M. revealed regarding antibiotic selection (on 11/20/23) he chose it as the best oral alternative being the most like the IV ampicillin. This was a clinical decision made to try to avoid having to subject the resident to the greater risk of IV and infusion when this oral alternative is likely to be effective. Review of urine culture results on 01/18/24 revealed >100,000 Proteus Mirabilis. Review of nursing progress notes did not indicate why the urine specimen was collected. There were no symptoms of a urinary tract infection documented. The physician was notified on 01/18/24 at 4:22 P.M. and an antibiotic (Augmentin 875 milligrams) was ordered twice daily for seven days. Review of the medication administration record revealed the antibiotic was given from 01/19/24 to 01/25/24 for a total of 14 doses. Review of physician progress notes from September 2023 to January 2024 revealed they were silent to any treatment of urinary tract infections. Interview with the Director of Nursing on 02/07/24 at 2:45 P.M. revealed the antibiotic was ordered 01/18/24 due to increased confusion/hallucinations. She confirmed Resident #84 did not meet the McGeer criteria for any of the urinary infections she was treated for. Review of the facility policy titled Antibiotic Stewardship Program dated 10/24/22 and revised 12/13/23 revealed the purpose of the program was to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. Licensed nurses were to follow protocols as established by the program. Antibiotic use protocols include the use of the McGeer criteria to define infections. Based on record review, staff interviews, review of laboratory test results, review of McGreer's criteria for infections, and facility policy review, the facility failed to follow antibiotic stewardship policies and procedures prior to starting antibiotic treatment for two residents (Residents #43, and #84). The facility also failed to ensure laboratory test results were received prior to starting antibiotic treatment for one resident (Resident #11). The deficient practices affected three residents (Residents #11, #43, and #84) of seven residents reviewed for infections and antibiotic use. The facility census was 88. Findings Include: Review of the medical record for Resident #11 revealed an initial admission date on 06/08/21 and a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365474 If continuation sheet Page 27 of 29 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 02/14/2024 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 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some readmission date on 10/23/23. Medical diagnoses included schizoaffective disorder, chronic obstructive pulmonary disorder (COPD), other irritable bowel syndrome, other disorders of urea cycle metabolism, delusional disorders, overactive bladder, urinary tract infection, and severe chronic kidney disease stage four. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #11 had mildly impaired cognition and scored 12 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #11 required variable assistance from staff to complete Activities of Daily Living ranging from set up help to maximal assistance. Review of progress notes for Resident #11 revealed she was sent to a local hospital on [DATE] to be evaluated for chest pain and have her medications reviewed. She was discharged back to the facility on [DATE] with a diagnosis of UTI and exacerbation of COPD. On 04/25/23 at 4:03 P.M. the progress notes indicated the hospital sent her back to the facility with an order for Cefdiner. There was no indication a urinalysis with culture and sensitivity (UA C&S) had been done for Resident #11 prior to beginning the course of antibiotic treatment with the Cefdiner which did not meet McGreer's criteria. On 04/29/23 at 11:01 A.M., Resident #11 was sent to another emergency room per her request. A complete UA C&S was completed and found the organism was not susceptible to Cefdinir. Review of the Medication Administration Record (MAR) dated April 2023 revealed Resident #11 had an order for Cefidinir (an antibiotic) 300 milligrams (mg) orally every 12 hours for a urinary tract infection (UTI) for 14 days with a start date on 04/25/23 at 9:00 A.M. and an end date on 05/01/23 at 1:20 P.M. Resident #11 was administered eight doses of the antibiotic from 04/25/23 to 04/28/23 then she went on a leave to the hospital beginning on 04/29/24. Review of the MAR dated May 2023 revealed Resident #11 returned to the facility on [DATE] and had an order for Cefidinir 300 mg orally two times a day related to UTI for seven days with a start date on 05/01/23 at 9:00 P.M. and an end date on 05/04/23 at 4:05 P.M. Resident #11 received six doses of the antibiotic from 05/01/23 to 05/04/23. Beginning on 05/04/23 at 9:00 P.M. a new order for Ciprofloxacin Hydrochloride (HCl) 500 mg orally two times a day for UTI for ten days began to be administered to Resident #11 with an end date of 05/14/23. Resident #11 received 20 doses of the Ciprofloxacin HCL from 05/04/23 to 05/14/23. Further review of the medical record revealed there was no evidence a UA C&S had been completed and resulted prior to Resident #11 being started Cefdinir antibiotic. Review of the laboratory test results for a urinalysis with culture and sensitivity (UA C&S) completed while Resident #11 was at the emergency room dated 05/04/23 revealed Resident #11 had a positive result for a urinary tract infection (UTI) and identified pseudomonas aeruginosa as the organism with a greater than 100,000 CFU/mL growth. Interview on 02/07/24 at 4:25 P.M. with the Director of Nursing (DON) #533 confirmed Resident #11 received doses of the Cefdinir antibiotic prior to obtaining any UA C&S lab results or verifying the resident had exhibited signs or symptoms of infection. DON #533 confirmed once UA C&S lab results were received, Resident #11 required antibiotic treatment with a different antibiotic that the organism was susceptible to. Review of the facility policy, Antibiotic Stewardship Program, revised 12/13/23, revealed the policy stated, antibiotic orders obtained upon admission, whether new admission or readmission, to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365474 If continuation sheet Page 28 of 29 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 02/14/2024 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 0881 facility shall be reviewed for appropriateness. Level of Harm - Minimal harm or potential for actual harm 2. Review of the medical record for Resident #43 revealed an admission date on 10/27/23. Medical diagnoses included Alzheimer's Disease, Type II Diabetes Mellitus with diabetic chronic kidney disease, chronic kidney disease stage 3, and unspecified psychosis. Residents Affected - Some Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #43 had impaired cognition and scored a seven out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #43 required varied assistance from staff to complete Activities of Daily Living (ADLs) which ranged from set up help only to substantial/maximal assistance. Resident #43 was frequently incontinent of bowel and bladder. Review of progress notes for Resident #43 revealed on 01/23/24 at 8:49 P.M., the resident continued with increased behaviors. The Nurse Practitioner visited and ordered a urinalysis with culture and sensitivity (UA C&S). On 01/24/24 at 12:54 A.M., an order for a UA C&S one time only for increased confusion and behaviors was administered. Review of the urinalysis with culture and sensitivity (UA C&S) laboratory test results reported to the facility on [DATE] revealed Resident #43 was positive for a urinary tract infection (UTI). The organism identified was Escherichia coli (e-coli) bacteria with a greater than 100,000 CFU/mL. Review of the Medication Administration Record (MAR) dated February 2024 revealed Resident #43 had an order for Cephalexin 500 milligrams (mg) orally three times a day for infection for five days with a start date on 02/01/24 at 6:00 A.M. Resident #43 received 14 doses of the antibiotic. Review of McGreer's Criteria for a UTI without a catheter revealed Resident #43's symptom of increased confusion was not a valid symptom to use in determining a UTI. Interview on 02/07/24 at 4:32 P.M. with the Director of Nursing (DON) #533 confirmed Resident #43 did not meet the McGreer's criteria for an infection and was treated with antibiotics. DON #533 stated the facility had not been using the McGreer's criteria to determine if a resident met the appropriate criteria for an infection and use of antibiotics and had been treating residents with antibiotics only based on a positive UA C&S result. Interview on 02/08/24 at 3:47 P.M. with Physician #703 revealed some of those UTI's (for Resident #43) probably are not really true UTI's. She has had positive urine cultures. Review of the facility policy, Antibiotic Stewardship Program, revised 12/13/23, revealed the policy stated, antibiotic use protocols: the facility uses the McGreer criteria to define infections. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365474 If continuation sheet Page 29 of 29