Inspection·September 5, 2023

F 0600 Level of Harm - Immediate jeopardy to resident health or safety On 08/15/23 at approximately 7:00 P.M., LPN #2 immediately assessed Resident #119, administered pain medication, and an x-ray was ordered by Certified Nurse Practitioner (CNP) #10. Upon results of right hip fracture, Resident #119 was transferred to the local hospital for evaluation and treatment. The resident's responsible party and physician were notified post incident by LPN #2 on 08/15/23 at approximately at 7:00 P.M. Residents Affected - Some • On 08/15/23 at approximately 7:00 P.M., Resident #40 was placed on one-to-one supervision post incident and was to remain with staff one-to-one supervision. The responsible party and physician were notified post incident on 08/15/23 by LPN #2 at approximately 7:00 P.M. • On 08/15/23 at 8:48 P.M., the DON notified the police department of the resident-to-resident abuse incident. • On 08/16/23 at 8:00 A.M., Staff Development Coordinator (SDC) #12 educated nursing staff on residents with orders for stop signs to ensure signs were in place at all times. • On 08/29/23 at 12:13 P.M., the DON educated all nursing staff to notify the DON or designee immediately if an assigned one-to-one staff member did not arrive for their shift. • On 08/29/23 at 12:54 P.M., Unit Managers (LPN #12, Registered Nurse (RN) #14 and LPN #15) audited resident orders to identify residents who wandered and needed assistance with ambulation. Resident orders, interventions, and care plans were reviewed and updated as needed. The facility implemented a plan to review audits at monthly Quality Assurance and Performance Improvement (QAPI) meetings. • On 08/29/23 at 2:00 P.M., Unit Managers (LPN #12, RN #14, and LPN #15) began auditing five residents daily, five times a week on various shifts for four weeks to ensure residents were receiving the appropriate assistance with ambulation, according to their plan of care. The audits would be reviewed at monthly QAPI meeting. • On 08/29/23 at 5:02 P.M., LPN #13, RN #14 and LPN #15 educated all in-house staff on the facility abuse policy and procedure and following resident plan of care interventions for ambulation. • On 08/29/23 at 5:27 P.M. an Ad-hoc QAPI meeting was held with the Administrator, DON, VPCO #11, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365720 If continuation sheet Page 2 of 9 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 365720 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Stow 2910 L'Ermitage Pl Stow, OH 44224 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 0600 Medical Director #16, RN #9, LPN #12, RN #14, Director of Maintenance (DOM) #17, LPN #18, Licensed Social Worker (LSW) #19, Social Services Assistant (SSA) #20 and Registered Dietitian (RD) #21. Level of Harm - Immediate jeopardy to resident health or safety • Residents Affected - Some On 08/29/23 at 7:00 P.M., residents known to have a history of aggression with other residents entering their room had a stop sign placed on their door to deter residents who wander from entering their room. • On 08/29/23 at 7:00 P.M., VPCO #11 educated the Administrator and DON on the facility abuse policy and procedure. • On 08/29/23 at 7:00 P.M., SDC #12, LPN #13, RN #14 and LPN #15 educated all staff on the facility abuse policy and following resident plan of care interventions for assistance with ambulation. The facility implemented a plan that no further staff would work until education was provided/completed. • On 08/29/23 at 7:00 P.M., Unit Managers (LPN #12, RN #14, and LPN #15) or designee began auditing five residents per day for four weeks with orders for stop signs in doorway to ensure placement. The audits would be reviewed at the monthly QAPI meeting. • On 08/30/23 at 8:00 A.M., the DON/designee began auditing/interviewing five staff members a week on various shifts for four weeks to ensure their knowledge of the process to location residents' ambulation plan of care. The audits will be reviewed at the monthly QAPI meeting. • On 08/30/23 at 11:15 A.M., Resident #40 was moved to another Pod where there weren't any residents who wander. Although the Immediate Jeopardy was removed on 08/30/23, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings include: Review of the closed medical record for Resident #119 revealed an admission date of 05/17/23 and a discharge date to the hospital on [DATE]. Resident #119 had diagnoses including Alzheimer's disease, conversion disorder with seizures or convulsions, and need for personal care. Resident #119 resided on C-Pod, a secured memory care unit. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365720 If continuation sheet Page 3 of 9 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 365720 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Stow 2910 L'Ermitage Pl Stow, OH 44224 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #119 had short and long-term memory problems, had severely impaired cognitive skills for daily decision making, had inattention and disorganized thinking, wandered that significantly intruded on the privacy and activities of others and received supervision of one-person physical assistance when walking in the corridor. Review of a wandering care plan dated 05/28/23 revealed Resident #119 was a wanderer related to disease process (Alzheimer's), was disoriented to place, and had impaired safety awareness. Resident #119 wandered aimlessly with eyes closed with an intervention to distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, and music. Review of the activities of daily living (ADL) care plan updated 06/01/23 revealed Resident #119 needed ADL assistance related to dementia, Alzheimer's disease and indicated ADL's might fluctuate day to day due to cognitive deficits with an intervention for the resident to transfer and ambulate with hand-held assistance of one staff. Review of the physical therapy Discharge summary dated [DATE] revealed Resident #119 was discharged from physical therapy services due to reaching maximum potential. Continued recommendations for Resident #119 included to transfer and ambulate with hand-held assistance (HHA). Resident #119's prognosis was good with consistent staff follow-through. Review of the August 2023 physician orders revealed an order (dated 08/03/23) for Resident #119 to transfer and ambulate with hand-held assist of one staff. Review of a facility SRI, tracking number 238142 dated 08/15/23 and created at 8:58 P.M. revealed the facility reported an incident of resident-to-resident physical abuse. The SRI revealed on 08/15/23 a nurse heard Resident #40 yelling, get out of my room then heard a loud noise. Upon entering the room, the nurse saw Resident #40 in her wheelchair and Resident #119 on the floor. Resident #119 was assessed to have a small bump on her head, was medicated with Tylenol for pain and was ordered a right hip x-ray. The final facility SRI investigation, reported to the State agency on 08/21/23 at 6:01 P.M. revealed the facility substantiated the physical abuse incident involving Resident #119. Review of a witness statement dated 08/15/23 and authored by State Tested Nursing Assistant (STNA) #3 included the following information: I stepped off the unit to use the restroom. When I came back, I was informed that the incident occurred. We were getting everyone ready for bed before this. I redirected Resident #119 away from Resident #40's room earlier. After everything happened, I was sitting with Resident #40. She said she didn't like anyone coming in her room. She told me that she didn't push her. She said she grabbed her hand and was trying to get her out of her room. I also heard her tell the nurse that she hated the resident that was in her room. Review of a witness statement dated 08/15/23 and authored by STNA #4 included the following information: during this incident, I was in another room with another resident when the nurse called for me and another aide. The nurse asked me to remove Resident #40 from her room. When Resident #40 was removed, she stated she didn't want anyone in her room. She wanted Resident #119 out of her room that she is not allowed. Review of a nursing note dated 08/15/23 at 8:20 P.M. revealed Resident #119's husband was notified of the resident's fall and interaction with another resident (Resident #40). The resident's husband was notified an x-ray was ordered of the right hip. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365720 If continuation sheet Page 4 of 9 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 365720 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Stow 2910 L'Ermitage Pl Stow, OH 44224 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Review of a radiology report, dated 08/15/23 revealed Resident #119 had an acute right femoral neck fracture with mild displacement. Review of a nursing note dated 08/15/23 at 10:06 P.M. revealed Resident #119's husband was notified of the x-ray results of an acute right femoral neck fracture with mild joint displacement. Resident #119 was to be sent to the local hospital. Residents Affected - Some Review of a facility incident report for a physical incident involving Resident #119 (on 08/15/23) dated 08/16/23 at 2:58 A.M. and authored by LPN #2 revealed this nurse was at medication cart outside of Resident #40's room when she heard resident (Resident #40) yell, hey, get out of my room! This nurse turned to enter Resident #40's room and saw Resident #40 push Resident #119 to the ground. Resident #119 fell to her right side. Resident #40 rolled towards Resident #119 with her wheelchair. This nurse was unable to tell if Resident #40 made contact with Resident #119 with the wheelchair. Predisposing factors included on the incident report noted (Resident #119) was confused, gait imbalanced, had impaired memory, was ambulating without assistance, and was a wanderer. The incident report also indicated Resident #40 was to be placed on one-to-one supervision for aggressive behaviors (following the incident) and indicated a physician ordered stop sign to Resident #40's door was not in place at the time of the incident. Review of a nurse's note (for the incident that occurred on 08/15/23) dated 08/16/23 at 3:21 A.M. and authored by LPN #2 revealed this nurse was at medication cart outside of Resident #40's room when this nurse heard another resident (Resident #40) yell, hey, get out of my room, this nurse turned to enter the room and saw resident (Resident #40) push Resident #119 to the ground. Resident #119 fell to her right side. Resident #40 rolled towards Resident #119 with her wheelchair. This nurse was unable to tell if Resident #40 made contact with Resident #119 with the wheelchair. The residents were separated immediately. Resident #119 was assessed for injury. Resident #119 was guarding the right side of her head; a quarter-sized red bump was observed to the upper right forehead. Resident #119 winced upon palpation of the of the right hip. Resident #119 tolerated minimum range of motion of the right extremity. Resident #119 was shaking and crying. Resident #119 was assisted to the wheelchair via two staff assist then to bed. CNP #10 was notified. A new order was received for a two-view x-ray to the right hip STAT and an order to administer Vistaril 25 mg. As needed Tylenol was administered per order. During the x-ray, this nurse observed Resident #119's right hip beginning to swell and redden. The x-ray results were positive for an acute right femoral neck fracture. A new order was received to send Resident #119 to the local hospital via 911. Resident #119 was transported to the local hospital. Review of the nurse's note dated 08/16/23 at 3:21 A.M. revealed a call was placed to the hospital for follow-up. Resident #119 was admitted was a diagnosis of bilateral pubic rami fracture. Review of the hospital palliative nurse practitioner progress note dated 08/17/23 revealed Resident #119, a [AGE] year-old female with a past medical history of dementia (non-verbal at baseline) presented from nursing facility after being pushed by another resident. She presented as a Level 2 trauma. Computed tomography with arterial portography (CTAP) showed mild T11 compression deformity and subacute superior and inferior pubic rami fractures. She was taken to the operating room on 08/16/23 for open reduction and internal fixation (ORIF) of right femoral neck. Post-operative complications included bradycardia, altered mental status and acute hypoxic respiratory failure with CO2 (carbon dioxide) retention. Rapid Response Team (RRT) was called, and patient was transferred to the intensive care unit (ICU) for possible non-invasive ventilation. Husband presented with paperwork for patient's wishes. Palliative care had been consulted to assisted with goals of care. Discussed option to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365720 If continuation sheet Page 5 of 9 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 365720 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Stow 2910 L'Ermitage Pl Stow, OH 44224 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some focus on Hospice with comfort as the main priority at this time. Given resident's current clinical status, resident could acutely decompensate to where she may pass quickly. Review of the hospital physician expiration summary dated 08/19/23 revealed Resident #119 was admitted (to the hospital) after fall with hip fracture. She underwent fixation of her hip the second day of her hospital stay. This was complicated by a delayed extubation in the post-anesthesia care unit (PACU), but patient returned to regular nursing floor (RNF). Then was transferred to surgical intensive care unit (SICU) for respiratory failure and hypotension, which improved with noninvasive care. Discussions with family at this time prompted change in code status to Do Not Resuscitate Comfort Care Arrest (DNR CCA) and they also talked to Hospice at this time. The resident transferred to a RNF but continued to decline. She returned to ICU for progressive respiratory failure and family opted to avoid escalating care. The resident passed away due to hypoxic respiratory failure at 9:57 A.M. Preliminary cause of death was respiratory failure after trauma. Interview on 08/28/23 at 3:03 P.M. with STNA #1 revealed Resident #119 passed away a week ago. STNA #1 stated Resident #40 wasn't normally aggressive; however, Resident #40 didn't like when people were in her room. STNA #1 was aware Resident #40 was to have one-to-one staff monitoring. Interview on 08/28/23 at 3:50 P.M. with LPN #2 revealed on 08/15/23 around 8:00 P.M., LPN #2 had completed Resident #40's skin assessment, taken her in the bathroom, got her ready for bed, administered her medications and then the resident was in bed. Resident #40 had then gotten out of bed, was in her wheelchair and was going in and out of her room retrieving towels and blankets. LPN #2 was outside of Resident #40's room at the medication cart doing medication pass when LPN #2 heard, hey, get her out of my room. LPN #2 stated there was stuff on top of the medication cart that LPN #2 had to put away since other residents were around, and LPN #2 stated, Hey [Resident #40], I'm on the way. There were two STNAs on the unit; one STNA was in the bathroom, and the other STNA was in another resident's room. LPN #2 saw Resident #40, was seated in a wheelchair, saw her reach up with her right hand and push Resident #119's left shoulder/arm while standing. Resident #119 fell to the ground, and LPN #2 heard a crack. LPN #2 attempted to get in-between the residents because Resident #40 was trying to wheel her wheelchair toward Resident #119. Resident #40 stated, Good, I'm glad she's hurt. LPN #2 assisted Resident #40 outside of the room, and one of the STNA staff then took Resident #40 to the common area to calm her down. LPN #2 stated Resident #119 was wearing her helmet and had hipsters on at the time of the incident. Resident #119 had a small red bump on her right temple below the helmet. LPN #2 touched Resident #119's hip and the resident winced. LPN #2 lifted the resident's right leg, and the leg didn't move well. Resident #119 was inconsolable, crying, shaking and in pain. The STNA staff transferred Resident #119 into a wheelchair which the LPN stated the resident tolerated well. LPN #2 administered Resident #119 Tylenol and Vistaril. During the x-ray, Resident #119's right hip was red and swollen. The x-ray results came back showing Resident #119 had a femoral neck fracture. Resident #119 was sent to the hospital. LPN #2 revealed she did not believe the Velcro stop sign was across Resident #40's doorway before Resident #119 wandered into Resident #40's room because Resident #40 was going in and out of her room. LPN #2 also revealed that Resident #119 was quiet, so Resident #119 likely wandered into Resident #40's room without LPN #2 seeing or hearing Resident #119 walking into the room. Observation on 08/28/23 at 4:25 P.M. revealed Resident #40 was sitting in the common area in a recliner with her feet propped up on a seat of a wheelchair. STNA #1 was sitting next to her. Interview, during the observation, with Resident #40 was attempted, however unsuccessful due to the resident's cognitive impairment. A follow-up interview with STNA #1 during the observation revealed Resident #40 did not have one-to-one monitoring from 6:00 A.M. to 10:00 A.M. that morning (08/28/23). STNA #1 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365720 If continuation sheet Page 6 of 9 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 365720 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Stow 2910 L'Ermitage Pl Stow, OH 44224 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some stated she was the only STNA assigned to the unit from 6:00 A.M. to 10:00 A.M. so she was in and out of other resident rooms completing resident care and the nurse was covering another unit, so the nurse was on and off the unit. STNA #6 arrived at 10:00 A.M. for the one-to-one monitoring of Resident #40. Interview on 08/28/23 at 4:28 P.M. with LPN #2 verified there wasn't a staff member assigned to Resident #40 for one-to-one monitoring this morning (08/28/23). LPN #2 also revealed she was assigned two units (A-Pod and C-Pod) until 10:30 A.M. so LPN #2 was on and off the C-Pod unit. Interview on 08/28/23 at 4:40 P.M. with STNA #4 revealed on 08/15/23 around 8:00 P.M. or 9:00 P.M., Resident #119 walked into Resident #40's room and Resident #40 pushed Resident #119. STNA #4 did not observe the incident because of being in another resident's room; however, the nurse called STNA #4 to assist with the incident. When STNA #4 entered the room, Resident #119 was on the floor, and the nurse was trying to obtain the resident's vital signs. Observation on 08/29/23 at 8:15 A.M. revealed Resident #40 was sitting in the recliner in the common area. STNA #1 and STNA #8 had their backs turned away from Resident #40, and LPN #8 was standing at the medication cart at the nursing station looking at the computer screen. Resident #28 walked over to Resident #40 and sat beside Resident #40 in another chair. Resident #40 did not have one-to-one monitoring by staff during the observation. Interview on 08/29/23 at 8:32 A.M. with RN #9 revealed Resident #119's physician's order to transfer and ambulate with hand-held assistance by one staff member was a result of a recommendation from physical therapy. Interviews on 08/28/23 at 4:13 P.M. and 08/29/23 at 9:50 A.M. were attempted with STNA #3 (who worked the C-Pod on the evening of 08/15/23); however, unsuccessful via telephone. Interview on 08/29/23 at 8:45 A.M. and 10:25 A.M. with the DON revealed she requested Resident #40 have the one-to-one monitoring order after the resident-to-resident incident (with Resident #119) from CNP #10. The DON verified Resident #40 had a history of being aggressive towards other residents who entered her room, verified Resident #119 was known to wander and verified the incident of resident-to-resident abuse resulting in the injury to Resident #119. There were seven additional residents, Resident #2, #28, #34, #39, #52, #54, #112 and #113 who the facility identified as residents who wandered and resided on C-Pod (the same pod as Resident #40), placing these residents also at risk of a resident to resident altercation with Resident #40, should they have wandered into the resident's room. Interview on 08/29/23 at 8:48 A.M with Director of Rehabilitation #22 revealed when ambulating with Resident #119, it was the expectation for a staff member to hold one of Resident #119's hands while the other hand of the staff member was on Resident #119's gait balance. Interview on 08/29/23 at 8:50 A.M. with LPN #7 revealed Resident #119 had a known history of wandering into other resident's rooms. A follow-up interview on 08/29/23 at 12:30 P.M. with the DON verified Resident #40 was not monitored one-to-one by a staff member on 08/28/23 from 6:00 A.M. to 10:00 A.M. nor was a staff member scheduled for one-to-one monitoring of Resident #40 on 08/28/23 from 6:00 A.M. to 10:00 A.M. The DON also verified Resident #119 was ordered to have hand-held assistance by one staff member while (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365720 If continuation sheet Page 7 of 9 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 365720 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Stow 2910 L'Ermitage Pl Stow, OH 44224 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 0600 ambulating which did not occur at the time of the resident-to-resident incident. Level of Harm - Immediate jeopardy to resident health or safety Interview on 08/29/23 at 12:45 P.M. with Resident #119's husband/Power of Attorney revealed he received a call from the facility that a resident had pushed Resident #119 down. The nurse notified him Resident #119 sustained a knot to her head and a broken hip. At that point, he rushed to the hospital to meet Resident #119. Residents Affected - Some Interview on 08/29/23 at 2:45 P.M. with CNP #10 revealed the nurse had called CNP #10 (on 08/15/23) stating a resident-to-resident altercation had occurred between Resident #40 and #119 when Resident #119 entered Resident #40's room, Resident #40 got mad and pushed Resident #119 causing Resident #119 to fall. Resident #119 was complaining of hip pain, so CNP #10 ordered an x-ray which was positive for an acute fracture. Resident #119 was sent to the hospital. CNP #10 also revealed Resident #119 was a known wanderer and had a history of taking items off the nurses' cart and taking other resident's food. Resident #40 was known to be very territorial over her room and would display verbally aggressive behaviors. CNP #10 verified she ordered the one-to-one staff monitoring of Resident #40 after the resident-to-resident altercation. Review of the nurse and STNA staff schedule from 08/28/23 revealed STNA #1 was scheduled to work on C-Pod from 6:00 A.M. to 2:00 P.M., LPN #2 was scheduled to work C-Pod from 6:00 A.M. to 2:00 P.M. There wasn't a nurse assigned to A-Pod from 6:00 A.M. to 2:00 P.M., and there wasn't a staff member assigned for one-to-one monitoring on C-Pod until 10:00 A.M. when STNA #6 was scheduled to arrive. Review of the medical record for Resident #40 revealed an admission date of 01/08/19 with diagnoses of paranoid schizophrenia, severe vascular dementia with behavioral and mood disturbance, delusional disorders, and anxiety. Resident #40 resided on C-Pod, a secured memory care unit. Review of a nurse's note dated 04/28/23 at 4:33 P.M. revealed the STNA notified this nurse Resident #52 was in Resident #40's room and Resident #40 punched Resident #52 in the stomach while staff was attempting to remove the resident from the area. Review of the interdisciplinary team (IDT) progress note dated 05/01/23 revealed the IDT team met to discuss the previous incident. Resident (Resident #52) was wandering and entered into resident (Resident #40's) room. Resident #40 hit Resident #52 in the stomach. A stop sign was placed on resident's door to deter coresidents from wandering. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #40 was severely cognitively impaired, had disorganized thinking and inattention that fluctuated, displayed physical behaviors towards others during one to three days of the seven-day assessment reference period, displayed verbal behaviors towards others during four to six days of the seven-day assessment reference period, and displayed other behavioral symptoms not directed towards others during four to six days of the seven-day assessment reference period. Review of the physician's orders for August 2023 revealed Resident #40 had an order (dated 05/01/23) to have a stop sign on the door to her room to deter coresidents from entering the room. Review of a nurse's note dated 08/15/23 at 8:35 P.M. revealed Resident #40's daughter was notified of an altercation with Resident #119. Review of the nurse's note dated 08/16/2 at 4:08 A.M. (for the incident that occurred on 08/15/23) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365720 If continuation sheet Page 8 of 9 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 365720 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Stow 2910 L'Ermitage Pl Stow, OH 44224 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some and authored by LPN #2 revealed this nurse was at medication cart outside of Resident #40's room when this nurse heard Resident #40 yell, hey, get out of my room. This nurse turned to enter room and saw resident push Resident #119 to the ground. Resident #119 fell to ground in front of Resident #40. Resident #40 rolled towards Resident #119 with the wheelchair. This nurse was unable to tell if Resident #40 made contact with Resident #119. The residents were separated immediately. Resident #40 was yelling, Good! I'm glad she's hurt. I hate her. Resident #40 was removed from the room until Resident #119 could be safely transferred and removed from the room. A new order for one dose of Vistaril 25 milligrams (mg), an antihistamine used to treat anxiety was noted. Resident #40 was to be placed on one-to-one supervision for aggressive behaviors and staff education regarding stop sign to door. Review of Resident #40's physical aggression care plan updated 08/16/23 revealed Resident #40 was physically aggressive or agitated related to anger and dementia. Resident #40 would strike staff when agitated. Resident #40 stuck coresident after wandering into her room on 04/29/23. Resident #40 pushed coresident, causing her to fall on 08/15/23. Interventions of a stop sign to the resident's door to deter coresidents wandering into her room, monitor and signs or symptoms of resident posing danger to self and/or others, and one-to-one supervision. Review of the facility's Abuse, Neglect and Exploitation policy, revised 10/24/22, revealed the facility would implement policies and procedures to prevent and prohibit all types of abuse, neglect, and misappropriation of resident property and exploitation that achieves identifying, correcting, and intervening in situations in which abuse, neglect, exploitation and/or misappropriation of resident property was more likely to occur with the deployment of trained and qualified, registered, licensed and certified staff on each shift in sufficient numbers to meet the needs of residents, and assure the staff assigned had the knowledge of the individual residents' care needs and behavioral symptoms and the identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect. The facility would make efforts to ensure all residents were protected from physical and psychosocial harm, as well as additional abuse, during and after investigation and increased supervision of the alleged victim and residents. This deficiency represents non-compliance investigated under Complaint Number OH00145778. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365720 If continuation sheet Page 9 of 9