Health inspection·August 17, 2023

F 0600 Level of Harm - Actual harm Residents Affected - Few Review of a 08/09/23 (came in on the 08/09/23 night shift) untimed statement by STNA #98 included she had witnessed STNA #76 being very condescending, making inappropriate comments and being aggressive with multiple residents including Resident #35. Per STNA #98, STNA #76 has made numerous comments in regards to her employment stating she can't be fired: she will use the race card and threatened to call the The National Advancement of Colored People (NWACP). Review of a 08/10/23 untimed STNA #99 statement revealed she was out in the hall on the 300 hall, by room [ROOM NUMBER], and overheard STNA #76 tell Resident #35 he was lazy and to do what she was asking him to do, by himself instead of begging her because he could. Review of an undated STNA #101 statement revealed she witnessed STNA #76 yell at Resident #35 after having to completely change him for a second time when he refused his shower. STNA #101 stated she reported it to a nurse who no longer works at the facility who said she would see what she could do. Review of a 08/10/23 untimed STNA #102 statement revealed she witnessed STNA #76 belittle Resident #35 on numerous occasions. Review of a 08/10/23 statement from Registered Nurse (RN) #97 included she asked Resident #35 about allegations of verbal abuse from STNA #76 and he confirmed verbal abuse and stated she said scoot your fat a$$ back in the chair, move your fu##### legs. Resident #35 stated he got upset when STNA #76 said that and cursed back at her. Interview on 08/17/23 at 3:09 P.M. with the Director of Nursing (DON) verified they walked STNA #76 out of the building on 08/10/23 and terminated her 08/15/23. STNA #76 would not give a statement. STNA #76 would not give the police a statement. During the course of the interviews, they identified several staff who had heard or seen something but had not reported it due to fear of retaliation. Staff also identified two other residents (#50 and #51) they saw or heard STNA #76 be inappropriate with so they were also added to the SRI and investigated. The DON verified those staff who heard or witnessed potential abuse and did not report it timely will receive discipline. Interview on 08/17/23 at 4:06 P.M. with Resident #35 revealed STNA #76 flung his legs into the bed. She stretched his legs out and flung them in the bed. Resident #35 told her it hurt. STNA #76 said you're not hurt. Resident #35 told her it hurt. Resident #35 said he gave a statement to the police. 2. Review of Resident #50's medical record revealed a 01/05/23 admission with diagnoses including quadriplegia, traumatic brain injury, major depressive disorder, anxiety disorder, and abnormal posture. Further review of the medical record including the Minimum Data Set (MDS) 3.0 annual assessment with a reference date of 07/27/23 indicated Resident #50 was independent for daily decision making. The resident required total assist of two for bed mobility, transfers, personal hygiene, toileting and extensive assist for eating. Resident #50 had upper and lower extremity functional limitation bilaterally. Review of the facility SRI #237972 with a created date of 08/10/23 revealed on 08/10/23 the Administrator was notified of an allegation of verbal abuse of residents by State Tested Nurse Aide (STNA) #76. During the course of the investigation, Resident #50's name was given by staff with knowledge (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365674 If continuation sheet Page 2 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365674 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Minerva 400 Carolyn Court Minerva, OH 44657 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 0600 Level of Harm - Actual harm Residents Affected - Few of inappropriate behaviors toward him by STNA #76. Behaviors of STNA #76 included flicking Resident #50's left nipple ring and penis, resulting in an allegation of sexual abuse. Resident #50 reported he was not affected by these acts and believed STNA #76 was just joking around. Review of a 08/10/23 untimed statement from Resident #50 included he answered yes when asked if anyone flipped his nipple ring. He said STNA #76 was joking with him. He denied she left a hoyer pad under him or cussed at him about changing his shirt. Review of staff statements included a 08/10/23 statement from STNA #100 as she witnessed STNA #76 cuss at Resident #50 about changing his shirt when he didn't want to. He swore at her so she got in his face. STNA #76 then hoyered him in bed and then left the pad under him and went to lunch. Another aide went in and finished providing care to Resident #50. STNA #100 started to hear things from STNA #76 last month/the beginning of month and was afraid of retaliation. There was a note at the bottom of the statement that stated STNA #100 was educated on the abuse policy at the bottom of the statement. Review of a 08/09/23 (night shift on 08/09/23) STNA #98's statement included she had witnessed STNA #76 being very condescending, making inappropriate comments and being aggressive with multiple residents including Resident #50. STNA #98 has made numerous comments in regards to her employment stating she can't be fired: she will use the race card and threatened to call the The National Advancement of Colored People (NWACP). Review of a 08/09/23 (night shift on 08/09/23) statement by Licensed Practical Nurse (LPN) #81 included STNA #76 had been verbally aggressive with the resident and was visually seen flicking Resident #50's nipple ring. LPN #81 and another nurse attempted to deescalate a situation with an aggressive resident and when STNA #76 came to the situation with an aggressive demeanor, the resident (#50) became more aggressive. Review of a 08/10/23 untimed statement from STNA #93 included STNA #76 would flick Resident #50's nipple ring when he would take a shower and would also do it in front of the 300/400 nurses station where the resident sits and would curse and scream at her and yell for someone to get her away from him. Review of an undated statement from STNA #94 included she heard STNA #76 swear at Resident #50. Two aides were putting the resident to bed and he swung at STNA #76. STNA #94 thought maybe he got hurt or was uncomfortable. STNA #76 grabbed Resident #50's right arm to stop him from hitting her and then stated something along the lines of you're not going to ever fu#### hit me again. STNA #94 reported she told a nurse, but doesn't know which one. STNA #94 couldn't remember the day it happened but thought it was a weekend. Review of a 08/10/23 untimed STNA #99 statement revealed she witnessed STNA #76 refusing to give care to Resident #50 because she wanted to eat. STNA #99 helped another aide use the mechanical lift to get Resident #50 into bed and left him there on the lift pad flat in his bed soiled without a call bell. Review of a 08/10/23 untimed statement by STNA #102 revealed she witnessed STNA #76 have an aggressive tone toward Resident #50 and inappropriate behavior including flicking Resident #50's nipple ring, on numerous occasions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365674 If continuation sheet Page 3 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365674 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Minerva 400 Carolyn Court Minerva, OH 44657 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 0600 Review of a 08/15/23 statement from Resident #50's sister included she asked him about the incident and he did tell her STNA #76 flicked his penis and nipple. Level of Harm - Actual harm Residents Affected - Few Review of a statement revealed Registered Nurse (RN) #97 on 08/16/23 asked Resident #50 if STNA #76 flicked his bare penis or did he have a brief on. He stated it was his bare penis. Review of a 08/16/23 statement from the DON included Resident #50 refused to speak with the police and doesn't want to press charges. Interview on 08/17/23 at 3:09 P.M. with the DON included on 08/16/23 she spoke to Resident #50 because the police were at the facility to take a report. The resident did not want to talk about it and refused to give the police a statement and did not want to press charges. He did not want to get STNA #76 in trouble and said she was just joking but the facility substantiated sexual abuse based on witness statements. The DON further stated the third resident mentioned by name (Resident #51) did not have any concerns of abuse when she interviewed him. Interview on 08/17/23 at 4:10 P.M. with Resident #50 revealed he did not want to talk about STNA #76. He did not want her to get in trouble. Review of the facility's Abuse, Neglect, and Exploitation policy (revised 10/24/22) included verbal abuse means the use of oral, written, or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Sexual abuse is non-consensual sexual contact of any type with a resident. The facility will implement policies and procedures providing residents, representatives, and staff information on how and to whom they may report concerns, incidents, and grievances without the fear of retribution; and providing feedback regarding the concerns that have been expressed. Identification of abuse includes resident, staff or family report of abuse. Verbal abuse of resident overheard. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. The facility will have written procedures that include reporting of all alleged violations to the Administrator. This deficiency is cited as an incidental finding to Complaint Number OH00145527. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365674 If continuation sheet Page 4 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365674 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Minerva 400 Carolyn Court Minerva, OH 44657 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility Self-Reported Incident (SRI) review, medical record review, interview, and facility policy review, the facility failed to ensure staff immediately reported staff to resident abuse.This affected two residents (#35 and #50) of three residents reviewed for abuse. Findings include: 1. Review of Resident #35's medical record revealed an admission date of 08/21/20 with admission diagnoses that included impulse disorder, shizoaffective disorder, bipolar, anxiety disorder, chronic obstructive pulmonary disease, congestive heart failure, morbid obesity, mood affect disorder and hypertension. Further review of the medical record including the Minimum Data Set (MDS) 3.0 annual assessment with a reference date of 06/15/23 indicated Resident #35 was independent for daily decision making. The resident required extensive assist for bed mobility, transfers, personal hygiene and toileting. Review of the facility SRI #237972 with a created date of 08/10/23 revealed on 08/10/23 the Administrator was notified of an allegation of verbal abuse of Resident #35 by State Tested Nurse Aide (STNA) #76. The accused staff member was interviewed and immediately placed on administrative leave. The allegation was substantiated and STNA #76 was terminated 08/15/23. Review of a 08/10/23 untimed statement from Resident #35 confirmed verbal abuse by STNA #76. He stated she told him to scoot your fat a$$ back in the chair, move your fu##### legs. He stated he got upset and cursed back at her. Review of staff statements included a 08/10/23 untimed statement by STNA #100 who witnessed STNA #76 verbally abuse Resident #35 in the shower room. STNA #76 was telling Resident #35 to scoot his fat a$$ back in the chair and to move his fu##### legs. STNA #76 totally was humiliating him (Resident #35). STNA #100 started to hear things from her (STNA #76) the beginning of August (2023) and was afraid of retaliation. Review of a 08/09/23 (came in on the 08/09/23 night shift) untimed statement by STNA #98 included she had witnessed STNA #76 being very condescending, making inappropriate comments and being aggressive with multiple residents including Resident #35. Per STNA #98, STNA #76 has made numerous comments in regards to her employment stating she can't be fired: she will use the race card and threatened to call the The National Advancement of Colored People (NWACP). Review of a 08/10/23 untimed STNA #99 statement revealed she was out in the hall on the 300 hall, by room [ROOM NUMBER], and overheard STNA #76 tell Resident #35 he was lazy and to do what she was asking him to do, by himself instead of begging her because he could. Review of an undated STNA #101 statement revealed she witnessed STNA #76 yell at Resident #35 after having to completely change him for a second time when he refused his shower. STNA #101 stated she reported it to a nurse who no longer works at the facility who said she would see what she could do. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365674 If continuation sheet Page 5 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365674 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Minerva 400 Carolyn Court Minerva, OH 44657 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of a 08/10/23 untimed STNA #102 statement revealed she witnessed STNA #76 belittle Resident #35 on numerous occasions. Review of a 08/10/23 statement from Registered Nurse (RN) #97 included she asked Resident #35 about allegations of verbal abuse from STNA #76 and he confirmed verbal abuse and stated she said scoot your fat a$$ back in the chair, move your fu##### legs. Resident #35 stated he got upset when STNA #76 said that and cursed back at her. Interview on 08/17/23 at 3:09 P.M. with the Director of Nursing (DON) verified they walked STNA #76 out of the building on 08/10/23 and terminated her 08/15/23. STNA #76 would not give a statement. STNA #76 would not give the police a statement. During the course of the interviews, they identified several staff who had heard or seen something but had not reported it due to fear of retaliation. Staff also identified two other residents (#50 and #51) they saw or heard STNA #76 be inappropriate with so they were also added to the SRI and investigated. The DON verified those staff who heard or witnessed potential abuse and did not report it timely will receive discipline. Interview on 08/17/23 at 4:06 P.M. with Resident #35 revealed STNA #76 flung his legs into the bed. She stretched his legs out and flung them in the bed. Resident #35 told her it hurt. STNA #76 said you're not hurt. Resident #35 told her it hurt. Resident #35 said he gave a statement to the police. 2. Review of Resident #50's medical record revealed a 01/05/23 admission with diagnoses including quadriplegia, traumatic brain injury, major depressive disorder, anxiety disorder, and abnormal posture. Further review of the medical record including the Minimum Data Set (MDS) 3.0 annual assessment with a reference date of 07/27/23 indicated Resident #50 was independent for daily decision making. The resident required total assist of two for bed mobility, transfers, personal hygiene, toileting and extensive assist for eating. Resident #50 had upper and lower extremity functional limitation bilaterally. Review of the facility SRI #237972 with a created date of 08/10/23 revealed on 08/10/23 the Administrator was notified of an allegation of verbal abuse of residents by State Tested Nurse Aide (STNA) #76. During the course of the investigation, Resident #50's name was given by staff with knowledge of inappropriate behaviors toward him by STNA #76. Behaviors of STNA #76 included flicking Resident #50's left nipple ring and penis, resulting in an allegation of sexual abuse. Resident #50 reported he was not affected by these acts and believed STNA #76 was just joking around. Review of a 08/10/23 untimed statement from Resident #50 included he answered yes when asked if anyone flipped his nipple ring. He said STNA #76 was joking with him. He denied she left a hoyer pad under him or cussed at him about changing his shirt. Review of staff statements included a 08/10/23 statement from STNA #100 as she witnessed STNA #76 cuss at Resident #50 about changing his shirt when he didn't want to. He swore at her so she got in his face. STNA #76 then hoyered him in bed and then left the pad under him and went to lunch. Another aide went in and finished providing care to Resident #50. STNA #100 started to hear things from STNA #76 last month/the beginning of month and was afraid of retaliation. There was a note at the bottom of the statement that stated STNA #100 was educated on the abuse policy at the bottom of the statement. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365674 If continuation sheet Page 6 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365674 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Minerva 400 Carolyn Court Minerva, OH 44657 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 0609 Level of Harm - Minimal harm or potential for actual harm Review of a 08/09/23 (night shift on 08/09/23) STNA #98's statement included she had witnessed STNA #76 being very condescending, making inappropriate comments and being aggressive with multiple residents including Resident #50. STNA #98 has made numerous comments in regards to her employment stating she can't be fired: she will use the race card and threatened to call the The National Advancement of Colored People (NWACP). Residents Affected - Some Review of a 08/09/23 (night shift on 08/09/23) statement by Licensed Practical Nurse (LPN) #81 included STNA #76 had been verbally aggressive with the resident and was visually seen flicking Resident #50's nipple ring. LPN #81 and another nurse attempted to deescalate a situation with an aggressive resident and when STNA #76 came to the situation with an aggressive demeanor, the resident (#50) became more aggressive. Review of a 08/10/23 untimed statement from STNA #93 included STNA #76 would flick Resident #50's nipple ring when he would take a shower and would also do it in front of the 300/400 nurses station where the resident sits and would curse and scream at her and yell for someone to get her away from him. Review of an undated statement from STNA #94 included she heard STNA #76 swear at Resident #50. Two aides were putting the resident to bed and he swung at STNA #76. STNA #94 thought maybe he got hurt or was uncomfortable. STNA #76 grabbed Resident #50's right arm to stop him from hitting her and then stated something along the lines of you're not going to ever fu#### hit me again. STNA #94 reported she told a nurse, but doesn't know which one. STNA #94 couldn't remember the day it happened but thought it was a weekend. Review of a 08/10/23 untimed STNA #99 statement revealed she witnessed STNA #76 refusing to give care to Resident #50 because she wanted to eat. STNA #99 helped another aide use the mechanical lift to get Resident #50 into bed and left him there on the lift pad flat in his bed soiled without a call bell. Review of a 08/10/23 untimed statement by STNA #102 revealed she witnessed STNA #76 have an aggressive tone toward Resident #50 and inappropriate behavior including flicking Resident #50's nipple ring, on numerous occasions. Review of a 08/15/23 statement from Resident #50's sister included she asked him about the incident and he did tell her STNA #76 flicked his penis and nipple. Review of a statement revealed Registered Nurse (RN) #97 on 08/16/23 asked Resident #50 if STNA #76 flicked his bare penis or did he have a brief on. He stated it was his bare penis. Review of a 08/16/23 statement from the DON included Resident #50 refused to speak with the police and doesn't want to press charges. Interview on 08/17/23 at 3:09 P.M. with the DON included on 08/16/23 she spoke to Resident #50 because the police were at the facility to take a report. The resident did not want to talk about it and refused to give the police a statement and did not want to press charges. He did not want to get STNA #76 in trouble and said she was just joking but the facility substantiated sexual abuse based on witness statements. The DON further stated the third resident mentioned by name (Resident #51) did not have any concerns of abuse when she interviewed him. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365674 If continuation sheet Page 7 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365674 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Minerva 400 Carolyn Court Minerva, OH 44657 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 08/17/23 at 4:10 P.M. with Resident #50 revealed he did not want to talk about STNA #76. He did not want her to get in trouble. Review of the facility's Abuse, Neglect, and Exploitation policy (revised 10/24/22) included verbal abuse means the use of oral, written, or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Sexual abuse is non-consensual sexual contact of any type with a resident. The facility will implement policies and procedures providing residents, representatives, and staff information on how and to whom they may report concerns, incidents, and grievances without the fear of retribution; and providing feedback regarding the concerns that have been expressed. Identification of abuse includes resident, staff or family report of abuse. Verbal abuse of resident overheard. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. The facility will have written procedures that include reporting of all alleged violations to the Administrator. This deficiency is cited as an incidental finding to Complaint Number OH00145527. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365674 If continuation sheet Page 8 of 8