Inspection·August 25, 2023

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 08/25/23 at 9:06 A.M., interview with Licensed Practical Nurse (LPN) #200 stated, on 07/16/23, a state tested nurse aide (STNA) made notification Resident #1 was non-responsive and had a elevated pulse rate. LPN #200 contacted emergency medical services (EMS), and the resident was subsequently sent to the hospital emergency room for evaluation. LPN #200 confirmed Resident #1 had a urinary indwelling catheter in place at the time of discharge which had been in place during the resident's admission to the facility. On 08/25/23 at 9:45 A.M., interview with the Director of Nursing (DON), during review of Resident #1's medical record, confirmed the resident had an indwelling urinary catheter in place at the time of admission and until discharge on [DATE]. The DON confirmed there was no documentation contained in the medical record which indicated the indwelling urinary catheter was in place, a supporting diagnosis or physician order for the use of the indwelling catheter, or documentation of maintenance and care. The DON indicated the facility discovered the missing documentation and initiated corrective action. Review of the facility catheterization policy, dated 01/01/22, revealed the use of an indwelling urinary catheter will be in accordance with physician orders, which will include the diagnosis or clinical condition making the use of the catheter necessary, size of the catheter and balloon, and frequency of change (if applicable). As a result of the deficient practice the facility has implemented corrective action as of 08/18/23 as follows: • On 07/18/23, the DON conducted a visual room to room audit for indwelling (Foley) urinary catheters. • On 07/20/23, all nurses were in-serviced by staff development on the facility policy for Foley catheters to include residents with Foley catheters have orders with type, size, and an appropriate diagnosis, have Foley catheter care orders each shift, and tasks for Foley catheter care each shift. • On 07/24/23, weekly audits were completed by the DON or designee on admissions and readmissions to the facility Monday through Friday for four weeks to validate if a resident admitted with a Foley catheter had orders with type, size, and diagnosis, and Foley catheter care each shift. The audits concluded on 08/18/23 with no concerns noted. • On 08/25/23 at 10:25 A.M., interview with LPN #200 and at 10:35 A.M. with Registered Nurse (RN) #300 confirmed attending indwelling catheter in-service training and were knowledgeable of the in-service topics. • (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366060 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 366060 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2023 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 0690 Level of Harm - Minimal harm or potential for actual harm On 08/25/23, review of two (#2 and #3) current resident's medical records and observation of catheter care and maintenance verified effectiveness of the corrective action. This deficiency represents non-compliance investigated under Complaint Number OH00144734. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366060 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 366060 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2023 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure there was documented evidence contained in the medical record to include the placement and care of an indwelling urinary catheter. This affected one (#1) of three residents reviewed for indwelling urinary catheters. The census was 70. Finding include: Review of Resident #1's medical record revealed the resident admitted to the facility on [DATE] with the diagnoses including, metabolic encephalopathy, acute lymphadenitis, autoimmune encephalitis, muscle weakness, depression, hypertension, dysphagia, anxiety disorder, and Alzheimer's disease. Review of a nursing admission assessment dated [DATE] revealed Resident #1 was dependent with toileting and elimination with assistance. There was no documentation an indwelling urinary catheter was in place. Review of a nursing admission evaluation completed on 06/08/23 revealed Resident #1 was documented with a Foley catheter (indwelling urinary catheter) in place. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was assessed with severe cognitive impairment and was sometimes understood, was totally dependent on staff for the completion of activities of daily living, and was always incontinent of bowel and bladder. There was no documentation an indwelling urinary catheter was in place. Review of a urinary continence evaluation dated 06/14/23 revealed Resident #1 was incontinent of bladder since admission. Further review revealed there was no indwelling urinary catheter in place. Review of the MDS assessment dated [DATE] revealed Resident #1 was assessed with severe cognitive impairment and was sometimes understood, was totally dependent on staff for the completion of activities of daily living, and utilized an indwelling urinary catheter. Further review of Resident #1's medical record lacked a physician order, a supporting diagnosis, or documentation of urinary catheter care and maintenance for the placement of an indwelling urinary catheter. On 08/25/23 at 9:06 A.M., interview with Licensed Practical Nurse (LPN) #200 stated, on 07/16/23, a state tested nurse aide (STNA) made notification Resident #1 was non-responsive and had a elevated pulse rate. LPN #200 contacted emergency medical services (EMS), and the resident was subsequently sent to the hospital emergency room for evaluation. LPN #200 confirmed Resident #1 had a urinary indwelling catheter in place at the time of discharge which had been in place during the resident's admission to the facility. On 08/25/23 at 9:45 A.M., interview with the Director of Nursing (DON), during review of Resident #1's medical record, confirmed the resident had an indwelling urinary catheter in place at the time of admission and until discharge on [DATE]. The DON confirmed there was no documentation contained in the medical record which indicated the indwelling urinary catheter was in place, a supporting diagnosis or physician order for the use of the indwelling catheter, or documentation of maintenance and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366060 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 366060 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2023 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 0842 care. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366060 If continuation sheet Page 5 of 5