Inspection·October 3, 2019

F 0585 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on record review and interview, the facility failed to ensure grievances were addressed in a timely manner. This affected one (Resident #3) of two residents reviewed for grievances. The census was 39. Residents Affected - Few Findings include: Review of the medical record for Resident #3 revealed an admission date of 09/02/16 with diagnoses including vascular dementia, anxiety, and depression. Review of grievance form for Resident #3 dated 09/25/19 revealed Resident #3's missing personal wheelchair was not mentioned on the grievance form. Interview with Resident #3's family member on 09/30/19 at 1:00 P.M. revealed Resident #3's personal wheelchair was found missing on 09/25/19 when Resident #3 returned to the facility from the hospital. Interview with Social Services Designee (SSD) #57 on 10/01/19 at 3:27 P.M. revealed she was informed by Resident #3's family on 09/25/19 that the resident's personal wheelchair was missing. The wheelchair had been left at the facility while the resident was in the hospital and that staff looked for it, but never found it. SSD #57 stated that when a resident is missing a personal item, then staff looks for it, and if it is not found then a grievance form is immediately filled out. She confirmed no grievance form was completed for the missing wheelchair. The therapy department was supposed to evaluate the resident for a new wheelchair, but the therapy referral had not been completed. Review of the undated policy titled Grievances/Complaints-Staff Responsibility revealed should a staff member overhear or be the recipient of a complaint voiced by a resident, a resident's representative (sponsor), or another interested family member of a resident concerning the resident's medical care, treatment, food, clothing, or behavior of other residents, etc., the staff member is encouraged to assist the resident, or person acting in the residents behalf, to file a complaint with the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365527 If continuation sheet Page 2 of 10 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 365527 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Springfield 1600 Saint Paris Pike Springfield, OH 45504 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and policy review, the facility failed to ensure care plans were revised to reflect the resident's current status. This affected two (Residents #18 and #27) of 18 residents reviewed for care plans. The census was 39. Findings include: 1. Medical record review for Resident #18 revealed an admission date of 07/06/19. Medical diagnoses included schizophrenia. Review of quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 was cognitively intact. Review of the care plan dated 07/08/19 for Resident #18 revealed he had a potential or actual skin impairment to skin integrity. Observation of Resident #18 on 09/30/19 at 6:40 P.M. revealed he was sitting in his room talking to someone that wasn't there. He had lesions on both arms and his abdomen. Some lesions were scabbed and some were open. Interview with Director of Nursing (DON) on 10/01/19 at 4:54 P.M. revealed she didn't revise the care plan for the skin for the open and closed lesions on Resident #18's bilateral upper extremities or his abdomen. She stated the resident came in with the lesions, but it was determined they were from his picking at his skin. Review of the policy titled Care Plans, Comprehensive, dated 01/28/11, revealed care plans should be revised as changes in the resident's condition dictates. 2. Review of the medical record for Resident #27 revealed an admission date of 01/09/18 with diagnoses including paranoid schizophrenia, anxiety, and depression. Resident #27 had a care plan for anti-psychotic medication use with interventions including administer medications as ordered, observe for adverse drug effects and notify physician as needed, observe for environmental stressors such as excessive heat, noise, overcrowding, and intervene as indicated. Review of Resident #27's physician orders revealed no physician order for an anti-psychotic medication. Interview with DON on 10/03/19 at 11:44 A.M. verified Resident #27 had a care plan for anti-psychotic medication use however did not have a physician order for an anti-psychotic medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365527 If continuation sheet Page 3 of 10 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 365527 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Springfield 1600 Saint Paris Pike Springfield, OH 45504 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 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review and drug reference review, the facility failed to ensure a subcutaneous injection was administered according the the standards of practice. This affected one (Resident #1) of one resident who received an injectable blood thinner. The census was 39. Residents Affected - Few Findings include: Medical record review for Resident #1 revealed an admission date of 11/30/18. Medical diagnoses included respiratory failure and quadriplegia. Review of physician orders dated 08/21/19 revealed Enoxaparin Sodium Solution (anticoagulant) 30 milligram (mg)/0.3 milliters subcutaneous, to give once a day for blood clots. Observation of medication administration on 10/02/19 at 9:25 A.M. revealed Licensed Practical Nurse (LPN) #42 administered the injection to the resident's right abdomen. LPN #42 did not pinch up the skin at the injection site prior to giving the medication. Interview with LPN #42 on 10/02/19 at 9:40 A.M. revealed she should have placed the injection two inches away from the belly button and squeezed up the skin to inject the Enoxaparin. She stated she knew she was supposed to administer the injection this way and didn't have a reason why she didn't. Review of Medline Plus-United States National Library of Medicine, revised 07/15/18, revealed instructions to administer a Enoxaparin injection was to lie down and pinch a folds of skin between finger and thumb and inject the medication and hold onto the skin until all of the medication was given. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365527 If continuation sheet Page 4 of 10 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 365527 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Springfield 1600 Saint Paris Pike Springfield, OH 45504 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 observation, record review and interview the facility failed to ensure incontinence care was provided after a resident was soiled. This affected one (Resident #6) of one reviewed for incontinence care. The facility identified 26 incontinent residents. Residents Affected - Few Findings include: Medical record review for Resident #6 revealed an admission dated of 07/01/15. Medical diagnoses included schizophrenia. Review of quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 was moderately cognitively impaired. She was an extensive assistance for toilet use and was always incontinent for bowel and bladder. During observation on 10/01/19 at 10:29 A.M. with Registered Nurse (RN) #49 and State Tested Nursing Assistant (STNA) #4, the resident's incontinent brief was removed to provide wound care. The brief was soiled with urine. After the wound care was provided, a clean incontinent brief was placed on the resident, but no incontinence care was performed. Interview with STNA #4 on 10/01/19 at 10:35 A.M. revealed she had been into the resident's rooms just recently and changed her and provided incontinence care. She stated she should have performed the incontinence care again. Review of the policy titled Perineal Care, revised 01/16/11, revealed the purpose of the procedure was to provide cleanliness and comfort to the resident, to prevent infections and skin irritation and to observe the resident's skin. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365527 If continuation sheet Page 5 of 10 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 365527 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Springfield 1600 Saint Paris Pike Springfield, OH 45504 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 Based on observation, record review and staff interview, the facility failed to ensure a dressing to a peripherally inserted central catheter (PICC) line was changed in a timely manner. This affected one (Resident #12) of one reviewed for PICC line dressings. The facility identified five PICC lines in the facility. Residents Affected - Few Findings include: Medical record review for Resident #12 revealed an admission date of 06/20/19. Medical diagnoses included dementia and respiratory failure. Review of physician orders dated 07/06/19 revealed to change dressing to the PICC line every seven days. Review of the Treatment Administration Record (TAR) dated 09/01/19 through 09/29/19 revealed the only documentation of a dressing change was on 09/24/19 by Licensed Practical Nurse (LPN) #22. Observation of the PICC line for Resident #12 on 09/30/19 at 11:30 A.M. revealed the PICC dressing was dated 09/14/19. Interview with LPN #42 on 09/30/19 at 11:52 A.M. verified the PICC line dressing was dated 09/14/19 and was out of date and should have been changed. She did not know why it wasn't changed and it was the faciltiy policy to change the dressing every seven days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365527 If continuation sheet Page 6 of 10 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 365527 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Springfield 1600 Saint Paris Pike Springfield, OH 45504 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 observation, record review, staff interview and policy review, the facility failed to ensure a recommendation for a splint was completed for a contractured hand. This affected one (Resident #6) of three residents reviewed for contractures. Findings include: Medical record review for Resident #6 revealed an admission dated of 07/01/15. Medical diagnoses included schizophrenia. Review of discharge occupational therapy notes dated 07/11/19 for Resident #6 revealed the resident was measured for a splint for positioning and contracture management. Observation of Resident #6 on 09/30/19 at 1:51 P.M. and 3:45 P.M. revealed she had a contracture in her left hand and did not have a splint on her hand. Observation on 10/01/19 at 7:34 A.M. revealed there wasn't a splint on her left hand. Interview with Therapy Program Director (TPD) #58 on 10/02/19 at 3:59 P.M. revealed there was a transition in the therapy department around the time Resident #6's splint was ordered. She stated the splint was in the facility but had never been placed on the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365527 If continuation sheet Page 7 of 10 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 365527 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Springfield 1600 Saint Paris Pike Springfield, OH 45504 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 - Few 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 policy review, the facility failed to ensure insulin pens were dated for 28 days after opening. This affected two (Residents #11 and #28) of seven who received insulin. Findings include: Observation of the medication cart with Licensed Practical Nurse (LPN) #41 on 10/02/19 at 8:30 A.M. revealed there was a Novolog FlexPen and Lantus Solostar that wasn't dated for Resident #11. An interview at the same time of the observation revealed the pens didn't have a seal on them and verified they should have been dated 28 days after taking them out of the refrigerator . For Resident #28, the medication cart also contained a Novolog FlexPen that wasn't dated and a Lantus Solostar that was dated what looked like 08/25/19 and was changed to 09/25/19 as the opening date for Resident #28. During interview at the time of the observation, LPN #41 said it looked like the date had been changed on the Lantus pen and the Novolog pen should have been dated 28 days after removing it from the refrigerator. Review of the faciltiy policy titled Stability of Common Insulins in Pens and Vials, dated 09/01/11, revealed Novolog FlexPen and Lantus Solostar unopened at room temperature should be dated for 28 days and discarded after this. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365527 If continuation sheet Page 8 of 10 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 365527 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Springfield 1600 Saint Paris Pike Springfield, OH 45504 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Based on record review, staff interview and review of the hospice contract, the facility failed to ensure documentation of hospice visits were readily available in the resident's record. This affected one (Resident #12) of one resident reviewed for hospice care. The facility identified one resident who was receiving hospice care. The facility census was 39. Findings include: Medical record review for Resident #12 revealed an admission date of 06/20/19. Medical diagnoses included dementia and respiratory failure. Review of physician orders dated 07/18/19 revealed hospice care for Resident #12 for a terminal prognosis related to dementia. Interview with a family member on 09/30/19 at 10:16 A.M. revealed hospice was signing in that they were providing the care but wasn't visiting the resident. Interview with the Director of Nursing (DON) on 10/03/19 at 10:04 A.M. revealed the staff from the hospice center was visiting Resident #12 and wrote their own notes on their own computers. She denied they were signing in and not visiting the resident because there wasn't a sign-in sheet. She said hospice would check in with the nursing staff and with her as well when they were going to visit with the resident. She stated the record of visits and what tasks were performed were not in the facility, but could call hospice and get them faxed for the past couple of months. A request was made at 12:00 P.M. for the notes, at 2:30 P.M. and again at 3:30 P.M. All that was provided were notes dated 09/05/19 through 09/08/19. Review the contract from hospice entitled Hospice Contract dated 08/21/18 revealed hospice will provide a complete and timely medical record on each hospice resident relating to all services rendered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365527 If continuation sheet Page 9 of 10 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 365527 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Springfield 1600 Saint Paris Pike Springfield, OH 45504 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 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed to ensure the Administrator attended the quality assurance committee meetings. This had the potential to affect all 39 residents. Residents Affected - Many Findings include: Review of the Quality Assessment and Process Improvement sign in sheets dated 01/10/19, 02/19/19, and 03/19/19 revealed the Administrator did not attend any of the quality assurance committee meetings held on these dates. Interview with the Director of Nursing on 10/03/19 at 1:48 P.M. verified the administrator did not attend the quality assurance committee meetings held on 01/10/19, 02/19/19, and 03/19/19. Review of the policy titled Quality Assurance and Process Improvement Committee, last revised 11/28/16, revealed attendance must include at least three other facility staff members, at least one must be the administrator, owner, board member, or other individual in a leadership role. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365527 If continuation sheet Page 10 of 10