Inspection·May 13, 2022

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to complete accurate comprehensive and quarterly assessments. This affected two (Residents #46 and #60) of 28 residents reviewed for accuracy of assessments. The facility census was 78. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #46 revealed the resident was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Diabetes Mellitus with Diabetic Neuropathy, and Osteoarthritis. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive impairment and requires extensive assistance with all Activities of Daily Living (ADL). The MDS indicated Resident #46 was receiving hospice services. During an interview on 05/04/22 at 9:09 A.M., Resident #46's assigned nurse, Registered Nurse (RN) # 334 revealed the resident does not receive hospice services. During an interview on 05/04/22 at 9:18 A.M., the MDS nurse, RN #400, revealed resident #46 did not receive hospice services, and section O part K of the MDS indicating the resident received hospice services had been selected in error. Review of the facility policy titled, Resident Assessment-RAI, revised 09/03/2020 revealed the facility makes a comprehensive assessment of each resident's needs, strengths goals, life history and preferences using the resident assessment instrument (RAI) specified by Centers for Medicare and Medicaid Services (CMS). 2. Review of the medical record for Resident #60 revealed a readmission date of 01/22/22 with diagnoses including end stage renal disease, dependence on renal dialysis, type two diabetes mellitus with diabetic chronic kidney disease. Review of the Comprehensive Minimum Data Set (MDS) assessment dated [DATE] and the quarterly MDS assessment dated [DATE], revealed the resident had no cognitive impairment and required limited assistance with Activities of Daily Living (ADL). Further review of the MDS's Section O part J, indicated the resident did not receive dialysis services. Review of Resident #60's May 2022 physician orders revealed orders for Hemodialysis every Monday, Wednesday, and Friday, at 9:00 A.M. with a dialysis center located at the facility. During an interview on 05/04/22 at 9:09 A.M., Resident #60's assigned nurse, Registered Nurse (RN) # 334 revealed the resident received dialysis treatments every week on Monday, Wednesday, and Friday. During an interview on 05/04/22 at 9:18 A.M., the MDS nurse, RN #400, revealed resident #60 did receive dialysis treatments weekly, and section O part J of the MDS indicating the resident did not receive dialysis services was omitted in error, for the MDS assessments completed on 01/22/22 and 04/01/22. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365675 If continuation sheet Page 2 of 33 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 05/13/2022 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 0641 Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled, Resident Assessment-RAI, revised 09/03/2020 revealed the facility makes a comprehensive assessment of each resident's needs, strengths goals, life history and preferences using the resident assessment instrument (RAI) specified by Centers for Medicare and Medicaid Services (CMS). Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365675 If continuation sheet Page 3 of 33 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 05/13/2022 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the medical record for Resident #33 revealed an admission date of 07/28/18. Diagnoses included diabetes, fibromyalgia, depression, pain, hypertension, dementia without behavioral disturbances. Review of the quarterly MDS dated [DATE] revealed Resident #33 was cognitively intact. Resident #33 required extensive assistance for bed mobility, transfers, and toilet use. She needed supervision for eating. Review of the care conferences for Resident #33 revealed the last one documented was 05/19/21. Interview with Resident #33 on 05/02/22 at 12:04 P.M., revealed she had not had a care conference in awhile. Interview with the SW #348 on 05/04/22 at 4:02 P.M., verified the last care conference held for Resident #33 was on 05/19/21. Review of policy titled Patient/Family Initial Care Conference dated 09/03/20, revealed the Comprehensive Care Conference was scheduled after the completion of the Comprehensive Care plan, seven-day advance notice was given to family via mail or telephone, and the Social Services Director/Designee was responsible for contacting family and maintaining documentation of notices. Based on record review, interview and policy review, the facility failed to ensure routine care conferences were completed. This affected three (Residents #33, #51, and #53) of three residents reviewed for care conferences. The facility census was 78. Findings include: 1. Review of the medical record revealed Resident #51 admitted to the facility on [DATE]. Diagnoses included undisclosed fracture of cervical vertebra, type II diabetes, and chronic diastolic heart failure. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #51 had moderately impaired cognition, no behaviors, did not refuse care, and did not wander. Review of the medical record revealed Resident #51 had documentation for care conferences on 06/25/21 attended by speech therapy, the social worker, the dietitian, the nursing staff and the healthcare Power of Attorney/daughter, and on 05/03/22 attended by the nursing staff, the social worker, and two daughters. Interview on 05/04/22 at 1:02 P.M., the Social Worker (SW) #465 stated Resident #51 was her own person, could communicate her needs to a certain extent, but needed family to be involved. The SW #465 stated she was the only social worker for 18 months, from March 2020 to [DATE], and had issues getting hold of the local daughter. The SW #465 verified during that time care conferences were not performed routinely with the interdisciplinary team, though she still met with families over the phone and spoke with residents routinely. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365675 If continuation sheet Page 4 of 33 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 05/13/2022 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. Review of the medical record revealed Resident #53 admitted to the facility on [DATE]. Diagnoses included acute respiratory failure with hypoxia, unspecified right ankle fracture, Congestive Heart Failure, type II diabetes, hypertension, and morbid obesity. Review of most recent quarterly MDS assessment dated [DATE] revealed Resident #53 was cognitively intact, had no behavior, did not wander, and occasionally rejected care. Review of the medical record revealed Resident #53 had care conferences on 02/24/2021 and 05/03/2022. Interview on 05/02/22 at 11:15 A.M., Resident #53 stated he was supposed to have somebody come in to review his care plan however no one ever came in and went over a care plan with him. Resident #53 stated he had a sister who was his medical POA but only if he was unable to make his own decisions. Interview on 05/04/22 at 1:06 P.M., the SW #465 stated she had problems getting a hold of Resident #53's sister. The SW #465 verified there was not any care conference documentation for Resident #53 between June 2021 and May 2022, and stated during that period there was no institutional support to complete the care conferences. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365675 If continuation sheet Page 5 of 33 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 05/13/2022 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 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Medical record review for Resident #33 revealed an admission date of 07/28/18. Diagnoses included diabetes, fibromyalgia, depression, pain, hypertension, dementia without behavioral disturbances. Residents Affected - Some Review of care plan, dated 06/23/21, revealed Resident #33 needed assistance with ADL related to hip replacement. Interventions were for staff to assist resident with bathing routinely and as needed. Review of quarterly MDS assessment, dated 04/27/22, revealed Resident #33 was cognitively intact. She required extensive assistance for bed mobility, transfers, and toilet use. Review of the shower documentation revealed Resident #33 had a shower on 04/12/22, 04/19/22 and 04/26/22. The shower schedule revealed Resident #33 was scheduled for showers on Tuesday and Friday. During interview on 05/02/22 at 11:59 A.M., Resident #33 stated she had not had any showers for the past two weeks and said there wasn't enough staff. During interview on 05/05/22 at 7:53 A.M., the DON verified Resident #33 only received three showers in the last three weeks and was supposed to receive two a week. 4. Review of the medical record for the Resident #53 revealed an admission date of 07/13/20. Diagnoses included acute respiratory with hypoxia, right ankle fracture, congestive heart failure, type II diabetes, hypertension, and morbid obesity. Review of the most recent MDS assessment dated [DATE] revealed the resident was cognitively intact, had no behaviors, occasionally rejected care, and did not wander. Resident #53 was a one to two-person physical assist and required limited assistance for bed mobility and locomotion, extensive assistance for transfers, dressing, toilet use, and personal hygiene. Review of the care plan dated 04/08/22 revealed Resident #53 needed activities of daily living assistance related to compromised respiratory and cardiac conditions. Resident #53 became upset and refused care if certain staff were not available to provide care. Resident #53 asked for care (bathing) during meal time and shift changes. Interventions included extensive one staff assistance with showers, short/simple instructions to promote independence, encourage the resident to participate to the fullest extent possible, praise all efforts at self-care, explain all procedures, monitor/report/document any changed in abilities. Review of the task documentation dated April 2022 revealed Resident #53 received one of nine showers scheduled. There was no documentation for showers scheduled on 04/01/22, 04/5/22, 04/08/22, 04/12/22, 04/15/22, 04/19/22, 04/26/22, and 04/29/22. Review of the shower sheets revealed Resident #53 received bathing assistance on 04/15/22, 04/26/22, 04/28/22. During interview on 05/05/22 at 1:55 P.M., the DON verified Resident #53 only had four showers and one refusal to shower out of nine scheduled showers documented for April 2022. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365675 If continuation sheet Page 6 of 33 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 05/13/2022 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 0677 Level of Harm - Minimal harm or potential for actual harm Review of policy titled Activities of Daily Living, dated 01/01/21 revealed the facility will ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. This includes the resident's ability to bathe, dress, and groom. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Residents Affected - Some This deficiency substantiates Complaint Number OH00131752. Based on observation, record review, interview and policy review, the facility failed to provide timely feeding assistance to a dependent resident. This affected one (Resident #5) of three residents reviewed for feeding assistance. The facility identified nine residents that required assistance with feeding. The facility also failed to ensure residents were provided with routine showers and/or bathing. This affected four (Residents #5, #33, #53, and #63) of five residents reviewed for hygiene. The facility census was 78. Findings include: 1a. Review of the medical record of Resident #5 revealed an admission date of 12/19/16. Diagnoses included respiratory failure, dysphagia following unspecified cerebrovascular disease, alcoholic cirrhosis of liver with ascites, heart failure, end-stage renal disease, dementia with behavioral disturbance, unspecified psychosis, essential hypertension, hypothyroidism, anxiety disorder, feeding difficulties, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/18/22, revealed the resident had severe cognitive impairment. The resident was dependent on two staff for bed mobility, transfers, and toilet use, and was dependent on one staff for eating. Review of the plan of care, dated 08/21/21, revealed Resident #5 had an activities of daily living (ADL) self-care performance deficit related to diagnosis of dementia and stroke. Interventions included to provide extensive assistance of one staff for eating. Review of the care plan dated 02/22/22 revealed Resident #5 had the potential for nutritional deficits related to dysphagia and feeding difficulties. Interventions included to provide one-on-one assist with feeding at all meals. Review of the physician orders dated 04/13/22 revealed the Resident #5 was ordered one-to-one assistance with meals. During observation on 05/03/22 at 2:13 P.M., Resident #5 laying in bed with his eyes closed. His meal tray was observed on his bedside table. The tray was covered and uneaten and the silverware remained clean and wrapped in a napkin. During interview on 05/03/22 at 2:19 P.M., Registered Nurse (RN) #330 verified Resident #5 had not yet received assistance with his meal. RN #330 stated his tray had been delivered approximately an hour ago and he was dependent on staff for eating. RN #330 stated there were four residents on this hall who were dependent on staff for eating and there was not enough staff available to feed all of them timely. RN #330 verified Resident #5 had not received timely assistance with his meal. During observation on 5/03/22 at 2:25 P.M., an unidentified State Tested Nursing Assistant (STNA) entered Resident #5's room and began to assist him with eating. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365675 If continuation sheet Page 7 of 33 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 05/13/2022 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 1b. Review of shower sheets revealed Resident #5 was scheduled on Wednesdays and Saturdays for bathing. The shower sheets showed he received bathing on 04/07/22, 04/14/22, 04/17/22, 04/21/22, 04/24/22, and 5/01/22 which was once a week for the past three weeks. During observation on 05/05/22 at 8:43 A.M., Resident #5 was up in his wheelchair and dressed for the day. His hair was greasy and he smelled of urine. During interview on on 05/05/22 at 8:45 A.M., Licensed Practical Nurse (LPN) #345 verified Resident #5's hair was greasy, but couldn't smell anything through her N-95 mask. She said she didn't know when the last time the resident was bathed. During interview on 05/05/22 at 1:55 P.M., the Director of Nursing (DON) verified Resident #5 had not received two showers a week as scheduled. 2. Review of the record of Resident #63 revealed an admission date of 10/18/17. Diagnoses included acute respiratory failure with hypoxia, epilepsy, lymphedema, weakness, essential hypertension, amyotrophic lateral sclerosis, morbid obesity, chronic peripheral venous insufficiency. Review of the quarterly MDS assessment, dated 04/07/22, revealed the resident had intact cognition. Resident #63 required the extensive assistance of two staff for bed mobility, dressing, toilet use, and personal hygiene and was dependent on two staff for transfers and bathing. During interview on 05/04/22 at 10:33 A.M., Resident #63 stated he had not had a bath since 04/25/22. Resident #63 stated he normally received bed baths, which he preferred. Review of the shower documentation revealed Resident #63 had not received showers as scheduled on 04/28/22 and 05/02/22. During interview on 05/04/22 at 1:00 P.M., the DON verified Resident #63 had not received showers as scheduled on 04/28/22 and 05/02/22. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365675 If continuation sheet Page 8 of 33 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 05/13/2022 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 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** 2. Record review revealed Resident #31 was admitted to the facility on [DATE]. Diagnoses included congestive heart failure, cerebrovascular disease, anxiety disorder, diabetes, and weight loss. Residents Affected - Few Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed the resident had severely impaired cognition. Review of physician orders revealed Resident #31 had a new physician order dated 04/20/22 for hospice services. Review of the medical record revealed no hospice provider documentation, including the hospice plan of care and hospice progress notes. Review of the Plan of Care dated 04/20/22, revealed Resident #31 was identified to receive hospice services. The interventions included to coordinate facility care with the hospice provider. Review of Licensed Social Worker (LSW) #348's progress notes dated 04/25/22 and review of Care Conference dated 04/25/22 revealed LSW #348, the physician, Resident #31's Power of Attorney and a facility nurse attended the care conference. During interview 05/05/22 8:53 A.M., Medical Records Staff #399 revealed no hospice records have been sent to be loaded into the computer for Resident #31, including plan of care, or hospice visiting records to communicate with facility staff providing care. Medical Records Staff #399 verified no written information is kept at the nurse station for caregivers to review for coordination of care. During interview on 05/05/22 8:55 A.M., Licensed Practical Nurse, (LPN) #349 verified visiting hospice staff provide only verbal reporting after providing care for Resident #31. LPN # 349 was unaware of how to access written hospice care and the hospice care plan. Review of the policy titled Hospice, dated 01/01/22, revealed the facility maintains a written hospice agreement that specify the process for hospice and facility communication of necessary information regarding the resident's care. Based on observation, record review, interview and policy review, the failed to ensure residents received treatments as per physician orders. This affected one (Resident #63) of one resident reviewed for edema. The facility identified three residents who had orders non-pharmacological treatments for edema. The facility also failed to coordinate hospice services. This affected one (Resident #31) of three residents reviewed for hospice services. The facility identified three residents who receive hospice services. The facility census was 78. Findings include: 1. Record review revealed Resident #63 was admitted on [DATE]. Diagnoses included acute respiratory failure with hypoxia, epilepsy, lymphedema, weakness, essential hypertension, amyotrophic lateral sclerosis, morbid obesity, chronic peripheral venous insufficiency. Review of the care plan dated 06/14/21 revealed the resident had lymphedema to lower extremities. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365675 If continuation sheet Page 9 of 33 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 05/13/2022 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 0684 Interventions included to complete treatments as ordered to lower extremities. Level of Harm - Minimal harm or potential for actual harm Review of the physician orders revealed an order dated 09/02/21 to wrap ace bandages around left leg up to the knee every day shift due to swelling and lymphedema. Residents Affected - Few Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/07/22, revealed the resident had intact cognition. The resident did not refuse care. The resident required extensive assistance of two staff for bed mobility, dressing, toileting, and personal hygiene and was totally dependent on two staff for transfers During interview on 05/02/22 at 11:49 A.M., Resident #63 stated nobody wraps his left leg as ordered. Resident #63 stated his legs had not been wrapped in at least three weeks. Concurrent observation revealed edema on both legs and the left leg had more edema. The left leg was not wrapped and no treatment was observed on the leg. During observation on 05/03/22 at 2:05 P.M., Resident #63's left leg was not wrapped. Concurrent interview with the resident and State Tested Nursing Assistant (STNA) #379 verified there were no wraps on Resident #63's left leg. During interview on 05/03/22 at 2:19 P.M., Registered Nurse (RN) #330 stated she thought Resident #63's wraps were supposed to be done on night shift because it is too hard to get to it during day shift because she is too busy. During observation on 05/04/22 at 10:33 A.M., Resident #63's leg was not wrapped. Concurrent interview with Resident #63 confirmed his legs were not wrapped. Resident #63 stated nobody had offered to wrap his legs during the last three days. Resident #63 stated he experiences discomfort in his leg more when it is not wrapped. Resident #63 denied pain in his leg at the time of the observation. Review of progress notes dated 05/02/22 through 05/04/22 revealed no evidence of Resident #63 refusing for his legs to be wrapped. Review of the Treatment Administration Record (TAR) revealed Licensed Practical Nurse (LPN) #346 signed the order for Resident #63's left leg ace wraps as complete on 05/04/22. The TAR was not signed off on 05/02/22 or 05/03/22. During observation on 05/05/22 at 9:08 A.M., Resident #63's left leg was not wrapped. Resident #63 affirmed his leg had not been wrapped at any time since observations started on 05/02/22. Resident #63 stated his nurse (LPN #346) yesterday told him she would do it but never got around to doing it. During interview on 05/05/22 at 2:10 P.M., LPN #346 stated she did not wrap Resident #63's legs on 05/04/22. LPN #346 affirmed she signed the TAR off as completed when it was not completed. LPN #346 further affirmed she did not document the rationale for not wrapping Resident #63's legs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365675 If continuation sheet Page 10 of 33 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 05/13/2022 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and policy review, the facility failed to ensure residents were assessed for alterations in skin integrity weekly and failed to ensure a treatment was ordered for a pressure ulcer. This resulted in Actual Harm when Resident #55 was admitted with a stage II pressure ulcer. No assessment or treatment was initiated on admission and the ulcer progressed to a stage III. This affected one (Resident #55) of ten residents reviewed for pressure ulcers. The census was 78. Residents Affected - Few Findings include: Medical record review revealed Resident #55 was admitted on [DATE]. Diagnoses included acute kidney failure, colostomy, neuromuscular dysfunction of bladder, diabetes, reduced mobility, muscle weakness, dysphagia, hypertension, and altered mental status. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #55 had severe cognitive impairment and required extensive assistance of two staff with activities of daily living (ADL). Review of the pressure ulcer risk assessment for Resident #55 dated 02/15/22 revealed resident was at high risk for the development of pressure ulcers. Review of the care plan for Resident #55, dated 02/16/22 revealed the resident was at risk for skin integrity impairments and pressure ulcers related to mobility deficits, medical diagnosed, decreased ADL self-performance and overall medical condition. Interventions included administer medications and treatments as ordered and monitor for effectiveness. Review of physician orders for February 2022 for Resident #55 revealed an order to complete skin assessment one day a week and document any skin issues and provide bathing two times a week. Review of the hospital discharge documentation date 03/27/22 reveal Resident #55 had a pressure injury on the right buttocks beginning on 03/24/22. There was no treatment ordered. Review of the nurses noted dated 03/27/22 at 8:00 P.M. revealed Resident #55 readmitted from the hospital. Orders were verified by the physician. Review of the nursing admission evaluation for Resident #55, dated 03/27/22, revealed the resident readmitted from the hospital on [DATE] with a right buttock pressure area stage II, measuring 2 centimeters (cm) by 1 cm by 0.1 cm. Interventions included administer treatment as ordered and evaluate for effectiveness and skin inspections by caregivers during care and showers and report changes to the licensed nurse immediately. Review of shower sheets and bathing document from 03/27/22 through 04/11/22 revealed caregivers completed three showers with no documentation of skin issues. Review of the skin assessment dated [DATE] revealed no skin area on the right buttock. Review of the wound evaluation dated 04/12/22 revealed a new pressure stage III area to the right buttock measuring 6.5 cm x 4.18 cm x 0.3 cm. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365675 If continuation sheet Page 11 of 33 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 05/13/2022 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 0686 Level of Harm - Actual harm Residents Affected - Few Review of physician order for Resident #55 dated 04/12/22 revealed an order to cleanse coccyx with normal saline, a dry and apply two by two gauze with calcium alginate and cover with a silicone foam border dressing every day. Review of the care plan for Resident #55, revised on 04/13/22, revealed the resident had a stage III pressure area on the coccyx and a low air loss mattress was added as a new intervention. During an interview on 05/04/22 at 2:12 PM, Registered Nurse (RN) #328, the wound nurse, stated 04/12/22, a charge nurse reported Resident #55 had a new stage III pressure ulcer to the coccyx area. RN #328 stated the physician orders upon initial admission, 02/15/22, were for preventative barrier cream treatment to buttocks, and weekly skin assessment. During an interview on 05/04/22 at 4:33 P.M. RN #328 stated on 03/27/22 RN #354 documented a stage II pressure ulcer to the right buttock measuring 2 cm by 1 cm by 0.1 cm. RN #354 did not notify the physician of the right buttock area and did not obtain a treatment order. RN #328 verified the physician should have been notified and a treatment order should have been obtained. RN #328 verified Resident #55 had no treatment to the right buttock and coccyx area from 03/27/22 through 04/12/2. The air mattress was new intervention beginning 04/13/22. The initial stage II right buttock area had increased in size to a stage III coccyx area. RN #328 stated the stage III pressure ulcer to the coccyx was avoidable. During interview on 04/05/22 at 1:30 P.M., the Director of Nursing, (DON), verified Resident #55's physician had not been notified of the new coccyx area on 03/27/22 and had no treatment to the coccyx ulcer from 03/27/22 through 04/11/22. The DON verified shower documentation sheets from 03/27/22 through 04/11/22 revealed no skin areas to the right buttocks and coccyx. During interview on 05/09/22 10:00 A.M., RN #354 verified she completed Resident #55 readmission documentation on 03/27/22. She verified a right buttocks pressure area that was noted in the hospital discharge documentation and removed the hospital wound treatment. The area measured 2 cm by 1 cm by 0.1 cm. RN #354 verified the physician was not notified of the hospital acquired right buttock pressure area. RN #354 stated RN #328 reviews the wound assessments, measures the wounds and notifies the physician to obtain treatment orders. RN #354 revealed on 04/12/22 she notified the Wound Nurse #328 the right buttock area had increased in size and required an air mattress. RN #354 verified no treatment was provided to the right buttock wound from 03/27/22 to 04/12/22. During observation on 05/10/22 at 9:45 A.M., Resident #55's wound treatment was observed with Licensed Practical Nurse (LPN) #346 and RN #328. The dressing was dated 05/09/22. The wound had a touch of slough, small amount of serosanguinous drainage, granulation, and measured approximately 2.5 cm by 3 cm. The wound was cleaned with normal saline and gauze. Santyl was placed in the wound bed and covered with calcium alginate and then covered with a Mepliex per physician orders. Review of the facility policy titled Pressure Ulcer/Skin Breakdown-Clinical Protocol, dated 01/01/22 revealed the physician was to be notified of all changes in condition and new skin alterations. This deficiency substantiates Complaint Number OH00131420. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365675 If continuation sheet Page 12 of 33 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 05/13/2022 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and policy review, the facility failed to ensure incontinence care was provided to residents. This affected two (Residents #33 and #26) of two residents reviewed for incontinent care. The facility identified there were 46 residents who were incontinent. The census was 78. Findings include: 1. Record review revealed Resident #33 was admitted on [DATE]. Medical diagnoses included diabetes, fibromyalgia, depression, pain, hypertension, dementia without behavioral disturbances. Review of care plan, dated 06/23/21, for Resident #33 revealed she needed activities of daily living (ADL) assistance related to hip replacement. her interventions were to check and change every two hours, change briefs and provide incontinence care. Review of quarterly MDS assessment, dated 04/27/22, revealed Resident #33 was cognitively intact. She required extensive assistance for bed mobility, transfers, and toilet use. She was frequently incontinent of bladder and always incontinent of bowel. Review of the incontinence documentation dated 05/02/22 revealed Resident #33 was changed at 12:31 A.M. During interview on 05/02/22 at 9:55 A.M., Resident #33 stated soaked with urine in her brief and on her sheets. She said the last time she was changed was at 5:00 A.M. She said this happens all the time. During observation on on 05/02/22 at 10:00 A.M. with State Tested Nursing Assistant (STNA) #392, Resident #33's brief was soaked with urine and the draw sheet and bed sheets were soaked with urine. STNA #392 stated she had not provided incontinent care to Resident #33 since she had come on shift at 7:00 A.M. 2. Record review revealed Resident #26 was admitted on [DATE]. Medical diagnoses included Spina Bifida with hydrocephalus. Review of care plan, dated 02/02/22, revealed Resident #26 needed assistance with ADL care related to Spina Bifida. Interventions were to check for bowel incontinence, change as needed and provide peri-care after elimination. Review of quarterly MDS assessment, dated 03/14/22, revealed Resident #26 was cognitively intact. She required extensive assistance for bed mobility, total dependence for transfers, extensive assistance for toilet use and independent for eating. She used an indwelling urinary catheter and was always incontinent of bowel. Review of incontinence care documentation for Resident #26 revealed she had a bowel movement on 05/02/22 at 12:32 A.M. During observation on 05/02/22 at 10:03 A.M. with STNA #392, Resident #26 was sitting up on the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365675 If continuation sheet Page 13 of 33 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 05/13/2022 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few side of the bed and her draw sheet and bed was soaked with urine and stool. Resident #26 stated she doesn't like to wait this long to get changed and said she hadn't been changed since last night and rang her call light sometime ago. During interview on 05/02/22 at 10:10 A.M., STNA #392 confirmed Resident #26 was soiled and the bed was soaked. STNA #392 said Resident #26 had rang her call light light but she was busy. Review of the policy titled Incontinence, dated 01/01/21, revealed based on resident's comprehensive assessment, all residents that are incontinent will receive appropriate treatment and services. Residents that incontinent of bladder and bowel will receive appropriate treatment to prevent infections and to restore continence to the extent possible. This deficiency substantiates Complaint Number OH00131752. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365675 If continuation sheet Page 14 of 33 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 05/13/2022 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Actual harm Based on record review, interview and policy review, the facility failed to ensure a resident experiencing chronic pain received as needed (PRN) pain medication in a timely manner. This resulted in actual harm when staff failed to ensure Resident #277 received PRN pain medication in a timely manner, when she reported pain. This affected one (#277) of three residents reviewed for pain. The facility identified 68 residents who received pain medication. The facility census was 78. Residents Affected - Few Findings include: Review of the medical record of Resident #277 revealed an admission date of 04/23/22. Diagnoses included acute respiratory failure with hypoxia, moderate persistent asthma, cellulitis of right and left lower limbs, stage 3 chronic kidney disease, pneumonia, muscle weakness, oral phase dysphagia, reduced mobility, anemia, and hypothyroidism. Review of the nursing admission evaluation dated 04/23/22 revealed the resident reported occasional pain during the last five days, which limited her day-to-day activities. The resident described the pain as intermittent and dull pain to her legs. Dressing changes made pain worse. Pain was managed by medication and decreasing movement helped to reduce pain. Review of the care plan contained in the nursing admission evaluation revealed an intervention of administering pain medications as ordered and give 30 minutes prior to treatments or care. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 04/30/22, revealed the resident had intact cognition. The resident did not exhibit any behaviors during the assessment period. The resident required extensive assistance of two staff for bed mobility and toileting, dependent on two assist for transfers. The resident was receiving PRN pain medications having occasional pain during the past five days, which had made it difficult to sleep at night but did not limit her daily activities. The resident was assessed as having a pain rating as high as six on a one to ten scale during the prior five days. Review of the plan of care dated 05/01/22 revealed the resident was at risk for chronic pain related to acute respiratory failure and cellulitis. Interventions included to administer pain medications as ordered and provide a half hour before treatments or care, anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Review of the physician orders revealed an order dated 04/23/22 for hydrocodone-acetaminophen tablet 5-325 milligrams (mg), give one tablet every six hours as needed for pain. During observation on 05/02/22 at 10:15 A.M., Resident #277 informed State Tested Nursing Assistant (STNA) #392 she was in pain. During observation on 05/02/22 at 10:17 A.M., Resident #277 was sitting on the edge of her bed with Physical Therapist (PT) #501 and an additional unidentified therapist at her bedside. Resident #277 complained of pain in her knees and was moaning. Resident #277 rated the pain a ten on on a one to ten scale. During interview at this time, Resident #277 stated she last received pain medication around 4:30 A.M. During observation on 05/02/22 at 12:07 P.M., Resident #277 was laying in bed, moaning. During interview at this time, Resident #277 rated her pain a ten and stated she had not received any pain (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365675 If continuation sheet Page 15 of 33 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 05/13/2022 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 0697 medication. Level of Harm - Actual harm Observation on 05/02/22 at 12:48 P.M., Resident #277's call light was activated. Licensed Practical Nurse (LPN) #373 entered the room and Resident #277 requested to be repositioned in bed and to see the nurse. Resident #277 continued to moan. At 12:53 P.M., STNA #392 and LPN #373 entered Resident #277's room and pulled her up in bed. Resident #277 let out a groan following being pulled up in bed. Residents Affected - Few During an interview on 05/02/22 at 12:56 P.M., STNA #392 stated she informed LPN #502 earlier of Resident #277's pain and LPN #502 told her she would go peek at Resident #277. During interview on 05/02/22 at 12:59 P.M., LPN #502 affirmed STNA #392 came and told her Resident #277 was complaining of pain at approximately 10:15 A.M. LPN #502 stated Resident #277 last had pain medication at 4:45 A.M. and could not have it again until 10:45 A.M LPN #502 stated she did not return to give Resident #277 after 10:45 A.M. LPN #502 stated she was in Resident #277's room two or three more times after that and she did not complain of pain again. LPN #502 stated she did not specifically ask Resident #277 about her pain again after talking with her at 10:15 A.M. During interview on 05/02/22 at 1:18 P.M., Resident #277 stated she had just received pain medication. During observation on 05/04/22 at 10:52 A.M., Resident #277 was laying in bed, moaning, and had tears streaming down her face. Resident #277 stated her pain level was a ten . She stated she told an STNA at 7:45 A.M. she needed pain medication but had not receive anything. Resident #277 stated her pain was in her legs and knees and attributed it to her cellulitis and arthritis. Resident #277 stated she had not seen the nurse since telling the nursing assistant she needed pain medication. During observation on 05/04/22 at 10:56 A.M., STNA #403 entered Resident #277's room to answer her call light. Resident #277 informed STNA #403 she needed pain medication. At 11:00 A.M., STNA #403 affirmed Resident #277 appeared to be in pain. During an interview on 05/04/22 at 11:00 A.M., RN #328 stated she was notified earlier of Resident #277's pain and STNA #403 had reminded her again, just prior to the interview, of Resident #277's complaint of pain. RN #328 stated she went to take a break after being notified of Resident #277's pain and had not yet provided her with pain medication. Review of nursing progress notes dated 05/02/22 through 05/04/22 revealed no evidence of the physician being provided any update on Resident #277's pain not being controlled. During interview on 05/05/22 at 8:51 A.M., Resident #277 stated she asked for a pain pill before 7:00 A.M. and the nurse informed her she was taking care of other residents. Resident #277 rated pain a ten at this time and stated she hurt in her legs. Review of the medication administration record (MAR) revealed Resident #277 received hydrocodone on 05/05/22 at 12:57 A.M. and 8:54 A.M. During an interview on 05/05/22 at 9:03 A.M., LPN #345 stated she was notified of Resident #277's pain at approximately 8:50 A.M. LPN #345 stated Resident #277 was crying and whining and rated her pain a five. LPN #345 stated she had just provided Resident #277 with pain medication. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365675 If continuation sheet Page 16 of 33 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 05/13/2022 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 0697 Level of Harm - Actual harm Residents Affected - Few During an interview on 05/05/22 at 11:05 A.M., PT #501 stated she worked with Resident #277 for 25 minutes on the morning of 05/02/22 and she whimpered and cried during the whole treatment. PT #501 stated Resident #277 rated the pain a ten and the resident told her she was always in pain. During observation 05/05/22 at 11:14 A.M., Resident #277 stated her pain was improved, however still rated her pain as a ten. During interview on 05/05/22 at 11:17 A.M., Rehab Coordinator (RC) #420 stated Resident #277's pain in her legs was limiting her progress in therapy. RC #420 stated on 05/04/22, he came to treat Resident #277 an hour after she received her pain medication and she continued to complain of pain. RC #420 stated he informed the nurse on duty. During interview on 05/05/22 at 3:34 P.M., Physician #500 stated she had not been notified of Resident #277's pain with her current regimen. During interview on 05/05/22 at 3:49 P.M. Physician #500 stated she spoke with facility staff regarding Resident #277's pain and changed Resident #277's hydrocodone to routine due to breakthrough pain. Review of the facility policy titled, Pain Management, dated 01/01/21 revealed the facility is to ensure pain management is provided to residents who require such services, residents with pain should be reassessed regularly and, if the resident's pain is not controlled by the current treatment regimen, the practitioner should be notified. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365675 If continuation sheet Page 17 of 33 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 05/13/2022 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 0711 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews the facility failed to ensure physician orders were accurate and implemented. This affected two (Residents #5 and #60) of 28 residents reviewed for accuracy of physician orders. The facility census was 78. Findings include: 1. Review of the medical record for Resident #60 revealed a readmission date of 01/22/22 with diagnoses including end stage renal disease, dependence on renal dialysis, type two diabetes mellitus with diabetic chronic kidney disease. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/01/22, revealed the resident had no cognitive impairment and required limited assistance with Activities of Daily Living (ADL). The MDS indicated the resident had one stage two pressure ulcer and the treatments included a pressure reducing device for her bed. Review of Resident #60's May 2022 physician orders revealed an order for a low loss air mattress, dated 12/29/21 and an order dated 04/29/22 to cleanse buttocks with peri wash, pat dry, apply Zinc Oxide cream every night shift for wound care, and every two hours as needed if soiled. Review of Resident #60's weekly skin assessment dated [DATE] revealed the resident had a healed stage two pressure wound to her left buttock measuring 0 centimeter (cm) in length (L), 0 cm in width (W) and 0 cm in depth (D). During interview on 05/03/22 at 12:18 P.M., Registered Nurse #328, the wound nurse, stated residents with less than a stage three pressure wound do not require a low loss air mattress. Resident #60's air mattress was discontinued on 04/26/22 when the residents pressure wound was assessed as healed. RN #328 stated the physician order should have been discontinued on 04/26/22. On 05/02/22 at 1:39 P.M., during an interview, Resident #60 revealed the facility removed the low loss air mattress from her bed last week. The resident stated she was informed by the wound nurse Registered Nurse (RN) #328 she no longer needed the air mattress because her wound had healed. On 05/04/22 at 8:47 A.M., during an interview the Director of Nursing (DON) stated Resident #60's order for the low loss air mattress had been discontinued on 04/26/22 and the resident's physician orders had not been updated to reflect the discontinued order. The DON stated the order should have been discontinued on 04/26/22. 2. Review of the medical record of Resident #5 revealed an admission date of 12/19/16. Diagnoses included respiratory failure, dysphagia, alcoholic cirrhosis of liver with ascites, heart failure, end-stage renal disease, dementia with behavioral disturbance, unspecified psychosis, essential hypertension, hypothyroidism, anxiety disorder, feeding difficulties, and major depressive disorder. Review of the quarterly MDS assessment, dated 04/18/22, revealed the resident had a severe cognitive impairment. The resident was assessed as exhibiting fluctuating inattention, disorganized thinking, and altered level of consciousness during the assessment period. The resident was assessed as not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365675 If continuation sheet Page 18 of 33 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 05/13/2022 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 0711 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few rejecting care during the assessment period. The resident was dependent on two staff for bed mobility, transfers, and toileting, and dependent on one staff for eating. Review of physicians orders revealed an order dated 05/22/20 for lipid, depakote, and Thyroid Stimulating Hormone (TSH) level every 6 months. The order was discontinued 10/20/21 and an order was placed the same date for lipid, depakote and TSH level every 6 months. Review of laboratory results dated 04/2020 through 05/04/22 revealed the resident had lipid, TSH, and valproic acid levels completed 08/27/20 and 04/04/22. Interview on 05/04/22 at 11:20 A.M., the DON verified labs were not completed every six months as per the physician's order. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365675 If continuation sheet Page 19 of 33 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 05/13/2022 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to ensure there was enough staff to respond to call lights, provide timely incontinence care, provide assistance with meals and provide treatments. This affected 11 (Residents #45, #34, #42, #33, #24, #68, #10, #64, #26, #5, #63, ) of 25 residents reviewed for staffing. The census was 78. Findings included: 1. During interview on 05/02/22 and 05/03/22, Residents #45, #34, #42, and #24 stated the response time for call lights was long. 2. During observation on 05/03/22 at 7:44 A.M., the call lights for Residents #10, #64 and #68 were on. During observation on 05/03/22 at 8:03 A.M., an unidentified State Tested Nursing Assistant (STNA) said there was no STNA assigned to these resident's hall. She did not stop to answer any of the three call lights. AT 8:13 A.M., Unit Manager UM) #328 came down the hall but did not answer any of the three call lights. Resident #38's call light. Resident #10's call light was answered at 8:21 A.M. Resident #64's light was answered at 8:23 A.M. and Resident #68's light was finally answered at 8:30 A.M. During interview on 05/03/22 at 8:34 A.M., Resident #68 stated it can take up to an hour for staff to answer call lights. Review of policy titled Call Lights: Accessibility and Timely Response, dated 01/02/21, revealed call lights would be directly relayed to a staff member or centralized location to ensure appropriate response. All staff members who see or hear an activated call light are responsible for responding. If a staff member cannot provide what the resident desires, the appropriate staff should be notified. 3. Record review revealed Resident #33 was admitted on [DATE]. Medical diagnoses included diabetes, fibromyalgia, depression, pain, hypertension, dementia without behavioral disturbances. Review of care plan, dated 06/23/21, for Resident #33 revealed she needed activities of daily living (ADL) assistance related to hip replacement. her interventions were to check and change every two hours, change briefs and provide incontinence care. Review of quarterly MDS assessment, dated 04/27/22, revealed Resident #33 was cognitively intact. She required extensive assistance for bed mobility, transfers, and toilet use. She was frequently incontinent of bladder and always incontinent of bowel. Review of the incontinence documentation dated 05/02/22 revealed Resident #33 was changed at 12:31 A.M. During interview on 05/02/22 at 9:55 A.M., Resident #33 stated soaked with urine in her brief and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365675 If continuation sheet Page 20 of 33 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 05/13/2022 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 0725 on her sheets. She said the last time she was changed was at 5:00 A.M. She said this happens all the time. Level of Harm - Minimal harm or potential for actual harm During observation on on 05/02/22 at 10:00 A.M. with State Tested Nursing Assistant (STNA) #392, Resident #33's brief was soaked with urine and the draw sheet and bed sheets were soaked with urine. STNA #392 stated she had not provided incontinent care to Resident #33 since she had come on shift at 7:00 A.M. Residents Affected - Some 4. Record review revealed Resident #26 was admitted on [DATE]. Medical diagnoses included Spina Bifida with hydrocephalus. Review of care plan, dated 02/02/22, revealed Resident #26 needed assistance with ADL care related to Spina Bifida. Interventions were to check for bowel incontinence, change as needed and provide peri-care after elimination. Review of quarterly MDS assessment, dated 03/14/22, revealed Resident #26 was cognitively intact. She required extensive assistance for bed mobility, total dependence for transfers, extensive assistance for toilet use and independent for eating. She used an indwelling urinary catheter and was always incontinent of bowel. Review of incontinence care documentation for Resident #26 revealed she had a bowel movement on 05/02/22 at 12:32 A.M. During observation on 05/02/22 at 10:03 A.M. with STNA #392, Resident #26 was sitting up on the side of the bed and her draw sheet and bed was soaked with urine and stool. Resident #26 stated she doesn't like to wait this long to get changed and said she hadn't been changed since last night and rang her call light sometime ago. During interview on 05/02/22 at 10:10 A.M., STNA #392 confirmed Resident #26 was soiled and the bed was soaked. STNA #392 said Resident #26 had rang her call light light but she was busy. STNA #392 stated she had 26 residents to care for and she had to pass breakfast trays and no one was helping take care of the residents but her. She said this happens all the time where the facility was short staffed and they don't replace the help. Review of the policy titled Incontinence, dated 01/01/21, revealed based on resident's comprehensive assessment, all residents that are incontinent will receive appropriate treatment and services. Residents that incontinent of bladder and bowel will receive appropriate treatment to prevent infections and to restore continence to the extent possible. 5. Review of the medical record of Resident #5 revealed an admission date of 12/19/16. Diagnoses included respiratory failure, dysphasia following unspecified cerebrovascular disease, alcoholic cirrhosis of liver with ascites, heart failure, end-stage renal disease, dementia with behavioral disturbance, unspecified psychosis, essential hypertension, hypothyroidism, anxiety disorder, feeding difficulties, and major depressive disorder. Review of the quarterly MDS assessment, dated 04/18/22, revealed the resident had a severe cognitive impairment. The resident was assessed as exhibiting fluctuating inattention, disorganized thinking, and altered level of consciousness during the assessment period. The resident was assessed as not rejecting care during the assessment period. The resident was dependent on two staff for bed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365675 If continuation sheet Page 21 of 33 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 05/13/2022 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 0725 mobility, transfers, and toileting, and dependent on one staff for eating. Level of Harm - Minimal harm or potential for actual harm Review of the plan of care dated 08/21/21 revealed Resident #5 had an ADL self-care performance deficit related to diagnosis of dementia and CVA. Interventions included to provide extensive assistance of one staff for eating. Review of the care plan dated 02/22/22 revealed Resident #5 had the potential for nutritional deficits related to dysphagia and feeding difficulties. Interventions included to provide one-on-one assist with feeding at all meals. Residents Affected - Some Review of physician orders revealed an order dated 04/13/22 for the resident to have one-to-one assistance with meals. During observation on 05/03/22 at 2:13 P.M., Resident #5 was laying in bed with his eyes closed. His meal tray was observed on his bedside table. The tray was covered and uneaten and the silverware remained clean and wrapped in a napkin. During interview on 05/03/22 at 2:19 P.M., Registered Nurse (RN) #330 verified Resident #5 had not yet received assistance with his meal. RN #330stated his tray had been delivered approximately an hour ago and he was dependent on staff for feeding. RN #330 stated there were four residents on this hall who were dependent on staff for feeding and there was not enough staff available to feed all of them timely. RN #330 further affirmed Resident #5 had not received timely assistance with his meal. During observation on 05/03/22 at 2:25 P.M., an unidentified STNA entered Resident #5's room and began to assist him with eating. 6. Record review revealed Resident #63 was admitted on [DATE]. Diagnoses included acute respiratory failure with hypoxia, epilepsy, lymphedema, weakness, essential hypertension, amyotrophic lateral sclerosis, morbid obesity, chronic peripheral venous insufficiency. Review of the care plan dated 06/14/21 revealed the resident had lymphedema to lower extremities. Interventions included to complete treatments as ordered to lower extremities. Review of the physician orders revealed an order dated 09/02/21 to wrap ace bandages around left leg up to the knee every day shift due to swelling and lymphedema. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/07/22, revealed the resident had intact cognition. The resident did not refuse care. The resident required extensive assistance of two staff for bed mobility, dressing, toileting, and personal hygiene and was totally dependent on two staff for transfers During interview on 05/02/22 at 11:49 A.M., Resident #63 stated nobody wraps his left leg as ordered. Resident #63 stated his legs had not been wrapped in at least three weeks. Concurrent observation revealed edema on both legs and the left leg had more edema. The left leg was not wrapped and no treatment was observed on the leg. During observation on 05/03/22 at 2:05 P.M., Resident #63's left leg was not wrapped. Concurrent interview with the resident and State Tested Nursing Assistant (STNA) #379 verified there were no wraps on Resident #63's left leg. During interview on 05/03/22 at 2:19 P.M., Registered Nurse (RN) #330 stated she thought Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365675 If continuation sheet Page 22 of 33 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 05/13/2022 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some #63's wraps were supposed to be done on night shift because it is too hard to get to it during day shift because she is too busy. During observation on 05/04/22 at 10:33 A.M., Resident #63's leg was not wrapped. Concurrent interview with Resident #63 confirmed his legs were not wrapped. Resident #63 stated nobody had offered to wrap his legs during the last three days. Resident #63 stated he experiences discomfort in his leg more when it is not wrapped. Resident #63 denied pain in his leg at the time of the observation. Review of progress notes dated 05/02/22 through 05/04/22 revealed no evidence of Resident #63 refusing for his legs to be wrapped. Review of the Treatment Administration Record (TAR) revealed Licensed Practical Nurse (LPN) #346 signed the order for Resident #63's left leg ace wraps as complete on 05/04/22. The TAR was not signed off on 05/02/22 or 05/03/22. During observation on 05/05/22 at 9:08 A.M., Resident #63's left leg was not wrapped. Resident #63 affirmed his leg had not been wrapped at any time since observations started on 05/02/22. Resident #63 stated his nurse (LPN #346) yesterday told him she would do it but never got around to doing it. During interview on 05/05/22 at 2:10 P.M., LPN #346 stated she did not wrap Resident #63's legs on 05/04/22. LPN #346 affirmed she signed the TAR off as completed when it was not completed. LPN #346 further affirmed she did not document the rationale for not wrapping Resident #63's legs. Review of the Treatment Administration Record (TAR) revealed Licensed Practical Nurse (LPN) #346 signed the order for Resident #63's left leg ace wraps as complete on 05/04/22. The TAR was not signed off on 05/02/22 nor 05/03/22. Observation and interview on 05/05/22 at 9:08 A.M. revealed Resident #63's left leg was not wrapped. Resident #63 affirmed his leg had not been wrapped at any time since observations started on 05/02/22. Resident #63 stated his nurse (LPN #346) yesterday told him she would do it but never got around to doing it. Interview on 05/05/22 at 2:10 P.M., LPN #346 stated she did not wrap Resident #63's legs on 05/04/22. LPN #346 affirmed she signed the TAR off as completed when it was not completed. LPN #346 further affirmed she did not document the rationale for not wrapping Resident #63's legs. This deficiency substantiates Complaint Numbers OH00131752, OH00131761, OH00131479, OH00114337 and OH00113490. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365675 If continuation sheet Page 23 of 33 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 05/13/2022 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 - Potential for minimal harm Based on personnel file review and staff interview, the facility failed to ensure State Tested Nurse Aide (STNAs) received annual performance review evaluations. This had the potential to affect all 78 residents who reside in the facility. The facility census was 78. Residents Affected - Many Findings include: Review of State Tested Nurse (STNA) #302's personnel file revealed STNA #302 was hired on 07/08/20. Further review of STNA #302's personnel file reviewed STNA #302 had not received an annual performance review evaluation from 07/08/20 to 07/08/21. Review of State Tested Nurse (STNA) #380's personnel file revealed STNA #380 was hired on 01/07/20. Further review of STNA #380's personnel file reviewed STNA #380 had not received an annual performance review evaluation from 01/07/21 to 01/07/22. Review of State Tested Nurse (STNA) #396's personnel file revealed STNA #396 was hired on 04/25/06. Further review of STNA #396's personnel file reviewed STNA #396 had not received an annual performance review evaluation from 04/21/21 to 04/25/22. Review of State Tested Nurse (STNA) #406's personnel file revealed STNA #406 was hired on 01/30/19. Further review of STNA #406's personnel file reviewed STNA #406 had not received an annual performance review evaluation from 01/30/21 to 01/30/22. Interview with the Administrator on 05/05/22 at 12:38 P.M. verified STNA #302, STNA #380, STNA #396 and STNA #406 had not had annual performance evaluations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365675 If continuation sheet Page 24 of 33 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 05/13/2022 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of pharmacy recommendations, staff interview and policy review, the facility failed to ensure pharmacy recommendations were timely addressed by the physician and timely implemented pharmacy recommendations agreed by the physician. This affected four (Residents #5, #31, #45, and #52) of five residents reviewed for unnecessary medications. The facility census was 78. Findings include: 1. Review of the medical record revealed Resident #45 admitted to the facility on [DATE]. Diagnoses included acute and chronic respiratory failure, with hypoxia, dependence on respirator ventilation status, chronic obstructive pulmonary disease, muscle weakness, major depressive disorder, anxiety disorder, insomnia, post traumatic stress disorder, and neuromuscular dysfunction of bladder. Review of Resident #45's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. Resident #45 also required supervision with eating and received anti-anxiety, antidepressant, anticoagulant, antibiotic, diuretic and opioid medications. Review of Resident #45's pharmacy recommendation dated 06/03/21 revealed Resident #45's sertraline 100 milligrams (mg) for depression should be evaluated for a dose reduction. Further review of the pharmacy recommendation dated 06/03/21 revealed the pharmacy recommendation was not addressed or signed by the physician. Review of Resident #45's pharmacy recommendation dated 06/03/21 revealed Resident #45's lorazepam 0.5 mg three times a day for anxiety disorder should be evaluated for a dose reduction. Further review of the pharmacy recommendation dated 06/03/21 revealed the pharmacy recommendation was not addressed or signed by the physician. Review of Resident #45's pharmacy recommendation dated 08/06/21 revealed Resident #45 had been on pantoprazole 40 mg twice a day which was increased to 40 mg. Consider whether to taper a histamine (H2) blocker such as famotidine 20 mg every night or maintenance dose of pantoprazole 40 mg daily. Further review of the pharmacy recommendation dated 08/06/21 revealed the pharmacy recommendation was not addressed or signed by the physician. Review of Resident #45's pharmacy recommendation dated 08/06/21 revealed Resident #45's sertraline 100 mg for depression should be evaluated for a dose reduction. Further review of the pharmacy recommendation dated 08/06/21 revealed the pharmacy recommendation was not addressed or signed by the physician. Review of Resident #45's pharmacy recommendation dated 08/06/21 revealed Resident #45's lorazepam 0.5 mg three times a day for anxiety disorder should be evaluated for a dose reduction. Further review of the pharmacy recommendation dated 08/06/21 revealed the pharmacy recommendation was not addressed or signed by the physician. Review of Resident #45's pharmacy recommendation dated 03/01/22 revealed Resident #45 had been on famotidine 20 mg twice a day since 10/20/21. Consider decreasing to a maintenance dose of famotidine (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365675 If continuation sheet Page 25 of 33 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 05/13/2022 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 20 mg at night. Further review of the pharmacy recommendation revealed the physician agreed with the recommendation to decrease famotidine to 20 mg every day on 03/07/22. Review of Resident #45's physician's order from 10/20/21 to 03/08/22 revealed Resident #45 was ordered famotidine 20 mg give one tablet by mouth two times a day for gastro esophageal reflux disease without esophagitis. Review of Resident #45's physician's order dated 03/17/22 revealed Resident #45 was ordered famotidine 20 mg give one tablet by mouth two times a day for gastro esophageal reflux disease without esophagitis. Interview with the Administrator on 05/04/22 at 8:18 A.M. verified Resident #45's pharmacy recommendations dated 06/03/21, and 08/06/21 were not addressed by the physician. The Administrator also verified Resident #45's famotidine 20 milligrams two times a day was not reduced per the physician's agreement on 03/07/22. 2. Review of the medical record of Resident #05 revealed an admission date of 12/19/16. Diagnoses included respiratory failure, dysphagia, alcoholic cirrhosis of liver with ascites, heart failure, end-stage renal disease, dementia with behavioral disturbance, unspecified psychosis, essential hypertension, hypothyroidism, anxiety disorder, feeding difficulties, and major depressive disorder. Review of the quarterly MDS assessment dated [DATE] revealed the resident had a severe cognitive impairment. The resident was assessed as exhibiting fluctuating inattention, disorganized thinking, and altered level of consciousness during the assessment period. The resident was assessed as not rejecting care during the assessment period. The resident was dependent on two staff for bed mobility, transfers, and toilet use, and dependent on one staff for eating. Review of a pharmacy recommendation note to the Attending Physician/Prescriber dated 09/01/21 revealed Resident #05 was receiving a multi-vitamin with minerals since 06/24/17. Recommendations were made to evaluate the need to continued use and consider discontinuing the multi-vitamin with minerals. The physician/prescriber response was blank. Review of the physician orders revealed the multi-vitamin with minerals was discontinued on 01/28/22. Interview on 05/04/22 at 1:00 P.M., the Director of Nursing (DON) verified the pharmacy recommendation made on 09/01/21 were not addressed timely. 3. Review of the medical record of Resident #52 revealed an admission date of 12/23/20. Diagnoses included paroxysmal atrial fibrillation, chronic obstructive pulmonary disease, acute respiratory failure, NSTEMI, reduced mobility, hypothyroidism, gastro-esophageal reflux disease, anxiety disorder, nicotine dependence, bipolar disorder, atherosclerotic heart disease, and essential hypertension. Review of the quarterly MDS assessment dated [DATE] revealed the resident had intact cognition. Review of the pharmacy recommendation notes to Attending Physician/Prescriber dated 06/02/21 revealed Resident #52 was taking Lorazepam (anxiolytic) 0.5 milligrams (mg) three times per day for anxiety disorder, Depakote 125 mg two times per day for bipolar disorder, and Celexa (antidepressant) 20 mg daily for depression. Recommendations were made to evaluate the current doses and consider a dose (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365675 If continuation sheet Page 26 of 33 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 05/13/2022 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 0756 reductions. The physician/prescriber responses were blank. Level of Harm - Minimal harm or potential for actual harm Review of the pharmacy recommendations notes to Attending Physician/Prescriber dated 08/09/21 revealed Resident #52 was taking Lorazepam (anxiolytic) 0.5 milligrams (mg) three times per day for anxiety disorder, Depakote 125 mg two times per day for bipolar disorder, and Celexa (antidepressant) 20 mg daily for depression. Recommendations were made to evaluate the current doses and consider a dose reductions. The physician/Prescriber responses were blank. Residents Affected - Some Review of the pharmacy recommendations notes to Attending Physician/Prescriber dated 09/02/21 revealed Resident #52 was taking Lorazepam (anxiolytic) 0.5 milligrams (mg) three times per day for anxiety disorder, Depakote 125 mg two times per day for bipolar disorder, and Celexa (antidepressant) 20 mg daily for depression. Recommendations were made to evaluate the current doses and consider a dose reductions. The physician responded on 09/08/21. Interview on 05/04/22 at 8:45 A.M., the DON verified there was no evidence of the pharmacy recommendations dated 06/02/21 and 08/09/21 until 09/08/21. Review of the pharmacy recommendations note to Attending Physician/Prescriber dated 10/04/21 revealed Resident #52 had orders for a Daily vite (vitamin supplement) since 01/08/21. Recommendations were made to evaluate the need for continued use and consider discontinuing the medication. The physician/Prescriber response was blank. Review of the physician orders revealed an order for Daily vite tablet (multiple vitamin) one tablet was discontinued 12/13/21. Interview on 05/04/22 at 1:00 P.M., the DON verified the physician/Prescriber response to the pharmacy recommendation dated 10/04/21 was blank and the Daily vite tablet was not discontinued until 12/13/21. 4. Review of the medical record revealed Resident #31 was admitted to the facility on [DATE]. Diagnoses included congestive heart failure, cerebrovascular disease, anxiety disorder, diabetes, and weight loss. Review of the comprehensive MDS assessment dated [DATE] revealed the resident had severely impaired cognition. Review of physician orders revealed Resident #31 received Abilify (an antipsychotic medication), and Sertraline (antidepressant medication) for a diagnosis of anxiety disorder. Review of the pharmacy recommendations dated 11/04/21 and 05/02/22, revealed the pharmacist reviewed medications for Resident #31 and made new recommendations. Review of the documentation provided by the DON revealed no pharmacy recommendation sheets for 11/04/22 and 05/02/22 and no physician response to a a pharmacy recommendation of 11/04/22 and 05/02/22. Review of the facility policy titled, Medication Regimen Review and Reporting, dated 09/2018 revealed pharmacy recommendations shall be acted upon within 30 calendar days and the rationale for accepting or rejecting the recommendation shall be documented in the medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365675 If continuation sheet Page 27 of 33 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 05/13/2022 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, observation, staff interview and policy review the facility failed to ensure insulin was administered without error. This affected one (Resident #31) of three residents observed for medication administration. The facility census was 78. Residents Affected - Few Findings included Review of the medical record review for Resident #31 revealed an admission date of 10/17/19. Diagnoses included diabetes. Review of the physician orders dated 09/15/21 revealed Novolog Solution 100 unit milliliters (ml) (Insulin Aspart) to inject five units subcutaneously before meals related to diabetes. Observation of the medication administration on 05/04/22 at 12:10 P.M. revealed Licensed Practical Nurse (LPN) #345 pulled out the Novolog pen and placed a needle on the end of the pen and dialed up five units of the insulin and administered the insulin to Resident #31. Interview with LPN #345 on 05/04/22 at 12:15 P.M. revealed she was not aware she was supposed to expel two units from the insulin pen to ensure the pen was working correctly. She she verified she had not expelled two units of insulin before administering it to Resident #31. Review of policy titled Subcutaneous Insulin dated 01/22/22 revealed to perform a safety test first before each injection. Performing the safety test ensures that you get the accurate dose by ensuring the pen and needle work properly. Select two dose units on the dosage selector and hold the pen with the needle pointing upward and tap the insulin reservoir to ensure any air bubbles rise to the top of the needle, push the insulin button in all the way and check to see if the insulin comes out and if so you may dial to the the physician ordered dosage. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365675 If continuation sheet Page 28 of 33 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 05/13/2022 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 0790 Provide routine and 24-hour emergency dental care for each resident. 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, staff and resident interview and policy review, the facility failed to ensure a resident received routine dental services. This affected one (Resident #45) of three residents reviewed for dental services. The facility census was 78. Residents Affected - Few Findings include: Review of the medical record revealed Resident #45 was admitted to the facility on [DATE]. Diagnoses included acute and chronic respiratory failure, with hypoxia, dependence on respirator ventilation status, chronic obstructive pulmonary disease, muscle weakness, major depressive disorder, anxiety disorder, insomnia, post traumatic stress disorder, and neuromuscular dysfunction of bladder. Review of Resident #45's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. Resident #45 was not reported to have a broken or loosely fitting full or partial denture. Review of Resident #45's dental visits from 06/04/20 to 05/05/22 revealed Resident #45 had not had any dental visits while at the facility. Review of Resident #45's dental care plan dated 03/19/22 revealed Resident #45 had an oral or dental health problem and Resident #45 had upper dentures. Interventions included coordinate arrangements for dental care and transportation as needed and as ordered. Observation of Resident #45 on 05/02/22 at 10:00 A.M. revealed Resident #45 was missing her bottom front teeth. Resident #45's remaining bottom teeth were brown in color. Interview with Resident #45 on 05/02/22 at 10:00 A.M. revealed Resident #45 had not been seen by the dentist since she was admitted to the facility. Interview with the Administrator on 05/04/22 at 2:44 P.M. verified Resident #45 did not have any dental visits since she was admitted to the facility on [DATE]. Observation on 05/05/22 at 11:43 A.M. revealed Resident #45 showed Registered Nurse (RN) #334 her upper dentures and her natural bottom teeth. Resident #45 told RN #334 she had cracked bottom teeth in addition to missing bottom teeth. Interview on 05/05/22 at 11:43 A.M. with RN #334 verified Resident #45 had upper dentures and had missing bottom teeth. RN #334 was unaware of Resident #45 receiving any dental visits while at the facility. Review of the facility policy titled Dental Services, dated 01/01/22 revealed routine dental services were available at the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365675 If continuation sheet Page 29 of 33 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 05/13/2022 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, interview and policy review, the facility failed to ensure the menu was followed and provide the correct puree diet food portion. This affected one (Resident #31) of three residents who received a physician ordered puree diet. The facility census was 78. Findings include: Review of the medical record revealed Resident #31 was admitted to the facility on [DATE]. Diagnoses included congestive heart failure, cerebrovascular disease, anxiety disorder, diabetes, and weight loss. Review of the Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed the resident had severely impaired cognition. Review of the physician orders dated May 2022 revealed Resident #31 had a puree consistency diet order. Observation on 05/04/22 at 11:55 A.M. during lunch tray line, revealed Resident #31 received three ounces of meat instead of the menu planned four ounces of meat. The portion of puree bread was an approximate served from an incorrect sized scoop. Interview on 05/04/22 at 12:00 P.M., with [NAME] #10 verified the served puree meat portion was one ounce less than the puree meat planned on the spreadsheet and the served puree bread portion was an estimate. [NAME] #10 stated she did not have the correct sizes of scoops for the puree meat or the puree bread. Interview on 05/04/22 at 12:05 P.M., the Regional Diet Manger (RDM) # 422 verified [NAME] #10 used the incorrect scoops for puree meat and puree bread, as listed on spreadsheet for Resident #31. RDM #422 provided an additional one ounce of puree meat for Resident #31. Review of the facility policy titled Spreadsheets and Portion Control, undated, revealed spreadsheets need to be read and followed for every meal. The proper serving utensil must be used to ensure adequate portion control. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365675 If continuation sheet Page 30 of 33 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 05/13/2022 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 - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and policy review the facility failed to maintain a sanitary kitchen and acceptable food storge practices. This had the potential to affect 72 out of 72 residents who received food from the kitchen. The facility census was 78. Findings include: Tour of kitchen on 05/02/22 at 8:50 A.M. revealed there were no towels at the employee hand washing sink and there was a 12 inch by six inch hole in the wall behind the hand washing sink. There was thawing wrapped meat in a pan of water. The reach in refrigerator and freezer had no temperature log completed after the date of 04/28/22 and had no inside thermometers. There were approximately 10 to 15 containers of covered food bowls without labels and dates. The dry storage shelving and pan storage shelves in the tray line contained debris of dried food. Two trash containers, on carts, had dried food debris on the wheels and up the sides of the trash containers. The walk-in refrigerator and the walk in freezer had no inside thermometer, and a last date of 04/30/22 of logged temperatures on the outside door. An unidentifiable meat was in a bag, unlabeled and undated. There were 10 pitchers of some type of liquid unlabeled and undated. In the walk-in refrigerator, a crate of individual milk cartons were stored directly on the floor. In the walk-in freezer, a 50-pound sealed bag of ice was stored directly on the floor. Interview on 05/02/22 at 9:05 A.M., the Diet Manger (DM) #418 verified the hand washing area should have hand towels, food should be labeled and dated, the meat should be thawed under running water, and the food in the walk-in refrigerator and freezer should be stored off the floor. Diet Manger #418 verified the kitchen equipment and storage areas needed cleaned. Observation on 05/05/22 at 7:58 A.M. with the Director of Nursing (DON) revealed Unit 300 resident pantry ice machine had an orange, slimy appearing substance on the interior ice bin dispenser. Approximately 10 cups of ice were in the bottom of the ice machine. The DON stated the ice machine was not working, and the ice had been stored in the nonfunctioning ice machine for resident ice water pass. The DON verified the ice should not be stored in the soiled ice machine. There were 10 unlabeled and undated food containers in the resident refrigerator. There were two containers of chicken salad, dated 04/31/22 and 03/16/22. The DON verified the chicken salad was expired and should not be consumed. Review of policy titled Ice Storage dated, 01/01/21, revealed the ice machine will be maintained to assure a safe and sanitary supply of ice. Review of the policy titled Food Receiving and Storage dated 01/01/22 revealed foods will be received and stored in a manner to comply with safe food handling practices including food kept off the floor, refrigeration will have inside thermometers, and food stored will be labeled and dated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365675 If continuation sheet Page 31 of 33 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 05/13/2022 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, review of personnel files, staff interview, and policy review the facility failed to ensure the facility implemented contact precautions for a resident with methicillin resistant staphylococcus aureus (MRSA). This affected one resident (#42) out of two residents reviewed for transmission based precautions. The facility identified 12 residents that were assisted by respiratory therapists. In addition, the facility failed to implement their tuberculosis control plan and ensure all newly hired employees were tested for tuberculosis. This had the potential to affect all 78 residents who resided in the facility. The facility census was 78. Residents Affected - Many Findings include: 1. Review of the medical record revealed Resident #42 was admitted to the facility on [DATE]. Diagnoses included acute and chronic respiratory failure, dependence on respirator ventilator status, tracheostomy status, type two diabetes mellitus, major depressive disorder, aphonia, other dysphagia, weakness, and atopic dermatitis. Review of Resident #42's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and required extensive assistance with bed mobility, dressing and personal hygiene. Resident #42 required supervision with eating and transfers did not occur. Resident #42 required total dependence with toilet use. Review of Resident #42's physician's order dated 03/29/22 and discontinued on 05/03/22 revealed Resident #42 was on contact precautions every day and night shift for methicillin-resistant staphylococcus aureus (MRSA). Observation of the facility on 05/02/22 at 9:37 A.M. revealed Resident #42 had a sign on the door to her room that stated Resident #42 was on contact precautions and a gown, gloves and mask should be worn. Further observation of the facility revealed Respiratory Therapist (RT) #358 was in Resident #42's room while wearing a KN95 mask, a face shield and gloves. RT #358 was not wearing a gown. RT #358 was observed giving Resident #42 a spoon and took her coffee cup and washed it out in the bathroom. RT #358 then removed her gloves and washed her hands in Resident #42's bathroom. RT #358 then proceeded to go back into Resident #42's room without a gown and gloves on and give Resident #42 a bag of her personal belongings that was in her room. Interview with RT #358 on 05/02/22 at 9:37 A.M. verified she was in Resident #42's room and was not wearing a gown. RT #358 also verified she took her gloves off in Resident #42's room and then proceeded to give Resident #42 a bag of items while she was not wearing gloves. RT #358 also verified Resident #42 was on contact precautions for a wound infection on her foot. Review of the facility's undated list of residents that were assisted by respiratory therapists revealed 12 residents (#01, #12, #16, #20, #30, #36, #44, #45, #50, #56, #322 and #323) that were assisted by respiratory therapists. Review of the facility policy titled Transmission Based Precautions, dated 08/13/20 revealed an order for isolation will be obtained for residents who are known or suspected to be infected or colonized with infectious agent that requires additional controls to prevent transmission immediately. The order for isolation will specify the type of isolation and the reason for isolation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365675 If continuation sheet Page 32 of 33 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 05/13/2022 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 Residents Affected - Many 2. Review of State Tested Nurse Aide (STNA) #390's personnel file revealed STNA #390 was hired on 09/01/21. Further review of STNA #390's personnel file revealed STNA #390 had not received a first or second step tuberculosis (TB) test upon hire. Review of State Tested Nurse Aide (STNA) #394's personnel file revealed STNA #394 was hired on 10/13/21. Further review of STNA #394's personnel file revealed STNA #394 had not received a first or second step tuberculosis (TB) test upon hire. Review of Maintenance Director #304's personnel file revealed Maintenance Director #304 was hired on 10/04/21. Further review of Maintenance Director #304's personnel file revealed Maintenance Director #304 had not received a first or second step tuberculosis (TB) test upon hire. Review of Licensed Practical Nurse (LPN) #375's personnel file revealed LPN #375 was hired on 09/07/21. Further review of LPN #375's personnel file revealed LPN #375 had not received a first or second step tuberculosis (TB) test upon hire. Review of Respiratory Therapist (RT) #351's personnel file revealed RT #351 was hired on 10/27/21. Further review of RT #351's personnel file revealed RT #351 had not received a first or second step tuberculosis (TB) test upon hire. Review of Registered Nurse (RN) #325's personnel file revealed RN #325 was hired on 06/30/21. Further review of RN #325's personnel file revealed RN #325 had not received a first or second step tuberculosis (TB) test upon hire. Review of Registered Nurse (RN) #328's personnel file revealed RN #328 was hired on 06/30/21. Further review of RN #328's personnel file revealed RN #328 had not received a first or second step tuberculosis (TB) test upon hire. Interview with the Administrator on 05/05/22 at 12:38 P.M. verified State Tested Nurse Aide (STNA) #390, STNA #394, Maintenance Director #304, Licensed Practical Nurse (LPN) #375, Respiratory Therapist #351, Registered Nurse (RN) #325 and RN #328 had not received two step tuberculosis tests upon hire. Review of the facility policy titled Tuberculosis Program, dated 01/01/21 revealed all staff should have baseline tuberculosis screening. A tuberculosis test will be conducted using a mantoux tuberculin skin test in a series of two given one to two weeks apart. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365675 If continuation sheet Page 33 of 33