Inspection·June 4, 2024

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete provided to Resident #1 as scheduled twice weekly and there was no evidence the resident's finger nails were cleaned or trimmed. The DON verified Resident #1 was scheduled for showers on Monday and Thursday on second shift. This deficiency represents non-compliance investigated under Complaint Number OH00154162 and Complaint Number OH00153096. Event ID: Facility ID: 365523 If continuation sheet Page 2 of 4 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 365523 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Oregon 904 Isaac Streets Drive Oregon, OH 43616 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, hospital documentation review, and review of a facility incontinence policy, the facility failed to ensure dependent residents received timely and sufficient care related to bowel incontinence. This affected one (#3) of three residents reviewed for the provision of incontinence care services in a facility census of 80. Findings include: Resident #3 admitted to the facility on [DATE] with the diagnoses including atrial fibrillation, congestive heart failure, type II diabetes mellitus, below the knee amputation of the left leg, hypertension, benign prostatic hyperplasia, leukemoid reaction, and right foot amputation. According to the most current Minimum Data Set assessment dated [DATE] assessed Resident #3 with intact cognition, the resident was dependent on staff for the completion of activities of daily living, utilized an indwelling urinary catheter, was frequently incontinent of bowel, and was at risk for pressure ulcer development with moisture associated skin damage. On 09/12/23 a nursing plan of care was revised to address Resident #3's episodes of bowel incontinence related to decreased mobility. Interventions included to check the resident at regular intervals and change as needed, provide peri-care after each incontinence episode, and apply house barrier cream after incontinence care. Review of a Situation, Background, Assessment, and Recommendation (SBAR) communication form dated 05/13/24 at 6:40 P.M. noted Resident #3 appeared pale, lethargic, and with altered mental status. Bright red blood was noted in the resident's urine following a cystoscopy (examination of the bladder through the urethra). Resident #3 had a family member present in the room when the decision was made to send the resident out with physician notification. Review of hospital emergency room documentation dated 05/13/24 at 6:30 P.M. noted Resident #3 to be evaluated for hematuria, nausea, and emesis. Review of progress notes recorded the resident was found to be covered in dried stool. Telephone interview on 06/03/24 at 3:40 P.M. with State Tested Nurse Aide (STNA) #301 revealed she assumed care of Resident #3 on 05/13/24 at 2:00 P.M. and was informed by the off-going STNA that Resident #3 would call out if needing incontinence care or assistance. STNA #301 stated she did not check the resident at anytime for incontinence. STNA #301 indicated Resident #3 went out to the hospital while she was assigned to monitor the dining room and did not have an opportunity to prepare the resident for discharge including incontinence care. On 06/03/24 at 2:37 P.M. interview with Licensed Practical Nurse (LPN) #400 revealed she was assigned to provide care to Resident #3 on 05/13/24. The resident was observed during the shift due to having blood in his urine as result of a cystoscopy performed previous day. Resident #3 became lethargic with a mental status change and the physician ordered the resident to be sent to the hospital for evaluation. LPN #400 stated she did not assess Resident #3 for bowel incontinence prior to discharging or anytime during her shift between 6:00 A.M. and 6:00 P.M. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365523 If continuation sheet Page 3 of 4 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 365523 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Oregon 904 Isaac Streets Drive Oregon, OH 43616 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 0690 Level of Harm - Minimal harm or potential for actual harm On 06/04/24 at 8:30 A.M. interview with the Director of Nursing (DON) and Administrator, during a review of the medical record and hospital documentation, verified Resident #3 was discovered with dried stool to his body upon admission to the hospital emergency room on [DATE]. The DON confirmed Resident #3 was dependent on staff for all care and required incontinence monitoring every two hours. It was confirmed STNA #301 did not provide incontinence checks as required or as indicated in the plan of care. Residents Affected - Few According to the facility incontinence policy revised 01/01/2022 revealed based on the resident's comprehensive assessment, all residents that are incontinent will receive appropriate treatment and services. Residents that are incontinent of bowel or bladder will receive appropriate treatment to prevent infections and to restore continence to the extent possible. Incontinent residents will be routinely checked based on the need of the resident. This deficiency represents non-compliance investigated under Complaint Number OH00154162 and Complaint Number OH00154156. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365523 If continuation sheet Page 4 of 4