Health inspection·June 26, 2025

F 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review and staff interview the facility failed to ensure residents with reclining wheelchairs were assessed for possible restraint use. This affected two (Resident #12 and #34) of two residents reviewed for possible restraint use. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #12 revealed an admission date of 01/05/21 with diagnoses that included end stage renal disease with hemodialysis, diabetes mellitus and atrial fibrillation. Review of the physician's orders for Resident #12 revealed on 10/17/24 that while resident is up in tilt-in-space wheel chair (wheelchair which can recline for comfort and positioning) to tilt resident back to 30-40 degrees every hour for 5-20 minutes as tolerates to relieve pressure off coccyx and sacrum. No evidence was found in the medical record to determine when the tilt-in-space wheelchair was initiated and no evidence of an assessment to determine if the tilt and space wheelchair was a restraint. Observation of Resident #12 on 06/23/25 at 10:44 A.M. revealed the resident was reclined in a tilt-in-space wheelchair. Interview with the Director of Nursing on 06/23/25 at 3:55 P.M. verified Resident #12 was not assessed for potential use of a restraint with the tilt-in-space wheelchair. The Director of Nursing further indicated the resident had utilized the tilt-in-space wheelchair for a prolonged period. 2. Review of the medical record for Resident #34 revealed an admission date of 04/15/23 with diagnoses that included Alzheimer's disease with dementia, diabetes mellitus and post-traumatic stress disorder. Review of the physician's orders for Resident #34 revealed on 10/17/24 that while resident is up in tilt-in-space wheel chair, to tilt the resident back to 30-40 degrees every hour for 5-20 minutes as tolerates to relieve pressure off coccyx and sacrum. No evidence was found to determine when the tilt-in-space wheelchair use was initiated. Further review of the medical record revealed no assessment was completed to determine if the use of the tilt-in-space wheelchair was a potential treatment. Observation of Resident #34 on 06/23/25 at 1:29 P.M. revealed the resident was reclined in a Page 1 of 4 365496 365496 06/26/2025 Arbors at Woodsfield 37930 Airport Road Woodsfield, OH 43793

F 0604 Level of Harm - Minimal harm or potential for actual harm tilt-in-space wheelchair. Additional observation on 06/23/25 at 3:01 P.M. revealed the resident was reclined in a tilt-in-space wheelchair. Interview with the Director of Nursing on 06/23/25 at 3:55 P.M. verified Resident #34 had not been assessed to determine if the use of a tilt-in-space wheelchair was a potential restraint prior to 06/23/25. Residents Affected - Few 365496 Page 2 of 4 365496 06/26/2025 Arbors at Woodsfield 37930 Airport Road Woodsfield, OH 43793

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure comprehensive assessments were accurate. This affected two residents (Resident #9 and #48) of 12 residents reviewed for accurate assessment. Residents Affected - Few Findings include: 1. Review of Resident #9's medical record revealed an admission date of 08/26/13 with diagnoses including cerebral palsy, major depressive disorder, generalized anxiety disorder, allergic rhinitis, excoriation (skin picking) disorder, irritant contact dermatitis, and candidiasis of the skin. Review of the physician orders revealed to administer hydroxyzine (Vistaril, an anti-histamine medication that is sometimes prescribed to treat anxiety) 50 milligrams (mg) by mouth every eight hours as needed for itching for 90 days written 04/24/25. Further review of the electronic medical record (EMR) revealed no evidence of the resident having received an anti-anxiety medication from 05/01/25 through 05/06/25. Review of the annual Minimum Data Set (MDS) dated [DATE] revealed the MDS reflected the resident had received an anti-anxiety medication during the seven day MDS review period (05/01/25 through 05/07/25). On 06/24/25 at 3:32 P.M., an interview with Corporate Nurse #100 confirmed the resident's annual MDS was not accurately coded to reflect the medications the resident received. She acknowledged the resident was marked on the MDS as having received an anti-anxiety medication when the resident was not receiving one. The Corporate Nurse verified Vistaril was an antihistamine and not an antianxiety medication and should not have been coded as such. 2. Review of Resident #48's medical record revealed an admission date of 04/18/25 with diagnoses including unspecified dementia with psychotic disturbances, post-traumatic stress disorder, type II diabetes, chronic kidney disease- stage III, atrial fibrillation, peripheral vascular disease and generalized anxiety disorder. Review of the physician orders revealed to administer rosuvastatin calcium oral tablet 40 milligrams by mouth at bedtime for hyperlipidemia. Review of the admission MDS dated [DATE] revealed the resident was cognitively intact. The resident's diagnoses (under Section I) did not include the diagnosis of hyperlipidemia despite the resident receiving rosuvastatin calcium every night at bedtime since admission to the facility. On 06/24/25 at 10:05 A.M. interview with the Director of Nursing and Corporate Nurse #100 verified that the resident's admission MDS completed on 04/25/25 was not coded accurately to reflect the resident's diagnosis of hyperlipidemia. Both acknowledged the resident had been receiving rosuvastatin at bedtime for hyperlipidemia since admission to the facility. 365496 Page 3 of 4 365496 06/26/2025 Arbors at Woodsfield 37930 Airport Road Woodsfield, OH 43793

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview the facility failed to ensure residents had appropriate indication for use of medications and did not have duplicate medication therapy without appropriate justification. This affected one (Resident #46) of five residents reviewed for medication use. Residents Affected - Few Findings include: Review of Resident #46's medical record revealed an admission date of 01/23/25 with diagnoses that included traumatic brain injury and post-traumatic hydrocephalus. No evidence of any gastro-esophageal reflux disorder (GERD) was identified. Review of the physician's orders revealed the current use of famotidine (medication for treatment of GERD) 20 milligrams (mg) twice daily and protonix (medication for treatment of GERD) 20 mg daily. Further review of the medical record including physician's progress notes and hospital records identified no current or prior diagnosis of GERD or justification for the duplicate medication therapy. Interview with the Director of Nursing on 06/24/25 at 2:35 P.M. verified Resident #46 did not have a diagnosis of GERD and received duplicate medication therapy for GERD. 365496 Page 4 of 4