Inspection·December 22, 2022

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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, resident observation and staff interview, the facility failed to ensure residents that required assistance with oral care were provided adequate care and services. This affected one resident (#1) of four residents reviewed for activities of daily living. The facility identified 29 residents that required staff assistance with activities of daily living. The census was 62. Residents Affected - Few Findings include: Review of Resident #1's medical record revealed an admission date of 08/30/19. Diagnoses included anoxic brain damage, anogenital herpes viral infection, anxiety disorder, pseudobulbar affect, contracture of the left and right hands, dysphagia, localized edema, and contracture of the left and right shoulders. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was assessed with impaired cognition and did not speak. The activities of daily living (ADLs) Care Area Assessment (CAA) as part of the annual MDS assessment revealed Resident #1 required the totally dependence of the physical assistance of two people for ADLs. Review of the care plan initiated on 08/31/19 with a revision date of 07/21/21 revealed Resident #1 was dependent upon staff for all ADL needs. ADL personal hygiene was identified as a deficit in the care plan and revealed an intervention that Resident #1 was dependent on one staff for personal hygiene and oral care and stated the residents ADLs will be completed daily by staff and all daily needs will be met. Review of the dental progress note dated 11/06/22 stated Resident #1 had heavy calculus and heavy plaque and recommended assistance from staff for daily oral hygiene. Observation on 12/19/22 at 3:03 P.M. of Resident #1 revealed an oily facial complexion with dry, white crusted lips. At the time of the observation when entering Resident #1's room a foul odor was noted. An additional observation made of Resident #1 on 12/20/22 at 11:58 A.M. revealed oily skin, dry cracked lips, and a foul odor coming from Resident #1. Interview with Licensed Practical Nurse (LPN) #315 at 12:00 P.M. on 12/20/22 verified the foul odor in the room of Resident #1 and stated the odor was from Resident #1. Review of nurse aide documentation for oral care from November 23, 2022, to December 22, 2022 revealed Resident #1 received oral care on 11/23/22, 11/24/22, 11/29/22, 11/30/22, 12/07/22, 12/09/22, 12/12/22, 12/13/22 and 12/18/22. Interview on 12/21/22 at 9:56 A.M. with State Tested Nurse Aide (STNA) #324 verified Resident #1 did not have daily documentation of oral care and stated if the oral care is not documented then oral care was not completed. STNA #324 further stated daily documentation of care is required. Interview with the Administrator on 12/22/22 at 8:30 A.M. verified the facility did not have a policy on activities of daily living and the ADL care required for each resident is identified in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366060 If continuation sheet Page 2 of 14 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 366060 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Sylvania 7120 Port Sylvania Drive Toledo, OH 43617 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 0677 care plan. Level of Harm - Minimal harm or potential for actual harm Review of the facilities admission packet revealed the resident's daily needs will be attended to by the dedicated staff. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366060 If continuation sheet Page 3 of 14 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 366060 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Sylvania 7120 Port Sylvania Drive Toledo, OH 43617 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 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 observation, resident interview, staff interview, record review, and review of the facility policy, the facility failed to ensure fall interventions were implemented for one (Resident #49) of two residents reviewed for fall interventions. The facility census was 62. Findings include: Review of the medical record for Resident #49 revealed an admission date of 04/23/21 with diagnoses of history of falling, difficulty in walking, and unsteadiness on feet. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #49 had impaired cognition and required supervision of one person for bed mobility and hygiene, was independent with setup help for transfers and eating, required limited assistance of one person for dressing, extensive assistance of one person for toileting. Review of the Fall Risk Assessment completed 05/20/22 revealed Resident #49 had a score of 17.0 indicating fall interventions were required. Review of the physician order dated 05/25/22 revealed Resident #49 required a mat to floor next to bed. Review of a nursing progress note dated 05/20/22 revealed Resident #49 slid out of bed and was observed laying on her buttocks next to her bed. Further review revealed Resident #49 stated this happens all the time. No injuries were reported. Review of a nursing progress note dated 10/27/22 revealed Resident #49 slid out of her bed onto the floor. She denied injury at that time. Review of a nursing progress note dated 11/20/22 revealed Resident #49 was found on her back on the floor by her bed. Resident #49 thought she fell out of bed in her sleep. Resident #49 denied injuries. Review of a nursing progress note dated 12/08/22 revealed Resident #49 reported she had slid out of bed overnight and had a skin tear. Review of the current care plan for Resident #49 revealed she was at risk for falls related to sleeping on the edge of the bed. Interventions included encouraging her to sleep in the middle of the bed and a floor mat on the exit side of the bed. Interview on 12/20/22 at 11:45 A.M. with Resident #49 revealed she had fallen out of bed seven times and felt the facility had not developed any interventions to help her. Concurrent observation revealed a fall mat in her room. Resident #49 stated the fall mat was not placed next to her bed when she went to bed at night. Observation and interview on 12/22/22 at 5:57 A.M. with State Tested Nurse Aide #346 confirmed Resident #49 was in bed and her floor mat was not on the floor next to her bed. Further observation (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366060 If continuation sheet Page 4 of 14 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 366060 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Sylvania 7120 Port Sylvania Drive Toledo, OH 43617 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 revealed the floor mat was rolled up and propped on the wall. Level of Harm - Minimal harm or potential for actual harm Interview on 12/22/22 at approximately 10:00 A.M. with the Director of Nursing confirmed no additional interventions were in place to deter Resident #49 from falling out of bed. Residents Affected - Few Review of the facility policy Fall Prevention Program, revised 01/01/22, revealed no guidance regarding implementing ordered interventions to prevent falls. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366060 If continuation sheet Page 5 of 14 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 366060 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Sylvania 7120 Port Sylvania Drive Toledo, OH 43617 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 observation, staff interview, record review, and review of the facility policy, the facility failed to ensure enteral nutrition (tube feeding) was provided per physician orders for one (Resident #6) of two residents reviewed for enteral nutrition. The facility census was 62. Residents Affected - Few Findings include: Review of the medical record for Resident #6 revealed an admission date of 09/10/22 with diagnoses of unspecified intracranial injury with loss of consciousness of unspecified duration, acute kidney failure, history of urinary tract infections. Review of the comprehensive minimum data set (MDS) assessment dated [DATE] revealed Resident #6 was rarely/never understood and was totally dependent on staff for all activities of daily life. Review of a physician order dated 12/01/22 revealed Resident #6 received enteral nutrition at 100 milliliters (ml) per hour for 12 hours daily from 6:00 P.M. to 6:00 A.M. Review of Resident #6's weight history revealed a significant weight loss of 19.9% over six months from 157.4 pounds on 06/07/22 to 134.1 pounds on 12/08/22. Additional review of Resident #6's weight revealed a further weight loss on 12/20/22 of 131.4 pounds. Review of a Nutrition assessment dated [DATE] revealed the enteral nutrition ordered provided adequate kilocalories and protein to meet Resident #49's estimated nutrition needs. Further review revealed Resident #49 should received 1200 ml volume of enteral nutrition daily. Review of the medication administration record (MAR) for December 2022 for Resident #49 revealed the volume of enteral nutrition infused nightly was inconsistently documented. Observation on 12/21/22 at 6:34 A.M. revealed Resident #6 in bed. The enteral nutrition bottle and tubing were already removed from his room. Interview on 12/21/22 at approximately 6:40 A.M. with Licensed Practical Nurse (LPN) #327 revealed she was the night shift nurse for Resident #6. Further interview confirmed his enteral nutrition infusion was already completed. Continued interview revealed LPN #327 did not change the enteral nutrition bottle during her shift, stating it works out that when the bottle finishes, he's done. Observation at that time of the enteral nutrition bottle Resident #49 received revealed the bottle contained one liter of fluid (1000 ml). Observation on 12/21/22 at 6:12 P.M. of LPN #330 revealed she hung the enteral nutrition bottle and connected the tubing to provide nutrition to Resident #6. The enteral nutrition pump was set to run at 100 ml per hour and the total volume was cleared to begin at zero to track the volume of enteral nutrition Resident #6 received. LPN #330 labeled the bottle with the date and time: 12/21/22 at 6:00 P.M. Observation on 12/22/22 at 5:58 A.M. revealed Resident #6 lying in bed. The enteral nutrition was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366060 If continuation sheet Page 6 of 14 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 366060 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Sylvania 7120 Port Sylvania Drive Toledo, OH 43617 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few no longer running and Resident #6 was disconnected from the tubing. Further observation revealed the bottle was labeled with the date 12/21/22. Interview at that time with LPN #348 confirmed she had not changed the bottle of enteral nutrition during the night shift. LPN #348 stated the volume administered from the pump was 1063 ml, though she had already cleared the pump and the volume could not be observed. Further interview and observation confirmed the bottle still contained 200 ml of formula. Continued interview revealed LPN #348 worked nights and when having worked with Resident #6 in the past she could not recall changing his enteral nutrition bottle. Telephone interview on 12/22/22 at 9:04 A.M. with Registered Dietitian (RD) #378 confirmed Resident #6 should receive 1200 ml of enteral nutrition daily. Further interview confirmed the enteral nutrition bottles contained 1000 ml and a second bottle would need to be hung for Resident #6 to receive the full volume required. RD #378 further revealed he was unaware whether nursing staff tracked the volume infused by the pump. Further interview revealed the RD #378 was unaware Resident #6 only received one bottle of enteral nutrition. Interview on 12/22/22 at approximately 10:00 A.M. with the Director of Nursing confirmed a second bottle would need to be hung to provide a total volume of 1200 ml daily. Review of the facility policy Feeding Tubes, dated 06/30/22, revealed feeding tubes will be utilized according to physician orders. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366060 If continuation sheet Page 7 of 14 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 366060 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Sylvania 7120 Port Sylvania Drive Toledo, OH 43617 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, medical record review, and review of facility policy, the facility failed to ensure physician orders were in place for oxygen use. This affected one (#24) of two residents reviewed for oxygen administration. The facility census was 62. Residents Affected - Few Findings include: Review of the medical record for Resident #24 revealed an admission date of 11/23/22 and a readmission date of 12/14/22 with medical diagnoses of chronic obstructive pulmonary disease and chronic respiratory failure. Review of the 5-day minimum data set (MDS) assessment dated [DATE] revealed Resident #24 had intact cognition and received oxygen. Review of the current physician orders revealed no orders for oxygen. Review of the current care plan revealed Resident #24 received oxygen via nasal cannula at 3 liters per minute. Observation on 12/19/22 at 10:44 A.M. revealed Resident #24 wearing a nasal cannula and receiving oxygen at 3 liters per minute. Interview at that time with Resident #24 confirmed she required oxygen and had no concerns with her care. Observation on 12/20/22 at 11:38 A.M. revealed Resident #24 wearing a nasal cannula and receiving oxygen at 3 liters per minute. Interview and observation on 12/20/22 12:44 P.M. with the Medication Technician #307 confirmed Resident #24 received oxygen, but no oxygen in use sign was posted outside her room. Interview on 12/20/22 at 2:01 P.M. with the Director of Nursing (DON) confirmed Resident #24 did not have an active order for oxygen since her readmission on [DATE]. Further interview confirmed the DON was aware Resident #24 received oxygen since returning to the facility on [DATE]. Review of the facility policy Oxygen Administration, revised 01/01/22, revealed oxygen is administered under orders of a physician. Further review revealed oxygen warning signs must be placed on the door of the resident's room where oxygen is in use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366060 If continuation sheet Page 8 of 14 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 366060 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Sylvania 7120 Port Sylvania Drive Toledo, OH 43617 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, staff interview, medical record review, review of facility policies, and review of manufacturer instructions ,the facility failed to ensure medications were administered as ordered. This resulted in three medication errors of 25 total opportunities for a medication error rate of 12%. This affected three (#17, #30 and #60) of nine residents observed during medication administration. The census was 62. Residents Affected - Few Findings include: 1. Review of Resident #17's record revealed an admission date of 11/23/21. Diagnoses included acute kidney failure, chronic obstructive pulmonary disease, diabetes mellitus type II, vitamin D deficiency, gastroesophageal reflux, atrial flutter, cerebral infarction, osteoarthritis, and dementia. Review of a physician order dated 12/13/22 revealed Resident #17 was ordered Insulin Detemir, 100 units per milliliter, with 15 units ordered to be injected subcutaneously each morning. Observation of Registered Nurse (RN) #300 on 12/20/22 at 8:13 A.M. revealed RN #300 completed hand hygiene, removed the individual bag labeled for Resident #17 from the top drawer of the medication cart, RN #300 then removed the insulin pen labeled for Resident #17 from the individualized bag, dialed the insulin pen to 15 units, removed a needle from the top right drawer of the medication cart and attached the needle to the insulin pen. RN #300 removed an alcohol wipe from the medication cart and proceeded into Resident #17's room. Continued observation of RN #300 revealed RN #300 entered Resident #17's room, completed hand hygiene and prepared Resident #17 for the subcutaneous injection. RN #300 cleaned the left lower abdomen with alcohol, allowed the alcohol prep to dry and proceeded to administer the subcutaneous injection of 15 units of Detemir insulin into the left lower abdomen. 2. Review of Resident #30's record revealed an admission date of 08/18/22. Diagnoses included diabetes mellitus type II, gastro-esophageal reflux disease, dementia, and multiple sclerosis. Review of a physician order dated 09/28/22 revealed Resident #30 was ordered Insulin Detemir, 100 units per milliliter with 40 units ordered to be injected subcutaneously each morning. Observation of Registered Nurse (RN) #300 on 12/20/22 at 8:19 A.M. revealed RN #300 completed hand hygiene, removed the individual bag labeled for Resident #30 from the top drawer of the medication cart, RN #300 then removed the insulin pen labeled for Resident #30 from the individualized bag, dialed the insulin pen to 40 units, removed a needle from the top right drawer of the medication cart and attached the needle to the insulin pen. RN #300 then removed an alcohol wipe from the medication cart and proceeded into Resident #30's room. Continued observation of RN #300 revealed RN #300 entered Resident #30's room, completed hand hygiene, inquired with Resident #30 as to where the insulin was to be injected. RN #300 cleaned the left lower abdomen of Resident #30 with alcohol, allowed the alcohol prep to dry and proceeded to administer the subcutaneous injection of 40 units of Detemir insulin into the left lower abdomen. 3. Review of Resident #60's record revealed an admission date of 09/30/22. Diagnoses included diabetes mellitus type II, hypertension, depressive disorder, and anemia. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366060 If continuation sheet Page 9 of 14 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 366060 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Sylvania 7120 Port Sylvania Drive Toledo, OH 43617 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of a physician order dated 10/11/22 revealed Resident #60 was ordered Glargine insulin 100 units per milliliter, 35 units each morning, injected subcutaneously. Observation of Registered Nurse (RN) #300 on 12/20/22 at 8:24 A.M. revealed RN #300 completed hand hygiene, removed the individual bag labeled for Resident #60 from the top drawer of the medication cart, RN #300 then removed the insulin pen labeled for Resident #60 from the individualized bag, dialed the insulin pen to 35 units, removed a needle from the top right drawer of the medication cart and attached the needle to the insulin pen. Continued observation of RN #300 revealed RN #300 entered Resident #60's room, completed hand hygiene, inquired with Resident #60 as to where the insulin was to be injected. RN #300 lifted the shirt of Resident #60 and proceeded to administer the subcutaneous injection of 35 units of Detemir insulin into the left middle abdomen. RN #300 stated Resident #60 requested alcohol not be used to prep skin prior to the administration of insulin. Interview with Resident #60 at the time of the observation revealed the injection stings when alcohol is used. Resident #60 verified the request of staff not to use alcohol to prep the skin prior to the administration of insulin. Interview with RN #300 on 12/20/22 at 8:30 A.M. verified the insulin pens for Residents #17, #30 and #60 were not primed. Interview with RN #357 at 8:50 A.M. on 12/20/22 revealed insulin pens are not primed when needles are attached to the insulin pen prior to the administration of insulin. Interview with RN #300 on 12/20/22 at 10:35 A.M. verified insulin pens are to be primed, RN #300 stated she was unaware of the need to prime insulin pens. Interview with the Director of Nursing (DON) on 12/20/22 at 11:34 A.M. verified insulin pens required priming. The DON further verified the nurses did not know when needles are applied to the insulin pen the needle needed to be primed. The DON stated education had been provided. Review of the education provided stated insulin pens are to be primed before each injection. Priming the pen means removing the air from the needle and cartridge to ensure the pen is working correctly. If the pen is not primed before each injection, too much or too little insulin may be administered. Review of the undated facility policy titled Administering Medications, stated medications are administered in accordance with prescribers' orders. Review of insulin glargine manufacturer's instructions, revised November 2018, revealed the user should always perform a safety test before each injection by selecting two units of insulin on the dosage selector and pressing the administration button all the way in to ensure insulin comes out of the needle tip. The safety test ensures the pen, and the needle are working correctly and removes all air bubbles. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366060 If continuation sheet Page 10 of 14 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 366060 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Sylvania 7120 Port Sylvania Drive Toledo, OH 43617 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on observation, staff interview, medical record review, review of drug manufacturer's instructions, and review of facility policies, the facility failed to ensure insulin was administered as ordered. This affected three (#17, #30 and #60) of nine residents observed during medication administration and three (#17, #30 and #60) of three residents reviewed for insulin usage. The facility census was 62. Residents Affected - Few Findings include: 1. Review of Resident #17's record revealed an admission date of 11/23/21. Diagnoses included acute kidney failure, chronic obstructive pulmonary disease, diabetes mellitus type II, vitamin D deficiency, gastroesophageal reflux, atrial flutter, cerebral infarction, osteoarthritis, and dementia. Review of a physician order dated 12/13/22 revealed Resident #17 was ordered Insulin Detemir, 100 units per milliliter, with 15 units ordered to be injected subcutaneously each morning. Observation of Registered Nurse (RN) #300 on 12/20/22 at 8:13 A.M. revealed RN #300 completed hand hygiene, removed the individual bag labeled for Resident #17 from the top drawer of the medication cart, RN #300 then removed the insulin pen labeled for Resident #17 from the individualized bag, dialed the insulin pen to 15 units, removed a needle from the top right drawer of the medication cart and attached the needle to the insulin pen. RN #300 removed an alcohol wipe from the medication cart and proceeded into Resident #17's room. Continued observation of RN #300 revealed RN #300 entered Resident #17's room, completed hand hygiene and prepared Resident #17 for the subcutaneous injection. RN #300 cleaned the left lower abdomen with alcohol, allowed the alcohol prep to dry and proceeded to administer the subcutaneous injection of 15 units of Detemir insulin into the left lower abdomen. 2. Review of Resident #30's record revealed an admission date of 08/18/22. Diagnoses included diabetes mellitus type II, gastro-esophageal reflux disease, dementia, and multiple sclerosis. Review of a physician order dated 09/28/22 revealed Resident #30 was ordered Insulin Detemir, 100 units per milliliter with 40 units ordered to be injected subcutaneously each morning. Observation of Registered Nurse (RN) #300 on 12/20/22 at 8:19 A.M. revealed RN #300 completed hand hygiene, removed the individual bag labeled for Resident #30 from the top drawer of the medication cart, RN #300 then removed the insulin pen labeled for Resident #30 from the individualized bag, dialed the insulin pen to 40 units, removed a needle from the top right drawer of the medication cart and attached the needle to the insulin pen. RN #300 then removed an alcohol wipe from the medication cart and proceeded into Resident #30's room. Continued observation of RN #300 revealed RN #300 entered Resident #30's room, completed hand hygiene, inquired with Resident #30 as to where the insulin was to be injected. RN #300 cleaned the left lower abdomen of Resident #30 with alcohol, allowed the alcohol prep to dry and proceeded to administer the subcutaneous injection of 40 units of Detemir insulin into the left lower abdomen. 3. Review of Resident #60's record revealed an admission date of 09/30/22. Diagnoses included diabetes mellitus type II, hypertension, depressive disorder, and anemia. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366060 If continuation sheet Page 11 of 14 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 366060 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Sylvania 7120 Port Sylvania Drive Toledo, OH 43617 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of a physician order dated 10/11/22 revealed Resident #60 was ordered Glargine insulin 100 units per milliliter, 35 units each morning, injected subcutaneously. Observation of Registered Nurse (RN) #300 on 12/20/22 at 8:24 A.M. revealed RN #300 completed hand hygiene, removed the individual bag labeled for Resident #60 from the top drawer of the medication cart, RN #300 then removed the insulin pen labeled for Resident #60 from the individualized bag, dialed the insulin pen to 35 units, removed a needle from the top right drawer of the medication cart and attached the needle to the insulin pen. Continued observation of RN #300 revealed RN #300 entered Resident #60's room, completed hand hygiene, inquired with Resident #60 as to where the insulin was to be injected. RN #300 lifted the shirt of Resident #60 and proceeded to administer the subcutaneous injection of 35 units of Detemir insulin into the left middle abdomen. RN #300 stated Resident #60 requested alcohol not be used to prep skin prior to the administration of insulin. Interview with Resident #60 at the time of the observation revealed the injection stings when alcohol is used. Resident #60 verified the request of staff not to use alcohol to prep the skin prior to the administration of insulin. Interview with RN #300 on 12/20/22 at 8:30 A.M. verified the insulin pens for Residents #17, #30 and #60 were not primed. Interview with RN #357 at 8:50 A.M. on 12/20/22 revealed insulin pens are not primed when needles are attached to the insulin pen prior to the administration of insulin. Interview with RN #300 on 12/20/22 at 10:35 A.M. verified insulin pens are to be primed, RN #300 stated she was unaware of the need to prime insulin pens. Interview with the Director of Nursing (DON) on 12/20/22 at 11:34 A.M. verified insulin pens required priming. The DON further verified the nurses did not know when needles are applied to the insulin pen the needle needed to be primed. The DON stated education had been provided. Review of the education provided stated insulin pens are to be primed before each injection. Priming the pen means removing the air from the needle and cartridge to ensure the pen is working correctly. If the pen is not primed before each injection, too much or too little insulin may be administered. Review of the undated facility policy titled Administering Medications, stated medications are administered in accordance with prescribers' orders. Review of insulin glargine manufacturer's instructions, revised November 2018, revealed the user should always perform a safety test before each injection by selecting two units of insulin on the dosage selector and pressing the administration button all the way in to ensure insulin comes out of the needle tip. The safety test ensures the pen, and the needle are working correctly and removes all air bubbles. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366060 If continuation sheet Page 12 of 14 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 366060 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Sylvania 7120 Port Sylvania Drive Toledo, OH 43617 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation, staff interview, and review of the facility recipe, the facility failed to ensure pureed foods were the correct texture. This affected four residents (#3, #4, #8, and #27) the facility identified on a pureed diet. The facility census was 62. Findings include: Observation of dining on 12/19/22 at 11:45 A.M. revealed residents in the dining room eating lunch. Further observation of the pureed chicken pot pie revealed concerns regarding appropriate texture due to the varied appearance of the texture. Tasting on 12/19/22 at 11:56 A.M. of the pureed chicken pot pie by the surveyor and the Dietary Account Manager #367 confirmed it was not fully pureed. The surveyor suggested the skins of corn were still intact while the Dietary Account Manager #367 suggested it was skins of beans that were still intact. Continued interview at that time confirmed the texture was inappropriate to be served as a pureed texture. Review of the recipe for Pot Pie Filling, Chicken revealed For Pureed: Measure desired number of servings into food processor. Blend until smooth. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366060 If continuation sheet Page 13 of 14 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 366060 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Sylvania 7120 Port Sylvania Drive Toledo, OH 43617 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 0926 Have policies on smoking. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and review of the facility policy, the facility failed to ensure smoking safety for one resident (#10) of one reviewed for smoking. The facility identified eight residents who smoked. The facility census was 62. Residents Affected - Few Findings include: Review of the medical record for Resident #49 revealed an admission date of 04/23/21 with diagnoses of history of falling, difficulty in walking, and unsteadiness on feet. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #49 had impaired cognition and required supervision of one person for bed mobility and hygiene, was independent with setup help for transfers and eating, required limited assistance of one person for dressing, extensive assistance of one person for toileting. Review of the Nursing Quarterly/Significant Change Evaluation dated 12/01/22 revealed a Safe Smoking Evaluation was completed on Resident #49 and the evaluation concluded Resident #49 was safe to smoke unsupervised in designated smoking areas. Observation on 12/19/22 at 10:25 A.M. revealed Resident #49 sitting outside the dining room door in front of a garbage can with a posted sign No smoking except in designated areas. The door from the dining room was propped open with a towel. A sign posted on the door stated Do not prop door. Further observation revealed multiple cigarette butts scattered along the walkway just outside the dining room door. No ashtray was visible. Interview at that time with the Director of Rehab (DOR) #379 confirmed Resident #49 was not in the designated smoking area. The DOR #379 identified the designated smoking area was approximately 20 feet away under a shelter. Further interview confirmed the door was propped open and should not be. Interview on 12/19/22 at 10:30 A.M. with State Tested Nurse Aide #304 confirmed cigarette butts were scattered around the walkway outside the dining room door. Review of the undated facility policy Resident Smoking Policy revealed residents were required to smoke only in designated smoking areas. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366060 If continuation sheet Page 14 of 14