Inspection·November 19, 2025

F 0686 Level of Harm - Actual harm Residents Affected - Few examine the foot. The facility did not reach out to the office regarding the drainage at any point. Significant desquamation and fracture blisters are noted with slough of superficial skin on the dorsum of the foot. Full-thickness dermis loss on the dorsum of the foot without significant ulceration or purulent drainage. The physician had a discussion with the patient on the need for daily dressing changes as soon as possible as there was concern about the state of the skin and the potential for this progressing to an infection that could possibly progress to an amputation. Orders included: referral to wound care, wound change dressings daily, Bactrim DS twice daily, no weight bearing on right foot, and remove boot for wound care and personal hygiene. Review of the orthopedic office visit for 06/27/25 revealed black eschar noted on the dorsum of right foot. Erythema/edema from prior examination significantly improved. No drainage. The physician had a discussion with FR #35 that they were pleased with the progress that the wound team has made on the edema and drainage of the foot. Discussed doing dressing changes twice daily with Silvadene over the eschar and continue Bactrim DS twice daily for another week and return in two weeks. Continue to wear boot, may be removed for dressing changes and showers, remain non weight bearing, continue wound care, continue antibiotic, and apply Silvadene ointment to eschar area. Review of the orthopedic office visit for 07/18/25 revealed FR #35 presented for routine follow up of bimalleolar ankle fracture being managed nonoperatively with open dorsal foot wound that has been managed with wound care. FR #35 reported that his wound dressing changes were not done twice a day as had been ordered. FR #35 reported the last dressing change on his foot was two days ago when he received a bath. On physical examination he has a dorsal necrotic unstageable ulcer of the right foot with malodorous bloody/purulent drainage. He does have surrounding erythema and pitting edema of the foot and ankle. Vascular skin changes noted to the mid-calf without extension of erythema beyond the foot wound margin. The physician had an extensive discussion with FR #35 that given the progression of his dorsal foot wound and vascular calcification seen on x-ray that there is concern about the blood flow to the foot to appropriately heal the wound that he has. The physician would like the resident to go to the emergency room given the purulent drainage and concern for wet gangrene of the foot to have a formal evaluation for possible amputation versus more aggressive wound care than he has been getting at the facility he has resided in. Interview on 10/16/25 at 2:08 P.M. with the Director of Nursing (DON) revealed FR #35 did not have a splint/boot until an orthopedic visit on 06/06/25. The DON verified that the boot nor the ace wrap were removed from 06/06/25 through 06/20/25. The DON verified no documentation was available regarding whether the nursing staff contacted the orthopedic office to obtain orders regarding the boot or ace wrap. The DON verified there should have been an order to monitor the boot and skin integrity under the boot. The DON further verified no skin assessments could be located from 06/06/25 through 06/20/25 with the exception of 06/10/25. Interview on 10/20/25 at 1:43 P.M. with Physical Therapy Assistant (PTA) #226 verified the resident came back from the orthopedic office with a boot. Review of the policy titled, Pressure Ulcer/Skin Breakdown-Clinical Protocol, dated 03/20/24 revealed weekly skin evaluation/assessment by the licensed nurse on residents who have no current pressure ulcers (PU) or pressure injury (PI). The plan of care for prevention and/or treatment of PU/PI's will be developed based on the assessments above to include but not limited to support surfaces, turning schedule/off-loading, moisture management, incontinence management, nutritional management, pain management, disease effects on perfusion and/or healing, and medications that affect perfusion and/or healing. The deficient practice was corrected on 06/23/25 when the facility implemented the following corrective actions: On 06/20/25, the wound Nurse Practitioner was notified of the wound by the Unit Manager. On 06/20/25, Licensed Practical Nurse (LPN) #35 notified FR #35 and his wife of new orders by the orthopedic (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365527 If continuation sheet Page 2 of 5 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 11/19/2025 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 0686 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete physician. On 06/23/25, the DON/designee audited all residents with splints for orders and skin assessed with no negative findings. On 06/23/25, the MDS nurse completed an audit of care plans for all residents with splints. On 06/23/25, the DON updated the Braden Scale (used to predict pressure injury risk) with a score of 14 indicating moderate risk. On 06/23/25, the DON/designee completed an audit of recent physician visits in the past two weeks for new orders with no negative findings. On 06/23/25, the DON placed an order for a soft air splint for FR #35. On 06/23/25, the DON/designee educated all nurses regarding after-visit summary for appointments and to clarify if devices are on the resident upon return from the appointment. The DON/designee will audit all new residents with splints for orders, skin condition, and care plan updates weekly times four weeks. The DON/designee will audit after visit summary for all residents with outside appointments for new orders and visual check of residents for new devices weekly for four weeks. An AD HOC Quality Assurance and Performance Improvement (QAPI) committee meeting was completed on 06/23/25. Results of the audits will be reviewed in the QAPI Committee meeting for one month with revisions to the plan/change in monitoring as deemed by the QAPI committee. This deficiency represents noncompliance investigated under Complaint number 2642319. Event ID: Facility ID: 365527 If continuation sheet Page 3 of 5 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 11/19/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, interview, and policy review, the facility failed to ensure fall interventions were in place. This affected one (#33) of four residents reviewed for falls. The facility census was 34.Findings include:Review of the medical record for Resident #33 revealed an admission date of 07/02/25 with diagnoses including but not limited to anoxic brain damage, respiratory failure, cardiac arrest, and anxiety.Review of the minimum data set (MDS) dated [DATE] revealed the resident had severe cognitive impairment. Resident #33 was dependent on staff for activities of daily living.Review of the care plan dated 10/07/25 revealed the resident was at risk for falls related to anoxic brain damage and muscle weakness. Interventions included perimeter overlay to air mattress and low bed.Observation on 10/20/25 at 1:27 P.M. of Resident #33 revealed the resident was lying in bed with an air mattress and the bed was in high position approximately chest high to surveyor with no one in the room.Interview on 10/20/25 at 1:32 P.M. with Certified Nursing Assistant (CNA #118) verified the bed was in high position with no one in the room. CNA #118 stated the resident's husband was in the room prior and would raise the bed when he visited. CNA #118 verified the husband was no longer at the facility and the bed was not lowered per care plan.Review of policy titled, Fall Prevention Program, dated 10/26/23 revealed the nurse will indicate the resident's fall risk and initiate interventions on the resident's baseline care plan. Interventions will be monitored for effectiveness. Event ID: Facility ID: 365527 If continuation sheet Page 4 of 5 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 11/19/2025 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, interview, and policy review, the facility failed to ensure proper hand hygiene was completed during a dressing change. This affected one (#7) resident of one resident observed for wound care. The facility census was 34.Findings include:Review of the medical record for Resident #7 revealed an admission date of 07/09/25 with diagnoses including but not limited to chronic obstructive pulmonary disease (COPD), chronic kidney disease stage four, dependence on respirator (ventilator) status, anxiety, and need for assistance with personal care.Review of the minimum data set (MDS) dated [DATE] revealed the resident was cognitively intact. The resident was dependent on staff for activities of daily living.Review of the physician order revealed right lower abdomen cleanse with normal saline, pat dry, apply moistened collagen and cover with foam dressing three times weekly and as needed.Observation on 10/20/25 at 2:16 P.M. of wound care with Licensed Practical Nurse (LPN #205) for Resident #7 revealed LPN #205 gathered supplies which included calcium alginate, scissors, normal saline vial, soft silicone foam dressing, and four by four dressings. LPN #205 cleaned scissors with an alcohol pad and placed them on clean trash bag laid out on treatment cart along with the dressing supplies. LPN #205 knocked on door, entered room and explained to the resident what she was going to do. Resident agreeable to dressing change. LPN #205 then washed hands, donned a gown and placed a clean barrier to cover the bed table and arranged the supplies. LPN #205 donned gloves and removed the old dressing from the residents right lower abdomen. Wound appeared beefy red and peri wound was intact. No odor was noted. LPN #205 then removed her gloves and donned a new pair of gloves. LPN #205 then opened four by four gauze packages and cleansed the wound with normal saline. LPN #205 removed gloves and donned new gloves. LPN #205 placed calcium alginate in the wound and opened the silicone foam dressing. LPN #205 stated that she would date the dressing prior to applying it to the resident. LPN #205 removed her gloves and dated the dressing. LPN #205 donned new gloves and placed the foam dressing over the wound. LPN #205 was not observed to wash or sanitize hands after removing soiled gloves and donning clean gloves on four occasions. Interview on 10/20/25 at 2:42 P.M. with LPN #205 revealed the nurse verified she did not wash or sanitize hands between glove changes. LPN #205 verified she was supposed to wash hands or sanitize hands prior to donning new gloves. Review of policy titled, Clean Dressing Change, dated 12/28/23 revealed policy explanation and compliance guidelines: explain the procedure to the resident and screen for privacy, multi-use wound care supplies should be dated and initialed when opened, set up clean field with needed supplies for wound cleansing and dressing application, establish area for soiled products to be placed, wash hands and put on clean gloves, place a barrier cloth or pad next to the resident under the wound to protect the bed linen and other body sited, loosen the tape and remove the existing dressing, remove gloves, wash hands and put on clean gloves, cleanse the wound as ordered, measure wound, wash hands and put on clean gloves, apply topical ointments or creams and dress the wound as ordered, secure dressing mark with date and initials, discard disposable items and gloves into appropriate receptacle and wash hands. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365527 If continuation sheet Page 5 of 5