Health inspection·August 15, 2022

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 08/08/22 at 10:13 A.M. revealed FM #191 asking State Tested Nursing Assistant (STNA) #104 to change Resident #56's sheet due to feces on it and pointing out the bathroom with the large amount of bowel movement on the floor and toilet. STNA #104 stated housekeeping would get to it. FM #191 told STNA #104 again the sheet had feces on it and needed changed and STNA #104 stated yeah, yeah I will tell housekeeping, they will get to it and walked away from FM #191 without changing the sheet or cleaning the bathroom. FM #191 asked another unidentified staff walking by the room about Resident #56's dirty sheet and bathroom and the staff kept going without addressing the concern. Observation on 08/08/22 at 10:38 A.M. of Resident #56's room revealed the sheet with feces was still on the bed and the bowel movement in the bathroom had not been cleaned. Observation on 08/08/22 at 10:48 A.M. revealed FM #191 ripping the sheet with feces off the bed and stopping Licensed Practical Nurse (LPN) #135 and telling her Resident #56's sheet needed changed due to feces on it. LPN #135 called STNA #104 over and told her Resident #56's sheet needed changed because it had feces on it. STNA #104 told LPN #135 she was too busy now to change the sheet and walked away. LPN #135 proceeded to change Resident #56's sheet. After changing the sheet LPN #135 found housekeeping and had the bathroom cleaned. Interview on 08/08/22 at 10:48 A.M. with FM #191 revealed Resident #56 was blind in one eye and had a hard time keeping the toilet from getting bowel movement all over it. FM #191 stated the bowel movement on the floor and on the toilet was a continuous problem he encountered almost every day when he arrived at the facility. 2. Review of Resident #47's medical record revealed an admission date of 06/12/16 and diagnoses included dementia, chronic obstructive pulmonary disease, and history of transient ischemic attacks and cerebral infarction without residual deficits. Review of Resident #47's Braden Scale For Predicting Pressure Sore Risk dated 06/15/22 revealed the resident was at high risk for developing a pressure ulcer. Review of Resident #47's quarterly Minimum Data Set (MDS) 3.0 assessment dated , 06/16/22 revealed Resident #47 had severe cognitive impairment. Resident #47 required extensive assistance of one staff member for bed mobility and toilet use and had total dependence on two staff members for transfers. Resident #47 required supervision of one staff member for eating. Review of Resident #47's care plan dated 07/20/22 included Resident #47 had an activity of daily living (ADL) self-care performance deficit related to diagnoses, dementia, pain. Resident #47 would improve current level of function in ADLs through the review date. Interventions included Resident #47 was able to feed self with meal setups. He at times needed more assistance based on his mood. Assist as needed and document. Observation on 08/09/22 at 8:15 A.M. of Resident #47 revealed he was lying almost flat in bed and his breakfast tray was placed on the bedside table. The bedside table was raised about 12 inches above Resident #47. Resident #47 stated he could not eat like that, and he could not even see what food there was to eat. Interview on 08/09/22 at 8:26 A.M. with State Tested Nurse Aide (STNA) #159 revealed she delivered Resident #47's breakfast tray. STNA #159 stated she woke Resident #47 up, but did not assist him in any way because he was able to adjust himself. STNA #159 did not enter Resident #47's room to see if (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365689 If continuation sheet Page 2 of 25 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 08/15/2022 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 0550 he needed any help. Level of Harm - Minimal harm or potential for actual harm Observation on 08/09/22 at 8:28 A.M. (after surveyor intervention) revealed Registered Nurse (RN) #120 entering Resident #47's room to assist him with his breakfast tray set up. RN #120 stated Resident #47's bedside table was pretty far above resident and she lowered the tray so he could eat. Residents Affected - Few Review of the facility policy titled Resident Rights revised, 01/01/22 included employees shall treat all residents with kindness, respect and dignity. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365689 If continuation sheet Page 3 of 25 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 08/15/2022 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure Resident #211 transfer notice contained the accurate state's information under the appeal rights. This affected one resident (#211) of two residents (#210 and #211) reviewed for hospitalizations. The facility census was 58. Findings include: Review of the medical record for Resident #211 revealed an admission date of 06/09/22 and a discharge date of 06/20/22. Diagnoses included acute embolism and thrombosis of deep veins of lower extremity, secondary malignant neoplasm of liver and intrahepatic bile duct, Alzheimer's disease, stage two pressure ulcer on the sacral region, and an unstageable ulcer on the right hip. Review of the admission minimum data set (MDS) assessment dated [DATE] revealed Resident #211 had severely impaired cognition and required extensive assistance of two staff for bed mobility, total dependence of two staff for transfers, and total dependence of one staff for toilet use. Review of the nurses' notes dated 06/20/22 timed 1:07 P.M. revealed therapy was in to work with Resident #211. Resident #211 exhibited a change of mental status (not eating, drinking, or talking). Daughter at bedside. Vital signs obtained. The nurse practitioner, Director of Nursing (DON) notified. Emergency Medical Services (911) called and transported Resident #211 to the local hospital. Review of the transfer notice dated 06/20/22 revealed, under the appeal rights section, the contact information included the Michigan Department of Licensing and Regulatory affairs and the State long term care Ombudsman located in [NAME], Michigan. Interview on 08/10/22 at 7:48 A.M. with Social Services Director (SSD) #110 verified the contact information for the state of Michigan was provided on the transfer notice. SSD #110 said in addition to providing the notice, she contacted the families and the residents to tell them they would contact the Ohio ombudsman and department of health. SSD #110 stated she provided the transfer notice which was provided by the corporation for her to use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365689 If continuation sheet Page 4 of 25 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 08/15/2022 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a bed hold notice was provided to Resident #211 upon hospitalization. This affected one resident (#211) of two residents (#210 and #211) reviewed for hospitalizations. The facility census was 58. Findings include: Review of the medical record for Resident #211 revealed an admission date of 06/09/22 and a discharge date of 06/20/22. Diagnoses included acute embolism and thrombosis of deep veins of lower extremity, secondary malignant neoplasm of liver and intrahepatic bile duct, Alzheimer's disease, stage two pressure ulcer on the sacral region, and an unstageable ulcer on the right hip. Review of the admission minimum data set (MDS) assessment dated [DATE] revealed Resident #211 had a severely impaired cognition and required extensive assistance of two staff for bed mobility, total dependence of two staff for transfers, and total dependence of one staff for toilet use. Review of the nurses' notes dated 06/20/22 timed 1:07 P.M. revealed therapy was in to work with resident. Resident #211 exhibited a change of mental status (not eating, drinking, or talking). Daughter at bedside. Vital signs obtained. The nurse practitioner, Director of Nursing (DON) notified. Emergency Medical Services (911) called and transported resident to the local hospital. Interview on 08/10/22 at 7:57 A.M. with Social Services Director (SSD) #110 stated because Resident #211 was not on Medicaid he did not receive a bed hold notice when he was hospitalized on [DATE]. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365689 If continuation sheet Page 5 of 25 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 08/15/2022 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 - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to timely provide care and treatment to ensure one resident (Resident #50) did not develop a pressure injury of the sacrum. Actual harm occurred when Resident #50 developed a Stage 4 (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. Epibole [rolled edges], undermining and/or tunneling often occur. Depth varies by anatomical location.) of the sacrum. The facility also failed to ensure pressure injuries of a lower stage did not develop for Resident #47. This affected two of three residents (#47, #50, and #57) reviewed for pressure injuries. The facility identified five resident with pressure ulcers. The census was 58. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #50 revealed an admission date of 08/12/20. Diagnoses included Stage 4 pressure ulcer of the sacral region , type 2 diabetes mellitus (DM), morbid obesity, and Alzheimer's disease. Review of the skin assessment dated [DATE] revealed no new or existing abnormal skin areas. Review of the care plan dated 05/31/22 revealed Resident #50 had impaired skin integrity in the form of pressure wound to the sacrum. Interventions included medications and treatments as ordered; observe area for increased redness, drainage, and edema; observe for signs of pain and administer analgesics as ordered; turn and reposition frequently as tolerated by resident; and pressure redistribution mattress. Review of the skin and wound evaluation dated 05/31/22 revealed Resident #50 had a Stage 4 pressure ulcer that was in-house acquired on the sacrum which measured 3.7 centimeters (cm) in length, 2.1 cm in width, and depth not applicable. The wound bed was pink and moist with light amount of drainage and no odor. The Peri-wound was approximately 1.0 cm out from the wound bed and was blanchable erythema. The skin appeared fragile and at-risk for breakdown. Review of the wound nurse practitioner note dated 05/31/22 revealed a new Stage 4 pressure ulcer on sacrum. The wound bed had slough and was necrotic with pink tissue. The peri wound was intact and fragile. Review of the dietary progress note dated 06/21/22 timed 3:47 P.M. revealed a wound review note indicating Resident #50 with pressure injury to sacrum. Diet order was carbohydrate-controlled diet (CCD), regular texture, thin liquids and intakes recorded were 25-50% on average with resident refusing meals on rare occasion. Supplements included Med Pass 120 milliliters (ml) three times per day with intakes 50-100% to provide 240 calories and 10 grams of protein per serving. Resident reported eating not so good due to being sore all over. Resident missing some teeth. Midline catheter in place for hydration, with one liter of normal saline administered on 06/14/22. Updated food preferences to include likes pudding and ice cream. Weight stable. No new registered dietitian (RD) recommendations at this time. Review of the skin and wound evaluation dated 06/28/22 revealed the Stage 4 pressure ulcer measured 1.1 cm in length x 0.6 cm width, and depth was not applicable. There was no evidence of infection, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365689 If continuation sheet Page 6 of 25 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 08/15/2022 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 and the surrounding tissue was fragile skin. No pain noted and the wound was improving. Level of Harm - Actual harm Review of a physician order dated 07/11/22 revealed an order for barrier cream to peri area and buttocks during incontinence care. Residents Affected - Few Review of the annual Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #50 had impaired cognition, required extensive assistance of two staff for bed mobility, total dependence of two staff for transfer, supervision of one staff for eating, extensive assistance of one staff for toilet use. Resident #50 had one Stage 4 unhealed pressure ulcer/injury. Review of the skin and wound evaluation dated 07/26/22 revealed the Stage 4 pressure ulcer measured 1.5 cm in length x 1.0 cm in width and depth 2.7 cm. No pain was noted. Cat Scan (CT) to pelvis was done to rule out osteomyelitis (bone infection), results were without definitive evidence of osteomyelitis. CT showed subcutaneous emphysema to coccyx area. Follow-up Magnetic Resonance Imaging (MRI) scheduled to rule out osteomyelitis. Wound culture of area as well. Wound bed area was unchanged since last assessment. Granulation tissue present. Moderate amount of serous drainage. Peri wound was intact, fragile, and at-risk for breakdown Review of the skin and wound evaluation dated 08/02/22 revealed the Stage 4 pressure ulcer measured 0.9 cm in length x 1.1 cm in width, and depth 3.0 cm. No pain noted. CT to pelvis done to rule out osteomyelitis, results were without definitive evidence of osteomyelitis. CT showed subcutaneous emphysema to coccyx area. Follow-up MRI scheduled on 08/19/22 to rule out osteomyelitis. Wound bed area was unchanged since last assessment. Granulation tissue present. Moderate amount of serous drainage. Peri wound was intact, fragile, and at-risk for breakdown. Review of physician orders dated 08/02/22 revealed an order for Dakins (1/2 strength) Solution 0.25 % (Sodium Hypochlorite) apply to sacrum wound topically every morning and at bedtime for wound care, and an order to cleanse sacrum with Dakins soaked gauze, irrigate wound with Dakins solutions, cover with ABD (large bulky gauze pad), and secure with tape every morning and at bedtime and as needed. Review of the skin and wound evaluation dated 08/09/22 revealed the Stage 4 pressure ulcer measured 0.9 cm in length x 1.0 cm width and depth 2.0 cm. Noted resident complained of pain seven out of 10. Wound bed was unchanged, pink, and moist. Granulation tissue noted to 100% of wound bed. Moderate amount of serous drainage noted. No signs or symptoms of infection. Peri-wound was intact, fragile, erythema noted. Resident #50 voiced discomfort/pain during wound assessment and dressing change. New order to medicate prior to dressing change. Review of the wound nurse practitioner note dated 08/09/22 revealed the Stage 4 pressure ulcer status was unchanged, wound bed had granulation tissue, pink tissue, and the periwound was intact and fragile. There was also new moisture associated skin dermatitis (MASD) due to friction or contact to body fluids on on the left buttock. Observation on 08/10/22 at 10:35 A.M. of Licensed Practical Nurse/Wound Nurse (LPN/WN) #147 with the assistance of State Tested Nursing Assistant (STNA) #142 providing Resident #50's sacral dressing change revealed the following: Observation of Resident #50's sacrum after removal of an ABD pad and calcium alginate revealed the sacral area, bilateral buttocks, and posterior upper thighs were very red and several open areas were noted on both the right and left buttocks. A small amount of reddish drainage was noted from the open areas on the bilateral buttocks, and an open area approximately (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365689 If continuation sheet Page 7 of 25 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 08/15/2022 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 Level of Harm - Actual harm Residents Affected - Few the size of a dime was noted on Resident #50's sacral area. Observation of the dime sized wound revealed the wound bed could not be visualized due to depth of the wound. LPN/WN #147 stated she would get a light so the wound bed could be visualized. LPN/WN #147 found a light and returned to the room with the Director of Nursing (DON). LPN/WN #147 illuminated Resident #50's sacral wound bed with the light and another piece of calcium alginate was found and removed. The DON stated a long piece of calcium alginate should be used instead of two short pieces. Resident #50's sacral wound bed was pink with a small amount of slough noted in the upper right-hand area of the wound. LPN/WN #147 stated she did not measure the wounds because she measured them on 08/09/22, but the open areas on Resident #50's left buttock were not present on 08/09/22 and she would measure the wounds later today and document the measurements in Resident #50's medical record. LPN/WN #147 irrigated and cleansed the dime size wound with Dakin's solution, applied a long piece of calcium alginate, used Calmoseptine (barrier) ointment to the open areas on Resident #50's bilateral buttocks stating the open areas on the buttocks were MASD. LPN/WN #147 placed an ABD pad over the area and taped and dated the dressing. Interview on 08/11/22 at 8:39 A.M. with STNA #150 revealed Resident #50 was compliant with care. Prior to finding the wound Resident #50 complained of her bottom hurting her and she did not want to get up in her chair due to the pain. STNA #150 stated it was hard to find the wound; they had to spread her buttock cheeks open to find it. STNA #150 stated she alerted the nurse when she had found the wound during resident care. Interview on 08/11/22 at 8:45 A.M. with STNA #130 revealed she remember seeing Resident #50's wound when it was a small opening. STNA #130 notified the nurse when she noticed the opening getting deeper. STNA #130 indicated when it was a small hole they were putting cream on it. Prior to the wound being found Resident #50 had been crying and complaining of pain but they were not able to find anything. STNA #130 stated they had to spread open her buttock cheeks to find the wound. STNA #130 stated Resident #50 was heavier, so to ensure the resident was thoroughly cleaned when completing incontinence care and bathing, staff were to spread her buttock cheeks. STNA #130 stated when she noticed the wound getting deeper, she notified Registered Nurse (RN) #153. STNA #130 could not remember the time frames. Interview on 08/11/22 at 8:53 A.M. with RN #153 revealed she couldn't recall any of the exact dates or timeframe but stated STNA #130 had informed her Resident #50's wound was getting deeper. RN #153 assessed the wound and then informed LPN/WN #147. LPN/WN #147 told RN #153 they were already aware. LPN/WN #147 stated the resident had been complaining of her bottom hurting and she had not been getting out bed much and couldn't turn herself. Interview on 08/11/22 at 9:15 A.M. with LPN/WN #147 indicated she believed she was working the evening of 05/31/22 when the aide notified her Resident #50 had something on her bottom when they were doing incontinence care. LPN/WN #147 was not sure who the aide was that notified her. LPN/WN #147 stated because of the resident's anatomy and the location of the wound by the time it was noticed it was definitely at Stage 4. LPN/WN #147 stated the preventive measures that were in place prior to the development of the wound included incontinence care, turning and repositioning, house barrier cream, and a nutritional supplement that was started in February 2022. LPN/WN #147 stated the nurses completed weekly head to toe skin assessments. LPN/WN #147 stated when she assessed the wound on 05/31/22 it measured 3.7 centimeters (cm) in length, 2.1 cm in width, and 0.1 cm in depth, and the skin around it was fragile. LPN/WN #147 stated the current treatment included to clean with alginate to wound bed, cover with foam border dressing every night shift and as needed. LPN/WN #147 stated the wound was stable but as of 08/10/22 the resident acquired MASD because of the tape used to secure the dressing. A new order was obtained to use a silicone border foam that was gentler on the skin. LPN/WN (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365689 If continuation sheet Page 8 of 25 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 08/15/2022 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 Level of Harm - Actual harm #147 stated Resident #50 still had pain with the dressing changes. LPN/WN #147 stated when the wound was identified she notified the regional dietitian who was covering on 05/31/22 and then again on 06/14/22. LPN/WN #147 confirmed there was no nutritional re-assessment or new recommendations around that time period, but Resident #50 was on a nutritional supplement, Med pas, three times per day. Residents Affected - Few Interview on 08/11/22 at 9:49 A.M. with Registered Dietitian (RD) #168 revealed she started working at the facility on 06/14/22 and first addressed Resident #50's nutritional status related to her wound on 06/21/22. RD #168 stated the nutritional assessment prior to 06/21/22 was dated 04/01/22. RD #168 stated when a dietitian is notified of wounds, they should address them as soon as possible. Interview on 08/11/22 at 11:52 A.M. with Wound Nurse Practitioner (WNP) #176 revealed she starting working at the facility sometime in June 2022. WNP #176 agreed Resident #50's wound to the sacrum was a Stage 4 pressure ulcer. WNP #176 said she would need more history on the resident to call it something else such as a pilonidal cyst. WNP #176 stated wounds could deteriorate to a Stage 4 fast depending on the preventative measures in place and nutrition was also an important role. WNP #176 stated Resident #50's wound was a Stage 4 when she got involved. Interview on 08/11/22 at 2:40 P.M. with the DON revealed she observed Resident #50's wound for the first time today. The DON felt it may not be pressure but something else such as a cyst that opened because the wound looked too perfect for a pressure ulcer. DON verified the skin assessment dated [DATE] documented no new skin issues. The DON stated Resident #50 had C-diff during that time, so she knew staff were observing the resident's skin during incontinence care. The DON confirmed documentation and treatment indicated a Stage 4 pressure ulcer. Interview on 08/11/22 at 2:57 P.M. with LPN #111 revealed when she completed Resident #50's skin assessment on 05/27/22 she didn't see anything. LPN #111 was informed on report by another nurse that something was found. LPN #111 stated when she first observed the wound after being told something was found it was a small, white circle or slit. LPN #111 stated there was not redness and she had to search for the wound to find it. LPN #111 had seen the wound recently and said it had gotten worse, much bigger, and it looked terrible now. LPN #111 stated Resident #50 had been complaining of pain on her bottom for two weeks prior to the wound being identified. Review of the facility's policy titled Pressure Ulcer/Skin Breakdown-Clinical Protocol revised 01/01/22 revealed based on the comprehensive assessment of a resident, a resident received care, consistent with professional standards of practice, to prevent pressure ulcers and did not develop pressure ulcers unless the individual's clinical condition demonstrated that they were unavoidable; and a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing. 2. Review of Resident #47's medical record revealed an admission date of 06/12/16 and diagnoses included dementia, chronic obstructive pulmonary disease, and history of transient ischemic attacks and cerebral infarction without residual deficits. Review of Resident #47's physician orders dated 06/12/19 revealed turn and reposition frequently every day and night shift. Review of Resident #47's Braden Scale For Predicting Pressure Sore Risk dated 06/15/22 revealed the resident was at high risk for developing a pressure ulcer. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365689 If continuation sheet Page 9 of 25 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 08/15/2022 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 Level of Harm - Actual harm Review of Resident #47's quarterly MDS assessment dated , 06/16/22 revealed the resident had severe cognitive impairment. Resident #47 required extensive assistance of one staff member for bed mobility and toilet use and had total dependence on two staff members for transfers. Resident #47 was always incontinent of urine and bowel and did not have a pressure ulcer. Residents Affected - Few Review of Resident #47's physician orders dated 07/08/22 revealed Resident #47 was discontinued from hospice services. Review of Resident #47's care plan dated 07/20/22 included Resident #47 was at risk for pressure ulcer development related to incontinence, restricted mobility, mood and diagnoses. Resident #47's risk of significant skin injury would be reduced, minimized through the review date. Interventions included to apply barrier cream as ordered; Resident #47 needed reminding, assistance to turn and reposition frequently, at least every two hours, more often as needed or requested; monitor and document, report as needed any changes in skin status: appearance, color. Review of Resident #47's Skin assessment dated [DATE] revealed Resident #47 had no new abnormal skin areas. Review of Resident #47's Braden Scale For Predicting Pressure Sore Risk dated 08/09/22 revealed the resident was at high risk for developing a pressure ulcer. Observation on 08/09/22 at 8:15 A.M. and 12:30 P.M. of Resident #47 revealed he was laying in bed, flat on his back with the head of his bed elevated. Interview on 08/09/22 at 3:15 P.M. with Certified Nursing Assistant (CNA) #127 revealed she had not taken care of Resident #47 for a couple days but he allowed her to change him when he needed it. CNA #127 stated when she provided Resident #47's incontinence care previously she noticed he had a little redness on his bottom. Observation on 08/09/22 at 3:59 P.M. of Certified Nursing Assistant (CNA) #127 providing incontinence care for Resident #47 revealed Resident #47's incontinence brief was saturated with urine. Resident #47's buttocks were very red and an open area about the size of a quarter was noted on the right buttock close to the sacrum and coccyx. Resident #47 cried out in pain when CNA #127 cleaned his buttocks and sacrum. CNA #127 did not apply barrier cream and was preparing to put a clean incontinence brief on Resident #47. After surveyor intervention CNA #127 confirmed Resident #47 had an open area on his right buttock. Registered Nurse (RN) #120 walked into the room and CNA #127 informed RN #120 about the open area on Resident #47's right buttock. RN #120 measured the wound for a length of 3.1 centimeters (cm), width 1.9 cm, depth of less than 0.1 cm. RN #120 sprayed the area with Skin prep (protective barrier) and applied a border gauze dressing. Resident #47 stated his bottom hurt and after surveyor intervention a pillow was placed under his right side. Review of Resident #47's progress notes dated 08/09/22 timed 5:53 P.M. revealed an STNA notified the nurse Resident #47 had a new area of skin impairment on his right buttocks. RN #120 assessed the area on the right buttocks which measured 3.1 cm by 1.9 cm by less than 0.1 cm depth. No drainage was noted, the wound bed was pink. The peri-wound (tissue surrounding wound) was within normal limits. The area was cleansed with normal saline, Skin prep applied topically and covered with small border foam gauze. Resident #47 repositioned for comfort. nurse practitioner notified, no further orders. Resident #47's guardian aware. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365689 If continuation sheet Page 10 of 25 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 08/15/2022 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 Observation on 08/10/22 at 7:35 A.M. of Resident #47 revealed he was lying in bed, flat on his back with the head of his bed elevated. Level of Harm - Actual harm Residents Affected - Few Observation on 08/10/22 at 9:21 A.M. of Resident #47 revealed he was lying in bed in the same position as 7:35 A.M., on his back with the head of his bed elevated. Observation on 08/10/22 at 10:15 A.M., and 08/10/22 at 11:47 A.M. of Resident #47 revealed he was lying in bed, flat on his back with the head of his bed elevated. Resident #47 was in the same position observed earlier in the day. Interview on 08/10/22 at 11:42 A.M. with STNA #159 revealed she did not ask Resident #47 if he wanted to get out of bed. STNA #159 stated she changed Resident #47's incontinence brief, but she did not reposition him or encourage him to let her reposition him at any time during her shift. STNA #159 stated Resident #47 liked to lay flat on his back. Interview on 08/10/22 at 3:45 P.M. of Licensed Practical Nurse/Wound Nurse (LPN/WN) #147 revealed she was not notified about Resident #47's wound on his right buttock. When asked why Resident #47 was not on a low air loss mattress due to his high risk for developing a pressure ulcer LPN/WN #147 stated Resident #47 was on hospice services and they did not use a low air loss mattress for him. LPN/WN #147 stated Resident #47 was no longer on hospice and she thought it was discontinued in 06/2022. Review of the facility policy titled Pressure Ulcer/Skin Breakdown-Clinical Protocol, revised 01/01/22 included based on comprehensive assessment of a resident, a resident received care consistent with professional standards of practice, to prevent pressure ulcers and did not develop pressure ulcers unless the individual's clinical condition demonstrated they were unavoidable. A resident with pressure ulcers received necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection and prevent new ulcers from developing. The plan of care for prevention and or treatment of pressure ulcer, injury would be developed based on assessment to include turning schedule, off-loading, moisture and incontinence management. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365689 If continuation sheet Page 11 of 25 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 08/15/2022 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the facility supervised smoke break times dated 11/27/17 (provided by the facility upon request) revealed supervised smoke break times were scheduled at 9:30 A.M., 11:00 A.M., 1:00 P.M., 3:00 P.M., 7:00 P.M. and 9:00 P.M. Review of the medical record for Resident #28 revealed an admission date of 06/15/22. Diagnoses included lung cancer, stroke, chronic obstructive pulmonary disease (COPD), and anxiety disorder Review of the safe smoking evaluation dated 06/16/22 revealed Resident #28 was to be supervised by staff, volunteer, or family member at all times when smoking. Under the comment section there was a notation indicating Resident #28 vaped and denied smoking for last seven years. Review of the smoking policy clarification and agreement revealed Resident #28 signed the agreement on 06/16/22. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 had intact cognition and was independent for bed mobility, ambulation, and required supervision of one staff for transfers. Observation on 08/10/22 at 11:03 A.M. revealed Resident #28 outside sitting in his wheelchair vaping. Continued observation at 11:22 A.M. revealed Resident #28 self-propel back into the building toward his room without giving the vaping device to State Tested Nurse Aide (STNA) #130 who was supervising smoking. Resident #28 was not observed placing the vaping device in the lock box located on the table inside the building. Interview on 08/10/22 at 11:22 A.M. with STNA #130 confirmed Resident #28 did not give the vaping device to her. STNA #130 was then observed to give the lock box to STNA #150. STNA #150 was observed asking Resident #28, who by this time was by the nursing station going toward his room, if he put the vaping device in the lock box. Resident #28 stated he did not put it back and STNA #150 took the vaping device from him. Interview on 08/10/22 at 11:25 A.M. with STNA #150 revealed Resident #28 had given the vaping device to her after she had asked for it and she put it in the lock box. STNA #150 stated all smoking materials were given back after smoke break and kept in the lock box. Observation on 08/10/22 at 2:30 P.M. of Resident #28 revealed the resident in his room lying in bed with what appeared to be a vaping device on his bedside tray table. It was a long white tube with a black cap like top and orange writing indicating guava mango ice along the tubing, a small 5% at the top of tube near the black cap like area, and near the bottom was also written in orange fruitia escobars. During interview with Resident #28 at the time of the observation Resident #28 identified the item as a marker indicating guava mango ice was the name of the color orange. Observation and interview on 08/10/22 at 2:34 P.M. with STNA #127 revealed she was not sure what vaping devices looked like but STNA #127 thought the item on Resident #28's bedside table was a vaping device. STNA #127 stated she took residents out for supervised smoke breaks, and they were supposed to put all smoking materials back in the locked box. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365689 If continuation sheet Page 12 of 25 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 08/15/2022 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During observation of the device with Registered Nurse (RN) #102 on 08/10/22 at 2:47 P.M., RN #102 asked Resident #28 what the device was, and Resident #28 stated it was a marker. RN #102 stated it did not look like a marker and picked it up. While in the hall on the nursing unit, an internet search of the device with RN #102 revealed it was a vaping device. RN #102 stated she thought the STNA had taken it from Resident #28 that morning and that she was going to take the vaping device to the Director of Nursing (DON). Interview on 08/11/22 at 9:03 A.M. with the DON verified the item was a vaping device and they had Resident #28 sign a behavior contract related to use and storage of vaping devices. Reviewed of the facility policy Smoking Policy Clarification and Agreement dated November 2017 revealed no smoking products (matches, lighters, other ignition sources, cigarettes, electronic cigarettes, cigars, pipes, tobacco and/or other inhaled tobacco substitutes) may be kept by a resident in his or her room due to safety precautions. All smoking products must be kept in a secure area as designate by the Administrator or designee. All smoking would be done under staff supervision (or other responsible party), in the designated smoking area at established times. 2. Record review revealed Resident #210 was admitted on [DATE] and discharged on 08/10/22. Diagnoses included acute/chronic respiratory failure with hypercapnia, metabolic encephalopathy, Parkinson's disease, history of pulmonary embolism, bipolar disorder, hypereosinophilic syndrome, asthma, dementia, chronic obstructive pulmonary disease, type 1 diabetes mellitus with hyperglycemia, obesity, anemia, major depressive disorder, hypertension, and history of transient ischemic attack. Review of the falls risk assessment dated [DATE] revealed Resident #210 was at high risk for falls. Review of the care plan dated 07/23/22 revealed Resident #210 was at risk for falls related to acute respiratory failure, Parkinson's disease, asthma, dementia, generalized weakness, chronic obstructive pulmonary disease, and hypertension. Interventions included anticipate and meet resident's needs based on nursing assessment, call light within reach and encourage the resident to use it for assistance, bed in low position when not providing care, determine causative factors of fall and resolve or minimize, physical therapy/occupational therapy to evaluate and treat as ordered or as needed, and perimeter mattress to bed. Review of admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #210 had severely impaired cognition and required extensive care with two assist for bed mobility and toilet use, total care with two assist with transfers with Hoyer (mechanical) lift, dressing and hygiene extensive care with one assist, eating supervision with set up help only. Review of the fall incident report dated 07/29/22 timed 1:32 A.M. revealed incontinence care was being provided by State Tested Nurse Aide (STNA) #113 and STNA #152 and when STNA #152 turned Resident #210 to her right side the resident fell out of bed onto the floor. Resident #210 was sent to the emergency room for evaluation and returned the same day with no injuries and no new orders. Review of progress note dated 07//29/22 timed 3:23 A.M. revealed Registered Nurse (RN) #106 was called into Resident #210's room by nurse aid due to a fall. RN #106 found Resident #210 lying on floor on her right side. Resident #210 was assisted back to bed via Hoyer lift. Resident #210 had a lump on right side of her head and complained of pain to her right hip. Vital signs were monitored. AT 7:06 A.M. notification to Director of Nursing (DON), Nurse Practitioner (NP), and resident family (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365689 If continuation sheet Page 13 of 25 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 08/15/2022 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 member. Resident #210 was sent to hospital for evaluation. Level of Harm - Minimal harm or potential for actual harm Review of Self-Reported Incident (SRI) dated 07/29/22 revealed an SRI was filed because a family representative for Resident #210 alleged physical abuse occurred. The family representative reported an aide let Resident #210 fall out of bed on purpose. The fall was witnessed by STNA #113 and STNA #152. A thorough investigation was completed, and the allegation was unsubstantiated. Residents Affected - Few Review of physician orders for July 2022 and August 2022 revealed physical therapy (PT) to evaluate and treat as indicated, occupational therapy (OT) to evaluate and treat, pressure reduction mattress to bed, bilateral grab bars to bed to increase independence with bed mobility, repositioning, and transfers, perimeter mattress to bed, and Hoyer/mechanical lift with two assist for transfers, and two assist for all care. Observations on 08/08/22 at 10:36 A.M., 4:47 P.M., on 08/09/22 at 7:10 A.M., 12:36 P.M., 2:30 P.M., and on 08/10/22 at 7:37 A.M., 9:32 A.M., 11:43 A.M., revealed Resident #210 in her room in bed with the head of bed elevated, call light in reach, bed in low position, and perimeter mattress in place. Interview on 08/08/22 at 1:11 P.M. with RN #102 revealed she heard about Resident #210's fall and reported she heard STNA #152 pulled a little too hard when turning her and the resident fell out of bed. Interview on 08/10/22 at 8:47 A.M. with the DON revealed when STNA #113 and STNA #152 were providing incontinence care they turned Resident #210 on her side and pulled the bath blanket closer. When STNA #152 pulled the bath blanket, Resident #210 kept going and STNA #152 couldn't stop the resident and the resident fell out of bed. The DON reported STNA #112 and #152 tried to catch Resident #210 and they couldn't, the resident landed on the floor, complained of hip hurting and was sent to the hospital for evaluation. The DON reported Resident #210 returned to the facility the same morning with no new orders and no injuries. Interview on 08/11/22 at 10:45 A.M. with RN #106 revealed on 07/29/22 she was called to Resident #210's room for a fall. Upon arrival Resident #210 was on the floor on her right side. RN #106 reported she assessed Resident #210 and with help of STNA #113, STNA #152, and RN #146 assisted Resident #210 back to bed via Hoyer Lift. RN #106 reported Resident #210 complained of pain to right side, right hip, right shoulder and had a lump on right side of her head. RN #106 reported notifications were done and Resident #210 was sent to the hospital for evaluation. RN #106 reported she did not witness the fall. Interview on 08/11/22 at 1:49 P.M. with STNA #113 revealed Resident #210 was her resident that night and she got STNA #152 to help provide incontinence care. STNA #113 reported she was on the left side of the bed and STNA #152 was on the right side of the bed. When STNA #152 pulled the bath blanket she pulled it so hard and fast, Resident #210's weight came over and the resident fell. STNA #113 reported she ran to the other side of the bed and tried to catch Resident #210, it happened so fast. STNA #113 reported STNA #152 also tried to catch Resident #210. STNA #113 reported Resident #210 landed on her right side on the floor. STNA #152 went and got RN #106 and RN #146 and STNA #113 stayed with the resident. RN #106, RN #145, and STNA #152 assisted Resident #210 back to bed via Hoyer lift. STNA #113 reported Resident #210 complained of her hip hurting and she was sent to hospital for evaluation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365689 If continuation sheet Page 14 of 25 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 08/15/2022 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 Level of Harm - Minimal harm or potential for actual harm Interview on 08/11/22 at 2:44 P.M. with RN #146 revealed she was called to Resident #210's room for a fall. RN #146 thought Resident #210 was on the floor on her left side. RN #146, STNA #113, and STNA #152 assisted Resident #210 to bed via a Hoyer lift. Resident #210 complained of soreness to her side and hip area. Resident #210 did not report hitting her head. Notifications were completed and Resident #210 was sent out to the hospital for evaluation. RN #146 was not present when the fall occurred. Residents Affected - Few Interview on 08/11/22 at 5:24 P.M. with STNA #152 revealed she was helping STNA #113 with incontinence care on Resident #210. STNA #152 pulled Resident #210 towards herself, and the resident fell out of bed. STNA #152 said she couldn't remember how it happened because it all happened so fast. STNA #152 was on one side of the bed and STNA #113 was on the other side of the bed. STNA #152 tried to stop the fall but couldn't, it happened too quickly. STNA #152 reported Resident #210 fell on her right side. STNA #152 immediately got RN #106 and RN #146 to help. STNA #152, STNA #113, RN #106 and RN #146 assisted Resident #210 back to bed via a Hoyer lift. STNA #152 reported the nurses checked Resident #210 out and Resident #210 was sent to the hospital. Review of the facility policy, Falls - Clinical Protocol, revised 01/01/22, revealed to prevent falls while maintaining and/or improving resident abilities and quality of life. Based on observation, interview, medical record review, review of manufacturer instructions, and review of the facility policy, the facility failed to provide a safe mechanical lift transfer for Resident #24, ensure Resident #210 was provided appropriate assistance with bed mobility during incontinence care, and ensure vaping supplies were kept secured. This affected one resident (Resident #24) of 16 residents (Resident #1, #3, #4, #11, #13, #19, #22, #26, #41, #48, #49, #50, #51, #52, and #58) reviewed who required a mechanical lift for transfers, one resident (Resident #210) out of three residents reviewed for falls, and one resident (Resident #28) out of nine residents reviewed for smoking. The facility census was 58. Findings include: 1. Review of the medical record for Resident #24 revealed an admission date of 03/29/21 and a readmission date of 10/26/21. Diagnoses included respiratory failure, paraplegia (paralysis in the lower half of the body), chronic pain, morbid obesity, heart disease, Covid-19, and pneumonia. Further review of the medical record revealed Resident #24 weighed 405 pounds (lbs) on 01/03/22. Review of the nursing notes dated 01/05/22 at 8:00 P.M., revealed Licensed Practical Nurse (LPN) #148 was notified by a State Tested Nursing Assistant (STNA) that while transferring Resident #24 to bed by way of mechanical lift, the lift tilted forward and resulted in Resident #24 hitting her head. Further review revealed Resident #24 had complaints of head and neck pain. Review of the nursing notes dated 01/05/22 at 10:00 P.M. revealed LPN #148 reported the incident to Certified Nurse Practitioner (CNP) #178 by way of telephone and an order was placed for a cervical spine x-ray and Oxycodone was ordered as needed for pain. Review of the x-ray results dated 01/06/22 revealed the impression to be unremarkable for injury. Review of the plan of care dated 06/15/22 revealed Resident #24 required two person staff assist for all transfers. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365689 If continuation sheet Page 15 of 25 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 08/15/2022 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of physician orders dated 06/15/22 revealed a Hoyer (mechanical lift) with two staff assist to be utilized for all transfers. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #24 was cognitively intact, mobilized with powerchair, was incontinent of bowel and bladder, and required extensive assist of two persons for activities of daily living and transfers. Review of the facility Incident Log dated from 08/03/21 to 07/11/22, revealed on 01/05/22 at 8:00 P.M., Resident #24 suffered a fall during a staff transfer. Interview on 08/08/22 at 10:42 A.M. with Resident #24 revealed while being transferred by two staff members to her bed, the mechanical lift tilted forward causing her to fall on top of the mattress and to hit her head/neck on headboard. Resident #24 further stated she had a history of chronic neck and back pain and was nervous when being transferred via the mechanical lift. Observation on 08/10/22 at 9:00 A.M. revealed four mechanical lifts, three models of the Invacare Hoyer lift Reliant 450 and one model of the Invacare Reliant 660, in good repair with a preventive maintenance date of 06/10/22. Further review revealed weight limit to be 450 lbs. Interview with STNA #117 on 08/10/22 at 9:20 A.M. revealed a cord had been lying underneath the base of the mechanical lift during Resident #24's transfer from her powerchair to the bed. STNA #117 stated while repositioning Resident #24 over her bed by way of pulling the sling, the mechanical lift tilted forward causing Resident #24 to come to rest on top of her mattress and hitting the top of her head against the headboard. Observation on 08/11/22 at 3:50 P.M., a mechanical lift for Resident #58 with STNA #104 and #127, from powerchair to bed revealed no concerns. Review of the manufacturer's instructions revealed during transfer with patient suspended in a sling, DO NOT roll caster base over uneven surfaces that could cause the patient lift to tip over. Use steering handle on the mast at all times to push or pull the patient lift. Review of the facility policy titled Safe Lifting and Movement of Residents dated 10/30/2020 revealed compliance guidelines and procedure for the safe use of mechanical lifts had not been implemented according to manufacturer's instructions in regards to the transfer of Resident #34 on 01/05/22. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365689 If continuation sheet Page 16 of 25 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 08/15/2022 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 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of the facility policy the facility failed to ensure one resident (Resident #300) known for wandering did not walk out of the facility unaccompanied by a staff member. This affected one resident (Resident #300) out of six residents (Resident's #5, #6, #7, #17, #21, #23) reviewed who were at risk for elopement. The facility census was 58. Residents Affected - Few Findings include: Review of Resident #300 medical record revealed an admission date of 12/21/21 and diagnoses included Alzheimer's disease, atrial fibrillation, and unsteadiness on feet. Resident #300 was transferred to a sister facility with a secured unit on 06/09/22. Review of Resident #300's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #300 had severe cognitive impairment and required extensive assistance of one person for locomotion on the nursing unit. Further review revealed Resident #300 was not steady when walking but able to stabilize without staff assistance. Review of Resident #300's care plan dated 12/22/21 included Resident #300 was an elopement risk, a wanderer, wanted to go home related to impaired safety awareness, and wandered aimlessly. Resident #300's safety would be maintained through the review date. Interventions included to distract Resident #300 from wandering by offering pleasant diversions, structured activities, food, conversation, television, book; to identify pattern of wandering. (was wandering purposeful, aimless, or escapist? Was resident looking for something? Did it indicate the need for more exercise?) and intervene as appropriate; provide structured activities: toileting, walking inside and outside. Review of Resident #300's assessments from 12/21/21 through 06/05/22 did not reveal an elopement, wandering risk assessment was completed. Review of Resident #300's Social Service progress notes dated 06/02/22 included the Social Worker spoke with family about safety concerns regarding Resident #300's wandering and potential elopement risk. Review of Resident #300's progress notes dated 06/05/22 at 3:59 P.M. revealed Resident #300 was found by an State Tested Nurse Aide (STNA) outside banging on another resident's window at 8:15 A.M. The STNA brought Resident #300 back into the building. Resident #300 was evaluated with vitals within normal limits, no noted skin issues, and no complaint of pain. The Director of Nursing (DON), Certified Nurse Practitioner (CNP) and daughter were notified. Resident #300 was placed on every 15 minute checks for 24 hours. Review of Self-Reported Incident tracking number 222417 revealed on 06/05/22 Resident #300 wandered outside of the building and was seen knocking on a resident window to get back in. Residents were being transferred from the COVID-19 unit back to their original rooms after recovering from COVID-19. Around 8:05 A.M. Resident #300 pushed on the hall door leading to the outside and walked out of the facility. The resident in the last room of the hall saw Resident #300 pushing on the door. Resident #300 was seen at 8:15 A.M. knocking on a resident's window by a staff member in the resident's room. The staff member brought Resident #300 back inside. The weather was 70 degrees Fahrenheit and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365689 If continuation sheet Page 17 of 25 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 08/15/2022 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 0744 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few sunny. A nurse immediately performed a head-to-toe and pain assessment with negative findings. When Resident #300 was brought into the facility she was walking with her usual fast paced gait. Resident #300 could not remember why she went outside. Staff were in other resident rooms providing care or on the other side of the facility and did not hear the alarm sounding. The doors were all checked and the alarms worked appropriately, but the alarms from the west side of the facility could not be heard on the east side and the east side door alarms could not be heard on the west side. Steps were taken to correct this issue. All staff were educated on responding to door alarms and elopement drills were completed on all shifts. All future room moves between the two sides of the facility would have a staff member stationed at the nurses station monitoring all the doors until the move was completed Review of Statement of Witness dated 06/05/22 written by STNA #145 revealed she was delivering a breakfast tray to a resident and heard knocking on glass, she turned around and saw Resident #300 standing outside the facility knocking on the residents window in room [ROOM NUMBER]. STNA #145 wrote she ran outside and on the way outside notified the nurse and another aide Resident #300 was outside the facility. STNA #145 did not hear any alarms sounding, another aide ran outside and assisted STNA #145 to bring Resident #300 inside. Resident #300 did not have a wheelchair outside with her. Interview on 08/09/22 at 4:31 P.M. with the DON revealed Resident #300 had dementia and was on the COVID-19 unit on 06/05/22. The DON stated 06/05/22 was the last day for the COVID-19 unit to be opened and the residents were being transferred back to their regular rooms one at a time. The DON indicated Resident #300 knocked on a resident window, STNA #145 saw her and brought Resident #300 back into the facility. The DON revealed STNA #145 told the nurse Resident #300 got out. The DON stated the staff were in resident rooms providing care, and one staff member heard an alarm and one did not. The STNA who heard the alarm was in the middle of providing care and could not look into why the alarm was going off. The DON stated Resident #300 tried to leave the facility previous to 06/05/22 but had not been successful. The DON stated Licensed Practical Nurse (LPN) #135 was providing wound care to a resident with a fan on and could not hear the alarm. The DON stated the alarm system was upgraded recently and now the alarm for the east side of the facility could be heard on the west side. The DON stated if an outside door was pushed an alarm would immediately sound and if the door was pushed for 15 seconds it would open. The DON stated Resident #300 was transferred to a sister facility with a secured unit. Interview on 08/10/22 at 8:05 A.M. with Licensed Practical Nurse (LPN) #135 revealed she remembered Resident #300 leaving the facility unaccompanied by a staff member on 06/05/22 but she could not remember if she was working that day. LPN #135 stated Resident #300 got out of the facility around the time the breakfast trays were passed to the residents and all staff were busy at that time. LPN #135 stated when breakfast trays were distributed to the residents, she would have been at the end of the hall, away from the nursing station administering medications to the residents. LPN #135 stated she was not assigned to the nursing unit Resident #300 resided on and she could not hear door the alarm from the end of the nursing unit she was on. Interview on 08/10/22 at 10:10 A.M. with Maintenance Director (MD) #109 revealed door alarm updates were completed approximately two weeks ago. MD #109 stated before the updates were completed the east and west nursing units had their own alarms and the alarms did not sound on the other side of the building. MD #109 stated now if a resident wandered to the east side of the facility and attempted to leave through an outside door an alarm would sound on the west side of the building. MD #109 stated this wasn't necessary previously because the east side had residents and staff assigned, but now the east unit was closed so the updates were necessary. MD #109 stated the door alarms were tripped (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365689 If continuation sheet Page 18 of 25 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 08/15/2022 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 0744 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few often during the day and staff did not always check the doors because they thought a resident was going outside to smoke. MD #109 stated he reminded the staff the doors needed checked every time the alarms sounded because a resident could be trying to go outside. Observation on 08/10/22 at 10:10 A.M. with MD #109 revealed if the alarm sounded at the nursing station on the west side of the facility it could be heard at the end of resident halls away from the nursing station, but the alarm was faint. Further observation revealed the nursing station was located in the center of the nursing unit, and the halls the residents resided on all connected to the nursing station. Interview on 08/10/22 at 2:40 P.M. with Registered Nurse (RN) #139 revealed when she arrived for work on 06/05/22 at 6:00 A.M. she learned the nurse called off who was supposed to work on the nursing unit Resident #300 resided on. RN #139 indicated RN #146 stayed over from night shift due to the call-off. RN #139 stated her assignment on 06/05/22 was to work on the COVID-19 nursing unit and the entry was at the back of the unit through an outside door. RN #139 stated STNA #130 was scheduled to work on the COVID-19 nursing unit with her, and all the residents were moving back to their permanent rooms on 06/05/22 because they had recovered from COVID-19. RN #139 indicated RN #146 assisted with moving the six residents from the COVID-19 unit on the east side of the facility back to their permanent rooms on the west side of the facility. RN #139 stated Resident #300 was anxious when she got report, and needed watched closely. RN #139 stated Resident #300 was moved first due to the need for close supervision, then the rest of the residents were moved. RN #139 stated after all the residents were moved she took a break and went outside to her car. RN #139 revealed when her break was over she found out Resident #300 had been outside unaccompanied by any staff member. RN #139 stated Licensed Practical Nurse (LPN) #135 was the nurse who reported the incident, but she was not the nurse assigned to the nursing unit Resident #300 resided on. RN #139 indicated STNA #104 was assigned to the nursing unit Resident #300 resided on and did not know if STNA #104 heard the alarm or turned the alarm off when Resident #300 exited the facility. RN #139 revealed Resident #22 heard the alarm and saw Resident #300 outside, but he could not let the staff know Resident #300 was outside the facility because he could not reach his call light. RN #139 stated STNA #104 told her no alarm went off, but when RN #139 tested all the doors in the facility for alarms on 06/05/22 all the alarms sounded. Interview on 08/11/22 at 8:20 A.M. with STNA #104 revealed on 06/05/22 residents were moved from the COVID-19 nursing unit back to their permanent room assignment. STNA #104 stated she was assigned to the nursing unit Resident #300 resided on and Resident #300 was agitated when she was moved to her room. STNA #104 stated Resident #300 would not be still, was combative, was roaming in her room and tried to get out the door at the back of the nursing unit that opened to the outside of the facility multiple times. STNA #104 indicated she re-directed Resident #300 away from the door and had her sit at the nursing station in her wheelchair, but Resident #300 was still restless. STNA #104 stated Resident #300 was sitting at the nurses station when she entered Resident #4's room to provide care. STNA #104 revealed while she was providing Resident #4's care she heard a door alarm sounding, and after she finished with the care she saw STNA #130 standing at the door leading to the outside of the nursing unit Resident #300 resided on. STNA #104 stated STNA #130 put the code in to turn the alarm off, but neither STNA #104 or STNA #130 saw any resident or staff outside the facility. STNA #104 stated she was told Resident #300 was sitting at the nurses station by an unidentified staff member, but she did not check to make sure Resident #300 was still there before she helped pass out resident breakfast trays. STNA #104 could not remember who told her Resident #300 was still sitting at the nurses station. STNA #104 stated the incident happened around breakfast and it was not more than a few minutes between the last time she saw Resident #300 and when Resident #300 exited the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365689 If continuation sheet Page 19 of 25 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 08/15/2022 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 0744 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 08/11/22 at 9:05 A.M. revealed Resident #22's room was the last room on the right side of the hall, and next to the door leading to the outside of the nursing unit Resident #300 resided on. Interview on 08/11/22 at 9:06 A.M. with Resident #22 revealed Resident #300 was at the door leading to the outside of the facility constantly on 06/05/22 trying to get out. Resident #22 stated the staff would have her go back to her room. Resident #22 stated Resident #300 was right back at door within five minutes every time she was encouraged to go to her room and got out at some point. Resident #22 stated he saw Resident #300 at his window, Resident #300 knocked on his window, then moved to next window and started knocking. Resident #22 stated he could not reach his call light to activate it so he could tell a staff member Resident #300 was outside the facility. Resident #22 stated he wanted to tell staff the resident was outside. Interview on 08/11/22 at 9:56 A.M. with STNA #130 revealed she was assigned to the COVID-19 unit on 06/05/22. STNA #130 stated there were about five residents in the COVID-19 unit scheduled to be transferred to the west side of the facility. STNA #130 indicated the staff had to rush to transfer the residents because there was a nurse call off and there was no nurse to work the COVID-19 unit. STNA #130 stated Resident #300 was brought to her room on the west side of the facility around 6:30 A.M. or 7:00 A.M., and she did not seem agitated. STNA #130 stated after the residents were transferred she was assigned to a nursing unit Resident #300 did not reside on. STNA #130 stated she did not hear an alarm because she was probably in a resident room with the door shut providing care or still on the other side of the facility. STNA #130 indicated she never heard an alarm sounding and did not know Resident #300 had left the facility until STNA #145 told her it happened. STNA #130 stated she never went to the door to see if a resident was outside, and did not punch a code in to turn the alarm off. Review of the facility policy titled Unsafe Wandering and Elopement Prevention revised, 01/01/22 included every effort would be made to prevent unsafe wandering and elopement episodes while maintaining the least restrictive environment for residents who were at risk for elopement. It was the responsibility of all personnel to report any resident attempting to leave the premises to the licensed nurse in charge as soon as practical. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365689 If continuation sheet Page 20 of 25 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 08/15/2022 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure an antipsychotic as needed medication was not ordered beyond 14 days without first re-evaluating the resident, and ensure all psychotropic medications were reviewed to ensure the appropriateness of their use. This affected one resident (Resident #44) of five residents reviewed for unnecessary medications. The facility census was 58. Findings include: Record review on 08/09/22 of Resident #44 revealed the resident was admitted to the facility on [DATE] with medical diagnoses including pathological fracture in neoplastic disease, right femur; malignant neoplasm of colon, liver and interscholastic bile duct; anxiety disorder; major depressive disorder, and retention of urine. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #44 had intact cognition. Review of physician orders for June, July and August 2022 revealed Resident #44 was ordered the antipsychotic medication Prochlorperazine Maleate (Prochlorperazine Maleate) 10 milligram (mg) tablet by mouth every six hours as needed. Review of physician orders for August 2022 revealed Resident #44 was ordered the following psychotropic medication: Lexapro tablet 20 milligram (mg) in the morning for depression, Olanzapine (antipsychotic) 10 mg give one tablet by mouth daily at bedtime, and Prochlorperazine Maleate (antipsychotic) 10 mg by mouth every six hours as needed. Review of the medication administration records (MARS) for June 2022, July 2022, and August 2022 revealed Prochlorperazine Maleate was not administered to Resident #44. Review of the facility's pharmacy documentation for medication regimen review revealed a medication regimen review was not completed for Resident #44. Interview on 08/09/22 at 8:47 A.M., with the Director of Nursing verified an evaluation of the use of psychotropic medications for Resident #44 was not performed. Interview on 08/11/22 at 11:16 A.M. with Nurse Practitioner #178 revealed he was not notified by the facility to evaluate the as needed use of antipsychotic medication. Review of facility policy, Use of Psychotropic Drugs and Gradual Dose Reductions, revised 01/01/22, revealed residents who use psychotropic drugs receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365689 If continuation sheet Page 21 of 25 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 08/15/2022 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 observations, interview, and record review, the facility failed to maintain a clean and sanitary kitchen and nursing unit refrigerator and ensure proper food storage. This had the potential to affect all residents. The facility census was 58. Findings include: Observations during the initial tour of the kitchen on 08/08/22 from 8:21 A.M. to 8:33 A.M. revealed a large icicle was hanging from the fan unit onto a box of food on a shelf down to a box of buns underneath the fan unit that was sitting on a crate and onto the floor in the walk-in freezer. The walk-in cooler had a slight unpleasant odor and there was a large white bucket of pickles that was uncovered sitting on the top shelf on the left hand side of the cooler. There was food debris on the floor between the oven and steamer and on two light fixtures above the stove were heavily coated in greased dust. The reach-in cooler close to the kitchen door had a large white splatter on the inside bottom. Interview on 08/08/22 between 8:21 A.M. to 8:33 A.M. with [NAME] #164 verified the findings. Observation on 08/09/22 at 8:57 A.M. of the nursing unit refrigerator with Registered Nurse (RN) #136 revealed various food splatters in the freezer, and the refrigerator contained pizza boxes, a small Ziplock bag of pickles, and Styrofoam containers all which were unlabeled and undated. Additional observation revealed five eight-ounce containers of expired milk, two dated 08/02/22 and three dated 07/19/22. Interview at time of observation with RN #136 verified the findings and stated she was not sure who was responsible for the upkeep of the refrigerator. Review of the facility's policy titled Kitchen Sanitation revised 01/01/22 revealed the food service area shall be maintained in a clean and sanitary manner. Review of the facility's policy titled Food Receiving and Storage revised 01/01/22 revealed foods stored in the refrigerator or freezer were to be covered, labeled, and dated (opened on and use by date). Food items and snacks kept on the nursing units should be maintained as indicated: Food items to be kept below 41 degrees Fahrenheit (F) should be placed in the refrigerator located at the nurses' station and labeled with an opened on and use by date, sealed, or covered and labeled. Foods belonging to residents should be labeled with the resident's name, the item and the opened on and use by date. Partially eaten food was not to be kept in the refrigerator. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365689 If continuation sheet Page 22 of 25 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 08/15/2022 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 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** 2. Review of the medical record for Resident #49 revealed an admission date of 08/16/12. Diagnoses included chronic obstructive pulmonary disease (COPD), respiratory failure, diabetes mellitus, and obesity. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed the resident had intact cognition and required extensive assistance of one staff for bed mobility and locomotion on and off the unit and total dependence of two staff for transfers. Residents Affected - Some Review of the progress note dated 08/08/22 timed 4:58 P.M. revealed Resident #49 had a non-productive cough, and shortness of breath with activity. Resident #49 was started on antibiotics and transmission-based precautions to rule out COVID-19. Observation on 08/09/22 at 8:55 A.M. revealed Nurse Unit Manager (NUM) #136 in Resident #49's room wearing only a surgical mask and face shield. Observation outside of Resident #49's room revealed transmission-based precaution (TBP) signs and a bin with personal protective equipment (PPE). Interview with NUM #136 upon exiting Resident #49's room verified the observation, NUM #136 stated the resident was on TBP due to complaining of a cough to the nurse practitioner yesterday. NUM #136 stated Resident #49 was a smoker and had COPD. Based on observation, interview, and record review, the facility failed to maintain infection control and infection prevention guidelines for community equipment. This affected one resident (Resident #3) out of 15 residents (Residents #3, #14, #18, #20, #21, #24, #28, #33, #37, #45, #48, #49, #50, #57) with an active physician order to monitor blood sugar. The facility failed to ensure proper hand hygiene during medication administration. This affected one resident (Resident #3) and had the potential to affect all facility residents. The facility failed to ensure staff donned proper personal protective equipment (PPE). This affected one Resident (Resident #49) and had the potential to affect all facility residents. The facility census was 58. Findings include: 1. Observation on 08/10/22 at 7:40 A.M. of medication administration with Licensed Practical Nurse (LPN) #135 revealed no hand hygiene was observed after capillary blood draw of Resident #3. LPN #135 removed her protective gloves and proceeded to touch objects on the resident's bedside table and the community glucometer (equipment that measures blood sugar). LPN #135 returned to the medication cart and placed the glucometer in a plastic cup on top of a disinfecting wipe noted to have been in place prior to returning the equipment. LPN #135 donned gloves without performing hand hygiene and drew up insulin by way of syringe. LPN #135 proceeded to administer injection to Resident #3 as ordered, returned to cart and removed gloves without performing hand hygiene. Interview on 08/10/22 at 8:02 A.M. with LPN #135 verified hand hygiene should be performed before and after the care of each resident and before and after removal of gloves. LPN #135 verified she placed the glucometer in the cup, on the top of an existing bleach wipe without wiping down the glucometer with the bleach wipe. LPN #136 confirmed the surface of the glucometer was to be cleansed with a new bleach wipe and left wet with solution for four minutes before reusing. Review of the facility policy titled Blood Glucose Machine Disinfection dated 07/15/20, revealed the procedure for the disinfection of capillary-blood sampling devices to prevent transmission of blood borne diseases to residents and employees as follows: blood glucose machines were to be cleaned (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365689 If continuation sheet Page 23 of 25 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 08/15/2022 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some and disinfected after each use and according to manufacturers instructions for multi-resident use; the blood glucose machine was to be disinfected after each use and according to the manufacturer's instructions, and the last procedure was to perform hand hygiene. Review of manufacturer instructions titled Cleaning and Disinfecting the Assure Platinum Blood Glucose Monitoring System revised 12/2017, revealed the disinfection procedure was needed to prevent the transmission of blood-borne pathogens. Guidelines for cleaning and disinfecting included to use a commercially available EPA-registered disinfectant detergent of germicide wipe. Review of the facility policy titled Medication Administration dated 01/01/22, revealed staff were to wash hands using facility protocol and product. The above observations and facility policy was verified on 08/11/22 at 2:25 P.M. with the Director of Nursing (DON). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365689 If continuation sheet Page 24 of 25 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 08/15/2022 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 - Many Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation and interview, the facility failed to ensure the residents' environment was maintained in a clean, sanitary, homelike condition and in good repair. This had the potential to all residents. The facility census was 58. Findings include: Observation on 08/08/22 at 9:40 A.M. of Resident #50 privacy curtain revealed various dried stains. Observation on 08/08/22 at 3:21 P.M. of Residents #52 and #59's room revealed the door of the armoire to the right and the door of the armoire closer to the room door did not stay shut. Resident #52's bedside tray table was in disrepair. The hot water handle in the bathroom was missing and the floor was dirty. The blinds in the window were in disrepair and under the window near the molding, the wall was cracked. Observation and interview on 08/10/22 from 8:27 A.M. to approximately 8:35 A.M. with Housekeeping Supervisor (HS) #169 of Resident #59's bathroom revealed the floor was dirty. HS #169 verified the observation but stated the dark areas of the floor was floor damage but the dark areas in the entryway of the bathroom was wax that he could clean up. HS #169 verified Resident #50's privacy curtain had stains and was soiled. HS #169 stated privacy curtains were swapped out monthly when the rooms were deep cleaned but could be changed sooner if they were soiled. Observation of Residents' #52 and #59's bathroom floor with HS #169 verified the floor was dirty. Observation and on 08/10/22 from 8:50 A.M. to 9:00 A.M. with Director of Maintenance (DOM) #109 of Residents' #52 and #59 room confirmed the armoire next to door would not stay closed and the other was missing the door, the hot water handle was missing, there were cracks in wall near the window, the window blinds were in disrepair, Resident #52's bedside table in disrepair, and further observation of the air condition unit revealed it was dusty. DOM #109 stated he was responsible for dusting the air conditioner units but reported the plan was to replace them. Observation on 08/10/22 at 8:12 A.M. of Resident #37's room revealed at least five large floor tile squares were missing from his floor at the foot of his bed. Interview on 08/10/221 at 11:30 A.M. with State Tested Nursing Assistant (STNA) #117 revealed Resident #37's floor tiles were missing for quite awhile and everyone knew about it including the nurses and Maintenance Director #109. Interview on 08/10/11 at 11:35 A.M. of Maintenance Director #109 confirmed Resident #37 was missing floor tiles from the floor at the foot of his bed. Maintenance Director #109 stated he might have been told about Resident #37's missing floor tiles before today. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365689 If continuation sheet Page 25 of 25