Health inspection·August 27, 2025

F 0689 Level of Harm - Immediate jeopardy to resident health or safety 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 review of a social media post, medical record review, staff interview, Police Detective (PD) interview, review of the facility video surveillance, review of the Local Police Department (LPD) report, review of the local weather report and review of the facility policy, the facility failed to ensure Resident #23, who had a diagnosis of alcohol dependence with induced persisting dementia, had a history of an elopement from a previous facility, was assessed to be at risk for elopement, and had a Wanderguard (wearable bracelet that triggers alarms at the doors to alert staff when a resident attempts to exit) applied to his left ankle, did not elope from the facility without staff knowledge. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injury, and/or death on 08/09/25 at 10:38 A.M. when Resident #23 removed his Wanderguard and was able to exit through the front door of the facility. Facility staff were unaware Resident #23 was missing until 08/10/25 at approximately 2:00 A.M. (about 15.5 hours after the resident eloped). Furthermore, Resident #23 was missing for approximately 52 hours before facility staff, who were driving around the local area searching for the resident, found the resident at a bus stop, approximately three miles from the facility. This affected one (#23) of three residents reviewed for elopement. The facility identified six (#14, #22, #23, #28, #34, and #44) residents at risk for elopement. The facility census was 66.On 08/09/25 at 3:02 P.M., the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on 08/09/25 at 10:38 A.M. when Resident #23, who had removed his Wanderguard, was able to exit out of the front door without staff knowledge. Resident #23 ambulated through the parking lot and crossed a moderately traveled two lane road with a speed limit of 35 miles per hour (MPH) before the resident could no longer been seen on the video camera. Facility staff confused Resident #23 with another resident of the facility and did not identify that Resident #23 was missing until 08/10/25 at approximately 2:00 A.M., nearly 15.5 hours after Resident #23 eloped. Resident #23 was not located until 08/11/25 at 2:32 P.M., when facility staff found the resident at a public bus stop. The route traveled by Resident #23 was unknown; however, the area surrounding the facility included heavily traveled four lane roads with speed limits of 40 to 45 MPH and a major interstate highway with speed limits of 60 to 65 MPH. During the time that Resident #23 was missing, it was unknown where he stayed, how he obtained food or hydration, and high temperatures in the area ranged from 90 degrees Fahrenheit (F) on 08/09/25 to 91 degrees F on 08/10/25 and 08/11/25.The Immediate Jeopardy was removed 08/11/25, when the facility implemented the following corrective action plan: On 08/10/25, the DON or designee educated licensed and non-licensed nursing staff on checking assignments prior to starting their shift for assignment location, nurse and Certified Nursing Assistants (CNAs) assigned to the hall, validating residents' identity utilizing photographs in the electronic medical record (EMR), the facility's Leave of Absence (LOA) policy, and the elopement policy. On 8/10/25, the DON reassessed all residents for elopement risk to ensure accuracy of assessments and care plans were reviewed and updated as needed to ensure adequate interventions were in place. On 08/10/25, the DON completed a visual audit of all residents with orders for a Wanderguard to ensure placement, with no concerns identified. On 08/10/25, the DON or designee completed an elopement drill on each shift at the facility, with no concerns identified. On 08/11/25 at 2:32 P.M., Regional Director of Operations (RDO) #603 located Resident #23 in downtown [NAME] at a public bus hub, approximately three miles from the facility. Regional Director of Clinical Services (RDCS) #604 contacted the local police department (LPD) at 2:34 P.M. for assistance. Emergency Medical Services (EMS) and the LPD responded. EMS assessed Resident #23 and medically cleared him to return to the facility. Resident #23 was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365523 If continuation sheet Page 2 of 8 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 08/27/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few transported back to the facility by PD #600. On 08/11/25 at approximately 3:15 P.M, Resident #23 returned to the facility and was placed on one-to-one (1:1) staff supervision to ensure his safety. Resident #23 will remain on 1:1 staff supervision until a more appropriate placement can be found. Registered Nurse (RN) #583 assessed Resident #23 and notified his responsible party and attending physician of his return. On 08/11/25, the DON reassessed Resident #23 for elopement risk, which remained at high risk, and the resident's care plan was reviewed and updated, to include continuous 1:1 staff supervision. On 08/11/25, the Administrator and DON completed a root cause analysis and determined Resident #23 likely removed his Wanderguard by using the blades from disposable razors to cut through the band, allowing the resident to exit through the front door of the facility without activating the alarms and locking the door. Additionally, staff failed to complete proper and accurate communication to ensure Resident #23, who was assessed to be at risk for elopement and had a Wanderguard, was accounted for timely, resulting in a delay in identifying a missing resident and initiating an immediate search, notification, and elopement procedure. On 08/11/25, an Ad Hoc Quality Assurance and Performance Improvement (QAPI) committee meeting was held to review the facility's wandering and elopement policy and procedure and corrective action plan. In attendance were the Administrator, DON, Therapy Director (TD) #611, Assistant Director of Nursing (ADON) #551, Dietary Manager (DM) #541, Social Services Director (SSD) #573, Director of Maintenance (DOM) #581, Housekeeping Director (HD) #583, Human Resources Director (HRD) #564, and Medical Director (MD) #610 (via telephone). On 08/11/25, the DON or designee educated all facility staff on the facility's elopement policy and ensuring adequate supervision of residents to prevent resident elopement without staff knowledge. On 08/11/25, the DON and Central Supply (CS) #518 completed a whole house visual audit to verify residents did not have sharp objects in rooms/common areas, including disposable razors. On 08/11/25, SSD #539 and RDO #580, in collaboration with Resident #23's responsible party, began exploring alternative, more appropriate, placement for the resident, to include a secured unit. Beginning on 08/11/25, the DON or designee will ensure elopement assessments are completed upon admission, readmission and when there is a significant change in condition. Interventions will be implemented for those found to be at risk for elopement, with care plans initiated or updated as needed. Beginning on 08/11/25, Staff Development Coordinator (SDC) #551 or designee will ensure all new licensed and non-licensed nursing staff are educated upon hire on how to recognize and identify the residents they are providing care for by utilizing information, including photographs, in the EMR and on the facility's elopement policy. Beginning on 08/11/25, the DON or designee will audit all new admissions and readmissions for elopement assessments Monday through Friday for four weeks to ensure residents who are identified to be at risk for elopement have appropriate interventions implemented. Beginning on 08/11/25, the DON or designee will interview five direct care staff per week for four weeks to ensure staff are able to recognize the residents that they are providing care for and confirm understanding of the actions to take to ensure adequate supervision for impaired residents to prevent elopement without staff knowledge. Beginning on 08/11/25, the DON or designee will audit resident rooms and common areas one time weekly for four weeks to ensure no sharp objects are left unattended by staff, including disposable razors. Interviews on 08/12/25 from 8:13 A.M. through 8:56 A.M. with Certified Nursing Assistant (CNA) #579, CNA #566, CNA #584, Registered Nurse (RN) #581, and Housekeeper (HSK) #582 verified the facility provided education on the elopement policy and procedure, securing of sharps, and properly identifying residents utilizing information included in the EMR. Observation on 08/12/25 at 8:45 A.M. of Resident #23 verified staff were assigned to provide 1:1 supervision. Review of two (#14 and #22) additional open resident medical records, reviewed for elopement, revealed no additional (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365523 If continuation sheet Page 3 of 8 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 08/27/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few concerns.Although the Immediate Jeopardy was removed on 08/11/25, the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action and monitoring to ensure on-going compliance.Findings include: Review of a social media post dated 08/10/25 at 4:40 P.M. revealed the facility had a resident with dementia missing from the facility. The post indicated the resident had been last seen at the facility before 6:00 P.M. the day prior (08/09/25).Review of Resident #23's medical record revealed an admission date of 07/17/25. Diagnoses included alcohol dependence with induced persisting dementia, cirrhosis, congestive heart failure (CHF), peripheral vascular disease (PVD), convulsions, diabetes mellitus, high blood pressure, cardiomyopathy (enlarged heart), and atherosclerotic heart disease (buildup of plaque on artery walls).Review of the hospital referral records, printed on 07/09/25, revealed Resident #23 presented to the hospital on [DATE] with altered mental status after leaving a long-term care (LTC) facility and being found at a bus stop (previous elopement from another facility).Review of the care plan, initiated on 07/17/25 and revised on 07/18/25, revealed Resident #23 was at risk for elopement, had a previous elopement from a facility, and was cognitively impaired. Interventions included to calmly redirect and divert the resident's attention and periodically evaluate the continued need of a Wanderguard. On 08/11/25, the plan of care was revised to include 1:1 (staff supervision).Review of the admission Minimum Data Set (MDS) assessment, dated 07/23/25, revealed Resident #23 was cognitively impaired.Review of the Brief Interview for Mental Status (BIMS) assessment, dated 07/18/25, revealed a score of zero, indicating Resident #23 was severely cognitively impaired.Review of the elopement risk assessment, dated 07/18/25, revealed Resident #23 was at risk of elopement due to a BIMS of zero and a history of elopement from a prior facility.Review of a physician order, initiated 07/18/25, revealed Resident #23 had an order for a Wangerguard to the left ankle, check placement and function each shift.Review of the Medication Administration Record (MAR) for August 2025 revealed Resident #23's Wanderguard was documented as in place and functioning, including on 08/09/25.Review of a nursing progress note, dated 08/10/25 at 6:00 A.M. and authored by the DON, revealed at approximately 2:00 A.M. the nurse, Licensed Practical Nurse (LPN) #505, entered the resident's room to see the resident and observed he was not in his room. A missing resident investigation was immediately initiated. According to video surveillance, Resident #23 exited through the front doors of the facility and exited on the south side of the property, crossed the street and walked toward the city's annual festival and did not return on 08/09/25. Upon investigation, Resident #23 called his ex-wife and left a voicemail indicating he did not want to be in the facility any longer and was going to the bus station. Resident #23 asked RN #515 to take a shower on the morning of 08/09/25. At that time, RN #515 verified the Wanderguard was on Resident #23 and functioning. Resident #23 was seen on the facility's video surveillance camera on 08/09/25 at 10:39 A.M. in the front lobby, directly around the corner where the front door was located, wearing khaki shorts and a red and white button up short sleeve shirt and tennis shoes. A CNA entered through the front door of the facility and, as the door was closing,Resident #23 was observed going around the corner and out through the front door before it closed. The facility's alarm system did not go off. Resident #23 was then observed under the front awning of the facility and the Wanderguard to the left ankle was no longer in place where it was previously located. A search of Resident #23's room and belongings revealed broken razors and a cell phone that did not belong to him. The facility staff conducted a head count and facility search inside and outside and were not able to locate Resident #23. The LPD was called to file a missing person report.An observation on 08/11/25 at 7:25 A.M. of Resident #23's room revealed the resident was not present. Further (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365523 If continuation sheet Page 4 of 8 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 08/27/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few observation revealed the resident's bed was stripped of linens, with two garbage cans and a white telephone (landline) sitting on top of the bed. The overbed table had change (coins), toiletries were on the nightstand, and one pair of light khaki pants were in the closet. Concurrent interview with Resident #22 (Resident #23's roommate) revealed He's (Resident #23) been gone for almost two and a half days. I thought he would be back last night. Resident #22 further stated, I heard him on the phone talking to a woman, talking something about Hollywood, he then stated he was going to catch the bus, so I gave him five bucks. He didn't have any money.An observation on 08/11/25 at approximately 7:40 A.M. of the resident sign in/out book revealed Resident #23 did not have a dedicated sign in/out sheet for himself. Further observation revealed no evidence Resident #23 had signed out on a Leave of Absence (LOA) from the facility at any time, including 08/09/25.An interview on 08/11/25 at 9:01 A.M. with the Administrator verified Resident #23 eloped from the facility, without staff knowledge, on 08/09/25 at approximately 10:38 A.M. and had not been located. Concurrent review of the facility's video surveillance verified that Resident #23 was in the front lobby area and exited the facility through the front door on 08/09/25 at 10:38 A.M. Further observation revealed Resident #23 was just outside the front doors, under the awning, speaking to another resident and then walked south out of the parking lot to the edge of the street, crossed the street, and continued walking until he was out of range of the video surveillance camera. Resident #23 was wearing white/khaki shorts, a red and white short-sleeved shirt, and tennis shoes. A Wanderguard was not observed on Resident #23's left ankle.An interview on 08/11/25 at 10:22 A.M. with the DON confirmed Resident #23 eloped from the facility on 08/09/25. The DON stated Resident #23 was not capable of signing himself out of the facility and never had family visit him at the facility. The DON stated the nurse assigned to provide care for Resident #23 on 08/09/25 had him confused with another resident, who she believed had left to go to a local festival.Interview on 08/11/25 at 11:50 A.M. with Admissions #537 revealed the front reception desk was not staffed on the weekends and the front doors were unlocked during the day.A telephone interview on 08/11/25 at 12:20 P.M. with RN #515 revealed she was the nurse assigned to Resident #23 on 08/09/25. RN #515 stated her routine was to check Wanderguards in the morning and completed that task on the morning of 08/09/25 but did not recall the exact time. RN #515 stated Resident #23 requested a shower that morning and CNA #557 assisted the resident. RN #515 stated she passed on in report at shift change (approximately 6:00 P.M.) that Resident #23 was Okay, with nothing negative to report. RN #515 further stated she did not recall any staff informing her that Resident #23 did not eat his lunch or dinner that day.Interview on 08/11/25 at 12:58 P.M. with CNA #557 revealed she worked on 08/09/25 and assisted Resident #23 to the shower room, although he was not on her assignment for the day. CNA #557 stated this was the first time she provided care for Resident #23 and was advised by RN #515 that Resident #23 was independent with care, and he just needed assistance into the shower room and linen for a shower. CNA #557 stated she let the resident into the shower room and offered help, but he declined and shut the door. CNA #557 stated Resident #23 exited the shower room in the same clothes he was wearing when he went in and changed into different clothing in his room. CNA #557 did not recall if the Wanderguard was in place on the resident's left ankle at the time of the shower.Interview on 08/11/25 at 2:00 P.M. with PD #600 revealed the report received from the staff to the reporting officer on 08/10/25 was that Resident #23 went to the local festival to watch the fireworks with other residents and did not return with the other residents. PD #600 stated that based on the new information provided by the surveyor, he would initiate a search of the area, including along a creek.An interview on 08/11/25 at approximately 3:15 P.M. with the Administrator and DON revealed Resident #23 had been located by facility staff.A telephone interview on 08/13/25 at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365523 If continuation sheet Page 5 of 8 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 08/27/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 8:01 A.M. with CNA #558 verified she worked on 08/09/25 and was assigned to provide care for Resident #23 from 6:00 P.M. to 10:00 P.M. CNA #558 stated she arrived on the unit and began answering call lights and on her rounds identified that Resident #23's dinner tray remained in his room, untouched. CNA #23 stated she asked LPN #505 about his whereabouts and learned Resident #23 went to a local festival (within walking distance) with family. CNA #558 stated that at 10:00 P.M., her assignment changed, and she was no longer assigned to Resident #23. CNA #558 stated when Resident #23 was identified as missing, at approximately 2:00 A.M. on 08/10/25, she assisted with conducting a head count of all residents, a search of the inside and outside of the facility, and provided a photograph of Resident #23 to other residents and the LPD when they arrived to take a report.A telephone interview on 08/13/25 at 9:07 A.M. with LPN #505 revealed she worked on 08/09/25 and was assigned to Resident #23. LPN #505 stated she received in report at shift change that Resident #23 went to a local festival with family. LPN #505 stated she did not recall if any of the staff reported Resident #23 did not eat his dinner and further stated if he was at the festival, she would have expected him to eat dinner with his family at the festival. LPN #505 stated that at approximately 2:00 A.M. on 08/10/25 she went to see if Resident #23 wanted his nighttime medications, even though they were late, and that was when she discovered he was not in his room and immediately began searching for him. LPN #505 stated she called the LPD and her supervisors to report the incident.Review of the LPD report, dated 08/10/25 at 4:48 A.M., revealed the facility filed a missing adult report for Resident #23. Further review revealed on 08/10/25 at 3:32 A.M., the facility notified the LPD that on 08/09/25, a resident (Resident #23) with dementia had left the facility and did not return. The facility staff could not confirm the last time the resident was seen at the facility and LPN #505 stated she believed Resident #23 left the facility during daylight hours, along with other residents, to attend Boomfest (local festival) and all other residents returned. Further review of the police supplemental report, dated 08/11/25 at 4:02 P.M., revealed Resident #23 had been located at a public bus hub and was safely returned to the facility by PD #600.Review of the local weather conditions from 08/09/25 through 08/11/25, located at https://wunderground.com/history/monthly/us/, revealed on 08/09/25, the high temperature in the area of the facility was 90 degrees F and on 08/10/25 and 08/11/25, the high temperature reached 91 degrees F.Review of the facility policy titled, Unsafe Wandering and Elopement Prevention, revised January 2022, revealed every effort would be made to prevent wandering and elopement episodes while maintaining the least restrictive environment for residents who were at risk for elopement. All residents who are at risk for harm because of unsafe wandering would be assessed by the interdisciplinary care planning team. The resident's care plan would be modified to indicate the resident was at risk for elopement episodes and staff would be informed at shift change of the modifications to the resident's care plan.This deficiency represents noncompliance investigated under Complaint Number 2588449. Event ID: Facility ID: 365523 If continuation sheet Page 6 of 8 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 08/27/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, staff interview, and review of the facility policy, the facility failed to ensure medication carts were secured when left unattended and further failed to appropriately dispose of oral syringes used for the administration of medication. This had the potential to affect seven (#22, #23, #28, #31, #34,#35, and #44) residents identified by the facility as being cognitively impaired, independently mobile, and resided on the C and D Halls. The facility census was 66. Findings include:Observation on 08/06/25 at 7:00 A.M., upon entry into the facility, revealed an unattended and unlocked medication cart near the beginning of the C and D Halls. On top of the medication cart was a clear plastic drinking cup that contained two small oral syringes (no needle attached), resembling the type of syringe that was used to administer liquid oral medications. Small droplets of an unknown clear substance were observed on the syringes and on the inside of the drinking cup. No facility staff were observed in the area. Continuous observation revealed at 7:05 A.M., Licensed Practical Nurse (LPN) #505 exited a resident's room, from behind a closed door, at the very end of the D Hall. Further observation revealed the D Hall had 13 resident rooms, a shower room, a soiled linen utility room, and other office type rooms. Interview on 08/06/25 at 7:05 A.M. with LPN #505 verified the medication cart was left unlocked and unattended. LPN #505 further confirmed the two syringes in the clear drinking cup on top of the medication cart had been used to administer morphine sulphate. LPN #505 stated this was not her medication cart and she was trying to clean up the mess left by night shift. LPN #505 verified shift change was at 6:00 A.M. (approximately one hour prior). Review of the facility policy titled, Medication Storage, revised January 2024, revealed it was the policy of the facility to ensure all medications housed on the premises would be stored according to the manufacturer's recommendations and ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. During a medication pass, medications would be under direct observation of the person administering medications or locked in the medication storage area or cart. This deficiency was an incidental finding discovered during the complaint investigation. Event ID: Facility ID: 365523 If continuation sheet Page 7 of 8 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 08/27/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete 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 review of the facility policy the facility failed to ensure foods were appropriately stored and further failed to ensure foods were discarded of past the use by dates. This had the potential to affect all residents residing in the facility, except for 13 (#3, #5, #6, #8, #12, #13, #15, #16, #17, #19, #20, #21, and #33) residents identified by the facility as receiving no food by mouth. The facility census was 66.Findings include:Observations on 08/06/25 from 7:20 A.M. to 7:42 A.M. of the kitchen revealed the milk cooler contained a crate holding 38 individual cartons of one percent milk with a stamped expiration date of 08/05/25, two unopened thickened orange juice containers with an expiration date of February 2024, and one unopened thickened apple juice with an expiration date of July 2025. Interview on 08/06/25 at 8:22 A.M. with Dietary Manager (DM) #541 verified the expired thickened orange juice, apple juice, and one percent milk. Observation on 08/06/25 at 8:25 A.M. of the east pantry (where the refrigerator was located to hold foods brought in by residents and/or family and visitors) revealed a bag containing food from a fast-food restaurant that was not labeled with a name and was dated 07/25/25; a container of potato salad, unlabeled with a name and dated 06/17/25; and food debris of cheese, lettuce, and croutons on the floor in front of the refrigerator. Concurrent interview with Licensed Practical Nurse (LPN) #506 verified the findings.Interview on 08/06/25 at 8:25 A.M. with DM #541 revealed dietary staff maintained the temperature logs for the pantry refrigerator and cleaned the refrigerator maybe two to three times per month but all staff were responsible for maintaining the refrigerator.Observation on 08/06/25 at 8:30 A.M. of the west pantry revealed an unlabeled plastic grocery bag of unknown food dated 07/04/25, one plastic grocery bag of unknown food unlabeled and undated, two different restaurant boxes that contained food that were undated, and an expired carton of milk that was dated 08/03/25. Concurrent interview with Medical Records Clerk (MRC) #561 verified the findings. Review of the facility policy title, Food Receiving and Storage revised July 2025, revealed foods should be received and stored in a manner that complied with safe food handling practices. All dry foods were labeled, dated, and rotated by using the first in-first out system. All foods stored in the refrigerator would be covered, labeled and dated. Review of the facility policy titled, Use and Storage of Food Brought in by Family or Visitor, revised July 2025, revealed family members and visitors may bring the resident food of their choosing. All food items that were already prepared by the family or visitor must be labeled with the contents and dated. The facility may refrigerate labeled and dated prepared items in the nourishment refrigerator. Food must be consumed by the resident within three days and, if not consumed within three days, the food would be thrown away by the facility staff. This deficiency represents non-compliance investigated under Complaint Number 1260630 and Complaint Number 1260631. Event ID: Facility ID: 365523 If continuation sheet Page 8 of 8