Inspection·November 9, 2022

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #24's quarterly MDS assessment dated [DATE] revealed the resident had cognitive impairment and Resident #24 required extensive assistance with bed mobility, dressing, and personal hygiene. Resident #24 also required total dependence with transfers, and toileting and Resident #24 was independent with eating. Review of Resident #24's progress note dated 04/26/22 revealed resident began with shortness of breath with abnormal lung sounds. The physician was notified, and Resident #24 was sent out to the emergency department for evaluation. Review of Resident #24's progress note dated 05/23/22 revealed Resident #24 readmitted to the facility from the hospital. Interview with Social Services Director (SSD) #12 on 11/08/22 at 11:17 A.M. verified the Ombudsman was not notified of Resident #24's transfer to the hospital on [DATE]. Review of the facility's transfer and discharge policy dated 07/28/20 revealed the facility shall provide notice of a resident's transfer to the ombudsman. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365527 If continuation sheet Page 2 of 15 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 11/09/2022 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to give notice of bed hold. This affected one (#24) out of five residents reviewed for hospitalizations. The facility census was 37. Findings include: Review of the Resident #24's chart revealed Resident #24 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting right dominant side, nontraumatic intracranial hemorrhage, heart failure, dysphagia, end stage renal disease, dependence on renal dialysis, encephalopathy, hypertension, weakness, chronic pain syndrome, hyperlipidemia, anemia, cardiomegaly, and generalized anxiety disorder. Review of Resident #24's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had cognitive impairment and Resident #24 required extensive assistance with bed mobility, dressing, and personal hygiene. Resident #24 also required total dependence with transfers, and toileting and Resident #24 was independent with eating. Review of Resident #24's progress note dated 04/26/22 revealed resident began with shortness of breath with abnormal lung sounds. The physician was notified, and Resident #24 was sent out to the emergency department for evaluation. Review of Resident #24's progress note dated 05/23/22 revealed Resident #24 readmitted to the facility from the hospital. Review of Resident #24's progress note dated 07/17/22 revealed Resident #24 was taken to the emergency room per family request. Review of Resident #24's progress note dated 07/25/22 revealed Resident #24 arrived back at the facility. Review of Resident #24's bed hold notices from 04/26/22 to 11/08/22 revealed Resident #24 had one bed hold notice dated 05/18/22. The bed hold notice dated 05/18/22 revealed Resident #24 wished to have her bed held for 30 days. Interview with the Administrator on 11/08/22 at 12:11 P.M. verified Resident #24 did not have a bed hold notice completed within 24 hours of her 04/26/22 or 07/25/22 hospitalizations. Review of the facility's bed hold prior to discharge policy dated 07/28/22 revealed the facility will provide written information to the resident and the resident representative regarding bed hold policies prior to transferring a resident to the hospital. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365527 If continuation sheet Page 3 of 15 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 11/09/2022 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 7. Review of Resident #14 medical record revealed an admission date of 06/10/22 and a diagnosis of chronic respiratory failure, unspecified hypoxia or hypercapnia, morbid (severe) obesity due to excess calories, acute kidney failure, chronic obstructive pulmonary disease, dependence on respirator (ventilator) status, tracheostomy status, aphonia, atrial fibrillation, congenital subglottic stenosis, type II diabetes mellitus, abnormalities of gait and mobility, lack of coordination, and altered mental status. Review of the quarterly MDS dated [DATE] revealed Resident #14 is cognitively intact. Her functional status is listed as extensive assistance of one or two staff for all activities of daily living except toileting and hygiene and she is totally dependent on two person assists. The MDS also revealed Resident #14 is always incontinent of urine and bowel. The MDS also revealed the resident had no pressure ulcers. Review of the care plan dated 07/08/22 revealed a no plan in place for antipsychotic medications. Review of the physician orders dated 08/06/22 revealed Ativan Tablet one milligram (mg), give one mg by mouth three times a day for anxiety, Seroquel Tablet 50 MG (Quetiapine Fumarate), give 25 mg by mouth at bedtime for mood disorder. Review of the Medication Administration Record (MAR) dated for 08/2022, 09/2022, 10/2022, and 11/2022 revealed Resident #14 was administered antipsychotic medications. Interview with Staff #50 on 11/08/22 at 11:45 A.M. confirmed the facility did not have a plan in place for antipsychotic medications. Based on interview and record review, the facility failed to ensure a resident had a care plan for antipsychotic medications, dialysis, feeding tubes, activities of daily living, anticoagulant medications and infection control isolation. This affected seven (#1, #6, #8, #14, #19, #20, and #24) out of fifteen residents reviewed for care plans. The facility census was 37. Findings include: 1. Review of the Resident #19's chart revealed Resident #19 was admitted to the facility on [DATE] with diagnoses including acute and chronic respiratory failure with hypoxia, pressure ulcer of sacral region stage four, other symptoms and signs involving the musculoskeletal system, contracture right ankle, contracture right knee, contracture left ankle, contracture of other specified joint, depression, weakness, muscle weakness, hyperlipidemia, gastro esophageal reflux disease, hypotension, alcohol abuse with alcohol induced anxiety disorder, and insomnia. Review of Resident #19's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and Resident #19 required total dependence with bed mobility, toileting, dressing, and personal hygiene. Resident #19 required extensive assistance with eating. Resident #19 was not reported to have a feeding tube on his MDS. Review of Resident #19's care plan dated 11/08/22 revealed no information related to a feeding tube. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365527 If continuation sheet Page 4 of 15 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 11/09/2022 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident #19's physician order dated 06/06/22 revealed staff were to monitor percutaneous endoscopic gastrostomy (PEG) tube site for signs and symptoms of infection. Notify the physician of any abnormalities every day and night shift for monitoring. Review of Resident #19's physician order dated 08/30/22 revealed Resident #19 was ordered to have the PEG tube site cleansed with normal saline, pat dry and apply a two by two split gauze twice daily and as needed every day and night shift. Review of Resident #19's physician orders from 09/01/22 to 11/08/22 revealed Resident #19 had no orders for flushing his feeding tube. Review of Resident #19's Medication Administration Record (MAR) from 09/01/22 to 11/08/22 revealed no documentation that Resident #19's feeding tube was flushed. Review of Resident #19's progress note dated 10/07/22 revealed Resident #19 was requesting a PEG tube removal. Interview with the Director of Nursing (DON) on 11/08/22 at 8:51 P.M. verified Resident #19 had a feeding tube, but he was not currently using it. The DON also confirmed Resident #19 did not have a care plan for his feeding tube, an order to flush his feeding tube or any documentation showing his feeding tube was flushed by staff. The DON stated Resident #19's should have had an order to flush his feeding tube. Review of the facility's feeding tubes policy dated 01/01/22 revealed feeding tubes will be maintained in accordance with current clinical standards of practice with interventions to prevent complications to the extent possible. The plan of care will reflect the use of a feeding tube and potential complications. 2. Review of the Resident #24's chart revealed Resident #24 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting right dominant side, nontraumatic intracranial hemorrhage, heart failure, dysphagia, end stage renal disease, dependence on renal dialysis, encephalopathy, hypertension, weakness, chronic pain syndrome, hyperlipidemia, anemia, cardiomegaly, and generalized anxiety disorder. Review of Resident #24's quarterly MDS assessment dated [DATE] revealed the resident had cognitive impairment and Resident #24 required extensive assistance with bed mobility, dressing, and personal hygiene. Resident #24 also required total dependence with transfers, and toileting and Resident #24 was independent with eating. Resident #24's MDS reported Resident #24 was on dialysis. Review of Resident #24's care plan dated 11/08/22 revealed Resident #24 did not have a care plan for dialysis. Observation of Resident #24 on 11/07/22 at 9:00 A.M. revealed Resident #24 was at dialysis that was performed by a separate company at the facility. Review of Resident #24's dialysis acute flow sheet dated 01/14/22 revealed Resident #24 was receiving dialysis services. Interview with the DON on 11/08/22 at 8:51 A.M. verified Resident #24 was on dialysis services and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365527 If continuation sheet Page 5 of 15 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 11/09/2022 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 0656 did not have a dialysis care plan. Level of Harm - Minimal harm or potential for actual harm Review of the facility's care planning dialysis special needs policy dated 01/01/22 revealed the facility will provide the necessary care and treatment consistent with professional standards of practice, physician orders, the comprehensive person centered care plan and the goals and preferences to meet the special medical, nursing, mental and psychosocial needs of residents receiving dialysis. Residents Affected - Some 3. Review of the medical record for Resident #1 revealed an admission date of 08/27/21 with medical diagnoses of chronic kidney disease stage IV, end stage renal disease, legal blindness, diabetes mellitus, morbid obesity, and peripheral idiopathic neuropathy. Review of the medical record for Resident #1 revealed a MDS dated [DATE] which revealed the resident was cognitively intact. The MDS revealed Resident #1 required extensive staff assistance for bed mobility, dressing, toileting, and bathing. Further review of the MDS revealed Resident #1 was dependent upon staff for transfers. Review of the medical record for Resident #1 revealed an Activities of Daily (ADL) care plan which did not have documentation to address Resident #1's bed mobility, dressing, grooming, bathing, or personal hygiene. Interview on 11/08/22 at 10:35 A.M. with Staff #50 confirmed Resident #1's ADL care plan did not contain documentation to address Resident #1's bed mobility, dressing, grooming, bathing, or personal hygiene. 4. Review of the medical record for Resident #6 revealed an admission date of 08/01/22 with medical diagnoses of acute respiratory failure, sepsis, encephalopathy, chronic kidney disease (CKD), epilepsy, diabetes mellitus and hypertension. Review of the medical record revealed a MDS dated [DATE] which revealed Resident #6 was cognitively intact. The MDS revealed Resident #6 required limited assistance with bed mobility, extensive staff assistance with toileting and dependent upon staff for personal hygiene. The MDS revealed Resident # 6 did not transfer or ambulate. Review of the medical record for Resident #6 revealed a physician order for Eliquis (blood thinner) 2.5 milligram by mouth two times per day for the prevention of deep vein thrombosis. Review of medical record revealed Resident #6's ADL care plan did not contain documentation to address Resident #6's bed mobility, dressing, grooming, bathing, or personal hygiene. Further review of Resident #6's care plans revealed there was no documentation to support the facility developed a comprehensive care plan for use of an anticoagulant (blood thinner) medication. Interview on 11/08/22 at 10:35 A.M. with Staff #50 confirmed Resident #6's medical record did not contain an anticoagulant care plan or that Resident #6 ADL care plan had documentation to address bed mobility, dressing, grooming, bathing, or personal hygiene. 5. Review of the medical record for Resident #8 revealed an admission date of 12/19/19 with medical diagnoses of cerebral infraction, chronic obstructive pulmonary disease (COPD), hypertension (HTN), dysphagia, urinary tract infection (UTI), right sided hemiparesis, and anxiety disorder. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365527 If continuation sheet Page 6 of 15 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 11/09/2022 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the medical record for Resident #8 revealed a MDS dated [DATE] which revealed Resident #8 had severe cognitive impairment. The MDS revealed Resident #8 was dependent upon staff for bed mobility, transfers, dressing, eating, toileting, and bathing. Review of the medical record for Resident #8 revealed a urinalysis was completed on 11/04/22 which revealed Resident #8's urine tested positive for Klebsiella pneumoniae Carbapenem Resistant Enterobacteriaceae (CRE), which is a multi-drug resistant organism. Review of the medical record for Resident #8 revealed there was no documentation to support the facility had developed a comprehensive care plan to address Resident #8's contact isolation due to CRE. Interview on 11/09/22 at 8:54 A.M. with DON confirmed Resident #8's medical record did not contain a comprehensive care plan for Resident #8's contact isolation due to CRE. 6. Review of the medical record for Resident #20 revealed an admission date of 07/30/22 with medical diagnoses of end stage renal disease, diabetes mellitus (DM) with peripheral angiopathy, severe protein calorie malnutrition, metabolic encephalopathy, adult failure to thrive, atrial flutter, Depression and hypertension. Review of the medical record for Resident #20 revealed a MDS dated [DATE] which revealed Resident #20 was cognitively intact. The MDS revealed Resident #20 required limited assistance with bed mobility and transfers and extensive assistance with toileting and dressing. The MDS revealed Resident #20 was dependent for bathing. Further review of the MDS revealed Resident #20 received dialysis and received an antidepressant medication. Review of the medical record for Resident # 20 revealed a physician order for Remeron (antidepressant) 7.5 milligrams by mouth every evening and Paxil 10 milligram by mouth daily for the treatment of Depression. Review of the medical record for Resident #20 revealed the dialysis care plan for Resident #8 did not contain the interventions as required by the policy titled Care Planning Dialysis Special Needs. Further review of medical record for Resident #20's revealed there was no documentation to support the facility developed a comprehensive care plan to address the use of antidepressant medications. Interview on 11/09/22 at 9:00 A.M. with DON confirmed Resident #20's medical record did not contain a comprehensive care plan for the antidepressant medications and the dialysis care plan did not contain interventions according to the Care Planning Dialysis Special Needs policy. Review of the policy titled Care Planning Dialysis Special Needs, revealed compliance guidelines for the facility's comprehensive dialysis care plans to include the following interventions: pre/post dialysis weights, documentation and monitoring of complications, assessing, observing and documenting care of access site, nutritional and hydration, lab tests, and vital signs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365527 If continuation sheet Page 7 of 15 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 11/09/2022 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 staff interviews, medical record review and policy review, the facility failed to review and revise care plans for two (Resident #1 and #8) out of 15 residents sampled for care plans. This had the potential to affect all the residents in the facility. The facility census was 37. Findings include: 1. Review of the medical record for Resident #8 revealed an admission date of 12/19/19 with medical diagnoses of cerebral infraction, chronic obstructive pulmonary disease (COPD), hypertension (HTN), dysphagia, right sided hemiparesis, and anxiety disorder. Review of the medical record for Resident #8 revealed a Minimum Data Set (MDS) dated [DATE] which revealed Resident #8 had severe cognitive impairment. The MDS revealed Resident #8 was dependent upon staff for bed mobility, transfers, dressing, eating, toileting and bathing. Further review of the medical record for Resident #8 revealed an Activity of Daily Living (ADL) care plan which stated the resident was independent with eating. Interview on 11/08/22 at 12:25 P.M. with certified nursing assistant (CNA) #25 stated Resident #8 was dependent upon staff to feed her all her meals due to the resident was no longer able to feed herself and has not been able to feed herself for quite some time. Interview on 11/09/22 08:51 A.M. with Director of Nursing (DON) confirmed Resident #8's ADL care plan was documented Resident #8 was independent with eating. DON confirmed Resident #8 was dependent with eating and the ADL care plan was not revised to accurately reflect the amount of assistance Resident #8 needed for eating. DON also stated the facility staff utilized Resident #8's [NAME] to determine the amount of assistance Resident #8 required for ADLs. Per the DON, the ADL information for the [NAME] is obtained from the ADL care plan. 2. Review of the medical record for Resident #1 revealed an admission date of 08/27/21 with medical diagnoses of chronic kidney disease stage IV, end stage renal disease, legal blindness, DM, morbid obesity, and peripheral idiopathic neuropathy. Review of the medical record for Resident #1 revealed a MDS dated [DATE] which revealed the resident was cognitively intact. The MDS revealed Resident #1 required extensive staff assistance for bed mobility, dressing, toileting, and bathing. Further review of the MDS revealed Resident #1 was dependent upon staff for transfers. Review of the medical record for Resident #1 revealed the residents care plans were initiated on 08/27/21. Review of the medical record revealed Resident #1's care plan review was initiated on 04/26/22 and the care plan review was not completed until 10/13/22. Further review of the medical record for Resident #1 revealed there was no documentation to support the facility had reviewed or revised Resident #1's comprehensive care plans between 08/27/21 to 04/26/22. Interview on 11/09/22 at 8:57 A.M. with Staff #50 stated the resident care plans are to be reviewed and updated after each quarterly MDS assessment. Staff #50 confirmed Resident #1's care plans were not reviewed or updated after each MDS assessment on 10/01/21, 12/04/21, 01/01/22, 01/17/22, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365527 If continuation sheet Page 8 of 15 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 11/09/2022 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 04/18/22, 06/24/22, and 09/02/22. Level of Harm - Minimal harm or potential for actual harm Review of Comprehensive Care Plan Policy revealed the comprehensive care plans will be reviewed and revised by the Interdisciplinary Team (IDT) after each comprehensive and quarterly MDS assessment. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365527 If continuation sheet Page 9 of 15 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 11/09/2022 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the proper care and services to a resident with a feeding tube. This affected one (#19) out of two residents reviewed for feeding tubes. The facility census was 37. Findings include: Review of the Resident #19's chart revealed Resident #19 was admitted to the facility on [DATE] with diagnoses including acute and chronic respiratory failure with hypoxia, pressure ulcer of sacral region stage four, other symptoms and signs involving the musculoskeletal system, contracture right ankle, contracture right knee, contracture left ankle, contracture of other specified joint, depression, weakness, muscle weakness, hyperlipidemia, gastro esophageal reflux disease, hypotension, alcohol abuse with alcohol induced anxiety disorder, and insomnia. Review of Resident #19's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and Resident #19 required total dependence with bed mobility, toileting, dressing, and personal hygiene. Resident #19 required extensive assistance with eating. Resident #19 was not reported to have a feeding tube on his MDS. Review of Resident #19's care plan dated 11/08/22 revealed no information related to a feeding tube. Review of Resident #19's physician order dated 06/06/22 revealed staff were to monitor percutaneous endoscopic gastrostomy (PEG) tube site for signs and symptoms of infection. Notify the physician of any abnormalities every day and night shift for monitoring. Review of Resident #19's physician order dated 08/30/22 revealed Resident #19 was ordered to have the PEG tube site cleansed with normal saline, pat dry and apply a two by two split gauze twice daily and as needed every day and night shift. Review of Resident #19's physician orders from 09/01/22 to 11/08/22 revealed Resident #19 had no orders for flushing his feeding tube. Review of Resident #19's Medication Administration Record (MAR) from 09/01/22 to 11/08/22 revealed no documentation that Resident #19's feeding tube was flushed. Review of Resident #19's progress note dated 10/07/22 revealed Resident #19 was requesting a PEG tube removal. Interview with the Director of Nursing (DON) on 11/08/22 at 8:51 P.M. verified Resident #19 had a feeding tube, but he was not currently using it. The DON also confirmed Resident #19 did not have a care plan for his feeding tube, an order to flush his feeding tube or any documentation showing his feeding tube was flushed by staff. The DON stated Resident #19's should have had an order to flush his feeding tube. Review of the facility's feeding tubes policy dated 01/01/22 revealed feeding tubes will be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365527 If continuation sheet Page 10 of 15 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 11/09/2022 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete maintained in accordance with current clinical standards of practice with interventions to prevent complications to the extent possible. Review of the Medscape article from the American Journey of Health System Pharmacy entitled Medication Administration Through Enteral Feeding Tubes (https://www.medscape.com/viewarticle/585397_10#:~:text=During%20continuous%20enteral%20feedings%2C%20tubes% dated 07/16/22 revealed various factors may contribute to tube occlusions and include eternal formulations and insufficient flushing. Event ID: Facility ID: 365527 If continuation sheet Page 11 of 15 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 11/09/2022 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. 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, staff interview, and policy review, the facility failed to conduct ongoing assessment of a resident for dialysis related complications prior to and post dialysis. The facility also failed to communicate the resident's vital signs and medical status with the dialysis center. This affected the one (Resident #20) out of the two residents who were reviewed for dialysis. The facility census was 37. Residents Affected - Few Findings include: Review of the medical record for Resident #20 revealed an admission date of 07/30/22 with medical diagnoses of end stage renal disease, diabetes mellitus (DM) with peripheral angiopathy, severe protein calorie malnutrition, metabolic encephalopathy, adult failure to thrive, atrial flutter, depression and hypertension. Review of the medical record for Resident #20 revealed a Minimum Data Set (MDS) dated [DATE] which revealed Resident #20 was cognitively intact. The MDS revealed Resident #20 required limited assistance with bed mobility and transfers and extensive assistance with toileting and dressing. Further review of the MDS revealed Resident #20 received dialysis. Review of the medical record for Resident #20 revealed a physician order dated 08/02/22 for dialysis on Monday, Wednesday, and Friday at the house dialysis den. Further review of the medical record revealed a physician order dated 08/03/22 for Situation Background Assessment Recommendation assessment (SBAR) to be completed prior to dialysis. Review of the medical record for Resident #20 revealed no documentation to support the SBARs had been completed since 08/03/22. Further review of the medical record for Resident #20 revealed no documentation to support the facility completed post dialysis assessments from 08/26/22 to 11/08/22. Interview on 11/08/22 at 3:00 P.M. with Director of Nursing (DON) confirmed the facility did not complete SBARs on Resident #20 prior to dialysis and that the facility did not completed a post dialysis assessment on Resident #20 from 08/26/22 to 11/08/22. The DON stated the facility did not have a dialysis policy but followed the policy titled Special Needs for their dialysis residents. Review of the policy titled Special Needs revealed compliance guidelines for medical conditions would be monitored and managed to prevent complications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365527 If continuation sheet Page 12 of 15 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 11/09/2022 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 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Minimal harm or potential for actual harm Based on review of the performance evaluations, staff interview and policy review, the facility failed to provide annual evaluations for two State Tested Nursing Assistants (STNAs) potentially affecting all residents. The finding potentially affected all 37 residents. Residents Affected - Many Findings include: On 11/08/22 at 9:20 A.M. the surveyor requested the performance evaluations for four State Tested Nursing Assistants (STNAs) from the Payroll and Benefits Coordinator (PBC) #2. At that time both the Administrator and PBC #2 verified there was no annual evaluation completed for either STNA #39 hired on 06/15/16 and STNA #40 hired on 03/20/20. Review of the policy titled Performance Appraisals dated 01/01/22 revealed all employees were evaluated at least annually. STNAs were evaluated by Registered Nurses or Licensed Practical Nurses. The Regional Human Resources staff was responsible for conducting audits to ensure compliance. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365527 If continuation sheet Page 13 of 15 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 11/09/2022 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 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** Based on staff interview and medical record review the facility failed to ensure an intravenous antibiotic medication was provided for Resident #286 based on physician orders from an Infectious Disease physician. This affected one (Resident #286) out of four residents looked at for medication errors. The facility census was 37. Residents Affected - Few Findings include: Review of the medical record for Resident #286 revealed an admission date of 10/29/22 and diagnoses of severe sepsis without septic shock, paroxysmal atrial fibrillation, encephalopathy, presence of cardiac pacemaker, pemphigus vulgaris, and mitral valve prolapse's. Review of the Minimal Data Set (MDS) dated [DATE] revealed Resident #286 was cognitively intact. Her functional status is listed as extensive one to two person assist for all activities of daily living. The MDS also revealed the Resident has an indwelling catheter and is continent of bowel. Review of the care plan dated 10/29/22 revealed the resident has endocarditis. Interventions included to administer antibiotic as per physician orders. Maintain universal precautions when providing resident care. Review of the hospital discharge documents dated 10/29/22 revealed a summary of hospitalization. Seen by Infectious Disease (ID) and recommended to continue Ceftriaxone two grams every 24 hours until 11/25/22. Review of the physician orders dated 11/05/22 revealed Ceftriaxone Sodium Solution reconstituted two grams. Use two grams intravenously every 24 hours for endocarditis until 12/01/2022 at 11:50 P.M., run at 200 milliliters (ML) per hour. Interview with the Director of Nursing (DON) on 11/08/22 at 12:05 P.M. Nurse #21 stated the daughter called on (11/04/22) the facility concerning why her mother hadn't received the antibiotic ordered from the hospital. Nurse #21 investigated and found the recommendation in the hospital discharge paperwork. Nurse #21 notified the physician, and the order was placed for the Ceftriaxone. The DON confirmed Resident #286 went without her intravenous (IV) medication from 10/29/22 to 11/05/22 when the medication was resumed. She confirmed the order was on the hospital discharge record and was missed by the admission nurse and herself. This deficiency substantiated Complaint Number OH00137343. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365527 If continuation sheet Page 14 of 15 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 11/09/2022 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 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 observations, staff interviews and policy review, the facility failed to provide a clean ice machine and clean scoop with container. The finding potentially affected all residents except for three (#16, #24 and #284) who did not consume ice from this machine. The census was 37 residents. Findings include: Observations during the kitchen tour on 11/07/22 at 10:00 A.M. with Food Services Director (FSD) #4 revealed the bottom of the scoop with container was black across from the ice machine. Inside the ice machine the white plastic piece had a brown/black film across the bottom. At that time, FSD #4 verified the finding and stated she was not aware of when or how often the scoop with container and ice machine was cleaned. Interview on 11/09/22 at 10:37 A.M. with the Director of Nursing (DON) identified three (#16, #24 and #284) residents who did not consume ice. Review of the policy titled Ice Storage dated 07/31/20 revealed the ice machines and ice storage/distribution containers provided a safe and sanitary ice supply for residents. The staff cleaned and sanitized the tray and ice scoop daily. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365527 If continuation sheet Page 15 of 15