Health inspection·December 18, 2023

F 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few On [DATE] at 7:42 A.M., the facility Administrator, and Regional Director Clinical Services (RDCS) #179 were made aware of CPR not being initiated for Resident #69 by LPN #170 via phone. • On [DATE] at 8:10 A.M., LPN #170 came into the facility to initiate education for all licensed nurses on the facility's policy and procedure for initiating CPR and location of code status for each resident (on Resident EMR dashboard and Resident hard chart). State Tested Nursing Assistants (STNAs) and Medication Technician (Med Tech) was educated on monitoring and reporting changes in condition. • On [DATE] at 8:30 A.M., LPN #170 checked the crash cart at the nurses' station to ensure all supplies were available for CPR and automatic external defibrillator (AED) machine was intact. • On [DATE] at 8:45 A.M., LPN #170 notified Nurse Practitioner (NP) #176 and Medical Director #177 on the passing of Resident #69 and that CPR was not initiated. • On [DATE] at 11:06 A.M., the Administrator reviewed CPR cards for all licensed nurses that are employed in the facility. Findings revealed that all nurses had CPR cards on file except LPN #109, LPN #123, and LPN #169. LPN #109, LPN #123, and LPN #169 provided CPR cards on [DATE] by 11:59 P.M. • On [DATE] at 12:00 P.M., LPN #170 called Social Services Director (SSD) #180 and Staff Development Coordinator (SDC) #112 to come to the facility and assist in the investigation and action plan for CPR not being initiated to Resident #69. • On [DATE] at 2:00 P.M., SDC #112 came to the facility and educated staff via in person and on the phone. All staff were educated on advance directives, CPR, notification of change in condition, and documentation in the medical record by 4:00 P.M on [DATE]. • On [DATE] at 2:00 P.M., SSD #180 came to the facility and audited care plans, resident preferences, and orders to ensure they matched in the electronic medical record and hard chart. The audit was completed on [DATE] at 4:00 P.M. • On [DATE] at 2:10 P.M., LPN #170 audited physician orders and code status paperwork to ensure they matched in both the electronic and hard charts. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365763 If continuation sheet Page 2 of 5 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 12/18/2023 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 0678 • Level of Harm - Immediate jeopardy to resident health or safety On [DATE] at 9:00 A.M., LPN #170 completed a 14 day look back ([DATE] to [DATE]) on current residents for proper notification to resident representatives, physicians and/or nurse practitioner. Look back audit was completed with no discrepancies by 4:30 P.M. on [DATE]. Residents Affected - Few • On [DATE] at 12:30 P.M., RDCS #179 conducted a code drill, and no concerns were identified at the time of the drill. • On [DATE] at 2:00 P.M. (change of shift), RDCS #179 conducted a code drill, and no concerns were identified at the time of the drill. • On [DATE] at 2:00 P.M., the Administrator disciplined RN #101 and LPN #123 for CPR not being done for Resident #69, who had a full code status on record. • On [DATE] at approximately 3:00 P.M., a Quality Assurance Performance Improvement (QAPI) meeting was conducted with the Administrator, RDCS #179, LPN #170, SSD #180, and Medical Director #177 attended via telephone. A performance improvement plan was made to conduct on-going audits for code status compliance, and CPR policy and procedure with return demonstration two times weekly for one month. Code drills will be conducted two times weekly on various shifts for four weeks and then monthly thereafter. • On [DATE] at 10:30 P.M., SDC #112 conducted a code drill, and no concerns were identified at the time of the drill. Findings include: Review of the closed medical record for Resident #69 revealed an admission date of [DATE] with a readmission date of [DATE] and a discharge date of [DATE] with diagnoses including but not limited to diabetes mellitus, chronic obstructive pulmonary disease, and Alzheimer's disease. The record indicated Resident #69 passed away on [DATE] at 5:40 A.M. The resident was in her room unresponsive and absent of vital signs. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment for Resident #69, dated [DATE], revealed the resident had severely impaired cognition. The assessment indicated the resident did not have a condition or chronic disease that would result in a life expectancy of less than six months. Review of the physician orders for [DATE] revealed that Resident #69 had orders for a Full Resuscitate. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365763 If continuation sheet Page 3 of 5 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 12/18/2023 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 0678 Level of Harm - Immediate jeopardy to resident health or safety Review of the plan of care for Resident #69 revealed the resident had advanced directives that indicated a Full Code. Interventions included involving the physician in advanced directives conversations and reviewing advanced directives with the resident/family. Review of a nurse's note dated [DATE] at 7:17 A.M. revealed that the funeral home was to pick up body. NP #176 was notified of the passing of Resident #69. Residents Affected - Few Review of a nurse's note dated [DATE] at 3:03 P.M. revealed that at 4:00 A.M., STNA #130 came to get LPN #123 to ask for assistance with incontinence care for Resident #69. LPN #123 stated she would assist after her medication pass was completed. At 5:30 A.M., STNA #130 and LPN #123 went to Resident 69's room. LPN #123 touched Resident #69 and told STNA #130 that the resident was gone. LPN #123 immediately went to go get RN #101, who went to the room when LPN #123 went to the office to start calls. The family was updated, and the family didn't want to come into the facility. Funeral home notified. Unable to get a hold of manager on duty, LPN #170. Report given to oncoming shift. Review of a nurse's note dated [DATE] at 8:21 A.M. revealed at approximately 5:40 A.M. (on [DATE]), LPN #123 came to find RN #101. LPN #123 was calling out I need you now. When RN #101 entered Resident #69's room, LPN #109 was standing over the resident. The resident appeared unresponsive with no respirations and was very pale. RN #101 checked for radial and jugular pulses bilaterally but did not find any pulse. Pupils were fixed and unresponsive to light. RN #101 listened for heart sounds but did not hear anything. All extremities were cool, as was the chest area that was auscultated. Lower extremities also had mottling up to the thigh area. Review of a nurse's note dated [DATE] at 1:47 P.M. revealed rigor mortis was observed involving all extremities by RN #101 and STNA #130. Interview on [DATE] at 5:12 A.M. with LPN #109 revealed that she was working a different hall and was asked to do an assessment on Resident #69 by LPN #123 and RN #101. Resident #69's extremities were cold, but her trunk area was warm. LPN #109 thought that LPN #123 and/or RN #101 would have checked the code status. Interview on [DATE] at 9:01 A.M. with LPN #170 revealed that she missed three phone calls early in the morning on [DATE] but returned the call to the facility at 6:30 A.M. at which time LPN #170 spoke to Medication Technician (Med Tech) #124, who stated that Resident #69 passed away. Med Tech #124 stated that she didn't believe the nurses did CPR. LPN #170 called LPN #123 and was made aware that CPR was not initiated for Resident #69. LPN #123 stated that Resident #69 was a full code, but LPN #123 did not initiate CPR because she was dead and that would have been stupid. LPN #170 educated LPN #123 on CPR for full codes. Interview on [DATE] at 9:33 A.M. with SSD #180 revealed she came to the facility (on [DATE]) and audited care plans, resident preferences, and orders to ensure they matched in the electronic medical record and hard chart. The audit was completed when she left around 4:00 P.M. Interview on [DATE] at 9:38 A.M. with LPN #123 revealed that she called for RN #101 and then left the room to find the chart but couldn't find it and made phone calls. LPN #123 stated that she thought everyone on the memory care unit was a Do Not Resuscitate (DNR) order. Interview on [DATE] at 9:45 A.M. with SDC #112 revealed she came to the facility and educated staff in person and on the phone. All staff were educated on advanced directives, CPR, notification of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365763 If continuation sheet Page 4 of 5 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 12/18/2023 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 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few change in condition, and documentation in the medical record. SDC #112 stated that she was in the building for a couple of hours. Review of the facility policy titled, Residents' Rights Treatment and Advance Directives, dated [DATE] with a revision date of [DATE], revealed if a resident experiences a cardiac arrest or respiratory arrest and the resident does not show obvious clinical signs of irreversible death, facility staff must provide basic life support, including CPR, prior to the arrival of emergency medical services, in accordance with the resident's advanced directives and any related physician order, such as code status, or in the absence of advanced directives or a DNR order. This deficiency represents non-compliance investigated under Complaint Number OH00149064. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365763 If continuation sheet Page 5 of 5