Health inspection·April 18, 2024

F 0656 directive. Level of Harm - Minimal harm or potential for actual harm Interview on 04/16/24 at 1:03 P.M. with the Director of Nursing (DON) verified Resident #24 did not have advanced directives included in the comprehensive care plan. Residents Affected - Some 5. Review of medical record for Resident #28 revealed an admission date of 05/25/23 with diagnoses including chronic respiratory failure with hypoxia, dementia, malignant neoplasm of bronchus or lung, major depressive disorder, and cognitive communication deficit. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 had severe cognitive impairment. Review of the physician orders revealed Resident #28 was a do not resuscitate comfort care (DNRCC), Review of the care plan dated 01/15/24 for Resident #28 revealed no care plan for advance directives. Interview on 04/16/24 at 1:03 P.M. with the Director of Nursing (DON) verified Resident #28 did not have advanced directives included in the comprehensive care plan. 6. Review of the medical record for Resident #30 revealed an admission date of 01/12/24 with diagnoses including displaced intertrochanteric fracture of right femur, chronic pain syndrome, chronic kidney disease stage three, and pain in right hip. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #30 was cognitively intact. Review of the physician orders revealed Resident #30 was a do not resuscitate comfort care arrest (DNRCCA). Review of the care plan dated 02/15/24 for Resident #30 revealed no care plan for advance directives. Interview on 04/16/24 at 1:03 P.M. with the Director of Nursing (DON) verified Resident #30 did not have advanced directives included in the comprehensive care plan. Review of the facility's policy titled Comprehensive Person-Centered Care Plan, revised March 2022, revealed the comprehensive person-centered care plan describes services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being including services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment. Based on review of the medical record, staff interview, and facility policy review, the facility failed to complete for advanced directives for six (#2, #15, #22, #24, #28, and #30) of six residents reviewed for advanced directives and one (#22) resident reviewed hospice. The facility census was 33. Findings include: 1. Review of the medical record for Resident #22 revealed the resident was admitted on [DATE]. Diagnoses included Alzheimer's disease, dementia, cerebral atherosclerosis, occlusion and stenosis of unspecified carotid artery disease, personal history of malignant neoplasm of bladder, benign prostatic hyperplasia (BPH) without lower urinary tract symptoms, and encounter for palliative care. (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 04/18/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 was severely cognitively impaired. Review of the facility's provided care plans for Resident #22 revealed the facility failed to develop and implement a comprehensive person-centered care plan for advanced directives and hospice services. Residents Affected - Some Interview on 04/16/24 at 1:03 P.M. with the Director of Nursing (DON) verified Resident #22 did not have advanced directives included in the comprehensive care plan. In addition, Resident #22 did not have a comprehensive care plan for hospice services to include information for coordination of care. FORM CMS-2567 (02/99) Previous Versions Obsolete 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 04/18/2024 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the facility failed to ensure communication was maintained between the facility and dialysis center. This affected one (Resident #2) of one reviewed for dialysis. The facility census was 33. Residents Affected - Few Findings include: Review of the medical record for Resident #2 revealed an admission date of 02/22/24. Diagnoses included end stage renal disease and kidney transplant status. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 was cognitively intact. Resident #2 was independent for activities of daily living. Review of the physician orders revealed Resident #2 received dialysis services on Monday, Wednesday, and Friday and check for thrill/bruit to fistula in right upper arm. There was no mention of where dialysis was performed with address and phone number in the physician orders for dialysis. Review of the care plan dated 02/22/24 revealed Resident #2 required hemodialysis related to end stage renal disease. The care plan did not include which dialysis center or contact information for the dialysis center. Review of the dialysis communication/referral forms to be sent with Resident #2 on dialysis days revealed the facility did not fill out their portion on 03/22/24, 04/07/24, 04/10/24, 04/12/24, and 04/15/24. Further review of the dialysis communication/referral forms sent with Resident #2 revealed the only forms sent with the resident on dialysis days were on 02/28/24, 03/13/24, 03/22/24, 04/07/24, 04/10/24, 04/12/24, and 04/15/24. Resident #2's dialysis days were Monday, Wednesday, and Friday. Since admission to the facility on [DATE], the resident would have been to dialysis 25 times at a minimum. The communication form was missed 19 dialysis days. Interview on 04/16/24 at 1:16 P.M. with the Director of Nursing (DON) verified the communication form was hit or miss on whether the dialysis center sends them back to the facility. The DON verified that several of the returned communication sheets were not filled out by the facility nurse and the dialysis center information was completed. The DON stated the dialysis center information would be listed on the face sheet. The DON verified the face sheet for Resident #2 did not include the dialysis center information. Interview on 04/16/24 at 2:15 P.M. with Dialysis Registered Nurse (RN #700) verified the communication forms have been missed due to staffing. RN #700 stated that they have a plan in place to improve the communication form being filled out for each dialysis treatment. RN #700 stated they do have communication on the phone with the facility. Review of the facility policy titled End-Stage Renal Disease, Care of a Resident with, revised September 2023, revealed agreements between the facility and the contracted end stage renal disease facility include all aspects of how the resident's care will be managed, including how the care plan will be developed and implemented, and how information will be exchanged between the facilities. 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 04/18/2024 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 observation, staff interview, and policy review, the facility failed to ensure open food products were dated and covered in the kitchen. This had the potential to affect all 33 residents who the facility identified to all receive food from the kitchen. The facility census was 33. Findings include: Observation on 04/15/24 at 8:20 A.M. of the kitchen revealed in the dry storage area, five bags of open pasta were not dated. In the walk-in refrigerator, two trays of mandarin oranges were not covered or dated and two bags of mozzarella cheese open with no date. In the walk-in freezer, one bag of Salisbury steak open with no date. In the reach-in refrigerator, there was one container of ham, one container of strawberries, and one container of dill pickles not dated. Interview on 04/15/24 at 8:30 A.M. with Dietary Manager (DM) #500 verified the five bag of pasta, two trays of mandarin oranges, two bags of mozzarella cheese, one bag of Salisbury steak, one container of each ham, strawberries, and pickles were all not dated. DM #500 verified the mandarin oranges were also not covered. DM #500 stated that they typically date the food as it comes into the facility on delivery date. Review of the facility's policy titled Food Receiving and Storage revised October 2017 revealed dry foods that are stored in bins will be removed from original packaging, labeled and dated (use by date). Such foods will be rotated using the first in- first out system. All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date). Open containers must be dated and sealed or covered during storage. 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 04/18/2024 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on the facility's water management program information, staff interview, review of the Centers for Disease Control (CDC) guidance, and review of the facility policy, the facility failed to have an appropriate Legionella water management program in place. This had the potential to affect all 33 residents in the facility. Residents Affected - Many Findings include: Review of the most recent Legionella documentation information revealed the facility's Legionella information contained both cold and hot water chlorine testing and eye wash station testing. The cold and hot water chlorine residual testing verified the facility had not conducted a chlorine residual testing since 11/29/23. The 2024 log for the eye wash station revealed the station was inspected (included running water for three minutes) on 02/01/24, 03/11/24, and 04/09/24. Interview on 04/18/24 at 9:00 A.M. and 9:45 A.M. with the Administrator verified the facility has not completed chlorine residual testing since November 2023. There was no evidence of flushing of stagnant water except for monthly inspections of the eyewash stations. The Administrator revealed the former maintenance director had left in December 2023. The position was filled in February or March 2024 through early April 2024. The maintenance director position had been filled effective 04/18/24. Interview on 04/18/24 at 12:25 P.M. with the Administrator and Regional Director of Operations #701 verified the facility did not have Legionella prevention, detection, and control measures in place including a risk assessment, facility mapping of water sources, flushes, or testing. The facility has identified five current unoccupied resident rooms including rooms 112, 115, 206, 214, and 215. Review of the undated CDC guidance titled, Overview of Water Management Programs, revealed water management programs identify hazardous conditions and take steps to minimize the growth and transmission of Legionella and other waterborne pathogens in building water systems. Developing and maintaining a water management program is a multi-step process that requires continuous review. Seven key elements of a Legionella water management program are to: o Establish a water management program team o Describe the building water systems using text and flow diagrams o Burden of Waterborne Disease o Read about various illnesses, including Legionnaires' disease, in CDC's first estimates of the impact of waterborne disease in the United States. o Identify areas where Legionella could grow and spread o Decide where control measures should be applied and how to monitor them o Establish ways to intervene when control limits are not met o Make sure the program is running as designed (verification) and is effective (validation) (continued on next page) 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 04/18/2024 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 0880 o Document and communicate all the activities Level of Harm - Minimal harm or potential for actual harm Review of the facility's policy titled Legionella Water Management Program, revised October 2023, revealed the water management program includes but not limited to the following a detailed description and diagram of the water system in the facility including receiving, cold water distribution, heating, hot water distribution, and waste. Also, the identification of areas in the water system that could encourage the growth and spread of Legionella or other waterborne pathogens including storage tanks, water heaters, filters, aerators, showerheads and hoses, misters, atomizers, air washers, humidifiers, hot tubs, fountains, and medication devices. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365887 If continuation sheet Page 7 of 7