Inspection·March 19, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm other with dignity and respect as well as care for each resident in a manner and in an environment or enhances residents quality of life. This deficiency represents non-compliance investigated under Complaint Number OH00150936. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365675 If continuation sheet Page 2 of 17 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 03/19/2024 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 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interviews, observations, and review of the facility policy, the facility failed to provide activities to the residents. This affected two (#73 and #74) of five residents reviewed for activities. The facility census was 76. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #73 revealed an admission date 02/14/23. Diagnoses included pressure ulcer, paraplegia, chronic obstructive pulmonary disease, and bipolar disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #73 was cognitively intact. Resident #73 was dependent on staff for bed mobility and transfers. Resident #73 used a wheelchair with staff at the facility to get to room or activities. Review of the plan of care dated 03/01/24 revealed Resident #73 had risks for altered activity patterns or pursuits related to her current medical condition. Interventions included to allow resident to make choices or decisions about their preferred activity pursuits, encourage to attend and participate in activity programs at highest function, and offer supplies for independent activities as needed. Review of the activity documentation date 03/06/24 revealed Resident #73 watched television and had salon appointment. Review of the facility monthly activity calendar revealed on 03/06/24, the activities scheduled were as follows: 11:00 A.M. new and views, 12:00 P.M. pre-meal activity, Saint [NAME] Day craft, 2:00 P.M. popsicle pass, 4:00 P.M. music and dinning, and 5:30 P.M. movie and a snack. Interview on 03/06/24 at 4:54 P.M. with Resident #73 who stated she had not played BINGO for weeks. Resident #73 stated she was not offered activities today. Resident #73 stated she did not get offered a popsicle today or the Saint [NAME]'s Day craft. Resident #73 stated she was unable to be up longer than two hours a day and had told a facility employee she wanted to play BINGO in her room over the telephone. Resident #73 had stated the last time she had played BINGO at the facility was on 02/22/24. Resident #73 stated Activity Director (AD) #399 never asked her to play BINGO. Interview on 03/06/24 at 5:00 P.M. with AD #399 stated that she had no help with activities at the facility. The last activity aide resigned on 12/20/23. AD #399 stated she did do the Saint [NAME] Day craft earlier that day (03/06/24) and also asked residents if they wanted a popsicle for afternoon snack. AD #399 stated she did not ask all residents at the facility to participate in the craft today or receive a popsicle. AD #399 stated she had never asked Residents' #73 if they wanted to get up out of their bed, go to activities, or have a popsicle in their room. AD #399 stated she did not run out of popsicles and had stock in freezer. Observation on 03/06/24 at 5:05 P.M. of the AD #399 freezer in her room with 50 or more popsicles in freezer. AD #399 stated she had not been asking Resident #73 to BINGO because she did not have a telephone that worked to call her in her Resident #73's room, when she was hosting BINGO in dining room with other residents. Interview on 03/07/24 at 11:00 A.M. with the Administrator stated the facility did have a portable phone at all the nursing stations. The Administrator stated AD #399 could have used the portable (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365675 If continuation sheet Page 3 of 17 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 03/19/2024 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 0679 Level of Harm - Minimal harm or potential for actual harm telephone to ensure Resident #73 was able to participate in BINGO. The Administrator stated she was in the process of hiring someone to help with activities at the facility. 2. Review of the medical record for Resident #74 revealed an admission dated 01/16/20. Diagnoses included acute and chronic respiratory failure, cerebral palsy, morbid obesity, and acute kidney failure. Residents Affected - Few Review of the MDS assessment dated [DATE] revealed Resident #74 was severely cognitively impaired. Resident #74 was dependent on staff for bed mobility and transfers. Review of the plan of care dated 02/28/24 revealed that Resident #74 was at risk for altered activity patterns and pursuits related to anxiety, bedbound, confusion, depression, disinterest, frequent naps or sleeping during the day, and impaired mobility. Interventions included friendly visits from staff and volunteers as resident will allow, involve resident in simple or structured activities with cues and adaptation, observe for impact of medical problems on activity participation, and provide resident with an activity calendar. Review of the facility's monthly activity calendar revealed on 03/06/24, the activities scheduled were as follows: 11:00 A.M. new and views, 12:00 P.M. pre-meal activity, Saint [NAME] Day craft, 2:00 P.M. popsicle pass, 4:00 P.M. music and dinning, and 5:30 P.M. movie and a snack. Review of the activity documentation date 03/06/24 revealed Resident #74 watched movies. Observation on 03/06/24 revealed Resident #74 had been watching television at 9:09 A.M., 10:20 A.M., 1:40 P.M., and 4:30 P.M. Interview on 03/06/24 at 4:42 P.M. with State Tested Nursing Aide (STNA) #234 stated she did not see Activity Director (AD) #399 in her hall today. STNA #234 stated sometimes the residents on her hall do not get offered activities, the entire day. Interview on 03/06/24 at 4:48 P.M. with Resident #74 stated she did not get offered to participate in activities for the Saint [NAME] Day craft or get offered a popsicle today. Resident #74 stated she wanted to get out of bed and participate in activities. Resident #74 stated she mostly does watch television. Interview on 03/06/24 at 5:00 P.M. with AD #399 stated that she had no help at the facility. The last activity aide resigned on 12/2023. AD #399 stated she did do the Saint [NAME] Day craft earlier that day (03/06/24), and also asked residents if they wanted a popsicle for afternoon snack. AD #399 stated she did not ask all residents at the facility to participate in craft today or receive a popsicle. AD #399 verified she had never asked Resident #74 if they wanted to get up out of their bed, go to activities, or have a popsicle in their room. AD #399 stated she did not run out of popsicles and had stock in freezer. Review of the facility policy titled Resident Self Determination and Participation in Activities dated 10/30/23 revealed resident preferences and interests shall be accommodated. Strategies to make accommodations shall be documented in the resident's care plan that included scheduling therapy sessions around resident's favorite television show, getting resident out of bed in time for preferred activities, allowing resident to stay in bed longer in order to preserve energy for activity participation. The resident had the right to choose activities, schedules, health care, and providers of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365675 If continuation sheet Page 4 of 17 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 03/19/2024 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 0679 health care services consistent with his or her interests, assessments, and plan of care. Level of Harm - Minimal harm or potential for actual harm This deficiency represents non-compliance investigated under Complaint Number OH00151120. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365675 If continuation sheet Page 5 of 17 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 03/19/2024 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 - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure a resident received the appropriate care and services for a treatment change to a nephrostomy tube. This resulted in Actual Harm to Resident #42 when a registered nurse utilized scissors to cut a dressing off and accidentally cut Resident #42's nephrostomy tube. Resident #42 had to undergo a surgical procedure to put the nephrostomy tube back into the right kidney and be monitored at the hospital for seven days. This affected one of three residents reviewed for an ostomy tube. Residents Affected - Few Findings include: Review of Resident #42's medical record revealed an admission date of 02/14/24. Diagnoses included neurogenic bladder disorder and depression. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 was severely cognitively impaired. Resident #42 was dependent on staff for transfers, personal care, and bed mobility. Review of the plan of care dated 02/17/24 revealed Resident #42 had bilateral nephrostomy tubes related to neurogenic bladder. Interventions were to observe signs and symptoms of urinary tract infection, change in mental status, fever, and blood in urine. Keep tubing free of kinks and twists. Maintain the drainage bag below the bladder level. Notify and report signs of peri-area redness, irritation, skin excoriation, and skin breakdown to the physician. Review of the physician order dated 02/22/24 for Resident #42 revealed to cleanse the right and left nephrostomy sites with soap and water, then apply four by four split gauze every night shift. Review of the progress note dated 03/03/24 documented by Registered Nurse (RN) #140 revealed RN #140 notified Nurse Practitioner (NP) #118 and received a new order to send Resident #42 to the local hospital due to right side nephrostomy tube disconnected. Review of the hospital document dated 03/03/24 through 03/09/24 revealed Resident #42 was admitted to the hospital due to an accidental cutting of nephrostomy tube. The urology department was consulted and recommended Interventional Radiology replacement of right nephrostomy tube. Resident #42 was admitted to hospital for the procedure, and to the telemetry unit for monitoring. Interview on 03/12/24 at 1:41 P.M. with RN #140 stated Resident #42's nephrostomy tube was tangled with tape and she could not get to the four-by-four gauze dressing to observe the skin and clean at the tubing site. RN #140 stated she cut the tape off the right nephrostomy tube accidentally when she was trying to cut the tape free from the tangled tubing, to get to the four-by-four gauze taken off and to cleanse the peri wound area at the external tubing of right abdomen. RN #140 stated she did tape the cut tubing back together to assist in closing off the open tubing. RN #140 stated she called the nurse practitioner. RN #140 stated she got an order to send Resident #42 to the hospital for evaluation of the right side nephrostomy. Interview on 03/12/24 at 1:45 P.M. with the Director of Nursing (DON) stated she was never notified about Resident #42's nephrostomy tube being cut and retaped back. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365675 If continuation sheet Page 6 of 17 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 03/19/2024 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 Level of Harm - Actual harm Residents Affected - Few Interview on 03/12/24 at 5:14 P.M. with NP #118 stated RN #140 should not have used scissors to remove the tape off of Resident #42's dressing and the injury was preventable to Resident #42. NP #118 verified Resident #42 had to be sent to the emergency room and did have a procedure for guided nephrostomy to place back into the right kidney. NP #118 stated there was no complication, but Resident #42 was admitted to the hospital for monitoring. Review of the facility policy titled Nephrostomy and Cystostomy Tube Care and Maintenance, dated 10/20/20, revealed the nurses were to monitor resident for discomfort associated with the tube, record output from each tube, specify location of output, document abnormalities, and report to physician immediately. This deficiency represents non-compliance investigated under Complaint Number OH00151795. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365675 If continuation sheet Page 7 of 17 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 03/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Milford 5900 Meadowcreek Drive Milford, OH 45150 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, and policy review, the facility failed to ensure a resident was transferred safely using a mechanical lift with two-person assistance as specified in the care plan. This affected one (#26) of three residents reviewed for accident hazards. The facility identified 26 residents that utilize mechanical lifts for transfers. The facility census was 72. Findings include: Review of the Resident #26's medical record revealed an admission date of 02/09/24, with diagnoses including: generalized idiopathic epilepsy and epileptic syndromes, dependence on renal dialysis, end stage renal disease, dependence on wheelchair, cognitive communication deficit, major depressive disorder, and generalized anxiety disorder. Review of Resident #26's admission change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident to be cognitively intact and Resident #26 was independent with eating. Resident #26 also required set up assistance with oral hygiene, personal hygiene, upper body dressing, and moderate assistance with toileting, rolling left and right, sitting to lying, lying to sitting, sitting to standing, chair or chair or bed to chair transfers, and toilet transfers. Resident #26 required maximal assistance with showering, and lower body dressing, and was dependent with putting on and taking off footwear. Review of Resident #26's activities of daily living care plan revised on 04/09/24 revealed Resident #26 required two-person assistance and the use of a mechanical lift with transfers. Observation of the facility on 04/17/24 at 11:53 A.M., revealed State Tested Nurse Aide (STNA) #59 was in Resident #26's room. Resident #26 was observed raised up in a mechanical lift and STNA #59 was observed pushing Resident #26 in the mechanical lift towards his bed. STNA #59 was the only staff member present in Resident #26's room, when STNA #59 was pushing Resident #26, while he was raised up in the mechanical lift. Interview on 04/17/24 at 11:53 A.M., with Licensed Practical Nurse (LPN) #26 verified STNA #59 was pushing Resident #26 in a mechanical lift while Resident #26 was raised up in the lift, alone with the assistance of no other staff. LPN #26 verified Resident #26 required two-person assistance with mechanical lift transfers and that two staff members were required during the use of mechanical lifts with all residents. Review of the policy titled, Safe Lifting and Movement of Residents, dated 10/30/20 revealed two staff shall be present to assist during all patient lifts utilizing mechanical lifts. This deficiency is a to then incidental finding discovered during the post survey revisit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365675 If continuation sheet Page 8 of 17 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 03/19/2024 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Residents Affected - Few Based on medical record review, review of video camera footage, review of the ventilator manual, family and staff interview, and review of the facility policy, the facility failed to timely respond to a resident's ventilator alarm. This affected one (Resident #34) of three residents reviewed for ventilators. The facility identified five residents who were on a ventilator. The facility census was 76. Findings include: Review of the medical record for Resident #34 revealed an admission date 02/06/24. Diagnoses included acute and chronic respiratory failure with hypercapnia, acute pulmonary insufficiency, and dependence on respirator (ventilator). Review of the Minimum Data Set (MDS) assessment date 02/13/24 revealed Resident #34 was cognitively intact. Resident #34 was dependent on staff for personal care dependent on a ventilator. Review of the plan of care dated 02/06/24 revealed Resident #34 was ventilator dependent related to acute on chronic respiratory failure, acute pulmonary insufficiency, and emphysema. The vent settings were 400 mode Assist Control (A/C) respiratory rate (RR), 16 Positive End-Expiratory Pressure (PEEP) five, with tracheostomy [NAME] number six. Interventions included keep head of the bed elevated above 30 degrees unless providing care, maintain a spare trach at bedside, observe for changes in respiratory status that included signs and symptoms of upper respiratory infection, observe for changes in respiratory rate or depth and use of accessory muscles. Review of the physician order dated 02/07/24 revealed Resident #34 had an order for oxygen to run at one to 10 liters per minute via tracheostomy everyday continuous. Resident #34 also had an order for setting of the ventilator at 400 Mode A/C RR: 16 PEEP: 5 F102: Adjust oxygen to maintain oxygen saturation of above 89% every day, and every shift. Review of the progress note dated 02/29/24 documented by Respiratory Therapist (RT) #144 stated Resident #34 was reconnected to vent to the tracheostomy two times during the shift; the second time the vent disconnected. RT #144 stated manual bagging was needed, due to low oxygenation of 75%, heart rate 42 beats per minute, easily arousal occurred, and increase of oxygenation was given quickly. Resident #34's saturation oxygen level came to 100%, heart rate 75 beats per minute before paramedics arrived. The family called the paramedics, and the family arrived 10 minutes following. Review of the progress note dated 02/29/24 documented by Licensed Practical Nurse (LPN) #187 revealed around 10:45 P.M. on 02/28/24, RT #144 had called out for help. LPN #187 had entered Resident #34's room and RT #144 placed ambu bag onto tracheostomy site, that gave a couple of breaths and stated Resident #34 was fine, and her oxygen saturation was in the 90s at that time. The emergency medical team arrived shortly after stating that the resident's family had placed a call and then began to assess Resident #34. The family arrived minutes later. The family wanted Resident #34 to go to the emergency room, but Resident #34 refused. Emergency medical team and family discussed with Resident #34 who continued to refuse to go. The progress note dated 02/29/24 revealed on 02/29/24 at 1:00 A.M., the family requested to obtain (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365675 If continuation sheet Page 9 of 17 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 03/19/2024 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #34's vital signs which the results were: blood pressure 84/48, heart rate 82 beats per minute, respiration was 20 beats per minute, and saturation of oxygen was 98%. Family requested Resident #34 go out to hospital due to being confused. Resident #34 was sent to local hospital. Review of the video footage in Resident #34's room, provided by Resident #34's family, with the Administrator and Director of Nursing revealed on 02/28/24 at 11:00 P.M., Resident #34 was laying in her bed on her back, elevated, and moving and the tracheostomy tube end was disconnected. The ventilator detached sounding the ventilator alarm in a loud continuous beeping for staff to address. The ventilator sounded for 11 minutes until 11:11 P.M. Resident #34 was still moving and had difficulty in taking breaths. Resident #34 used accessory muscles to breathe deeper. There was no staff in the room during the 11 minutes when the ventilator alarm was sounding. RT #144 came into the room at 11:11 P.M. to Resident #34's left side bed. RT #144 was in between the resident and the vent. Resident #34 was not moving, and eyes were shut. RT #144 immediately hooked tracheostomy tube back up. RT #144 set up the nonrebreather oxygen tank in the room. RT #144 shouted for help. LPN #187 came into Resident #34's room at 11:12 P.M. Interview on 03/11/24 at 10:00 A.M. with the family member of Resident #34 stated the video started recording the night of 02/28/24 at 11:00 P.M. The camera in the room was sound activated. The family member stated she tried to call the facility at the nursing station, and no one answered, so she called 911 emergency and sent the squad to check on her. Interview on 03/11/24 at 1:50 P.M. with the Administrator and Director of Nursing (DON) verified Resident #34's ventilator alarmed for 11 minutes before the staff responded to the alarm. The Administrator and DON verified Resident #34's ventilator alarm should have been responded to immediately and Resident #34 should not have been detatched for 11 minutes. Interview on 03/11/24 at 5:12 P.M. with RT #111 stated most residents who were on ventilators were weaned off during the day at the facility. RT #111 stated after three minutes a resident being off the ventilator, the resident starts suffering brain anoxia. RT #111 stated the beeping ventilator should have been assessed immediately to keep breathing patent. Interview on 03/11/24 at 5:48 P.M. with RT #144 stated when she was told to come to Resident #34 room, RT #144 stated Resident #34's oxygen saturation was 75%. RT #144 stated Resident #144 was unarousable and still had a pulse. RT #144 stated she used the ambu bag with oxygen from an oxygen tank that filled the ambu bag with oxygen. RT #144 stated Resident #34 had disconnected again at tracheostomy with ventilator tubing that came off again. RT #144 stated Resident #34's ventilator tubing had come off several times that night. RT #144 stated she did not see any other staff on the floor. Resident #34 was doing good the first time the vent tubing came off; She was talking and awake. RT #144 stated that she had placed an additional connector piece at the tracheostomy to help keep the tubing from popping off. RT #144 stated the family had called the police due to the facility not answering the phone. RT #144 stated the floor had many vents that night and she was in another room with a vent resident assessing her with her breathing. Review of the ventilator manual dated 03/10/11 revealed the [NAME] Trilogy 100 Ventilator manual stated to respond immediately to any alarm it may indicate a potentially life-threatening condition. Review of the facility policy titled Ventilator Unit-General dated 06/27/16 revealed the policy established the minimum guidelines for respiratory and licensed nursing care for residents who are on ventilator and tracheostomy care dependent. While the resident was on mechanical ventilation, assess (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365675 If continuation sheet Page 10 of 17 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 03/19/2024 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and document the following every four to six hours or as ordered by physician the following: pulse rate, respiration rate, breath sounds, color, and consistency of secretions (if suctioning was indicated), oxygen saturation, ventilator settings, and alarms. Visual checks are done every two hours and documented. If the resident was off the mechanical ventilator, assess and document a tracheostomy assessment every four to six hours in its place with the following: oxygen delivery device and liter flow, oxygen saturation, breath sounds, pulse rate, respiratory rate, color, and consistency of secretions (if suctioned). Ventilators alarms are the priority and are responded to immediately. The deficient practice was corrected on 03/07/24 when the facility implemented the following corrective actions: • On 02/29/24, the Director of Nursing (DON) assessed the five residents who were on a ventilator to ensure the care plans, physician orders, RT notes, and assessments were correct. No issues were found. • On 02/29/24, the DON/designee educated all staff on responding to ventilator alarms and call lights. The DON/designee educated all staff on communicating expectations prior to leaving the floor and/or taking a break. • On 02/29/24, an Ad Hoc Quality Assurance and Process Improvement was held with the Administrator, DON and Medical Director #500 regarding the incident with Resident #34 and to discuss the facility's corrective action plan. • On 03/01/24, the respiratory therapist assessed all five residents on a ventilator to ensure they were properly connected to the ventilator. • On 03/01/24, the DON/designee will complete ventilator alarm drills every day for one week. Then randomly three times a week for four weeks. • Beginning on 03/01/24, the DON/Designee will complete ventilator audits on any new admissions weekly for four weeks. • On 03/01/24, the RT/designee will audit ventilators to ensure they are properly connected three times a week for four weeks. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365675 If continuation sheet Page 11 of 17 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 03/19/2024 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 0695 • Level of Harm - Minimal harm or potential for actual harm Review of the facility's ventilator alarm drills for the first week from 03/01/24 to 03/07/24 revealed the staff timely responded to the ventilator alarms. Residents Affected - Few This deficiency represents non-compliance investigated under Complaint Number OH00151795 and Complaint Number OH00151796. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365675 If continuation sheet Page 12 of 17 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 03/19/2024 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, review of video footage, family and staff interview, and review of the facility policy, the facility failed to provide timely assessment and pressure to a resident's dialysis access site that was actively bleeding. This affected one (Resident #34) of three residents reviewed for dialysis. The facility census was 69. Residents Affected - Few Findings include: Review of the medical record for Resident #34 revealed an admission date 02/06/24. Diagnoses included end stage renal disease and acute pulmonary insufficiency. Review of the Minimum Data Set (MDS) assessment date 02/13/24 revealed Resident #34 was cognitively intact. Resident #34 was dependent on staff for transfers, personal care, toileting, upper and lower dressing, and bathing. Review of the plan of care dated 02/07/24 revealed Resident #34 was at risk of abnormal bleeding or hemorrhage related to anticoagulant therapy, recent surgery, and medication. Interventions included avoiding activities that could result in injury, observe for and report to physician of bleeding, blood tinged or frank blood in urine, blood in stools, and significant sudden changes. The plan of care, dated 02/11/24, revealed the focus area for impaired genitourinary status related to end stage renal disease and received dialysis. Interventions included observing dialysis access sites and reporting to physician for signs and symptoms of bleeding or signs of infection, redness, swelling, local warmth, and tenderness. Review of the physician order dated 02/20/24 for Resident #34 revealed an order to get to dialysis every Monday, Wednesday, and Friday and to monitor the thrill (a rumbling sensation that you can feel) and bruit (a rumbling sound that can hear) arteriovenous (AV) shunt site (access type that is created by connecting an artery to a vein under the skin, usually in the upper or lower arm and can monitor to see how well the dialysis access is functioning). every shift. Review of the video footage of Resident #34 in her room, provided by the family, with the Administrator and Director of Nursing revealed on 02/20/24, Resident #34 was laying in her bed on her back and had two-one areas of bright red blood areas on the front of her gown at 5:19 A.M. Registered Nurse (RN) #119 had come into the room to visit Resident #34 and spoke to her. Resident #34 was moving and trying to tell him something. The video does not give you what exactly had been said due to the sounds of the ventilator and gastric tube running in the room. On 02/20/24 at 6:25 A.M. Respiratory Therapist #104 came into Resident #34's room to her left side to look at her and ventilator. RT #104 had checked ventilator. Resident #34's gown was more saturated with blood doubling in size on her left side of her gown near her fistula site on her left lower arm. At 7:20 A.M., RT #104 came back into the room and performed tracheostomy care. At 7:49 A.M., State Tested Nursing Aide (STNA) #175 came into the room and Resident #34 had stated something to her that needed suction and the nurse. At 8:10 A.M., RT #111 came into Resident #34's room to Resident #34's left side of bed. Resident #34 had a large area of blood size of five inches irregular diameter. At 7:49 A.M., STNA #175 came into Resident #34's room to assist in care, then left the room. From 5:19 A.M. to 8:32 A.M., there were no staff assessing to see where the blood was coming from when the blood stains were visible on Resident #34's gown. At 8:33 A.M., Licensed Practical Nurse (LPN) #111 came into the room to assess the left arm and applied pressure to Resident #34's left lower arm at fistula cite. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365675 If continuation sheet Page 13 of 17 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 03/19/2024 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 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 03/07/24 at 2:07 P.M. with the family of Resident #34 stated there were several times that Resident #34's dressing had fallen off her left forearm at fistula site. The family stated she remembered 'fighting' with a nurse, who could not remember name, to address Resident #34's fistula on left arm that was bleeding. Interview on 03/11/24 at 2:00 P.M. with the Director of Nursing (DON) verified the staff took too long to assess and apply pressure to Resident #34's left lower arm at fistula on 02/20/24. Review of the facility policy titled Care Planning and Special Needs Dialysis revealed the facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences to meet the special medical, nursing, mental and psychosocial needs of residents receiving dialysis. This deficiency represents non-compliance investigated under Complaint Number OH00151796. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365675 If continuation sheet Page 14 of 17 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 03/19/2024 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 record review, observations, review of the guidance from Centers for Disease Control and Prevention (CDC). staff interviews, and review of the facility policy, the facility failed to implement recommended infection control practices to prevent the spread of COVID-19 and failed to perform appropriate hand hygiene and sterile practices during a resident's wound treatment. This affected (#2, #9, #14, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #33, #34, #35, #36, #37, #38, #40, #42, #43, #44, #46, #47, #48, #49, #50, #51, #52, #53, #54, #55, #56, #57, and #73). The facility census was 76. Residents Affected - Some Findings include: 1. Review of the medical record for Resident #14 revealed an admission date 03/02/24. Diagnoses included COVID-19 on 03/05/24, acute diastolic heart failure, pulmonary fibrosis, nonrheumatic mitral valve insufficiency, Alzheimer's disease, and dementia. Resident #14 was transferred to the local hospital on [DATE]. Review of the medical record for Resident #2 revealed an admission date of 01/25/24. Diagnoses included end stage renal disease, chronic obstructive pulmonary disease, and acute chronic systolic and diastolic heart failure. Resident was tested for COVID-19 on 03/04/24 and 03/11/24 and tested negative. Observation on 03/06/24 at 12:07 P.M. revealed Medication Technician (MT) #780 entered Resident #14's room, who was positive for COVID-19, wearing an N-95 mask, gown, and gloves. MT #780 was not wearing eye protection. Resident #14 had a sign that was posted on the outside of the wall by the door, and the sign stated droplet precautions included wearing N-95, gown, gloves, and face protection. A personal protective box was located on the right side of the door for use of personal protective equipment. The box had adequate supplies. MT #780 came out of Resident #14's room, had taken all personal protective equipment (PPE) except her N-95 and other mask under that was still on her face. MT #780 performed hand hygiene, then took the N-95 off her face and moved it to the top of her head. MT #780 had left the second mask on her face, and still had the N-95 on top of her head when she entered Resident #2's room to provide care. MT #780 was standing at the side of Resident #2's bed assisting Resident #2, who was lying in bed. Interview on 03/06/24 at 12:10 P.M. through 12:20 P.M. with MT #780 confirmed she still had the old N-95 on the top of her head in Resident #2's room. MT #780 confirmed she did not wear eye protection in Resident #14's room who was COVID-19 positive. Interview on 03/06/24 at 1:00 P.M. with the Director of Nursing (DON) and Administrator confirmed the staff were to wear eye protection in resident rooms who were positive for COVID-19. Review of the CDC guidance titled Viral Respiratory Pathogens Toolkit for Nursing Homes, dated 09/28/23, revealed healthcare professionals who enter the room of a resident with signs or symptoms of an unknown respiratory viral infection that is consistent with SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection. Review of the facility policy titled Transmission-Based Precautions, dated 12/27/23, revealed based upon the pathogen or clinical syndrome, if there was a risk of exposure of mucous membranes or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365675 If continuation sheet Page 15 of 17 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 03/19/2024 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 - Some substance spraying of respiratory secretions was anticipated, gloves and gown, as well as goggles or face shield should be worn. This policy was intended for droplet precautions to try and prevent transmission of pathogens spreading through close respiratory or mucous membrane contact with respiratory secretions that were generated by resident who was coughing, sneezing, or talking. 2. Review of the employee punch time sheet dated 02/19/24 through 02/20/24 revealed Registered Nurse (RN) #119 had worked at the facility. Review of the facility's document for staff who tested positive for COVID-19 revealed RN #119 tested positive for COVID-19 on 02/20/24. Interview on 03/07/24 at 11:00 A.M. with RN #119 verified he worked on 02/19/24 when he had symptoms of COVID-19 when starting his night shift on 02/19/24. RN #119 did not state his specific symptoms. RN #119 stated he had come to work for his night shift, feeling unwell, and had COVID-19 symptoms. RN #119 stated he had tried to call the Administrator to explain, and she never answered her phone. Subsequent interview on 03/11/24 at 5:23 P.M. with RN #119 confirmed he had taken a rapid test on 02/20/24 at 5:00 A.M. while working at the facility as a nurse. RN #119 stated that he took care of the residents residing on 300-hall and half the residents on the 200-hall. RN #119 stated he wore an N-95 face mask during the entire shift to protect the residents. Interview on 03/11/24 at 11:00 A.M. with the Administrator stated employees who have symptoms of COVID-19 were to be tested at the facility. The employee who comes down with symptoms was to notify staff to perform a rapid test at the facility. The Administrator stated during the after hours, she was on call to answer telephone calls to address employee's needs. The Administrator stated she may not have answered her telephone during the night of 02/19/24. Review of the facility's list of residents who RN #119 was assigned to for his night shift on 02/19/24 revealed 37 residents (#9, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #33, #34, #35, #36, #37, #38, #40, #42, #43, #44, #45, #46, #47, #48, #49, #50, #51, #52, #53, #54, #55, #56, and #57) were assigned to RN #119 on 02/19/24. Review of the CDC guidance titled Viral Respiratory Pathogens Toolkit for Nursing Homes, dated 09/28/23, revealed there should be sick leave policies for healthcare professionals (HCP) that are non-punitive, flexible, and consistent with public health guidance to discourage presenteeism and allow HCP with respiratory infection to stay home for the recommended duration of work restriction. 3. Review of the medical record for Resident #73 revealed an admission date 02/14/23. Diagnosis included Stage IV pressure ulcer (Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed) of the sacral region. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #73 was cognitively intact. Review of plan of care dated 08/23/23 revealed that Resident #73 was at risk for impaired skin integrity related to wound currently on sacrum. Interventions included to administer treatments as ordered, complete wound evaluation to observe the progress of the resident's skin condition, and notify the physician of signs and symptoms of infection or change in wound in type, amount, color of drainage, bleeding or foul odor. Observation on 03/12/24 at 3:44 P.M. revealed Wound Nurse (WN) #125 and Registered Nurse (RN) #140 performed wound care to Resident #73's coccyx. RN #140 performed hand hygiene then placed gloves on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365675 If continuation sheet Page 16 of 17 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 03/19/2024 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 - Some hands. RN #140 had positioned Resident #73 to her left side with coccyx area exposed. RN #140 took off dirty gloves, then applied a new pair of gloves to take old dirty dressing off Resident #73's coccyx. RN #140 did not perform hand hygiene when she changed her gloves. At 3:49 P.M., RN #140 took off dirty gloves, then applied a new pair of gloves to cleanse the coccyx wound with four by four dressing and normal saline. RN #140 did not perform hand hygiene when she changed her gloves. At 3:53 P.M., RN #140 changed her gloves then reached her dirty hands into her left pocket scrub pants to get the hand sanitizer. RN #140 confirmed it was the first time she was hand hygiene. RN #140 used the hand sanitizer from her pocket and confirmed it was the first time she had used the hand sanitizer. RN #140 applied new gloves, then applied cream to Resident #73's peri wound on buttocks. At 3:54 P.M., RN #140 took the abdominal dressing with calcium alginate silver that was laying on the towel on Resident #73's mattress to the wound bed. At 3:59 P.M., WN #125 verified RN #73 should not have placed the clean dressing on Resident #73's towel on her mattress. WN #125 stated RN #140 should have kept the dressing sterile until it was time to apply to the wound. Review of the facility policy titled Clean Dressing Change dated 12/28/23 revealed the staff were to wash hands before wound care, after touching dirty surfaces, before applying gloves, after cleaning or apply barrier cream, after treatments, and before leaving a resident's room. Review of the facility policy titled Hand Hygiene, dated 12/13/23, revealed the use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to applying gloves, and immediately after removing gloves. This deficiency represents non-compliance investigated under Master Complaint Number OH00152047, Complaint Number OH00151842, Complaint Number OH00151506, and Complaint Number OH00151053. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365675 If continuation sheet Page 17 of 17