Health inspection·August 15, 2019

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the medication administration record revealed Resident #33's blood sugar was 340 on 07/23/19 at 1200 P.M. There was no documentation in the medical record to indicate the physician was notified of the elevated blood sugar. Review of the medication administration record revealed Resident 33's routine Novolog dose was not given at supper on 07/28/19. A note indicated her blood sugar was 85, but the note did not indicate if she was symptomatic. Her routine Novolog dose was also held on 07/29/19 at 12:00 P.M. for a blood sugar of 68, however, the note did not indicate any symptoms of low blood sugar. Review of the medication administration record for August 2019 revealed Resident #33's blood sugar was 61 on 08/09/19 at 8:00 A.M. , 307 on 08/10/19 at 8:00 A.M. and 318 on 08/10/19 at 5:30 P.M. These blood sugar levels were all within the ranges of the physician's orders that required them to be called to the physician or nurse practitioner. However, there was no documentation these blood sugars were reported to the physician or nurse practitioner. Review of the facility policy for physician notification of changes in condition or status, updated on 10/07/10, revealed the nurse would notify the physician when there were instructions to notify the physician. The policy also indicated the nurse would record this information in the resident's medical record. Interview with Resident #33's physician, MD #500, on 08/13/19 at 4:20 P.M. revealed he did not recall specific notification from the nursing staff regarding the blood sugars as listed above. He verified the parameters for notification were conflicting, but that the resident's blood sugars were within the parameters for notification. He stated he did look at the medication administration record to check the blood sugar levels but he did not generally review the nursing notes. Thus, he did not see the nurses' notes related to the hypoglycemic episodes on 07/19/19 and 07/21/19. He also verified there was no order specifically to hold the resident's routine insulin doses, although he stated the nurses could hold the medication if the resident was symptomatic of a low blood sugar. An interview with the Director of Nursing (DON) on 08/15/19 at 1:00 P.M. revealed she spoke to the nurse practitioner, who stated she was aware the resident's blood sugars were up and down, but confirmed there was no documentation in the medical record to verify the physician or nurse practitioner were notified of the blood sugar variances for Resident #33 in the event treatment changes were needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365689 If continuation sheet Page 2 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365689 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Fairlawn The 575 S Cleveland Massillon Road Fairlawn, OH 44333 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 observation, record review and interview, the facility failed to provide treatment to Resident #52's pressure ulcer per the physician orders. This affected one of one resident reviewed for pressure ulcers. Residents Affected - Few Findings include: Review of Resident #52's medical record revealed the resident was re-admitted to the facility on [DATE] with diagnoses including osteomyelitis (infection in the bone) of the vertebra, sacral and sacrococcygeal region, dementia without behavioral disturbance, hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following a cerebral infarction (stroke) affecting the right dominant side. Review of Resident #52's physician orders revealed an order dated 07/22/19 for nursing staff to gently cleanse the wound and wound bed with normal saline, pat dry, lightly pack wound with Dakin's solution soaked gauze, and cover with an adhesive foam dressing twice daily and as needed. Review of Resident #52's pressure ulcer wound grid dated 08/08/19 revealed he had a Stage IV pressure ulcer (a full-thickness skin and tissue loss exposing the fascia, tendon, muscle, ligaments, cartilage and/or bone which may contain slough or eschar, which is dead or devitalized tissue) measuring 7.0 cm (centimeters) in length by 4.0 cm wide by 2.0 cm in depth. The form indicated nursing staff were to cleanse the pressure ulcer wound with normal saline, apply a Dakin's solution soaked gauze dressing and cover with a foam pad twice daily. Observation on 08/13/19 at 1:27 P.M. with Licensed Practical Nurse (LPN) #610 revealed she washed her hands, applied gloves, removed Resident #52's old pressure ulcer wound dressing on his coccyx, cleansed the wound using wound wash and gauze, removed her gloves, washed her hands, put on new gloves, applied Dakin's solution to gauze, packed the Dakin's soaked gauze into the wound and covered the wound with a foam dressing. Interview on 08/13/19 at 2:36 PM. with LPN #610 confirmed she did not use normal saline to cleanse Resident #52's coccyx pressure wound as indicated in the physician orders. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365689 If continuation sheet Page 3 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365689 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Fairlawn The 575 S Cleveland Massillon Road Fairlawn, OH 44333 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide adequate supervision for Resident #24 during toileting. Actual harm occurred when Resident #24 was left unsupervised in the bathroom, fell and hit her head causing a laceration requiring an emergency room visit and a staple was needed to close her head/scalp laceration. This affected one of six residents reviewed for accidents. Findings include: Review of Resident #24's medical record revealed the she was admitted to the facility on [DATE] with diagnoses including lack of coordination, difficulty walking and dementia without behavioral disturbance. Review of Resident #24's Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated she had severe cognitive impairment and memory impairment. Review of Resident #24's current fall care plan revealed she was high risk for falls related to her confusion, use of psychoactive medications, unsteadiness when walking, incontinence and history of falls. Interventions dated 08/08/17 and 03/05/18 indicated staff were educated on not leaving Resident #24 alone in the bathroom. There was an additional intervention dated 05/30/19 which indicated Resident #24 was to be supervised by staff when in the bathroom. Resident #24's [NAME] (a reference care card providing information for staff for the provision of resident care) indicated she was to be supervised by staff during toileting. Review of Resident #24's progress note dated 07/27/19 at 2:16 P.M. indicated she was in the bathroom when she fell to the floor and was observed with blood coming from her head. Emergency Medical Services (EMS) were called and pressure with a towel was applied on the resident's head to stop the bleeding. The resident was transferred to the hospital. Review of Resident #24's progress note dated 07/27/19 at 5:44 P.M. revealed she returned from the hospital and she had a laceration to her scalp with one staple in place, which was used to close the laceration. Review of the undated fall witness statement authored by State Tested Nursing Assistant (STNA) #609 indicated she put Resident #24 on the toilet and left her alone in the bathroom. She left and went to provide care to another resident. When STNA #609 was done with the other resident and was coming out of the their room, she was told Resident #24 had fallen and hit her head. Interview on 08/13/19 at 3:39 P.M. with the Director of Nursing (DON) confirmed STNA #609 left Resident #24 in the bathroom unsupervised to provide care to another resident. The DON said Resident #24 attempted to get off of the toilet by herself and fell. The DON verified this resulted in a head/scalp laceration requiring her to be transported to the hospital emergency room. A staple was placed in the back of the resident's head to close the laceration. The DON confirmed Resident #24's [NAME] indicated she was to be supervised during toileting. Interview on 08/14/19 at 9:51 A.M. with STNA #609 confirmed she had worked in the facility approximately fourteen months but was unaware Resident #24 required continuous supervision during toileting. STNA #609 confirmed she left Resident #24 unattended on 07/27/19 while the resident was in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365689 If continuation sheet Page 4 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365689 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Fairlawn The 575 S Cleveland Massillon Road Fairlawn, OH 44333 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 bathroom to answer another resident's call light and the resident fell causing a laceration to the resident's head resulting in an emergency room visit for care and treatment. Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365689 If continuation sheet Page 5 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365689 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Fairlawn The 575 S Cleveland Massillon Road Fairlawn, OH 44333 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure Resident #52's medical record contained a physician order for oxygen therapy. This affected one of two residents reviewed for respiratory care. Residents Affected - Few Findings include: Review of Resident #52's medical record revealed the resident was re-admitted to the facility on [DATE] with diagnoses including muscle weakness, dementia without behavioral disturbance, hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following a cerebral infarction (stroke) affecting the right dominant side. Review of Resident #52's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment. Review of Resident #52's current respiratory care plan revealed an intervention dated 06/13/19 for oxygen settings via nasal cannula as ordered by the physician. Review of Resident #52's medical record did not reveal a physician order for oxygen therapy. Observations at 08/12/19 at 9:00 A.M. and 08/14/19 at 8:42 A.M. revealed Resident #52 was lying in bed with oxygen infusing at two liters per nasal cannula via an oxygen concentrator. Interview on 08/14/19 at 9:05 A.M. with the Director of Nursing confirmed Resident #52's medical record did not contain a physician order for oxygen therapy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365689 If continuation sheet Page 6 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365689 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Fairlawn The 575 S Cleveland Massillon Road Fairlawn, OH 44333 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 observation, interview and record review the facility failed to ensure Resident #50's medications and renal diet were provided as ordered by the physician. This affected one resident of one resident reviewed for dialysis services. Residents Affected - Few Findings include: Review of Resident #50's medical record revealed an admission date of 05/07/18 with diagnoses including obesity, anemia, end stage renal (kidney) disease with dependence on dialysis, diabetes, and hypotension (low blood pressure). Review of a quarterly Minimum Data Set assessment dated [DATE] revealed Resident #50 was alert and oriented with intact cognition and rejected care one to three days in the seven day review period. Review of a care plan dated 05/16/18 revealed Resident #50 received dialysis treatments on Tuesdays, Thursdays and Saturdays. Review of Resident #50's current physician orders revealed an order dated 08/08/19 directing staff to send all morning and afternoon medications to dialysis with the resident every Tuesday, Thursday and Saturday; an order dated 07/01/19 for dialysis treatments at 7:15 A.M. on Tuesdays, Thursdays and Saturdays; an order dated 06/30/19 for midodrine hydrochloride five milligrams (mg) one tablet by mouth three times per day for hypotension, hold medication if blood pressure was over 120/80 millimeters Mercury (mm Hg); an order dated 06/30/19 for sevelamer carbonate (renvela) 800 mg, give two tablets by mouth with meals for end-stage renal disease; an order dated 07/02/19 for aspirin 81 mg, give one tablet by mouth in the morning for heart failure; an order dated 07/02/19 for clopidogrel bisulfate 75 mg, give one tablet by mouth in the morning for heart failure; an order dated 07/02/19 for multiple vitamins-minerals tablet, give one tablet by mouth in the morning for supplement; an order dated 07/02/19 for pantoprazole sodium tablet delayed release 20 mg, give one tablet by mouth in the morning related for gastro-esophageal reflux disease without esophagitis; an order dated 07/02/19 for spironolactone tablet 25, mg give one tablet by mouth in the morning related to end-stage renal disease; and an order dated 07/16/19 for velphoro tablet chewable 500 mg, give by mouth with meals to prevent low calcium levels. A diet order dated 06/30/19 indicated Resident #50 received a liberal renal diet. Review of pre-dialysis and post-dialysis documentation for August 2019 verified Resident #50 received dialysis on 08/08/19 (Thursday), and 08/10/19 (Saturday). Review of Resident #50's August 2019 Medication Administration Record (MAR) indicated a 9 was recorded 08/08/19 for the 9:00 A.M. doses of sevelamer carbonate, aspirin, clopidogrel bisulfate, multiple vitamins-minerals, pantoprazole sodium, spironolactone and velphoro tablets. A 9 indicated there would be a nurses' note written regarding the medication. A 4 was recorded on 08/08/19 for the midodrine hydrochloride doses scheduled at 2:00 P.M. and 10:00 P.M. indicating the medication was outside the parameters for administration. A 9 was recorded for the midodrine hydrochloride dose scheduled for 6:00 A.M. on 08/08/19. Review of Resident #50's nurses' notes on 08/08/19 indicated the sevelamer carbonate, aspirin, clopidogrel bisulfate, multiple vitamins-minerals, pantoprazole sodium, spironolactone and velphoro (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365689 If continuation sheet Page 7 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365689 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Fairlawn The 575 S Cleveland Massillon Road Fairlawn, OH 44333 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few tablets were given to the resident to take at dialysis. Review of a single nurses' note dated 08/10/19 did not reveal any information to indicate the medications were given to the resident to take at dialysis. Interview with Resident #50 on 08/14/19 at 8:34 A.M. revealed the facility recently started sending his medications with him to dialysis. Resident #50 stated he received his medications when he returned to the facility after his dialysis treatments and stated the dialysis center did not administer medications. Resident #50 stated last Thursday (08/08/19) and last Saturday (08/10/19) he was provided with the whole day's worth of medications and the medications were still present in his room. Interview on 08/14/19 at 9:00 A.M. with Dialysis Technician #605 verified they were familiar with Resident #50 and stated the resident arrived to the dialysis center with medications from the facility and this had been happening for about two weeks. Dialysis Technician #605 said if Resident #50 took any medication at the dialysis center, the dialysis nurse was required to observe the administration. Interview on 08/14/19 at 9:05 A.M. with Dialysis Registered Nurse (DRN) #606 revealed Resident #50 did not typically come to the dialysis center with medications. DRN #606 denied Resident #50 taking any medications during his treatment on 08/08/19. Interview on 08/14/19 at 9:44 A.M. with Physician #607 revealed he oversaw Resident #50's medical care at the facility. Physician #607 did not think Resident #50 would be able to self-administer his own medication but it would depend as the resident was alert and oriented, but seemed a little off. Physician #607 was not aware Resident #50 had not received his medications at the facility or at the dialysis center on 08/08/19. An interview was conducted on 08/14/19 at 9:52 A.M. with the Director of Nursing (DON) and Resident #50. Resident #50 stated he had not taken medication given to him when he went to the dialysis center as they were labeled 11:00 A.M. and he did not have food at that time. Resident #50 pointed to his lunch box during the interview. The DON retrieved three white envelopes containing pills from Resident #50's lunch box, which goes with him to dialysis. Observation of the three medication envelopes revealed one with a notation, 11 A.M. (no date) midodrine five mg; one marked 11 A.M. (no date) with renvela 800 mg (2 tabs) and one marked 5 P.M. (no date) with renvela 800 mg (2 tabs). The DON confirmed Resident #50 did not receive his medications as ordered on 08/08/19 and 08/10/19. In addition, review of Resident #50's meal ticket revealed he was on a liberal renal diet. Dislikes listed included milk, potatoes, tomato products, dairy products and scrambled eggs. Observation of Resident #50's breakfast meal on 08/14/19 in his room starting at 8:34 A.M. revealed two bowls of Cheerios cereal, one of which had been consumed, and a banana on his over-bed table. Bananas are high in potassium and people with kidney disease have difficulty filtering out excess potassium, thus foods low in potassium are recommended. An interview was conducted on 08/14/19 at 8:44 A.M. with Licensed Practical Nurse (LPN) #604 and Registered Dietitian (RD) #601 upon entry into Resident #50's room. RD #601 was asked if a banana was appropriate for a resident on a renal diet and she indicated Resident #50's labs were good. A follow-up interview on 08/14/19 with RD #601 at 9:24 A.M. verified the banana was not appropriate for Resident #50 since he was on a renal diet and should be added to the dislike list on his meal (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365689 If continuation sheet Page 8 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365689 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Fairlawn The 575 S Cleveland Massillon Road Fairlawn, OH 44333 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 ticket so he would not receive them. 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: 365689 If continuation sheet Page 9 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365689 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Fairlawn The 575 S Cleveland Massillon Road Fairlawn, OH 44333 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. The facility error rate was 18.51%, with 5 errors in 27 opportunities. This affected two of four residents observed for medication pass (Resident #'s 2 and 52). Residents Affected - Few Findings include: 1. Review of the record of Resident #2 revealed he was admitted to the facility on [DATE] with diagnoses including myasthenia gravis, gastroesophageal reflux disease and iron deficiency. An observation of medication pass for Resident #2 was made on [DATE] at 8:25 A.M. with Licensed Practical Nurse LPN #613. LPN #613 could not find the correct dose of Ferrous Gluconate (an iron supplement, ordered [DATE]), so LPN # 611, who was nearby, found a box of the medication for LPN #613. LPN #613 popped a tablet into the cup for the resident from a blister sealed package that was in a box. The package and the blister package all were marked with an expiration date of 02/19, (February 2019). LPN #613 then individually put all pill in clear plastic envelopes to crush them in preparation for administration to the resident. The surveyor asked LPN #613 to pause, she verified she was ready to crush the medication but verified after reviewing the box and blister package that the Ferrous Gluconate was expired. She discarded the medication and LPN #611 obtained a new box of the medication which was not expired. LPN #613 also prepared doses of Omeprazole Delayed Release 20 milligrams (a medication to treat stomach upset, ordered [DATE]) and Potassium Chloride extended release 10 milliequivalents (a potassium supplement, ordered [DATE]) with other medications for Resident #2. The Omeprazole was in a capsule form, but when LPN #613 opened the capsule into a cup, part of the capsule contents were in a more solid form, so she crushed them mechanically, as she did the potassium, stating he took them better if they were crushed. LPN #613 verified after the medication was given that all of the medications for Resident #2 had been crushed. Review of a list provided by the facility of medications that should not be crushed prior to administration revealed the Omeprazole and Potassium should not be crushed prior to administration due to the extended release properties of the medications. The Director of Nursing verified on [DATE] at 4:30 P.M. the medications should not have been crushed and that the nurse should have not have attempted to administer an expired medication. 2. Review of the record of Resident # 52 revealed he was admitted to the facility on [DATE] with diagnoses including history of stroke, vitamin deficiency and hypertension. The resident had a gastrostomy tube, a flexible tube inserted into the stomach through the abdominal wall, through which he received his medications. Observation of medication pass was conducted for Resident #52 on [DATE] with Licensed Practical Nurse LPN # 612 at 9:32 A.M. LPN #612 prepared multiple medications for Resident #52, including three liquid medications, and five pills or tablets. The medications included Vitamin C two tablets and a dose of Metoprolol (to treat high blood pressure). She prepared the tablets and capsules by either (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365689 If continuation sheet Page 10 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365689 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Fairlawn The 575 S Cleveland Massillon Road Fairlawn, OH 44333 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 0759 emptying them or crushing them mechanically, putting them into small plastic medication cups. Level of Harm - Minimal harm or potential for actual harm LPN #612 took all the medications into the room and set them in a line on the nightstand. She began the administration of the medication through the gastrostomy tube, after having mixed a small amount of water into each cup of the crushed medications. She flushed the tube, and then poured the first medication down the tube, flushed again and then poured the second medication down the tube. The two cups with the first two medications contained a significant amount of medication still in the cup that had not mixed in the water and was not administered. LPN #612 continued the medication pass, with all other medications administered in their entirety. After completing the medication pass, LPN #612 began to stack all the medication cups to throw them away. She was stopped by the surveyor and observed the contents remaining in the first two cups. The first cup contained a yellowish medication, which LPN #612 indicated was the Vitamin C. The second cup contained a large amount of pill residual, which was the Metoprolol, the blood pressure medication. LPN #612 verified the amount of medication in the cups was significant and verified the resident had not received the full dose of these medications and would not have if she would have continued to discard the cups. She then did administer the rest of the medications to the resident after the intervention by the surveyor. Residents Affected - Few Review of the facility policy on Administration of Medications through an Enteral Tube (gastrostomy tube), revised [DATE], revealed the medications should be diluted before administration. An interview with the Director of Nursing on [DATE] at 4:30 P.M. confirmed the full dose of medication should be administered as ordered. The medication error rate was 18.51%, with 5 errors in 27 opportunities. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365689 If continuation sheet Page 11 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365689 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Fairlawn The 575 S Cleveland Massillon Road Fairlawn, OH 44333 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure Resident #50's medications were appropriately stored and labeled. This affected one resident of one resident reviewed for dialysis. Findings include: Review of Resident #50's medical record revealed an admission date of 05/07/18 with diagnoses including obesity, anemia, end stage renal (kidney) disease with dependence on dialysis, diabetes, and hypotension (low blood pressure). Review of a quarterly Minimum Data Set assessment dated [DATE] revealed Resident #50 was alert and oriented with intact cognition. Review of a care plan dated 05/16/18 revealed Resident #50 received dialysis treatments on Tuesdays, Thursdays and Saturdays. Interview with Resident #50 on 08/14/19 at 8:34 A.M. revealed the facility recently started sending medications with him to dialysis. Resident #50 stated he received medications when he returned to the facility after dialysis treatments and stated the dialysis center did not administer medications. Resident #50 stated last Thursday (08/08/19) and last Saturday (08/10/19) he was provided with the whole day's worth of medications and the medications were still present in his room. An interview was conducted on 08/14/19 at 9:52 A.M. with the Director of Nursing (DON) and Resident #50. Resident #50 stated he had not taken medication given to him when he went to the dialysis center as they were labeled 11:00 A.M. and he did not have food at that time. Resident #50 pointed to his lunch box during the interview. The DON retrieved three white envelopes containing pills from Resident #50's lunch box, which goes with him to dialysis. Observation of the three medication envelopes revealed one with a notation, 11 A.M. (no date) midodrine five mg; one marked 11 A.M. (no date) with renvela 800 mg (2 tabs) and one marked 5 P.M. (no date) with renvela 800 mg (2 tabs). A follow-up interview with the DON on 08/14/19 at 10:23 A.M. verified the medications in the undated envelopes found in Resident #50's room were not labeled and stored properly. Review of the policy, Storage of Medications, dated 06/23/19 revealed drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy was authorized to transfer medications between containers. Drug containers that had missing, incomplete, improper or incorrect labels were to be returned to the pharmacy for proper labeling before storing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365689 If continuation sheet Page 12 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365689 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Fairlawn The 575 S Cleveland Massillon Road Fairlawn, OH 44333 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview and menu spreadsheet review the facility failed to ensure meals were provided as planned on the menus. This affected three residents (Resident #43, Resident #62 and Resident #85) of three residents on a pureed diet and one resident (Resident #6) of one resident on a level-II mechanically altered diet. The facility census was 81 residents. Findings include: Review of the spreadsheet titled, Week 4, Day 3 corresponding to 08/13/19 revealed residents receiving a pureed diet were to receive a #12-scoop of pureed pork, a #8-scoop of pureed potatoes, a #16-scoop of pureed cauliflower, a #16-scoop of pureed bread and a #10-scoop of pureed peanut butter brownie. The spreadsheet indicated residents receiving a level-II mechanically altered diet were to receive ground garlic pork, soft mashed potatoes, soft mashed cauliflower, a #16-scoop of pureed bread and a #10-scoop of pureed peanut butter brownie. The level-II mechanically altered diet consisted of moist and soft foods; meats were to be minced and moistened with sauces or gravies. Observation of lunch tray service on 08/13/19 starting at 11:37 A.M. revealed Dietary Manager (DM) #600 setting up the tray line. Tray service started at 11:49 A.M. At 11:52 A.M., a puree meal was plated and noted to not receive pureed bread. No other meals were noted to receive pureed bread throughout the observation and pureed bread was not observed on the steam table. Interview on 08/13/19 at 12:30 P.M. with Registered Dietitian (RD) #601 and Corporate Registered Dietitian (CRD) #602 verified the pureed bread had not been prepared nor provided for the lunch meal. A follow-up interview on 08/13/19 at 1:45 P.M. with RD #601 and CRD #602 identified Resident #6, Resident #43, Resident #62 and Resident #85 as residents who should have received pureed bread during the lunch meal on 08/13/19. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365689 If continuation sheet Page 13 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365689 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Fairlawn The 575 S Cleveland Massillon Road Fairlawn, OH 44333 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 record review, the facility failed to prepare, store and distribute food in a sanitary kitchen environment. This affected 80 of 81 residents receiving meals from the kitchen. The facility identified Resident #52 as not receiving food by mouth. Findings include: 1. Observation of the kitchen on 08/12/19 from 8:30 A.M. to 8:53 A.M. with Dietary Manager (DM) #600 revealed in the walk-in cooler, three of the five blower fans were coated in dust. In the dry storage room, one box of cornbread was noted to be dated 09/24/18. Observation of the hood over the flat-top grill revealed a sticker indicating the hood had last been cleaned on 02/28/19 and a cobweb was noted on the right-most light over the hood. In the dish room, the log to left of the high-temperature dish machine to record dishwasher temperatures was incomplete. Observation of a dishmachine temperature log for August 2019 revealed there were spaces for staff to document temperatures three times daily. There were only breakfast temperatures recorded on 08/01/19, 08/02/19, 08/03/19, 08/04/19, 08/06/19, 08/07/19, 08/08/19 and 08/09/19 and one lunch temperature recorded on 08/05/19. No temperatures were recorded since 08/09/19. Interview with DM #600 verified these findings at the time of observation. DM #600 did not know how often cooler fans were cleaned since they had been employed by the facility only since June 2019. DM #600 acknowledged there was a training deficit regarding staff recording dish machine temperatures and said the dietary department had lost five staff members in the last month. Review of the facility policy for use of the dishwashing machine dated 10/21/13 revealed temperatures would be checked with each machine cycle and staff would record the results in a facility approved log, three times a daily. Review of the facility policy on kitchen sanitation dated 06/23/16 revealed kitchen surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent accumulation. Review of requested cleaning documentation for the last three months revealed the last time any kitchen cleaning was documented as completed was the first week of June, 2019. 2. Observation of nursing unit refrigerators with Registered Dietitian (RD) #601 on 08/12/19 from 8:53 A.M. to 9:08 A.M. revealed on the [NAME] unit, the refrigerator had spilled juice on the bottom surface. Two take-out food containers were unlabeled and undated in this refrigerator. Observation of the sign (no date) posted on the [NAME] nursing unit refrigerator revealed all items placed in the refrigerator were to be labeled and dated. The sign directed staff to wipe up spills and keep the refrigerator clean. Interview with RD #601 verified these findings at the time of observation. RD #601 stated staff were to wipe up spills in the refrigerator as they occurred. RD #601 stated food in the nursing unit refrigerators would be safe to eat for three days before needing to be discarded. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365689 If continuation sheet Page 14 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365689 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Fairlawn The 575 S Cleveland Massillon Road Fairlawn, OH 44333 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 FORM CMS-2567 (02/99) Previous Versions Obsolete Review of the facility policy on Foods Brought by Facility/Visitors dated 04/23/18 revealed perishable foods were to be stored in re-sealable containers with tightly fitting lids in the refrigerator. Containers were to be labeled with the resident's name, the item and the use by date. Review of the facility policy on food receiving and storage revised 06/23/16 revealed food and snack items on the nursing units were to be labeled with the resident's name, the item and the use by date. Partially eaten food was not to be kept in the refrigerator. Event ID: Facility ID: 365689 If continuation sheet Page 15 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365689 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Fairlawn The 575 S Cleveland Massillon Road Fairlawn, OH 44333 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to maintain clean, functional and sanitary shower rooms. This affected Resident #41, Resident #56 and Resident #61 and affected four of four facility shower rooms, which had the potential to affect all residents residing in the facility, except for 13 residents receiving only bed baths (Residents #8, 9, 15, 29, 35, 40, 43, 48, 50, 52, 62, 70 and 80). Findings include: On 08/12/19 at 10:10 A.M. interview with Resident #41 revealed the 200 hall shower room fan was not functioning and had not been since their admission [DATE]). Resident #41 indicated the shower room gets so hot it is difficult to breath and the nurse aides almost pass out from the heat. Observation on 08/12/19 at 10:20 A.M. in the room of Resident #56 and Resident #61 revealed significant chipped paint, scrapes and scuff marks on the walls by both resident's beds. A large unpainted patched hole was noted on the wall next to the window. An interview with Housekeeper #615 at the time of the observation verified the condition of the walls in this room. On 08/14/19 a tour of the facility's shower rooms was conducted from 11:34 A.M. until 11:59 A.M. with Maintenance Director (MD) #614. A non-functional ventilation fan was noted in the 100 hall shower room with a missing fan cover which exposed a fan filter covered with dirt and debris. The fan cover was observed on the floor leaning against the wall adjacent to the wall housing the fan. The 200 hall shower room was noted to have a covered ventilation fan with matted debris protruding through the fan cover. MD #614 removed the fan cover and discovered a matted filter tangled around the fan, covered with dirt and debris, and a large clump of matter and debris, described by MD #614 as a bird's nest behind the matted filter. MD #614 declined to turn the fan on and check for functioning due to the condition of the fan. The 300 hall shower room was noted to have a fan which did operate when turned on but made a continuous loud clunking noise until turned off by MD #614. The 500/600 hall shower room was noted to have no fan installed, only one functioning air conditioning unit on the wall adjacent to the bathtub. Each of the four shower rooms were noted to have a hole in the ceiling without a vent cover. Interview with MD #614 during the tour verified the observations and confirmed that the ceiling holes in the four shower rooms were access to the heating, air conditioning and ventilation system of the building. MD #614 further explained the ceiling holes were not equipped with mechanical ventilation, and the fans in the shower rooms were on the schedule to be checked annually. Interview on 08/14/19 at 12:00 P.M. with State Tested Nursing Assistant (STNA) #609 confirmed the fan in the 200 hall shower room was not functioning, and indicated it had been that way for at least two months. Interview on 08/14/19 at 12:19 P.M. with STNA #617 verified the fan in the 100 hall shower room had no cover, and stated the fan was not used during showers because it was broken. Interview on 08/14/19 at 12:25 P.M. with STNA #616 verified there were loud clunking noises made when the 300 hall shower room fan was operated, and stated the fan was not used unless the residents complained that it got too hot. Interview on 08/14/19 at 2:04 P.M. with MD #614 revealed the shower room fans were not on a list (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365689 If continuation sheet Page 16 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365689 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Fairlawn The 575 S Cleveland Massillon Road Fairlawn, OH 44333 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 0921 for regular checks and maintenance. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365689 If continuation sheet Page 17 of 17