Health inspection·July 6, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record review, and review of the facility policy, the facility failed to ensure fall interventions were in place for a resident with a history of falling. This affected one (Resident #17) of four residents reviewed for falls. The facility census was 36. Findings include: Review of the medical record for Resident #17 revealed an admission date of 09/10/21 with diagnoses including chronic pain, insomnia, and a history of falling. Review of a progress note dated 06/02/23 revealed Resident #17 fell at approximately 3:00 A.M. while standing and attempting to remove her nightgown while a state tested nurse aide (STNA) was changing the chair pad. Resident #17 stumbled backwards due to her slip-on slippers. Review of an additional progress note dated 06/02/23 revealed a plan to remove the slip-on slippers and replace them with the new enclosed slippers. Review of the current care plan for Resident #17 revealed she was at risk for falls. Interventions included ensuring Resident #17 was wearing appropriate footwear, including fully enclosed slip resistant shoes, skid resistant slippers, or gripper socks when ambulating or mobilizing in her wheelchair. Review of the facility's Fall Scene Huddle Worksheet revealed Resident #17 fell on [DATE] due to wearing slip-on slippers and the intervention was to use gripper socks instead of slippers. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 had intact cognition and required extensive assistance of one person for bed mobility, transfers, toileting and hygiene. Resident #17 had one fall without injury since the previous assessment completed 05/30/23. Observation on 07/05/23 at 9:17 A.M. revealed Resident #17 sitting in her recliner in her room wearing slip-on slippers. Observation on 07/05/23 at 12:18 P.M. revealed Resident #17 sitting in her wheelchair in the dining room wearing slip-on slippers. Interview at that time with Licensed Practical Nurse (LPN) #400 confirmed Resident #17 was wearing slip-on slippers. LPN #400 confirmed Resident #17 was supposed to be wearing fully enclosed slippers. Interview on 07/06/23 at 11:49 A.M. with the Director of Nursing (DON) confirmed Resident #17 should be wearing gripper socks, not backless slippers. The DON stated she spoke with Resident #17 who was agreeable to wearing gripper socks. Observation and interview on 07/06/23 at 11:53 A.M. with Registered Nurse (RN) #433 revealed Resident #17 sitting in her wheelchair in the dining room. RN #433 confirmed Resident #17 was wearing slip-on slippers. Interview on 07/06/23 at 2:53 P.M. with STNA #499 revealed she was assigned to provide care for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365887 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 365887 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Serenity Spring Senior Living at Arlington 100 Powell Drive Arlington, OH 45814 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Resident #17 during the morning shift on 07/06/23 and was aware Resident #17 should be wearing gripper socks because the slip on slippers were causing her to fall. STNA #499 stated she did not notice Resident #17's footwear throughout the day. Review of the facility's fall policy, last reviewed on March 2023, revealed fall interventions should be implemented and updated in the care plan, as needed. Event ID: Facility ID: 365887 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 365887 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Serenity Spring Senior Living at Arlington 100 Powell Drive Arlington, OH 45814 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, staff interview, and review of the facility policy, the facility failed to ensure a resident who was on a fluid restriction had fluid allowances designated to ensure staff knew how much to give the resident at meals, snacks, and medication pass. This affected one (Resident #17) of one resident reviewed on a fluid restriction. The facility census was 36. Residents Affected - Few Findings include: Review of the medical record for Resident #17 revealed an admission date of 09/10/21. Diagnoses included heart failure and chronic kidney disease. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 had intact cognition and was not on a therapeutic diet. Review of a physician order dated 05/16/23 revealed Resident #17 was on a 48-ounce fluid restriction (1,419 millimeters) daily. There was no fluid allocation listed in the physician order on how much fluids Resident #17 can receive at meals, snacks and medication pass for each day. Review of the current care plan revealed Resident #17 had a potential nutritional problem related to debility and had a history of noncompliance with her fluid restriction. Interventions included a 48-ounce daily fluid restriction. The care plan did not include the specific amount of fluids Resident #17 should receive at meals, snacks and medication pass for the day. Review of the meal ticket for Resident #17 revealed she had a 1,500 milliliter daily fluid restriction. There was no specific amount listed on the meal ticket for how much fluids Resident #17 should receive at each meal. Observation and interview on 07/05/23 at 11:50 A.M. with Licensed Practical Nurse (LPN) #400 revealed Resident #17 had a glass of water, a mug of coffee, and a eight-ounce glass of juice sitting in front of her in the dining room. LPN #400 confirmed Resident #17 had a glass of water, a mug of coffee, and a glass of juice for her lunch meal sitting in front of her. Interview on 07/05/23 at 2:30 P.M. with Dietary Aide #521 confirmed Resident #17 was on a fluid restriction and staff were not supposed to give Resident #17 water unless she requested it. Dietary Aide #521 confirmed she provided fluids to Resident #17 at mealtimes and was unable to define the amount of fluid Resident #17 should receive with meals. Interview on 07/06/23 at 3:30 P.M. with the Director of Nursing (DON) confirmed the fluid allocation for Resident #17's fluid restriction was not defined in the care plan or the physician orders. Review of the facility policy titled Resident at Risk For Dehydration, Fluid Maintenance, reviewed 05/08/23, revealed fluid allocations for residents on a fluid restriction would be identified and distributed among meals, snacks, and medication passes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365887 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 365887 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Serenity Spring Senior Living at Arlington 100 Powell Drive Arlington, OH 45814 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 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. Based on record review, observation, and staff interview, the facility failed to provide adequate portions of protein to residents on texture modified diets. This affected seven residents (#6, #12, #19, #23, #27, #29, and #91) identified by the facility to be on texture modified diets. The facility census was 36. Findings include: Observation during meal service on 07/05/23 beginning at 11:52 A.M. revealed [NAME] #520 served pureed ham using a two-ounce scoop and minced and moist (chopped small) ham using a 1.625 ounce scoop. Interview on 07/05/23 at 12:25 P.M. with [NAME] #520 revealed she did not have a spreadsheet with serving sizes. [NAME] #520 further verified the appropriate serving sizes were listed on each resident's meal tickets. [NAME] #520 confirmed the portion size listed on the meal tickets for pureed ham was five ounces and confirmed she only provided a two ounce portion. [NAME] #520 confirmed the portion listed on the meal ticket for minced and moist ham was four ounces and confirmed she only provided a 1.625 ounce portion. [NAME] #520 confirmed the residents who received texture modified meat did not receive the correct portion. Review of the facility's list of diets revealed Residents #6, #12, #19, #23, #27, #29, and #91 were on texture modified diets. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365887 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 365887 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Serenity Spring Senior Living at Arlington 100 Powell Drive Arlington, OH 45814 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 Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, staff interviews, and review of the facility policy, the facility failed to ensure proper hand hygiene was used during food preparation and dishwashing. This affected one resident (#11) and had the potential to affect all 36 residents residing in the facility. The facility census was 36. Findings include: 1. Observation of meal service on 07/05/23 beginning at 11:52 A.M. revealed [NAME] #520 wearing plastic gloves and touching serving utensils, drawers, and the lid of the plate-warming machine. [NAME] #520 did not change her gloves and continued to plate Resident #11's meal. [NAME] #520 picked up a knife with her right hand, and held the ham in place with her left gloved hand and cut the ham into bite-sized pieces. [NAME] #520 then placed the plate on the meal cart and the meal cart left the kitchen to be passed out to residents. [NAME] #520 did not change her gloves during the observation. Interview on 07/05/23 at 12:00 P.M. with [NAME] #520 confirmed she touched Resident #11's ham with her left gloved hand which had touched several non-food items in the kitchen. [NAME] #520 confirmed she was aware she should not have touched ready-to-eat food without washing her hands and putting on clean gloves. 2. Observation on 07/05/23 at approximately 12:45 P.M. revealed Dietary Aide #521 rinsing dirty dishes and stacking them into the dish rack, then opening the dish machine and removing clean dishes, without washing her hands in between touching the dirty dishes and clean dishes. Further observation revealed Dietary Aide #521 pushed the dirty dishes into the machine, then began unloading clean dishes and putting them away. Interview with Dietary Aide #521 confirmed she touched the clean dishes after handling dirty dishes without washing her hands. Dietary Aide #521 stated she was unaware of the need to wash her hands between touching dirty and clean dishes. Dietary Aide #521 did not re-wash the clean dishes she had already unloaded. Review of the facility's policy titled Hand Washing and Glove Use, reviewed 06/14/23, revealed employees must wash hands before handling food, when switching tasks, and after performing any activity that could contaminate hands. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365887 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 365887 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Serenity Spring Senior Living at Arlington 100 Powell Drive Arlington, OH 45814 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility's infection control logs, and staff interview, the facility failed to ensure residents were receiving the correct antibiotics. This affected one (Resident #17) of five residents reviewed for antibiotic medications. The facility census was 36. Residents Affected - Few Findings include: Record review for Resident #17 revealed the resident was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, chronic kidney disease, and altered mental status. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 had impaired cognition. Review of Resident #17's care plans dated 09/2022 revealed a focus area for increased risk of urinary tract infections (UTI). Interventions included to monitor and report any signs and symptoms of a UTI. Review of Resident #17's laboratory results dated [DATE] revealed the resident's urine culture was positive for E-Coli. On 05/17/23, the resident's culture results revealed the presence of Enterbacter Cloacae bacteria. Review of Resident #17's physician orders revealed on 05/10/23, the primary physician ordered Cephalexin (oral antibiotic) 500 milligrams (mg) daily for seven days for a UTI. On 05/26/23, the nephrologist physician ordered Ciprofloxacin (an oral antibiotic) 250 mg for five days due to a UTI. On 06/21/23, the primary physician ordered Bactrim (an oral antibiotic) 800 mg daily for 10 days for UTI. Review of the Medication Administration Records (MAR) dated 05/2023 and 06/2023 revealed Resident #17 received the prescribed antibiotics per order. Review of Resident #17's medical records revealed there were no follow up laboratory results or urine cultures after 05/16/23. Review of the facility's infection control log with the Director of Nursing (DON) identified Resident #17 was on the log in 05/2023 for a UTI and in 06/2023 for a UTI. Interview on 07/06/23 at 2:00 P.M. with the DON reviewed the laboratory results, the resident's physician orders for antibiotics, and MARs. The DON verified for the positive culture on 05/01/23, the primary physician ordered two oral antibiotics and the neurologist physician ordered one oral antibiotic for the positive culture on 05/16/23. The DON verified the three antibiotics were ordered within a 30-day period without a follow up culture test being completed after the 05/16/23 test. The DON verified this practice did not follow the antibiotic stewardship guidelines and policy the facility follows. Review of the facility policy titled Antibiotic Stewardship, dated 10/2021, revealed the purpose of the program is to reduce the use of antibiotics. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365887 If continuation sheet Page 7 of 7