Health inspection·October 24, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm [DATE] with diagnoses including acute kidney failure, wedge compression fracture of fifth lumbar vertebra, and adult failure to thrive. Review of the Baseline Care Plan (BCP) assessment dated [DATE] revealed Resident #268 was substantial to maximal assist for ADLs and was occasionally incontinent of bowel and bladder. Residents Affected - Some Review of the care plan dated 10/16/23 revealed Resident #268 had an ADL self-care performance deficit. Interventions included staff assistance of one person for toileting. Review of the progress note dated 10/16/23 at 5:06 P.M. revealed Resident #268 admitted to the facility incontinent of bowel and bladder. Observation and interview on 10/17/23 at 10:26 A.M. revealed Resident #268 was yelling out from her bed for help and her call light was not activated. Upon entering the room, Resident #268 revealed she was placed on the bedpan 30 minutes ago and her buttocks were numb and hurting. Resident #268 revealed she could not identify the staff member who placed her on the bedpan. Interview and observation on 10/17/23 at 10:28 A.M. during the time of incontinence care for Resident #268 with Registered Nurse (RN) #848 and #909 revealed she was sitting on a bedpan with an incontinence brief in place. Resident #268 brief was intact and fully secured in place. Upon removal of brief, Resident #268 had a large amount of stool in place. RN #848 and #909 revealed they did not know how long Resident #268 was left on the bedpan and did not know why she would be placed on a bedpan with a brief fully intact. RN #848 and #909 verified the findings at the time of the observation. 3. Review of the medical record for Resident #52 revealed she was admitted to the facility on [DATE] with diagnoses including type two diabetes, depression, and anxiety disorder. Review of the annual MDS 3.0 assessment dated [DATE] revealed she had a BIMS score of 15 that indicated she was alert and oriented to person place and time. Resident #52 was moderate assist to independent for ADLs. Observation during the annual screening process with Resident #52 on 10/16/23 at 11:17 A.M. revealed Registered Nurse (RN) #968 entered Resident #52's room without knocking and proceeded to question Resident #52 on who she was talking to. Interview on 10/16/23 at 11:17 A.M. with RN #968 revealed she heard Resident #52 talking as if she was on a conference call on the phone and entered to see who she was talking to. RN #968 revealed she knew the protocol for entering residents rooms and was supposed to knock prior to entering. Interview with RN #968 verified she entered Resident #52's room without knocking first. Interview on 10/16/23 at 11:18 A.M. with Resident #52 revealed sometime staff entered her room without knocking. 4. Review of the medical record revealed Resident #49 was admitted on [DATE] with diagnoses of chronic kidney disease, dementia, aphasia, dysphagia, hypertension, anemia, pressure ulcer of sacral region, gastrostomy status, history of COVID-19, hypertensive heart disease, and chronic atrial fibrillation. The annual MDS 3.0 assessment dated [DATE] revealed Resident #49 had severely impaired cognition (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365046 If continuation sheet Page 2 of 24 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 365046 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Daughters of Miriam Center for Nursing & Rehabilit One David N Myers Parkway Beachwood, OH 44122 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 0550 and was rarely understood. Level of Harm - Minimal harm or potential for actual harm Observation on 10/18/23 at 2:35 P.M. revealed RN #977 entered Resident #49's room without knocking. Residents Affected - Some Observation on 10/18/23 at 2:39 P.M. revealed RN #977 entered Resident #49's room again without knocking. Interview on 10/18/23 at 2:49 P.M. with RN #977 confirmed she did not knock before entering Resident #49's room because She is not going to be able to hear me anyways! RN #977 verified she was suppose to knock before entering resident rooms. Review of the facility document titled Offering/Removing Bedpan/Urinal dated February 2018, revealed the facility had a policy in place to not allow a resident to sit on a bedpan for extended periods. Further review of the policy revealed it would cause discomfort and cause skin breakdown for the resident. Review of the Rights and Responsibilities Code of Conduct and Ohio Revised Code sections 3721.10 to 3721.17 located in the admission Agreement revealed residents had the right to have room doors closed and to not have them opened without knocking, except in a case of an emergency and to respect their privacy and personal belongings. Review of the document revealed the facility did not implement the policy. This deficiency represents non-compliance investigated under Master Complaint Number OH00147069 and Complaint Number OH00146916. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365046 If continuation sheet Page 3 of 24 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 365046 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Daughters of Miriam Center for Nursing & Rehabilit One David N Myers Parkway Beachwood, OH 44122 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 0567 Honor the resident's right to manage his or her financial affairs. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview the facility failed to obtain signed authorization with a witness not connected to the facility to open resident accounts. This affected two residents (#36 and #121) of five residents reviewed for personal resident fund accounts. The facility census was 142. Residents Affected - Few Findings include: On 10/23/23 at 1:30 PM a review of personal resident funds was conducted with Resident Banker (RB) #763 and the Administrator. Review of the personal resident fund account for Resident #36 revealed a balance of $1737.34. There was not an authorization for the facility to open and manage resident funds. This was verified by an interview with RB #763 and the Administrator at the time of the review. Review of the personal resident fund account for Resident #121 revealed a balance of negative $46.00. There was not an authorization for the facility to open and manage resident funds. This was verified by an interview with RB #763 and the Administrator at the time of the review. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365046 If continuation sheet Page 4 of 24 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 365046 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Daughters of Miriam Center for Nursing & Rehabilit One David N Myers Parkway Beachwood, OH 44122 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure a complete and accurate care plans had been established for Resident #11. This affected one resident (#11) of 29 residents reviewed for care plans. The facility census was 142. Findings include: Review of the medical record revealed Resident #11 was admitted on [DATE]. Diagnoses included multiple sclerosis, Alzheimer's Disease with late onset dementia, anemia, neuromuscular dysfunction of bladder, age-related osteoporosis, depression, hypothyroidism, osteogenesis, presence of urogenital implants, history of COVID-19, and retention of urine. Review of Resident #11's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #11 had intact cognition and had a foley catheter for bladder elimination. Review of Resident #11's care plan dated 09/12/23 did not include foley catheter care. Review of physician orders for October 2023 revealed no orders for foley catheter care. Interview on 10/24/23 at 10:26 A.M. with the Director of Nursing (DON) verified Resident #11 did not have a care plan for foley catheter care. Review of the facility policy, Catheter Care, Urinary, revised September 2014, revealed the purpose of the procedure was to prevent catheter-associated urinary tract infections and to review the resident's care plan to assess for any special needs of the resident. Review of the facility policy, Care Plan, Comprehensive Person-Centered, revised March 2022, revealed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365046 If continuation sheet Page 5 of 24 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 365046 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Daughters of Miriam Center for Nursing & Rehabilit One David N Myers Parkway Beachwood, OH 44122 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #90's medical record revealed an admission date of 01/07/22. Diagnoses included stroke with left sided weakness. Residents Affected - Few Review of care plan dated 07/25/23 revealed Resident #90 had self care performance deficits. Interventions included assist resident with care as needed. Review of MDS dated [DATE] revealed Resident #90 had intact cognition. Resident #90 required extensive assistance with bed mobility, transfers, toileting and personal hygiene. Review of a progress note dated 10/11/23 revealed Resident #90 had spilled hot coffee on herself resulting in a second degree burn to her right thigh. Review of physician orders dated 10/12/23 revealed cleanse Resident #90's right thigh burn with normal saline, apply silvadene (burn ointment) cream, apply xeroform (lubricated wound dressing) and cover with absorbent dressing twice a day and as needed. Interview on 10/16/23 at 12:25 P.M. with Resident #90 revealed approximately a week ago she had burned her leg after spilling a cup of hot coffee. Observation of Resident #90 at time of interview revealed she was in bed and her right leg was exposed. Resident #90's right leg had a gauze dressing wrapped around her leg that was not intact and was not covering the entire burned area. Observation further revealed Resident #90 had a large burn from the top portion of her right outer thigh that extended down to close proximity of the resident knee area. Resident #90 stated wound care was performed almost every day. Observation of wound care on 10/19/23 beginning at 11:10 A.M. for Resident #90 with LPN #807 revealed she was unable to locate the resident ordered wound cream or normal saline to perform the wound care. LPN #807 stated she would inform the unit manager to attempt to locate the needed supplies. At 11:44 A.M. unit manager, LPN #853, had returned to the unit and had informed LPN #807 she was unable to locate Resident #90's ordered wound cream. LPN #853 stated she had contacted the nurse practitioner and had obtained new orders for Resident #90's wound care until the ordered wound cream was delivered to the facility. At 12:26 P.M. LPN #807 had entered Resident #90's room to begin wound care. Observation of wound care with LPN #807 revealed Resident #90 had a foam dressing dated 10/19/23 to the top portion of the resident's right thigh. LPN #807 stated the physician orders for the wound care did not include a foam dressing and she was not able to state why a foam dressing had been placed on Resident #90's burned area. Further observation revealed no other dressings to Resident #90's large, burned area. LPN #807 stated the orders stated to cover the entire burned area with xeroform (lubricated wound dressing) and cover with an absorbent dressing. Further observation revealed Resident #90 had a thin piece of an unidentified material (appeared to be a piece of wound tape) that was stuck to a section of Resident #90's burned area. LPN #807 was unable to state what the material was. This violation represents non-compliance investigated under Master Complaint Number OH00147069. Based on record review, facility policy review and interview the facility failed to administer insulin per physician order and complete blood sugar testing related to the administration of insulin for Resident #66. This affected one resident (#66) of five residents reviewed for medication administration. In addition, based on observation, interview and record review, the facility failed to ensure (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365046 If continuation sheet Page 6 of 24 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 365046 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Daughters of Miriam Center for Nursing & Rehabilit One David N Myers Parkway Beachwood, OH 44122 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 adequate care and treatment of a burn-related wound for Resident #90. This affected one resident (#90) of five residents reviewed for wound care. The facility census was 142. Findings include: 1. Review of the medical record revealed Resident #66 was admitted on [DATE] with a diagnosis including type two diabetes mellitus (DM). Review of the quarterly Minimum Data Set (MDS) 3.0 assessment date 10/02/23 revealed Resident #66 had intact cognition. Review of the physician orders dated October 2023 revealed an order for glargine subcutaneous (SQ) solution pen-injector 100 unit/Milliliter (U/ml) (Insulin Glargine) inject 12 units SQ at bedtime related to type two DM and insulin Lispro injection solution 100 U/ml (Insulin Lispro) inject four units SQ with meals related to type two DM. Review of the Medication Administration Record (MAR) for October 2023 revealed the blood sugar to be checked at 9:00 P.M. and administer the insulin glargine 12 units SQ at that time. The glargine insulin was given without first checking Resident #66's blood sugar on 10/01/23, 10/05/23, 10/06/23 and 10/11/23 which was indicated on the MAR by the letters NA. The letters NA were not listed on the MAR as a code to be used for documentation. Review of the MAR for October 2023 revealed insulin Lispro injection solution 100 U/ml to inject four units SQ with meals (and check blood sugars at meals) was not administered per physician orders and/or blood sugars (BS) not checked prior to administration on the following dates/times: 10/02/23 at 8:00 A.M., 12:00 P.M. and 5:00 P.M. the BS slot had a letter X (no blood sugar level recorded) in the slot and a code #5 indicating the insulin was not given due to vitals/labs outside parameters. On 10/04/23 at 8:00 A.M. and 12:00 P.M. no BS was taken (blank slot) and no signature signed off for insulin administered. On 10/05/23 8:00 A.M, 12:00 P.M. and 5:00 P.M. the BS slot had an X and signature for code #5 indicating medication not administered. On 10/06/23 the BS at 8:00 A.M. was recorded as 117 with a code #5 with signature indicating the medication not administered. On 10/07/23 at 12:00 P.M. a BS of 152 was recorded and signature with code #5 indicating medication not administered, and at 5:00 P.M. a BS was recorded at 134 and signature with code #5 indicating medication not given. On 10/08/23 at 8:00 A.M. a BS was not recorded, and insulin was not given. On 10/08/23 at 5:00 P.M. a BS of 130 was recorded and signature with code #5 indicating medication not administered. On 10/10/23 at 8:00 A.M. and 12:00 P.M. a BS was not recorded, and the insulin was not given and at 5:00 P.M. a BS of 130 was recorded and signature with code #5 indicating medication not administered. On 10/11/23 at 8:00 A.M, 12:00 P.M., and 5:00 P.M. a BS of 106, 124, and 119 respectfully and signature with a code #5 indicating medication not administered. On 10/12/23 for 5:00 P.M. the BS was not taken, and medication not administered. On 10/13/23 at 8:00 A.M. a BS had an X and signature with code #5 indicating medication not administered. On 10/14/23 at 8:00 A.M. a BS of 103 was recorded and a signature with code #5 indicating medication not administered and 12:00 P.M. a BS of 128 and signature with code #5 indicating medication not administered. On 10/15/23 at 8:00 A.M. a BS with an X recorded and 12:00 P.M. BS of 135 and both the 8:00 A.M. and 12:00 P.M. signature with code #5 indicating medication not administered. During an interview on 10/16/23 at 10:15 A.M. with Resident #66 revealed concerns she was diabetic, and her blood sugar wasn't taken, and medications were not provided as ordered. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365046 If continuation sheet Page 7 of 24 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 365046 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Daughters of Miriam Center for Nursing & Rehabilit One David N Myers Parkway Beachwood, OH 44122 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 Interview on 10/19/23 at 12:00 P.M. with Director of Nursing (DON) regarding Resident #66's MAR documentation pertaining to the X, NA and blank spots for BS and insulin administration revealed she did not know what it meant, and she would have to check. Interview on 10/19/23 at 1:57 P.M. with LPN #853 revealed she didn't know what the X or NA in the BS slot meant. LPN #853 verified the X or NA was not one of the documentation codes listed on the MAR. LPN #853 verified the blood sugars were not taken per physician orders and insulin not administered per physician orders. LPN #853 kept saying we need to do a lot of education. LPN #853 verified for glargine insulin on 10/01/23, 10/5/23, 10/06/23, 10/11/23, and for Lispro insulin any blank slot, NA, and X indicated the blood sugar was not taken and verified #5 with signature meant no insulin medication was administered. Interview on 10/19/23 at 2:15 P.M. with RN #848 revealed she didn't know what the X or NA in the BS slot meant. RN #848 verified the X or NA was not one of the codes listed on the MAR. RN #848 verified the blood sugars were not taken per physician orders or insulin not administered per physician orders. RN #848 reported education would need to be done. RN #848 verified for glargine insulin for 10/01/23, 10/5/23, 10/06/23, 10/11/23, and for Lispro insulin any blank slot, NA, and X indicated no blood sugar was not taken and verified #5 with signature meant no insulin medication was administered. Review of facility policy, Medication Administration, effective date 09/14/20 revealed the individual administering the medications will check the label three (3) times and verify the right patient/resident right medication, right dose, right time, right route, right documentation and ensure patient/resident is in proper positioning. Review of facility policy, Obtaining a Fingerstick Glucose Level, revised October 2011, revealed the purpose of the procedure is to obtain a blood sample to determine the resident's blood glucose level and the following documentation guidelines to include the date and time procedure performed, name and title of individual who performed the procedure, if resident refused, reason why, and intervention taken, the blood sugar results and to follow facility policies and procedures for appropriate nursing interventions regarding blood sugar results (if resident is on sliding scale coverage, and/or physician intervention is needed to adjust insulin or oral medication doses, etc , the signature and title of the person recording the date, report results promptly, notify supervisor if resident refuses, and report other information in accordance with facility policy and professional standards of practice). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365046 If continuation sheet Page 8 of 24 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 365046 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Daughters of Miriam Center for Nursing & Rehabilit One David N Myers Parkway Beachwood, OH 44122 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** 2. Review of the medical record for Resident #99 revealed an admission date of 02/15/20. Diagnoses included anemia, difficulty in walking, muscle weakness, lung cancer, and stroke. Residents Affected - Few Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident's cognition was not assessed, the resident required extensive assistance of one staff for bed mobility, transfers, and toilet use. The assessment also indicated the resident had one stage three pressure ulcer (full thickness tissue loss where fat may be exposed) and one deep tissue injury. Review of wound notes dated 09/06/23 through 10/16/23 revealed Resident #99 had impaired skin including a right heel wound. Recommendations included monitor site for signs and symptoms of infection, bogginess, drainage, erythema; air mattress to bed and check for function every shift and as needed; elevate heels off mattress while in bed with pillows or heel offloading boots; and left heel to pad and protect with foam daily and prn. The resident was noted to be noncompliant with elevating heels or heel offloading boots. Review of the October 2023 physician orders included orders for low air loss mattress, check for bottoming out every shift for skin precautions with a start date of 06/19/23. Review of the census list revealed the resident moved from the first floor to the third floor on 10/11/23. Interview and observation on 10/17/23 at 3:47 P.M. of Resident #99 in bed laying on her back on a regular mattress with her right foot wrapped, offloading boot in use and legs propped on a pillow. Interview at this time with Resident #99 revealed her air mattress was still in her old room and she had been in the current room since last Monday. Resident #99 stated she was told someone was supposed to bring her the air mattress. Observation on 10/17/23 at 3:55 P.M. with LPN #991 of Resident #99's mattress revealed LPN #991 verified the mattress Resident #99 was laying on was a regular mattress and not the low air loss mattress. LPN #991 stated the resident told her earlier today she was waiting on her air mattress to be brought up. Interview on 10/18/23 at 9:17 A.M. with Resident #99 revealed still no update on her air mattress and observed she was still laying in the regular mattress. Interview on 10/19/23 at 10:22 A.M. with Resident #99 revealed she had not heard anything regarding her air mattress and observed she still had the regular mattress. Interview on 10/19/23 at 1:54 P.M. with Housekeeping Supervisor (HKS) #958 revealed he just brought up the air mattress for Resident #99 about 10 minutes ago. Observation at this time of Resident #99 was up and dressed sitting in a wheelchair in her room. The air mattress was on the bed and in the process of inflating on the bed. HSK #958 stated it should take about 20 minutes to inflate it and that it was brand new out of the box. Review of the facility policy titled Pressure Ulcers/Skin Breakdown-Clinical Protocol, revised April 2018 revealed under treatment/management the physician will order pertinent wound treatments, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365046 If continuation sheet Page 9 of 24 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 365046 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Daughters of Miriam Center for Nursing & Rehabilit One David N Myers Parkway Beachwood, OH 44122 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 Level of Harm - Minimal harm or potential for actual harm including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.), and application of topical agents. Under monitoring, revealed current approaches should be reviewed for whether they remain pertinent to the resident/patient's medical conditions, are affected by factors influencing wound development or healing, and the impact of specific treatment choices made by the resident/patient or a substitute decision-maker. Residents Affected - Few This deficiency represents non-compliance investigated under Master Complaint Number OH00147069. Based on observation, record review, policy review and interview the facility failed to provide adequate care and services to identify, assess and/or provide treatments to promote healing of a pressure ulcer for Resident #19 and Resident #99. This affected two residents (#19 and #99) of five residents reviewed for wound care and/or pressure ulcers. The facility census was 142. Findings include: 1. Review of Resident #19's medical records revealed an admission date of 03/11/22. Diagnoses included stage four pressure ulcer ( full thickness loss of tissue exposing bone, muscle or tendon) of the sacrum (tailbone), muscle weakness, and difficulty walking. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #19 had impaired cognition. Resident #19 required extensive assistance with bed mobility, toileting and personal hygiene and total dependence for transfers. Review of progress notes dated 08/26/23 to 08/27/23 revealed Resident #19 was identified as having an open area to the coccyx, the area was assessed and measured and the physician and family had been notified. Further review of the medical record for any wound assessment dated [DATE] revealed no evidence of the wound identified on 08/26/23 being measured and assessed for care and treatments prior to the resident being sent to the hospital. On 08/27/23 Resident #19 was sent to the hospital for evaluation and treatment following a fall. Review of hospital records from 08/27/23 to 09/05/23 revealed Resident #19's care included treatments to a wound on her sacrum. Review of a progress note dated 09/05/23 revealed Resident #19 was readmitted to the facility. Review of physician orders dated 09/27/23 through 10/20/23 revealed to cleanse sacral wound with normal saline, pack wound with Dakins (antiseptic solution) soaked gauze and cover completely twice daily and as needed. Review of the care plan dated 09/28/23 revealed Resident #19 was admitted with a pressure ulcer upon admission from the hospital. Interventions included administer treatment as ordered and monitor for effectiveness. Observation of wound care on 10/18/23 at 12:22 P.M. with Licensed Practical Nurse (LPN) #942 for Resident #19 revealed the resident had a foam dressing dated 10/18/23, the dressing was not intact and was not fully covering the sacral wound. LPN #942 confirmed the dressing was not covering the wound and had proceeded to remove the dressing. When LPN #942 removed the dressing two small balled up (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365046 If continuation sheet Page 10 of 24 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 365046 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Daughters of Miriam Center for Nursing & Rehabilit One David N Myers Parkway Beachwood, OH 44122 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete dry pieces of gauze fell out of Resident #19's sacral wound. LPN #942 verified the observation and explained Resident #19's wound orders were to pack the sacral wound with Dakins soaked gauze. LPN #942 stated the gauze should have been in one piece and should have been moistened. An interview conducted on 10/24/23 at 1:33 P.M. with the Director of Nursing (DON) revealed the nursing supervisor had been aware Resident #19 had an open area to her sacrum on 08/26/23 which was the day prior to Resident #19's hospital admission. The DON confirmed there was no evidence of a wound assessment measuring the wound or putting any treatments or interventions in place prior to the resident being sent to the hospital on [DATE]. Event ID: Facility ID: 365046 If continuation sheet Page 11 of 24 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 365046 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Daughters of Miriam Center for Nursing & Rehabilit One David N Myers Parkway Beachwood, OH 44122 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** 3. Review of the medical record for Resident #126 revealed an admission date of 06/25/23. Diagnosis included congestive heart failure, type two diabetes mellitus, difficulty walking, muscle weakness, age related osteoporosis, and unsteadiness on feet. Review of the morse fall scale dated 06/25/23 revealed the resident was high risk for falls. Review of the incident audit report dated 07/03/23 revealed Resident #126 had an unwitnessed fall in her room. The audit report stated the following: the resident was observed sitting on the floor, in front of wheelchair, blood on the floor in front of dresser, bedside table moved to side, telephone on the floor off the hook in blood. Call light attached to rail and within reach, not sounding, resident was wearing pants, sweater, skid free socks, and oxygen was in place. Resident was bleeding from left side of head, with hematoma present. Resident stated, I fell out of the chair. Action taken included vital signs were obtained, on oxygen via nasal cannula, 911 was called, range of motion (ROM) performed and were within normal limits (WNL) of resident. Cold pack placed on left side of head. Staff attempted to lay resident down, resident complained of nausea, and sat back up. Resident still unable to tell staff what happened. Rescue squad in and assessed resident, stood, and pivoted patient to cot and left facility. Resident's son and nurse practitioner were called and informed of fall and being sent to hospital. New intervention included Dycem (prevents sliding) to wheelchair cushion. Review of the incident audit report dated 08/04/23 revealed Resident #126 had an unwitnessed fall in her room. The audit report stated the following: staff heard a loud crash and therapy staff were first to enter the resident's room. The resident was observed laying on the floor against the wall beside the closet bleeding from the head. Resident was responsive and alert. Vital signs were obtained. Resident was seen by the nurse practitioner and ordered to send to the hospital via 911. Ice applied to head until 911 arrived. Resident stated she slipped trying to go to the bathroom. Resident's son was informed. Under notes section, the new invention included call before fall sign placed in the resident room to remind her to use her call light for assistance. Review of the quarterly MDS assessment dated [DATE] revealed the resident had intact cognition, used a walker and/or wheelchair, and had two or more falls with injury since admission. Review of the plan of care revised 08/15/23 revealed Resident #126 was at risk for falls related to history. Fall with injury on 07/03/23 and 08/14/23 fall with injury. Intervention included call before you fall sign placed in the resident room to remind her to use her call light for assistance. Observation 10/18/23 at 4:10 P.M. of Resident #126 in her room sitting in her wheelchair, shoes on her feet but no call before you fall signs observed in the resident's room. Interview on 10/18/23 at 4:17 P.M. with STNA #708 revealed Resident #126 had not had any recent falls. Review of Resident #126's care plan with STNA #708 verified one of her fall interventions included a call before fall sign placed in the resident's room. Observation and interview on 10/18/23 at 4:30 P.M. with STNA #708 verified there was no call before you fall sign placed in the resident's room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365046 If continuation sheet Page 12 of 24 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 365046 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Daughters of Miriam Center for Nursing & Rehabilit One David N Myers Parkway Beachwood, OH 44122 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 This deficiency represents non-compliance investigated under Complaint Number OH00147069. Level of Harm - Minimal harm or potential for actual harm Based on observation, medical record review, resident interview, staff interview, and policy review, the facility failed to utilize proper transfer technique for Resident #258 and Resident #19, and failed to ensure fall interventions were implemented to mitigate fall risks for Resident #126. This affected three residents (#258, #19 and #126) of four residents reviewed for accidents/hazards. The facility census was 142. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #258 revealed she was admitted to the facility on [DATE] with diagnoses including displaced intertrochanteric fracture of right femur, muscle weakness, and difficulty in walking. Review of the Five day Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating she was alert ad oriented to person, place, and time. Resident #258 was maximal assist for Activities of Daily Living (ADLs). Review of the care plan dated 10/05/23 revealed Resident #258 had an ADL self-care performance deficit and was at risk for falls due to a history of falls. Interventions included staff assistance of one-person for transfers and to be free from injury. Review of the physician orders dated 10/06/23 revealed an order for physical therapy evaluation and treatment five to six times per week for 45 days. Review of the physical and occupational therapy evaluations dated 10/06/23 revealed Resident #258 was a maximal assist of two-people for transfers, moderate to maximal assist for sit-to-stand and basic functional transfers, and required moderate to maximal assist for standing balance and safe ambulation. Observation on 10/17/23 at 10:14 A.M. revealed Resident #258 was sitting in a chair scale adjacent to her bed. State Tested Nurse Assistant (STNA) #871 was standing next to Resident #258 on her right side while STNA #762 was standing near the window on the opposite side of the bed. Observation revealed STNA #871 lifted Resident #258 out of the chair scale and into her arms. Resident #258's body was positioned on STNA #871's forearms and then STNA #258 moved her onto the side of the bed and positioned Resident #258's legs into the bed. STNA #258 used no assistive devices or medical equipment such as a wheelchair or wheeled walker at the time of the transfer. STNA #762 did not assist with the transfer. Interview on 10/17/23 at 10:16 A.M. with STNA #871 revealed Resident #258 was alert and oriented but could not ambulate on her own. STNA #871 revealed she was obtaining Resident #258 weight, but she did not require a mechanical lift. STNA #871 revealed she was trained in appropriate techniques and devices to lift and move residents. STNA #871 verified at the time of the interview the above observation of the manual transfer by lifting Resident #258 into her arms and placing her in the bed. Interview on 10/17/23 at 10:18 A.M. with Resident #258 confirmed STNA #871 weighed her in the chair scale and picked her up and placed her in the bed by herself. Resident #258 revealed STNA #762 assisted once she was in bed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365046 If continuation sheet Page 13 of 24 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 365046 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Daughters of Miriam Center for Nursing & Rehabilit One David N Myers Parkway Beachwood, OH 44122 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 Interview on 10/24/23 at 2:22 P.M. with Rehab Director (RD) #868 revealed Resident #258 was a sit-to-stand for all transfers and required contact guard to minimal assist of one-person utilizing a wheelchair to walker. RD #868 revealed she should not have been manually lifted from the chair scale into her bed by staff. 2. Review of Resident #19's medical record revealed an admission date of 03/11/22 with diagnoses including muscle weakness and difficulty walking. Review of the care plan dated 09/28/23 revealed Resident #19 had self care deficits related to impaired mobility. Interventions included one person staff assist with use of a gait belt for transfers. Review of MDS 3.0 assessment dated [DATE] revealed Resident #19 had impaired cognition. Resident #19 required extensive assistance with bed mobility, toileting and personal hygiene. Resident #19 was totally dependent for transfers. Review of current physician orders for October 2023 revealed no orders related to transfers. Observation of transfer assistance on 10/18/23 at 9:52 A.M. with STNA #828 and #964 for Resident #19 revealed the resident was in a wheelchair and was requesting to be placed in bed. STNA #828 and #964 had assisted Resident #19 to stand and pivot into bed. STNA #828 and #964 had not used any assistive devices to assist with the transfer. Interview with STNA #828 and #964 revealed they were not aware of any assistive devices required to transfer Resident #19 and stated that was how they always transferred her. Interview on 10/24/23 at 2:16 P.M. with RD #868 revealed Resident #19 was no longer receiving physical therapy services due she had not been making progress. RD #868 stated Resident #19 had been discharged from services on 10/12/23 and at the time of the discharge a recommendation had been made for the use of mechanical lift for transfers. RD #868 stated the nursing staff should have informed the physician of the recommendations and orders should have been in place. RD #868 confirmed there were no physician orders to address the transfer status requiring use of a mechanical lift for Resident #19. RD #868 reviewed the care plan dated 09/28/23 and verified the care plan indicated Resident #19 required the use of a gait belt during transfers and did not specify a mechanical lift was needed to transfer Resident #19. Review of the facility document titled Safe Lifting and Movement of Residents revised July 2017, revealed the facility had a policy in place to protect the safety and well-being of staff and residents, and to promote quality care by using appropriate techniques and devices to lift and move residents. Review of the policy revealed manual lifting of residents would be eliminated when feasible. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365046 If continuation sheet Page 14 of 24 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 365046 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Daughters of Miriam Center for Nursing & Rehabilit One David N Myers Parkway Beachwood, OH 44122 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 Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review and interview the facility failed to timely collect a urine specimen for suspicion of a urinary tract infection for Resident #19 and failed to ensure physician's orders were in place for Foley catheter care for Resident #11. This affected two residents (#11 and #19) of three residents reviewed for Foley catheter care. The facility census was 142. Findings include: 1. Review of Resident #19's medical records revealed an admission date of 03/11/22. Diagnoses included neuromuscular bladder, difficulty walking and muscle weakness. Review of the care plan dated 09/28/23 revealed Resident #19 was on antibiotic therapy related to frequent urinary tract infections. Interventions included administer antibiotics as ordered. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #19 had impaired cognition. Resident #19 required extensive assistance with toileting and personal hygiene. Resident #19 was incontinent of bowel and bladder. Review of physician orders dated 10/11/23 revealed to straight cath (non indwelling urinary catheter used to collect urine specimen) to obtain a urinalysis and a culture and sensitivity. Review of a progress note dated 10/13/23 revealed unable to collect urine via straight cath. Review of a progress note dated 10/14/23 revealed urine was not collected. Review of progress note dated 10/18/23 revealed urine was not collected. Review of a progress note dated 10/23/23 at 8:15 P.M. authored by a nurse practitioner revealed Resident #19's family requested resident be sent to the hospital for evaluation and treatment related to abdominal pain. Progress note stated Resident #19's family had multiple complaints regarding the ordered urine collection. Observation on 10/24/23 at 7:42 A.M. revealed Resident #19 was present at the facility and was sleeping in bed. Interview on 10/24/23 at 7:55 A.M. with Licensed Practical Nurse (LPN) #959 revealed she had been informed in morning report Resident #19 was to be taken to the hospital last night, however, she had been informed transportation had not shown up to transport the resident. Interview on 10/24/23 at 9:10 A.M. with LPN #853 revealed she had not been aware Resident #19 had not been transported to the hospital last night. LPN #853 stated she had called the transportation company who stated they would at the facility within approximately 30 minutes. Observation on 10/24/23 at 10:03 A.M. revealed Resident #19 was being transported out of the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365046 If continuation sheet Page 15 of 24 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 365046 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Daughters of Miriam Center for Nursing & Rehabilit One David N Myers Parkway Beachwood, OH 44122 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 Residents Affected - Few Interview on 10/24/23 at 2:38 P.M. with LPN #853 confirmed the urine sample had been unable to collected and sent prior to the resident being sent to the hospital. 2. Review of the medical record revealed Resident #11 was admitted on [DATE]. Diagnosis included multiple sclerosis, Alzheimer's disease with late onset, dementia, anemia, neuromuscular dysfunction of bladder, age-related osteoporosis, depression, hypothyroidism, osteogenesis, presence of urogenital implants, history of COVID-19, and retention of urine. Review of the physician orders dated October 2023 revealed no orders for foley catheter care. No previous orders were in place regarding Resident #11's foley catheter care. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment date 10/03/23 revealed Resident #11 had intact cognition. Resident #11 had a foley catheter for bladder elimination. Review of Resident #11's care plan dated 07/11/23 did not include foley catheter care. Interview on 10/24/23 at 10:26 A.M. with Director of Nursing (DON) confirmed Resident #11's physician orders did not contain foley catheter care. Review of the facility policy, Catheter Care, Urinary, revised September 2014, revealed the purpose of the procedure is to prevent catheter-associated urinary tract infections and to review the resident's care plan to assess for any special needs of the resident. This deficiency represents non-compliance investigated under Master Complaint Number OH00147069. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365046 If continuation sheet Page 16 of 24 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 365046 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Daughters of Miriam Center for Nursing & Rehabilit One David N Myers Parkway Beachwood, OH 44122 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. Based on observation and interview the facility failed to ensure medications were not left unattended at the residents bedside. This affected three residents (#69, #84 and #129) of 142 residents observed for medication storage. The facility census was 142. Findings include: 1. Observation on 10/17/23 at 8:38 A.M. revealed Resident #129 was in bed in her room with a medication cup containing one white pill and one brownish colored pill, a medication cup with an orange colored liquid medication, a medication cup with a red colored liquid medication and a medication cup with a clear liquid medication. Resident #129 was not interviewable. 2. Observation on 10/17/23 at 8:40 A.M. revealed Resident #84 was in his room standing next to his bedside table and Resident #84 had a medication cup with several medications inside. Upon entering Resident #84's room Licensed Practical Nurse (LPN) #959 entered and stated Resident #84 knows to take his meds, I was just coming back to check if he did. 3. Observation on 10/17/23 at 8:43 A.M. revealed Resident #69 was sleeping in bed, he had a medication cup with several medications inside on his bedside table. Upon exiting Resident #69's room LPN #959 was observed in Resident #129's room administering the medications previously observed as left unattended on the residents bedside table. LPN #959 stated Resident #129 didn't like to take his medications so she came back to try again. LPN #959 remained in Resident #129's room to observe resident taking her medications. LPN #959 stated residents medication should not be left unattended however she would come back to check to see if they took them. LPN #959 had returned to Resident #69's room to ensure medications had been consumed and medication cup was observed to have been empty. Resident #69 refused an interview at the time of the observation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365046 If continuation sheet Page 17 of 24 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 365046 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Daughters of Miriam Center for Nursing & Rehabilit One David N Myers Parkway Beachwood, OH 44122 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation and interview the failed to ensure meals were served at a palatable temperature. This had the potential to affect 39 residents (#8, #12, #19, #21, #23, #27, #28, #29, #31, #31, #34, #35, #36, #39, #45, #46, #53, #69, #72, #77, #81, #82, #84, #86, #88, #89, #90, #97, #98, #100, #102, #104, #109, #114, #117, #123, #125, #128, and #129) of 39 residents who resided on unit MY2 on the second floor. The facility census was 142. Residents Affected - Some Findings include: Observation of a test tray on 10/18/23 at 6:12 P.M. of the dinner meal with Dietary Manager (DM) #969 revealed the temperature of the salisbury steak was 116.2 degrees Fahrenheit (F), mashed potatoes was 112.6 degrees F, mixed vegetables was 107.3 degrees F, and the chicken barley soup was 145.4 degrees F. The Salisbury steak, mashed potatoes, and mixed veggies tasted very good but was cold to taste. During the observation DM #969 declined to taste the meal but verified the temperatures. Interviews on 10/18/23 between 6:23 P.M. and 6:27 P.M. with Residents #39 and #82 stated the meal was cold when they received it. Resident #82 stated it's always cold. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365046 If continuation sheet Page 18 of 24 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 365046 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Daughters of Miriam Center for Nursing & Rehabilit One David N Myers Parkway Beachwood, OH 44122 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 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. Based on observation, record review, and interview the facility failed to ensure meals were served in a timely manner according to the designated meal times for the facility. This had the potential to affect 39 residents (#8, #12, #19, #21, #23, #27, #28, #29, #31, #31, #34, #35, #36, #39, #45, #46, #53, #69, #72, #77, #81, #82, #84, #86, #88, #89, #90, #97, #98, #100, #102, #104, #109, #114, #117, #123, #125, #128, and #129) of 39 residents who resided on unit MY2 on the second floor. The facility census was 142. Findings include: Review of the mealtimes revealed breakfast was at 8:30 A.M., lunch 12:30 P.M., and dinner 5:30 P.M. Observation on 10/16/23 at 1:06 P.M. revealed lunch trays were still being plated in a common kitchen for delivery to the resident rooms on the second floor MY2 unit. Observation on 10/17/23 at 9:47 A.M. of breakfast trays for the second floor MY2 unit resident rooms revealed trays were still being delivered and Resident #35, who was not interviewable, did not get her tray until 9:47 A.M. Interview on 10/18/23 at 10:46 A.M. with Dietary Manager (DM) #944 and Registered Dietitian (RD) #923 verified the mealtimes were breakfast at 8:30 A.M., lunch at 12:30 P.M., and dinner at 5:30 P.M. and all floors were to start meals service at those times. Observation on 10/18/23 at 1:24 P.M. with State Tested Nurse Aide (STNA) #809 still passing lunch trays on the second floor MY2 unit. Interview at this time with STNA #809 stated this was common for meals to be delivered this late. This deficiency represents non-compliance investigated under Complaint Number OH00147069. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365046 If continuation sheet Page 19 of 24 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 365046 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Daughters of Miriam Center for Nursing & Rehabilit One David N Myers Parkway Beachwood, OH 44122 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 0810 Provide special eating equipment and utensils for residents who need them and appropriate assistance. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure adaptive equipment was provided with meals. This affected one resident (#40) of five residents reviewed for nutrition. The facility census was 142. Residents Affected - Few Findings include: Review of the medical record for Resident #40 revealed an admission date of 09/30/21. Diagnoses included dysphagia, muscle weakness, and hemiplegia and hemiparesis following a stroke affecting the left non-dominant side. Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #40 had intact cognition. Review of the physician orders for October 2023 revealed the resident had a diet order for regular diet, pureed texture, and regular (thin) consistency diet. Review of the plan of care revised on 09/12/23 for nutrition revealed the resident received a mechanical altered diet due to dysphagia and received built-up utensils. Observation on 10/16/23 at 1:11 P.M. of Resident #40 in bed eating lunch revealed the resident's tray ticket read built-up utensils but observed regular utensils on the tray. Interview at this time with Resident #40 stated she was supposed to have different silverware. Observation and interview on 10/16/23 at 1:17 P.M. with Stated Tested Nurse Aide (STNA) #823 verified the observation and stated she had never seen Resident #40 with built-up utensils at meals. Interview on 10/18/23 at 4:17 P.M. with STNA #708 stated Resident #40 required tray set up but was able to feed herself. STNA #708 stated she had never seen her with built -up utensils but had seen it written on her meal ticket for built -up utensils. Interview on 10/23/23 at 11:04 A.M. with Registered Dietitian (RD) #923 stated she spoke with the Resident #40's daughter on Thursday 10/19/23 and got a history on the built-up utensils. RD #923 stated it was discussed at the 09/12/23 care conference and RD #923 recalled the resident's daughter had requested the use of the built-up utensils so RD #923 had added it to the meal ticket and care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365046 If continuation sheet Page 20 of 24 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 365046 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Daughters of Miriam Center for Nursing & Rehabilit One David N Myers Parkway Beachwood, OH 44122 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, record review, facility policy review and interview the facility failed to ensure all food items were properly stored and served in a manner to prevent contamination, spoilage and/or food borne illness. This had the potential to affect 141 of 141 residents who received meal trays from the kitchen. The facility identified one resident (#108) who received nothing by mouth (NPO status). The facility census was 142. Findings include: 1. On 10/16/23 at 9:30 A.M. an initial tour of kitchen was conducted with Dietary General Manager (DGM) #944. There were seven half-gallon containers of whole milk noted in the dairy refrigerator that had a sell by date of 10/09/23. There were four large dry storage bins containing potato flakes, sugar, flour and breadcrumbs. Each bin had a scoop inside of it. On 10/16/23 at 9:50 A.M. DGM #944 verified the sell by date on the seven half gallons of whole milk was 10/09/23. DGM #944 also verified the scoops inside of the storage bins containing potato flakes, sugar, flour and breadcrumbs. Review of the policy titled Food Storage dated October 2019 revealed scoops would be provided for bulk items and stored outside of the container and sell by date items are to be discarded within five to seven days of the date. 2. Observation on 10/16/23 at 12:33 P.M. of the lunch meal service to the resident rooms on the third floor revealed the cake portions on the meal trays were not covered and were on an open cart that had been pushed throughout the facility to get to the third floor. Observation on 10/16/23 at 12:43 P.M. of a second cart of room lunch trays revealed an open cart with uncovered cake on the lunch trays was traveling through the facility. Interview at this time with State Tested Nurse Aide (STNA) #823 verified the observation and stated the dessert was supposed to be covered but they did not have any saran wrap to cover the cake. Observation on 10/16/23 at 1:04 P.M. of the lunch tray cart arrived to the second floor and the cake remained uncovered on meal trays. Interview on 10/16/23 at 1:06 P.M. with STNA #701 verified the observation and stated she did not know why they were not covered. Observation on 10/16/23 at 1:11 P.M. of the second lunch cart arriving on the second floor with the desserts uncovered on the trays. Interview on 10/16/23 at 1:12 P.M. STNA #265 verified the observation and stated she did not why they were not covered. 3. Observation on 10/18/23 at 5:23 P.M. of tray line food temperatures for dinner on unit MY2 with Dietary Staff (DS) #829 revealed chicken barley soup 164.3 degrees Fahrenheit (F), mixed vegetables 172.8 degrees F, Salisbury steak 147.2 degrees F, mashed potatoes 131 degrees F, pureed meat 136.4 degrees F, pureed vegetables 129.9 degrees F, mechanical meat 159 degrees F, and pureed soup 143.8 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365046 If continuation sheet Page 21 of 24 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 365046 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Daughters of Miriam Center for Nursing & Rehabilit One David N Myers Parkway Beachwood, OH 44122 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 degrees F. Interview at this time with DS #829 stated the minimum standard was 140 to 165 degrees Fahrenheit and she would normally take the item and heat up to temperature. DS #829 verified the mashed potatoes and pureed veggies did not meet temperature and then stated she turned up the temperature of the steam table and then touched the side of the pan with pureed veggies and stated it felt warmer. DS #829 did not get a second temperature for these items. Residents Affected - Many Observation on 10/18/23 at 5:35 P.M. of 12 small plates each with a chocolate chip cookie all uncovered on a silver tray sitting on a table located against the wall across from the steamtable, also observed two meal carts each with two meal trays sitting on top of each cart. There were also chocolate chips cookies on each tray that were uncovered. Interview on 10/18/23 at 5:44 P.M. with Dietary Manager (DM) #969 verified the observation and covered the silver tray of cookies with a sheet of parchment paper. DM #969 stated they usually wrap them. Review of the food temperature log dated 10/18/23 at 5:22 P.M. completed by DS #829 revealed at the bottom of the form in a different handwriting there were written a second set of temperatures for the pureed Salisbury steak at 157 degrees F and the mashed potatoes at 160 degrees F. The form indicated the minimum holding standard for hot food items was greater than or equal to 140 degrees F (optimal 165 degrees). A follow-up interview on 10/23/23 at 12:25 P.M. with DS #829 stated she did not take a second set of temperatures on the 10/18/23 dinner meal. Review of the facility policy titled Food Temperature, revised January 2023 revealed food temperatures will be obtained and recorded by each dining server prior to meal service from the steam tables. Any food item that fails to meet minimum acceptable temperature will be removed from service and re-thermalized to the minimum acceptable temperature. Each food temperature log contains guidance for minimum holding temperature standards. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365046 If continuation sheet Page 22 of 24 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 365046 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Daughters of Miriam Center for Nursing & Rehabilit One David N Myers Parkway Beachwood, OH 44122 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 observation, record review, facility policy review, review of the Centers for Disease Control (CDC) Considerations for Preventing Spread of COVID-19, and interview the facility failed to maintain proper infection control practices/procedures to prevent the spread of infection including COVID-19. This had the potential to affect eight residents (#17, #64, #80, #136, #259, #262, #263 and #265) who resided on the same unit as Resident #261 who was in isolation for COVID-19. The facility census was 142. Residents Affected - Some Findings include: Review of Resident #261's medical record revealed an admission date of 10/13/23. Diagnoses included COVID-19 and lung cancer. Review of the current physician orders for October 2023 revealed Resident #261 was on isolation precautions for all care and services related to being positive for COVID-19. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 10/13/23, revealed the assessment was in progress. Review of the care plan dated 10/15/23 revealed no interventions related to COVID-19. Observation on 10/17/23 at 7:01 A.M. revealed State Tested Nursing Assistant (STNA) #755 had exited Resident #261's room. Further observation revealed signs posted outside of Resident #261's room indicated the resident was in isolation precautions, and isolation supplies hanging in a bin outside of Resident #261's room included, gowns, gloves, and masks. STNA #755 was observed to remove her gown and gloves outside of Resident #261's room and placed them inside a linen cart. The STNA was observed to have been wearing two surgical masks underneath of an N95 mask. STNA #755 failed to complete hand hygiene after removing her gown and gloves and she continued to wear the same N95 mask and a face shield. Interview with STNA #755 at the time of the observation confirmed Resident #261 was positive for COVID-19. The STNA revealed she was not aware of where to place the used gown and gloves. STNA #755 stated she had only used red biohazard bags for C-diff residents. STNA #755 had continued to wear the face shield and N95 that had been worn inside of Resident #261's room. STNA #755 was asked about wearing two surgical masks underneath of the N95 and stated she was not aware if that was an appropriate technique. STNA #755 then removed the N95 mask and discarded it in the linen cart and stated she would discard her face shield before she went outside to her car. STNA #755 stated she was not aware if she was to disinfect the face shield and stated she would just throw it away. STNA #755 stated she should have used hand hygiene after she had removed the PPE. Interview on 10/17/23 at 9:55 A.M. with Infection Preventionist (IP) #860 revealed staff were required to wear personal protective equipment (PPE) including an N95 mask, eye protection, gown and gloves prior to entering a room of a COVID positive resident. IP #860 revealed staff were required to remove PPE prior to exiting an isolation room and place the PPE into a red biohazard bag. Review of facility policy titled Covid-19 Personal Protective Equipment (PPE) Use During Pandemic revised 08/2022 revealed staff were to wear an N95 mask, eye protection, gown and gloves during care of residents on isolation precautions. Review of the CDC guidance updated 09/10/21 titled Interim Infection Prevention and Control (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365046 If continuation sheet Page 23 of 24 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 365046 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Daughters of Miriam Center for Nursing & Rehabilit One David N Myers Parkway Beachwood, OH 44122 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes revealed older adults living in congregate settings are at high risk of being affected by respiratory and other pathogens, such as SARS-CoV-2. A strong infection prevention and control (IPC) program is critical to protect both residents and healthcare personnel (HCP). Even as nursing homes resume normal practices, they must sustain core IPC practices and remain vigilant for SARSCoV- 2 infection among residents and HCP in order to prevent spread and protect residents and HCP from severe infections, hospitalizations, and death. In general, healthcare facilities should continue to follow the IPC recommendations for unvaccinated individuals (e.g.,use of Transmission-Based Precautions for those that have had close contact to someone with SARS-CoV-2 infection) when caring for fully vaccinated individuals with moderate to severe immunocompromise due to a medical condition or receipt of immunosuppressive medications or treatments. HCP caring for residents with suspected or confirmed SARS-CoV-2 infection should use full PPE (gowns, gloves, eye protection, and a NIOSH-approved N95 or equivalent or higher-level respirator). Source control and physical distancing (when physical distancing is feasible and will not interfere with provision of care) are recommended for everyone in a healthcare setting. This deficiency represents non-compliance investigated under Complaint Number OH00146916. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365046 If continuation sheet Page 24 of 24