Inspection visit

Health inspectionJanuary 12, 2024

ARBORS AT MARIETTACMS #36568731 citations on this visit

31 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 31 deficiencies, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0551 Give the resident's representative the ability to exercise the resident's rights. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the probate court local rules of practice, and interview the facility failed to ensure a resident had a legal guardian when the resident no longer had the ability to maintain capacity. This affected one resident (#7) of two residents reviewed for advance directives. Residents Affected - Few Findings included: Record review revealed Resident #7 was admitted to the facility initially on [DATE] with diagnoses including cognitive communication deficit (added [DATE]), intellectual disabilities (added [DATE]), dementia with mild psychotic disturbance (added [DATE]), major depression, bipolar, anxiety, chronic obstructive pulmonary disease, multiple sclerosis, chronic respiratory failure with hypoxia, asthma, hemiplegia, peripheral vascular disease, plasma-protein metabolism, calculus of gallbladder, spinal stenosis, wedge compression fracture of second lumbar vertebra, nontoxic single thyroid nodule, constipation, contracture of right upper arm, dysphagia, hypertensive heart, gout, hyperlipidemia, gastro-esophageal reflux disease, and chronic kidney disease. Review of Resident #7's face sheet (undated) revealed the resident had no guardian or contact person. The resident resided on the facility's secure/dementia unit. Resident #7 was covered by Medicaid and Medicare insurance. Review of Resident #7's Minimum Data Set (MDS) 3.0 assessments dated [DATE] to [DATE] revealed the resident's brief interview for mental status (BIMS) score on [DATE] was nine (moderately impaired cognition impairment). On [DATE] the resident had a significant change MDS that indicated the resident BIMs could not be conducted due to the resident being rarely or never understood. The resident's five-day MDS dated [DATE] also indicated the BIMS could not be conducted due to the resident being rarely or never understood. Review of Resident #7's Preadmission Screening and Resident Review Results Notice dated [DATE] revealed the resident had a significant change in condition (decline). The resident had dementia, serious mental illnesses (mood disorder and pain or other severe anxiety disorder) and physical or mental disability (intellectual disability). The resident had indications of substantial functional impairment. The resident did not have a court appointed legal guardian or legal representative. Review of email correspondence dated [DATE] to [DATE] revealed on [DATE] the facility Social Worker (SW) #121 sent an email to Advocacy and Protective Service, Incorporated (APSI) requesting the need for a guardian for Resident #7 because she was not able to make medical decisions and had no family. APSI responded on [DATE] and instructed the SW to complete the referral application along with a copy of the resident's birth certificate, social security card, and proof of eligibility for county (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 69 Event ID: 365687 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 365687 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Marietta 400 Seventh Street Marietta, OH 45750 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 0551 board of developmental disabilities services. Level of Harm - Minimal harm or potential for actual harm Review of email correspondence dated [DATE] revealed SW #121 responded back from [DATE] email indicating she had completed the referral and the resident needed a guardian in place as soon as possible. On [DATE] APSI responded they still needed the resident's birth certificate, social security card, and proof of eligibility from the county board. There was no evidence of further communication between the facility and APSI. Residents Affected - Few Review of the APSI referral application form dated [DATE] revealed Resident #7 had no living will, power of attorney, or existing advance directives, or burial plan. The resident was difficult to understand and had no court appointed guardian. The resident was unable to make her own medical decision and had no family or friends. The instructions on the APSI referral application included all the following documents MUST be included with the completed APSI guardianship referral form to process the referral: eligibility determination instrument, birth certificate, social security card, and statement of expert evaluation. There was no evidence the facility obtained the resident's birth certificate or social security card. Review of Statement of Expert Evaluation dated [DATE] revealed the resident was not capable of making decisions regarding medical and financial decisions and guardianship should be established. Review of the probate court local rules of practice for guardianship dated [DATE] revealed an application must be completed and filed by the guardian. If the resident had adult children who are known to reside in Ohio their address must be provided, and the court would send notice of the hearing to those children. If emergency guardianship was required, the person desiring to be appointed must prepare and file all documents. Further review of Resident #7's medical record revealed the facility had the resident sign consent to decline pneumococcal vaccine on [DATE] after she was declared not capable of making medical decisions by a physician ([DATE]). Review of Resident #7's personal funds account dated [DATE] to [DATE] revealed the facility had bought the resident a google [NAME] that cost $107.23 on [DATE] and paid $1,200.00 to a funeral home on [DATE]. The resident was not able to make financial decisions at that time per the resident's MDS assessments. Interview on [DATE] at 9:45 A.M. and 10:18 A.M., with SW #121 revealed she had contacted APSI, and they would not assist her with guardianship due to the facility didn't have the resident's social security card or birth certificate. The SW indicated she wasn't sure how to apply for emergency guardianship or whom to contact. The SW reported the resident's husband was a resident at the facility but had expired years ago at the facility and she wasn't aware of any other family members. The resident had been a resident at the facility since 2006 and no one had obtained a copy of the resident's social security card or birth certificate. She had contacted probate court but did not document the conversation but stated she was told there was no one in the area taking new residents for guardianship and the local health department confirmed the resident was not born in Ohio. SW #121 confirmed she had not reached out to any attorneys to see if they could assist or would be willing to accept guardianship for the resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365687 If continuation sheet Page 2 of 69 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 365687 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Marietta 400 Seventh Street Marietta, OH 45750 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 0551 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on [DATE] at 7:45 A.M., with SW #121 revealed she had discovered yesterday that Resident #7 had two children. The facility was going to try to reach out to the daughter because she thought the resident other child (son) had expired. Interview on [DATE] at 7:51 A.M. with Resident#7 revealed she could not recall what state she was born in, however when asked if she had two children she replied yes. The resident was not able to provide reliable information. Interview on [DATE] at 8:21 A.M., with State Tested Nurse's Aide (STNA) #131 and STNA #167 revealed the resident had severe cognition impairment and she hardly talked but would scream when she wanted anything. She has a call button but doesn't know how to use it and tries to get up on her own. The resident needs a guardian due to not being able to make medical or financial decisions. The STNA's reported they thought the resident was adopted and her husband was resident at the facility years ago but had expired. Interview on [DATE] at 10:53 A.M. with the Probate Court Personnel #400 revealed it was the facility's responsibility to find a guardian and to submit the proper paperwork to the courts. The courts don't have a list of people that were willing to accept residents, however there was an agency in the community that may be able to help such as APSI and sometimes local attorneys. Interview on [DATE] at 11:03 A.M., with local attorney office Secretary #401 confirmed that Attorney #402 accepts residents for guardianship as well as Attorney #403 who was also a local attorney in town. Interview on [DATE] at 8:29 A.M. and 2:50 P.M., with the Administrator, revealed the facility legal department was now involved in helping the facility find guardianship for Resident #7. The facility found out the resident was born in Virginia, and the facility was in the process of obtaining the birth certificate. The Administrator confirmed in [DATE] the resident was not capable of making financial decisions, however her funds were over the allowed amount and the facility had to help the resident spend down the account, so she did not lose her funding. Interview on [DATE] 9:22 A.M., with the Director of Nursing (DON) confirmed she had Resident #7 sign the pneumococcal vaccine consent even though she was not capable of making medical decisions due to the corporate office requires the form to be completed so they can track immunizations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365687 If continuation sheet Page 3 of 69 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 365687 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Marietta 400 Seventh Street Marietta, OH 45750 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 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, staff interview, and policy review, the facility failed to ensure a resident was afforded the right to choose how often they bathed and received the type of bathing activity they preferred. This affected one resident (#83) of two residents reviewed for choices. Findings include: A review of Resident #83's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included Parkinson's disease, need for assistance with personal care, and major depressive disorder. A review of Resident #83's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues and was cognitively intact. She was not known to have displayed any behaviors or reject care during the seven day assessment period. She had a functional limitation in her range of motion of her bilateral lower extremities. A partial/ moderate assist was needed with showers/ bathing. A review of Resident #83's care plans revealed she had an activities of daily living (ADL) self-care performance deficit related to myopathy and left foot drop. The goal was for her ADL needs to be met through the next review date. The interventions indicated the resident preferred showers as her bathing activity of choice and wanted them on the afternoon shift every Monday, Wednesday, Friday, and as needed. A review of Resident #83's shower documentation under the task tab of the electronic medical record (EMR) for the past 30 days (12/11/23 through 01/08/24) revealed her preference was for showers and they were to be provided on the afternoon shift every Monday, Wednesday, Friday, and as needed. She was documented as having received a shower on all her scheduled shower days during that 30 day period, with the exception of 12/13/23, 12/25/23, and 12/29/23. A bed bath was documented as having been given on those three days in place of a shower, which was her preferred bathing activity. A review of Resident #83's nurses' progress notes revealed there was not any documentation to support why a bed bath had been given on 12/13/23, 12/25/23, and 12/29/23 in place of a shower. There was no indication that a shower had been offered and refused by the resident on those days. On 01/02/24 at 2:11 P.M., an interview with Resident #83 revealed it was her preference to be showered three times a week. She stated she was only getting two a week, if that. On 01/09/24 at 12:58 P.M., an interview with State Tested Nursing Assistant (STNA) #115 revealed Resident #83 required an extensive assist for her ADL's. She was not sure what the resident's preference was regarding the type of bathing activity she received. She was also not sure what shift the resident was showered/ bathed on. The frequency in which a resident was showered/ bathed depended on the resident's preference. The activity assistance put the resident's preference into the computer so they aides knew when they were to be showered/ bathed. She reported, when she offered the resident a shower, the resident would not refuse. She had not known the resident to decline a shower and want a bed bath instead. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365687 If continuation sheet Page 4 of 69 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 365687 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Marietta 400 Seventh Street Marietta, OH 45750 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 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 01/09/24 at 1:24 P.M., an interview with Licensed Practical Nurse (LPN) #211 revealed Resident #83 required assistance with personal care and had the use of a Hoyer lift for transfers. She was not aware of what the resident's preference was for bathing. She was not aware of the resident having refused any showers when offered. Documentation of showers were done by the aides and entered into the computer. The aides worked 12 hour shifts so if a resident was an afternoon shower it could be done at the end of the day shift or the beginning of the night shift. Aides were supposed to notify the nurse if showers were refused and she would document the refusal in the progress notes. She was not able to explain why bed baths were given to the resident on the three days she was marked as having received them when showers should have been given according to her preference. A review of the facility's policy on Promoting/ Maintaining Resident Dignity (revised 10/26/23) revealed it was the practice of the facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment that maintains or enhances resident's quality of life by recognizing each resident's individuality. All staff members were involved in providing care to residents to promote and maintain resident dignity and respect resident rights. During interactions with residents, staff must report, document and act upon information regarding resident preferences. The resident's former lifestyle and personal choices would be considered when providing care and services to meet the resident's needs and preferences. They were to groom and dress residents according to resident preference. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365687 If continuation sheet Page 5 of 69 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 365687 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Marietta 400 Seventh Street Marietta, OH 45750 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 0569 Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. Level of Harm - Minimal harm or potential for actual harm Based on review of resident financial records and staff interview, the facility failed to notify a resident that received Medicaid benefits when the amount in the resident's account reached $200 less than the SSI resource limit for one person, and that, if the amount in the account, reaches the SSI resource limit for one person, the resident may lose eligibility for Medicaid or SSI. This affected one of six residents whose financial records were reviewed (#59). The facility handled the funds for 62 residents. The facility census was 97. Residents Affected - Few Findings include: Review of the financial records for Resident #59 revealed the facility managed her funds. Review of a statement landscape revealed the balance in the resident's account had been greater than $1800.00 since 05/31/23. On 05/31/23 the balance was $1819.35. The current balance in the account was $1920.74. Interview with Business Office Manager #135 on 01/10/24 at 9:04 A.M. confirmed Resident #59 received Medicaid benefits. She further revealed Resident #59's power of attorney was sent a letter on 06/16/23 notifying her that the balance was within $200 of the resource limit. However, the power of attorney had not acknowledged receiving the letter and the facility had no evidence it was received by the power of attorney. Business Office Manager #135 confirmed there had been no further attempts to notify the power of attorney that the balance had remained within $200 of resource limit since 06/16/23. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365687 If continuation sheet Page 6 of 69 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 365687 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Marietta 400 Seventh Street Marietta, OH 45750 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident record review, interview, and facility policy review, the facility failed to ensure a resident's advanced directives were clear and consistent. This affected one resident (#25) of two residents reviewed for advanced directives. The facility census was 97. Findings included: Review of Resident #25's medical record revealed she was admitted to the facility on [DATE] with diagnoses including acute kidney failure, type two diabetes with diabetic neuropathy, morbid (severe) obesity due to excess calories, and unsteadiness on feet. Review of Resident #25's quarterly Minimum Data Set (MDS) assessment, dated [DATE], revealed she was cognitively intact. Review of Resident #25's electronic medical record face sheet revealed she was a full resuscitation in case of an emergency for her advanced directives. Review of Resident #25's physician order, dated [DATE], identified she was a full resuscitation. Review of Resident #25's plan of care, dated [DATE], revealed her advanced directives were Do Not Resuscitate - Comfort Care (DNR-CC) code status. Review of Resident #25's paper medical record revealed a Cardiopulmonary Resuscitation (CPR) form identified the box beside NO CPR was marked with an X and it was signed by Resident #25 on [DATE]. Review of Resident #25's paper medical record revealed a State of Ohio Do Not Resuscitate (DNR) Comfort Care form, signed and dated by Resident #25 and her physician on [DATE]. Interview on [DATE] at 3:05 P.M. with Resident #25 verified she did not want CPR performed on her in case her heart stopped beating, or she stopped breathing. Interview on [DATE] at 3:09 P.M. with Unit Manger (UM) #300 verified Resident #25's electronic medical record identified she was a full resuscitation and her paper record revealed she was a DNR-CC. UM #300 verified the guidance was contradictory and staff would not know what to do if Resident #25's heart stopped or she stopped breathing. UM #300 verified Resident #25's advanced directives would need to be clarified and there needed to be clear and consistent documentation. Review of the facility policy titled, Residents' Rights Regarding Treatment and Advance Directives, (reviewed/revised [DATE]), revealed it was the policy of the facility to support and facilitate resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advance directive. Further review revealed any decision making regarding the resident's choices will be documented in the resident's medical record and communicated to the interdisciplinary team and staff responsible for the resident's care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365687 If continuation sheet Page 7 of 69 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 365687 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Marietta 400 Seventh Street Marietta, OH 45750 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation, interview, and policy review the facility failed to ensure the noise levels were not too loud for Resident #82 and failed to ensure the walls were in good repair for Resident #46, #60, and #192. This affected four residents (Resident #82, #46, #60, #192) of five residents reviewed for environment. The facility census was 97. Findings include: Observation on 01/02/24 at 10:21 A.M. revealed the wall in Resident #46's room had a eight-inch area of wall which had been patched but not painted. Interview on 01/02/24 at 3:09 P.M. with Resident #82 revealed the facility is too loud because another resident keeps a television turned up and Resident #82 has sensitive hearing. Resident #82 stated she could not keep her door closed, and the other resident did not have to turn the television down and declined to wear hearing aids. Observation on 01/03/24 at 8:46 A.M. revealed a ceiling at the foot of Resident #192's bed by the window had a brown-stained tile and there were four quarter-sized holes in the wall in the middle of the room. During a tour with Maintenance Assistant (MA) #245 on 01/09/24 from 3:58 P.M. to 4:08 P.M., verified the hallway outside of Resident #82's room was observed to be loud while resident was trying to rest, two white patches above the first bed in Resident #46's room and three white patches on the opposite wall, a brown-stained ceiling tile at the foot of a bed, eight quarter-sized holes in the middle of the wall, and six inches of a baseboard was missing leaving a sharp edge, as well as two white patches on the wall in Resident #60's room. Review of a policy titled Safe and Homelike Environment (dated 01/01/22) revealed the facility should provide a comfortable and homelike environment including comfortable sound levels that do not interfere with residents' hearing. The policy stated maintenance services will be provided as necessary to maintain a sanitary, orderly, and comfortable environment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365687 If continuation sheet Page 8 of 69 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 365687 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Marietta 400 Seventh Street Marietta, OH 45750 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of self-reported incident (SRI), review of grievance/concern log, interviews, and policy review the facility failed to resolve a resident's grievances. This affected one resident (#65) of two residents reviewed for personal property. Finding include: Medical record review revealed Resident #65 was admitted to the facility on [DATE] with diagnoses including osteomyelitis, paraplegia, atrial fibrillation, pressure ulcer, heart failure, neuromuscular dysfunction of the bladder, and chronic pain. Interview on 01/02/24 at 9:39 A.M., with Resident #65 revealed someone had stolen $60.00 the first part of December (2023) out of his room while he was at an appointment. The resident also reported his transfer board was missing as well. He had to buy a new transfer board to leave the facility for Christmas due to the facility couldn't find his and the therapy would not let him borrow one from the facility. The facility had completed an investigation regarding the stolen money; however, they haven't investigated the missing transfer board that he was aware of. The resident reported he was supposed to be reimbursed for the money, but the facility has not paid him yet and he would like to be reimbursed for the transfer board as well. Review of the grievance/concern log dated 12/2023 revealed Resident #65 had reported $60.00 missing on 12/11/23 and the resolution was the resident was reimbursed on 12/20/23. There was no evidence of Resident #65's missing transfer board. Review of the facility SRI dated 12/13/23 revealed Resident #65 reported $60.00 missing on 12/11/23 to the Social Worker (SW) #121. The allegation of abuse was unsubstantiated; however, the resident's money would be replaced, and he would be offered a lockbox. Further review revealed no evidence of an investigation for the resident's missing transfer board. Interview on 01/02/24 at 9:26 A.M. and 4:36 P.M. with the Administrator confirmed the resident had not been reimbursed for the $60 at this time due to the reimbursement form was completed, however it was never sent to the corporate office for some unknown reason. The Administrator reported she was not aware of the missing transfer board and would start a SRI and an investigation. The Administrator reported she spoke to the Corporate Office today to have the $60.00 and $54.31 for the transfer board expedited so they could pay the resident even though there was no evidence the money was misappropriated, or the resident even had a transfer board. She reviewed the residents inventory sheet today and there was no evidence the resident had a transfer board when he was admitted . Interview on 01/03/24 at 9:00 A.M., with the Director of Nursing (DON) confirmed she was aware of the allegation of the missing transfer board, however she had called Resident #65's friend and it was determined the transfer board was left at the previous facility the resident had resided at. Therapy had reported the resident never had his own personal transfer board at the facility. The facility was still going to reimburse the resident for the transfer board since he had already bought one. Review of the facility policy titled Complaint and Grievance Process (dated 01/01/22) revealed any (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365687 If continuation sheet Page 9 of 69 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 365687 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Marietta 400 Seventh Street Marietta, OH 45750 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 0585 Level of Harm - Minimal harm or potential for actual harm individual may file a complaint either directly to the facility or the Secretary of Health and Human Services. The facility would assist the individual with the complaint and grievance process. Complaints and their disposition will be documented. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365687 If continuation sheet Page 10 of 69 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 365687 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Marietta 400 Seventh Street Marietta, OH 45750 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the resident or their representative was provided with a written summary of the baseline care plan. This affected one residents (#88) of 27 sampled residents. The facility census was 97. Findings include: Review of the closed medical record for Resident #88 revealed an admission date of 09/29/23. The resident had diagnoses including malignant neoplasm of the prostate, liver, colon, and bone. He went home on [DATE] but was readmitted on [DATE] as he was unable to care for himself at home. He remained at the facility until 11/20/23, when he was transferred to the hospital. He did not return to the facility. Record review revealed a care plan meeting was held on 10/02/23 with the resident and his daughter. There was a section of the care plan meeting form to indicate who a copy of the care plan was provided to. It stated upon request. An additional care plan meeting was held on 10/19/23 with the resident. There was a section of the care plan meeting form to indicate who a copy of the care plan was provided to. It stated upon request. There was no evidence a written copy of the baseline care plan had been provided to the resident or his daughter. There was no evidence they refused a copy. Interview with Social Service Worker #125 on 01/09/24 at 10:55 A.M. revealed she conducted the care plan meetings for the baseline care plan. She stated that either a copy of the baseline care plan was provided or they refuse it. However, she stated she did not document this and usually just documented upon request. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365687 If continuation sheet Page 11 of 69 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 365687 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Marietta 400 Seventh Street Marietta, OH 45750 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the concern log, review of invoice, observation, and interview the facility failed to ensure a resident had a comprehensive plan of care for vision. This affected one resident (#70) of two residents reviewed for sensory needs. Findings include: Medical record review revealed Resident #70 was admitted to the facility on [DATE] with diagnoses including cognitive communication deficit. Review of the grievance/concern log dated 02/23/23 and 06/07/23 revealed Resident #70's glasses were missing. The resolution on 02/23/23 indicated the glasses would be replaced. There was no documentation regarding the resolution of resident's missing glasses for 06/07/23. Review of Resident #70's vision note dated 03/07/23 revealed the resident had 20/30 vision in bilateral eyes and required glasses. There was an additional note to encourage the resident to wear the glasses part-time for reading. Review of Resident #70's eye glass invoice dated 03/07/23 revealed the resident received a pink pair of glasses. Review of Resident #70's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had adequate vision without corrective lens. Review of Resident #70's current plan of care revealed no evidence of a vision plan of care. Interview on 01/03/24 at 11:07 A.M., with Resident #70's daughter via phone revealed the residents' glasses were missing again. Observation on 01/04/24 at 8:32 A.M., with State Tested Nurse's Aide (STNA) #131 and #167 revealed no evidence Resident #70's glasses were in her room. Interview on 01/04/24 at 9:08 A.M. with Social Worker (SW) #121 revealed she had Resident #70's glasses in her office due one of the staff gave them to her because the resident was refusing to wear them. The SW confirmed the resident did not have a plan of care for vision nor a plan of care for refusal to wear the glasses. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365687 If continuation sheet Page 12 of 69 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 365687 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Marietta 400 Seventh Street Marietta, OH 45750 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** 2. Record review revealed Resident #70 was admitted to the facility on [DATE] with diagnoses including dementia without behavioral disturbance with psychotic disturbance, mood disturbance, and anxiety, moderate protein-calorie malnutrition, hypertension, anemia, anxiety, heart disease, inguinal hernia, esophagitis, hypokalemia, reflux disease, depression, insomnia, cognitive communication deficit, dysphonia, hypothyroidism, adult failure to thrive, hyperlipidemia, and right wrist fracture. Review of Resident #70's admission assessment dated [DATE] revealed the resident had top dentures. Review of Resident #70's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognition impairment. Review of Resident #70's face sheet (undated) revealed the resident's daughter was listed as power of attorney. Review of Resident #70's dental plan of care dated 10/13/23 revealed no evidence the resident had dentures. Review of Resident #70's care plan conference worksheet dated 11/22/23 revealed the sheet was incomplete/blank. Further review revealed the last documented care conference was 08/16/23, however there was no evidence the resident or her daughter attended. Review of Resident #70's social service note dated 7/27/23 revealed a quarterly care conference invite was mailed to the resident's daughter on this date. The care conference is to take place on 08/24/23 at 1:45 P.M. Social Worker continues to follow to assist as needed. There was no documented evidence the resident's daughter was notified the care conference was changed to 08/16/23. Interview on 01/03/24 at 11:11 A.M., with Resident #70's daughter revealed she had not been invited to attend a care plan conference every quarter. In addition, Resident #70's daughter revealed her mother's dentures are missing. Observation on 01/04/24 at 8:29 A.M. with State Tested Nurse's Aide (STNA) #167 revealed Resident #70 had top dentures in a denture up in her bathroom with her name on them. Interview on 01/04/24 at 11:33 A.M., with Social Worker (SW) #125 confirmed she notified Resident #70's daughter of the care conference on 08/16/23, however the letter sent out to the family indicated the care conference would be on 08/24/23. SW #125 confirmed there was no documented evidence that the resident or her daughter was notified of the change of date for the care conference. SW #125 reported she had just started in July of 2023 and in December of 2023 she had COVID and got behind. The SW confirmed there should have been a care conference in November of 2023, however there wasn't one on her schedule. The SW reported she just emailed the daughter to set up a care conference this month. Interview on 01/04/24 at 2:08 P.M., with Minimum Data Set Nurse #219 confirmed Resident #70's dental plan of care did not reflect the resident's upper dentures and she would revise the plan of today to reflect the upper dentures. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365687 If continuation sheet Page 13 of 69 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 365687 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Marietta 400 Seventh Street Marietta, OH 45750 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 Review of the facility policy titled Participation 77 Care Review-Assessment/Care Plans (dated 10/20/20 and revised on 01/01/22) revealed each resident and his/her family member are encouraged to participate in the development of the resident's comprehensive assessment and care plan. The resident and his/her family or legal representative are invited to attend and participate in the resident's assessment and care planning conference. The comprehensive care conference was scheduled after the completion of the comprehensive care plan and quarterly. The care conference would be attended by Social Service Dietary and Activities, and Nursing. A seven-day advance notice of the care planning conference to the resident and interested family member for all conferences. Such notice was made by mail or telephone. The social services director of designee was responsible for contracting the resident family and for maintaining the record of such notices including input form the family members when that are not able to attend. 3. Medical record review revealed Resident #65 was admitted to the facility on [DATE] with diagnoses including osteomyelitis, Stage 4 pressure ulcers (full-thickness tissue loss) to left and right buttocks, paraplegia, and heart failure. Review of Resident #65's impaired skin integrity skin plan of care initiated 10/13/23 revealed turning and repositioning as needed, elevate heels as tolerated, and pressure redistribution device in chair. There was no evidence the plan of care was revised to include turning every two hours, prevolon boots, roho cushion, limited sitting for one hour at a time, bed only, and Hoyer lift. Review of Resident #65's wound center note dated 12/18/23 revealed the intervention included bed only, Hoyer lift, prevolon boots, roho cushion, limited sitting one hour at a time, and turn every two hours. Review of Resident #65's wound note dated 01/09/24 revealed the resident had two Stage 4 pressure ulcers; one on the right gluteus and one on the left gluteus. Interview on 01/10/24 at 9:23 A.M., with Registered Nurse (RN) #143 confirmed Resident #65's skin integrity plan of care was not revised to include turning every two hours, prevolon boots, roho cushion, limited sitting for one hour at a time, bed only, and Hoyer lift. Based on record review, interview, and policy review, the facility failed to revise comprehensive care plans and failed to have quarterly care conferences. This affected three residents (#18, #65, and #70) of four residents reviewed for care planning. The facility census was 97. Findings include: 1. Record review revealed Resident #18 was admitted to the facility on [DATE] with diagnoses including atrial fibrillation, atherosclerotic heart disease, congestive heart failure, and type II diabetes. Review of a quarterly minimum data set (MDS) assessment completed on 06/06/23 revealed Resident #18 had intact cognition and had no behaviors. Review of an assessment titled Care Plan Conference Summary revealed Resident #18 had a care conference on 12/08/22, then had a care conference on 07/27/23. Review of the MDS schedule revealed Resident #18 had a quarterly MDS on 12/02/22, a quarterly MDS on 03/03/23, a quarterly MDS on 06/02/23, a quarterly MDS on 06/06/23, a discharge MDS on 07/03/23, an annual MDS on 08/23/23, and a quarterly MDS on 11/22/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365687 If continuation sheet Page 14 of 69 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 365687 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Marietta 400 Seventh Street Marietta, OH 45750 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 Interview on 01/02/24 at 11:29 A.M. with Resident #18 revealed she did not have any care planning conferences. Interview on 01/08/24 at 1:59 P.M. with Licensed Social Worker (LSW) #125 revealed care conferences should be completed once per quarter and she keeps track of when care conferences are due for each resident by looking at the assessments which are triggered by the MDS staff because the care conferences and MDS' do not always fall in the same timeframe. LSW #125 reported she invites residents and families to care conferences by sending them letters with the date and time of the conference. LSW #125 stated she could not provide any documentation to show Resident #18 had been invited to any care conferences. LSW #125 stated Resident #18 had not had a care conference since July 2023 because the assessment did not repopulate on the assessment board, but a care conference was scheduled for January 2024. LSW #125 confirmed Resident #18 did not have quarterly care conferences. Review of a policy titled Comprehensive Care Plans (dated 06/30/22) revealed comprehensive care plans will be prepared by an interdisciplinary team which includes a resident or representative to the extent practicable. Additionally, the comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment, every effort will be made to schedule a care plan meeting at the best time of the day for the resident and family or Ombudsman if they resident wishes to invite them in lieu of family, and a summary of the comprehensive care plan will be given to the resident and will include initial goals of the resident, summary of the resident's medication and dietary instructions, services and treatments, and any updates completed at the care plan meeting. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365687 If continuation sheet Page 15 of 69 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 365687 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Marietta 400 Seventh Street Marietta, OH 45750 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** Based on observations, medical record review, and staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the care plan, and resident choice, in the areas of orthopedic follow up services, hospice services, and specialty physician consult services. This affected three residents (#26, #80, and #191) of 27 sampled residents. The facility census was 97. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #80 revealed an admission date of 09/27/23 with diagnoses including dementia and hypertension. The resident resided on the secured dementia unit. A Minimum Data Set assessment completed 10/01/23 documented a Brief Interview for Mental Status score of 4, indicating severe cognitive impairment. It indicated the resident had no functional limitation in range of motion and required only supervision or touching assistance for sit to stand, chair to bed, toilet transfer, and walking 10 feet. It indicated a fall history but no falls since admission. Observations on 01/08/24 at 7:50 A.M. revealed the resident to be seated in a wheelchair with a fracture boot on the right foot. Review of nurse's progress notes revealed on 12/07/23 at 11:27 A.M. the nurse was alerted by a state tested nursing assistant of Resident #80's fall. When entering the room it was noticeable the floor had just been mopped. Resident #80 was on the floor laying on her back complaining of pain in right ankle. Skin assessment completed with no physical injuries noted. The resident denied hitting her head. The resident was lifted off the floor via Hoyer lift and placed on bed. An ice pack was applied to the right ankle. The resident's physician was notified and 911 called for transport to emergency room. Review of an x-ray report for Resident #80 on 12/07/23 revealed an oblique fracture of the distal fibula which is mildly displaced and a mildly comminuted fracture of the medial malleolus noted. Review of the emergency room notes from 12/07/23 revealed an orthopedic glass splint was applied. The resident was to be non-weight bearing and follow up with orthopedics in one week. The resident returned to the facility on [DATE]. Physician's orders were obtained on 12/08/23 for vascular checks to the right foot every shift and as needed. On 12/10/23 there was an order for non-weight bearing to right leg every shift for fracture. A nurse practitioner note on 12/70/23 stated the resident slipped on the wet floor today and had fall related to that. The resident went to the emergency room and found to have a distal tibia fracture that was mildly displaced. The resident was put on splint and bedrest. Follow up with orthopedics. A nurse's progress note on 12/13/23 at 3:54 P.M. indicated an orthopedic appointment on 12/15/23. Review of the orthopedic consultation notes on 12/15/23 revealed Resident #80 was seen status post bimalleolar right ankle fracture. Patient should be non weight bearing. Please take boot off three times a day for skin checks. Follow up in office in one week. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365687 If continuation sheet Page 16 of 69 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 365687 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Marietta 400 Seventh Street Marietta, OH 45750 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 - Minimal harm or potential for actual harm Residents Affected - Few Review of the medical record revealed as of 01/08/24, there was no evidence Resident #80 had returned for orthopedic care for the fracture as recommended by orthopedics. Interview with the Director of Nursing (DON) on 01/09/24 at 7:55 A.M. confirmed Resident #80 had not been seen by orthopedics since 12/15/23 and was supposed to have a follow up appointment one week after that. The DON stated she does not know why the resident was not seen again as recommended. The DON stated an appointment was made for 01/09/24. Review of an orthopedic consultation note for 01/09/24 revealed patient was seen today status post right ankle fracture. She may be weight bearing as tolerated with boot. Ski boot for ambulation only, does not need to wear it for sleeping. Follow up in office in one month. 2. Review of the medical record for Resident #26 revealed an admission date of 07/31/18. The resident had diagnoses including chronic obstructive pulmonary disease, protein-calorie malnutrition, respiratory failure, pancreatitis, chronic kidney disease, fistula of intestines, malignant neoplasm of thyroid, chronic hepatitis B, and chronic pain. Review of the Minimum Data Set assessment completed 10/23/23 revealed a Brief Interview for Mental Status score of 15, indicating intact cognition. The resident required moderate assist with transfers and toileting. The resident had a physician's order on 09/29/23 to admit to hospice services. Record review did not reveal any evidence of hospice visits or care provided. There was no evidence the hospice provider had provided a copy of their plan of care to the facility. Interview with Unit Manager (UM) #300 on 01/04/24 at 2:45 P.M. revealed the hospice nurse comes at least twice per week and the hospice aide once per week for Resident #26. UM #300 confirmed the hospice visit notes are typically kept in a binder at the nurse's station. She confirmed the facility did not have any evidence of any hospice services provided since 09/29/23. She stated she would have to call the hospice agency and get a copy of them. Review of hospice records, after obtained from the hospice provider, revealed care started on 09/28/23 for a terminal diagnosis of severe protein calorie malnutrition. Notes on 12/04/23 indicated the hospice staff would provide all core services/provision of care as outlined in the hospice plan of care including: wound care three times weekly, treatments as included in the plan of care, pain management, medication management, and instruction on catheter management. The resident was also receiving hospice chaplain services. On 12/06/23 notes stated a home health aide visits three times weekly starting 12/11/23. 3. Record review revealed Resident #191 was admitted to the facility on [DATE] with diagnoses including encephalopathy, chronic obstructive pulmonary disease, schizophrenia, anxiety, seizures, hypertension, needs for assistance with personal care, difficult walking, gastro-esophageal reflux disease, hyperlipidemia, irritable bowel syndrome, Vitamin D deficiency, constipation, and moderate intellectual disabilities. Review of Resident #191's handwritten physician order dated 12/17/23 revealed house psych to see for schizophrenia and local gastric intestinal (GI) referral for history of ulcerative colitis. Laboratory testing (complete blood count (CBC), complete metabolic profile (CMP), iron profile, Vitamin B12, Thyroid, and Vitamin D) to be done on 12/18/23 for hypertension (HTN) anemia, fatigue, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365687 If continuation sheet Page 17 of 69 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 365687 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Marietta 400 Seventh Street Marietta, OH 45750 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 Vitamin deficiency. Also, on 12/18/23 a Depakote level for epilepsy was to be drawn. Level of Harm - Minimal harm or potential for actual harm Review of Resident #191's admission history and physical dated 12/17/23 revealed to have follow up blood work tomorrow and have psychology see her. The resident had been running up and down the hallways. She has currently fallen twice. She was on significant psychotropic medication and just needed to clarify, if they would like Depakote to be discontinued. She has a history of ulcerative colitis. Residents Affected - Few Review of Resident #191's administration note dated 12/18/23 revealed the CBC, CMP, iron profile, B12, TSH, Vitamin D level for HTN, anemia, fatigue, vitamin D deficiency was not collected due to the resident refused. The physician was advised and would attempt to draw tomorrow morning. There was no mention of the Depakote level, house psych, or GI consult. Further review of the medical record (paper and electronic) revealed no evidence a second attempt was made to collect the laboratory test per orders or documented evidence the physician was notified the labs were not collected. There was no evidence the GI consult was made. Review of Resident #191's impaired cardiovascular care plan related to hypertension and high cholesterol initiated 12/18/23 revealed labs as ordered for testing. Review of Resident #191's at risk for fluid volume deficit related to cognitive impairment dated 12/18/23 revealed to do labs as ordered. Review of Resident #191's impaired gastrointestinal status related to history of constipation inflammatory bowel disease gastroesophageal reflux disease dated 12/17/23 revealed labs as ordered. Interview on 01/03/24 at 10:59 A.M. with the Director of Nursing (DON) confirmed Resident #191 had refused laboratory testing on 12/18/23, however there was no documented evidence a second attempt was tried or evidence the doctor was notified the labs were not obtained. The DON confirmed the GI consult was not made per the orders on 12/17/23. Review of the facility policy titled Laboratory and Diagnostic Guidelines (dated 10/30/20 and revised 10/26/23) revealed the facility set guidelines to track the timely completion, reporting, and monitoring of laboratory and diagnostic tests, results, and notifications which are used to monitor resident status and/or therapeutic medication levels. The physician should be notified of all refused lab test results orders and reason why. The physician should be notified if the labs test was unable to be completed, reason why, and request for a new order. All notification attempts at notification, and response should be noted in the resident medial record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365687 If continuation sheet Page 18 of 69 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 365687 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Marietta 400 Seventh Street Marietta, OH 45750 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 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the facility failed to arrange an audiology consult per physician's orders for a resident who was hard of hearing. This affected one resident (#30) of two residents reviewed for communication. The facility census was 97. Residents Affected - Few Findings include: Record review revealed Resident #30 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, atrial fibrillation, hyperlipidemia, congestive heart failure, and conductive hearing loss. Review of a care plan dated 08/16/23 revealed Resident #30 was at risk for impaired communication related to hard of hearing and interventions included audiology referral as needed. Review of orders revealed an order from 12/11/23 to please schedule audiology exam dx (diagnosis): hearing loss. Review of a progress note from 12/11/23 by Physician #303 revealed Resident #30 was seen regarding complaints of bilateral hearing loss with a plan of getting a consult for an audiology exam. Interview on 01/02/24 at 5:19 P.M. with Resident #30 revealed the resident was hard of hearing and denied the use of a hearing aid. During the interview, questions were repeated multiple times and above normal conversational tone for Resident #30 to hear. Interview on 01/04/24 at 2:20 P.M. with Resident #30 confirmed she does have a hard time hearing and she did ask someone about hearing aids but never heard back. Interview on 01/09/24 at 12:24 P.M. with Licensed Social Worker (LSW) #125 confirmed Physician #303 gave an order on 12/11/23 for Resident #30 to be referred to audiology for a consult. LSW #125 confirmed a referral for audiology had not been completed. LSW #125 stated she reviewed an audiology visit that occurred after Resident #30 admitted to the facility and she was not seen, and Resident #30 was also not on the list for the upcoming audiology visit. LSW #125 sent a referral on 01/09/24 for Resident #30 to be seen by the audiologist. Review of a policy titled Hearing and Vision Services (dated 10/30/23) revealed the facility is to ensure residents have access to and receive proper treatment and assistive devices to maintain vision and hearing abilities. Additionally, employees should refer any identified need for hearing or vision services/appliances to the social worker who is responsible for assisting residents in locating and utilizing any available resources for the provision of hearing services the resident needs then make an appointment and arrange transportation if needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365687 If continuation sheet Page 19 of 69 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 365687 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Marietta 400 Seventh Street Marietta, OH 45750 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 - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, interview, and policy review the facility failed to ensure pressure ulcer treatments were administered as ordered. This affected one resident (#65) of two reviewed for pressure ulcers. The facility census was 97. Residents Affected - Few Findings included: Medical record review revealed Resident #65 was admitted to the facility on [DATE] with diagnoses including osteomyelitis, Stage 4 pressure ulcers (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible on some parts of the wound bed) to left and right buttocks, paraplegia, and heart failure. Review of the wound center note dated 12/18/23 revealed the resident would return in three weeks (01/08/24). Review of Nurse Practitioner (NP) note dated 12/27/23 revealed the resident reported he would not be going to the wound center for three weeks due to the holidays fell on Monday, which was his scheduled day. The resident reported he would like his dressing changed to twice a day until he was able to go back to the wound center due to he was having a lot of soiling in his depends from the two wounds on his buttocks. The NP plan was to change the dressing change orders to twice a day for now until he can get back with the wound center as he was having a lot of drainage between dressing changes. Review of the written order dated 12/27/23 revealed to do dressing changes to the right ischium and left buttocks twice daily until appointment with wound center. Review of Resident #65's orders and treatment administration record (TAR) dated 12/27/23 to 01/03/24 revealed no evidence the 12/27/23 order to increase dressing changes to twice a day was implemented per the written order on 12/27/23. Review of Resident #65's December 2023 TAR revealed no evidence the pressure ulcer treatments to the left and right gluteal were administered on 12/13/23, 12/15/23, and 12/22/23. Review of the January 2024 TAR revealed no evidence the treatment was completed on day and night shift on 01/05/24, the day shift on 01/07/24, and the night shift on 01/08/24 to the left and right gluteal pressure ulcers. Review of Resident #65's wound note dated 01/09/24 revealed the resident had two Stage 4 pressure ulcers. One on the right gluteus and one on the left gluteus. Interview on 01/03/24 at 9:00 A.M., with Resident #65 revealed he had spoken to the doctor last week and staff were to change his two-pressure ulcer dressings twice daily, however they have only been changing it once daily. Interview on 01/03/24 at 9:00 A.M., with the Director of Nursing (DON) confirmed there was a new order written on 12/27/23 to change the two-pressure ulcer dressings twice daily, however it was never (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365687 If continuation sheet Page 20 of 69 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 365687 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Marietta 400 Seventh Street Marietta, OH 45750 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 implemented for an unknown reason. Level of Harm - Minimal harm or potential for actual harm Interview on 01/10/24 at 9:52 A.M., with Registered Nurse (RN) #143 confirmed Resident #65's treatments were not administered as ordered on 12/13/23, 12/15/23, 12/22/23, 01/05/24, 01/07/24, and 01/08/24. Residents Affected - Few Review of the facility policy titled Pressure Ulcer/Skin Breakdown-Clinical Protocol dated 10/30/22 and revised on 01/02/23 revealed the provider would authorize pertinent orders related to wound treatments, including dressings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365687 If continuation sheet Page 21 of 69 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 365687 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Marietta 400 Seventh Street Marietta, OH 45750 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #80 revealed an admission date of 09/27/23 with diagnoses including dementia and hypertension. The resident resided on the secured dementia unit. Review of the plan of care dated 09/28/23 revealed the resident was at risk for falls/injury related to impaired cognition with decreased safety awareness, wandering, history of falls. The goal was to reduce the risk of injury. Interventions included to ensure the resident's room was free from accident hazards including no trip hazards. The plan of care was revised 12/08/23 to educate housekeeping to ensure parameters were marked off when mopping floor and excess water is not left on floor. A Minimum Data Set (MDS) assessment completed 10/01/23 documented a Brief Interview for Mental Status (BIMS) score of four, indicating severe cognitive impairment. The MDS noted the resident had no functional limitation in range of motion and required only supervision or touching assistance for sit to stand, chair to bed, toilet transfer, and walking 10 feet. The MDS also noted the resident had a fall history but no falls since admission. A fall risk assessment on 12/07/23 indicated no falls and a score of 13. (A score of 10 or higher is at risk for falls per fall risk evaluation form). Review of nurse's progress notes revealed on 12/07/23 at 11:27 A.M. the nurse was alerted by an STNA of Resident #80's fall. When entering the room it was noticeable the floor had just been mopped. Resident on the floor laying on her back complaining of pain in right ankle. Skin assessment completed with no physical injuries noted. Resident denied hitting head. Resident lifted off floor via hoyer lift and placed on bed. Ice pack applied to ankle. Physician notified. 911 called for transport to emergency room. Review of an x-ray report for Resident #80 on 12/07/23 revealed an oblique fracture of the distal fibula which is mildly displaced and a mildly comminuted fracture of the medial malleolus noted. Review of emergency room notes from 12/07/23 revealed an orthopedic glass splint was applied. The resident was to be non-weight bearing and follow up with orthopedics in one week. The resident returned to the facility on [DATE]. Physician's orders were obtained on 12/08/23 for vascular checks to the right foot every shift and as needed. On 12/10/23 there was an order for non-weight bearing to right leg every shift for fracture. A nurse practitioner note on 12/07/23 revealed the resident slipped on wet floor today and had fall related to that. Went to the emergency room and found to have a distal tibia fracture that was mildly displaced. Put on splint and bedrest. Follow up with orthopedics. Review of an incident report dated 12/07/23 at 8:45 A.M. revealed alerted by STNA of resident fall. (as described earlier in nurses note 12/07/23 at 11:27 A.M.). It indicated the resident had a pain level of eight (out of 10). Pre-disposing factors were wet floor, impaired memory, and ambulating without assistance. A statement from STNA #248 on 12/07/23 revealed she was collecting breakfast trays and another STNA (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365687 If continuation sheet Page 22 of 69 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 365687 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Marietta 400 Seventh Street Marietta, OH 45750 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 - Actual harm asked for help pulling a resident up. She helped pull up other resident. STNA #248 heard the housekeeper telling us someone was on the floor and Resident #80 was yelling. STNA #248 went to check on the resident while other STNA went to get the nurse. Resident #80 was on the floor saying her right leg hurt. The floor was very wet. Residents Affected - Few A statement from STNA #167 on 12/07/23 revealed she was outside on a 15 minute break. Came back in and heard the housekeeper say someone was on the floor. Resident #80 was on the floor close to the bathroom door on her back saying her right leg was hurting. STNA #167 got the nurse. The resident's floor was soaking wet and very slick when we went in there. A statement from STNA #131 on 12/07/23 revealed she was feeding a resident in her room while another aide was picking up breakfast trays. The third aide was on break. We heard the housekeeper yell someone was on the floor and Resident #80 was screaming for help. When she got to the room, Resident #80 was laying on the floor on her back holding her leg. The floor was very wet. There was a wet floor sign outside the door. Notified nurse. Review of a statement (undated) by Housekeeper #204 revealed she was cleaning Resident #80's room. Finished up mopping and headed across the hall to G2 to begin cleaning when she heard a loud thump. Nurses aides came out of the dining area where she immediately told them that Resident #80 had fallen. Wet floor sign was up and she mopped Resident #80's room like all 20 rooms she'd been mopping for five years. Wet floor signs were always placed at the door of the areas being mopped. Resident #80 was constantly wandering and sometimes stumbling around. (The statement did not indicate where Resident #80 was at the time the mopping of her room was done). A significant change MDS assessment completed 12/12/23 documented a BIMS of five reflecting severe cognitive impairment. The MDS also noted the resident now had impairment in range of motion on one side of lower extremity, and was dependent on staff for sit to stand, chair to bed mobility, and toilet transfer. The MDS noted the resident had one fall with major injury since admission [DATE]). A nurse's progress note on 12/13/23 at 3:54 P.M. indicated an orthopedic appointment on 12/15/23. Review of the orthopedic consultation notes on 12/15/23 revealed Resident #80 was seen status post bimalleolar right ankle fracture. Patient should be non-weight bearing. Please take boot off three times a day for skin checks. Follow up in office in one week. Observations on 01/08/24 at 7:50 A.M. revealed the resident was seated in a wheelchair with a fracture boot on the right foot. Interview with Housekeeper #204 on 01/08/24 at 1:15 P.M. revealed Resident #80 was in bed when she mopped the floor in her room. She stated the resident then got up and fell and did not pay any attention to the wet floor sign she put up. She stated after the incident, she was instructed to only mop if a resident was not in the room and stated she must put up a velcro strip with stop sign across the door to keep the resident out of the room until the floor dries. She stated they also now close the dining room doors to keep residents out while it is mopped. A follow-up interview with Housekeeper #204 on 01/09/24 at 8:40 A.M. confirmed Resident #80 was in bed when she mopped the room. She stated she placed the wet floor sign just inside the door. She stated Resident #80 looked like she was sleeping so she did not say anything to her about not getting up while the floor was wet. She stated she left the room and later observed the resident on the floor in her room. She stated the resident was laying on the floor about half way between the bed and door. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365687 If continuation sheet Page 23 of 69 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 365687 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Marietta 400 Seventh Street Marietta, OH 45750 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 Interview with Registered Nurse #143 on 01/09/24 at 8:15 A.M. revealed the resident's on the secured dementia unit were cognitively impaired so they don't read wet floor signs. Level of Harm - Actual harm Residents Affected - Few Review of the fall prevention program policy dated 10/30/20 and revised 10/26/23 revealed each resident's risk factors and environmental hazards would be evaluated when developing the resident's comprehensive plan of care. Interventions would be monitored for effectiveness. 4. A review of Resident #42's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease, a non-displaced fracture of the upper end of the left humerus (shoulder), unsteadiness on feet, abnormalities of gait and mobility, and muscle weakness. A review of Resident #42's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues and her cognition was moderately impaired. She had a functional limitation in her range of motion to one side of her upper extremities and no mobility devices were used. The resident was indicated to have had a fall since her prior assessment. She had one fall with an injury that was not major injury and one fall with major injury. Her last annual MDS assessment completed on 08/09/23 revealed the resident required supervision with the assist of one for transfers, ambulation, locomotion, and toilet use. Balance issues were present at that time, but the resident was able to stabilize without assistance. A review of Resident #42's care plans revealed she was at risk for falls/injury related to a history of falls and hypotension. The goal was to reduce the risk of injury through the next review date. Interventions included ensuring the resident was wearing appropriate footwear when out of bed (10/24/23), remove slippers from room (10/31/23), non-skid footwear to reduce the risk of slipping as the resident allows (11/07/23), and the use of non-skid shoes when ambulating (11/07/23). A review of Resident #42's physician's orders revealed the resident had an order to encourage the resident to wear gripper socks (socks with a non-slip sole) while in bed due to the resident being known to toilet herself. The order originated on 05/10/23. Her orders also included wearing non-skid shoes when ambulating (05/11/23) and ensuring she was wearing appropriate footwear when out of bed (10/24/23). A review of an incident report dated 10/23/23 at 9:10 P.M. revealed the nurse was summoned by an STNA to the second floor saying Resident #42 fell on the elevator. The nurse found the resident lying on the floor by the elevator door. The resident was complaining of intense pain and the nurse noted that a slight touch, pressure, or movement of the arm caused the resident to moan in pain. The nurse immobilized the left upper extremity (LUE) and assisted the resident back gently to her wheelchair while awaiting for the squad. When asked what happened, the resident reported her slippers got caught between the elevator and the floor causing her to fall. The immediate action taken was to ensure the resident was wearing appropriate footwear when out of bed. Injuries that resulted from the fall was a suspected fracture of the left upper arm. Predisposing physiological factors included confusion and predisposing situation factors included improper footwear. A witness statement from STNA #101 revealed she was standing at the nurses' station when the resident walked onto the elevator and stumbled over her slipper. She fell back against the wall and rolled her face down on the floor. The resident was evaluated in the emergency room and it was confirmed she had a fracture of the left humerus. A review of the facility's fall investigation dated 10/24/23 at 8:16 A.M. revealed Resident #42's fall that occurred on 10/23/23 was reviewed by interdisciplinary team (IDT). The intervention added (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365687 If continuation sheet Page 24 of 69 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 365687 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Marietta 400 Seventh Street Marietta, OH 45750 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 - Actual harm Residents Affected - Few to prevent additional falls from occurring included ensuring the resident was wearing appropriate footwear when out of bed. Other interventions implemented as a result of that fall was to obtain orthostatic blood pressures and the removal of any slippers from the resident's room. A review of an incident report for a fall occurring on 12/30/23 at 3:15 P.M. revealed Resident #42 was in the second floor dining room when she fell. The resident reported she was just walking through when she fell down. Other residents in the dining room revealed the resident's shoe was coming off and she slipped. She was not wearing proper footwear at the time of the fall. The fall was not witnessed by staff, but they heard the commotion in the dining room stating that a resident had fallen. The staff heard a loud boom on the floor and found the resident lying on her right side with coffee spilled all over the floor. A review of the facility's fall investigation for Resident #42's fall that occurred on 12/30/23 revealed the new fall prevention intervention added was for the resident to sit while drinking beverages. They also checked her footwear for proper fitting. On 01/03/24 at 8:31 A.M., an observation of Resident #42 noted her to be sitting on the side of her bed with bare feet. She was not noted to be wearing any gripper socks of non-skid footwear as per her plan of care. She had also been observed ambulating in her room in her bare feet the day before. On 01/08/24 at 8:28 A.M., further observations of Resident #42 noted her to be lying in bed in a supine position with her eyes closed. Her feet were visible as they were not covered with her blanket and the resident was again observed to be lying in bed with bare feet. There was a pair of house slippers without backing to the heel area that was sitting on the floor at the foot end of her bed. On 01/08/24 at 9:00 A.M., an interview with STNA #227 revealed she had worked at the facility since November 2023. She reported Resident #42 required supervision to one assist with ambulation. She considered the resident to be at risk for falls and was aware that the resident has had a history of falls. She was asked what fall prevention interventions were in place for the resident. She indicated the resident was to have the use of gripper socks at night and was to have shoes on when up. They also tried to keep a close eye on her. She indicated if the resident had a night gown on she was to have gripper socks on as well. She verified the resident was lying in bed and did not have any gripper socks on her feet. She also verified the resident had a pair of house slippers without backing to the heel area on the floor at her bedside. On 01/08/24 at 9:08 A.M., an interview with LPN #211 revealed Resident #42 was independent with ambulation, but has had a history of falls. She was asked what fall prevention interventions were in place for the resident and reported she would have to check the care plan to see if she was a fall risk and what fall prevention interventions were to be in place. She recalled the most recent fall prevention intervention added was not to walk and drink at the same time. She then reported ensuring the resident had appropriate footwear on was another fall prevention intervention. All staff were responsible for ensuring fall prevention interventions were in place. She denied she was informed in report that the resident had refused to have her gripper socks on her feet last night to explain why gripper socks were not in place that morning. She verified the resident did not have gripper socks on at the present time when lying in bed. She also verified there was a pair of house slippers on the floor next to the bed and one of her prior fall interventions in response to a previous fall was for the removal of slippers from her room. She asked the resident if she could put her gripper socks on and the resident replied that she could. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365687 If continuation sheet Page 25 of 69 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 365687 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Marietta 400 Seventh Street Marietta, OH 45750 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 - Actual harm Residents Affected - Few On 01/08/24 at 10:45 A.M., an interview with the DON was completed regarding Resident #42's falls and interventions in place to prevent additional falls from occurring. She acknowledged the resident was observed up ambulating without proper footwear on last week and follow up observations on 01/08/24 found her to not have gripper socks on when in bed as per his plan of care. She also acknowledged the resident was observed to have a pair of slippers in her room that was at the foot of the bed. She confirmed the removal of slippers from the room was a fall prevention intervention that had previously been implemented following a fall. She stated she thought they had been previously removed by the family, but she would have to look into it to see if the family had brought another pair in for the resident or not. She confirmed the removal of slippers from the resident's room continued to be a fall prevention intervention that should be followed. A review of the facility's fall policy revised 10/26/23 revealed each resident would be assessed for the risks of falling and will receive care and services in accordance with the level of risk to minimize the likelihood of falls. Each resident's risk factors and environmental hazards would be evaluated when developing the resident's comprehensive plan of care. Interventions would be monitored for effectiveness and the plan of care would be revised as needed. When a resident experienced a fall, the facility would review the resident's care plans and update as indicated. 3. Medical record review revealed Resident #70 was admitted to the facility on [DATE] with diagnoses including dementia, unsteadiness on feet, muscle weakness, cognitive communication deficit, abnormalities of gait and mobility, depression, high blood pressure, and heart disease. Review of Resident #70's fall risk evaluation dated 06/08/23, 07/08/23, and 09/19/23 revealed the resident was a high risk for falls. Review of Resident #70's fall plan of care dated 10/13/23 revealed non-skid strips to the foot of the bed to reduce the risk of slipping. Observation on 01/04/24 at 7:53 A.M. of Resident #70 revealed the resident was resting in bed. The bed was against the wall on the left side. There was a floor mat on the right side. There was non-skid strips noted on the floor on the other side of the mat (not near the foot of the bed) in the middle of the floor. Observation on 01/08/24 7:57 A.M. with State Tested Nurse's Aide (STNA) #107 and STNA #112 confirmed the non-skid strips were not located at the foot of bed to reduce the risk of falling per the plan of care. The STNA's confirmed the resident was ambulatory and wanders hallways frequently. Interview on 01/08/24 at 8:04 A.M. and 9:44 A.M. with the Director of Nursing (DON) confirmed the plan of care indicated there were to be non-skid strips to the foot of the bed and she would have staff move the non-skid strips right away. Review of Resident #70's fall investigation, progress notes, SOC form, and initial fall reports revealed: a. Review of the initial fall assessment dated [DATE] revealed the resident had fallen on 02/06/23, however there was no detail regarding the actual fall. Review of Resident #70's progress notes revealed no evidence of documentation regarding the fall. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365687 If continuation sheet Page 26 of 69 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 365687 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Marietta 400 Seventh Street Marietta, OH 45750 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 Review of the fall investigation, which was not part of the medical record, dated 02/06/23 revealed the resident was found by an STNA on the floor beside the bed with the blanket tangled around both legs. Level of Harm - Actual harm Residents Affected - Few Interview on 01/08/24 at 2:05 P.M., with the DON confirmed there were no documented details of the residents fall in the medical record. b. Review of Resident #70's progress note dated 05/15/23 revealed the resident had fallen on 05/14/23 and hit the back of her head. Review of Resident #70's SOC form dated 05/15/23 revealed on 05/14/23 the resident had fallen and had a head injury. The new intervention was a medication review. Review of the fall investigation, which was not part of the medical record, dated 05/14/23 revealed the staff heard the door alarm sounding and staff found the resident lying on her left side holding her head. The new intervention was a medication review. Review of Resident #70's medical record revealed no evidence a medication review was conducted. Interview on 01/08/24 at 2:05 P.M., with the DON confirmed there was no documented evidence a medication review was conducted. c. Review of the initial fall note dated 05/23/23 revealed the resident had fallen on 05/23/23 and new orders were received for orthostatic blood pressures and pulse every shift for three days, medication review, and to monitor tooth. Review of the fall investigation, which was not part of the medical record, dated 05/23/23 revealed the resident found by an STNA on her knees on the floor attempting to stand up. The resident was bleeding from her mouth and nose. The resident had a tooth that was slightly loose and had complaints of pain but could not rate. There was no evidence of the root cause of the fall. Review of the resident's medical record revealed no evidence the orthostatic blood pressure and pulse was monitored for three days, a medication review was completed, or documented evidence the tooth was monitored. Interview on 01/08/24 at 2:05 P.M., with the DON confirmed there was no documented evidence that orthostatic blood pressure and pulse were monitored for three days following the fall, no evidence a medication review was conducted, or documented evidence the tooth was monitored. d. Review of the fall investigation, which was not part of the medical record, dated 05/31/23 revealed no evidence of the root cause of the fall. The resident was found in the bathroom by housekeeping with blood on her hands and forehead. Interview on 01/08/24 at 2:05 P.M., with the DON confirmed there was no documented evidence of what the root cause of the fall was. e. Review of Resident #70's initial fall note dated 06/08/23 revealed the resident had fallen on 06/08/23. Intervention includes ensuring the resident had non-skid socks on while awake, which was an intervention already implemented on 05/19/23 because of a fall. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365687 If continuation sheet Page 27 of 69 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 365687 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Marietta 400 Seventh Street Marietta, OH 45750 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 - Actual harm Review of the fall investigation, which was not part of the medical record, dated 06/08/23 revealed an aide saw the resident tried to sit on the chair and fell and bumped her head. The resident was not wearing appropriate footwear. The immediate action taken was to ensure the resident had nonskid socks on while awake. Residents Affected - Few Interview on 01/08/24 at 2:05 P.M., with the DON confirmed the resident did not have non-skid socks on which was the root cause of the fall. The DON confirmed a staff member observed the fall and there was no evidence the staff member intervened to prevent the fall. f. Review of Resident #70's initial fall note dated 07/08/23 revealed the resident had fallen on 07/08/23 and had a soft hematoma on the left side of the head. Staff were re-educated in the use of proper footwear and cleaning up spills. Review of fall investigation, which was not part of the medical record, dated 07/08/23 revealed the resident did not have appropriate footwear on (bare feet) and slipped on orange juice on the floor. Interview on 01/08/24 at 2:05 P.M., with the DON confirmed the resident had fallen again because of not having proper footwear in-place and there was orange juice on the floor which resulted in the resident falling. Review on the facility policy titled Fall Prevention Program dated 10/26/23 revealed each resident would be assessed for the risks of falling and would receive care and services in accordance with the level of risk to minimize the likelihood of falls. The facility would utilize a standardized risk assessment for determining a resident's fall risk. When a resident experiences a fall the facility would assess the resident, complete a post-fall assessment, complete and incident report, notify the physician and family, review, and update plan of care, document all assessments and actions, and obtain witness statement in the care of injury. 5. Review of Resident #24's medical record revealed she was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including hemiplegia, unspecified affecting the left non-dominant side, cerebral infarction, unspecified, type two diabetes mellitus with unspecified complications, essential (primary) hypertension and nicotine dependence. Review of Resident #24's census revealed she was out of the facility from 11/16/22 to 12/20/22 and 11/25/23 to 11/27/23. Review of Resident #24's annual MDS assessment, dated 10/05/23, revealed she was cognitively intact. Review of Resident #24's plan of care, dated 07/20/23, revealed she was a smoker and interventions included periodically complete safe smoking evaluations and she was to use a smoking apron. Review of Resident #24's Nursing Quarterly/Significant Change Evaluations, dated 04/16/23, 07/05/23, 07/06/23 and 10/08/23, revealed she was not a smoker. Review of Resident #24's physician order, dated 11/27/23, identified she was to use a smoking apron due to poor safety awareness. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365687 If continuation sheet Page 28 of 69 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 365687 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Marietta 400 Seventh Street Marietta, OH 45750 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 Review of Resident #24's most recent Nursing readmission Evaluation, dated 11/29/23, revealed she may smoke with the smoking aide of a smoking apron. Level of Harm - Actual harm Residents Affected - Few Interview on 01/02/24 at 11:17 A.M. with Resident #24 revealed she had always been a smoker while living in the facility. Observation on 01/03/24 at 3:52 P.M. of Resident #24 outside on the smoking patio preparing to smoke with no smoking apron on. She was holding a cigarette and STNA #241 was lighting resident cigarettes with a lighter. STNA #241 reported she didn't know Resident #24 needed a smoking apron. STNA #241 reported there was usually a list in the smoking box to notify staff which residents needed a smoking apron for safety. Observation of the smoking box revealed a paper which identified Resident #24 was to have a smoking apron. STNA #241 verified Resident #24 would not have been provided a smoking apron if this surveyor had not approached her regarding the issue. STNA #241 also did not take the smoking blanket outside to have in case of an emergency. When asked about the smoking blanket, STNA #241 responded I don't even know where the smoking blanket is. Interview on 01/03/24 at 5:45 P.M. with Registered Nurse #143 verified Resident #24's smoking assessments in the Nursing Quarterly/Significant Change Evaluations, dated 04/16/23, 07/05/23, 07/067/23, and 10/08/23 were not accurate and should be. Review of the facility policy titled, Smoking, reviewed/revised 01/01/22, revealed the purpose of this procedure was to establish uniform guidelines related to smoking, smoking safety, and electronic cigarettes (known as e-cigarettes and other vapor and/or nicotine use devices). Further review revealed smoking assessments would be completed upon admission, quarterly, with a significant change in status related to smoking, or anytime the facility determined it was warranted. Additionally, residents who smoke would have their specific interventions identified on the resident Kardex for staff review which included smoking aprons. Based on observation, medical record review, interviews, policy review, mechanical lift user manual review, and review of fall assessments, the facility failed to provide adequate assistance, supervision and/or interventions to prevent resident falls. The facility also failed to develop and implement adequate safety interventions for resident smoking to prevent accidents/injury. This affected five residents (#24, #42, #47, #70, and #80) of five residents reviewed for accidents. Actual psychosocial and physical harm occurred on 12/27/23 during a staff assisted transfer using a mechanical lift for Resident #47 resulting in a fall. During the transfer facility staff failed to provide a safe, clear, environment resulting in the lift becoming stuck under the resident's wheelchair. Staff pulled the mechanical lift in an effort to release it from under the wheelchair causing Resident #47 to bounce in the mechanical lift which then leaned too far to the left, tipping over and Resident #47 made contact with her roommate's bed causing the resident to fall to the floor. Following the incident, the resident complained of neck and shoulder pain that was described as intermittent aching, burning and pressing, causing occasional disruption of her sleep and activities requiring medication to control the pain that did not have a lasting effect. In addition, following the incident, Resident #47 was noted to be afraid and sad of using the hoyer lift and cried when she was required to use it. Actual harm occurred on 12/07/23 when Resident #80, who was cognitively impaired attempted to get out bed, slipped, fell and fractured her right ankle. At the time of the incident, the resident's floor was identified to have been wet due to just being mopped creating an environmental hazard for the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365687 If continuation sheet Page 29 of 69 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 365687 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Marietta 400 Seventh Street Marietta, OH 45750 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 resident. Level of Harm - Actual harm Findings included: Residents Affected - Few 1. Record review revealed Resident #47 admitted to the facility on [DATE] with diagnoses including Crohn's disease, chronic respiratory failure, type II diabetes, hypertensive heart disease, acute kidney failure, adjustment disorder with mixed anxiety and depressed mood, anxiety disorder, major depressive disorder, and congestive heart failure. Review of physician orders revealed Resident #47 was ordered buspirone, an anti-anxiety medication, 10 milligrams (mg) two tablets every morning and at bedtime on 09/14/23, Eliquis, a blood thinning medication, five mg twice a day on 11/14/23, fluoxetine, an antidepressant, 60 mg once a day on 09/15/23, and hydrocodone-acetaminophen 5-325 mg once every eight hours as needed for pain on 09/15/23. Review of a quarterly Minimum Data Set (MDS) completed on 10/04/23 revealed Resident #47 had intact cognition, had a depression scale score of zero indicating no depression, and was dependent on staff for transfers. Review of the care plan dated 10/18/23 revealed Resident #47 was at risk for an impaired mood/psychiatric status related to anxiety, depression with potential for restlessness, agitation, tearfulness, and being withdrawn with a goal of having reduced complications related to altered mood status through 01/16/24. Interventions included observing for and reporting any signs or symptoms for change in mood from Resident #47's baseline to physician, observe for signs of distress, observe mood to determine if problems appear to be related to external causes, and offer encouragement. Review of an initial fall assessment completed on 12/27/23 at 2:35 P.M. revealed Resident #47 was being transferred from her bed to chair when she fell. The facility initiated an intervention to ensure clean and safe environment when completing hoyer transfers and ask visitors to step outside if needed. A Fall Risk Evaluation completed on 12/27/23 at 2:44 P.M. revealed Resident #47's most recent fall occurred on 12/27/23, conditions that placed her at risk for falls included pain, psychiatric or cognitive, orthopedic, abnormal labs, and circulatory issues. Resident #47's fall risk was scored at 20. A skin check completed on 12/27/23 at 2:46 P.M. revealed no new skin issues related to the fall. An assessment titled Resident/Family Education Record completed on 12/27/23 at 4:07 P.M. revealed Resident #47 was verbally educated regarding a staff assisted fall resulting in shoulder and neck discomfort but Resident #47 had declined to go to the emergency department and wanted to see how she was feeling tomorrow (12/28/23). Review of staff education for Safe Lifting and Movement of Residents completed on 12/27/23 revealed State-Tested Nursing Assistant (STNA) #136 and STNA #182 were educated on safe hoyer transfers. Review of a fall investigation completed on 12/27/23 by Licensed Practical Nurse (LPN) #175 revealed LPN #175 was called to Resident #47's room where she observed the resident lying on the floor with a hoyer pad under her and the hoyer lift still attached to the pad. Nursing aides stated the hoyer lift leg got stuck under the wheelchair and it tipped the hoyer but the aides were able to slowly lower the resident to the floor without any injuries and the resident described the incident as I knew I was going down but slowly. LPN #175 documented no injuries at the time of the fall and reported Resident #47 had zero pain. LPN #175 documented the predisposing factors for the fall as crowding. Review of a statement from STNA #136 on 12/27/23 revealed she and another STNA (#182) were transferring Resident #47 from her bed to her wheelchair, they had requested the visitors to leave the room (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365687 If continuation sheet Page 30 of 69 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 365687 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Marietta 400 Seventh Street Marietta, OH 45750 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 - Actual harm Residents Affected - Few so there was plenty of space to work but one visitor remained in the room seated in a chair. STNA #136 continued by stating she and STNA #182 began the transfer while trying not to touch the visitor, and once they began connecting the hoyer to the wheelchair and sliding the legs of the hoyer open, they realized one leg of the lift was stuck under the wheelchair. STNA #136 stated Resident #47's body then started going towards the left and they tried to balance her but they were unable to manage the weight, but due to the leg of the hoyer being stuck under the chair, they were able to slowly lower Resident #47 to the ground without injuring her. A statement from STNA FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365687 If continuation sheet Page 31 of 69 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 365687 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Marietta 400 Seventh Street Marietta, OH 45750 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 medical record review, observation, interview, and policy review the facility failed to ensure suprapubic catheter treatments and antibiotics were administered per order. This affected one resident (#65) of one resident reviewed for urinary catheter/urinary tract infection. Findings include: Medical record review revealed Resident #65 was admitted to the facility on [DATE] with diagnoses including neuromuscular dysfunction of bladder, paraplegia, pressure ulcers, and heart failure. Review of Resident #65's pertinent charting for infections dated 12/31/23 and 01/01/24 revealed the resident had completed antibiotic (Clindamycin) regimen and was still having pain and redness around catheter site. New antibiotic being ordered. Review of Resident #65's current orders revealed on 12/21/23 a new order was written to wash suprapubic catheter site with soap and water, pat dry, apply split drain gauze and change daily. There was no evidence a new antibiotic order was written after the resident finished the Clindamycin on 12/31/23. Review of Resident #65's suprapubic catheter plan of care dated 12/21/23 revealed to report signs of peri-area redness, irritation, skin excoriation/breakdown and to administer medications as ordered. The plan of care did not include to wash suprapubic site with soap and water, pat dry, apply split drain gauze and change daily. Interview and observation on 01/02/24 at 9:48 A.M., with Resident #65 revealed he had recently had a suprapubic catheter surgically inserted, and it was infected. He had completed an antibiotic, and the doctor was supposed to start another antibiotic however, the staff has never started it. The resident pulled down the sheet to show the surveyor and the area around the suprapubic catheter was red, swollen, and there was serosanguinous drainage noted on his depends from the suprapubic catheter. Resident #65 also reported staff had not been applying a drain sponge around the suprapubic catheter per orders. Interview on 01/03/24 at 8:49 A.M., with Licensed Practical Nurse (LPN) #175 and the Director of Nursing (DON) revealed the physician had ordered Bactrim on 12/31/23 due to the suprapubic catheter still had drainage and redness after the resident completed the Clindamycin, however LPN #175 reported she forgot to put the order in and just realized it this morning. Observation on 01/03/24 at 9:00 A.M., of Resident #65 with the Director of Nursing (DON) revealed there was no drainage sponge noted around the suprapubic catheter and the area was still red, swollen, and there was serosanguinous drainage noted on the depends again. The resident confirmed staff did not put a drain sponge on yesterday or today. The resident reported to the DON he was supposed to be started on a new antibiotic, but the staff had not started it yet. The DON confirmed the resident did not have a drain sponge in place per the physician order. Review of the facility policy titled Catheter Care Procedure-Urinary (dated 10/30/20 and revised 12/28/23) revealed the facility would provide catheter care to all residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365687 If continuation sheet Page 32 of 69 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 365687 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Marietta 400 Seventh Street Marietta, OH 45750 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on observations, medical record review, policy review, and staff interview, the facility failed to evaluate a resident's decline in intake to ensure the resident maintained acceptable parameters of nutritional status, such as body weight. This affected one resident (#80) of four residents reviewed for nutritional status. The facility census was 97. Residents Affected - Few Findings include: Review of the medical record for Resident #80 revealed an admission date of 09/27/23 with diagnoses including dementia and hypertension. The resident resided on the secured dementia unit. A Minimum Data Set (MDS) assessment completed 10/01/23 documented a Brief Interview for Mental Status (BIMS) score of 4, indicating severe cognitive impairment. It indicated the resident was independent with eating. It stated the resident was 64 inches tall, weighed 118 pounds, and had no weight changes. The resident was admitted on a regular diet. Review of the plan of care dated 09/28/23 revealed the resident was at risk for altered nutritional status related to age, variable intake, abnormal labs, history of significant weight fluctuations, and weight loss. The goal was for the resident to have adequate nutrition to meet nutritional needs for weight stability without significant change and have no signs/symptoms of malnutrition. Interventions included labs related to nutritional status as ordered, observe percentage of meal intake for changes in eating habits, and occupational/speech therapy screen as needed. The resident also had a plan of care for activities of daily living performance deficit which stated the resident required supervision and cueing with meals. A nutrition evaluation on 09/28/23 stated the resident's ideal body weight weight was 120 pounds plus or minus 10%. The resident had not had a change in weight and was not on a weight loss regimen. It stated she fed herself and had her own teeth. Meal intake averages 88%. Current diet order meets needs. Goal is for weight maintenance. The resident's weight was 118 pounds. Review of weight records revealed Resident #80 had the following weights: 9/27/23 and 9/28/23 118 pounds, 10/17/23 121.8 pounds, 10/24/23 121 pounds, 11/1/23 123 pounds, 11/21/23 116 pounds (This represents a 5.6% significant weight loss in one month). Review of nutrition progress notes by Dietary Director #186 on 11/21/23 revealed Resident #80 had a 5% weight loss and weighed 116 pounds. Meal intakes average 78% (down from 88% in September). Recommend continue with current nutrition plan. On 11/28/23 the resident continued to weigh 116 pounds. On 11/30/23 Dietary Director #186 noted the resident's intake had decreased to 52%. Fortified pudding was ordered twice daily. There was no evidence of any evaluation of why her meal intakes had decreased. On 12/01/23 the resident weighed 112.6 pounds (an additional 3.4 pound weight loss in 3 days). On 12/05/23 Dietary Director #186 noted the resident had decreased 3.4 pounds in one week. Intake averages at 56%. House supplement 60 milliliters twice daily was recommended and started. On 12/05/23 the resident weighed 111 pounds (an additional 1.6 pound weight loss in 4 days). A significant change Minimum Data Set assessment was completed on 12/12/23. The resident had a BIMS (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365687 If continuation sheet Page 33 of 69 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 365687 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Marietta 400 Seventh Street Marietta, OH 45750 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few of 5, indicating severe cognitive impairment. It indicated the resident had weight loss and required set up help with eating. A nutrition evaluation on 12/13/23 indicated the resident weighed 111 pounds. However, a weight was documented on 12/13/23 of 110 pounds. The evaluation noted a weight loss of 9%. Goal was for weight maintenance. Meal intakes average 52%. There was no evidence of any evaluation of why her meal intakes had decreased. On 12/19/23 the resident weighed 114.6 pounds (gain of 4.6 pounds). However, meal intakes were noted to be an average of 46% on 12/20/23 dietary progress note. On 12/27/23 and 12/28/23 the resident weighed 112.6 (loss of 2 pounds). A nutrition progress note by Dietary Director #186 on 12/27/23 stated the resident's weight had decreased 2 pounds in one week and her average meal intakes were 38% (down from 88% on admission). The fortified pudding was discontinued and the house supplement was increased to five times daily. There was no evidence of any evaluation of why her meal intakes had decreased. On 01/02/24 the resident weighed 112.8 pounds, down from 123 pounds in November 2023. A dietary progress note on 01/03/24 indicated her average meal intake was 32%. Observations on 01/08/24 at 7:50 A.M. revealed Resident #80 to be sitting in a wheelchair in the secured unit dining room. She was seated at a table by herself. Her breakfast meal was sitting in front of her. She had two slices of french toast (not cut up and no syrup), bacon, a bowl of oatmeal, juice, and milk in a carton with no straw. A couple bites were taken out of one of the slices of french toast as if the resident picked it up and bit off bites. The resident was now just sitting and not eating. At 8:10 A.M. (20 minutes later) the resident was still sitting and had not eaten or drank anything. She had not received any cueing to eat from the two staff that were in the dining room but were at different tables feeding other residents. At 8:11 A.M. State Tested Nursing Assistant (STNA) #107 approached Resident #80 and asked her if she was finished eating. The resident stated no. STNA #107 asked the resident if she wanted syrup on her french toast. STNA #107 then added the syrup and cup up the french toast into small pieces. STNA #107 sat down beside Resident #80. The resident then began to eat (21 minutes after initially having her tray and not eating). At 8:14 A.M. the resident was then given a straw for her milk carton. At 8:17 A.M. the resident remained eating with STNA #107 sitting beside her. She had taken a few bites of her french toast. About two minutes after sitting down, STNA #107 then got up and left. Resident #80 then stopped eating again and did not take another bite or drink. At 8:22 A.M. another STNA asked Resident #80 if she was doing ok. Resident #80 shook her head yes and the staff kept on going. The resident was still not eating. At 8:23 A.M. she had not eaten anything else since STNA #107 had gotten up from beside her. At 8:26 A.M. another aide from across the room asked the resident if she was doing ok. The resident said yes, but was not eating or drinking. No cueing to eat was provided. At 8:32 A.M. STNA #218 picked up her tray. STNA #218 stated the resident ate 50% of her meal (the resident ate about 1 and half slice of the french toast, half of her juice, no bacon, no oatmeal, no milk). Interview with STNA #107 on 01/08/24 at 1:30 P.M. revealed she had worked on dayshift on the secured unit for about three months. She stated she was aware that Resident #80 was not eating well. She stated the resident could feed herself but does need staff to set her tray up such as cutting up foods and taking off lids. She stated the resident usually ate her meals in the dining room. She confirmed the resident's french toast had not been cut up or syrup added when her tray was delivered and a straw had not been provided. She confirmed the resident was eating when she was sitting with her. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365687 If continuation sheet Page 34 of 69 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 365687 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Marietta 400 Seventh Street Marietta, OH 45750 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 0692 Level of Harm - Minimal harm or potential for actual harm She stated she did not realize the resident stopped eating after she got up and left. She stated she did not know why the resident's intake had decreased over time but stated that maybe she does not like to eat alone and staff should sit her at a table where staff are nearby and can prompt her to eat. There was no evidence of any lab work being done to check the resident's nutritional status. Residents Affected - Few Interview with Dietary Director #186 on 01/09/24 at 7:44 A.M. revealed Resident #80 could feed herself but needed cueing. She confirmed the resident was significantly cognitively impaired. She confirmed no lab work had been done to evaluate the resident's nutritional status. She stated she felt the resident's decreased meal intakes were related to the progression of her disease/behaviors but stated staff should provide the set up assistance and cueing the resident needs to ensure she eats as much as she will. Review of the facility policy titled weight monitoring (dated 10/30/20 and revised 10/26/23) revealed the facility would utilize a systemic approach to optimize a resident's nutritional status. This process includes: identifying and assessing each resident's nutritional status and risk factors; evaluating/analyzing the assessment information; developing and consistently implementing pertinent approaches, and monitoring the effectiveness of interventions and revising them as necessary. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365687 If continuation sheet Page 35 of 69 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 365687 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Marietta 400 Seventh Street Marietta, OH 45750 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 Based on medical record review, resident interview, and staff interview, the facility failed to ensure a resident received timely respiratory care. This affected one resident (#73) of three residents reviewed for respiratory care. The facility census was 97. Residents Affected - Few Findings include: Review of the medical record for Resident #73 revealed an admission date of 06/03/23 and diagnoses including chronic obstructive pulmonary disease (COPD) and alcoholic cirrhosis of the liver. Review of a Minimum Data Set assessment completed 12/15/23 revealed a Brief Interview for Mental Status score of 12, indicating moderately impaired cognition. Review of a nurse practitioner progress note dated 12/26/23 at 1:45 P.M. revealed the resident had recent heart catheterization. He was having some chest pain today with drop in oxygen saturation to 88%. He tells me that his pain is localized right to his left sided chest. He does have a moist cough. He does have some shortness of breath. He does not feel it is heart related. He has a history of heart failure as well as hypertension. Does not appear in any distress. Breathing even and unlabored. Did have a low-grade fever this morning of 99.3. The plan: does not want to be sent out to hospital today. He does have some abnormal lung sounds, sounds moist. The nurse practitioner identified she was going to get a chest x-ray for the resident and will continue to monitor him closely. Review of nurse's progress notes revealed on 12/26/23 at 2:31 P.M. a new order was received for a chest x-ray due to cough. Review of an x-ray report revealed a 2 view chest x-ray was completed on 12/27/23. The x-ray conclusion was patchy modest bilateral airspace disease. Pneumonia should be considered in the appropriate clinical setting. Recommend follow up examination to confirm resolution of findings. The report date was 12/27/23 at 1:19 P.M. However, there was no evidence the results were reported to the nurse practitioner until 12/28/23 (x-ray result signed and dated 12/28/23). Review of a nurse practitioner progress note on 12/28/23 at 12:20 P.M. stated resident (#73) had an episode of fever with some hypoxia, shortness of breath yesterday. He had a chest x-ray obtained which does show patchy modest bilateral airspace disease. Pneumonia should be considered. Today, the resident reports feeling fatigued. He has a cough. He is short of breath and just overall not feeling well. Temperature 98.2. Oxygen saturation 95%. He is alert and oriented and in no acute distress. His lungs are diminished bilaterally in the bases. Clear in the uppers. The nurse practitioner's assessment was pneumonia with cough and hypoxia. The nurse practitioner's plan was to start him on Levaquin 750 mg daily for 7 days (antibiotic). A nurse's progress note on 12/28/23 at 6:37 P.M. stated the nurse practitioner had been in to see resident. New orders received for Levaquin every day x 7 days for a diagnosis of pneumonia. Oxygen at 2 liters to maintain oxygen saturation 90% or greater, duoneb every 6 hours as needed for shortness of breath, Robitussin every 6 hours as needed for cough. Review of the medication administration record revealed that, although the Levaquin antibiotic was ordered on 12/28/23, it was not started until the morning of 12/29/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365687 If continuation sheet Page 36 of 69 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 365687 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Marietta 400 Seventh Street Marietta, OH 45750 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 FORM CMS-2567 (02/99) Previous Versions Obsolete Interview with Resident #73 on 01/04/24 at 10:40 A.M. revealed he was in bed in his room and felt his treatment for pneumonia went slowly after being seen by the nurse practitioner on 12/26/23 (x-ray 12/27/23, antibiotics ordered 12/28/23 but not started until 12/29/23). He stated he was feeling better now and had just finished his antibiotics. Interview with Nurse Practitioner #301 on 01/04/24 at 10:55 A.M. confirmed there was a delay in treatment of Resident #73's pneumonia. She stated the nurse practitioner should have been notified of x-ray results on 12/27/23 (not 12/28/23) and antibiotics should have been started the same day they were ordered (not wait until the next day). She stated the order could even be changed to something the facility had available in the facility emergency supply so that it could be started timely. Event ID: Facility ID: 365687 If continuation sheet Page 37 of 69 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 365687 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Marietta 400 Seventh Street Marietta, OH 45750 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 - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, interview, and policy review the facility failed to schedule a pain management appointment for a resident per physician orders. This affected one resident (#65) of one resident reviewed for pain. Residents Affected - Few Findings include: Medical record review revealed Resident #65 was admitted to the facility on [DATE] with diagnoses including osteomyelitis, chronic pain, right hip pain, low back pain, radiculopathy, lumbar and cervical region, paraplegia, Stage 4 pressure ulcers, and heart failure. Review of Resident #65's pain plan of care dated 10/16/23 revealed the resident had low back, pain, pressure ulcers, right hip pain, myalgia, neuralgia, and polyneuropathy. The resident's intervention included pain management/physician referral. Review of Resident #65's pain assessment dated [DATE] revealed the resident had frequent pain in back and hips that was a constant ache. The pain occasionally affected his sleep and physical activities. Review of the Nurse Practitioner (NP) note dated 12/27/23 revealed the resident was complaining of severe right hip pain that he told her he had seen a pain doctor in the past for the SI joint. He would like to go ahead and follow up with a pain doctor for possible injections. The NP Plan was to go ahead and schedule the resident a follow up appointment with the pain doctor for his low back pain and right hip pain. Review of Resident #65's written order dated 12/27/23 revealed to schedule an appointment with the pain doctor of injections of the SI joint. Interview on 01/02/24 at 9:48 A.M., with Resident #65 revealed he was having increased pain his hip and back. The facility was supposed to make an appointment for him to see the pain specialist, but he has still not heard anything. Interview on 01/03/24 at 11:47 A.M., with Resident #65 and the Director of Nursing (DON) revealed the resident reported he was having increased pain. His pain has been from three to seven on a scale from zero to ten. He can tolerate pain five to six. The DON confirmed the facility was not aware of the order written on 12/27/23 and the appointment with the pain specialist had not been made. Review of the facility policy titled Pain Management (dated 10/20/20 and revised 10/26/23) revealed the facility would ensure that pain management was provided to residents who required such services. Based on assessment or evaluation, the facility in collaboration with the attending physician would develop, implement, monitor, and revise as necessary intervention to prevent or manage each resident's pain. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365687 If continuation sheet Page 38 of 69 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 365687 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Marietta 400 Seventh Street Marietta, OH 45750 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview, and resident interview, the facility failed to ensure a resident who required dialysis services received ordered care. This affected one resident (#197) of one resident reviewed for dialysis. The facility census was 97. Residents Affected - Few Findings include: Review of the medical record for Resident #197 revealed an admission date of 12/19/23 and diagnoses including end stage renal disease, diabetes, and morbid obesity. A Minimum Data Set assessment completed 12/23/23 documented a Brief Interview for Mental Status score of 15, indicating intact cognition. It also documented the resident was on dialysis. Interview with Resident #197 on 01/03/24 at 3:25 P.M. revealed she goes out for dialysis three times weekly on Monday, Wednesday, and Friday. She stated, and it was observed, that she has a port in her chest used for the dialysis treatments. She stated she leaves around 6-6:30 A.M. and returns around 11-11:30 A.M. She confirmed she had went to dialysis on 01/03/24. Review of physician's orders revealed an order for dialysis on Monday, Wednesday, and Friday with chair time at 6:30 A.M. at a dialysis center. The name, address, and phone number of the dialysis center was listed. The surveyor asked the facility for the contract for that dialysis center and the Administrator confirmed on 01/04/24 at 2:30 P.M. that the dialysis center, address, and phone number listed in the physician's order was not the correct dialysis center that Resident #197 went to. Review of medication administration records revealed that on 12/22/23 (Friday), 12/27/23 (Wednesday), 12/29/23 (Friday), and 01/03/24 (Wednesday) Resident #197's morning medications were documented as administered at times when the resident would have been at dialysis. The morning medications were set up to be given between 7:00 A.M. and 10:00 A.M. Medications were documented as administered at the following times: 12/22/23: 8:59 A.M., 12/27/23 8:56 A.M., 12/29/23 7:53 A.M. and 01/03/24 7:49 A.M., even though the resident would have been at dialysis at those times. There was no documentation in the record to indicate that the resident did not go to dialysis on those days. Interview with the Director of Nursing (DON) on 01/04/24 at 8:15 A.M. confirmed the medications were documented as given at times when the resident would have been out of the facility for dialysis. She confirmed Resident #197 goes Monday, Wednesday, and Friday and leaves at 6:15 A.M. and gets back at lunch time. The DON stated she did not know if the resident went for dialysis on Christmas day or New Years day. Interview with Registered Nurse (RN) #143 on 01/04/24 at 11:15 A.M. revealed that Licensed Practical Nurse (LPN) #217 told her that she documented the medications as given on 12/27/23 at 8:56 A.M. but did not give them until the resident got back from dialysis (lunch time). She confirmed the medications should not be documented until they are actually given to the resident. Review of communication sheets from dialysis revealed the only communication sheet available was from 12/20/23. Resident #197 would have been scheduled to have dialysis on 12/22/23, 12/25/23, 12/27/23, 12/29/23, 01/01/24, and 01/03/24. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365687 If continuation sheet Page 39 of 69 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 365687 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Marietta 400 Seventh Street Marietta, OH 45750 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 Interview with LPN #217 on 01/04/24 at 9:03 A.M. confirmed the only communication sheet from dialysis was for 12/20/23. She stated the dialysis center is to send back a communication sheet to notify the facility regarding the dialysis session. She stated the facility was having trouble getting them from the dialysis center. On 01/04/24 at 11:10 A.M. LPN #217 stated she was unable to get any further communication sheets from dialysis as they were closed that day. Residents Affected - Few Review of a nutrition assessment dated [DATE] revealed it was recommended to add a double entree to the diet order per Dietary Director #186. Review of physician's orders revealed an order for regular diet with double entree. Observation of the lunch meal on 01/04/24 at 12:10 P.M. revealed the lunch tray delivered to Resident #197's room. The resident received one pork chop, noodles, green beans, a roll, peaches, and cold tea. No double entree was noted. The tray card did not indicate to provide double entree. The resident stated, at that time, that she had never received a double entree. Interview with LPN #126 on 01/04/24 at 12:10 P.M. confirmed the resident had not received a double entree. Interview with Dietary Director #186 on 01/04/24 at 2:07 P.M. revealed she had recommended the double entree for Resident #197 for extra protein due to her dialysis. There was no evidence in the medical record of any laboratory testing for protein levels. There was no evidence that the Dietary Director had been in communication with the dialysis center to obtain the results of any laboratory testing that had been done at dialysis. Interview with Dietary Director #186 on 01/09/24 at 7:43 A.M. confirmed no laboratory testing had been completed at the facility to check protein levels. She stated she had called the dietician at the dialysis center last week but did not get to talk to him/her. She stated she did talk to the dietician at the dialysis center yesterday but had not documented it. She stated they do blood work monthly at dialysis but they had not provided the facility with any of the results. She stated that yesterday, the dietician at dialysis asked her to start the resident on protein supplements twice daily. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365687 If continuation sheet Page 40 of 69 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 365687 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Marietta 400 Seventh Street Marietta, OH 45750 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of medication error reports, review of staff education reports, resident interview, and staff interview, the facility failed to ensure residents only received medications ordered and intended for them, medications were administered in accordance with professional standards, and medications were administered within appropriate time frames set forth by the physician's orders. This affected 11 residents (#12, #17, #38, #46, #54, #60, #63, #64, #70, #191, and #192) who were identified from a review of one medication error report. Findings include: 1. A review of Resident #38's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included unspecified dementia, Parkinson's disease, schizophrenia, bipolar disorder, and hyperlipidemia. A review of Resident #38's physician's orders revealed the resident had an order to receive Atorvastatin 40 milligrams (mg) by mouth (po) at bedtime (hs) for hyperlipidemia. His orders included some psychotropic medications such as anti-anxiety medication and antipsychotic medication, but he did not have any orders to receive an anti-depressant. A review of an initial pertinent charting for a change in condition dated 12/28/23 at 9:15 P.M. revealed Resident #38 was involved in a medication error. No other information was included as to what medications were received in error. The change in condition form revealed the resident's vital signs were checked and the physician was notified. A review of a medication error report dated 12/28/23 at 9:30 P.M. that was completed by Registered Nurse (RN) #226 revealed Resident #38 was accidentally given the wrong medication. The nurse indicated the medication had been pulled, crushed, and mixed with pudding before it was given. The resident took a small bite, but had not finished consuming all of it before it was realized it was not the correct resident. The physician was notified, vital signs were obtained, and the resident was monitored for any immediate adverse reactions. He was to be monitored for the next 72 hours. The intervention implemented was to review medication administration protocols to prevent similar situations in the future. Again, the medication error report failed to identify exactly what medications the resident was given in error. A written statement by the facility's Director of Nursing (DON) that was part of their investigation into the medication error for Resident #38 revealed she had received a call from RN #226 on 12/28/23 at 9:51 P.M. The nurse had informed the DON of a medication error that had occurred for another resident (Resident #191). In giving her account to the DON pertaining to Resident #191's medication error, RN #226 told the DON she was so flustered after committing the medication error for Resident #191, that she gave another resident the wrong medications. The other resident was confirmed as being Resident #38. On 01/09/24 at 2:51 P.M., an interview with the DON revealed the investigation into Resident #38's medication error was not complete as the medication error (incident) report did not identify what medications were given in error. She had not spoken with the nurse involved to determine what medications were erroneously given to Resident #38 or who the medications he received were intended for. She (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365687 If continuation sheet Page 41 of 69 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 365687 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Marietta 400 Seventh Street Marietta, OH 45750 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 0755 was asked to obtain that information and to provide for review. Level of Harm - Minimal harm or potential for actual harm On 01/09/24 at 4:00 P.M., the DON provided a copy of the December 2023 medication administration record (MAR) for Resident #84. An interview with the DON shortly after confirmed Resident #38 received the medications intended for Resident #84 that was to be given to that resident at bedtime on 12/28/23. The medications that were due at bedtime for Resident #84 (that was given to Resident #38) included Atorvastatin (medication ordered for the treatment of hyperlipidemia) 40 mg po every hs, Duloxetine Hydrochloride (an anti-depressant) 60 mg po hs, and Trazadone HCL (an anti-depressant) 25 mg po q hs. The Duloxetine HCL (Hydrochloride) and the Trazadone HCL were not ordered for Resident #38. Residents Affected - Some On 01/10/24 at 9:50 A.M., further interview with the DON revealed she had talked with the nurse (RN #226) about the medication error for Resident #38. RN #226 reported she was pulling Resident #84's medications out of the medication administration cart for administration, but had her medication cart outside of Resident #38's room. When the medication tech (Medication Tech #119) asked whose medications they were, the nurse erroneously told her they were Resident #38's medications instead of Resident #84. The DON was asked why Medication Tech #119 would be passing medications that she had not prepared herself and had pulled out of the medication cart by RN #226, she replied she did not know. The DON acknowledged the nurse should not have pulled Resident #84's medications from the cart without being the one who administered the medications. The DON stated she provided education to the nursing staff regarding medication administration and the utilization of the medication techs/ aides as a result of the medication errors that occurred on 12/28/23. A review of the education provided to the facility's nurses and medication aides revealed the education was provided on 12/29/23. It included education on the proper utilization of the medication techs, medication administration, and signing off medications as you administered them. They reviewed the six rights of medication administration for nurses that included the right patient, right drug, right dosage, right route, right time, and right documentation. On 01/10/24 at 11:30 A.M., an interview with Resident #38 confirmed he was involved in a medication error occurring on 12/28/23 that included him receiving another resident's medications. He stated he only took about half of the medication given, as it was crushed and placed in pudding, before the nurse intervened. He denied he had any ill effects of receiving the wrong medications. On 01/10/24 at 11:45 A.M., an interview with Medication Aide #224 revealed she received her training/ medication tech classes in the facility on the 3rd floor. Her clinicals were completed in a sister facility in another town. She confirmed her training included only administering medications that were prepared by them. She denied she would ever pass medications to a resident that had been prepared by another staff member. A review of the facility's policy on Medication Errors revised 01/01/22 revealed it was the policy of the facility to provide protections for the health, welfare, and rights of each resident by ensuring residents received necessary care and services safely in an environment free of significant medication errors. Medication errors were defined as the observed or identified preparation or administration of medications or biologicals which was not in accordance with the prescriber's order, manufacturer's specifications regarding the preparation and administration of the medications, or accepted professional standards and principles which apply to professionals providing services. The facility would ensure medications were administered according to physician's orders and in accordance with accepted standards and principles, which apply to professionals providing services. To prevent medication errors and ensure safe medication administration, nurses should verify the following (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365687 If continuation sheet Page 42 of 69 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 365687 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Marietta 400 Seventh Street Marietta, OH 45750 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some information: right medication, dose, route, and time of administration, and the right resident and right documentation. 2. Review of the facility medication error investigation for Resident #191, which was not part of the medical record, dated 12/28/23 at 9:00 P.M., revealed the medication tech had administered the medication for G wing residents even before the scheduled shift and failed to notify the nurse and did not sign off on the medication administration record leading the nurse to believe that the medication had not been given yet. There was no evidence of the other resident affected by this incident or evidence they were monitored for side effects. Interview on 01/10/24 at 9:07 A.M., with the DON confirmed that giving medication prior to the scheduled administration time would be a medication error. The DON reported she didn't realize the medication tech had administered all night medications early to residents on G-wing until yesterday (01/09/24) when the surveyor had brought it to her attention. The facility had not started an investigation at this time to determine which residents were affected. Interview on 01/10/24 at 9:51 A.M., with the DON revealed there were nine other residents residing on G-wing the evening of 12/28/23 that received medication out of the scheduled time frame by the medication tech. The residents were Residents #60, #64, #63, #17, #12, #46, #70, #54, and #192. The DON had interviewed the medication tech yesterday (01/09/24) and she reported she had started her medication pass around 6:30 P.M. and had administered the nighttime medication, which was not due until 8:00 P.M., to residents on G-wing. Review of the facility medication error policy (dated 01/01/22) revealed it was the facility's responsibility to provide protection for the health, welfare, and rights of each resident by ensuring residents receive care and services safely in an environment free of significant medication error. The facility shall ensure medication will be administered according to physician order. If a medication error occurs, the following procedure will be initiated: a nurse assesses and examines the resident's condition and notifies the physician or health care practitioner as soon as possible; monitor and document the residents' condition, including response to medical treatment or nursing interventions; document action taken in the medical record; once the resident was stable the nurse reports the incident to the appropriate supervisor and completes the incident or occurrence report. Review of the facility education sheet (undated) revealed the six rights of medication administration was the right patient, drug, dosage, route, time, and documentation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365687 If continuation sheet Page 43 of 69 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 365687 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Marietta 400 Seventh Street Marietta, OH 45750 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 - Few 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 interview, resident record review, and facility policy review, the facility failed to ensure medication regimen review irregularities were reviewed by the physician and Director of Nursing (DON). This affected one resident (#47) of five residents reviewed for unnecessary medications. The facility census was 97. Findings include: Review of Resident #47's medical record revealed she was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including chronic respiratory failure, type two diabetes mellitus, acute kidney failure, acute congestive heart failure, constipation, major depressive disorder, and generalized anxiety disorder. Review of Resident #47's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/04/23, revealed she was cognitively intact. Review of Resident #47's medication regimen review (MRR), dated for recommendations created between 06/01/23 and 06/23/23, revealed the pharmacy had noted Resident #47 was receiving an antipsychotic, Abilify, to treat anxiety, an inappropriate indication. A list of conditions and diagnoses for the use of the antipsychotic medication was provided by the pharmacy. The pharmacy requested the medical director and Director of Nursing (DON) to please check the appropriate diagnosis or consider discontinuation of the medication. Review of the MRR revealed no documentation by the medical director or the DON to confirm their review and response. Interview on 01/08/24 at 1:20 P.M. with the DON verified the Medication Regimen Review, dated 06/23/23, did not have any documentation to support the physician or the DON had reviewed and addressed the pharmacy irregularity. Review of the facility policy titled, Addressing Medication Regiment Review Irregularities, (reviewed/revised 01/01/22), revealed it was the policy of the facility to provide a Medication Regimen Review (MRR) for each resident in order to identify irregularities and response to those irregularities in a timely manner to prevent the occurrence of an adverse drug event. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365687 If continuation sheet Page 44 of 69 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 365687 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Marietta 400 Seventh Street Marietta, OH 45750 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to ensure resident medications were monitored per orders. This affected two residents (#65, #70) of five residents reviewed for medication review. Residents Affected - Few Findings include: 1. Medical record review revealed Resident #65 was admitted to the facility on [DATE] with diagnoses including hyperlipidemia and heart failure. Review of Resident #65's medication orders dated 10/14/23 and 01/10/24 revealed the resident was receiving Lipitor 40 mg at bedtime for hyperlipidemia. Review of Resident #65's pharmacy review dated 11/27/23 revealed the pharmacist recommended laboratory monitoring for the resident's Lipitor therapy. The physician agreed on 11/29/23 to check lipid panel and liver function test (LFT) every six months. Review of Resident #65's laboratory orders revealed on 12/03/23 staff entered an order for lipid panel and LFT's every six months, however the start date wasn't until 12/04/24 (a year later). Review of Resident #65's laboratory results dated 10/2023 to 01/2024 revealed no evidence a lipid panel or LFT's were obtained. Review of Resident #65's plan of care for impaired cardiovascular status and hyperlipidemia dated 10/13/23 revealed labs/diagnostic testing as ordered. Interview on 01/10/24 at 11:10 A.M. and 11:18 A.M., with the Director of Nursing (DON) confirmed the order for the lipid panel and LFT was entered incorrectly, and the resident should have labs done when the order was obtained and then every six months after that. The DON confirmed she could not find any evidence the lipid panel or LFT was obtained. The DON reported she had spoken to the provider and the labs would be obtained tomorrow 01/11/24. 2. Medical record review revealed Resident #70 was admitted to the facility on [DATE] with diagnoses including hypertension, heart disease, and hyperlipidemia. Review of Resident #70's medication orders revealed the resident was on Lipitor 40 milligrams (mg) from 04/11/23 to 11/27/23. Review of Resident #70's laboratory orders dated 05/03/23 revealed to obtain a lipid panel and LFT every April and October. Review of Resident #70's laboratory results revealed no evidence the lipid panel or LFT's were obtained per orders. Review of Resident #70's impaired cardiovascular plan of care related to hyperlipidemia and hypertension dated 10/13/23 revealed to obtain labs and diagnostic testing as ordered. Interview on 01/08/24 at 4:00 P.M., with Registered Nurse (RN) #143 confirmed the resident did not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365687 If continuation sheet Page 45 of 69 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 365687 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Marietta 400 Seventh Street Marietta, OH 45750 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 0757 have a lipid panel and LFT in October per order. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365687 If continuation sheet Page 46 of 69 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 365687 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Marietta 400 Seventh Street Marietta, OH 45750 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of medication error report, review of drug administration information sheet, staff education sheet, interview, and policy reviews the facility failed to ensure residents were free of significant medication errors. This affected one resident (#191) of one resident reviewed for psychotropic medication review. Residents Affected - Few Findings include: Record review revealed Resident #191 was admitted to the facility on [DATE] with diagnoses including encephalopathy, chronic obstructive pulmonary disease, schizophrenia, anxiety, seizures, hypertension, needs for assistance with personal care, difficult walking, gastro-esophageal reflux disease, hyperlipidemia, irritable bowel syndrome, vitamin D deficiency, constipation, and moderate intellectual disabilities. Review of Resident #191's pertinent charting-change in condition progress note dated 12/29/23, 12/31/23, and 01/02/24 revealed on 12/28/23 the resident received a duplicate medication administered on night shift. No adverse reaction was noted at this time. Close monitoring for any adverse reaction for 72 hours. There was no documented evidence of which medication was given in error to ensure proper monitoring or evidence of monitoring on 12/30/23. Review of the facility medication error investigation, which was not part of the medical record, dated 12/28/23 at 9:00 P.M., revealed no evidence of which medications were given in error. Th incident description indicated the resident inadvertently received a duplicate dose of nighttime medication due to a miscommunication of the nurse with the medication tech. The medication tech had already administered the medication for G wing residents even before the scheduled shift and failed to notify the nurse and did not sign off on the medication administration record leading the nurse to believe that the medications had not been given yet. The immediate action was to check the Resident #191's vitals and neuro checks. The staff were re-educated regarding the importance of giving the medication at scheduled times, and accurately charting the time medication was given to avoid the risk of a similar error in the future. There was no evidence of which medication was given in error, resident assessment portion was blank, and there was no evidence of a statement from the medication tech. Review of the medication administration time (undated) that was provided to the survey team on entrance (01/02/24) revealed morning medications were administered from 7:00 A.M. to 10:00 A.M., afternoon medication was administered from 11:00 A.M. to 2:00 P.M., evening medications were administered form 4:00 P.M. to 7:00 P.M., and night medication were administered 8:00 P.M. to 11:00 P.M. Review of Resident #191's medication administration record dated 01/04/23 for 12/28/23 revealed a handwritten note on top of the record indicating the medication tech administered the medications around 7:00 P.M. The medications in question that were given in error were highlighted and included: Acetaminophen 325 milligrams (mg) two tablets for pain, Benzotropine 1 mg for decreased muscle control, Remeron 15 mg at bedtime for appetite, Miralax for constipation, Depakote delayed release 125 mg for seizures, Buspirone 15 mg for anxiety, Perphenazine 16 mg for schizophrenia, Zyprexa 10 mg for schizophrenia, and Lipitor 20 mg for hyperlipidemia. Staff had signed off the medication was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365687 If continuation sheet Page 47 of 69 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 365687 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Marietta 400 Seventh Street Marietta, OH 45750 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 administered at 7:54 P.M. and they were scheduled to be administered at 8:00 P.M. Level of Harm - Minimal harm or potential for actual harm Review of the Depakote drug information sheet provided by the facility dated 08/2023 revealed Depakote should be administered at the same time each day. If someone has overdosed and has serious symptoms such as passing out or trouble breathing call 911 or otherwise call poison control center right away. Laboratory testing should be done while you are taking this medication. Residents Affected - Few Review of the facility education sheet (undated) revealed the six rights of medication administration was the right patient, drug, dosage, route, time, and documentation. Review of the facility medication error policy (dated 01/01/22) revealed it was the facility's responsibility to provide protection for the health, welfare, and rights of each resident by ensuring residents receive care and services safely in an environment free of significant medication error. The facility shall ensure medication will be administered according to physician order. If a medication error occurs, the following procedure will be initiated: a nurse assesses and examines the resident's condition and notifies the physician or health care practitioner as soon as possible; monitor and document the residents' condition, including response to medical treatment or nursing interventions; document action taken in the medical record; once the resident was stable the nurse reports the incident to the appropriate supervisor and completes the incident or occurrence report. Review of the facility policy titled Medication Administration (dated 01/01/22) revealed medication was administered by licensed staff or authorized staff as ordered by the physician and in accordance with professional standards of practice in a manner to prevent contamination or infection; sign MAR after administered. Review of the facility policy titled Med Tech/Certified Medication Aide Playbook (dated 10/2022) revealed immediately after following administration of a medication, tech certified medication aide must document in the medical record the name of the medication and dose administered, date, time, route, and their name. The medication tech would report to the nurse at the beginning and end of the shift. Interview on 01/03/24 at 3:55 P.M., with Registered Nurse (RN) #143 revealed on 12/28/23 the medication tech gave the medication to Resident #191 around 7:00 P.M., and they were not due until 8:00 P.M. and the medication tech did not sign off the medication administration record when she administered the medications, then the night nurse administered the medication at 8:00 P.M., when they were due resulting in duplicate medications. Interview on 01/08/24 at 1:25 P.M., and 01/09/24 at 2:14 P.M., with the DON revealed she was off the day of the incident and did not obtain a statement from the medication tech. It was her understanding that the medication tech administered the medication too early (7:00 P.M.) and was not able to sign the medication off on the medication administration record because they were not due until 8:00 P.M. The resident receives Depakote, perphenazine, and buspirone three times a day, zyprexa, benzotropine, and miralax twice daily, and the other medications were just once daily. The resident was ordered labs on 12/18/23; however, they still have not be obtained yet including a Depakote level to ensure therapeutic level. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365687 If continuation sheet Page 48 of 69 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 365687 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Marietta 400 Seventh Street Marietta, OH 45750 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete The DON called the nurse and medication tech on 01/09/24 to obtain additional information and the medication tech indicated she started the medication pass at 6:30 P.M. The medication tech confirmed she gave the medication too early and that's why they were not signed off on the medication administration record. When the medication tech went to sign off the administration record, she noticed the nurse had signed the medication off already and when she inquired the nurse said she administered medication to the resident as well. Event ID: Facility ID: 365687 If continuation sheet Page 49 of 69 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 365687 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Marietta 400 Seventh Street Marietta, OH 45750 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 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, interview, and policy review the facility failed to ensure laboratory tests were obtained per orders. This affected one resident (#191) of one resident reviewed for change of condition. Residents Affected - Few Findings include: Record review revealed Resident #191 was admitted to the facility on [DATE] with diagnoses including encephalopathy, chronic obstructive pulmonary disease, schizophrenia, anxiety, seizures, hypertension, needs for assistance with personal care, difficult walking, gastro-esophageal reflux disease, hyperlipidemia, irritable bowel syndrome, vitamin D deficiency, constipation, and moderate intellectual disabilities. Review of Resident #191's admission history and physical dated 12/17/23 revealed to have follow-up blood work tomorrow and have psychology see her. The resident had been running up and down the hallways. She had currently fallen twice. She was on significant psychotropic medication and just need to clarify, if Depakote to be discontinued. She has a history of ulcerative colitis. Review of Resident #191's handwritten physician order dated 12/17/23 revealed house psych to see for schizophrenia and local gastric intestinal (GI) referral for ulcerative colitis history. Laboratory testing (complete blood count (CBC), complete metabolic profile (CMP), iron profile, vitamin B12, thyroid, and vitamin D) to be done on 12/18/23 for hypertension (HTN) anemia, fatigue, and vitamin deficiency. Also on 12/18/23 a Depakote level for epilepsy was to be drawn. Review of Residents #191's paper and electronic medical record revealed no evidence the laboratory tests were completed on 12/18/23 per orders. Review of the Administration note dated 12/18/23 revealed the CBC, CMP, iron profile, B12, TSH, Vitamin D level for HTN, anemia, fatigue, vitamin D deficiency was not collected due to the resident refused. The physician was advised and would attempt to draw tomorrow morning. There was no mention of the Depakote level, house psych, or GI consult. Further review of the medical record review revealed no evidence a second attempt was made to collect the laboratory test or the physician was notified. There was no evidence the GI consult was made. The resident was seen by psych services on 12/21/23 and 12/28/23. Interview on 01/03/24 at 10:59 A.M. with the DON confirmed Resident #191 had refused laboratory testing on 12/18/23, however there was no second attempt to try again or that the doctor was notified the labs were not obtained, however he was notified on 12/18/23 of the refusal. Review of Resident #191's impaired cardiovascular care plan related to hypertension and high cholesterol imitated 12/18/23 revealed labs as ordered. Review of Resident #191's at risk for fluid volume deficit related to cognitive impairment dated 12/18/23 revealed to do labs as ordered. Review of Resident #191's impaired gastrointestinal status related to history of constipation inflammatory bowel disease, gastroesophageal reflux disease dated 12/17/23 revealed to complete labs as (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365687 If continuation sheet Page 50 of 69 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 365687 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Marietta 400 Seventh Street Marietta, OH 45750 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 0770 ordered. Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled Laboratory and Diagnostic Guidelines (dated 10/30/20 and revised 10/26/23) revealed the facility set guidelines to track the timely completion, reporting, and monitoring of laboratory and diagnostic tests, results, and notifications which are used to monitor resident status and/or therapeutic medication levels. The physician should be notified of all refused lab test orders and reason why. The physician should be notified if the labs test was unable to be completed, reason why, and request for a new orders. All notification, attempts at notification, and response should be noted in the resident medical record. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365687 If continuation sheet Page 51 of 69 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 365687 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Marietta 400 Seventh Street Marietta, OH 45750 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on facility documentation review, interview, and facility policy review, the facility failed to provide evidence all food was temperature checked prior to serving to confirm food had reached a safe cooking temperature. This had the potential to affect all 91 residents who received food from the facility kitchen. Six residents (#1, #23, #28, #29, #39, and #198) received nothing by mouth and did not receive food from the facility kitchen. The facility census was 97. Residents Affected - Some Findings include: Review of the Service Line Checklists, dated 12/01/23 to 12/31/23, revealed there were no documented food temperatures on 12/15/23 for breakfast and lunch (prior to service to the residents) and no documented food temperatures on 12/19/23 for lunch. Interview on 01/03/24 at 9:50 A.M. with Dietary Manager #191 verified there was no evidence to support food temperatures were assessed for breakfast and lunch on 12/15/23 and for lunch on 12/19/23. He verified that without checking the temperatures of food, there would be no way to confirm it had reached or was maintained at a safe temperature for consumption. Review of the facility policy titled, Food Preparation and Service, (reviewed/revised 01/01/22), revealed food service employees shall prepare and serve food in a manner that complies with safe food handling practices. Further review revealed temperatures of foods held in a steam table will be monitored by food service staff. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365687 If continuation sheet Page 52 of 69 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 365687 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Marietta 400 Seventh Street Marietta, OH 45750 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Based on review of the facility's week at a glance menu, menus posted in the dining areas, review of the facility's daily newsletter, resident interview, and staff interview, the facility failed to ensure residents were informed of all alternate meals that were made available to them to allow them to make informed choices about the food they wanted to eat with each meal. This had the potential to affect all but six residents (Resident #1, #23, #28, #29, #39, and #198) who the facility identified as receiving nothing by mouth (NPO) and did not receive any food from the kitchen. Findings include: On 01/03/24 at 7:59 A.M., an interview with Resident #43 revealed he had food complaints when interviewed during the annual survey. He felt the food could be better and did not like what was always offered by the facility. He questioned whether the facility was required to offer an alternate meal, in addition to the main meal that was served for each of the three meals they received. He stated he often asked for an alternate to what was being served but there was only so many hot dogs you could eat before being tired of them. He was not aware of there being an alternate menu they could select a meal from other than the limited food items that were provided on their always offered menu. A review of the facility's menu for a week at a glance for week one of the cycle menu revealed alternates were included for each of the three meals. The alternate meal items were listed at the bottom of the main menu to include an alternate protein/ vegetable and starch. The week at a glance menu was not made available to the residents and was not the menu posted in the dining rooms or in the halls. A review of the menus posted in dining areas that were accessible to the residents who ate in the dining room revealed they only included the main menu food items that were available for breakfast, lunch, and dinner for a three day period. It did not include any of the food items that were known to be available on the alternate menu that was only kept in the kitchen. A review of the facility's daily newsletter that was passed out to the residents in the mornings revealed it included the same food items for each of the three meals that were were available on the main menu and the same food items that were posted in the dining rooms. The newsletter included the facility's always offered menu items that included a hot dog, grilled cheese, deli meat sandwich (bologna and cheese), peanut butter and jelly sandwich, side salad, and mashed potatoes. It did not include the food items that were known to be available as part of the alternate menu that was included on the week at a glance menus kept in the kitchen. On 01/03/24 at 4:30 P.M., State Tested Nursing Assistant (STNA) #112 was observed at the nurses station on the third floor passing out beverages to the residents prior to the evening meal. She was asked how residents were made aware of the meal options available to them for each of the three meals. She stated she thought the meals for the day were communicated to the residents in the facility's daily newsletter and were also posted in the halls and in the dining rooms. She reviewed the daily newsletter and confirmed it only included the main meals that were available that day and did not include the alternative meals that were available to the residents. She then went to check the menus that were posted in the hall and in the dining room on the third floor and confirmed they did not include the alternate meals either. She acknowledged that there was nothing posted or provided to the residents to let them know they had an alternate menu for each meal that they could choose. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365687 If continuation sheet Page 53 of 69 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 365687 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Marietta 400 Seventh Street Marietta, OH 45750 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some facility's resident council president (Resident #57) was in the hall by the nurses' station and overheard the conversation taking place on how residents were informed of what meals were available to them. She entered into the conversation and re-iterated concerns with the residents not being informed of any alternate meals that were available to them. She stated they used to have the alternate meal posted in the daily newsletter and it also used to be included on the menus posted in the dining room, but they quit including it on those areas. Resident #57 said she was told someone from corporate or the State informed the facility that they did not have to do that any longer. On 01/03/24 at 4:33 P.M., an interview with STNA #229, who was also present in the area of the nurses' station and overheard the conversation with STNA #112 and Resident #57, revealed she felt the residents should be informed of what meal alternates were available to them for each meal. She agreed the residents may eat better, if the meal received was of their choosing and not just the meal served as part of the main menu. On 01/03/24 at 4:35 P.M., STNA #112 called the kitchen and spoke with the dietary manager to find out how residents were informed of the alternate meals that were made available to them. She was told by the dietary manager that the residents or the staff would have to call to see what the alternate meal was, if the resident did not like what had been served. The dietary manager verified the alternate meal was not communicated on any menu or in the daily newsletter that the residents had access to other than what was included on their always offered menu. On 01/03/24 at 4:45 P.M., an interview with Registered Nurse (RN) #143 was completed and she was informed the residents had voiced concerns with not being aware of what food items were available to them, other than the main meal on the week at a glance menus. She confirmed the daily newsletter and the menus posted that residents had access to only identified the main meal on the menu and an alternate menu was not made available to them. She stated in other facilities she worked in they had a select menu where an activity aide would go around and ask each resident what they wanted to eat for the following days' meals. She stated she would look to see if they could incorporate something like that or she would see if they could update the daily newsletter and menus posted throughout the facility to also include the alternate menu so residents could make an informed choice. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365687 If continuation sheet Page 54 of 69 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 365687 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Marietta 400 Seventh Street Marietta, OH 45750 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 facility policy review, the facility failed to store food in a sanitary manner and failed to ensure food preparation equipment was clean. This had the potential to affect all 91 residents who received food from the facility kitchen. Six residents (#1, #23, #28, #29, #39, and #198) received nothing by mouth and did not receive food from the facility kitchen. The facility also failed to ensure two residents (#32 and #62)'s personal refrigerators were kept clean and at an appropriate temperature and failed to ensure four residents (#10, #33, #62, and #81)'s personal refrigerator temperatures were logged for safety. The facility census was 97. Findings included: 1. Observation on 01/02/24 at 8:09 A.M. revealed the onion powder and ground cinnamon containers were not closed properly. Observation on 01/03/24 at 9:15 A.M. revealed the onion powder, ground cinnamon, garlic powder, and lemon pepper seasoning salt containers were not closed properly. Interview on 01/03/24 at 10:10 A.M. with [NAME] #192 verified the spice container noted above were open, not closed properly and should have been closed for sanitation. 2. Observation on 01/02/24 at 8:09 A.M. of the can opener with a dried black substance on the puncture. There was also a white dried substance noted on the puncture. Interview on 01/02/24 at 8:20 A.M. with Dietary Manager #191 verified the can opener was dirty with dried substances. He reported the can opener was to be cleaned after each use and it was on the cleaning schedule for each evening to be cleaned and sanitized. He verified the can opener had not been used in preparing breakfast. Review of the facility document titled, CH2 End of Shift Checkout Sheet, undated, revealed the can opener was to be cleaned and sanitized at the end of the shift. Review of the policy titled, Environment, revised 09/2017, revealed all food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition. Further review revealed all food contact surfaces will be cleaned and sanitized after each use. 3. a. Observation on 01/08/24 at 8:03 A.M. of Resident #10's personal refrigerator revealed no temperature log on the refrigerator unit or in the room. Interview on 01/08/24 at 8:09 A.M. with Med Tech #225 verified there was no refrigerator temperature log on or around Resident #10's refrigerator. b. Observation on 01/08/24 at 8:03 A.M. of Resident #62's personal refrigerator revealed the thermometer inside read 48 degrees Fahrenheit and the mechanical unit was iced over. The refrigerator held the following perishable items: five cartons of milk, a container of sour cream, two containers of mayonnaise, and a bottle of ranch dressing. There was no temperature log noted on the refrigerator unit or in the room. An interview at the time with Resident #62 revealed the facility staff used to check the temperature of her refrigerator every day, but they hadn't for a while. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365687 If continuation sheet Page 55 of 69 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 365687 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Marietta 400 Seventh Street Marietta, OH 45750 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 Interview on 01/08/24 at 8:10 A.M. with Med Tech #255 verified the unit was not at an acceptable temperature of 41 degrees Fahrenheit or less, the mechanical unit was iced over and there was food in the unit that was perishable. She also verified there was no temperature log on or around Resident #62's refrigerator. c. Observation on 01/08/24 at 8:05 A.M. of Resident #33's personal refrigerator revealed no thermometer in the refrigerator and no temperature log on the refrigerator or in the room. Interview on 01/08/24 at 8:09 A.M. with STNA #103 revealed she did not know who was responsible for monitoring resident refrigerator temperatures. Interview on 01/08/24 at 8:10 A.M. with Med Tech #225 verified there was no thermometer in Resident #33's refrigerator and there should be. She also verified there was no temperature log on or around Resident #33's refrigerator. Med Tech #225 did not know who was responsible for monitoring resident refrigerator temperatures. She thought it may be housekeeping. d. Observation on 01/08/24 at 8:06 A.M. of Resident #81's personal refrigerator revealed no temperature log on the unit or in the room. Interview on 01/08/24 at 8:10 A.M. with Med Tech #225 verified there was no refrigerator temperature log on or around Resident #81's refrigerator. e. Observation on 01/08/24 at 8:11 A.M. of Resident #32's personal refrigerator revealed the thermometer inside read 50 degrees Fahrenheit, the mechanic unit was iced over, and the interior of the unit was dirty. The refrigerator held lunch meat sandwiches. Interview on 01/08/24 at 8:15 A.M. with State Tested Nursing Assistant (STNA) #111 verified the unit was not at an acceptable temperature of 41 degrees Fahrenheit or less, the mechanical unit was iced over, the refrigerator was dirty and there was food in the unit that was perishable. Interview on 01/08/24 at 8:40 A.M. with Licensed Practical Nurse (LPN) #211 revealed any staff can document a resident refrigerator temperature and the log should be on or near the refrigerator unit. Interview on 01/08/24 at 8:41 A.M. with the Director of Nursing (DON) revealed the resident refrigerator temperature logs should be in the unit narcotic books. Observation of the unit E and F narcotic books with the DON revealed no resident refrigerator temperature logs. Interview on 01/08/24 at 10:25 A.M. with the DON verified third floor residents' refrigerator temperatures should have been checked and logged daily but there was no documentation to support this was done. Review of the facility policy titled, Resident Refrigerators, (reviewed/revised 01/01/22), revealed the facility did not provide a refrigerator in a resident's room. However, it was the policy of the facility to ensure safe and sanitary use of any resident-owned refrigerators when approved by the administrator for use in the facility. Further review revealed housekeeping staff shall record refrigerator temperatures daily on a temperature log attached to the refrigerator. A thermometer shall remain in the refrigerator. Temperatures will be at or below 41 degrees. If temperatures are out of range, maintenance staff shall be notified and all foods that require refrigeration will be discarded immediately, and remedies will be put into place. Housekeeping staff shall clean the refrigerator (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365687 If continuation sheet Page 56 of 69 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 365687 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Marietta 400 Seventh Street Marietta, OH 45750 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 daily and discard any foods that are out of compliance. Nursing staff shall clean up spills as needed or refer to housekeeping staff. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365687 If continuation sheet Page 57 of 69 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 365687 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Marietta 400 Seventh Street Marietta, OH 45750 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 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and facility policy review, the facility failed to ensure garbage and refuse was disposed of properly. This had the potential to affect all 97 residents residing in the facility. Residents Affected - Many Findings included: Observation on 01/02/24 at 9:20 A.M. of the facility dumpster/compactor revealed trash on the ground around the dumpster/compactor. The trash included milk cartons, straws, lids, rubber gloves and a used depends. Interview on 01/02/24 at 9:22 A.M. with State Tested Nursing Assistant (STNA) #131 verified the debris on the ground around the dumpster/compactor and that it should not be there. Review of the facility policy titled, Environment, (revised 09/2017), revealed all trash will be properly disposed of in external receptacles (dumpsters) and the surrounding area will be free of debris. Review of the facility policy titled, Disposal of Garbage and Refuse, (reviewed/revised 01/01/22), revealed refuse containers and dumpsters kept outside the facility shall be designed and constructed to have tightly fitting lids, doors, or covers. Surrounding area shall be kept clean so that accumulation of debris and insect/rodent attractions are minimized. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365687 If continuation sheet Page 58 of 69 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 365687 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Marietta 400 Seventh Street Marietta, OH 45750 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 medical record review, observation, resident interview, staff interview, and policy review, the facility failed to ensure a resident showing signs of Covid-19 was promptly identified, tested, and placed in transmission based precautions (TBP's) for Covid-19 when symptoms originated, failed to ensure staff wore appropriate personal protective equipment (PPE) when entering a room of another resident who was on TBP's for being positive for Covid-19, failed to timely identify and place a third resident in TBP's who had a multi-drug resistant organism in his urine, and failed to ensure sharps (syringes and vacutainers needles) were properly disposed of inside of sharps containers so the needles could not be easily retrieved. This affected three residents (#21, #72, and #82) of three residents reviewed for infections (two for Covid-19 and one for urinary tract infections) and had the potential to review all residents that resided in the facility. Residents Affected - Many Findings include: 1. A review of Resident #21's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included cerebral palsy, benign prostatic hyperplasia, and obstructive and reflux uropathy. A review of Resident #21's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was able to make himself understood and was able to understand others, but his cognition was severely impaired. He was indicated to have the use of an indwelling urinary catheter. A review of Resident #21's care plans revealed he had the need for an indwelling urinary catheter related to obstructive uropathy. His goal was to have reduced catheter-related complications through the next review. The interventions included observing for signs and symptoms of UTI and report to the physician, provide prophylactic interventions as ordered, and to administer medications as ordered. His care plans were updated on 01/02/24 to reflect he had an infection as evidenced by a UTI. That care plan included the need to administer medications and treatments to treat infection and/or symptoms as ordered. They were to obtain labs/ cultures/ diagnostic testing as ordered and report the results to the physician. A review of Resident #21's progress notes revealed a nurse's note dated 12/31/23 at 9:45 P.M. that revealed the resident had returned from emergency room at 9:17 P.M. He was given a dose of Rocephin intravenously (IV) for the treatment of a UTI. He was discharged back to the facility with an order to complete at 10-day course of Ciprofloxacin (Cipro) 500 milligrams (mg) twice a day for 10 days. The physician was made aware of above and was in agreement with the orders. A review of Resident #21's physician's orders confirmed the resident was ordered to receive Ciprofloxacin HCl 500 MG by mouth two times a day for 10 days for the treatment of a UTI. The order originated on 01/01/24. A review of Resident #21's urinalysis results for a urinalysis that had been collected at the hospital on [DATE] at 8:45 A.M. revealed the preliminary report showed the resident had the growth of two organisms (Pseudomonas Aeruginosa and Proteus Mirabilis) that were at a quantity greater than 100,000 colonies/ milliliter. The culture report indicated the sensitivity testing was to follow. There was a second preliminary urine culture report for a urinalysis that was done on 12/31/23 at 12:15 P.M. that showed Pseudomonas Aeruginosa and Proteus Mirabilis were again identified as the organisms (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365687 If continuation sheet Page 59 of 69 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 365687 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Marietta 400 Seventh Street Marietta, OH 45750 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 growing in the resident's urine. The second urine culture report indicated for sensitivity information on that report refer to the previous urine culture report specimen (No. B 37921) received 12/31/23. Antibiotic susceptibility testing would not be routinely repeated on identical organisms isolated within 5 days of each other. Further review of Resident #21's electronic medical record (EMR) revealed it was absent for the sensitivity testing report that was to follow for the urinalysis that had been collected on 12/31/23 at 8:15 A.M. Findings were verified by Medical Records Employee #181. She was asked to contact the hospital to see if they had the sensitivity testing report that was the absent report on 01/03/24 at 4:20 P.M. On 01/03/24 at 4:40 P.M., a copy of the sensitivity testing report from the urinalysis that was collected on 12/31/23 at 8:45 A.M. was provided for review. The final urine culture results showed Resident #21 had Pseudomonas Aeruginosa and Proteus Mirabilis- Extended Spectrum Beta Lactamases (ESBLs) (an enzyme found in some strains of bacteria that can't be killed by many of the antibiotics that were typically used to treat infections that have been associated with poor outcomes). The sensitivity report revealed both organisms identified were susceptible to Meropenum and Gentamycin. They were not susceptible to Ciprofloxacin, which was the antibiotic the resident had been placed on and was to receive twice a day for 10 days to treat his UTI. The sensitivity report did indicate Proteus Mirabilis- ESBL was multi-resistant and contact isolation protocol should be used with that organism. On 01/04/24 at 10:20 A.M., an interview with the Director of Nursing (DON) confirmed Resident #21's urine cultures sensitivity testing report from the urinalysis that had been collected while the resident was in the hospital on [DATE] at 8:45 A.M. was not previously available in the resident's EMR until it was requested for review on 01/03/24 at 4:20 P.M. She further acknowledged that the resident's culture and sensitivity report that was obtained from the hospital showed the resident had ESBL in his urine and the antibiotic (Cipro) that was ordered for him was not effective in treatment of the organisms identified in the urine's culture and sensitivity report. She was asked why the resident had not been placed in contact isolation for ESBL in his urine, after the final culture and sensitivity report was obtained upon request on 01/03/24 at 4:40 P.M. She verified the lab report showed the bacterial isolate on the resident was multi-resistant and contact isolation protocol should be used with the resident. On 01/04/24 at 10:40 A.M., an interview with State Tested Nursing Assistant (STNA) #134 revealed the aides were responsible for performing catheter care on Resident #21 and were also responsible for emptying of a resident's catheter bag. They typically emptied the resident's catheter bag at least three times a shift. She described the process in which the catheter bag was emptied and stated the staff would don gloves only when emptying the catheter, unless they had something in their urine. She was asked if the resident had anything in his urine and reported they just found out that he did. They were in the process of moving him down to the first floor, so he could be put in isolation. She took care of the resident yesterday and at that time she was only wearing gloves when emptying his catheter bag. A review of the facility's policy on Transmission Based (Isolation) Precautions (revised 05/22/23) revealed it was their policy to take appropriate precautions to prevent transmission of pathogens, based on the pathogens modes of transmission. Contact precautions referred to measures that were intended to prevent transmission of infectious agents which were spread by direct or indirect contact with the resident or the resident's environment. Facility staff would apply TBP's, in addition to standard precautions, to residents who were known or suspected to be infected or colonized with certain (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365687 If continuation sheet Page 60 of 69 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 365687 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Marietta 400 Seventh Street Marietta, OH 45750 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 infectious agents requiring additional controls to prevent transmission. Contact precautions were intended to prevent transmission of pathogens that were spread by direct or indirect contact with the resident or the resident's environment. Healthcare personnel caring for residents on contact precautions should wear a gown and gloves for interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. Donning PPE upon room entry and discarding before exiting the room was done to contain pathogens, especially those that have been implicated in transmission through environmental contamination. Contact precautions would be used for residents infected or colonized with MDRO's (multi-drug resistant organisms). 2. On 01/02/24 at 3:29 P.M., an interview with Resident #82 revealed she did not feel well. She was noted to have some nasal congestion and a dry cough. She requested her interview to be paused on a couple of occasions to get a drink of water and a cough drop. She complained of a headache and was sensitive to loud noises. She reported she had been tested for Covid-19 about a week ago and was negative. On 01/03/24 at 3:36 P.M., an ongoing observation of Resident #82 noted her to be sitting on the side of her bed coughing. Her cough was more moist than it had been the day prior to. She remained in a room by herself but was not under any type of TBP's. On 01/04/24 at 8:40 A.M., a follow up observation of Resident #82 noted her to be in her room sitting on the side of the bed. She had been placed in droplet isolation precautions and was identified by the facility as being positive for Covid-19. She continued with a moist cough, congestion, and complaints of a headache. A review of Resident #82's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included unspecified dementia, asthma, hypertension, and adult onset diabetes mellitus. A review of Resident #82's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues and was cognitively intact. She was not known to display any behaviors or reject care. A review of Resident #82's care plans revealed she had Covid-19/ symptoms of Covid-19/ and a positive Covid-19 test. The care plan was initiated on 01/04/24. The interventions included administering any treatments to treat infection and/ or symptoms. A review of Resident #82's nurses progress notes revealed a nurse's note dated 01/02/24 at 7:41 P.M. that indicated the resident was complaining of a headache more frequently over the past couple of days. She had been given Tylenol on an as needed basis with some effectiveness. The resident requested to see the physician the next time he was in the facility doing rounds. A nurse's progress note dated 01/03/24 at 8:06 P.M. revealed Resident #82 had complaints of a recent frequent headache that was not new to the resident or thought to be a new symptom of Covid-19. The resident had been known to frequently request Acetaminophen on an as needed (prn) basis related to a diagnosis of cervical degenerative disc disease with effectiveness documented. The progress notes did not document anything about the resident having nasal congestion or a cough despite observations of the resident on 01/02/24 and 01/03/24 noted her to have those symptoms. A nurse's progress note dated 01/03/24 at 8:35 P.M. revealed Resident #82 had been rapid tested for Covid-19 during routine testing and found to be positive for Covid-19. The floor staff asked the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365687 If continuation sheet Page 61 of 69 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 365687 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Marietta 400 Seventh Street Marietta, OH 45750 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 resident if she was experiencing any symptoms and the note indicated the resident only complained of a headache, which was noted to be a chronic issue related to cervical stenosis. The resident was placed in isolation precautions and the physician was notified. A nurse's progress note dated 01/04/24 at 3:39 P.M. revealed Resident #82 was ordered to receive Molnupiravir (an antiviral medication) 800 milligrams (mg) by mouth two times a day for 5 days for Covid-19. It was to continue until 01/10/2024. She was also given an order to receive Robitussin on an as needed basis every four hours for a cough. On 01/08/24 at 4:35 P.M., an interview with the DON confirmed Resident #82 was noted to be positive for Covid-19 through routine outbreak testing. She claimed the only symptom the resident was known to have was a headache, which was not out of the normal for the resident. She denied she was aware of the resident having any cough or nasal congestion prior to testing her for Covid-19. On 01/08/24 at 5:20 P.M., a follow up interview with the DON and Registered Nurse (RN) #143 was completed to review the timeline of Resident #82's symptoms and when she was tested for Covid-19. They acknowledged the resident was observed on 01/02/24 at 3:29 P.M. (while being interviewed) when she had complaints of not feeling well, a headache, and was noted to have nasal congestion and a cough. They further acknowledged another observation was made of the resident on 01/03/24 at 3:36 P.M. of her sitting on the side of her bed with a moist cough continuing. The resident was not in TBP's for suspected Covid-19, nor had she been tested for Covid-19 at that point in time when she was showing symptoms consistent with Covid-19. The DON and RN #143 verified Resident #82 was not tested for Covid-19 until 01/03/24 at 8:35 P.M. (greater than 24 hours after she was observed with congestion and a cough). They were questioned as to why there was a delay in identifying symptoms of Covid-19 and a delay in testing for Covid-19 when her symptoms had were noted on 01/02/24. They confirmed the facility already had one resident positive for Covid-19 and should have been vigilant to be observing other residents with symptoms of Covid-19. The DON stated that was the first they were hearing of the resident having any symptoms other than just a headache. They confirmed the resident should have been tested sooner for Covid-19, if she was displaying any of the symptoms consistent with Covid-19. A review of the facility's policy on Covid-19 Prevention, Response and Reporting (revised 05/26/23) revealed it was the policy of the facility to ensure that appropriate interventions were implemented to prevent the spread of Covid-19 and promptly respond to any suspected or confirmed Covid-19 infections. Staff would be alert to signs of Covid-19 and notify the resident's physician if the resident had a cough, congestion/ runny nose, or a headache among other symptoms. 3. On 01/02/24 at 4:15 P.M., an observation of the sharps container in Resident #38's room noted there to be syringes in the top of the sharps container that had not dropped down to the bottom of the container. There was a syringe that was vertical and stuck in the flapper of the insert that prevented the flapper from moving. Additional syringes used for vaccination were stuck at the top of the container and was retrievable. Findings were verified by RN #250. On 01/02/24 at 4:17 P.M., RN #250 removed the sharps container that was hanging on the bathroom wall and replaced it with a new one. She reported the syringe that was stuck in the top of the sharps container that was vertical prevented the flapper mechanism to work resulting in the other syringes that had been placed in the sharps container to not drop securely into the bottom of the container. She acknowledged the syringes that had not been dropped to the bottom of the container was retrievable and could pose a risk to any resident from a potential needle stick. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365687 If continuation sheet Page 62 of 69 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 365687 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Marietta 400 Seventh Street Marietta, OH 45750 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 On 01/02/24 at 5:11 P.M., an observation of Resident #30's bathroom revealed his sharps container had multiple syringes, vacutainer needles (used for blood draws), and straight razors resting at the top of the sharps container at the flapper area and had not been safely dropped into the bottom of the sharps container. All items were retrievable due to not dropping to the bottom of the container. Findings were verified by RN #250. She apologized for the sharps container being found that way and stated she would take care of it. On 01/04/24 at 10:40 A.M., an interview with the DON revealed the facility had recently changed the type of sharps containers they were using that went along with their on-site sharps disposal system. She reported the flapper in the insert was not allowing sharps to be dropped down into the container as easily as their prior sharps containers did. She stated she would have to remove one of the flappers in the insert to allow the sharps to more easily drop down into the container. There would still be a plastic piece that would go across the insert to prevent anyone from reaching down into the sharps container. A review of the facility's policy on Sharps Disposal (revised 10/30/23) revealed contaminated sharps would be discarded immediately or as seen as feasible into designated containers. Contaminated sharps would be discarded into containers that were closable. Designated individuals would be responsible for sealing and replacing containers when they were 75-80% full to protect employees from punctures and/ or needle sticks when attempting to push sharps into the containers. Whoever observed incorrect disposal or handling of contaminated sharps should report the information to the Infection Control Coordinator. 4. Review of Resident #72's medical record revealed he was admitted to the facility on [DATE] with diagnoses including malignant neoplasm of the rectum, chronic obstructive pulmonary disease, viral hepatitis C, and other disorders of the lung. Review of Resident #72's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/12/23, revealed he was cognitively intact. Review of Resident #72's progress note, dated 12/28/23 at 1:09 P.M., revealed he had a positive COVID rapid test, and he was to be placed in transmission based precautions. Review of Resident #72's physician order, dated 12/28/23, identified he was to be in transmission based precautions. Observation on 01/02/24 at 12:15 P.M. of Resident #72's door revealed there was signage on the door directing anyone entering to stop and see the nurse. Additional signage directed anyone entering the room to don (put on) an isolation gown, gloves, N-95 mask and eye protection. Observation at this time revealed isolation carts outside of the room revealed all personal protective equipment (PPE) was present to be donned prior to entering the room. Observation on 01/02/24 at 12:20 P.M. of State Tested Nursing Assistant (STNA) #111 donning an isolation gown, gloves, and changing from a surgical mask to a N-95 mask prior to taking lunch into Resident #72. She did not don any eye protection. STNA #111 took Resident #72's tray into his room and set it up for him on his over bed table while he was lying in bed. She then doffed (removed) her isolation gown, gloves, and N-95 mask, entered Resident #72's rest room and washed her hands. Upon exiting the room, STNA #111 donned a new surgical mask. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365687 If continuation sheet Page 63 of 69 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 365687 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Marietta 400 Seventh Street Marietta, OH 45750 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 FORM CMS-2567 (02/99) Previous Versions Obsolete Interview on 01/02/24 at 12:24 P.M. with STNA #111 verified she did not wear any eye protection when she entered Resident #72's room who was on droplet isolation due to being COVID-19 positive. She verified she should have donned eye protection but forgot. She verified she had been trained to wear eye protection when caring for residents on droplet isolation. Review of the facility policy titled, Transmission-Based (Isolation) Precautions, (reviewed/revised 12/27/23), revealed it was the facility policy to take appropriate precautions to prevent transmission of pathogens, based on the pathogens' mode of transmission. Further review revealed the facility staff will apply Transmission-Based Precautions, in addition to standard precautions, to residents who are known or suspected to be infected or colonized with certain infectious agents requiring additional controls to prevent transmission. Additionally, the policy revealed the appropriate precaution for COVID-19 was airborne, droplet, and contact isolation and healthcare personnel should wear a facemask for close contact with an infectious resident. Event ID: Facility ID: 365687 If continuation sheet Page 64 of 69 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 365687 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Marietta 400 Seventh Street Marietta, OH 45750 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the facility's infection control tracking logs, staff interview, and policy review, the facility failed to ensure a resident was not treated with an antibiotic, unless they met criteria for the treatment of an infection. They also failed to ensure a resident treated for a urinary tract infection caused by a multi-drug resistant organism received the appropriate antibiotic the identified organisms were sensitive to. This affected one resident (#21) of two residents reviewed for urinary tract infections (UTI) and one resident (#47) of five residents reviewed for unnecessary medications. Residents Affected - Few Findings include: 1. A review of Resident #21's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included cerebral palsy, benign prostatic hyperplasia, and obstructive and reflux uropathy. A review of Resident #21's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was able to make himself understood and was able to understand others, but his cognition was severely impaired. He was indicated to have the use of an indwelling urinary catheter. A review of Resident #21's care plans revealed he had the need for an indwelling urinary catheter related to obstructive uropathy. His goal was to have reduced catheter-related complications through the next review. The interventions included observing for signs and symptoms of UTI and report to the physician, provide prophylactic interventions as ordered, and to administer medications as ordered. His care plans were updated on 01/02/24 to reflect he had an infection as evidenced by a UTI. That care plan included the need to administer medications and treatments to treat infection and/or symptoms as ordered. They were to obtain labs/ cultures/ diagnostic testing as ordered and report the results to the physician. A review of Resident #21's progress notes revealed a nurse's note dated 12/31/23 at 9:45 P.M. that revealed the resident had returned from emergency room at 9:17 P.M. He was given a dose of Rocephin intravenously (IV) for the treatment of a UTI. He was discharged back to the facility with an order to complete at 10-day course of Ciprofloxacin (Cipro) 500 milligrams (mg) twice a day for 10 days. The physician was made aware of above and was in agreement with the orders. A review of Resident #21's physician's orders confirmed the resident was ordered to receive Ciprofloxacin HCl 500 MG by mouth two times a day for 10 days for the treatment of a UTI. The order originated on 01/01/24. A review of Resident #21's urinalysis results for a urinalysis that had been collected at the hospital on [DATE] at 8:45 A.M. revealed the preliminary report showed the resident had the growth of two organisms (Pseudomonas Aeruginosa and Proteus Mirabilis) that were at a quantity greater than 100,000 colonies/ milliliter. The results indicated the sensitivity testing was to follow. There was a second preliminary urine culture report for a urinalysis that was done on 12/31/23 at 12:15 P.M. that showed Pseudomonas Aeruginosa and Proteus Mirabilis were again identified as the organisms growing in the resident's urine. The second urine culture report indicated for sensitivity information on that report refer to previous urine culture report specimen (No. B37921) received 12/31/23. Antibiotic susceptibility testing would not be routinely repeated on identical organisms isolated within 5 days of each other. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365687 If continuation sheet Page 65 of 69 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 365687 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Marietta 400 Seventh Street Marietta, OH 45750 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 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Further review of Resident #21's electronic medical record (EMR) revealed it was absent for the sensitivity testing report that was to follow for the urinalysis that had been collected on 12/31/23 at 8:15 A.M. Findings were verified by Medical Records Employee #181. She was asked to contact the hospital to see if they had the sensitivity testing report that was absent report on 01/03/24 at 4:20 P.M. On 01/03/24 at 4:40 P.M., a copy of the sensitivity testing report from the urinalysis that was collected on 12/31/23 at 8:45 A.M. was provided for review. The final urine culture results showed Resident #21 had Pseudomonas Aeruginosa and Proteus Mirabilis- Extended Spectrum Beta Lactamases (ESBLs) an enzyme found in some strains of bacteria that can't be killed by many of the antibiotics that were typically used to treat infections that have been associated with poor outcomes). The sensitivity report revealed both organisms identified were susceptible to Meropenum and Gentamycin. They were not susceptible to Ciprofloxacin, which was the antibiotic the resident had been placed on and was to receive twice a day for 10 days to treat his UTI. On 01/04/24 at 10:20 A.M., an interview with the Director of Nursing (DON) confirmed Resident #21's urine cultures sensitivity testing report from the urinalysis that had been collected while the resident was in the hospital on [DATE] at 8:45 A.M. was not previously available in the resident's EMR until it was requested for review on 01/03/24 at 4:20 P.M. She further confirmed the resident's culture and sensitivity testing report that was obtained from the hospital showed the resident's organisms he had that was causing his UTI were not susceptible to the antibiotic he was receiving. She stated the facility's infection preventionist should be reviewing residents upon their return from the hospital to see if any antibiotics had been ordered and to follow up to ensure they had all testing results that had been obtained at the hospital to ensure the appropriate antibiotics were ordered. She indicated the physician had been made aware of the resident being on Ciprofloxacin upon his return to the facility and wanted the antibiotic continued. She acknowledged the infection preventionist should have followed up to get the sensitivity testing results to ensure the antibiotic that was ordered to treat his infection was effective. She acknowledged the resident continued to receive Cipro until it was brought to their attention that the Cipro was not effective in treating his type of UTI based on the organisms grown. The facility's policy on Antibiotic Stewardship Program (dated 10/24/22) revealed it was the policy of the facility to implement an antibiotic stewardship program as part of the facility's overall infection prevention and control program. The purpose of the program was to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. The infection preventionist, with oversight from the DON, served as the leader of the antibiotic stewardship program and received support from the Administrator and other governing officials of the facility. The infection preventionist coordinated all antibiotic stewardship activities, maintained documentation, and served as a resource for all clinical staff. The facility was to use the McGeer's criteria to define infections. Antibiotic orders obtained upon admission, whether a new admission or a readmission, to the facility should be reviewed for appropriateness. They were to monitor the response to antibiotics and laboratory results when available to determine if the antibiotic was still indicated or adjustments should be made. 2. Review of Resident #47's medical record revealed she was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including chronic respiratory failure, type two diabetes mellitus, acute kidney failure, acute congestive heart failure, constipation, major depressive disorder, and generalized anxiety disorder. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365687 If continuation sheet Page 66 of 69 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 365687 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Marietta 400 Seventh Street Marietta, OH 45750 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 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #47's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/04/23, revealed she was cognitively intact. Review of Resident #47's physician order, dated 07/08/23, identified she was to receive Cefdinir oral capsule 300 milligram (mg) one capsule by mouth every 12 hours for a urinary tract infection (UTI) until 07/10/23. Review of Resident #47's medication administration record (MAR), dated 07/23, revealed she did receive the Cefdinir twice a day for three days as ordered on 07/08/23, 07/09/23, and 07/10/23. Review of Resident #47's facility antibiotic stewardship documentation, dated 07/04/23, revealed she did not meet the requirement for the use of an antibiotic for a UTI. Based on the documentation, Resident #47 needed to meet both criteria one and two. Resident #47 only had documentation to support criteria number two was met. Interview on 01/08/24 at 1:18 P.M. with the DON verified that based on the facility antibiotic stewardship documentation, Resident #47 did not meet the requirement for the Cefdinir for a UTI. Review of the facility policy titled, Antibiotic Stewardship Program, (reviewed/revised 10/24/22), revealed it was the policy of the facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The purpose of the program was to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. Further review revealed the facility used the McGeer criteria to define infections and the Loeb Minimum Criteria may be used to determine whether to treat an infection with antibiotics. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365687 If continuation sheet Page 67 of 69 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 365687 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Marietta 400 Seventh Street Marietta, OH 45750 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, policy review, and staff interview, the facility failed to ensure residents were offered a pneumococcal immunization as appropriate. This affected three of five residents reviewed for immunizations (Residents #80, #21, and #82). The facility census was 97. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #80 revealed an admission date of 09/27/23. There was no evidence the resident had received or been offered a pneumococcal immunization. Interview with the Director of Nursing (DON) on 01/03/24 at 2:23 P.M. confirmed the resident had not had and resident/responsible party had not been offered a pneumococcal immunization. She stated it was offered on 01/03/24 and the daughter wanted her to have one but it had not been provided yet. 2. Review of the medical record for Resident #21 revealed an admission date of 08/10/22. Record review revealed he had received a Prevnar 13 vaccine on 01/26/23. (He was less than 65 when getting this vaccine). There was no evidence he had received a follow up dose of PPSV23 as recommended. Interview with the Director of Nursing on 01/03/24 at 11:55 A.M. revealed the facility had gotten a consent signed for the resident to receive the follow up dose of PPSV23 on 11/29/23 but it had not yet been given. 3. Review of the medical record for Resident #82 revealed an admission date of 10/21/23. The resident had received Prevnar 13 on 10/29/19 and was older than 65. There was no evidence a follow up dose of PPSV23 had been offered or provided. This was confirmed by the Director of Nursing on 01/03/24 at 2:23 P.M. Review of the facility policy on Pneumococcal vaccine series (dated 03/01/22 and revised 10/30/23) revealed it was the policy to offer residents immunization against pneumococcal disease in accordance with current Center for Disease Control (CDC) guidelines and recommendations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365687 If continuation sheet Page 68 of 69 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 365687 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Marietta 400 Seventh Street Marietta, OH 45750 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 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Based on medical record review, policy review, and staff interview, the facility failed to offer COVID-19 vaccines to residents. This affected two residents (#46 and #26) of five residents reviewed for immunizations. The facility census was 97. Findings include: 1. Review of the medical record for Resident #46 revealed an admission date of 02/07/19. Review of the immunization record revealed it simply stated the resident refused a COVID-19 vaccine. However, there was no documented evidence of education provided regarding the vaccine or a signed declination of the vaccine. Interview with the Director of Nursing on 01/03/24 at 2:23 P.M. confirmed no evidence for Resident #46 of education or signed declination of COVID-19 vaccine. 2. Review of the medical record for Resident #26 revealed an admission date of 07/17/23. Review of the immunization record revealed the resident had received COVID-19 vaccines on 01/18/21 and 06/10/22. There was no evidence the resident was provided with a booster or education regarding a booster vaccine. Interview with the Director of Nursing on 01/03/24 at 2:23 P.M. revealed boosters are to be provided annually and there was no evidence it was offered or declined for Resident #26. Review of the facility policy titled COVID-19 Vaccination (dated 05/01/22 and revised 10/20/23) revealed it is the policy of the facility to minimize the risk of acquiring, transmitting, or experiencing complications from COVID-19 by educating and offering residents and staff the COVID-19 vaccine. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365687 If continuation sheet Page 69 of 69

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Citations

31 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0561GeneralS&S Dpotential for harm
F561 - Self-determination
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
0569GeneralS&S Dpotential for harm
F569 - Notice of certain balances
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
0578GeneralS&S Dpotential for harm
F578 - The right to request, refuse, and/or discontinue treatment, to participate in or
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
0584GeneralS&S Epotential for harm
F584 - Safe Environment
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
0655GeneralS&S Dpotential for harm
F655 - Comprehensive Person-Centered Care Planning
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
0656GeneralS&S Dpotential for harm
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
0657GeneralS&S Dpotential for harm
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
0685GeneralS&S Dpotential for harm
F685 - Vision and hearing
Assist a resident in gaining access to vision and hearing services.
0686GeneralS&S Dpotential for harm
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
0689SeriousS&S Gactual harm
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
0690GeneralS&S Dpotential for harm
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
0692GeneralS&S Dpotential for harm
F692 - Assisted nutrition and hydration
Provide enough food/fluids to maintain a resident's health.
0695GeneralS&S Dpotential for harm
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
0697GeneralS&S Dpotential for harm
F697 - Pain Management
Provide safe, appropriate pain management for a resident who requires such services.
0698GeneralS&S Dpotential for harm
F698 - Dialysis
Provide safe, appropriate dialysis care/services for a resident who requires such services.
0755GeneralS&S Epotential for harm
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
0756GeneralS&S Dpotential for harm
F756 - Drug Regimen Review
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
0757GeneralS&S Dpotential for harm
F757 - Unnecessary Drugs—General
Ensure each resident’s drug regimen must be free from unnecessary drugs.
0760GeneralS&S Dpotential for harm
F760 - Residents are free of any significant medication errors
Ensure that residents are free from significant medication errors.
0770GeneralS&S Dpotential for harm
F770 - Laboratory Services
Provide timely, quality laboratory services/tests to meet the needs of residents.
0804GeneralS&S Epotential for harm
F804 - Food and drink
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
0806GeneralS&S Epotential for harm
F806 - Food and drink
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
0812GeneralS&S Fpotential for harm
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
0814GeneralS&S Fpotential for harm
F814 - Food Safety Requirements
Dispose of garbage and refuse properly.
0880GeneralS&S Fpotential for harm
F880 - Infection Control
Provide and implement an infection prevention and control program.
0881GeneralS&S Dpotential for harm
F881 - Infection prevention and control program
Implement a program that monitors antibiotic use.
0883GeneralS&S Dpotential for harm
F883 - Influenza and pneumococcal immunizations
Develop and implement policies and procedures for flu and pneumonia vaccinations.
0887GeneralS&S Dpotential for harm
F887 - Infection control
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
0551GeneralS&S Dpotential for harm
F551 - In the case of a resident who has not been adjudged incompetent by the state
Give the resident's representative the ability to exercise the resident's rights.
0585GeneralS&S Dpotential for harm
F585 - Grievances
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
0684GeneralS&S Dpotential for harm
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.

FAQ · About this visit

Common questions about this visit

What happened during the January 12, 2024 survey of ARBORS AT MARIETTA?

This was a inspection survey of ARBORS AT MARIETTA on January 12, 2024. The surveyor cited 31 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at ARBORS AT MARIETTA on January 12, 2024?

Yes, 31 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to and the facility must promote and facilitate resident self-determination through support o..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed June 22, 2026. If you believe any information is inaccurate, report it here.

Health inspection·January 12, 2024