Health inspection·January 9, 2020

F 0569 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Review of a facility policy titled, Resident Trust Fund Policies and Procedures, last revised 02/01/18, revealed the Resident Trust Fund (RTF) designee would review month-end resident balances each month to identify resident trust balances at or exceeding the state asset limit. For Ohio the limit was $2,000 and the resident would need to be notified when their account reached $1,800. The Medicaid Asset Limit Notification/$200 letter would be generated by the Business Office/AR Manager and mailed to the resident and/or responsible party monthly for any resident that has reached the threshold. Event ID: Facility ID: 365763 If continuation sheet Page 2 of 7 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 365763 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Mifflin 1600 Crider Rd Mansfield, OH 44903 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff interview, the facility failed to ensure a resident's bathroom had adequate lighting and was maintained in good repair. This affected one (#74) of one resident reviewed for environment. The facility census was 80. Findings include Medical record review revealed Resident #74 had an admission date of 11/04/16. Diagnoses included chronic respiratory failure with hypoxia, anorexia, end stage renal disease, dementia, anxiety, and difficulty walking. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition. The resident was noted with highly impaired vision. Review of the care plan revised 05/21/19 revealed the resident had altered vision status and legal blindness. Review of the interventions revealed staff should identify environmental conditions affecting visual function including poor lighting. Interview on 01/06/20 at 12:23 P.M. with Resident #74 revealed the lights in her bathroom had been out for a long time. The resident stated she told staff about the lights needed fixed. Observation on 01/06/20 at 12:25 P.M. revealed two of three lights in the resident's bathroom were not working. Further observation revealed the caulk and drywall near the shower needed repair. Additionally, the finish on the bathroom vanity was worn off. Observation on 01/08/20 at 1:04 P.M. and subsequent interview with Registered Nurse (RN) #302 verified two of the three lights in the resident's bathroom were not working. RN #302 verified most of the finish had worn off the bathroom vanity and verified the caulk and drywall near the shower were in disrepair. Interview on 01/09/20 at 10:01 A.M. with the Director of Maintenance (DOM) #122 verified he was not informed the lights needed fixed in the resident's bathroom until 01/08/20. DOM #122 verified the caulk, drywall and bathroom vanity needed repaired. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365763 If continuation sheet Page 3 of 7 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 365763 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Mifflin 1600 Crider Rd Mansfield, OH 44903 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, staff interview, and review of facility policy, the facility failed to complete a concern form and provide evidence of follow up regarding missing items. This affected one Resident (#34) of one resident reviewed for personal property. The facility census was 80. Findings include: Review of Resident #34's medical record revealed he admitted to the facility 09/10/13 with diagnoses including chronic respiratory failure. Review of Resident #34's Minimum Data Set (MDS) assessment dated [DATE] revealed he was cognitively intact. Interview on 01/07/20 at 8:45 A.M. with Resident #34 revealed he was missing a pair of black gym shorts and a white tee shirt and reported it to everyone on 01/03/20. Interview on 01/07/20 at 11:44 A.M. with Housekeeping Manager (HM) #110 confirmed on 01/03/20, she had been notified by Resident #34 he was missing a white shirt and black shorts. She revealed on 01/04/20 one of her housekeepers brought Resident #34 all of his clean clothes. HM #110 revealed Resident #34 had a fit and began cussing at the housekeeper. He told the housekeeper the clothing that had been brought in was not the missing items. She confirmed there had not been a resolution on 01/04/20 regarding the missing clothing. She revealed the housekeeping staff and Resident #34 disagreed on whether the missing clothing was returned. HM #110 revealed she talked to Resident #34 01/06/20 and told him housekeeping staff did return the missing items and he continued to argue with her and denied the missing items had been returned. HM #110 revealed the resident had tons of clothes and he was not missing anything. HM #110 revealed when items were reported missing to her, she would check their closets and adjoining room's closets and if they were not found she would fill out a quality assurance form. She confirmed a concern form was never completed for Resident #34 because he is mean and being rotten. She further confirmed there was no evidence of follow-up of Resident #34's missing items. Interview on 01/07/20 at 2:03 P.M., with Resident #34 confirmed housekeeping staff had spoken to him the morning of 01/04/20 and had brought in clean clothes, however his gym shorts and shirt were not in the clothing brought to him. He revealed HM #110 told him those were the missing clothing items and they never came to a resolution. Review of a facility policy titled, Lost and Found, last revised 01/16/11, revealed the facility would assist all personnel and residents in safe-guarding their personal property. Resident or family complaints of missing items must be reported to the Director of Nursing Services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365763 If continuation sheet Page 4 of 7 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 365763 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Mifflin 1600 Crider Rd Mansfield, OH 44903 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview, and policy review, the facility failed to implement physician ordered preventative pressure ulcer interventions. This affected one (#48) of three residents reviewed for pressure ulcers. The facility census was 80. Residents Affected - Few Findings include Medical record review revealed Resident #48 had an admission date of 02/21/17 with diagnoses including myelodysplastic syndrome, diabetes mellitus type two, anemia in chronic kidney disease, and protein-calorie malnutrition. Review of a physician order dated 08/27/19 revealed to keep the resident's heels off the bed as the resident allowed. Review of a pressure ulcer risk assessment dated [DATE] revealed Resident #48 was at high risk for developing pressure ulcers. Observation on 01/06/20 at 1:41 P.M. revealed Resident #48 was in bed and her heels were not elevated off the bed. Observation on 01/07/20 at 2:50 P.M. revealed Resident #48's heels were not elevated off the bed. Interview on 01/07/20 at 2:55 P.M. with State Tested Nursing Assistant (STNA) #102 verified Resident #48's heels were not elevated off the bed. STNA #102 searched the resident's room and was unable to locate a pillow to elevate the resident's heels. Review of the policy Pressure Ulcers/Pressure Injury Prevention and Treatment-Clinical Protocol, last revised 11/28/19 revealed at risk residents need to have interventions implemented promptly to attempt to prevent pressure ulcers/pressure injuries. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365763 If continuation sheet Page 5 of 7 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 365763 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Mifflin 1600 Crider Rd Mansfield, OH 44903 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 medical record review, observation, and staff interview, the facility failed to ensure appropriate monitoring was completed for a resident with a indwelling foley catheter. This affected one Resident (#63) of one reviewed for catheter care. The facility census was 80. Findings include: Review of the medical record revealed Resident #63 was initially admitted to the facility in 2013 with the most recent readmission on [DATE]. Diagnoses included multiple sclerosis, Methicillin Staphylococcus Aureus (MRSA/infection), and obstructive uropathy (obstructive urine flow). Review of the comprehensive assessment, dated 12/11/19, revealed Resident #63 had moderate cognitive impairment and had an indwelling urinary catheter. Review of Resident #63's care plan related to the indwelling catheter revealed the resident was at risk for infection of the urinary tract related to Foley catheter and history of urinary tract infections. Review of Resident #63's Treatment Administration Record (TAR) revealed there was no evidence of monitoring the indwelling catheter bag for color, cloudiness, odor, or any urine output recorded on 12/01/19, 12/04/19, 12/08/19, 12/12/19, 12/15/19, 12/16/19, 12/19/19, 12/22/19, and 12/25/19. Observation on 01/08/20 at 5:21 P.M., of Resident #63's catheter care with State Tested Nursing Assistants (STNAs) #102 and #103 revealed there was no leg device to secure the catheter for safety. Interview on 01/08/20 at 5:33 P.M., with the Director of Nursing (DON) confirmed Resident #63 did not have a leg device to secure the catheter bag and confirmed there was no documentation of the monitoring of the resident's urine on the dates mentioned above. Review of facility policy titled, Catheter Care, Urinary, dated 01/2013, revealed to monitor the resident to be sure he or she is not lying on the catheter and keep the catheter and tubing free from kinks. Record the resident's output, per policy and procedure. Empty the collection bag at least every eight hours. Utilize a leg strap or other catheter securing device to reduce friction and movement at the insertion site when appropriate. This deficiency substantiates Complaint Number OH00109391. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365763 If continuation sheet Page 6 of 7 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 365763 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Mifflin 1600 Crider Rd Mansfield, OH 44903 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. Based on medical record review, resident interview, staff interview, and facility policy review, the facility failed to ensure medications were timely acquired for a newly admitted resident. This affected one (#235) of three new admissions reviewed. The facility census was 80. Findings include: Medical record review revealed Resident #235 had an admission date of 01/04/20, with diagnoses including anorexia nervosa (eating disorder), severe protein-calorie malnutrition, post traumatic stress disorder, depressive disorder, and anxiety. Review of the admission physician orders dated 01/04/20 revealed Resident #235 was ordered Fluoxetine 40 milligrams (mg) by mouth, daily in the morning for depression, and Potassium Phosphate Monobasic 250 mg by mouth, three times per day for anorexia nervosa. Review of the Medication Administration Record (MAR) dated 01/04/20 through 01/08/20 revealed the Fluoxetine was not available to administer to the resident until 01/07/20, and the Potassium Phosphate Monobasic 250 mg was not available for administration until 01/08/20. Interview on 01/06/20 at 11:46 A.M. with Resident #235 revealed she had been in the facility for three days and had not received Fluoxetine or the Potassium-Phosphorous. Interview on 01/09/20 at 9:57 A.M., with the Director of Nursing (DON) verified the resident had not received the Fluoxetine until 01/07/20 and had not received the Potassium-Phosphorous until 01/08/20. The DON revealed if medications were not received from the facility pharmacy then the nurse should notify the pharmacy. The DON revealed if the medication was not available then the facility would obtain the medication from a local pharmacy. Review of the policy Ordering and Receiving from Pharmacy Provider dated 09/2010 revealed if the first dose of medication is scheduled to be given before the next regularly scheduled pharmacy delivery, please telephone or transmit the medication orders to the pharmacy immediately upon receipt. Inform the pharmacy of the need for prompt delivery. Timely delivery of new orders is required so medication administration is not delayed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365763 If continuation sheet Page 7 of 7