Inspection·September 26, 2019

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on record review, facility policy review and staff interview the facility failed to complete a Bureau of Criminal Investigation (BCI) background check on one staff (Business Office Manager (BOM) #46) of seven personnel files reviewed. This had the potential to affect forty-seven residents (Resident #52, #34, #3, #24, ##49, #18, #37, #56, #66, #80, #45, #26, #31, #77, #47, #27, #36 ,#8, #55,#73, #68, #62, #30, #74, #61, #51, #25, #58, #42, #13, #35, #5, #17, #69, #50, #57, #9, #28, #20, #48, #63, #67, #15 and #53) with personal funds accounts at the facility. The facility census was 87. Residents Affected - Some Findings include: Review of Business Office Manager (BOM) #46's personnel file revealed no evidence a BCI background check was completed. Review of the facility's BCI log revealed the facility did not have the BCI background check completed for BOM #46 During interview on 09/24/19 at 5:32 P.M., Payroll/Human Resources Director (HR) #77 revealed the Bureau of Criminal Investigations (BCI) background check was not completed for one staff, Business Office Manager (BOM) #46. During interview on 09/24/19 at 5:59 P.M., BOM #46 revealed she did not go to have her BCI (fingerprints) background check completed as she was never directed to. BOM #46 stated her date of hire was 08/14/19. Review of the facility's policy titled Abuse Prevention Program, dated 02/22/18, revealed the facility will conduct employee background checks per state and federal regulations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365675 If continuation sheet Page 2 of 14 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 365675 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Milford 5900 Meadowcreek Drive Milford, OH 45150 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 - Few 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** 3. Review of the Resident #75's medical record revealed and admission date of 08/28/19 with diagnoses including recent decannulation of tracheostomy. Review of Resident #75's plan of care dated 08/28/19 revealed no interventions related to the resident's recent decannulation of the tracheostomy and the care for the stoma. Review of Resident #75's Interdisciplinary Team (IDT) progress note dated 09/24/19 revealed resident had a recent decannulation of the tracheostomy. The stoma was open and healing. Interview on 09/24/19 at 9:28 A.M. with the Director of Nursing confirmed Resident #75's plan of care did not include interventions related to the resident's stoma or respiratory status. The facility did not provide a policy related to tracheostomy care. This deficiency substantiates Compliant Number OH00107171. Based on record review and interview, the facility failed to develop care plans for a resident's stoma care and a resident's vision needs and failed to implement a resident's fall care plan and interventions. This affected three (Residents #62, #63 and #75) of 19 residents reviewed for care planning. The facility census was 87. Findings include: 1. Record review revealed Resident #63 was admitted to the facility on [DATE] with diagnoses including feeding difficulties, gastro esophageal reflux disease, essential hypertension, muscle weakness difficulty in walking, hyperlipidemia, major depressive disorder, type two diabetes mellitus, psychosis not due to substance or known physiological condition, bullous pemphigoid and osteoporosis. Review of Resident #63's physician's orders dated 01/04/19 revealed resident was to have a pull tab alarm to her wheelchair to alert staff of unassisted transfers. Review of Resident #63's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired and required extensive assistance with bed mobility, eating, transfer, dressing, toileting and personal hygiene. Review of Resident #63's progress notes dated 08/18/19 revealed the resident was found on the floor by staff at 11:45 A.M. Resident #63 fell out of her wheelchair face first in the hallway. Resident #63 had a knot of the right front forehead and a cut on her nose and a few small cuts on both hands. Resident #63's family and physician were notified and the resident was sent out to the hospital. Resident #63 had swelling and bruising to her nose, face and right hand upon return from the hospital on [DATE] with no new orders. Review of Resident #63's care plan revealed resident was to have an alarm to her wheelchair to alert staff of unassisted transfers at the time of her fall on 08/18/19. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365675 If continuation sheet Page 3 of 14 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 365675 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Milford 5900 Meadowcreek Drive Milford, OH 45150 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 - Few Review of Resident #63's fall investigation dated 08/18/19 revealed Resident #63 was sitting in her wheelchair and fell out face first on the hallway floor. The resident had a chair alarm listed on her care plan prior to the fall and resident's alarm was not in place at the time of the fall. Review of Resident #63's progress note dated 08/19/19 revealed resident fell on [DATE]. She was was last seen in the hallway in front of the social services and scheduler's office in her wheelchair using her feet to propel herself. The Scheduler heard Resident #63 fall and immediately went out and got the nurse to assess the resident and assist her back into her wheelchair. Resident #63 used a chair alarm, but the alarm was not in place at the time of the fall. Interview with the Administrator on 09/25/19 at 9:24 A.M. verified resident fell in the hallway on 08/18/19 and she sustained facial fractures as a result of the incident. The Administrator confirmed resident did not her chair alarm in place at the time of the incident. Review of the facility policy titled Falls, dated June 2018, revealed the facility revealed fall interventions should be developed and implemented for falls. The policy also stated a care plan will be developed and implemented to address identified fall risks. 2. Record review revealed Resident #62 was admitted to the facility on [DATE] with diagnoses including congestive heart failure, insomnia, presence of cardiac pacemaker, sleep apnea, type two diabetes mellitus, major depressive disorder, hypothyroidism and cardiomyopathy. Review of Resident #62's optometry note dated 01/09/19 revealed resident was seen for a decrease in his near vision. Resident #62 was recommended to use over the counter reading glasses to assist with near vision. Review of Resident #62's care plan revealed no information regarding a vision care plan for Resident #62's vision needs. Interview with the Director of Nursing (DON) on 09/24/19 at 6:17 A.M. verified resident did not have a care plan to address his vision needs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365675 If continuation sheet Page 4 of 14 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 365675 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Milford 5900 Meadowcreek Drive Milford, OH 45150 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 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure an alarm was in place on a resident's wheelchair as care planned to prevent a fall. Resident #63 suffered actual harm when she fell face first from her wheelchair, sustaining fractures to her face. This affected one (Resident #63) of three residents reviewed for falls. The facility census was 87. Findings include: Medical record review revealed Resident #63 was admitted to the facility on [DATE] with diagnoses including feeding difficulties, gastroesophageal reflux disease, essential hypertension, muscle weakness difficulty in walking, hyperlipidemia, major depressive disorder, type two diabetes mellitus, psychosis not due to substance or known physiological condition, bullous pemphigoid and osteoporosis. Review of Resident #63's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired and require extensive assistance with bed mobility, eating, transfer, dressing, toileting and personal hygiene. Review of Resident #63's physician's orders dated 01/04/19 revealed the resident was to have a pull tab alarm to her wheelchair to alert staff of unassisted transfers. Review of the care plan for falls, revised 08/08/19, indicated the resident was to have an alarm to her wheelchair to alert staff of unassisted transfers. Review of Resident #63's progress notes dated 08/18/19 revealed the resident was found on the floor by staff at 11:45 A.M. Resident #63 fell out of her wheelchair face first in the hallway. The resident had a big knot on the right front forehead, a cut on her nose and small cuts on both her hands. Resident #63's family and physician were notified and the resident was sent out to the hospital. Resident #63 had swelling and bruising to her nose, face and right hand upon return from the hospital on [DATE]. There were no new orders. Review of the facility's fall investigation dated 08/18/19 revealed Resident #63 was sitting in her wheelchair and fell out face first on the hallway floor. The chair alarm was not in place at the time of the fall. Review of Resident #63's progress note dated 08/19/19 revealed the resident fell on [DATE]. Resident #63 was last seen in the hallway in front of the social services and scheduler's office in her wheelchair using her feet to propel herself. Scheduler #01 heard Resident #63 fall and immediately went out and got the nurse to assess the resident and assist her back into her wheelchair. Resident #63 used a chair alarm, but the alarm was not in place at the time of the fall. Interview with the Administrator on 09/25/19 at 9:24 A.M. verified the resident fell in the hallway on 08/18/19 and she sustained facial fractures as a result of the incident. The Administrator confirmed the resident did not have her chair alarm in place at the time of the incident. Review of the facility policy titled Falls, dated June 2018, revealed the facility fall interventions should be developed and implemented for falls. The policy also stated a care plan will be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365675 If continuation sheet Page 5 of 14 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 365675 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Milford 5900 Meadowcreek Drive Milford, OH 45150 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 developed and implemented to address identified fall risks. Level of Harm - Actual harm This deficiency substantiates compliant number OH00107171. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365675 If continuation sheet Page 6 of 14 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 365675 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Milford 5900 Meadowcreek Drive Milford, OH 45150 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 record review and interview, the facility failed to provide 90 day and annual performance reviews for State Tested Nursing Assistants (STNA). This affected four (STNA's #182, #162, #155 and #75) of four files reviewed. This had the potential to affect all the residents at the facility. The facility census was 87. Residents Affected - Few Findings include: 1. Review of STNA #182's personnel file revealed a hire date of 03/27/19. Documentation did not reveal a ninety-day performance evaluation was completed. 2. Review of STNA #162's personnel file revealed a hire date of 01/30/19. Documentation did not reveal a ninety-day performance evaluation was completed. 3. Review of STNA #155's personnel file revealed a hire date of 06/08/10. Documentation did not reveal an annual performance evaluation was completed. 4. Review of STNA #75's personnel file revealed a hire date of 09/18/13. Documentation did not reveal an annual performance evaluation was completed. Interview on 09/24/19 at 5:50 P.M. with Payroll Coordinator (PC) #77 revealed ninety-day and annual performance evaluations were not completed on the above STNA's. The facility did not provide a policy related to staffing and annual performance reviews. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365675 If continuation sheet Page 7 of 14 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 365675 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Milford 5900 Meadowcreek Drive Milford, OH 45150 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a resident's as needed psychotropic medication was limited to 14 days and failed to ensure a resident's psychotropic drugs receive gradual dose reductions. This affected one (Resident #17) of five residents reviewed for unnecessary medications. The facility census was 87. Findings include: Record review of Resident #17's chart revealed the resident was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, vascular parkinsonism, epilepsy dysphagia, weakness, vascular dementia with behavioral disturbance, chronic kidney disease, anemia, anxiety disorder, major depressive disorder, altered mental status and other abnormalities of gait. Review of Resident #17's physician orders revealed on 12/02/18, the resident was ordered Escitalopram oxalate 10 milligrams (mg) by mouth in the morning for depression; on 01/24/19, Abilify 2 mg by mouth every morning and bedtime for major depressive disorder; and on 08/07/19, Haldol 2.5 mg intramuscularly every four hours as needed for hallucinations. Review of Resident #17's Medication Administration Record (MAR) for August 2019 revealed the resident received Haldol 2.5 mg intramuscularly every four hours as needed for hallucinations on 08/07/19, 08/14/19, 08/15/19, 08/21/19 and 8/26/19. Review of Resident #17's MAR for September 2019 revealed resident received her Haldol 2.5 mg intramuscularly every four hours as needed for hallucinations on 09/04/19, 09/05/19, 09/07/19, 09/15/19, 09/18/19 and 09/21/19. Review of Resident #17's medical record revealed no documentation a gradual dose reduction or contraindications to a gradual dose reduction was attempted for either the Escitalopram or the Abilify. Review of Resident #17's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed resident to be severely cognitively impaired and the resident received antipsychotics, anti-anxiety and anti-depressants daily with no gradual dose reductions being completed. Interview with the Director of Nursing (DON) on 09/26/19 at 4:00 P.M. verified the as needed Haldol was not limited to 14 days and that no gradual dose reduction had been attempted for either the Escitalopram or the Abilify. Review of the facility policy titled Antipsychotic Medication Use, dated November 2012, revealed no information regarding gradual dose reductions or time limitations to as needed psychotropic medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365675 If continuation sheet Page 8 of 14 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 365675 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Milford 5900 Meadowcreek Drive Milford, OH 45150 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 observation, record review and interview, the facility failed to ensure the ice machine was maintained in a sanitary manner. This affected 80 residents. Seven residents (Resident #6, Resident #10, Resident #41, Resident #65, Resident #75, Resident #237 and Resident #238) that were identified in the facility as being no food by mouth (NPO). The facility census was 87. Findings include: Observation of the ice machine on 09/23/19 at 11:01 A.M. revealed a black substance on the interior plate of the ice machine. Interview with Maintenance Director #52 on 09/23/19 at 11:01 A.M. verified the black substance and said he cleans the ice machine monthly. Review of the facility's Ice Machine Service Log from 12/31/19 to 09/22/19 revealed the ice machine was last cleaned between 08/26/19 and 09/08/19. Review of the facility policy titled Ice, dated September 2017, revealed the ice will be prepared and distributed in a safe and sanitary manner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365675 If continuation sheet Page 9 of 14 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 365675 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Milford 5900 Meadowcreek Drive Milford, OH 45150 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a resident's discharge to the hospital and fall documentation and assessments were documented in the medical record. This affected one (Resident #63) of 19 residents reviewed for complete medical records. The facility census was 87. Findings include: Record review revealed Resident #63 was admitted to the facility on [DATE] with diagnoses including feeding difficulties, gastro esophageal reflux disease, essential hypertension, muscle weakness difficulty in walking, hyperlipidemia, major depressive disorder, type two diabetes mellitus, psychosis not due to substance or known physiological condition, bullous pemphigoid and osteoporosis. Review of Resident #63's chart revealed resident discharged to the hospital on [DATE] readmitted to the facility on [DATE]. No information regarding the reason for Resident #63's discharge to the hospital was found in the chart. Review of Resident #63's progress notes dated 04/06/19 revealed Resident #63's roommate reported resident fell on [DATE]. No apparent injuries were noted. Review of the facility's fall investigation, dated 04/06/19, revealed Resident #63's fall was reported to Licensed Practical Nurse (LPN) #92 on 04/06/19. Resident #63's roommate informed LPN #92 that the resident fell out of her bed on 04/04/19. Review of State Tested Nursing Assistant (STNA) #300's witness statement, dated 04/06/19, revealed resident fell on [DATE]. STNA #300's statement reported she was walking to the linen room to get linens and upon passing Resident #63's room she heard Resident #63 calling for help. Resident #300 entered Resident #63's room and found Resident #63 on the floor. STNA #300 reported she immediately informed Registered Nurse (RN) #181 of the fall. STNA #300 was told by RN #181 that she was very busy doing her medication pass and had to hang an intravenous bag and was informed to get Resident #63's vitals and to get her up. STNA #300 got assistance from STNA #71 to get Resident #63 off the floor. STNA #300 documented Resident #63 had no injuries and that she changed her after she put her back in bed. Review of LPN #92's witness statement dated 04/06/19 revealed Resident #63's roommate stated that Resident #63 fell out of bed on 04/04/19. Resident #63's roommate stated she heard Resident #63 yelling for help and when she found her, she was on the floor. Resident #63's roommate stated she got STNA's to help get Resident #63 back in bed. Review of STNA #71's witness statement, dated 04/08/19, revealed STNA #300 went to check on Resident #63 while doing rounds on 04/05/19. STNA #300 came out of Resident #63's room and informed staff that resident was on her fall mat on the floor. STNA #71 reported he helped assist Resident #63 back into bed. Interview with the Director of Nursing (DON) on 09/26/19 at 10:00 A.M. verified Resident #63's hospitalization on 01/01/19 was not documented in the chart. The DON reported she did not have any information regarding the reason Resident #63 was discharged to the hospital on [DATE]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365675 If continuation sheet Page 10 of 14 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 365675 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Milford 5900 Meadowcreek Drive Milford, OH 45150 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview with LPN #92 on 09/25/19 at 10:09 A.M. revealed Resident #63's roommate informed her that Resident #63 had fallen on 04/04/19. LPN #92 stated she immediately informed the Director of Nursing (DON) of the fall and assessed Resident #63. She stated the fall on 04/04/19 was not previously reported or documented in the chart. LPN #92 also confirmed there were no nursing assessments or monitoring of Resident #63 after the fall until 04/06/19 when she was informed of the incident from Resident #63's roommate. Review of Resident #63's chart revealed no information regarding any documentation or nursing assessments of the fall until 04/06/19. Review of the facility policy titled Falls, dated June 2018, revealed the facility should attempt to define the possible causes of the fall within 24 hours. Staff should also observe the resident for evident trauma, provide emergency care and assessments as indicated, neuro checks should be completed for all unwitnessed falls, the physician and responsible party should be notified as soon as the resident is stabilized and findings should be documented in the resident's medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365675 If continuation sheet Page 11 of 14 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 365675 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Milford 5900 Meadowcreek Drive Milford, OH 45150 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 observation, record review and interview, the facility failed to ensure staff followed isolation precautions. This affected one (Resident #51) of six residents reviewed for infections; and failed to ensure Mantoux two-step testing was completed on newly hired staff. This affected five (State Tested Nursing Assistant (STNA) #182, STNA #155, STNA #75, Registered Nurse (RN) #81 and Business Office Manager (BOM) #46 of seven staff reviewed for personnel files. This had the potential to affect all of the residents at the facility. The facility census was 87. Residents Affected - Many Findings include: 1. Record review revealed Resident #51 was admitted to the facility on [DATE]. Review of Resident #51's physician's orders revealed resident was ordered on isolation precautions on 09/12/19 for Clostridium Difficile (Cdiff). Observation of Resident #51's room on 09/23/19 at 10:37 A.M. revealed there were two trash cans lined with red bags, but no receptacle for soiled laundry. Observation of Resident #51's room on 09/26/19 at 4:22 P.M. revealed a sign on the door frame indicating that visitors should talk to the nurse before entering the room. There was also infection control equipment such as gowns, masks and gloves hanging on the door. State Tested Nurse Aide (STNA) #76 was observed in the resident's room, without personal protective equipment, making the bed while the resident was in the room. There was no receptacle for soiled laundry. Interview with Licensed Practical Nurse (LPN) #920 at the time of the observation verified STNA #76 was not wearing personal protective equipment in the room and there was no receptacle for soiled laundry. Review of the facility policy titled Isolation and Initiating Transmission Based Precautions, dated 03/01/11, revealed transmission based precautions will be initiated when there is a reason to believe that a resident has a communicable infectious disease. Infection control coordination shall ensure protective equipment such as gloves, gowns and masks are maintained near the resident's room so that everyone entering the room can access them and a laundry hamper and appropriate waste containers are placed in or near the resident's room and that each is lined with a red plastic liner. Transmission-based precautions shall remain in effect until the attending physician discontinues them. 2. Review of STNA #182's personnel file revealed no documentation to support any Mantoux testing was completed upon hire. 3. Review of STNA #155's personnel file revealed she received a step one Mantoux skin tests, however the second step skin test was not completed upon hire. 4. Review of STNA #75's personnel file revealed only a step one Mantoux skin test was administered upon hire. 5. Review of RN #81's personnel file revealed she received the first step Mantoux skin test, however the second step skin test was not completed upon hire. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365675 If continuation sheet Page 12 of 14 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 365675 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Milford 5900 Meadowcreek Drive Milford, OH 45150 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 Level of Harm - Minimal harm or potential for actual harm 6. Review of Business Office Manager #46's personnel file revealed she received a step one Mantoux skin test, however the second step skin test was not completed upon hire. Interview and record review of the personnel files on 09/24/19 at 5:50 P.M. with Payroll Coordinator #77 revealed the above staff did not have Mantoux test for tuberculosis as required. Residents Affected - Many Review of the facility's policy titled, Tuberculosis Employee Screening, dated November 2016, revealed the initial tuberculosis (TB) testing will be a two-step injection. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365675 If continuation sheet Page 13 of 14 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 365675 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Milford 5900 Meadowcreek Drive Milford, OH 45150 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review and interview, the facility failed to ensure the facility had an effective pest control program to ensure the kitchen and food storage areas were free of gnats. This affected all residents residing in the facility except seven residents (Resident #6, Resident #10, Resident #41, Resident #65, Resident #75, Resident #237 and Resident #238) that were identified in the facility as being no food by mouth (NPO). The facility census was 87. Residents Affected - Some Findings include: Observation of the kitchen on 09/23/19 at 8:59 A.M. revealed approximately 10 gnats in the area outside the kitchen door in which ice and bread were stored. There were also approximately six gnats in the dry storage room located inside the kitchen and 20 gnats inside the dish room and cooking area of the kitchen. Observation of the kitchen on 09/25/19 at 11:59 A.M. revealed approximately five gnats in the kitchen around the serving area while [NAME] #900 was serving residents food. Interview with Dietary Manager #800 on 09/23/19 at 8:59 A.M. verified the facility had gnats in the kitchen and food storage areas. Review of the facility's pest control records revealed general pest control treatments were completed on 06/26/19, 07/25/19, 08/26/19 and 09/23/19. There was no documented concern of gnats in the kitchen and other food storage areas. The records did not include in specific treatments of the kitchen for gnats. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365675 If continuation sheet Page 14 of 14