Inspection·December 20, 2023

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few chair causing pain in his back, shoulders, legs, and buttocks. Resident #15 stated he had been requesting another wheelchair since he was admitted in July 2023, but it had not been provided. Resident #15 stated PT had also recommended a different wheelchair for him. Interview on 12/20/23 at 9:35 A.M. with Registered Nurse (RN) #100 revealed Resident #15 did not like to get up out of bed unless he was able to sit in a dialysis chair, which was more comfortable for him to sit in. RN #100 confirmed Resident #15 was not able to tolerate sitting in the manual wheelchair provided to him for very long. Interview on 12/20/23 at 12:56 P.M. with Rehabilitation Director (RD) #155 revealed Resident #15 had started the process to be fitted for a custom wheelchair a month or two ago, but the chair was not ready yet. RD #155 stated the manual wheelchair provided for Resident #15 was not the appropriate size for the resident and had been donated to the facility from a previous resident. RD #155 stated he requested a Broda chair for Resident #15, but the facility was not able to accommodate the request due to a lack of storage space and added expense to the facility. RD #155 confirmed the manual wheelchair was snug width wise and was not the proper height for Resident #15. RD #155 stated he suggested the nursing staff stop using the manual wheelchair for Resident #15 due to an improper fit for the resident. Review of the facility policy titled Accommodations of Needs, revised 01/01/22, revealed the facility will treat each resident with respect and dignity and will evaluate and make reasonable accommodations for the individual needs and preferences of a resident. 2. Interview on 12/19/23 at 4:25 P.M. with Resident #41 revealed call light responses were long and, on the three days per week the facility provided dialysis, the response times were worse. Observation on 12/19/23 at 4:47 P.M. revealed the call light had been activated for room [ROOM NUMBER], Resident #22's room. Continuous observation revealed two different staff walked past room [ROOM NUMBER], without answering the call light or checking on the residents in the room. At 5:32 P.M. (45 minutes later), a State Tested Nurse Aide (STNA) was observed responding to the call light. Interview on 12/19/23 at 4:50 P.M. with Resident #15 revealed call lights were not responded to promptly, stating sometimes it was over an hour before staff responded. Interview on 12/19/23 at 5:34 P.M. with Resident #22 confirmed his call light had been activated and an STNA had just entered the room to check on him. Interview on 12/19/23 at 6:15 P.M. with the Administrator confirmed a call light response time of 45 minutes was well outside the expectation for a response time. The Administrator expected staff to answer call lights within five minutes,whenever possible, noting there may be a delay if staff were assisting another resident. Even if staff were assisting another resident with care, the Administrator verified it still should not take 45 minutes to respond to a call light. Review of the Resident Council meeting minutes dated 10/17/23 revealed the residents voiced concerns related to call lights not being answered timely. This deficiency represents non-compliance investigated under Complaint Number OH00148646 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 12/20/2023 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 Based on medical record review, resident interview, staff interview, review of shower schedules and review of facility policy, the facility failed to ensure residents, who were dependent for care, received showers as scheduled. This affected two (#15 and #21) of three residents reviewed for activities of daily living (ADLs). The facility census was 40. Residents Affected - Few Findings Include: 1. Review of the medical record for Resident #15 revealed an admission date of 07/21/23 and a readmission date of 08/03/23. Diagnoses included acute transverse myelitis in demyelinating disease of central nervous system (inflammation of part of the spinal cord), acute and chronic respiratory failure with hypoxia, rheumatoid arthritis, muscle weakness, mild cognitive impairment of uncertain or unknown etiology, unspecified abnormalities of gait and mobility, unspecified lack of coordination, [NAME] Nile Virus infection with encephalitis (inflammation of the brain), and quadriplegia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 09/30/23, revealed Resident #15 had intact cognition and required extensive assistance to total dependence from one to two staff to complete ADLs. Review of Resident #15's progress notes from 10/19/23 to 12/19/23 revealed no documentation related to showers, including refusals. Review of the care plan, revised 12/19/23, revealed Resident #15 had an ADL self-care performance deficit related to quadriplegia, cognition, and weakness. Interventions included bathing with two person assistance. Review of the shower bed board revealed Resident #15 was scheduled to receive showers during day shift on Sundays and Thursdays. Review of shower documentation for the last 30 days revealed Resident #15 received showers on 11/23/23, 11/26/23, 11/30/23, 12/10/23, and 12/14/23. There was no documentation Resident #15 received showers as scheduled on 11/16/23, 11/19/23, or 12/03/23. Interview on 12/19/23 at 4:50 P.M. with Resident #15 revealed he only received bed baths but preferred an actual shower. Additionally, Resident #15 stated he only received one bed bath per week instead of twice weekly, as scheduled. Resident #15 stated he had only had his hair washed once in the last two or three weeks. Interview on 12/20/23 at 8:25 A.M. with the Administrator verified there was no evidence Resident #15 received showers on 11/16/23, 11/19/23, or 12/03/23 as scheduled. 2. Review of the medical record for Resident #21 revealed an admission date on 08/27/21. Medical diagnoses included end stage renal disease, type II Diabetes Mellitus, morbid obesity, psychotic disorder with delusions, hoarding disorder, cognitive communication deficit, and muscle wasting and atrophy. Review of the quarterly MDS assessment, dated 09/22/23, revealed Resident #21 had intact cognition and required extensive assistance from two or more staff to complete ADLS. (continued on next page) 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 12/20/2023 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #21's progress notes from 10/19/23 through 12/19/23 revealed no documentation related to showers, including refusals. Review of the care plan, dated 07/27/23, revealed Resident #21 had an ADL self-care performance deficit related to chronic kidney disease, depression, generalized weakness, impaired vision, neuropathy, obesity, and opioid use. Interventions included bathing assistance from two staff. Review of the shower bed board revealed Resident #21 was scheduled to receive showers during night shift on Mondays and Thursdays. Review of shower documentation for the last 30 days revealed there was no documented showers for Resident #21. Interview on 12/20/23 at 1:15 P.M. with the Administrator confirmed there was no evidence Resident #21 received showers or bed baths as scheduled. This deficiency represents non-compliance investigated under Complaint Number OH00148646 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 12/20/2023 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, family interview, and staff interview, the facility failed to ensure transportation was arranged for scheduled outside appointments, resulting in missed appointments. This affected one (#15) of three residents reviewed for transportation needs. The facility census was 40. Residents Affected - Few Findings Include: Review of the medical record for Resident #15 revealed an admission date of 07/21/23 and a readmission date of 08/03/23. Medical diagnoses included acute transverse myelitis in demyelinating disease of central nervous system (inflammation of part of the spinal cord), acute and chronic respiratory failure with hypoxia, rheumatoid arthritis, muscle weakness, mild cognitive impairment of uncertain or unknown etiology, unspecified abnormalities of gait and mobility, unspecified lack of coordination, [NAME] Nile Virus infection with encephalitis (inflammation of the brain), and quadriplegia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 09/30/23, revealed Resident #15 had intact cognition and required extensive assistance to total dependence from one to two staff to complete Activities of Daily Living (ADLs). Review of Resident #15's progress notes revealed no evidence related to scheduling transportation for outside appointments on 09/19/23 or 11/30/23. Interview on 12/19/23 at 4:50 P.M. with Resident #15 revealed he had missed a couple of scheduled appointments due to the facility not being able to arrange transportation for him. Resident #15 stated his wife scheduled all of his outside appointments and provided the facility with at least three weeks notice for each appointment in order to give the facility ample time to secure transportation. Interview on 12/20/23 at 8:25 A.M. with the Administrator revealed the facility had difficulty with finding transportation for Resident #15 to attend outside appointments because of limited transportation options available to provide stretcher transportation for a resident with a tracheostomy. The Administrator stated the facility did not have a Respiratory Therapist (RT) available to go with Resident #15 to ensure safe transport if the resident went in a wheelchair to his appointments. The Administrator stated Resident #15 needed supervision to be transported by wheelchair for safety. Interview on 12/20/23 at 10:50 A.M. with the Director of Nursing (DON) revealed some of Resident #15's appointments needed to be rescheduled due to inability to secure transportation. The DON confirmed Resident #15's wheelchair fitting appointment on 11/30/23 was canceled because the facility was in the middle of a COVID-19 outbreak and was in contingency staffing at that time. Follow-up interview on 12/20/23 at 3:08 P.M. with the Administrator and DON confirmed Resident #15's appointment on 11/30/23 for a custom wheelchair fitting was canceled due to the facility being unable to secure transportation. Both verified Resident #15 had missed some, but not many, outside appointments due to being unable to secure transportation. Interview via telephone on 12/20/23 at 3:31 P.M. with Resident #15's wife revealed the facility had discussed potential difficulty with securing transportation to outside appointments for Resident #15 prior to his admission. Resident #15's wife stated she had expressed the importance of Resident #15 getting to his appointments and the facility admitted him. Resident #15's wife stated the facility (continued on next page) 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 12/20/2023 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few canceled transportation on 09/18/23 for a 09/19/23 urology appointment due to the resident being in the hospital. Resident #15's wife stated she had informed the facility Resident #15 would be discharged from the hospital on [DATE] and would be able to keep the 09/19/23 appointment and they canceled it anyway. On 11/30/23, Resident #15 had an appointment to be fitted for a custom wheelchair. The facility arranged transportation with a local company and had told Resident #15's wife they would be sending a Respiratory Therapist (RT) with the resident. Approximately two hours before the scheduled pick up time on 11/30/23, the facility canceled transportation because they did not have an RT to send with Resident #15. The appointment was rescheduled for 01/04/24. Resident #15's wife stated it was important for the resident to have kept the appointment on 11/30/23 due to private insurance costs and deductibles prior to the new benefit year starting. Resident #15's wife stated the facility was aware of the appointment three to four weeks in advance to ensure transportation was available. This deficiency represents non-compliance investigated under Complaint Number OH00148646. 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 12/20/2023 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on resident interview, staff interview, and review of staff schedules, the facility failed to ensure adequate staffing to meet residents needs. This had the potential to affect all 40 residents of the facility. The facility census was 40. Findings Include: Interview on 12/19/23 at 4:25 P.M. with Resident #41 revealed he did not feel the facility had enough staff. Resident #41 stated there were long call light response times and they were longer on the three days per week the facility provided dialysis services. Resident #41 stated there was usually one nurse and one State Tested Nurse Aide (STNA) on each of the two halls. Interview on 12/19/23 at 4:50 P.M. with Resident #15 revealed he only received bed baths once a week and was scheduled to receive showers twice a week. Resident #15 stated there was not enough staff and it sometimes took longer than one hour for staff to respond to call lights. Interview on 12/20/23 at 9:35 A.M. with Registered Nurse (RN) #100 revealed the back hallway (200 hall) was an especially heavy hallway with residents who required a lot of assistance. RN #100 stated the STNAs did the best they could, but the facility staffed based on the census and not the acuity level of the residents. RN #100 stated all of the residents, except one, on the 200 hall (18 residents) required two person assistance. The 200 hall also had residents with tracheostomies and ventilators. Additionally, the facility provided dialysis three days per week and the STNAs were responsible for ensuring those residents were up out of bed, dressed and transported to and from dialysis in addition to their regular tasks of answering call lights, providing showers, providing personal care, and passing meal trays. RN #100 stated that is a lot for one or two aides to be responsible for. Interview on 12/20/23 at 11:35 A.M. with STNA #113 revealed she did not feel the facility had enough staff to provide resident care. STNA #113 stated it was impossible to complete the required checks on residents every two hours. STNA #113 stated she was able to check on residents three times in a 12 hour shift and she should be completing six checks on each of the residents. STNA #113 also stated she was not able to complete all resident showers as scheduled. Interview on 12/20/23 at 12:22 P.M. with Social Services (SS) #141 revealed he had been a STNA prior to his current position. SS #141 stated the back hallway (200 hall) had a very high resident acuity. SS #141 stated he used to work as an STNA on that hallway and it could take 45 minutes to complete care for one resident and, by the time the care was done, there may be eight or nine other call lights going off. SS #141 stated he was usually able to complete his tasks but would have to stay late to ensure all tasks were completed because it is a lot back there. Interview on 12/20/23 at 1:26 P.M. with STNA #104 revealed she worked mostly on the 200 hall and did not feel the facility had enough staff. STNA #104 stated she was usually able to answer call lights in a timely manner but sometimes she answered the call light, turned it off, and would tell the resident she would have to come back to provide needed assistance later. STNA #104 stated she had difficulty completing scheduled showers, especially on dialysis days, and was not able to complete two hour checks on residents as required, noting it was about every three hours she was able to check on residents. (continued on next page) 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 12/20/2023 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Interview on 12/20/23 at 5:10 P.M. with the Administrator confirmed she was aware of staff concerns related to staffing. The Administrator was actively hiring additional staff but was having difficulty retaining new staff because of the high acuity level of the residents. Review of the staff schedules from 11/24/23 through 11/30/23, revealed the following day shift STNA staffing levels: 11/24/23, two STNAs (one on each hall) and 11/25/23 two STNAs for the full 12 hour shift (one on each hall) and one STNA for four hours. This deficiency represents non-compliance investigated under Complaint Number OH00148646. 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 12/20/2023 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on medical record review, resident interview, staff interview, review of a medication error investigation and review of facility policy, the facility failed to ensure medications were administered according to physician orders. This affected one (#15) of three residents reviewed for physician orders. The facility census was 40. Findings Include: Review of the medical record for Resident #15 revealed an admission date of 07/21/23 and a readmission date of 08/03/23. Medical diagnoses included acute transverse myelitis in demyelinating disease of central nervous system (inflammation of part of the spinal cord), acute and chronic respiratory failure with hypoxia, rheumatoid arthritis, muscle weakness, mild cognitive impairment of uncertain or unknown etiology, unspecified abnormalities of gait and mobility, unspecified lack of coordination, [NAME] Nile Virus infection with encephalitis (inflammation of the brain), and quadriplegia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 09/30/23, revealed Resident #15 had intact cognition and required extensive assistance to total dependence from one to two staff to complete Activities of Daily Living (ADLs). Review of Resident #15's Medication Administration Record (MAR) for November 2023 revealed the following orders: GlycoLax Powder (Polyethylene Glycol 3350), with instructions to give 17 grams (gm) by mouth one time only for colon prep, mix 0.5 Miralax bottle in 32 ounces of Gatorade for one day (in liquid) and mix whole bottle in 64 ounces sport drink then divide into two bottles. The start date and time for these orders was 11/08/23 at 5:00 P.M. Further review of the MAR confirmed the medications were administered as ordered on 11/08/23. Additional review of the MAR revealed the following order, to be completed on 11/09/23 at 2:30 A.M.: GlycoLax Powder (Polyethylene Glycol 3350), with instructions to give 17 grams (gm) by mouth one time only for colon prep, mix 0.5 Miralax bottle in 32 ounces of Gatorade for one day. Drink eight ounces every 15 minutes until completed with a start date of 11/09/23 at 2:30 A.M. The medication was marked as administered on 11/09/23 at 7:09 A.M. (nearly five hours after the medication was due to be administered). Review of a progress note dated 11/09/23 at 1:00 P.M. revealed Resident #15 returned from a scheduled colonoscopy, with a need to reschedule with the physician's office. Review of incident reports from 09/19/23 to 12/19/23 revealed on 11/09/23 at 2:30 A.M., a medication error occurred for Resident #15. Review of the facility medication error investigation, dated 11/09/23, revealed Resident #15 had a colonoscopy ordered to be completed on 11/09/23 at 7:30 A.M. at the hospital and did not receive GlycoLax Powder medication at 2:30 A.M. as ordered. Resident #15's colonoscopy was not able to be completed due to stool being present in his upper colon. Interview on 12/20/23 at 4:50 P.M. with Resident #15 revealed he had a colonoscopy scheduled to be completed in November 2023 but the nurse messed up the bowel preparation and he was only provided with one of the drinks instead of two that were needed for the prep. Resident #15 was sent to the hospital for the procedure but, after the procedure was started, was told it would have to be rescheduled due to inadequate preparation. (continued on next page) 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 12/20/2023 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 12/20/23 at 10:50 A.M. with the Director of Nursing (DON) verified Resident #15 was not administered one of the Miralax and Gatorade mixtures at 2:30 A.M., per the physician's orders. Resident #15 did not receive the mixture until 7:09 A.M. (nearly five hours late) and, due to the error, Resident #15 was not able to receive his scheduled colonoscopy procedure. Review of the facility policy titled, Medication Administration, revised 01/01/22, revealed the policy revealed medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. This deficiency represents non-compliance investigated under Complaint Number OH00148646. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365527 If continuation sheet Page 10 of 10