Health inspection·March 13, 2024

F 0550 revealed staff must ensure window blinds are closed prior to rendering incontinence care. Level of Harm - Minimal harm or potential for actual harm 2. Review of the medical record for Resident #65 revealed an admission date of 02/13/24. Diagnoses included systolic congestive heart failure, chronic obstructive pulmonary disease (COPD), dementia, hypertension, spinal stenosis, functional urinary incontinence, and dysphagia. Residents Affected - Few Review of the admission MDS assessment dated [DATE] revealed Resident #65 had intact cognition. Resident #65 was dependent on staff and required assistance from two staff for bed mobility, toileting, and bathing. Resident #65's medication regimen included antipsychotic, antianxiety, antidepressant, anticoagulant, diuretic, and scheduled opioid medications. Interview on 03/05/24 at 11:30 A.M. with Resident #65 revealed she felt staff did not take their time to learn her care needs correctly and were disrespectful when she verbalized concerns. She stated, they just don't care. During the interview, Resident #65 confirmed her medications were given mixed in applesauce. Interview on 03/05/24 at 11:45 A.M. with Registered Nurse (RN) #223 confirmed Resident #65 received her oral medications mixed with applesauce per resident preference. Observation of video footage from 02/25/24 provided by Resident #65 and her representative revealed RN #201 entered the resident's room at 1:35 P.M. with a medicine cup and spoon and told Resident #65 she was going to use the resident's applesauce to administer her medications. As RN #201 removed the lid, Resident #65 stated, that smells bad! RN #201 replied yeah, I don't know. I don't work in the kitchen. RN #201 asked if Resident #65 would like her medication without the mixture in the bowl, but then stated, I mean, I already mixed it, while proceeding to spoon feed the mixture of food substance and medications into Resident #65's mouth. Resident #65 was heard stating it was nauseating, and RN #201 agreed and said she could smell it too. Interview with the Administrator, after viewing video recordings on 03/12/24 at 3:30 P.M., confirmed it was RN #201 administering Resident #65's medications on 02/25/24 at 1:35 P.M., and Resident #65 informed RN #201 that the applesauce used with the medication smelled bad, prior to medication administration. This deficiency represents non-compliance investigated under Complaint Number OH00151487. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365718 If continuation sheet Page 2 of 34 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 365718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Streetsboro 1645 Maplewood Dr Streetsboro, OH 44241 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and review of video footage, the facility failed to ensure choices that were significant to Resident #65 related to care were honored per resident and resident family request. This affected one resident (Resident #65) of 22 residents reviewed for resident rights. The facility census was 66. Findings include: Review of the medical record for Resident #65 revealed an admission date of 02/13/24. Diagnoses included systolic congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), dementia, hypertension, spinal stenosis, functional urinary incontinence, and dysphagia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #65 had intact cognition. Resident #65 was incontinent, dependent on staff for toileting and bathing, and required assistance from two staff for bed mobility, toileting, and bathing. Review of the care plan dated 02/13/24 revealed Resident #65 Resident had an activities of daily living (ADL) self-care performance deficit and impaired pulmonary/respiratory status related to anxiety, CHF, COPD, history of smoking, pain, respiratory failure, shortness of breath, and bilevel positive airway pressure (BiPAP) via Trilogy (all in one ventilation device, capable of delivering invasive and non-invasive ventilation modes). On 03/04/24, an intervention was added indicating Resident #65's family requested a sign on the door to always wear a mask when entering the resident's room. The care plan also revealed Resident #65 had episodes of bowel and bladder incontinence related to cognitive impairment, CHF, depression, diuretic use, generalized weakness, impaired mobility, pain, and physical limitations. Interventions included assisting with toileting hygiene, checking and changing at regular intervals, observing for redness, irritation, skin excoriation and reporting findings to the nurse or physician, and providing disposable incontinence products. Observation on 03/05/24 at 10:30 A.M. of Resident #65's incontinence care revealed State Tested Nurse Aide (STNA) #217 wore a surgical mask below her nose throughout the duration of resident care. Further observation revealed size two extra-large (XL) bariatric briefs were the incontinence briefs used for Resident #65. Interviews on 03/05/24 at 10:50 A.M. with STNA #217 and STNA #218 confirmed they were aware Resident #65 typically wore a size five XL bariatric brief and that the facility did not have any for them to use. STNA #218 stated she informed Social Services Designee (SSD) #200 they needed more of the bariatric-sized briefs, especially the five XL. She verbalized concern the two XL could cause skin irritation in the groin area because they were snug on Resident #65. During this interview, STNA confirmed her surgical mask was below her nose and she has trouble with it falling. STNA #217 also confirmed she was aware of Resident #65 and her family's request that masks be worn when in her room due to fear of respiratory compromise. Interview on 03/05/24 at 11:30 A.M. with Resident #65 confirmed she was fearful of getting a respiratory infection, and staff were not consistently wearing masks per her request or were wearing the masks below their nose or chin when they did put them on. Resident #65 also confirmed the briefs she was wearing were smaller than the ones she prefers. During the interview, Resident #65's daughter (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365718 If continuation sheet Page 3 of 34 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 365718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Streetsboro 1645 Maplewood Dr Streetsboro, OH 44241 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was present and confirmed she had witnessed several nurses refuse to wear or improperly wear their masks when in her mom's room. She further confirmed Resident #65 needs a size five XL brief, but the facility had not provided them for the past several days. Interview on 03/13/24 with STNA #213 confirmed the facility does not stock enough bariatric-sized briefs and she had several residents who were larger and must wear briefs that do not fit them well. During the interview, STNA #213 provided Resident #65 as an example of a resident who needed the white bariatric five XL briefs, and she does not have any. She stated she checked central supply and there are no bariatric sizes available. Observation of the central supply room on 03/13/24 at 3:55 A.M. with STNA #228 revealed several packages and boxes full of size large briefs. There were a couple small and medium packages in the supple room. No extra-large or larger sized briefs were found in the central supply room during this observation. Interviews on 03/13/24 with STNA #228 at 3:55 A.M. and with STNA #229 at 3:59 A.M. confirmed there was only one central supply room in the facility and to their knowledge, there was nowhere else in the facility they were stored. Both stated during these interviews that if the briefs needed are not in the central supply room or a resident's room, then they do not have them. Interview on 03/13/24 at 4:30 A.M. with the Director of Nursing (DON) revealed the facility does have bariatric-sized briefs, but they are kept locked in the medical records room. She further stated residents who met the measurement criteria were provided the briefs and that central supply distributed them twice per week to those meeting specific criteria. During the course of the survey, video recordings of Resident #65 receiving care in her room were provided by her daughter. Review of these videos revealed staff did not properly don a surgical face mask when providing care to Resident #65 on dates and times as follows: • Observation of a video recording in Resident #65's room on 02/25/24 from 1:35 P.M. to 1:44 P.M. of Registered Nurse (RN) #201 revealed her surgical mask was below her nose during medication administration, assisting the resident with her drink, and placing and removing food items from her bedside table. RN #201 continued rendering more than eight minutes of close resident care with her mask placed below her nose, including replacement of the BiPAP chinstraps around Resident #65's head and face, placing the BiPAP mask and initiating BiPAP, initiating an aerosol treatment, repositioning the resident, and replacing blankets and pillows around the resident. • Observation of a video recording compilation of Resident #65's room on 02/28/24 from 4:58 P.M. to 5:00 P.M. and 5:02 P.M. to 5:03 P.M. revealed RN #201 in Resident #65's room with a surgical mask below her nose. Further recording at 5:02 P.M. revealed RN #201 returned to the resident's room with the surgical mask below her chin. After viewing the videos alongside the Administrator on 03/13/24 at 3:30 P.M., the Administrator confirmed Resident #65 and her family requested anyone entering the residents room wear a mask. The Administrator further confirmed the videos demonstrated staff failed to properly mask per resident and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365718 If continuation sheet Page 4 of 34 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 365718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Streetsboro 1645 Maplewood Dr Streetsboro, OH 44241 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0561 family choice. Level of Harm - Minimal harm or potential for actual harm This deficiency was an incidental finding identified during the complaint investigation. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365718 If continuation sheet Page 5 of 34 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 365718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Streetsboro 1645 Maplewood Dr Streetsboro, OH 44241 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, interview, and review of the facility policy, the facility failed to ensure Resident #66's representative was notified of a significant change in condition. This affected one resident (#66) of three residents reviewed for notification of changes. The facility census was 66. Findings include: Review of the medical record for Resident #66 revealed an admission date of 01/19/24. Diagnoses included chronic respiratory failure with hypoxia, tracheostomy status, ventilator dependence, epilepsy, adult failure to thrive, colostomy status, dysphagia, and feeding difficulties. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #66 had intact cognition, was dependent for toileting, and required substantial assistance for bathing and personal hygiene. Resident #66 required oxygen therapy, suctioning, tracheostomy care, and intravenous medications. Review of the progress notes revealed a nursing note dated 02/05/24 at 2:37 P.M. that Resident #66 developed abnormal lung sounds and two plus pitting edema to her extremities, and there was concern of possible fluid overload. The note further revealed the pulmonologist was contacted and an order was obtained for a STAT (to be done immediately) chest x-ray with front and lateral views. There was no documented evidence the resident's representative was notified of Resident #66's change in condition. Review of the progress note dated 02/05/24 at 5:41 P.M. revealed Resident #66's lab report indicated low potassium and new orders were received from the Nurse Practitioner for Potassium 40 milliequivalents (mEq) to be administered at that time and again six hours later. There was no documented evidence Resident #66's representative was notified of lab results or new orders. Review of the progress note dated 02/06/24 revealed Resident #66 was found unresponsive at 5:25 A.M. and at 5:30 A.M. two nurses confirmed the absence of heart sounds, carotid pulse, and respirations. The note further revealed notification was made to the on-call Certified Nurse Practitioner (CNP) and the Director of Nursing (DON) was made at 5:50 A.M. The progress note further revealed the initial attempt to contact the resident's power of attorney (POA) was made at 6:00 A.M., second attempt was made at 6:08 A.M., and notification was successful at 6:35 A.M. Interview on 03/12/24 at 4:05 P.M. with the DON confirmed no notifications were made on 02/05/24 to Resident #66's representative/POA regarding her change in condition, lab results, or new orders. Review of the facility policy titled Notification of Changes, dated 01/01/22, revealed even in competent individuals, the facility must contact the resident's representative or designated family member of significant changes in health status, especially in the case of sudden illness, because the resident may not be able to notify them personally. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365718 If continuation sheet Page 6 of 34 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 365718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Streetsboro 1645 Maplewood Dr Streetsboro, OH 44241 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The deficient practice was corrected on 02/07/24 when the facility implemented the following corrective actions: • On 02/06/24, identified all resident had the potential to be affected by the deficiency and the DON reviewed resident medical records. • On 02/06/24, the Staff Development Coordinator (SDC) and the DON educated all nurses on lab monitoring, orders, and medication changes. • On 02/07/24, the Regional Director of Clinical Services provided education to the DON and the SDC on ensuring proper notification was in place for all new orders and changes in condition. • On 02/07/24, the facility held an interdisciplinary team meeting and an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting. • Beginning on 02/07/24, the DON or designee will monitor for proper notification of all new orders and changes in condition from the prior day(s) in the morning clinical meetings daily on Mondays through Fridays. • The nurse manager will perform audits on all prior day orders for notifications and proper documentation in the electronic medical records Monday through Friday for four weeks. Daily audits commenced on 02/06/24. • Results of audits will be reviewed in the next QAPI Committee meeting in one month and revisions or changes in monitoring will be made as deemed necessary by the QAPI Committee. This deficiency represents non-compliance investigated under Complaint Number OH00151113. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365718 If continuation sheet Page 7 of 34 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 365718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Streetsboro 1645 Maplewood Dr Streetsboro, OH 44241 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, review of the Ohio Department of Health's Gateway, and review of the facility policy the facility failed to implement their policy for abuse regarding an allegation of staff-to-resident resident abuse for Resident #65. This affected one resident (#65) of six residents reviewed for abuse. The facility census was 66. Residents Affected - Few Findings include: Review of the medical record for Resident #65 revealed an admission date of 02/13/24. Diagnoses included respiratory failure, congestive heart failure (CHF), dementia, depression, and chronic obstructive pulmonary disease (COPD). Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #65 was cognitively intact. She was totally dependent on staff for toileting and showering and required substantial or maximum assistance for oral and personal hygiene. Interview on 03/06/24 at 11:26 A.M. with Resident #65 revealed Registered Nurse (RN) #201 was rough with her when providing care. Interview on 03/06/24 at 2:20 P.M. with the Administrator confirmed she had no knowledge of any concerns regarding care provided to Resident #65 by staff. She was then informed Resident #65 and her daughter reported Registered Nurse (RN) #201 was rough with her when providing care. Interview on 03/11/24 at 10:03 A.M. with the Administrator confirmed she had not reported the allegation of staff-to-resident abuse to the state agency, started an investigation, or suspended the alleged perpetrator following the allegation of abuse against RN #201. Review of the facilities' self-reported incidents (SRI) in Ohio Department of Health's Gateway revealed an SRI regarding the allegation of staff-to resident abuse made by Resident #65 and her daughter regarding RN #201 was reported to the state agency on 03/11/24 at 5:05 P.M. Review of the facility policy titled Abuse, Neglect and Exploitation, dated 07/28/20, revealed an immediate investigation was necessary when a suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect, or exploitation occurred. Reporting of alleged violations to the state agency and other required agencies would occur immediately but no later than two hours after the allegation was made. This deficiency was an incidental finding identified during the complaint investigation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365718 If continuation sheet Page 8 of 34 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 365718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Streetsboro 1645 Maplewood Dr Streetsboro, OH 44241 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, review of the Ohio Department of Health's Gateway, and facility policy review the facility failed to report an allegation of staff-to-resident abuse involving Resident #65 within the required time frame to the state agency. This affected one resident (#65) of six residents reviewed for abuse. The facility census was 66. Findings include: Review of the medical record for Resident #65 revealed an admission date of 02/13/24. Diagnoses included respiratory failure, congestive heart failure (CHF), dementia, depression, and chronic obstructive pulmonary disease (COPD). Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #65 was cognitively intact. She was totally dependent on staff for toileting and showering and required substantial or maximum assistance for oral and personal hygiene. Interview on 03/06/24 at 11:26 A.M. with Resident #65 and her daughter revealed Registered Nurse (RN) #201 was rough with her when providing care. Interview on 03/06/24 at 2:20 P.M. with the Administrator confirmed she had no knowledge of any concerns regarding care provided to Resident #65 by staff. She was then informed Resident #65 and her daughter reported RN #201 was rough with her when providing care. Interview on 03/11/24 at 10:03 A.M. with the Administrative confirmed she had not reported the allegation of staff-to resident abuse to the state agency regarding RN #201. Review of the facilities' self-reported incidents (SRI) in Ohio Department of Health's Gateway revealed an SRI regarding the allegation of staff-to resident abuse made by Resident #65 and her daughter regarding RN #201 was reported to the state agency on 03/11/24 at 5:05 P.M. Review of the facility policy titled Abuse, Neglect and Exploitation, dated 07/28/20, revealed an immediate investigation was necessary when a suspicion of abuse, neglect or exploitation or reports of abuse, neglect or exploitation occurred. Reporting of alleged violations to the state agency and other required agencies would occur immediately but no later than two hours after the allegation was made. This deficiency was an incidental finding identified during the complaint investigation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365718 If continuation sheet Page 9 of 34 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 365718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Streetsboro 1645 Maplewood Dr Streetsboro, OH 44241 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and facility policy review the facility failed to thoroughly investigate an allegation of staff-to-resident abuse involving Resident #65. This affected one resident (#65) of six residents reviewed for abuse. The facility census was 66. Residents Affected - Few Findings include: Review of the medical record for Resident #65 revealed an admission date of 02/13/24. Diagnoses included respiratory failure, congestive heart failure (CHF), dementia, depression, and chronic obstructive pulmonary disease (COPD). Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #65 was cognitively intact. She was totally dependent on staff for toileting and showering and required substantial or maximum assistance for oral and personal hygiene. Interview on 03/06/24 at 11:26 A.M. with Resident #65 and her daughter revealed Registered Nurse (RN) #201 was rough with her when providing care. Interview on 03/06/24 at 2:20 P.M. with the Administrator confirmed she had no knowledge of any concerns regarding care provided to Resident #65 by staff. She was then informed Resident #65 reported RN #201 was rough with her when providing care. Interview on 03/11/24 at 10:03 A.M. with the Administrative confirmed she had not started an investigation regarding the allegation against RN #201. Review of the facility policy titled Abuse, Neglect and Exploitation, dated 07/28/20, revealed an immediate investigation was necessary when a suspicion of abuse, neglect or exploitation or reports of abuse, neglect or exploitation occurred. This deficiency was an incidental finding identified during the complaint investigation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365718 If continuation sheet Page 10 of 34 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 365718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Streetsboro 1645 Maplewood Dr Streetsboro, OH 44241 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and facility policy review the facility failed to ensure Residents #5 and #43 received showers consistently. This affected two residents (#5 and #43) of four residents reviewed for showers. The facility census was 66. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #5 revealed an admission date of 01/10/23. Diagnoses included diabetes, chronic obstructive pulmonary disease (COPD), arthritis, and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 was moderately cognitively impaired. She required set-up and clean-up assistance for oral hygiene, personal hygiene, and toileting and supervision for showering and bathing. It was very important to her to choose between a tub bath, shower, bed bath, or sponge bath. Review of the care plan dated 02/01/24 revealed Resident #5 had a self-care performance deficit due to COPD, depression, kidney disease, and anxiety. Interventions included assistance of one person for bathing, honoring choices and preferences, and providing cues and assistance as needed. Interview on 03/07/24 at 3:02 P.M. with Resident #5 revealed she did not always want showers when they were offered or scheduled. Review of the state tested nurse aide (STNA) tasks dated 02/08/24 through 03/04/24 revealed Resident #5 was to receive a shower on Mondays, Thursdays, and as needed. The resident received a shower on Wednesday, 02/14/24, Thursday, 02/15/24, and Thursday, 02/22/24. She refused on Thursday, 02/08/24, Monday, 02/19/24, and Thursday, 02/29/24. There was no documented evidence a shower was offered, received, or refused a shower on Monday, 02/12/24 or Monday, 02/26/24. Review of the nursing progress notes revealed the resident refused to shower on Friday, 02/09/24 and Tuesday, 02/20/24. Information obtained from Resident #5's daughter revealed she helped her mother shower on Saturday, 01/27/24. Prior to that, her last shower was Monday, 01/22/24. She reported her mother was not receiving proper hygiene and had not received a shower in one week. 2. Review of the medical record for Resident #43 revealed an admission date of 10/03/23. Diagnoses included rheumatoid arthritis, gastroesophageal reflux disease (GERD), and hypothyroidism. Review of the quarterly MDS assessment dated [DATE] revealed Resident #43 was cognitively intact. She required set-up help for eating and oral hygiene, substantial or maximum assistance for showering and personal hygiene, and was totally dependent upon staff for toileting. Review of the comprehensive MDS assessment dated [DATE] revealed it was important for Resident #43 to choose between a tub bath, shower, bed bath, or sponge bath. Review of the STNA tasks dated 02/11/24 through 03/11/24 revealed the resident received a shower on Thursday, 02/29/24 and Thursday, 03/07/24. She refused a shower on Thursday, 02/22/24 and Monday, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365718 If continuation sheet Page 11 of 34 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 365718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Streetsboro 1645 Maplewood Dr Streetsboro, OH 44241 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm 03/04/24. There was no documented evidence a shower was offered, received, or refused from 02/11/24 through 02/22/24. Review of the nursing progress notes revealed the resident refused to shower on Saturday, 02/24/24, Monday, 02/26/24 and Tuesday, 03/05/24. Residents Affected - Few Interview on 03/04/24 at 1:15 P.M. with Registered Nurse (RN) #201 revealed she felt the facility could do a better job of ensuring showers were completed as scheduled. Interview on 03/06/24 at 2:02 P.M. with STNA #202 revealed showers were documented in the electronic medical record. If the resident refused, the nurse was asked to verify the refusal. Interview on 03/11/24 at 8:59 A.M. with Resident #43 revealed she had not received a shower in six weeks. She reported she got bed baths maybe once every two weeks. Interview on 03/11/24 at 1:56 P.M. with the Administrator confirmed showers would be documented in the electronic medical record. She verified there was no other evidence showers had been refused or provided to Residents #5 and #43 outside of what was documented in the STNA tasks identified above. Review of the facility policy titled Bathing a Resident, dated 10/01/22, revealed the facility would assist residents with bathing to maintain proper hygiene. This deficiency represents noncompliance investigated under Complaint Numbers OH00151297 and OH00150535. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365718 If continuation sheet Page 12 of 34 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 365718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Streetsboro 1645 Maplewood Dr Streetsboro, OH 44241 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to ensure activities were offered to meet Residents #30, #4, and #14's preferences. This affected three residents (#30, #4, and #14) of three residents reviewed for activities and had the potential to affect all 66 residents in the facility. Residents Affected - Few Findings include: Interview on 03/04/24 at 1:13 P.M. with Resident #30 revealed she wanted to get up for the day and missed a smoke break already, which she enjoys participating in. Interview on 03/04/24 at 1:20 P.M. with Registered Nurse (RN) #201 revealed residents often complained to her about activities, and there was nothing to do in the evenings or on weekends. Interview on 03/06/24 at 2:02 P.M. with State Tested Nurse Aide (STNA) #202 revealed residents complained about being bored, especially on weekends. She revealed there were no activities provided after 1:00 P.M. or 2:00 P.M. and residents were restless. Interview on 03/11/24 at 8:59 A.M. with Resident #4 revealed there was not much to do in the facility. Interview on 03/11/24 at 12:59 P.M. with Resident #14 revealed she did not think there were enough activities. She revealed activities were conducted in the common area where the facility also conducted job interviews, and residents felt they could not be themselves while facility staff were in the dining area. Interview on 03/12/24 at 2:40 P.M. with Activity Director #215 revealed many of the residents in the facility enjoy playing cards. She revealed bingo was held three times a week, field trips occurred two times per month, and crafts were on Fridays. The facility offered five to six activities per day. Evening activities were available on Mondays and Thursdays only, Wednesday nights residents were encouraged to participate in independent activities. Activity staff were available on weekends from 8:30 A.M. to 3:00 P.M.; no activities took place after 2:00 P.M. on the weekends. Residents who did not want to participate in group activities, the activity staff would check in with them once to twice per week. Random intermittent observations on 03/04/24, 03/05/24, 03/05/24, 03/11/24 and 03/12/24 revealed group activities occurred in the resident dining area. Group activities consisted of independently led card games, bingo, trivia, and music. Observation on 03/12/24 at 11:00 A.M. revealed pet therapy was occurring with a therapy dog visiting residents in their rooms. Review of the activity calendars for January, February, and March 2023 revealed a limited number of activities occurring past 3:00 P.M. during the week, organized activities ending at 2:00 P.M. on the weekends with an individual activity scheduled for 3:00 P.M., and trivia occurred almost daily. This deficiency represents noncompliance investigated under Complaint Number OH00151297. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365718 If continuation sheet Page 13 of 34 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 365718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Streetsboro 1645 Maplewood Dr Streetsboro, OH 44241 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility policy the facility failed to ensure call lights were answered in a timely fashion. This affected two residents (#25 and #36) of three residents reviewed for call lights. The facility census was 66. Residents Affected - Few Findings Include: 1. Review of the medical record for Resident #25 revealed an admission date of 11/04/08. Diagnoses included heart failure, morbid obesity, depression, and bladder dysfunction. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 was cognitively intact. She required substantial or maximum assistance with toileting and showering and set-up help for eating, personal hygiene, and oral hygiene. Review of the care plan dated 02/23/24 revealed Resident #25 had a self-care deficit related to impaired mobility, morbid obesity, and difficulty walking. Interventions included encouragement to use her call light, placing assistive devices in reach, and honoring choices and preferences. Observation on 03/04/24 at 12:29 P.M. of the 200-hall revealed the call light had been activated for Resident #25. Observation on 03/04/24 at 12:45 P.M. revealed Registered Nurse (RN) #201 was seated at the nurse's station within view of Resident #25's call light. Observation on 03/04/24 at 12:46 P.M. revealed State Tested Nurse's Aide (STNA) #205 began passing out lunch trays on the 200-hall. Three other employees were observed assisting with passing out lunch trays and did not respond to Resident #25's call light. Observation on 03/04/24 at 12:47 P.M. revealed Medication Technician (MT) #203 entered Resident #25's room and turned off her call light. The light remained unanswered for a total of 18 minutes. Interview on 03/04/24 at 12:49 A.M. with MT #203 revealed everyone was responsible for answering call lights, and they should be answered as soon as possible. She revealed she forgot to turn off the call light for Resident #25 and did not address the resident's need, which was a request for denture adhesive. She revealed she was aware there were times employees walked by call lights and did not answer them if they felt the resident did not need anything. 2. Review of the medical record for Resident #36 revealed and admission date of 07/29/22. Diagnoses included kidney disease, diabetes, osteoarthritis, and overactive bladder. Review of the quarterly MDS assessment dated [DATE] revealed Resident #36 was cognitively intact. He required substantial or maximum assistance for showering, partial or moderate assistance for hygiene and set-up help for eating and oral hygiene. He was totally dependent on others for toileting. Review of the care plan dated 01/04/24 revealed Resident #36 had a self-care deficit related to diabetes, depression, generalized weakness, and psychoactive drug use. Interventions included assistance of one person for bathing, bed mobility, dressing, personal hygiene and toileting, encouragement (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365718 If continuation sheet Page 14 of 34 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 365718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Streetsboro 1645 Maplewood Dr Streetsboro, OH 44241 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 to use the call light and assist as needed with daily tasks. Level of Harm - Minimal harm or potential for actual harm Observation on 03/12/24 at 9:40 A.M. revealed Resident #36's call light had been activated. Residents Affected - Few Observation on 03/12/24 at 10:04 A.M. revealed STNA #205 entered Resident #36's room and turned off his call light. The light remained on for a total of 24 minutes. Interview on 3/12/24 at 10:05 AM with STNA #205 revealed Resident #36 requested assistance with his colostomy bag. She revealed she was not able to meet this need and planned to get the nurse. Resident #36 told her someone else had already offered to get the nurse for him, but no nurse had taken care of his colostomy bag. STNA #205 confirmed anyone could answer call lights. She also revealed 24 minutes was longer than it should take for staff to respond to a call light. Interview on 03/12/24 at 1:08 P.M. with Resident #36 revealed it took the facility a long time to answer his call light at times. Interview on 03/12/24 at 3:07 P.M. with the Administrator revealed anyone was able to answer call lights. If staff were not able to meet the resident's need, she asked them to leave the light on and find a qualified staff member to help the resident. Review of the facility policy titled Call Lights: Accessibility and Timely Response, dated 12/28/23, revealed any staff member who saw or heard a call light was responsible for responding. If that staff could not meet the residents' needs, they were responsible for notifying the appropriate personnel. This deficiency is an incidental finding identified during the complaint investigation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365718 If continuation sheet Page 15 of 34 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 365718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Streetsboro 1645 Maplewood Dr Streetsboro, OH 44241 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review the facility failed to ensure timely incontinence care was provided for Residents #8 and #43. This affected two residents (#8 and #43) of three residents reviewed for incontinence care. The facility census was 66. Findings include: 1. Review of the medical record for Resident #8 revealed an admission date of 03/03/20. Diagnoses included anemia, hypothyroidism, overactive bladder, and adult failure to thrive. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 was moderately cognitively impaired. She required supervision for eating, assistance of one person bathing, toileting and dressing, and assistance of two people for transfers. Review of the care plan dated 01/04/24 revealed Resident #8 was always incontinent of bowel and bladder due to cognitive impairment and a decreased sensation to void. Interventions included assisting with toileting hygiene, checking and changing at regular intervals and observing for redness, irritation, skin excoriation, and reporting findings to the nurse or physician. Interview on 03/12/24 at 10:55 A.M. with Resident #8 revealed that on more than one occasion, she had gone 12 hours without being checked on or changed. Resident #8 stated she gets sore down there while pointing to her perineal area. Resident #8 further stated she could see a red area when her briefs get changed. Resident #8 did not recall when she was last checked for incontinence, but stated her brief felt like it was not positioned correctly and made her very uncomfortable. Observation on 03/12/24 at 11:05 A.M. of Resident #8 receiving incontinence care from State Tested Nurse Aide (STNA) #216 revealed Resident #8 had a moderately wet brief and a small bowel movement. Further observation revealed a dark pink area on Resident #8's right groin along where the brief sat and bright red discoloration of the prominent edges of the labia majora. Review of the bladder elimination task in the electronic medical record from 02/29/24 through 3:25 A.M. on 03/13/24 revealed no documented evidence that Resident #8 was checked for incontinence during the following intervals: • between 02/29/24 at 6:36 P.M. and 03/01/24 at 6:49 P.M. • between 03/02/24 at 12:00 P.M. and 03/03/24 at 5:21 A.M. • between 03/03/24 at 9:24 A.M. and 03/04/24 at 12:40 A.M. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365718 If continuation sheet Page 16 of 34 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 365718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Streetsboro 1645 Maplewood Dr Streetsboro, OH 44241 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 • Level of Harm - Minimal harm or potential for actual harm between 03/04/24 at 5:32 A.M. and 03/05/24 at 5:32 P.M. • Residents Affected - Few between 03/07/24 at 9:03 A.M. and 03/08/24 at 3:52 A.M. • between 03/10/24 at 12:00 P.M. and 03/11/24 at 2:41 A.M. • between 03/12/24 at 4:56 A.M. and 03/12/24 at 11:26 A.M. • As of 3:25 A.M. on 03/13/24, there was no further documentation of bladder elimination since 03/12/24 at 11:26 A.M. 2. Review of the medical record for Resident #43 revealed an admission date of 10/03/23. Diagnoses included rheumatoid arthritis, gastroesophageal reflux disease (GERD), and hypothyroidism. Review of the quarterly MDS assessment dated [DATE] revealed Resident #43 was cognitively intact. She required set-up help for eating and oral hygiene, substantial or maximum assistance for showering and personal hygiene, and was totally dependent upon staff for toileting. Review of the care plan dated 01/12/24 revealed Resident #43 had episodes of bowel and bladder incontinence due to a decreased sensation to void. Interventions included assisting the resident with toileting needs, checking, and changing at regular intervals as needed, and observing for redness, skin irritation, or excoriation, and notifying the nurse or physician. The resident requested not to be awakened at nighttime unless she asked. Review of the STNA tasks dated 02/29/24 through 03/13/24 revealed the only documented evidence Resident #43 was provided incontinence care occurred on the following dates and times: • 02/29/24 at 5:59 A.M. and 6:50 A.M. • 03/01/24 at 4:01 A.M. and 10:18 A.M. • 03/02/24 at 1:31 A.M. and 1:59 P.M. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365718 If continuation sheet Page 17 of 34 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 365718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Streetsboro 1645 Maplewood Dr Streetsboro, OH 44241 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 • Level of Harm - Minimal harm or potential for actual harm 03/03/24 at 5:51 A.M. and 9:45 A.M., • Residents Affected - Few 03/04/24 at 1:56 A.M., 9:30 A.M. and 7:16 P.M. • 03/05/24 at 5:58 A.M. and 9:20 A.M. • 03/06/24 at 4:40 A.M. and 1:59 P.M. • 03/07/24 at 4:15 A.M. and 1:45 P.M. • 03/08/24 at 9:35 A.M. and 11:59 P.M. • 03/09/24 at 1:39 A.M. and 1:59 P.M. • 03/10/24 at 3:40 A.M. • 03/11/24 at 2:55 A.M. and 1:59 P.M. • 03/12/24 4:24 A.M. and 1:59 P.M. Interview on 03/13/24 at 3:50 A.M. with the Director of Nursing (DON) revealed the standard of care was to check and change residents every two hours for incontinence . Review of the facility policy titled 'Incontinence, dated 10/26/23, revealed incontinent residents would receive appropriate treatment and services to prevent infection and restore continence to the extent possible. This deficiency represents noncompliance investigated under Complaint Numbers OH00151487 and OH00151297. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365718 If continuation sheet Page 18 of 34 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 365718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Streetsboro 1645 Maplewood Dr Streetsboro, OH 44241 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, medical record review, and observation of a video recording, the facility failed to provide appropriate respiratory treatment to Resident #65. This affected one resident (#65) of three residents reviewed for respiratory care and services. The facility census was 66. Residents Affected - Few Findings include: Review of the medical record for Resident #65 revealed an admission date of 02/13/24. Diagnoses included systolic congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), dementia, hypertension, spinal stenosis, functional urinary incontinence, and dysphagia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #65 had intact cognition. She was dependent on staff and required assistance from two staff for bed mobility, toileting, and bathing. Resident #65 received oxygen therapy. Review of a physician's order dated 02/13/24 revealed Resident #65 was ordered bilevel positive airway pressure (BiPAP, a non-invasive ventilation device that helps you breathe) to be always on, except for when eating. Another order, dated 02/13/24, revealed Resident #65 was to have oxygen on at three liters via nasal cannula (NC) when eating and with the BiPAP when not eating. Review of the care plan revealed Resident #65 had an impaired pulmonary/respiratory status. An intervention dated 02/13/24 included keeping Resident #65's head of bed elevated to aid in comfort and facilitate optimal breathing and to avoid shortness of breath while lying flat. Other interventions included observing and alleviating anxiety related to shortness of breath, and providing BiPAP, oxygen, and treatments as ordered. Review of a progress note dated 03/05/24 revealed Respiratory Therapist (RT) #226 entered the room of Resident #65 and found the resident receiving a bed bath and lying flat with her nasal cannula on. RT #226 then placed Resident #65 on the BiPAP for comfort. Observation on 03/05/24 of Resident #65 in her room revealed a sign near her bedside table stating Resident #65 should be placed on three liters of oxygen via NC for all medication passes and not to lift her mask or give medications through the side of her mask. Further observation of Resident #65's whiteboard to the left of her bed on 03/05/24 and 03/06/24 revealed a written message in black dry-erase ink directing the resident be placed on her NC for medication administration. An interview on 03/05/24 at 11:30 A.M. with Resident #65 confirmed she was anxious regarding her care and had a fear of choking when given medications with the BiPAP on. Resident #65 confirmed some of the nurses gave her medication under her BiPAP mask, with the BiPAP on. During this interview, Resident #65's daughter voiced the same concerns, reiterating the nurses are not following safe medication practices and she fears aspiration or worse. During the interview, the resident's daughter showed pictures and a short video on her phone of Resident #65 receiving medications under her mask. Interview on 03/06/24 at 3:00 P.M. with RT #226 confirmed Resident #65 was lying flat in bed receiving a bed bath by one state tested nurse aide (STNA) #217 on 03/05/24 and did not have her BiPAP on when she entered the room. RT #226 confirmed she placed Resident #65 on the BiPAP for comfort and assisted during the rest of the bed bath. RT #226 further confirmed Resident #65 should not be lying (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365718 If continuation sheet Page 19 of 34 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 365718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Streetsboro 1645 Maplewood Dr Streetsboro, OH 44241 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 flat and should not be taken off her BiPAP unless eating, drinking, or receiving her medications. Level of Harm - Minimal harm or potential for actual harm Interview on 03/12/24 at 1:40 P.M. with RT #225 confirmed administration of food, beverage, or medications under a BiPAP mask causes a high risk for aspiration. Further interview with RT #225 revealed best practice is to lift a BiPAP mask fully away from the face, administer medications and allow time to swallow completely, and make certain the resident is ready before resecuring the mask. For residents on continuous oxygen, a nasal cannula may be used during medication administration while the BiPAP is not in use. During this interview, RT #225 stated staff were made aware of Resident #65's preference of having the NC placed during medication administration versus pulling the BiPAP mask fully off the face and not applying oxygen for medication administration. Residents Affected - Few During the survey, video footage of care provided in Resident #65's room was provided by Resident #65's daughter, with approval from the resident. Observation of this video recorded on 03/05/24 from 11:03 P.M. to 11:06 P.M., and viewed alongside the Administrator on 03/12/24 at 3:30 P.M., revealed the following: At 11:04 P.M. on 03/05/24, registered nurse (RN) #230 told Resident #65 This is that one and a half pill that I usually just sneak in your mask. The recording further showed RN #230 lifted the bottom corner near the left side of Resident #65's BiPAP mask (with BiPAP machine running), gave a spoonful of medication mixed with applesauce, and immediately set the mask back down in place. The Administrator was interviewed on 03/12/24 following observation of the video footage from 03/05/24. During the interview, the Administrator acknowledged the BiPAP mask was not completely removed from Resident #65's face for medication administration. This deficiency represents non-compliance investigated under Complaint Number OH00151487. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365718 If continuation sheet Page 20 of 34 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 365718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Streetsboro 1645 Maplewood Dr Streetsboro, OH 44241 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, payroll-based journal review, and interviews with staff and residents the facility failed to have sufficient staffing to meet the care needs of all residents. This affected six residents (#39, #25, #36, #5, #43, #8) of 22 residents reviewed for care concerns and had the potential to affect all residents. The facility census was 66. Findings include: 1. Interviews with residents and staff between 03/04/24 and 03/13/24 revealed the following: • Interview on 03/04/24 at 1:15 P.M. with Registered Nurse (RN) #201 revealed she felt the facility could do a better job of ensuring showers were completed as scheduled. • Interview on 03/06/24 at 1:14 P.M. with Resident #39 revealed it didn't matter if she had her call light on for 15 minutes or 45 minutes, staff did not respond. • Interview on 03/12/24 at 11:17 A.M. with Resident #25 revealed her call it has been on for up to two hours at a time. At that point she tries to get up and take care of things for herself. • Interview on 03/12/24 at 1:08 P.M. with Resident #36 revealed it often took a long time for staff to respond to his call light. • Interview on 03/13/24 at 2:03 A.M. with RN #212 revealed it was hard to get all the residents up and ready for dialysis on dialysis days. She revealed the meds were often passed late, and people went eight to nine hours without being changed. 2. Observation on 03/04/24 at 12:29 P.M. of the 200-hall revealed the call light had been activated for Resident #25. Observation on 03/04/24 at 12:45 P.M. revealed RN #201 was seated at the nurse's station within view of Resident #25's call light. Observation on 03/04/24 at 12:46 P.M. revealed State Tested Nurse Aide (STNA) #205 began passing out lunch trays on the 200-hall. Three other employees were observed assisting with passing out lunch trays and did not respond to Resident #25's call light. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365718 If continuation sheet Page 21 of 34 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 365718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Streetsboro 1645 Maplewood Dr Streetsboro, OH 44241 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation on 03/04/24 at 12:47 P.M. revealed Medication Technician (MT) #203 entered Resident #25's room and turned off her call light. The light remained unanswered for a total of 18 minutes. Interview on 03/04/24 at 12:49 A.M. with MT #203 revealed everyone was responsible for answering call lights, and they should be answered as soon as possible. She revealed she forgot to turn off the call light for Resident #25 and did not address the resident's need, which was a request for denture adhesive. She revealed she was aware there were times employees walked by call lights and did not answer them if they felt the resident did not need anything. Interview on 03/04/24 at 1:15 P.M. with RN #201 revealed on dialysis days (Mondays, Wednesdays, and Fridays) there were several residents who needed to get up early to go to dialysis, and care was often delayed for residents who did not have dialysis. She felt the facility could do a better job of ensuring showers were completed as scheduled. 3. Interview on 03/07/24 at 3:02 P.M. with Resident #5 revealed she did not always want showers when they were offered or scheduled. Review of the STNA tasks dated 02/08/24 through 03/04/24 revealed Resident #5 was to receive a shower on Mondays, Thursdays, and as needed. The resident received a shower on Wednesday, 02/14/24, Thursday, 02/15/24, and Thursday, 02/22/24. She refused on Thursday, 02/08/24, Monday, 02/19/24, and Thursday, 02/29/24. There was no documented evidence a shower was offered, received, or refused a shower on Monday, 02/12/24 or Monday, 02/26/24. Review of the nursing progress notes revealed the resident refused to shower on Friday, 02/09/24 and Tuesday, 02/20/24. Information obtained from Resident #5's daughter revealed she helped her mother shower on Saturday, 01/27/24. Prior to that, her last shower was Monday, 01/22/24. She reported her mother was not receiving proper hygiene and had not received a shower in one week. Interview on 03/11/24 at 1:56 P.M. with the Administrator confirmed showers would be documented in the electronic medical record. She verified there was no other evidence showers had been refused or provided to Resident #5 outside of what was documented in the STNA tasks identified above. 4. Interview on 03/11/24 at 8:59 A.M. with Resident #43 revealed she had not received a shower in six weeks. She reported she got bed baths maybe once every two weeks. Review of the STNA tasks dated 02/11/24 through 03/11/24 revealed Resident #43 received a shower on Thursday, 02/29/24 and Thursday, 03/07/24. She refused a shower on Thursday, 02/22/24 and Monday, 03/04/24. There was no documented evidence a shower was offered, received, or refused from 02/11/24 through 02/22/24. Review of the nursing progress notes revealed the resident refused to shower on Saturday, 02/24/24, Monday, 02/26/24 and Tuesday, 03/05/24. Interview on 03/11/24 at 1:56 P.M. with the Administrator confirmed showers would be documented in the electronic medical record. She verified there was no other evidence showers had been refused or provided to Resident #43 outside of what was documented in the STNA tasks identified above. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365718 If continuation sheet Page 22 of 34 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 365718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Streetsboro 1645 Maplewood Dr Streetsboro, OH 44241 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled Bathing a Resident, dated 10/01/22, revealed the facility would assist residents with bathing to maintain proper hygiene. 5. Interview on 3/11/24 at 8:59 A.M. with Resident #43 revealed the facility was short staffed, and she often was not given the opportunity to get out of bed, especially on dialysis days. Residents Affected - Some Observation and interview on 03/11/24 at 11:53 A.M. with Resident #43 revealed the resident remained lying down in bed. She revealed showers were also not given on dialysis days and she has stopped asking to get out of bed or get a shower on dialysis days. Interview on 03/11/24 at 12:35 P.M. with STNA #202 revealed staffing on dialysis days was not good. Incontinence care was often delayed as a result, and residents knew their care would be delayed on dialysis days. She revealed she often stayed over her scheduled working hours to ensure showers were done, although they were later in the day than normal. 6. Observation on 03/12/24 at 9:40 A.M. revealed Resident #36's call light had been activated. Observation on 03/12/24 at 10:04 A.M. revealed STNA #205 entered Resident #36's room and turned off his call light. The light remained on for a total of 24 minutes. Interview on 3/12/24 at 10:05 AM with STNA #205 revealed Resident #36 requested assistance with his colostomy bag. She revealed she was not able to meet this need and planned to get the nurse. Resident #36 told her someone else had already offered to get the nurse for him, but no nurse had taken care of his colostomy bag. STNA #205 confirmed anyone could answer call lights. She also revealed 24 minutes was longer than it should take for staff to respond to a call light. Interview on 03/12/24 at 1:08 P.M. with Resident #36 revealed it took the facility a long time to answer his call light at times. Interview on 03/12/24 at 3:07 P.M. with the Administrator revealed anyone was able to answer call lights. If staff were not able to meet the resident's need, she asked them to leave the light on and find a qualified staff member to help the resident. 7. Review of the medical record for Resident #8 revealed an admission date of 03/03/20. Diagnoses included anemia, hypothyroidism, overactive bladder, and adult failure to thrive. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 was moderately cognitively impaired. She required supervision for eating, assistance of one person bathing, toileting and dressing, and assistance of two people for transfers. Review of the care plan dated 01/04/24 revealed Resident #8 was always incontinent of bowel and bladder due to cognitive impairment and a decreased sensation to void. Interventions included assisting with toileting hygiene, checking and changing at regular intervals and observing for redness, irritation, skin excoriation, and reporting findings to the nurse or physician. Interview on 03/12/24 at 10:55 A.M. with Resident #8 revealed that on more than one occasion, she had gone 12 hours without being checked on or changed. Resident #8 stated she gets sore down there while pointing to her perineal area. Resident #8 further stated she could see a red area when her briefs get changed. Resident #8 did not recall when she was last checked for incontinence, but stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365718 If continuation sheet Page 23 of 34 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 365718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Streetsboro 1645 Maplewood Dr Streetsboro, OH 44241 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 her brief felt like it was not positioned correctly and made her very uncomfortable. Level of Harm - Minimal harm or potential for actual harm Observation on 03/12/24 at 11:05 A.M. of Resident #8 receiving incontinence care from STNA #216 revealed Resident #8 had a moderately wet brief and a small bowel movement. Further observation revealed a dark pink area on Resident #8's right groin along where the brief sat and bright red discoloration of the prominent edges of the labia majora. Residents Affected - Some Review of the bladder elimination task in the electronic medical record from 02/29/24 through 3:25 A.M. on 03/13/24 revealed no documented evidence that Resident #8 was checked for incontinence during the following intervals: • between 02/29/24 at 6:36 P.M. and 03/01/24 at 6:49 P.M. • between 03/02/24 at 12:00 P.M. and 03/03/24 at 5:21 A.M. • between 03/03/24 at 9:24 A.M. and 03/04/24 at 12:40 A.M. • between 03/04/24 at 5:32 A.M. and 03/05/24 at 5:32 P.M. • between 03/07/24 at 9:03 A.M. and 03/08/24 at 3:52 A.M. • between 03/10/24 at 12:00 P.M. and 03/11/24 at 2:41 A.M. • between 03/12/24 at 4:56 A.M. and 03/12/24 at 11:26 A.M. • As of 3:25 A.M. on 03/13/24, there was no further documentation of bladder elimination since 03/12/24 at 11:26 A.M. Interview on 03/13/24 at 3:50 A.M. with the Director of Nursing (DON) revealed the standard of care was to check and change residents every two hours for incontinence. 8. Review of the medical record for Resident #43 revealed an admission date of 10/03/23. Diagnoses included rheumatoid arthritis, gastroesophageal reflux disease (GERD), and hypothyroidism. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365718 If continuation sheet Page 24 of 34 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 365718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Streetsboro 1645 Maplewood Dr Streetsboro, OH 44241 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the quarterly MDS assessment dated [DATE] revealed Resident #43 was cognitively intact. She required set-up help for eating and oral hygiene, substantial or maximum assistance for showering and personal hygiene, and was totally dependent upon staff for toileting. Review of the care plan dated 01/12/24 revealed Resident #43 had episodes of bowel and bladder incontinence due to a decreased sensation to void. Interventions included assisting the resident with toileting needs, checking, and changing at regular intervals as needed, and observing for redness, skin irritation, or excoriation, and notifying the nurse or physician. The resident requested not to be awakened at nighttime unless she asked. Review of the STNA tasks dated 02/29/24 through 03/13/24 revealed the only documented evidence Resident #43 was provided incontinence care occurred on the following dates and times: • 02/29/24 at 5:59 A.M. and 6:50 A.M. • 03/01/24 at 4:01 A.M. and 10:18 A.M. • 03/02/24 at 1:31 A.M. and 1:59 P.M. • 03/03/24 at 5:51 A.M. and 9:45 A.M., • 03/04/24 at 1:56 A.M., 9:30 A.M. and 7:16 P.M. • 03/05/24 at 5:58 A.M. and 9:20 A.M. • 03/06/24 at 4:40 A.M. and 1:59 P.M. • 03/07/24 at 4:15 A.M. and 1:45 P.M. • 03/08/24 at 9:35 A.M. and 11:59 P.M. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365718 If continuation sheet Page 25 of 34 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 365718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Streetsboro 1645 Maplewood Dr Streetsboro, OH 44241 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 • Level of Harm - Minimal harm or potential for actual harm 03/09/24 at 1:39 A.M. and 1:59 P.M. • Residents Affected - Some 03/10/24 at 3:40 A.M. • 03/11/24 at 2:55 A.M. and 1:59 P.M. • 03/12/24 4:24 A.M. and 1:59 P.M. Interview on 03/13/24 at 3:50 A.M. with the DON revealed the standard of care was to check and change residents every two hours for incontinence. 9. Review of the payroll-based journal (PBJ) staffing data report for fiscal year (FY) quarter four 2023 (July 1 - September 30) revealed the facility had a one-star staff rating. This deficiency represents noncompliance investigated under Master Complaint Number OH00151581 and Complaint Numbers OH00151487 and OH00151113. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365718 If continuation sheet Page 26 of 34 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 365718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Streetsboro 1645 Maplewood Dr Streetsboro, OH 44241 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to timely provide and obtain medications to meet Resident #66's needs. This affected one resident (#66) of six residents reviewed for medication administration. The facility census was 66. Findings include: Review of the medical record for Resident #66 revealed an admission date of 01/19/24. Diagnoses included chronic respiratory failure with hypoxia, tracheostomy status, ventilator dependence, epilepsy, adult failure to thrive, colostomy status, dysphagia, and feeding difficulties. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #66 had intact cognition, was dependent for toileting, and required substantial assistance for bathing and personal hygiene. Resident #66 required oxygen therapy, suctioning, tracheostomy care, and intravenous medications. Review of physician's orders in the electronic medical record revealed medication orders dated 01/19/24, including: • Phenobarbital 60 milligrams (mg) (anticonvulsant), 1 tablet by mouth two times per day for seizures. • Diphenoxylate-Atropine 2.5-0.025 mg (antidiarrheal), one tablet by mouth three times a day (may have up to 16 doses per day) Review of the Physician orders and medication administration record (MAR) also revealed the following duplication of orders for Loperamide Hydrochloride (HCL) as follows: • Loperamide HCL 2 mg (antidiarrheal), two tablets by mouth before meals and at bedtime (start date 01/19/24, stop date 01/23/24) • Loperamide HCL 2 mg, two tablets by mouth in the afternoon (start date 01/20/24, stop date 01/26/24 • Loperamide HCL 2 mg, two tablets by mouth in the evening (start date 01/20/24, stop date 01/26/24) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365718 If continuation sheet Page 27 of 34 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 365718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Streetsboro 1645 Maplewood Dr Streetsboro, OH 44241 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 • Level of Harm - Minimal harm or potential for actual harm Loperamide HCL 2 mg, two tablets by mouth at bedtime (start date 01/20/24, stop date 01/26/24) • Residents Affected - Few Loperamide HCL 2 mg, two tablets by mouth one time daily (start date 01/20/24, stop date 01/26/24) Review of the MAR for January 2024 revealed the following medications were not given to Resident #66 as ordered: • Phenobarbital 60 mg, one tab by mouth two times/day for seizures was not administered on the evening of 01/19/24, morning of 01/20/24, morning and evening on 01/21/24, morning and evening of 01/22/24, or the morning of 01/23/24. • Diphenoxylate-Atropine 2.5-0.025 mg, one tablet by mouth three times daily (up to 16 doses/day) - No doses of this medication were given on 01/20/24 or 01/21/24. • Loperamide HCL 2 mg, two tablets by mouth - MAR signoffs for the order frequency of before meals and at bedtime, as well as the MAR signoffs for the four separate orders reflecting this medication was to be given in the morning, afternoon, evening, and at bedtime were all reviewed and compared. After reviewing all five orders on the January MAR, there was no evidence Resident #66 received Loperamide HCL on 01/21/24 at lunch time or in the evening, nor did she receive this medication on 01/22/24 at lunch time, in the evening, or at bedtime. Review of the progress note dated 01/21/24 revealed the shipment received from the pharmacy revealed the following controlled medications were not received: oxycodone 7.5 mg (narcotic pain medication), diphenoxylate-atropine 2.5-0.025 mg, and phenobarbital 60 mg. The progress note indicated the pharmacy was contacted, facility informed a prescription was required, and the nurse practitioner (NP) was notified. Review of the electronic medication administration record (eMAR) notes for phenobarbital revealed notes entered on 01/20/24, two notes on 01/22/24, and one note on 01/23/24 the medication was not delivered from the pharmacy. One note on 01/22/24 at 11:27 P.M. noted the phenobarbital was on back-order. Review of the eMAR progress notes for diphenoxylate-atropine revealed one note, entered 01/20/24 at 2:19 P.M. stating Meds not here. Review of the eMAR progress note, entered 01/22/24 at 9:20 AM., revealed Loperamide HCL was unavailable as house stock and was changed to a pharmacy delivery. Further review of eMAR notes regarding Loperamide HCL revealed four additional notes confirming the medication was not given in the afternoon, evening, or at bedtime on 01/22/24 due to unavailability from pharmacy and not being stocked by (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365718 If continuation sheet Page 28 of 34 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 365718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Streetsboro 1645 Maplewood Dr Streetsboro, OH 44241 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 the facility. Level of Harm - Minimal harm or potential for actual harm Interview on 03/12/23 at 4:05 P.M. with the Director of Nursing (DON) confirmed Resident #66 had not received the ordered Phenobarbital until the evening dose on 01/23/24, did not receive Loperamide per physician orders on 01/21/24 and 01/22/24, and did not receive the ordered diphenoxylate-atropine on 01/20/24 or 01/21/24. The DON further revealed the NP was notified the phenobarbital was not given with no new orders received. She further revealed the pharmacist informed her the phenobarbital dose was not a common dose and not stocked by the pharmacy. During the interview, the DON revealed the facility did not have loperamide in stock and once she was notified Resident #66 was not receiving ordered doses, she purchased the drug at an outpatient pharmacy. Residents Affected - Few Review of email communications between the facility and the contracted pharmacy from 03/13/24 at 7:02 A.M. revealed the pharmacy received a verbal order from the provider on 01/21/24 and the distributor does not have weekend deliver. Review of the policy titled Medication Administration, dated 01/17/23, revealed medications are administered as ordered by the physician. This deficiency represents non-compliance investigated under Complaint Numbers OH00151487 and OH00151113. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365718 If continuation sheet Page 29 of 34 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 365718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Streetsboro 1645 Maplewood Dr Streetsboro, OH 44241 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, policy review, and review of video footage, the facility failed to implement appropriate infection control measures to help prevent the development and/or transmission of infections. This affected one resident (#65) of four residents reviewed for infection control. The facility census was 66. Residents Affected - Few Findings include: Review of the medical record for Resident #65 revealed an admission date of 02/13/24. Diagnoses included systolic congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), dementia, hypertension, spinal stenosis, functional urinary incontinence, and dysphagia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #65 had intact cognition. Resident #65 was incontinent and dependent on staff for care and required assistance from two staff for bed mobility, toileting, and bathing. Review of Resident #65's physician order, dated 02/13/24, revealed the resident was on enhanced barrier precautions (EBP) from 02/13/24 until 02/28/24 at 2:42 P.M. Another order, dated 02/28/24 at 2:42 P.M., revealed Resident #65 was to be placed on transmission-based precautions (TBP) while ruling out COVID-19 infection. On 03/04/24, Resident #65 had an order to be placed back on EBP. Further review of the orders revealed Resident #65 required continuous bilevel positive airway pressure (BiPAP), a non-invasive ventilation device that helps you breathe. Review of the care plan revealed Resident #65 had the care plan updated on 03/04/24 from a focus of TBP that was put into place on 02/28/24 to EBP for multiple comorbidities. Observation on 03/05/24 of the outside of Resident #65's room revealed a sign indicating the resident was on EBP, a cart containing gowns, gloves, and surgical masks, and a sign directing staff to always wear a mask when in the resident's room per request of the resident's daughter. An interview on 03/05/24 at 11:30 A.M. with Resident #65 confirmed she was fearful of getting an infection an anxious because staff were not always taking appropriate precautions, including wearing the appropriate personal protective equipment (PPE) when indicated and had improperly worn surgical masks. During this interview, the resident's daughter voiced the same concerns, reiterating staff do not follow proper infection control procedures. An interview on 03/06/24 with Registered Nurse (RN) #224 confirmed Resident #65 was placed on EBP due to immunosuppression and poor lung capacity with continuous BiPAP. During the survey, various video footage of care provided in Resident #65's room was provided by Resident #65's daughter, with approval from the resident. The videos were viewed per their request. The following incidents summarize the findings from these videos: • Observation of a video recording in Resident #65's room on 02/25/24 from 1:35 P.M. to 1:44 P.M. of Registered Nurse (RN) #201 revealed she did not have on a gown or gloves, and her surgical mask was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365718 If continuation sheet Page 30 of 34 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 365718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Streetsboro 1645 Maplewood Dr Streetsboro, OH 44241 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 - Few below her nose during medication administration, assisting the resident with her drink, and placing and removing food items from her bedside table. RN #201 continued rendering more than eight minutes of close resident care without a gown, and with her mask placed below her nose, including replacement of the BiPAP chinstraps around Resident #65's head and face, placing the BiPAP mask and initiating BiPAP, filling a nebulizer cup with medication to be aerosolized, starting the aerosol treatment as the medication was being aerosolized into the air as she walked to the other side of the bed to hook it up in-line to the BiPAP, repositioning the resident, and shaking and placing blankets and pillows. • Observation of a video recording compilation of Resident #65's room on 02/28/24 from 4:58 P.M. to 5:00 P.M. and 5:02 P.M. to 5:03 P.M. revealed RN #201 in Resident #65's room with a surgical mask below her nose, no face shield, and no gloves while handling the resident's spoon, medicine cup, and a bowl on the bedside table. Further recording at 5:02 P.M. revealed RN #201 returned to the resident's room with no gloves, no gown, no face shield, and a surgical mask below her chin. RN #201 proceeded to remove the medication from the resident's room during this recording, stating the resident would get the medication when her dinner tray arrived. • Observations of a video recording of Resident #65's room on 03/07/24 from 7:44 P.M. to 7:55 P.M. revealed Resident #65 received incontinence care by two staff members between 7:47 P.M. And 7:52 P.M. During the incontinence care observation via video, State Tested Nurse Aide (STNA) #213 failed to remove her used gloves, perform hand hygiene, and reapply clean gloves when she moved between care which caused contamination of her gloved hands and care that consisted of dispensing and applying a cream to the groin area she just cleaned. Further review of the video showed STNA #213 used the same gloved hands to wash, rinse, and dry Resident #65's perineal area and buttocks and then not performing hand hygiene or a glove change before handling, dispensing, or applying the cream to Resident #65's bottom. • Observations of a video recording of Resident #65's room on 03/07/24 from 11:38 P.M. to 11:41 P.M. revealed RN #230 did not don a gown for resident care, including removing the BiPAP mask, applying oxygen through a nasal cannula (NC), ensuring the resident swallowed her medication, removing the NC, reapplying the BiPAP mask, and resuming the BiPAP preprogrammed treatment. An interview on 03/12/24 at 3:30 P.M. with the Administrator, after she viewed the videos, confirmed the following: 1) The 02/25/24 video from 1:35 P.M. to 1:44 P.M demonstrated RN #201 performing care lasting more than eight minutes with a mask below her nose and no gown for care including medication administration, manipulation of BiPAP devices, repositioning, and manipulation of pillows and bed linen. She also confirmed no gloves were used for handling the resident's applesauce and administering medications. 2) Staff should have donned an N95 mask, face shield, gown, gloves, and the medication should not have been taken out of the room once laying on the bedside table, since Resident #65 started on TBP on 02/28/24. 3) She confirmed it was STNA #213 in the video on 03/07/24 from 7:44 P.M. to 7:55 P.M. who did not change gloves or perform hand hygiene between dirty and clean procedures. 4) No gown was worn by RN #230 during resident care. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365718 If continuation sheet Page 31 of 34 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 365718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Streetsboro 1645 Maplewood Dr Streetsboro, OH 44241 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 - Few Review of the Facility's infection control log revealed Resident #65 developed a fever and green mucous on night shift 02/27/24 and was placed on TBP on 02/28/24 until COVID-19 could be ruled out. Review of the policy titled Enhanced Barrier Precautions, (EBP), revised 08/31/23, revealed a resident with certain conditions or devices may be placed on EBP if the facility determines they are an increased risk of transmission or acquisition of a multi-drug resistant microorganism (MDRO). The policy stated EBP must be used for high-touch resident care, including changing linens and device use and care. Review of the policy titled Transmission-Based (Isolation) Precautions, last revised on 12/27/23, revealed residents suspected of having COVID-19 or other communicable disease should be placed on isolation precautions while awaiting confirmation. Review of the policy updated on 05/26/23 titled COVID-19 Prevention, Response, and Reporting revealed health care providers entering the room of a resident with suspected COVID-19 must wear a fit-tested respirator with N95 filter or higher, gown, gloves, and eye protection. The policy further revealed these precautions were to be maintained until symptomatic residents were afebrile, symptoms had improved, and they had two consecutive negative tests from specimens collected 48 hours apart. This deficiency represents non-compliance investigated under Master Complaint Number OH00151581, and Complaint Numbers OH00151487, and OH00150414. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365718 If continuation sheet Page 32 of 34 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 365718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Streetsboro 1645 Maplewood Dr Streetsboro, OH 44241 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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure the call light in the bathroom was reset appropriately after use to ensure Resident #39 was able to activate the call light in the room. This affected one resident (#39) of three residents reviewed for call light functionality. The facility census was 66. Residents Affected - Few Findings include: Review of the medical record for Resident #39 reviewed and admission date of 02/09/24. Diagnoses included hypertension, depression, and repeated falls. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 was moderately cognitively impaired. She required set-up assistance for eating, personal hygiene, oral care, and toileting, and supervision for showering. Interview on 03/06/24 at 1:14 P.M. with Resident #39 revealed she had her call light on for at least 15 minutes. Observation at the time of the interview revealed no evidence the call light had been activated. Interview on 03/06/24 at 1:16 P.M. with Licensed Practical Nurse (LPN) #208 confirmed there was no evidence an audible or visual sound was present to indicate the call light was activated for Resident #39. She asked Resident #39 to push her call button again and again confirmed there was no evidence the button had been pushed. LPN #208 then confirmed the call light in the bathroom had been activated at an earlier time and was never reset. Interview on 03/06/24 at 1:21 P.M. with Maintenance Director #207 revealed if a call light was activated and the system was not reset, any other call lights within that room could not be activated until the initial light was reset. He revealed he audited call lights for functionality weekly and did not have any concerns with call lights not functioning properly. This deficiency was an incidental finding identified during the complaint investigation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365718 If continuation sheet Page 33 of 34 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 365718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Streetsboro 1645 Maplewood Dr Streetsboro, OH 44241 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, record review, interview, and facility policy review the facility failed to ensure the environment was maintained in a clean and sanitary manner. This had the potential to affect all 13 residents (#45, #46, #47, #48, #49, #50, #51, #52, #53, #54, #55, #56 and #57) residing on the secured unit as well as Resident #43 who used the shower on the secured unit. The facility census was 66. Findings include: Interview on 03/11/24 at 8:59 A.M. with Resident #43 revealed the last time she had a shower in the secured unit shower room there was a terrible odor. Observation on 03/06/24 at 1:20 P.M. of the central bath/shower room on the secured unit revealed two of three shower stalls had chipping in the center of the inside shower wall panel. One shower stall had a broken area around the water faucet control panel with exposed plumbing area noted. One stall had a soiled washcloth on the floor, and another had used towels and washcloths on the floor. There were multiple brown spots on the shower floor, as well as a raised brown substance approximately 2.5 inches by 1 inch. Observation at that time also revealed a pervasive odor (smelled like stool) throughout the shower room, which was stronger near the middle shower stall. The above findings were confirmed by State Tested Nurse Aide (STNA) #209 at the time of the observation. Interview on 03/06/24 at 1:20 P.M. with STNA #209 confirmed the showers are supposed to be cleaned and disinfected by the aides after each use. The shower stalls were not cleaned after use, brown substances were on the shower floor, and there were broken pieces of the shower walls on both shower stalls being used on that until. She also confirmed the third shower stall was not being used at this time. The facility identified 13 residents (#45, #46, #47, #48, #49, #50, #51, #52, #53, #54, #55, #56 and #57) resided on the secured unit, as well as Resident #43 used the shower room on the secured unit. Review of the facility policy titled Routine Cleaning and Disinfection, dated 02/01/22, revealed the facility would ensure routine cleaning occurred to provide a safe and sanitary environment. This included the removal of visible soil from objects and surfaces. This deficiency represents noncompliance investigated under Complaint Number OH00150414. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365718 If continuation sheet Page 34 of 34