Inspection·July 20, 2022

F 0641 Level of Harm - Minimal harm or potential for actual harm 2. Review of the medical record revealed Resident #8 was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), diabetes mellitus, and dementia. Review of the physician's order dated 08/26/21 revealed Resident #8 had an advance directive including palliative care program for COPD. There were no physician's orders for hospice services. Residents Affected - Some Review of the quarterly MDS 3.0 assessment dated [DATE] revealed hospice services had been documented for Resident #8. Interview on 07/11/22 at 1:29 P.M. with LPN #512, who was also the MDS nurse, revealed she had documented hospice services for Resident #8. LPN #512 verified Resident #8 was not receiving hospice services and she had documented this in error. 3. Review of the medical record revealed Resident #35 was admitted on [DATE] with diagnoses including dementia with behavioral disturbances. Review of the physician's order dated 02/10/21 revealed Resident #35 had an advance directive including palliative care program for dementia. There were no physician's orders for hospice services. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed hospice services had been documented for Resident #35. Interview on 07/11/22 at 1:29 P.M. with LPN #512, who was also the MDS nurse, revealed she had documented hospice services for Resident #35. LPN #512 verified Resident #35 was not receiving hospice services and she had documented this in error. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365006 If continuation sheet Page 2 of 12 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 07/20/2022 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on record review, interview, and policy review the facility failed to ensure medications were administered as ordered. This affected three (Resident's #1, #20 and #22) of 11 residents reviewed for medications being administered as ordered. The facility census was 40. Residents Affected - Few Findings include: 1. Review of the medial record for Resident #1 revealed an admission date of 04/04/19 with diagnoses including diabetes mellitus, dementia, human immunodeficiency virus (HIV), and chronic kidney disease. Review of the physician's orders dated 06/03/22 for Resident #1 revealed he had an order for Insulin Aspart Solution 100 units/milliliters (mL.), inject seven units subcutaneously with meals related for hyperglycemia and Insulin Aspart Solution 100 units/mL., sliding scale with meals (insulin amount given depending on blood sugar readings). Review of the Medication Administration Record (MAR) for June 2022 for Resident #1 revealed nursing staff did not administer Insulin Aspart Solution seven units with meals on 06/14/22, 06/15/22 and 06/24/22 at 5:00 P.M. The MAR also revealed nursing staff did not check Resident #1's blood sugar or administer sliding scale coverage with Insulin Aspart Solution on 06/12/22, 06/14/22, 06/15/22 and 06/24/22 at 5:00 P.M. Review of the MAR for July 2022 for Resident #1 revealed nursing staff did not administer Insulin Aspart Solution seven units with meals on 07/0/3/22 at 5:00 P.M. The MAR also revealed nursing staff did not check Resident #1's blood sugar or administer sliding scale coverage with Insulin Aspart Solution on 07/03/22 at 5:00 P.M. Review of Resident #1's care plan dated 05/09/22 revealed he was at risk for hyperglycemia (high blood sugar) and hypoglycemic (low blood sugar) reactions. Interventions included for the staff to administer medications as the physician ordered. Interview on 07/13/22 at 10:34 A.M. with the Director of Nursing (DON) verified the nursing staff had not signed off the MAR for the Insulin Aspart orders on the dates listed above. Review of the facility policy titled, Administration Procedures for All Medications, dated September 2018, revealed nursing staff were to document administration of medications in the MAR. 2. Review of the medical record for Resident #20 revealed an admission date of 02/08/22 with diagnoses including diabetes mellitus, dementia, congestive heart failure, and anxiety. Review of the physician's orders for Resident #20 revealed she was to have Ambien 5 milligrams (mg) (medication for insomnia) one time a day in the evening dated 04/28/22; Atorvastatin Calcium (medication for high cholesterol) 40 mg at bedtime dated 04/28/22; Protonix 40 mg (medication for acid reflux) to be given daily in the morning dated 04/29/22; Buspirone HCL 15 mg (medication for anxiety) to be administered one time a day at 4:00 P.M. dated 05/25/22; and Novolog Flex Pen Solution Pen-Injection 100 units/mL sliding scale based on blood sugar at meals for diabetes mellitus dated 06/13/22. Review of the MAR for June 2022 for Resident #20 revealed nursing staff did not administer Ambien 5 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365006 If continuation sheet Page 3 of 12 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 07/20/2022 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few mg the evening of 06/14/22, 06/15/22 and 06/24/22; Atorvastatin Calcium 40 mg at bedtime on 06/14/22; Protonix 40 mg in the morning on 06/25/22 and 06/30/22; and Novolog Solution sliding scale or blood sugar on 06/14/22 at 11:30 A.M. and 4:30 P.M., and 06/15/22 at 4:30 P.M. Review of the MAR for July 2022 for Resident #20 revealed nursing staff did not administer Ambien 5 mg the evening of 07/03/22; Buspirone HCL 15 mg on 07/03/22 at 4:00 P.M.; and Protonix 40 mg in the morning of 07/02/22 and 07/10/22. Interview on 07/13/22 at 2:59 P.M. with the DON verified the medications were not signed off indicating they were not administered on the days listed above. Review of the facility policy titled, Administration Procedures for All Medications, dated September 2018, revealed nursing staff were to document administration of medications in the MAR. 3. Review of the medical record for Resident #22 revealed an admission date of 10/21/21 with diagnoses including diabetes mellitus, heart failure and depression. Review of the physician's orders for Resident #22 revealed orders for Insulin Glargine Solution 100 unit/mL, inject 6 units subcutaneously at bedtime for diabetes mellitus dated 01/27/22; Melatonin 5 mg at bedtime for insomnia dated 01/27/22; Polyethylene Glycol Powder 17 grams in the evening for constipation dated 02/04/22; Insulin Lispro Solution 100 units/mL, per sliding scale based on blood sugar results before meals dated 03/17/22; Lipitor 20 mg (medication for high cholesterol) in the evening dated 03/21/22; and Carvedilol 6.25 mg (medication for high blood pressure and heart failure) in the evening dated 05/21/22. Review of the MAR for June 2022 for Resident #22 revealed nursing staff did not administer Insulin Glargine Solution six units on 06/02/22, 06/10/22, 06/14/22, 06/15/22 and 06/24/22 at 8:00 P.M.; Melatonin 5 mg on 06/10/22, 06/14/22, 06/15/22 and 06/24/22 at 9:00 P.M.; Polyethylene Glycol Powder 17 grams on 06/10/22, 06/14/22, 06/15/22 and 06/24/22 on the evening shift; Insulin Lispro sliding scale and blood sugar checks on 06/02/22, 06/10/22, 06/14/22, 06/15/22 and 06/24/22 at 4:00 P.M.; Lipitor 20 mg on 06/10/22, 06/14/22, 06/15/22 and 06/24/22 in the evening; and Carvedilol 6.25 mg on 06/10/22, 06/14/22, 06/15/22 and 06/24/22 in the evening. Interview on 07/13/22 at 10:34 A.M. with the DON verified the medications were not signed off indicating they were not administered on the days listed above. Review of the facility policy titled, Administration Procedures for All Medications, dated September 2018, revealed nursing staff were to document administration of medications in the MAR. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365006 If continuation sheet Page 4 of 12 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 07/20/2022 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 pressure relieving interventions were implemented and pressure ulcer treatments were performed for Resident #35. This affected one (Resident #35) of one resident reviewed for pressure ulcers. The facility census was 40. Residents Affected - Few Findings include: Review of the medical record revealed Resident #35 was admitted on [DATE] with diagnoses including dementia, lack of coordination, and hypertension. Review of the care plan dated 03/12/20 for Resident #35 revealed she had the potential for alteration in skin integrity related to incontinence, depression, need for personal assistance, and obesity. Interventions included to administer treatments as ordered, therapeutic specialty mattress to bed and monitor for functioning, and to turn and reposition as needed. Review of the physician's orders for Resident #35 revealed orders for skin prevention included a low air loss pressure mattress to the bed, check function every shift dated 05/12/20 and protective moisture barrier topically to bilateral buttocks every shift for protection, wash with soap and water and pat dry area before applying dated 05/12/20. Resident #35 had an order for turning and repositioning every two hours dated 07/05/22. She also had an order for a treatment to her left buttock and to clean with normal sterile saline, pat dry and apply Triad Cream (zinc-based cream) per incontinence episodes every shift dated 07/05/22. Review of Wound Physician #573's progress note dated 07/04/22 revealed Resident #35 had an abrasion to her left buttock observed initially on 07/04/22. The nursing staff was to cleanse the area with wound cleanser, apply Triad Cream twice daily and as needed, turn and reposition her every two hours, keep the peri area clean and dry, and use an air mattress. Review of the Wound Physician #573's progress note dated 07/11/22 revealed Resident #35 still had the left buttock abrasion but also had developed a right buttock stage two pressure area (partial-thickness loss of dermis) which was first observed on 07/11/22. The nursing staff was to cleanse the areas, apply Triad Cream twice daily and as needed, reposition the resident every two hours, keep her peri area clean and dry, and utilize an air mattress. Review of the Treatment Administration Record (TAR) for June 2022 revealed nursing staff did not apply moisture barrier on dayshift on 06/15/22, in the evening of 06/05/22, 06/14/22, 06/15/22 and 06/24/22, and on 06/03/22, 06/06/22, 06/11/22, 06/14/22, 06/21/22, 06/22/22, 06/23/22 and 06/26/22 at night; and did not check the function of the low air loss pressure redistribution mattress to the bed in the evening of 06/05/22, 06/14/22, 06/15/22 and 06/24/22, and on 06/03/22, 06/06/22, 06/11/22, 06/14/22, 06/21/22, 06/22/22, 06/23/22 and 06/26/22 at night. Review of the TAR for July 2022 revealed nursing staff did not apply moisture barrier on the evening shift on 07/04/22 and 07/10/22 and on night shift on 07/01/22, 07/04/22, 07/06/22, 07/09/22 and 07/10/22; check function of the low air loss pressure redistribution mattress to the bed on the evening shift on 07/04/22 and 07/10/22 and on night shift on 07/01/22, 07/04/22, 07/06/22, 07/09/22 and 07/10/22; turn and reposition the resident every two hours on 07/06/22, 07/09/22 and 07/10/22 in the evening and on 07/06/22 at night; and perform the treatment to the left buttock on 07/10/22 in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365006 If continuation sheet Page 5 of 12 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 07/20/2022 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 0686 evening and at night on 07/06/22, 07/09/22 and 07/10/22. Level of Harm - Minimal harm or potential for actual harm Interview on 07/13/22 at 10:34 A.M. with the Direct of Nursing (DON) verified the TARs for June 2022 and July 2022 to have treatments and skin prevention orders not documented as completed for the dates listed above. Residents Affected - Few Review of the facility policy titled, Pressure Ulcer Prevention Protocols/Risk Assessment, dated 11/13/19, revealed the facility was to place a pressure redistribution mattress to the bed and to protect skin from moisture by utilizing techniques including applying moisture barrier and turning and repositioning the resident as appropriate to meet the resident's needs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365006 If continuation sheet Page 6 of 12 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 07/20/2022 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 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. Based on interview, record review, and review of the facility policy on falls, the facility failed to ensure new fall prevention interventions were implemented after Resident #18 experienced falls. This affected one (Resident #18) of one resident reviewed for falls. The census was 40. Findings include: Review of the medical record for Resident #18 revealed an admission date of 08/18/20 with diagnoses including dementia with behavioral disturbance, schizoaffective disorder, delusional disorder, depression, muscle weakness, and difficulty in walking. Review of the fall investigations revealed Resident #18 experienced falls on 04/16/22, 05/21/22, and 07/01/22. Further review of the fall investigations revealed no new fall prevention interventions were implemented after Resident #18 experienced falls. Review of the falls care plan revised 07/12/22 revealed no new fall prevention interventions were implemented on or around 04/16/22, 05/21/22, and 07/01/22. Interview on 07/14/22 at 12:46 P.M. with the Director of Nursing (DON) verified no new interventions were implemented after Resident #18 experienced falls. Review of the facility policy titled Falls - Clinical Protocol, dated 11/13/2019, revealed facility staff and the resident's physician would identify pertinent interventions to try to prevent subsequent falls. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365006 If continuation sheet Page 7 of 12 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 07/20/2022 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on record review, interview and policy review, the facility failed to ensure scheduled pain medications were administered to Resident #22 as ordered by the physician. The facility also failed to ensure pain assessments were performed as ordered by the physician for Resident #22. This affected one (Resident #22) of one resident assessed for pain management. The facility census was 40. Residents Affected - Few Findings include: Review of the medial record for Resident #22 revealed an admission date of 10/21/21 with diagnoses including diabetes mellitus, chronic kidney disease, and osteoarthritis. Review of the care plan dated 11/03/21 for Resident #22 revealed she was at risk for pain discomfort related to osteoarthritis, cancer to her head/scalp area, depression, and diabetic neuropathy (weakness, numbness, and pain from nerve damage). Interventions included to assess for pain and to administer pain medications per the physician's order. Review of the physician's order dated 01/27/22 revealed nursing staff were to monitor for pain every shift. Resident #22 also had a physician's order dated 06/07/22 for Gabapentin 300 milligrams (mg) (nerve pain medication) two times a day for pain. Review of the Medication Administration Record (MAR) for June 2022 revealed nursing staff had not assessed Resident #22 for pain on the evening shifts of 06/10/22, 06/14/22, 06/15/22 and 06/24/22. The MAR also revealed Resident #22 had not received her Gabapentin 300 mg doses on the evening shift of 06/10/22, 06/14/22, 06/15/22 and 06/24/22 Review of the MAR for July 2022 revealed staff had not assessed Resident #22 for pain on the evening shift of 07/03/22. The MAR also revealed Resident #22 had not received her Gabapentin 300 mg. dose on 07/03/22 on the evening shift. Interview on 07/11/22 at 9:41 A.M. with Resident #22 revealed she did not get medications on time or at all including her pain medications. She stated she was in pain at times because the nursing staff did not administer her pain medications as ordered. Interview on 07/18/22 at 2:35 P.M. with the Director of Nursing (DON) verified Gabapentin was not signed off on the MAR as administered on the dates listed above. The DON also verified the pain assessments were not signed off as completed on the MAR on the dates listed above. Review of the facility policy titled, Pain Assessment and Management, dated 11/13/19, revealed the staff were to assess the resident's pain and consequences of pain at each shift and document. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365006 If continuation sheet Page 8 of 12 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 07/20/2022 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 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 and interview, the facility failed to ensure dialysis residents were monitored before and after dialysis treatments. The facility also failed to ensure resident dialysis catheters were assessed as ordered by the physician. This affected three (Resident's #12, #22, and #140) of three residents receiving dialysis. The facility census was 40. Residents Affected - Many Findings include: 1. Review of the medical record revealed Resident #12 was admitted on [DATE] with diagnoses including end stage renal disease and dependence on renal dialysis. There were no dialysis assessments performed for Resident #12 before going to dialysis or after returning. Review of the physician's order dated 02/01/22 revealed Resident #12 had dialysis on Tuesdays, Thursdays, and Saturdays. Resident #12 also had a physician's order dated 01/05/22 for staff to monitor the left inter-jugular dialysis site every shift for signs of infection and to ensure that ports are clamped; document abnormal findings; report to dialysis center and nephrologist; dressing changes per dialysis center-reinforce if needed; if the catheter was dislodged or bleeding was found, apply pressure for 15 minutes; and if bleeding does not stop call 911 and notify the physician and dialysis center. Review of the Treatment Administration Record (TAR) for June 2022, revealed assessments of the left inter-jugular dialysis site were not performed as ordered by the physician on dayshift on 06/15/22; on the evening shift on 06/04/22, 06/05/22, 06/14/22, 06/24/22; and on the night shift on 06/03/22, 06/06/22, 06/11/22, 06/14/22, 06/22/22, 06/23/22 and 06/26/22. Review of the TAR for July 2022, revealed assessments of the left-inter jugular dialysis site were not performed as the physician had ordered on the evening shift on 07/04/22, 07/06/22 and on 07/10/22; and on the night shift on 07/01/22, 07/04/22, 07/06/22, 07/09/22 and 07/10/22. Interview on 07/14/22 at 9:46 A.M. with the Director of Nursing (DON), verified there were no assessments before or after dialysis for Resident #12. The DON verified nursing staff had not signed off on the TAR for the dialysis site assessments ordered by the physician on the dates listed above. 2. Review of the medical record revealed Resident #22 was admitted on [DATE] with diagnoses including chronic kidney disease and dependence on renal dialysis. There were no dialysis assessments performed for Resident #22 before going to dialysis or after returning. Review of the physician's order dated 04/05/22 revealed Resident #22 had dialysis on Tuesdays, Thursdays, and Saturdays. Resident #22 also had a physician's order dated 04/05/22 for staff to assess her dialysis shunt every shift; assess for bruit, thrill, and signs of infection; document abnormal findings and report to the dialysis center and nephrologist; if bleeding was noted to apply pressure for 15 minutes, and if bleeding continued to call 911 and notify the doctor. Review of the TAR for June 2022, revealed assessments of the dialysis shunt were not performed as ordered by the physician on dayshift on 06/15/22; on the evening shift on 06/04/22, 06/05/22, 06/14/22, 06/24/22; and on the night shift on 06/03/22, 06/06/22, 06/11/22, 06/14/22, 06/21/22, 06/22/22, 06/23/22 and 06/26/22. Review of the TAR for July 2022, revealed assessments of the dialysis shunt were not performed as ordered by the physician on the evening shift on 07/06/22 and on 07/10/22; and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365006 If continuation sheet Page 9 of 12 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 07/20/2022 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 0698 on the night shift on 07/01/22, 07/04/22, 07/06/22, 07/09/22 and 07/10/22. Level of Harm - Minimal harm or potential for actual harm Interview on 07/14/22 at 9:46 A.M. with the DON, verified there were no assessments before or after dialysis for Resident #22. The DON verified nursing staff had not signed off on the TAR for the dialysis shunt assessments ordered by the physician on the dates listed above. Residents Affected - Many 3. Review of the medical record revealed Resident #140 was admitted on [DATE] with end stage renal disease and dependence on renal dialysis. There were no dialysis assessments performed for Resident #140 before going to dialysis or after returning. There were no physician's orders to assess Resident #140's dialysis shunt. Review of the physician's order dated 06/23/22 revealed Resident #140 had dialysis on Mondays, Wednesdays, and Fridays. Review of the TAR for June 2022, revealed Resident #140 had dialysis on 06/29/22. The nursing staff had not signed off on the TAR if Resident #140 had gone to dialysis on 06/24/22 or 06/27/22. Review of the TAR for July 2022, revealed Resident #140 had dialysis on 07/01/22 and 07/06/22. The nursing staff had not signed off on the TAR if Resident #140 went to dialysis on 07/04/22, 07/08/22 or 07/11/22. Review of the care plan dated 07/08/22 for Resident #140 revealed nursing staff were to notify the physician if dialysis shunt problems; if no bruit or thrill or bleeding; if signs and symptoms of infection at port site; abnormal lab values; signs and symptoms of fluid retention; peripheral edema; weight gain; neck vein distension, orthopnea (shortness of breath with lying flat), elevated blood pressure, tachycardia (fast heart rate); and tachypnea (fast breathing). Interview on 07/14/22 at 9:46 A.M. with the DON, verified there were no assessments before or after dialysis for Resident #140. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365006 If continuation sheet Page 10 of 12 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 07/20/2022 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure Resident #20 was free of significant medication errors. This affected one (Resident #20) of one resident reviewed for significant medication errors. The facility census was 40. Residents Affected - Few Findings include: Review of the medical record revealed Resident #20 was admitted on [DATE] with diagnoses including dementia, schizophrenia, and anxiety. Review of the handwritten physician medication order dated 06/23/22 revealed Resident #20 was ordered Lexapro 10 milligrams (mg) daily for seven days and then increase Lexapro to 20 mg daily. Review of the Medication Administration Record (MAR) for June 2022 revealed Resident #20 had an order for Lexapro 10 mg one time a day for antidepressant for seven days then increase to 20 mg daily dated 06/24/22. Review of the MAR for July 2022 revealed Resident #20 was administered Lexapro 10 mg on 07/01/22, 07/02/22, 07/04/22 and 07/05/22 at 4:00 P.M. Lexapro 10 mg was discontinued on 07/06/22. Resident #20 had another order for Lexapro dated 07/01/22 for 20 mg and was administered this medication on 07/01/22, 07/03/22, 07/04/22 and 07/05/22 at 6:00 A.M. Resident #20 received Lexapro 30 mg on 07/01/22, 07/04/22, and 07/05/22. Interview on 07/13/22 at 4:05 P.M. with Pharmacist #567 revealed Lexapro is given at 10 mg for the first seven days to assess for toxicity to the resident. Pharmacist #567 stated the medication is then increased to Lexapro 20 mg daily. Interview on 07/13/22 at 4:11 P.M. with the Direct of Nursing (DON) verified the medication error of Resident #20's Lexapro 10 mg not being discontinued on 06/30/22 after seven days per the physician's order. The DON verified Resident #20 received a total of 30 mg of Lexapro on 07/01/22, 07/04/22, and 07/05/22 per the MAR. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365006 If continuation sheet Page 11 of 12 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 07/20/2022 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 - Few 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, staff interview, and review of the facility's administration procedures for all medications, the facility failed to ensure medications were dated when opened and disposed of when expired or discontinued. This affected two (Resident's #1 and #20) of two residents whose insulins were stored in the medication cart. The facility census was 40. Findings include: 1. Review of the medical record revealed Resident #1 was admitted on [DATE] with diagnoses including diabetes mellitus and dementia. Review of the physician's orders revealed Resident #1 had an order dated [DATE] for Insulin Aspart Solution (medication for diabetes), inject seven units subcutaneously with meals. He also had an order dated [DATE] for Insulin Aspart Solution for sliding scale, which would provide a dose depending on the resident's blood sugar. Resident #1's blood sugars were noted to range from 123 to 435 in [DATE]. Resident #1's blood sugars were noted to be between 68 to 538 in [DATE]. Observation on [DATE] at 12:43 P.M. with Licensed Practical Nurse (LPN) #557 of the [NAME] Medication Cart revealed Resident #1 had two Insulin Aspart vials. One vial was dated [DATE] (the date the medication was opened) and the other vial was undated but had a pharmacy dispense date of [DATE]. LPN #557 stated she did not have time to go through the medication cart to date medications that the other nurses had opened. Review of the facility policy titled, Administration Procedures for All Medications, updated [DATE], stated staff were to check the expiration date on the package/container before administering any medications. The staff were to place a date on the container when opening multi-dose containers. 2. Review of the medical record revealed Resident #20 was admitted on [DATE] with diagnoses including diabetes mellitus and dementia. Review of the physician's orders revealed Resident #20 had an order dated [DATE] for Humalog KwikPen Solution (medication for diabetes), inject per sliding scale three times a day with meals. This order was discontinued on [DATE]. Resident #20's insulin order changed to Novolog Flex Pen on [DATE]. Observation on [DATE] at 12:43 P.M. with LPN #557 of the [NAME] Medication Cart revealed Resident #20 had two Humalog Kwik Pens. One Humalog Kwik Pen was dated [DATE] (the date the medication was opened) and the other Humalog Kwik Pen was undated but had a pharmacy dispense date of [DATE]. LPN #557 verified the Humalog Kwik Pens were expired and had been discontinued. Review of the facility policy titled, Administration Procedures for All Medications, updated [DATE], stated staff were to check the expiration date on the package/container before administering any medications. The staff were to place a date on the container when opening multi-dose containers. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365006 If continuation sheet Page 12 of 12