Inspection·February 6, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few changed her clothing. LPN #370 stated at the time of the shower they did not see any skin issues. Once the shower was completed the resident went out of the shower room and went out to smoke with the other residents. LPN #370 stated when the resident came back inside, LPN #370 and RN #333 noticed she had blood on her arm and had three injuries of unknown origin to their right forearm. LPN #370 stated they were unsure if RN #333 notified the guardian or the residents brother. LPN #370 stated they filled out a risk assessment related to the injuries of unknown origin. LPN #370 she did not notify the on-call nurse or the DON as she was on orientation and did not know if RN #333 notified them either. Interview on 02/05/25 at 9:30 A.M. with the DON revealed they confirmed the on-call nurse nor herself were notified of the injury of unknown origin. The DON stated they opened an SRI on 02/04/25 and started the investigation. The DON confirmed there was not an investigation started, or an SRI started on the day of injury. Interview on 02/05/25 at 9:50 A.M. with RN #333 revealed they were orienting LPN #370 on 02/02/25 and both noticed Resident #36 had been incontinent and both nurses took her to the shower room, washed her up, changed her clothing and combed out her hair, and then when exiting the shower room, the resident noticed it was time for a smoke break and went out to smoke with the other residents. RN #333 stated during her shower the resident did not have any skin issues. Upon returning from smoking the resident was found to have three skin tears to right forearm and documented them as injury of unknown origin because they did not know what happened or where they came from. RN #333 stated they filled out a risk assessment related to injury of unknown origin and put orders in for wound care to the skin tears to cleanse them with wound cleanse pat dry and cover with a border foam dressing. RN #333 stated they notified the Nurse Practitioner of the injuries of unknown origin but did not notify the DON or the on-call nurse. Review of the facility policy titled Abuse, Neglect, and Exploitation last revised 01/10/24 revealed under section IV Identification of Abuse, Neglect, and Exploitation, letter B Possible indicators of abuse include, but are not limited to, number three stated Physical injury of a resident of unknown source. Under section V Investigation of Alleged Abuse, Neglect, and Exploitation, letter A an immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur, letter B written procedures for investigation include: 1. identifying staff responsible for the investigation, 3. investigating different types of alleged violations, 4. identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations, 5. focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause and, 6. providing complete and thorough documentation of the investigation. Under section VII Reporting/Response 1. Reporting of alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within specified time frames as required by state and federal regulations: A. immediately, but no later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or B. not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365718 If continuation sheet Page 2 of 11 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 02/06/2025 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 interview and record review the facility failed to investigate injuries of unknown origin to the state agency within the required time frame. This affected one resident (Resident #36) out of three residents reviewed for abuse. The facility census was 67. Residents Affected - Few Findings include: Review of the medical record for Resident #36 revealed an admission date of 09/15/21. Diagnosis included psychosis not due to a substance or known physiological condition, fibromyalgia, chronic obstructive pulmonary disease, post-traumatic stress disorder, anxiety, major depressive disorder, hypertension and nicotine dependency. Review of Resident #36's annual Minimum Data Set (MDS) dated [DATE] revealed the resident had intact cognition. Resident #36 was independent with dressing, personal hygiene, they required setup or clean up assistance with eating, substantial to maximal assistance with bed mobility, and was dependent on staff for oral hygiene, and toileting hygiene. Review of Resident #36's progress notes dated 02/02/25 at 6:26 P.M. revealed Registered Nurse (RN) #333 documented Resident #36 had three new skin tears of unknown origin. Review of the Facility Self-Reported Incidents (SRI) revealed there were no reported injuries of unknown origins reported to the state agency for Resident #36 or dated for 02/02/25. Interview on 02/04/25 at 2:54 P.M. with the Director of Nursing (DON) revealed Registered Nurse (RN) #333 documented on 02/02/25 at 6:26 P.M., she observed three skin tears of unknown origin. The DON stated RN #333 did not notify them of the injuries of unknown origin. The DON stated they did not open a SRI related to Injury of Unknown Origin. Interview on 02/04/25 at 3:11 P.M. with Licensed Practical Nurse (LPN) #302 revealed they remembered Resident #36 had been incontinent, which was not normal for her and was more agitated then normal. LPN #302 stated she was not assigned to Resident #36, but RN #333 and LPN #370 were and seen them take the resident into the shower and when finished the resident went out to smoke with the other residents after her shower. Interview on 02/04/25 at 3:16 P.M. with LPN #370 revealed Resident #36 normally paces all day and loves to eat ice chips. LPN #370 stated themselves and RN #333 noticed the resident had been incontinent which was not normal, so they took her into the shower, washed her up, combed her hair, and changed her clothing. LPN #370 stated at the time of the shower they did not see any skin issues. Once the shower was completed the resident went out of the shower room and went out to smoke with the other residents. LPN #370 stated when the resident came back inside, LPN #370 and RN #333 noticed she had blood on her arm and had three injuries of unknown origin to their right forearm. LPN #370 stated they were unsure if RN #333 notified the guardian or the residents brother. LPN #370 stated they filled out a risk assessment related to the injuries of unknown origin. LPN #370 she did not notify the on-call nurse or the DON as she was on orientation and did not know if RN #333 notified them either. LPN #370 stated they did not do any investigation into how the resident sustained the injuries of unknown origin. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365718 If continuation sheet Page 3 of 11 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 02/06/2025 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 02/05/25 at 9:30 A.M. with the DON revealed they confirmed the on-call nurse nor herself were notified of the injury of unknown origin. The DON stated they opened an SRI on 02/04/25 and started the investigation. The DON confirmed there was not an investigation started, or an SRI started on the day of injury. Interview on 02/05/25 at 9:50 A.M. with RN #333 revealed they were orienting LPN #370 on 02/02/25 and both noticed Resident #36 had been incontinent and both nurses took her to the shower room, washed her up, changed her clothing and combed out her hair, and then when exiting the shower room, the resident noticed it was time for a smoke break and went out to smoke with the other residents. RN #333 stated during her shower the resident did not have any skin issues. Upon returning from smoking the resident was found to have three skin tears to right forearm and documented them as injury of unknown origin because they did not know what happened or where they came from. RN #333 stated they filled out a risk assessment related to injury of unknown origin and put orders in for wound care to the skin tears to cleanse them with wound cleanse pat dry and cover with a border foam dressing. RN #333 stated they notified the Nurse Practitioner of the injuries of unknown origin but did not notify the DON or the on-call nurse. RN #333 stated the did not do any investigation into how the resident sustained the injuries of unknown origin. Review of the facility policy titled Abuse, Neglect, and Exploitation last revised 01/10/24 revealed under section IV Identification of Abuse, Neglect, and Exploitation, letter B Possible indicators of abuse include, but are not limited to, number three stated Physical injury of a resident of unknown source. Under section V Investigation of Alleged Abuse, Neglect, and Exploitation, letter A an immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur, letter B written procedures for investigation include: 1. identifying staff responsible for the investigation, 3. investigating different types of alleged violations, 4. identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations, 5. focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause and, 6. providing complete and thorough documentation of the investigation. Under section VII Reporting/Response 1. Reporting of alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within specified time frames as required by state and federal regulations: A. immediately, but no later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or B. not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365718 If continuation sheet Page 4 of 11 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 02/06/2025 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #2's medical record revealed an admission date of 09/06/21. Diagnosis included interstitial pulmonary disease, obesity, sick sinus syndrome, major depressive disorder, gastroesophageal reflux disease, chronic pain, hypertension, and history of pulmonary embolism. Residents Affected - Few Review of Resident #2's quarterly MDS dated [DATE] revealed the resident had intact cognition. They required setup or clean up assistance for eating and oral hygiene, she was dependent on staff for toileting hygiene, showers, dressing, personal hygiene and transfers by two staff members and use of a mechanical lift. Resident #2 used a motorized wheelchair and was independent on in the chair for wheelchair mobility. Review of Resident #2's activities care plan dated 12/20/24 revealed there was a care plan initiated stating Resident #2 was funny, lighthearted and pleasant to be around. She was mostly bed bound but would occasionally come out for bingo or prize auction. Resident #2 watched shows on television and on her phone and loved pet visits. Interventions included the resident would accept and/or participate with daily visits form staff, she would participate in activities of her choosing, staff were to provide daily visits for encouragement, monitor her wants or needs and for socialization, and staff were to provide monthly activity calendar. Review of Resident #2's activity documentation dated 11/01/24 through 01/31/25 revealed the resident participated or accepted 13 activities in November 2024 and December 2024 and eight in January 2024. Interview on 02/03/25 at 11:50 A.M. with Resident #2 revealed she stayed in her room most days and the activity staff did not come down to her room to do any activities with her. Resident #2 stated the activity staff always take the same couple of residents on outings and she was never included. Resident #2 stated the activities they have her documented as attending were from when the Certified Nursing Assistant (CNA) assigned to her would go down to the activity and sneak her the treats like popcorn to her. Interview on 02/06/25 at 12:31 P.M. with Resident #2 revealed there was an activity at 11:00 A.M. where popcorn was provided to the residents who attended the activity and not offered to the residents in their rooms. Resident #2 stated the CNA she is very close with had to sneak down to the activity and take some popcorn for her. Resident #2 stated they never come down and offer the snacks provided at the activity. Resident #2 stated she would like to go to activities or on outings or at the very least just be asked if she would like to go. She stated she would like something to do or at least be offered. She stated you can only watch so much television or look at her phone. Resident #2 stated she is very bored. 3. Review of the medical record for Resident #10 revealed an admission date of 09/02/22. Diagnosis included chronic respiratory failure, end stage renal disease (ESRD), diabetes, heart failure, morbid obesity, dependence on renal dialysis, osteoarthritis, major depressive disorder, anemia, sleep apnea, gastroesophageal reflux disease (GERD), lymphedema, hypotension, and incontinent of bowel and bladder. Review of Resident #10's quarterly MDS dated [DATE] revealed the resident was cognitively intact. Resident #10 required setup or clean up assistance with eating and oral hygiene. Resident #10 was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365718 If continuation sheet Page 5 of 11 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 02/06/2025 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few dependent on staff for personal hygiene, bed mobility, lower body dressing and transfers with the use of a mechanical lift. Additionally Resident #10 required partial assistance with upper body dressing. Review of Resident #10's care plan dated 10/12/23 revealed he was a dialysis resident. He tended to stay in his room and self-recreate. He watched movies, television and plays games on his phone. Resident #10 was an avid football fan and enjoys college football. Interventions and goals included the resident would accept or participate in daily visits form staff, and he would participate in activities of his choice. Staff were to provide daily visits to encourage and monitor his wants, needs and for socialization. Additionally, staff were to provide monthly activity calendar. Review of Resident #10's activity documentation dated 11/01/24 through 01/31/25 revealed the resident participated or accepted seven activities in November 2024, four activities in December 2024 and two activities in January 2024. Interview on 02/04/25 at 9:36 A.M. with Resident #10 revealed the resident stated the activity department makes up monthly calendars and only do a few of the activities on them. Resident #10 stated they do not come in his room and do activities with him or provide him with puzzles or cross word puzzle books. Resident #10 stated he had to buy his own puzzle books for something to do other than watching television or playing games on his phone. Resident #10 stated he gets bored often. Interview on 02/06/25 at 12:41 P.M. with AD #363 revealed they confirmed Resident #10 was marked active for only 13 activities in a three-month period and the dates usually correlated with his one-on-one activities. AD #363 confirmed the one-on-one activities occurred once a week and were approximately 15 minutes long. AD #363 confirmed the residents activity care plan stated Resident #10 was to receive daily visits and they did not happen. Interview on 02/06/25 at 2:30 P.M. with Resident #10 revealed when asked about refusals of participation in activities as documented by activity staff he stated, How can he refuse activities if he is never offered to participate in them, additionally Resident #10 stated the one-on-one activities were the Activity Director or the Activity Assistants coming in to talk to him once a week for no longer than 15 minutes. He stated, That is a joke, talking with someone is not an activity. Review of facility list of Residents who went on outings from November 2024 and December 2024 revealed the same five residents Resident #4, #16, #40, #48, and #53 were the only ones who went out on the outings on 11/12/24 shopping, 11/26/24 lunch outing, 12/06/24 shopping, and 12/20/24 lunch outing. All outings were canceled in January 2025 due to AD #363 had balance issues and did not feel comfortable driving the bus. Review of the facility policy titled Activities, last revised 10/30/23 revealed under the section titled Policy stated It is the policy of the facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences of each resident. Facility-sponsored group and individual activities and independent activities will be designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, as well as encourage both independence and interaction within the community. Based on record review, observations and interviews, the facility failed to provide therapeutic activities to meet the needs and preferences of the resident population. This affected three Residents (#2, #10, and #47) of three residents investigated for activities. The facility census was 67. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365718 If continuation sheet Page 6 of 11 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 02/06/2025 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 Findings include: Level of Harm - Minimal harm or potential for actual harm 1. Review of the medical record revealed Resident #47 was admitted to the facility on [DATE] with diagnoses including anxiety disorder, cerebral edema, pain, cerebral infarction due to unspecified occlusion or stenosis, right hemiplegia and hemiparesis, aphasia, dysphagia, post traumatic seizures. Residents Affected - Few Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #47 had a brief Interview of Mental Status (BIMS) score of 00, indicating severe cognitive impairment, and she was dependent on staff for transfers and mobility. Review of the care plan dated 11/28/24 revealed Resident #47 was at risk for altered activity patterns/pursuits related to anxiety, impaired mobility, sensory deficits. Resident #47 was unable to do things for herself. She enjoyed bingo when she was up. She liked to people watch. Interventions included staff to provide daily visits for encouragement, monitor her wants/needs, and socialization, one-on-one (1:1) visits from staff and volunteers as resident will allow, allow and encourage hallway activities as able, encourage activities that assure success and are non-threatening, and encourage to accept redirection into group activities to increase socialization. Observation on 02/03/25 at 10:37 A.M. revealed Resident #47 was observed lying in bed flat on her back watching an animated show on the television (TV) and presented with a flat affect. Resident #47 made eye contact with the surveyor but did not respond verbally. Observations on 02/04/25 at 10:07 A.M. revealed Resident #47 was lying in bed in her room with the TV on. On 02/04/25 at 3:54 P.M. Resident #47 was lying in bed on her back receiving enteral feeding with flat affect. The TV was showing an animated show. Observation on 02/05/25 at 9:37 A.M. revealed Resident #47 was lying in bed on her back with flat affect. The TV was showing an animated program. Resident #47 did not respond verbally to the surveyor this morning. Observation on 02/06/25 at 10:27 A.M. revealed Resident #47 was up in her chair in her room. Interview on 02/05/25 at 9:27 A.M. with Activity Director (AD) #363 revealed Resident #47 received 1:1 with activities staff probably only once a week and stated, they need to get her up and out of the room more. Resident #47 can't play bingo but enjoys sitting among the players and was aware of when numbers are called on her own card. Therapy observed activities and give Resident #47 a Reese's cup on special occasions. Record review of activities 1:1 log dated 10/29/24 through 02/04/25 revealed one 1:1 activity sessions were attempted per week. Two 1:1's were documented as unsuccessful as Resident #47 was marked as sleeping. The duration of each completed 1:1 was undocumented. Interview on 02/06/25 at 10:50 A.M. with AD #363 revealed 1:1's with Resident #47 usually occurred once weekly on Tuesdays and lasted about 15 minutes. The surveyor reviewed Resident #47's activity attendance logs with AD #363 who stated, we really need to get her up more. Resident #47's attendance logs stated she was present at four group activities from 11/01/24 through 01/31/25. All other entries were marked as not applicable, resident refused, or resident unavailable. The surveyor noted 1:1's were not scheduled on the monthly activity calendar, and AD #363 confirmed and stated she does not put them on the calendar. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365718 If continuation sheet Page 7 of 11 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 02/06/2025 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 - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview and policy review, the facility failed to secure sharp objects were disposed of properly. This had the potential to affect six residents (#17, #32, #53, #119, #121 and #122) identified as being ambulatory and residing on the 600 unit. The facility census was 67. Findings include: On 02/04/25 at 11:25 A.M. an observation of a treatment cart on the 600 unit revealed an open compartment for sharp objects. The open compartment did not contain a second receptacle for securing sharp objects. The open compartment contained nine used syringes, three lancets (a sharp object used to pierce fingers to test blood sugars) and one used needle for an insulin injector pen. Licensed Practical Nurse (LPN) #361 verified the exposed syringes, lancets and needle at the time of the observation. A review of the policy titled; Safe and Homelike Environment dated 01/01/2022 revealed the facility will provide a safe, clean, comfortable and home like environment. This includes ensuring that the residents can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365718 If continuation sheet Page 8 of 11 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 02/06/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and policy review, the facility failed to provide a safe clean refrigerator for resident use. This affected one resident (#53) of 16 residents identified as having personal refrigerators. Residents Affected - Few Findings include: On 02/03/25 at 9:30 A.M. an observation of the room for Resident #53 revealed a mini refrigerator. A temperature log on the front of the refrigerator revealed a date of September 2024. The inside of the refrigerator was noted to be dirty with a pink dried substance on the inside. An interview with Registered Nurse (RN) #347 at the time of the observation verified the date of the temperature log as September 2024. RN #347 also verified the refrigerator was dirty with a dried pink substance inside. A review of the policy titled; Resident Refrigerators dated 01/01/2022 revealed the facility will ensure safe, sanitary use of any resident-owned refrigerators. The policy also stated housekeeping shall record temperatures daily on a temperature log attached to the refrigerator. The policy further stated housekeeping staff shall clean the refrigerator daily and discard any foods that are out of compliance. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365718 If continuation sheet Page 9 of 11 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 02/06/2025 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 0838 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Based on record reviews and interview the facility failed to ensure the Facility Assessment was completed accurately and thoroughly. This had the potential to affect all 67 residents. Findings Include: Review of the Facility Assessment revealed it was dated 01/2024 through 12/2024. The assessment did not have the names of the Administrator, Director of Nursing or Medical Director in the lines indicated nor was it marked as being reviewed. There was no indication of the type and number of staff needed to provide care and services. Interview on 02/05/25 at 12:30 P.M. with Administrator confirmed the Facility Assessment was not thorough and accurate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365718 If continuation sheet Page 10 of 11 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 02/06/2025 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, policy review, the facility failed to provide incontinence care utilizing proper personal protective equipment to ensure enhanced barrier precautions were followed. This affected one resident (#118) of 17 residents identified as being on enhanced barrier precautions. The facility census was 67. Residents Affected - Few Findings include: A review of medical records for Resident #118 revealed a date of admission of 01/14/25 with diagnoses including but not limited to chronic peptic ulcer, hypertension, chronic kidney disease stage four and diabetes mellitus type two. Review of Resident #118's active physician orders revealed orders included, [NAME] (JP) drain (a drain inserted in the abdomen to remove fluids) anchor securely and empty every shift, wound care to bilateral lower buttocks, cleanse with normal saline, pat dry, apply mixed collagen particles, zinc oxide two times daily, wound care to left heel, cleanse with normal saline then Dakins solution, pat dry, paint with iodine swab sticks, cover with ABD pad and wrap with Kerlix and enhanced barrier precautions. An admission Minimum Data Set assessment dated [DATE] revealed a BIMS of 15 (cognitively intact). A care plan dated 01/14/25 revealed Resident #118 required enhanced barrier precautions. Interventions included, Utilize Enhanced Barrier Precautions when providing high contact resident care activities (dressing, bathing, transferring, personal hygiene, changing linens, changing briefs/assisting with toileting and use gown and gloves when providing direct care. On 02/04/25 at 4:05 P.M. observation of incontinence care for Resident #118 revealed Certified Nurse Assistants (CNAs) #305 and #360 rendering care without gowns on. Registered Nurse (RN) #347 verified CNAs #305 and #360 did not have gowns on while incontinence care was rendered at the time of the observation. RN #347 also verified there was a sign for enhanced barrier precautions posted on the door of Resident #118 and there was personal protective equipment stocked in the three-drawer plastic cart outside of the room. RN #347 verified CNAs #305 and #360 should have had gowns on. A review of the policy titled; Enhanced Barrier Precautions dated 2024 revealed enhanced barrier precautions refers refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown, and gloves use during high-contact resident care activities. Subpoint four stated high contact resident care activities included providing personal hygiene and changing briefs or assisting with toileting. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365718 If continuation sheet Page 11 of 11