Inspection·May 16, 2019

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Potential for minimal harm Based on record review and staff interview the facility failed to ensure Notices of Medicare Non-Coverage issued to residents contained all of the required information. This affected three residents (Resident #138, #139 and #140) of three residents reviewed for beneficiary notices. Residents Affected - Some Findings Include: 1. Review of Resident #138's Notice of Medicare non coverage (NOMNC) form for services ending 12/13/18 and signed 12/07/18 revealed the notice contained no specific information about what services would be discontinued. 2. Review of Resident #139's Notice of Medicare non coverage (NOMNC) form for services ending 03/20/19 and signed 03/13/19 revealed the notice contained no specific information about what services would be discontinued. 3. Review of Resident #140's notice of Medicare non coverage (NOMNC) form for services ending 02/13/19 and signed 02/13/19 revealed the notice contained no specific information about what services would be discontinued. Social Service Designee #348 verified the notices for Resident #138, #139 and #140 lacked specific information about what services were being discontinued in an interview on 05/14/19 at 1:44 P.M. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365006 If continuation sheet Page 2 of 4 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 365006 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillside Plaza 18220 Euclid Ave Cleveland, OH 44112 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure medications in the [NAME] wing cart were secured under lock when the nurse was not in attendance. This had the potential to affect 17 residents (Resident #1, #4, #5, #6, #9, #13, #14, #15, #16, #18, #22, #24, #26, #35, #36, #187 and #189) on the [NAME] hall who received medications administered by the nursing staff. The facility census was 40. Findings Include: Observation on 05/15/19 at 4:30 P.M. in the [NAME] hallway revealed an unlocked medication cart stationed to the east of room [ROOM NUMBER]. No nurse was observed in the hallway or looking into the hallway. On 05/15/19 at 4:33 P.M. Licensed Practical Nurse #100 emerged from room [ROOM NUMBER] which was west of room [ROOM NUMBER], and past a large metal box fixed on the wall which extended approximately eight inches from the wall and approximately thirty three inches wide across the wall, partially blocking the view between the two rooms when standing at the doorway or in the hallway. Upon returning, LPN #100 placed medication on the top of the cart and confirmed she had left the cart unlocked while unattended and up the hallway out of view. The facility identified 17 residents, Resident #1, #4, #5, #6, #9, #13, #14, #15, #16, #18, #22, #24, #26, #35, #36, #187 and #189 on the [NAME] hall who received medications administered by the nursing staff. Review of the facility's policy, titled Medications, Biologicals, Syringes and Needles revised 10/31/16 revealed the facility was to ensure all medications and biologicals were securely stored in a locked cabinet /cart or locked medication room that was inaccessible by residents and visitors. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365006 If continuation sheet Page 3 of 4 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 365006 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillside Plaza 18220 Euclid Ave Cleveland, OH 44112 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 0839 Employ staff that are licensed, certified, or registered in accordance with state laws. Level of Harm - Potential for minimal harm Based on record review and interview the facility failed to properly verify the nursing license of Licensed Practical Nurse (LPN) #100 prior to the employee working in the facility. This affected one LPN (LPN #100) of four LPNs whose personnel files were reviewed and had the potential to affect all 40 residents residing in the facility. Residents Affected - Many Findings include: On 05/16/19 review of the personnel file for LPN #100 revealed an application date of 11/02/18 and hire date of 11/14/18. However, various facility orientation papers such as handwashing and gait belt policies were signed on 11/13/18. The file contained a license for a nurse with the same first and last name, but whom had been licensed as a nurse beginning in 1964. The page was dated 11/19/18. Additional records in the employee's file indicated a birth year in 1979, fifteen years after the licensure date. Interview on 05/16/19 at 12:15 P.M. with Human Resources Employee (HR) #105 confirmed the license in the file did not belong to LPN #100 as she had a different middle name and her birth year was listed as 1979. HR #105 stated she had not been aware of the error and did no know if the license had been retrieved manually by the facility staff or if it had been generated by following a link during the onboarding process that automatically retrieved nursing licenses since she had not looked up the license herself. Interview on 05/15/19 at 3:15 P.M. with LPN #100 revealed she had been working at the facility on an as needed basis, usually on the weekends, since November 2018. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365006 If continuation sheet Page 4 of 4