Health inspection·November 8, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interviews with Resident #13, Resident #24, Resident #52 on 10/30/24 at 1:00 P.M. revealed they did not like the music playing on the radio and were not given a choice of their preference for the type of music they wanted to play during their meals. On 10/30/24 at 1:33 P.M. LPN #734 verified the music was not appreciated by several of the residents and turned the music off and did not change the radio station. LPN #734 agreed the residents probably did not like the music and was unable to say who chose the music. An interview with Activity Director #824 on 10/30/24 at 1:33 P.M. indicated the staff had chosen the type of music played during meals and the music could be changed to a different radio station according to resident preference. An interview with CNA #900 on 10/30/24 at 1:48 P.M. verified the above findings and stated she worked for a contracted staffing agency and did not know Resident #62 needed fed her meal and verified the residents were not served their meal at the same time who were seated together. An interview with LPN #763 on 10/30/24 at 1:59 P.M. stated Resident #62 needed fed her meals and verified the above findings and stated the CNA assigned to supervise the residents in the dining room were responsible for feeding the residents. 2. Review of the medical record revealed Resident #13 was admitted on [DATE] with diagnoses including anemia, adult failure to thrive, diabetes mellitus, cognitive communication deficit, heart arrhythmia, Alzheimer's dementia, anxiety, intestinal disease, osteoarthritis, spinal stenosis, morbid obesity, asthma, severe malnutrition, dysphagia and gastroesophageal reflux disease. Resident #13's plan of care revised on 10/10/24 indicated she had an activity of daily living performance deficit. Interventions on the plan of care revealed she needed assistance with setting up her meals with food cut in to small bites and close supervision for safety. Review of the medical record revealed Resident #24 was admitted on [DATE] with diagnoses including dementia, high blood pressure, embolism (object or bodily substance obstructing blood flow) and thrombus (blood clot) of the superficial and deep veins of the left lower extremity, end-stage glaucoma, peripheral vascular disease, pulmonary embolism, neurocognitive disorder, dysphagia, high cholesterol, diabetes mellitus, and osteoarthritis. Resident #24's plan of care revised on 01/22/24 indicated she had an activity of daily living self-care performance deficit. Intervention on the care plan included assisting Resident 324 with setting up her meal and provide supervision of one staff member. Resident #13 and Resident #24 were seated in the dining room on 10/30/24 at 12:30 P.M. waiting for their lunch to be served. Both residents stated they often had to wait an extended period of time for meals to be served. The meal cart arrived in the dining room at 1:04 P.M. and the staff started to serve the meal trays to the residents. All the meal trays were delivered to the residents and Resident #13 and Resident #24 did not receive their meal. Residents were not served at the same time who were seated together. Resident #13 and Resident #24 stated they were not informed why their meal tray was late and thought they were not going to receive a meal tray for lunch. At 1:34 P.M. Resident #13 and Resident #24 received their meal tray. An interview with CNA #900 on 10/30/24 at 1:48 P.M. verified the residents were not served their (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365046 If continuation sheet Page 2 of 55 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 11/08/2024 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 meal at the same time who were seated together. Level of Harm - Minimal harm or potential for actual harm This deficieny represents non-compliance investigated under Complaint Number OH00158389 and OH00159168. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365046 If continuation sheet Page 3 of 55 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 11/08/2024 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record reivew, and facility policy review, the facility failed to ensure the physician was notified in a timely manner for a change in condition for Resident #162 and for Resident #126. This affected two Residents (#126 and #162) of two reviewed for notification of change. The facility census was 166. Findings include: 1. Review of the closed medical record for Resident #162 revealed an admission date of [DATE] and discharge date of [DATE]. Diagnoses included chronic respiratory failure, chronic obstructive pulmonary disease (COPD), malignant neoplasm of bronchus or lung, atherosclerotic heart disease, essential hypertension, generalized muscle weakness, difficulty in walking, repeated falls, and history of fractures including right femur, left tibia, T9-T10 (thoracic spine) vertebra, and right clavicle. Review of the plan of care initiated on [DATE] revealed Resident #162 was at risk for falls related to history of falls with fracture and weakness. Interventions included Dycem (non-slip self-adhesive strip) to wheelchair, ensure call light in reach, encourage use of call light, wear appropriate footwear when ambulating, follow facility fall protocol, evaluate and treat as needed, and offer to toilet resident every two hours and as needed. Review of the Un-Witnessed Fall incident report dated [DATE] at 4:22 P.M. revealed Resident #162 had an unwitnessed fall in her room. It was noted Certified Nurse Practitioner (CNP) #833 was notified on [DATE] at 4:12 P.M. and Resident #162's brother was notified on [DATE] at 4:21 P.M. Review of the progress note dated [DATE] at 4:31 P.M. revealed Resident #162 was found on the floor in her room and was complaining of pain in the lower extremity. An X-ray was ordered, CNP notified, and voicemail left for Resident #162's brother. Resident #162's vitals were stable. Review of the Radiology Results Report dated [DATE] at 11:47 P.M. revealed bilateral hip X-rays with two to three views on each side. The left hip results showed no evidence of acute fracture or dislocation. The right hip results showed near anatomic alignment of the intertrochanteric right femur post fixation and no dislocation. Review of the witness statement dated [DATE] for Licensed Practical Nurse (LPN) Unit Manager #787 stated he called CNP #833 and requested another X-ray of the knee and lower leg. An order was obtained and X-ray company was contacted. Review of Nursing Progress Note dated [DATE] at 3:31 P.M. revealed a call was placed to CNP regarding hip X-rays being negative by LPN Unit Manager #787. Increased swelling to right knee and lower leg was noted with new order for X-ray to right knee and lower leg. Review of Nursing Progress Note dated [DATE] at 4:31 A.M. revealed X-ray results were received and revealed an acute mildly displaced fracture of the distal femur and tri-compartmental degenerative changes in the knee. It was noted nurse attempted to notify physician of X-ray result however was awaiting response. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365046 If continuation sheet Page 4 of 55 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 11/08/2024 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 0580 Level of Harm - Minimal harm or potential for actual harm Review of Nursing Progress Note dated [DATE] at 5:35 A.M. revealed upon medication pass Resident #162 was found unresponsive. Cardiopulmonary Resuscitation (CPR) was initiated and continued until Emergency Medical Services (EMS) arrived. EMS pronounced Resident #162 deceased at 5:52 A.M. The nurse on call notified physician via urgent message and was awaiting response. Resident #162's family was contacted several times however was awaiting return call. Residents Affected - Few Review of Nursing Progress Note dated [DATE] at 6:37 A.M. revealed numerous attempts were made to contact the physician without success by Agency LPN #827. Review of Nursing Progress Note dated [DATE] at 7:12 A.M. revealed a message was left for physician without successful contact by Assistant Director of Nursing (ADON). CNP was notified at this time by phone and notified Resident #162 had expired. Review of Nursing Progress Note dated [DATE] at 7:28 A.M. revealed the physician retuned call to ADON and was notified of the x-ray result from [DATE] and Resident #162 had expired. Physician to call the coroner's office. Review of the undated facility Investigation Timeline revealed Resident #162 had fall on [DATE]. On [DATE] at 3:31 P.M. it was noted Resident #162 had swelling to knee and an x-ray to the area was ordered. Results were received via fax and in electronic medical record (EMR) at 9:15 P.M. on [DATE]. The facility identified X-ray results were located at approximately 4:00 A.M. on [DATE]. Resident #162 was found unresponsive at approximately 5:30 A.M. on [DATE] and CPR started, EMS arrived at approximately 5:40 A.M, and Resident #162 was pronounced deceased at 5:52 A.M. LPN Night Supervisor #608 notified ADON at 6:03 A.M. NP #833 was notified via text by ADON at 7:10 A.M. and returned call at 7:12 A.M. Physician #832 was notified via text by ADON at 7:28 A.M. and returned call at 8:10 A.M. It was noted Physician #832's contact information was inaccurate on the face sheet. All nurses were educated on notification of change and to call the medical director if no response was received within one hour and checking the fax machine every four hours. Interview on [DATE] at 11:34 A.M. with Director of Nursing (DON) and ADON revealed they had completed an investigation into Resident #162's fall, fracture, and subsequent death. DON and ADON confirmed the radiology results came through on the fax machine at 9:15 P.M. on [DATE] and were not identified by nursing staff until [DATE] at approximately 4:00 A.M. DON and ADON confirmed Agency LPN #827 had not called the correct number for Physician #832 when attempting to make notification. DON indicated Agency LPN #827 had used the number on the face sheet which was the office phone number for Physician #833 and not a line that was monitored 24 hours per day. DON indicated Physician #833's direct line had to be updated into the face sheets following the incident. Interview on [DATE] at 7:56 A.M. with Agency LPN #827 via phone revealed on [DATE] she had been assigned to care for Resident #162 on night shift. Agency LPN #827 indicated during report at the beginning of her shift the previous nurse had notified her there was a pending X-ray result for Resident #162. Agency LPN #827 indicated she questioned the other nurse on floor about how to receive lab and radiology reports at about 12:00 A.M. on [DATE]. Agency LPN #827 confirmed she did not locate the X-ray results for Resident #162 until approximately 4:00 A.M. on [DATE]. Agency LPN #827 reported she attempted to reach the physician on the results at approximately 4:41 A.M. on [DATE]. Agency LPN #827 confirmed on [DATE] at approximately 5:30 A.M. Resident #162 was found unresponsive, required CPR, and was pronounced deceased at 5:52 A.M. by EMS. Agency LPN #827 confirmed she was unable to contact the physician or family prior to the end of her shift. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365046 If continuation sheet Page 5 of 55 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 11/08/2024 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on [DATE] at 2:30 P.M. with CNP #833 confirmed she had been notified when Resident #162 fell on [DATE]. CNP #833 indicated she was again notified on [DATE] by LPN Unit Manager #787 that Resident #162 was complaining of knee pain. CNP #833 reported she was not required to be on call throughout the night. CNP #833 stated at about 8:00 A.M. on [DATE] the ADON called her to inform her of Resident #162's passing and the fracture. CNP #833 indicated the results came through on fax and was unsure what the delay was in results being reported. CNP #833 indicated had she been notified of the fracture at a reasonable hour Resident #162 would have been sent out to the hospital for evaluation. Interview on [DATE] at 4:04 P.M. with Physician #832 revealed she had not been notified of Resident #162's fall on [DATE]. Physician #832 indicated when she questioned why she had not been notified she was not given an answer and just told they were trying to figure out what had happened. Physician #832 stated if she had been notified, she would have ordered an X-ray and for a fracture she would have sent Resident #162 to the hospital. Physician #832 stated she was on call at night and was able to be reached directly on her cell phone. Physician #832 stated she was not notified of Resident #162's fracture or passing until approximately 6:00 A.M. on [DATE]. Review of facility policy Change in a Resident's Condition or Status, undated revealed The nurse supervisor or charge nurse will notify the resident's attending physician or on-call physician when there was an accident involving the resident, significant change to the resident's physical or mental condition, a need to alter the resident's medical treatment significantly, and a need to transfer the resident to a hospital or treatment center. 2. Review of the medical record for Resident #126 revealed an admission date of [DATE] with diagnoses including end stage renal disease, peripheral vascular disease, dependence on renal dialysis, type one diabetes mellitus with kidney complications and retinopathy, chronic diastolic congestive heart failure, dysarthria, anxiety disorder, acquired absence of kidney, and neuromuscular dysfunction of the bladder. Review of the significant change Minimum Data Set (MDS) 3.0 assessment completed on [DATE] revealed Resident #126 had intact cognition and required substantial to maximal assistance with chair to bed, toilet, and shower transfers. Further review of the MDS revealed Resident #126 was on dialysis. Review of the physician orders revealed an order dated [DATE] for Resident #126 to be transported to Centers for Dialysis Care (CDC) every Monday, Wednesday, and Friday to receive dialysis related to end stage renal disease. Review of the care plan dated [DATE] revealed Resident #126 required dialysis every Monday, Wednesday, and Friday at CDC related to renal failure. Interventions included monitoring and reporting complications related to dialysis. Review of the progress notes from [DATE] through [DATE] revealed no indication Resident #126 did not receive her scheduled dialysis treatment on [DATE] or that any medical provider was notified she had not received dialysis on [DATE]. Interview on [DATE] at 3:18 P.M. with Resident #126 confirmed she did not receive her ordered dialysis that day because the transportation company responsible for taking her to the appointment never showed up. During the interview, Resident #126 stated she had missed a previous dialysis appointment due to the lack of transportation, but she was unable to provide detail as to the date it had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365046 If continuation sheet Page 6 of 55 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 11/08/2024 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 0580 occurred. Level of Harm - Minimal harm or potential for actual harm Interview on [DATE] at 11:48 A.M. with Unit Secretary #681 confirmed Resident #126 did not go to dialysis on [DATE] due to the lack of transportation and the appointment had to be rescheduled for [DATE]. Further interview confirmed Unit Secretary #681 called the nurses station on [DATE] to inform them Resident #126 had missed her dialysis appointment but she was unable to recall who she spoke with. Unit Secretary #126 also confirmed Resident #126 was transported to the hospital prior to the rescheduled dialysis appointment. Residents Affected - Few Interview on [DATE] with Registered Nurse (RN) #814 confirmed Resident #126 missed her dialysis appointment on [DATE] and that she was supposed to receive dialysis three times a week. RN #814 further explained when a resident misses a scheduled dialysis appointment, the protocol was to reschedule the appointment for the next day, unless the resident refuses. During RN #814's explanation of missed dialysis appointment protocols, physician or provider notification was not mentioned. Interview on [DATE] at 12:05 P.M. with CDC Representative #840 confirmed Resident #126 did not receive her scheduled dialysis on [DATE]. Interview on [DATE] at 12:45 P.M. with Nurse Practitioner (NP) #839 confirmed she was supposed to be notified when dialysis residents did not receive their scheduled dialysis. NP #839 further confirmed she was not notified Resident #126 did not receive dialysis on [DATE]. During the interview, NP #839 revealed that had she been informed, she would have ordered Resident #126 to have a chest x-ray and labs to make sure there were no concerns related to fluid overload due to the missed dialysis treatment. Review of the policy titled End-Stage Renal Disease, Care of Resident with revised [DATE] revealed the facility was to communicate dialysis concerns with the dietician, staff, and medical provider. This deficiency represents non-compliance investigated under Complaint Number OH00158529. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365046 If continuation sheet Page 7 of 55 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 11/08/2024 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on record review and interview with staff the facility failed to follow-up with grievances involving Resident #167 in a timely manner. This affected one resident (#167) of three residents reviewed for grievances. The census was 166. Findings include: Review of the closed medical record for Resident #167 revealed an admission date of 12/16/19 and a discharge date of 01/19/24. Diagnoses included heart failure, dysphagia and dementia without behavioral disturbance. Review of the concern log revealed an entry on 01/04/24 from the family of Resident #167 regarding issues including missing dentures and request for medical records. The notes indicated the team met with the family regarding concerns and gave a consent to be seen by the dentist for replacement dentures. It stated the Administrator discussed replacement options. Review of the email dated 01/08/24 at 1:30 P.M. from the son to the Administrator revealed the son typed he had left five voicemails in the past ten days for Medical Records department. He was asking for a response by the next day. Review of the email dated 08/23/24 at 1:01 P.M. from the daughter to the Administrator revealed the subject line was marked as Dentures- IMPORTANT (time sensitive). Attached to the email was an itemized receipt for the dentures. The daughter requested a response by 08/30/24. Interview on 10/30/24 at 10:30 A.M. with the Administrator revealed he was aware of Resident #167's missing dentures and acknowledged they had a meeting with family who also requested medical records. The Administrator verified he received the email dated 01/08/24 stating he forwarded the request for medical records and sent the son a request form to be completed. He stated he never heard from him again regarding the medical records. A follow-up interview at 5:16 P.M. with the Administrator revealed the resident was put on the list to be seen by the dentist however Resident #167 was discharged prior to the visit stating he lost touch with the son after that. He stated the facility was not going to pay for the dentures but wanted to see if they would be covered under insurance. A subsequent interview on 11/04/24 at 9:30 A.M. with the Administrator revealed he denied receiving the email dated 08/23/24 regarding reimbursement for dentures but verified it was the correct email address for him as it changed with new ownership. He denied having any further interaction after Resident #167 was discharged on 01/19/24. This deficiency represents non-compliance investigated under Complaint Number OH00159071, OH00158529 and OH00158389. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365046 If continuation sheet Page 8 of 55 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 11/08/2024 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 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure Resident #62, Resident #108 and Resident #79 were assisted with eating their meal. This affected three residents (#62, #108 and #79) out of seven residents reviewed for activity of daily living (ADL) assistance. The facility census was 166. Residents Affected - Few Findings include: 1. Resident #62 was admitted on [DATE] and re-admitted on [DATE] with diagnoses including severe dementia with behaviors, hemiplegia (one sided paralysis) and hemiparesis (weakness on one side) following a cerebral infarction (stroke) affecting the left non-dominant side, dysphagia (difficulty swallowing), osteoarthritis, and hyperlipidemia (high cholesterol). Resident #62 had medical conditions including weakness with abnormal gait and mobility, used a wheelchair for mobility, and needed assistance with personal care. A review of the Resident #62's Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated she was rarely or never understood. Resident #62's physician order dated 09/14/24 revealed the nurse was to ensure Resident #62 was fed all her meals. If Resident #62 pushed her food away then re-approach Resident #62 with food. A review of Resident #62's plan of care revised 12/19/22 indicated an activity of living deficit related to cognition and ability. Interventions on the plan of care indicated she required one person to feed her meals and required two-person assistance for toileting, transfers, and assistance with bathing, showering, bed mobility, dressing, personal hygiene and oral care. An observation of the meal service on 10/30/24 from 12:30 P.M. to 2:00 P.M. revealed Resident #62 was assisted to the dining room in her wheelchair at 12:40 P.M. At 1:15 P.M. Resident #62 was served her lunch by Certified Nursing Assistant (CNA) #900. CNA #900 set the meal tray in front of Resident #62 and repositioned Resident #62 in an upright position, uncovered her meal plate and set-up the tray for Resident #62 and then walked away to continue to serve the meal trays to the other residents in the dining room. At 1:19 P.M. Licensed Practical Nurse (LPN) #763 walked over and fed Resident #62 a few bites of her meal while standing next to her. LPN #763 walked away from Resident #62 and left the dining room. Resident #62 sat in front of her meal tray and tried to eat a few bites of her meal. At 1:48 P.M. Resident #62's meal tray was removed from the table and CNA #900 assisted Resident #62 back to the common area in the nursing unit. Resident #62 ate approximately 10% of her meal. An interview with CNA #900 on 10/30/24 at 1:48 P.M. verified the above findings and stated she worked for a contracted staffing agency and did not know Resident #62 needed fed her meal and verified the residents were not fed at the same time who were seated together. An interview with LPN #763 on 10/30/24 at 1:59 P.M. stated Resident #62 needed fed her meals and verified the above findings and stated the CNAs assigned to supervise the residents in the dining room were responsible for feeding the residents. 2. Resident #108 was admitted on [DATE] with diagnoses including osteoporosis, vitamin D (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365046 If continuation sheet Page 9 of 55 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 11/08/2024 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 0676 deficiency, and hemorrhagic thrombocytopenia. Level of Harm - Minimal harm or potential for actual harm A review of Resident #108's nursing ADL functional assessment dated [DATE] indicted she needed assistance with setting up her meal and encourage her to be out of bed for all of her meals. Residents Affected - Few Resident #108's plan of care revised on 02/07/24 indicated an activity of daily living self-care performance deficit. Interventions on the care plan indicated Resident #108 needed assistance with setting up her meal and supervision when eating her meal. An interview with Resident #108 on 10/28/24 at 10:42 AM revealed she needed assistance with getting out of bed and had to wait a long time in the morning for assistance. Resident #108 stated the staff had not offered to assist her out of bed yet today. An observation on 11/04/24 at 10:16 A.M. revealed CNA #841 delivered Resident #108 her meal tray. CNA #841 repositioned Resident #108 in her bed, raised the head of the bed and placed the meal tray on the over-the-bed tray across her lap while lying in bed. CNA #841 set up the meal for Resident #108 and left the room. Resident #108 was not encouraged to get out of bed or supervised during the meal. An interview with CNA #841 on 11/04/24 at 10:16 A.M. verified the above findings and stated the only time Resident #108 was assisted out of bed was when her daughter visited and assisted with feeding her meal. CNA #841 stated Resident #108 did not need supervision during meals and verified the staff were unable to supervise Resident #108 for her meals when she was eating in bed. Review of the facility policy and procedure titled Meal Assistance revised March 2022 indicated residents shall receive assistance with meals in a manner that meets the individual needs of each resident. 3. Review of the medical record for Resident #79 revealed an initial admission date of 12/24/17 and a re-entry date of 06/05/23. Diagnoses included epilepsy, hypertensive heart with heart failure, gastrostomy status, type two diabetes mellitus, hyperlipidemia, primary hypertension, unspecified protein-calorie malnutrition, anemia, neuromuscular dysfunction of bladder, vascular dementia, major depression, schizoaffective disorder, and oropharyngeal phase dysphagia. Review of the quarterly MDS 3.0 assessment completed on 10/06/24 revealed Resident #79 had moderate cognitive impairment with no behaviors or rejection of care. Further review of the MDS revealed Resident #79 required partial to moderate feeding assistance, had a history of holding food in her mouth or cheeks, coughed or choked during meals or with medication administration, complained of swallowing difficulty, was on a mechanically altered diet and received 51 percent or more of her nutrition through a feeing tube. Review of the physician order revealed a diet order dated 08/13/24 for a regular diet with pureed texture and mildly thick (nectar) consistency liquids with no straw related to oropharyngeal dysphagia. Review of the care plan dated 07/02/19 to 01/06/25 revealed Resident #79 had the potential for weight and hydration issues related to variable oral intake, mechanically altered diet, and varying ability to feed herself. Interventions included assisting Resident #79 to eat per Occupation Therapist (OT) recommendation and providing enteral feeds per physician orders. The care plan also indicated a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365046 If continuation sheet Page 10 of 55 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 11/08/2024 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 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few deficit in activities of daily living (ADL) self-care deficit. Interventions included directions for staff to feed Resident #79 at all meals and indicated she was a full feed with no straws. Review of the Speech-Language Pathology (SLP) dated 10/14/24 revealed Resident #79 had minimum to mild progress toward maintaining ability to consume pureed solids and nectar thick liquids to maximize nutritional intake and enhance hydration to reduce risk of aspiration, penetration, malnutrition, and weight loss by exhibiting minimal to mild oropharyngeal impairment. Review of the point of care feeding assistance response history from 09/12/24 (date the care plan was last updated to reflect Resident #79 was a full feed) through 11/04/24 revealed one date, 09/25/24, when Resident #79 was unavailable, and 52 days she was available for meals. During that time, Resident #79 had documentation indicating limited feeding assistance was provided zero days, extensive assistance was provided for at least one meal on two dates (09/19/24 and 11/04/24), and total assistance was provided for at least one meal on eight dates (09/12/24, 09/13/24, 09/16/24, 09/19/24, 09/20/24, 10/08/24, 10/24/24, and 10/30/24). Documentation from all other dates in that time span indicated no assistance was provided or supervision only was provided. Review of the pre-printed [NAME] 2 Assignment sheet for the CNAs revealed Resident #79 was on a mechanical soft, thin liquid diet. There was no mention of her requiring feeding assistance. This was confirmed by LPN #787 on 11/05/24 at 11:15 A.M. Review of the [NAME] 2, South 1 preprinted assignment sheet for unit nurses revealed Resident # 79 took pills crushed and was on a mechanical soft diet. There was nothing regarding Resident #79's need for feeding assistance. It was confirmed during an interview with LPN #787 on 11/05/24 at 11:15 A.M. that the assignment sheet did not indicate Resident # 79 needed feeding assistance. Interview on 10/28/24 from 10:36 A.M. to 10:45 A.M. with Resident #79 revealed she felt she never got help to eat as she asked the surveyor to help feed her. At the time of this interview, a breakfast tray was observed on the bedside table alongside the left side of the bed, out of reach from the resident with lids and plate cover intact and silverware undisturbed. At 10:45 A.M., Resident #79 placed her call light on to request staff assistance with breakfast. Observation on 10/28/24 at 10:52 A.M. revealed Certified Nursing Assistant (CNA) #841 brought a rewarmed tray of breakfast food to Resident #79, set-up the tray, in front of Resident #79, and exited the resident's room. Interview with CNA #79 at this time confirmed Resident #79 had not received assistance with her breakfast earlier that morning so she just rewarmed the food and completed meal set-up prior to exiting the room just then. CNA #841 further confirmed Resident #79 was left to eat alone and that as per the report she received, Resident #79 only needed assistance with the set-up for meals and not hands-on feeding assistance or supervision. Observation on 10/31/24 at 9:31 A.M. revealed the tube feeding pump beeping and a breakfast tray set-up in front of Resident # 79. At the time of the observation, no staff were providing feeding assistance, and a towel was noted over Resident #79's chest with food dropped on it and a small amount pureed food was noted on the left side of her mouth. An interview with Resident #79 at the time of this observation confirmed that staff set her tray up and placed it in front of her about 15 to 20 minutes earlier and did not offer to help her eat, which she reiterated happened frequently. She stated she tried to eat on her own and was too tired to continue. Interview on 10/31/24 at 9:41 A.M. with CNA #842 confirmed she received report from the nurse or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365046 If continuation sheet Page 11 of 55 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 11/08/2024 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 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few off going CNA at the change of shift and was only informed of one of her assigned residents (Resident #98) who needed feeding assistance. She further confirmed Resident #79 was one of her assigned residents and she received assistance with meal set-up. During the interview, CNA #842 pulled an assignment sheet from her pocket and verified that Resident #79 was not listed as requiring feeding assistance. Observations continued from the hallway on the unit on 10/31/24 until 10:11 A.M. which revealed no staff had entered the room of Resident #79 to offer assistance with breakfast. Interview on 10/31/24 at 10:23 A.M. with Dietitian #711 confirmed Resident #79 had pretty poor oral intake of meals and that she relied on tube feedings as her primary source of nutrition. During the interview, Dietitian #711 confirmed that Resident #79's level of feeding assistance was inconsistent but staff were to provide assistance with meals. Interview on 11/04/24 at 3:07 P.M. with CNA #843 revealed she arrived at the unit at 11:30 A.M. and Resident #79 still had her breakfast tray beside her bed which was untouched. She further confirmed Resident #79 did not eat anything from her lunch tray on this date and received no feeding assistance because she was unaware Resident #79 required any assistance. During this interview, another CNA was present (CNA #749) who confirmed she was unaware Resident #79 received meals and thought she was only fed through a feeding tube. Interview on 11/05/24 at 11:10 A.M. with Licensed Practical Nurse (LPN) Unit Manager #787 confirmed if a resident required feeding assistance, it should be noted on the staff assignment sheets. LPN Unit Manager #787 also revealed he was aware staff do not like to use the new assignment sheets, but nurses still were required to give a run-down of resident needs to CNAs in morning change of shift report, which should include residents needing feeding assistance. Interview on 11/05/24 at 11:35 AM with Director of Therapy (DOT) #658 revealed Resident #79 was currently on a functional maintenance program with the SLP to ensure she maintains safety with her current diet. DOT #658 further confirmed Resident #79 needed cues to maintain safe eating strategies, which included small bites and sips, alternating liquids and solids, time between bites, and double swallows. Review of the policy titled Assistance with Meals last revised March 2022 revealed staff were to help feed residents who needed assistance with eating. The policy further revealed residents were to be fed with attention to safety, comfort, and dignity. This deficiency represents non-compliance investigated under Complaint Number OH00159168 and OH00158529. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365046 If continuation sheet Page 12 of 55 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 11/08/2024 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 - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of witness statements, review of facility incident investigation, review of the medical examiner report, review of the police report, and review of the facility policy, the facility failed to ensure timely injury identification and physician notification and treatment following a fall with fracture for Resident #162. Residents Affected - Few Actual Harm occurred on [DATE] 4:30 P.M. when the facility failed to obtain timely and appropriate imaging (x-ray) for Resident #162 following a fall with injury resulting in a delay in treatment. Following the fall, the resident complained of increased pain, had swelling, an abrasion to the knee and was unable to stand. On [DATE] at 3:15 P.M a new order was written for an x-ray of the area. X-ray results on [DATE] at 9:15 P.M. were positive for a right femur fracture. However, facility staff did not locate the x-ray results until [DATE] at 4:00 A.M. at which time they failed to seek medical intervention/treatment for the resident. Resident #162 expired on [DATE] at 5:52 A.M. unrelated to the fracture following unsuccessful cardiopulmonary resuscitation (CPR) and emergency medical services (EMS) intervention. The Certified Nurse Practitioner (CNP) and Physician were not contacted until after Resident #162's passing of the injury related to the fall. This affected one resident (#162) of seven residents reviewed for falls. The facility census was 166 residents. Findings include: Review of the closed medical record for Resident #162 revealed an admission date of [DATE] with diagnoses including chronic respiratory failure, chronic obstructive pulmonary disease (COPD), malignant neoplasm of bronchus or lung, atherosclerotic heart disease, essential hypertension, and history of fractures with a discharge date of [DATE]. Review of the care plan for Resident #162 initiated [DATE] revealed the resident was at risk for falls related to history of falls with fracture and weakness. Interventions included staff should follow the facility fall protocol and evaluate and treat the resident as needed. Review of the care plan for Resident #162 dated [DATE] revealed the resident was a full code status. Review of the Minimum Data Set (MDS) assessment for Resident #162 dated [DATE] revealed the resident had intact cognition and required staff assistance with activities of daily living (ADLs). Review of the fall incident report for Resident #162 dated [DATE] timed at 4:22 P.M. revealed the resident had an unwitnessed fall in her room when she tried to get up unassisted. Resident #162 complained of pain at level of six out of 10 and sustained an abrasion to the right knee. Review of the physician's order for Resident #162 revealed an order dated [DATE] timed at 4:30 P.M. for an x-ray to the bilateral hips related to a fall. The order was discontinued. Review of a progress note for Resident #162 dated [DATE] timed at 4:31 P.M. revealed the resident was found on the floor in her room and was complaining of pain to the lower extremity. An x-ray was ordered, and no injuries were reported in the progress note. Review of medication administration note for Resident #162 dated [DATE] timed at 8:50 P.M. revealed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365046 If continuation sheet Page 13 of 55 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 11/08/2024 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 staff administered Tylenol for pain to the resident with effective results. Level of Harm - Actual harm Review of medication administration note for Resident #162 dated [DATE] timed at 8:52 P.M. revealed staff administered oxycodone for pain to the resident with effective results. Residents Affected - Few Review of the physician's orders for Resident #162 revealed an order dated [DATE] timed at 11:00 P.M. for an x-ray to the resident's bilateral hips related to a fall. The order was completed. Review of x-ray report for Resident #162 dated [DATE] timed at 11:47 P.M. revealed the bilateral hip x-rays showed no fractures or dislocations. Review of the nursing progress note for Resident #162 dated [DATE] timed at 12:28 P.M. revealed the note documented Licensed Practical Nurse (LPN)/Unit Manager (UM) #787 checked on the resident who was resting in bed, declined pain medication, and showed no signs of distress. Review of a witness statement for Resident #162 per LPN/UM #787 dated [DATE] revealed at 3:15 P.M. Certified Nursing Assistant (CNA) #825 had reported swelling to the resident right leg during a bed bath. LPN/UM #787 called Certified Nurse Practitioner (CNP) #833 and requested an x-ray of the right knee and lower leg. The nurse obtained the order and contacted the x-ray company. Review of the nursing progress note for Resident #162 dated [DATE] timed at 3:31 P.M. revealed a call was placed to CNP #833 regarding the negative results for the resident's bilateral hip x-rays. CNP #833 gave an order for an x-ray to the right knee and lower leg due to swelling. Review of the physician's orders for Resident #162 revealed an order dated [DATE] timed at 4:00 P.M. for an x-ray to the right lower leg and knee. The order was completed. Review of the health status note for Resident #162 dated [DATE] timed at 7:35 P.M. revealed the resident had no complaints of pain on day shift and did not want a shower. Resident #162 agreed to a bed bath and during the bed bath swelling to the resident's right knee was noted. The x-ray technician arrived to the facility on [DATE] at 5:30 P.M. to obtain the x-ray ordered to the resident's right knee and lower leg. Review of the x-ray report for Resident #162 dated [DATE] timed at 9:15 P.M. revealed an acute mildly displaced fracture of the resident's right distal femur. Review of the nursing progress note for Resident #162 dated [DATE] timed at 4:31 A.M. (over seven hours after the x-ray report was completed) revealed x-ray results were received and revealed an acute mildly displaced fracture of the distal femur. The note included the nurse had attempted to notify the physician of the x-ray results and was awaiting a response. Review of the nursing progress note for Resident #162 dated [DATE] timed at 5:35 A.M. revealed upon medication pass Resident #162 was found unresponsive. CPR was initiated and continued until EMS arrived. EMS pronounced Resident #162 deceased at 5:52 A.M. The nurse on call notified physician via urgent message and was awaiting a response. Review of the nursing progress note for Resident #162 dated [DATE] at 7:28 A.M. revealed the physician returned a call to the facility and was notified of the x-ray results for the resident's right leg and that the resident had passed away. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365046 If continuation sheet Page 14 of 55 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 11/08/2024 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 Review of the police report for Resident #162 dated [DATE] revealed the resident appeared to have died from natural causes. Level of Harm - Actual harm Residents Affected - Few Review of the medical examiner's report for Resident #162 dated [DATE] revealed the resident's cause of death was hypertensive and atherosclerotic cardiovascular disease and at the time of death the resident had a right femoral fracture sustained from an accidental fall on [DATE]. Review of the facility undated investigation timeline for Resident #162 revealed the resident had a fall on [DATE] and sustained an abrasion to the right knee. On [DATE] at 3:31 P.M. Resident #162 had swelling to the right knee and an x-ray to the area was ordered. The x-ray results for Resident #162 which showed a right femoral fracture were received via fax and in electronic medical record (EMR) on [DATE] at 9:15 P.M. The x-ray company called the facility on [DATE] at 11:20 P.M. to report the findings, but no one from the facility answered. Facility staff stated they did not receive a call from the x-ray company. The x-ray results showing the fracture for Resident #162 were not located by the facility until [DATE] at approximately 4:00 A.M. CNP #833 was notified via text by the Assistant Director of Nursing (ADON) at 7:10 A.M. and returned the call at 7:12 A.M. Physician #832 was notified via text by the ADON at 7:28 A.M. and returned call at 8:10 A.M. It was noted Physician #832's contact information was inaccurate and the information the x-ray company had to contact for significant findings was inaccurate. Review of facility Quality Improvement Performance (QAPI) Performance Improvement Plan (PIP) dated [DATE] revealed a root cause analysis was completed regarding Resident #162's fall with fracture. The problem was identified as lack of timely notification of a change in condition, lack of timely assessment for change in condition, and failure to follow protocol related to fall with injury. Interview on [DATE] at 11:34 A.M. with the Director of Nursing (DON) confirmed the facility had completed an investigation into Resident #162's fall and fracture. The DON confirmed Resident #162's x-ray results came through on the fax machine at 9:15 P.M. on [DATE] but were not identified by nursing staff until [DATE] at approximately 4:00 A.M. The DON confirmed Agency LPN #827 had not called the correct number for Physician #832 when attempting to make notification and consequently Resident #162 did not receive timely care for her right femoral fracture. Interview on [DATE] at 12:57 P.M. with CNA #825 via phone confirmed on [DATE] she had been assigned to care for Resident #162 on day shift. CNA #825 reported Resident #162 had refused meals on [DATE] and had remained in bed per her usual. CNA #825 reported Resident #162 had refused her scheduled shower however agreed to a bed bath sometime after lunch. CNA #825 indicated Resident #162 stated she was unable to stand up for a shower and told CNA #825 about her fall. Resident #162 asked CNA #825 not to touch or move her knee during bed bath. CNA #825 stated when she pulled down the covers, she observed Resident #162's knee to be swollen and had a red rug burn type mark on her knee. CNA #825 stated she notified LPN UM #787. Interview on [DATE] at 1:39 P.M. with LPN #769 via phone revealed on [DATE] she found Resident #162 lying on the floor of her room and she did a quick assessment of the resident, took vital signs, and notified the resident's nurse, Agency LPN #828 of the fall. Interview on [DATE] at 2:12 P.M. with LPN #690 via phone confirmed on [DATE] she had been assigned to care for Resident #162 on night shift. LPN #690 confirmed on [DATE] she had checked in on Resident #162 and the resident stated she had fallen earlier, and her leg was hurting. LPN #690 stated she looked at Resident #162's leg but noticed no bruising and administered pain medications. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365046 If continuation sheet Page 15 of 55 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 11/08/2024 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 - Actual harm Residents Affected - Few Interview on [DATE] at 7:56 A.M. with Agency LPN #827 via telephone confirmed on [DATE] she had been assigned to care for Resident #162 on night shift. Agency LPN #827 indicated during report at the beginning of her shift the previous nurse had notified her there was a pending x-ray result for Resident #162. Agency LPN #827 stated she saw Resident #162 at the beginning of her shift and Resident #162 was alert and reported no pain. Agency LPN #827 indicated she observed Resident #162's knee and noted it was swollen with some bruising. Agency LPN #827 indicated she questioned the other nurse on floor about how to receive lab and radiology reports at about 12:00 A.M. on [DATE]. Agency LPN #827 confirmed she did not locate the x-ray results for Resident #162 until approximately 4:00 A.M. on [DATE]. Agency LPN #827 confirmed he attempted to reach the physician regarding the x-ray results which showed a fracture for Resident #162 at 4:41 A.M. on [DATE]. Agency LPN #827 confirmed she had not sent Resident #162 to the hospital for the fracture as she had not contacted the physician and indicated she was told by an unknown person they were treating in house. Agency LPN #827 confirmed on [DATE] at approximately 5:30 A.M. Resident #162 was found unresponsive, required CPR, and was pronounced deceased at 5:52 A.M. by EMS. Agency LPN #827 confirmed she was unable to contact the physician prior to the end of her shift. Interview on [DATE] at 8:45 A.M. with LPN/UM #787 confirmed on [DATE] he was notified by a housekeeper that a resident had fallen. LPN/UM #787 confirmed he found Resident #162 in her room sitting on her buttocks leaning against dresser. LPN/UM #787 stated Resident #162 was complaining of pain to leg and thigh/knee area and an x-ray to the bilateral hips was obtained. LPN/UM #787 confirmed on [DATE] at 3:15 P.M. STNA #825 reported the resident had swelling to right knee and he contacted CNP #833 for an x-ray of the right knee. Interview on [DATE] at 9:26 A.M. via phone with RN Supervisor #671 confirmed x-ray results were released directly under the results tab in the electronic medical record (EMR). RN Supervisor #671 confirmed if a resident had an unwitnessed fall and complained of pain or had swelling, they were supposed to be sent to the hospital. RN Supervisor #671 confirmed she was not sure why Resident #162 was not sent to the hospital on [DATE] following the fall. Interview on [DATE] at 2:30 P.M. with CNP #833 confirmed she was notified when Resident #162 fell on [DATE]. CNP #833 and she had ordered an x-ray of the resident's entire leg and was unsure why only the hip was initially obtained. CNP #833 indicated she was again notified on [DATE] by LPN Unit Manager #787 that Resident #162 was complaining of knee pain. CNP #833 questioned why the entire leg was not x-rayed as initially requested and gave order to x-ray resident's right knee. CNP #833 reported she was not required to be on call throughout the night. CNP #833 stated at about 8:00 A.M. on [DATE] the ADON called her to inform her of Resident #162's passing and the fracture. CNP #833 indicated the results came through on fax machine and was unsure why there was a delay with the results being reported. CNP #833 indicated had she been notified of the fracture at a reasonable hour Resident #162 would have been sent out to the hospital for evaluation. Interview on [DATE] at 4:04 P.M. with Physician #832 confirmed she had not been notified of Resident #162's fall on [DATE]. Physician #832 stated if she had been notified, she would have ordered an x-ray and for a fracture she would have sent Resident #162 to the hospital. Physician #832 stated she was on call at night and was able to be reached directly on her cell phone. Physician #832 stated she was not notified of Resident #162's fracture or passing until approximately 6:00 A.M. on [DATE]. Review of facility policy titled Fall Protocol dated [DATE] revealed the facility when a resident experienced a fall the facility would assess for injury, complete an incident report, notify physician and family, review care plan, initiate interventions, and document actions. The nurse should call (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365046 If continuation sheet Page 16 of 55 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 11/08/2024 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 the medical director if there was no return call from the attending physician. Level of Harm - Actual harm Review of facility policy titled Change in a Resident's Condition or Status undated revealed the nurse supervisor or charge nurse would notify the resident's attending physician or on-call physician when there was an accident involving the resident, a significant change to the resident's physical or mental condition, a need to alter the resident's medical treatment significantly, and/or a need to transfer the resident to a hospital or treatment center. Residents Affected - Few This deficiency represents noncompliance investigated under Complaint Number OH00158882 and OH00158529. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365046 If continuation sheet Page 17 of 55 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 11/08/2024 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 - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and review of the facility policy, the facility failed to assess Resident #163's wound and obtain appropriate treatment orders upon re-admission from the hospital and failed to complete pressure ulcer treatments as ordered by the physician or nurse practitioner to prevent a decline in the wound resulting in suspected osteomyelitis (serious bone infection). Residents Affected - Few Actual Harm occurred on 10/02/24 when Resident #163's pressure ulcer progressed from a Stage III pressure ulcer (full thickness tissue loss, subcutaneous fat may be visible but bone, tendon or muscle are not exposed, slough may be present but does not obscure the depth of tissue loss, may include undermining and tunneling) measuring 1.5 centimeters (cm) by 2.0 cm with a depth of 0.1 cm to an unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) with suspected osteomyelitis measuring 10.7 cm by 7.0 cm with a depth of 1.0 cm due to the facility's lack of timely assessment/monitoring and implementation of wound care orders following the resident's re-admission from the hospital as well as the facility's failure to ensure wound care was provided as ordered once orders were obtained. This affected one resident (#163) of three residents reviewed for pressure sores. The facility census was 166. Findings include: Review of Resident #163's closed medical record revealed Resident #163 was admitted to the facility on [DATE] with diagnoses including end stage renal disease, diabetes, and moderate malnutrition. The resident was hospitalized from [DATE] to 08/30/24 and returned to the facility with a new diagnosis of cerebral infarction and was noted to have a new wound on his buttocks. The resident was transferred to the hospital on [DATE] for hypotension and lethargy and did not return to the facility. Review of the care plan dated 08/19/24 noted Resident #163 was at risk for skin breakdown. Care plans for a pressure reducing cushion to the chair, pressure reducing mattress to the bed, and regular repositioning were initiated 08/19/24. Record review of Resident #163's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident exhibited mild or no cognitive impairment and had one Stage III pressure ulcer present on admission. The assessment noted the resident was always incontinent of bowel and bladder and needed substantial (staff) assistance to roll or turn in bed. Pressure reducing devices for bed and chair were noted. A progress note dated 08/30/24 revealed the resident was readmitted to the facility on [DATE] at 7:30 P.M. with an undefined wound on his buttocks. Review of the resident's previous physician orders revealed no specific order for regular turns or limiting wheelchair time. Record review revealed wound care orders were not initiated until 09/02/24. Review of Resident #163's assessments revealed the resident was identified as having a very high risk for pressure ulcer breakdown on 08/31/24. The re-admission skin assessment dated [DATE] identified a wound on the resident's sacrum with no additional information related to the wounds size, source, or other qualities. On 09/04/24 Wound Nurse Practitioner #826 assessed the resident and identified the resident had a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365046 If continuation sheet Page 18 of 55 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 11/08/2024 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 Stage III pressure ulcer (to the sacrum) measuring 1.5 cm by 2 cm with a depth of 0.1 cm. Level of Harm - Actual harm A nurse practitioner assessment/note by Wound Nurse Practitioner #826 dated 09/11/24 revealed Resident #163 was not on a low air-loss (LAL) mattress and his wound now measured 3.0 cm by 2.0 cm with a depth of 0.1 cm. The nurse practitioner changed the wound care orders and ordered a LAL mattress at that time. Residents Affected - Few A nutrition therapy note dated 09/13/24 acknowledged Resident #163's pressure ulcer and identified the resident was tolerating Novasource renal supplements. On 09/18/24 facility assessment revealed Resident #163's pressure ulcer was noted to be larger, measuring 7.0 cm by 5.0 cm with a depth of 0.2 cm. There were no new orders on this date. A nurse practitioner (NP) note/assessment by Wound Nurse Practitioner #826 dated 09/25/24 revealed the resident's sacral pressure ulcer measured 8.2 cm by 5.0 cm with a depth of 0.2 cm. The nurse practitioner noted the resident had not been seen last week due to dialysis. The NP changed the resident's dressing orders and ordered a ROHO cushion (a pressure reduction cushion to prevent or treat pressure ulcers). The last nurse practitioner wound assessment by Wound Nurse Practitioner #826 on 10/02/24 identified the resident's pressure ulcer was classified as being unstageable, measuring 10.7 cm by 7.0 cm with a depth of 1.0 cm. The nurse practitioner noted the wound was worse and ordered testing for potential osteomyelitis (serious bone infection) including an x-ray of the sacrum and antibiotics. She also noted educating the resident to limit time in the chair when not at dialysis. The wound nurse practitioner assessments made no indication that the decline of the pressure ulcer was unavoidable. Review of Resident #163's treatment administration record (TAR) revealed no documented evidence of wound care until 09/03/24, four days after readmission. There was no documented evidence of wound care on the afternoon of 09/27/24 and 10/04/24. Wound care was documented as not completed due to the resident sleeping on the morning of 09/26/24. Wound care was documented as not completed due to the resident having appointments on the morning of 09/04/24, 09/20/24, 09/27/24, and 10/04/24. Review of the progress notes on these days revealed no clear documentation of appointments except on 09/04/24 and 09/20/24 when it was noted the resident was at dialysis. A LAL mattress was ordered starting 09/12/24 and documented as in place every shift until his discharge. Review of Resident #163's care plans in place as of the resident's discharge on [DATE] revealed no noted behavior of refusals of care. Review of Resident #163's progress notes dated 08/16/24 through 10/06/24 revealed noncompliance with pressure sore care was only documented on 10/02/24 (four days before discharge), when it was noted that education was provided, but the resident remained noncompliant with positioning and cushion use. However, this had not been care planned nor were there any additional nursing progress notes to reflect any non-compliance. Record review of an x-ray of Resident #163's sacrum completed 10/04/24 revealed it identified an area concerning osteomyelitis with a recommendation for further evaluation. Interview with Unit Manager #816 on 10/30/24 at 11:33 A.M. revealed she recalled Resident #163 was often noncompliant with repositioning and dressing changes. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365046 If continuation sheet Page 19 of 55 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 11/08/2024 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 - Actual harm Residents Affected - Few Interview with Wound Nurse Practitioner #826 at 4:28 P.M. on 10/30/24 revealed she ordered a work-up for suspicion of osteomyelitis in Resident #163's wound, however he was hospitalized before she learned the results. She stated she had concerns with the resident's wound care not being completed as ordered and recalled events where his wound dressings were not changed for multiple days despite orders. She noted she sometimes had to make orders for wound care twice daily at the facility just to make sure residents get them at least daily due to care being skipped. Interview with the Director of Nursing (DON) on 10/31/24 at 9:06 A.M. verified Resident #163's wound declined in the facility and there were multiple missed treatments with no documentation indicating the decline was unavoidable and no documentation of refusals of care beyond one note. Record review of the facility's undated pressure ulcer prevention policy revealed residents were to be assessed for risks and educational needs, and interventions for at-risk residents to be put in place. Pressure sore risk assessments were to be done on admission, quarterly, and with significant changes. The policy noted interventions available for use but did not clarify any specifics for how they should be initiated or tracked. This deficiency represents noncompliance investigated under OH00158683 and OH00158550. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365046 If continuation sheet Page 20 of 55 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 11/08/2024 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, and review of the medical record, the facility failed to ensure residents received prescribed treatments or application of appliances as prescribed to maintain or prevent a decline in range of motion (ROM). This affected one resident (Resident #27) of one resident reviewed for ROM/mobility. The facility census was 166. Findings include: Review of the medical record for Resident #27 revealed an admission date of 01/07/24 with diagnoses including chronic obstructive pulmonary disease (COPD), depression, primary hypertension, osteoarthritis, muscle weakness, pain in left shoulder, and hemiplegia or hemiparesis following a cerebral infarction affecting the left non-dominant side. Review of the annual Minimum Data Set (MDS) 3.0 assessment completed on 10/13/24 revealed Resident #27 had intact cognition and no behaviors or rejection of care. Further review of the MDS revealed Resident #27 had impaired range of motion (ROM) on one side of her upper and lower extremities and suffered from hemiparesis or hemiplegia. Review of the physician orders revealed orders dated 07/06/23 for Resident #27 to wear a left hand split throughout the day as tolerated and a PRAFO boot (a custom fit ankle foot orthosis) on the left foot when in bed. Further review of the orders revealed staff were to monitor for skin breakdown or adverse reactions to the splint. Review of the care plan dated 01/07/23 to 01/13/25 revealed Resident #27 had an activities of daily living (ADL) self-care deficit weakness and poor left-sided mobility and required the assistance of one to two staff for all ADLs. Further review of the care plan interventions revealed Resident #27 was to wear a left hand splint throughout the day as tolerated and a PRAFO boot to the left foot when in bed. The interventions further directed staff to monitor for skin breakdown related to left hand splint and left foot brace use. Review of the occupational therapy discharge summary signed 06/18/24 for dates span 02/28/24 to 06/18/24 revealed a recommendation Resident #27 continue to wear the left resting hand splint throughout the day as tolerated and for staff to monitor for skin breakdown or any adverse reactions. Review of the medical record point-of-care task documentation list revealed there were no required tasks related to staff ensuring a left hand splint or left PRAFO boot was applied to Resident #27. Review of the medication administration record (MAR) and the treatment administration record (TAR) from the past three months revealed no nursing documentation indicating application of splints or braces for Resident #27. Interview on 10/28/24 at 10:05 A.M. with Resident #27 revealed she felt she needed therapy as she stated her foot was stuck downward and her hand was too tight and closed all the time. During the interview, Resident #27 confirmed she had a hand splint, but did not know where it went, hadn't worn it in what she described as possibly a few months, and staff did not provide any exercises to prevent her hand from getting worse. Observation of Resident #27 and her surroundings at the time of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365046 If continuation sheet Page 21 of 55 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 11/08/2024 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few interview revealed a contracture of the left hand, no left hand splint in place and two signs on Resident #27's bulletin board, one with a picture of the hand splint and the other with instructions on how to properly apply the hand splint. Follow-up observations on 10/29/24 at 4:05 P.M., 10/30/24 at 9:48 A.M., and 10/31/24 at 9:55 A.M. revealed Resident #27 was not wearing a left hand splint. Interviews with Resident #27 at the time of each observation confirmed that staff had not inquired about the hand splint or attempt to apply one. Interview on 10/31/24 at 10:51 A.M. with Licensed Practical Nurse (LPN) #715 confirmed she had observed a blue splint on Resident # 27's left hand in the past, but did not know when she was supposed to wear it. At the time of the interview, LPN #715 confirmed Resident #27 was not wearing a hand splint and that she confirmed with Resident #27 she did not know where the splint was. Interview on 11/04/24 at 12:38 P.M. with LPN #844 confirmed she had nothing on her report sheet stating Resident # 27 was to wear a hand splint and had no other information pertaining to the hand splint to offer. Interview on 11/04/24 at 9:27 A.M. with Director of Therapy #658 confirmed Resident #27 was last admitted to Occupation Therapy (OT) services on 02/28/24 for evaluation of splinting of the left hand. Director of Therapy #658 further confirmed Resident #27 was discharged on 06/18/24 and was able to tolerate the resting left hand splint up to four hours daily. During the interview, Director of Therapy #658 confirmed therapy discharge recommendations were for Resident #27 to wear the left hand splint daily as tolerated, and staff were to monitor for skin breakdown or adverse reactions. Observation on 11/04/24 at 12:23 P.M. revealed Resident #27 was in bed with no hand split. An Interview conducted at the time of the observation with Resident #27 confirmed no staff had offered to help find her left hand splint or apply it. Resident #27 further stated it was very difficult to put the splint on herself without staff assistance but could sometimes do it herself if she had it available. Resident #27 further stated she felt like her left hand was closed tighter than when she was previously wearing her brace consistently. Interview on 11/04/24 at 2:50 P.M. CNA #843 confirmed she received no report that Resident #27 had a hand splint or a PRAFO boot. She further confirmed Resident #27 was wearing neither and searched the drawers in one of Resident #27's dressers, with permission of Resident #27, and did not find the hand splint. She further confirmed the foot brace was on Resident #27's bedroom floor but she did not know when it was to be applied. Interview on 11/04/24 at 2:53 P.M. with CNA #749 confirmed she had not provided care for Resident #27 in a long time and she was unaware of an order for any splints or braces. Interview on 11/04/24 with Resident #27 at 3:05 P.M. confirmed she had a brace for her left foot that was lying on the floor, but she had not worn it in a while. She did not confirm or deny that she wanted to wear the PRAFO boot while she was in bed or whether staff had offered to place it on her left foot. Resident #27 then reiterated she was more concerned with wearing her hand splint. Interview on 11/04/24 with LPN Unit Manager #787 at 3:10 P.M. confirmed the facility did not provide restorative nursing services and further confirmed Resident #27 had orders placed in 2023 for a left resting hand splint and Left foot PRAFO boot. He further confirmed both were listed on Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365046 If continuation sheet Page 22 of 55 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 11/08/2024 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 0688 Level of Harm - Minimal harm or potential for actual harm #27's care plan but were not on the [NAME] (a document describing resident care needs) for nursing staff due to them being entered on the care plan incorrectly. This deficiency represents non-compliance investigated under Complaint Number OH00158529. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365046 If continuation sheet Page 23 of 55 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 11/08/2024 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 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review and interview, the facility failed to develop and implement a comprehensive and individualized fall prevention program to prevent falls, ensure falls were thoroughly investigated and/or ensure residents were safely transferred. Actual harm occurred on 10/03/24 at approximately 11:40 P.M. when Resident #19, who was cognitively impaired, was at high risk for falls and had a history of fall and required substantial or maximal staff assistance for activities of daily living (ADLs), sustained an unwitnessed fall that resulted in displaced fractures of the right seventh through 12th ribs and a non-displaced sternal fracture. Prior to the fall on 10/03/24, Resident #19 had a care planned intervention for staff to check on her between the hours of 10:00 P.M. and 12:00 A.M., due to a previous fall in the facility. However, there was no evidence in the medical record this intervention was monitored and/or being completed. Resident #19 was transferred to the hospital on [DATE] at approximately 1:40 A.M. due to pain and was admitted to the cardiac intensive care unit (ICU). This affected two residents (#19 and #68) of seven residents reviewed for falls. The facility census was 166. Findings include: 1. Review of the medical record for Resident #19 revealed an admission date of 04/29/18 with diagnoses including age-related osteoporosis, presence of left artificial shoulder joint, presence of right artificial hip joint, history of falling, Alzheimer's disease, pleural effusion, chronic pulmonary embolism, non-displaced fracture of the sternal end of the clavicle and multiple fractures of ribs with delayed healing. Review of the fall care plan, initiated 06/25/21, revealed Resident #19 was at risk for falls related to dementia, impaired safety awareness, and a history of falls. Interventions included on 06/25/21 were to ensure resident was wearing appropriate footwear, call light within reach and encourage the resident to use the call light for assistance, and anticipate and meet the resident's needs. Additional interventions initiated included educate resident on putting hands into chair seat before sitting to ensure proper positioning (08/17/22), remind resident to not rush and take her time while ambulating (12/12/22), therapy consult for walker safety and management (05/26/23), remain with resident during duration of toileting and do not leave resident unattended (05/30/23), call before you fall sign placed in room (09/07/23), keep all mail and new paper at bedside or within reach (10/19/23), check resident between 10 P.M. to 12 A.M. to ensure she was sleeping (09/27/24), place bedside commode next to bed (10/05/24), and place resident in Broda chair in common area and a fall mat at bedside (10/28/24). Review of the fall risk assessment, dated 08/09/24, revealed Resident #19 was high risk for falls with a score of 65. The assessment indicated Resident #19 had fallen before, had more than one diagnosis in the chart, utilized crutches or a cane or a walker, had a weak gait, and knew her own limits. Review of a facility fall investigation dated 09/26/24 at 10:54 P.M. and authored by Licensed Practical Nurse (LPN) #799 revealed the resident had an unwitnessed fall in her room. She thought it was morning, was trying to get herself dressed, lost her balance and fell to the floor. She was assessed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365046 If continuation sheet Page 24 of 55 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 11/08/2024 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 with no injury. A new intervention was added to check on Resident #19 between 10:00 P.M. and 12:00 A.M. to ensure she was in bed and the care plan was updated. Level of Harm - Actual harm Residents Affected - Few Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 09/30/24, revealed Resident #19 had severe cognitive impairment, required partial or moderate (staff) assistance for toilet transfers, had experienced one fall with no injury since the prior assessment, and reported no pain or hurting in the five days prior to the assessment. Review of physician orders for October 2024 revealed no orders pertaining to fall interventions. Review of the significant change MDS 3.0 assessment, dated 10/13/24, revealed Resident #19 had severe cognitive impairment and required substantial or maximal (staff) assistance with activities of daily living ADLs. Review of a facility fall investigation dated 10/03/24 at 11:40 P.M. revealed LPN #690 heard Resident #19 screaming for help from her room, and when the nurse walked in the resident was on the bathroom floor and said she hit her back. The nurse did vital sign check and with the assistance of three staff transferred the resident back to bed. The resident started to complaint of right-side pain and cried when we touched her side. The resident was unable to describe what happened. An ice pack was applied, acetaminophen (non-narcotic pain medication) was given, and no injury was observed at the time of the incident. The resident was noted to have a pain level of six out of 10 (ten being severe pain). The resident was oriented to self only and complaining of pain. Predisposing environment factors included a wet floor. It was also noted Resident #19 was confused, ambulating without assistance and was trying to toilet herself. A follow up note dated 10/04/24 revealed the resident was transferred to the local hospital on [DATE] around 1:40 A.M. for an evaluation. The nurse called for an update at 6:35 A.M. and found the resident was in the ICU with rib fractures. A new intervention was added for a bedside commode and the care plan was updated. There was no information on this incident report to indicate when Resident #19 had last been checked by staff. Review of a witness statement, dated 10/03/24, written by LPN #690 revealed Resident #19 was observed on the bathroom floor screaming for help, reported hitting her head, and complained of pain to the right side. Vital signs were normal, range of motion was normal, and neurological checks were initiated. There was no information on this statement to indicate when Resident #19 had last been checked by staff. Review of a second witness statement, dated 10/03/24, written by an unknown facility staff member (the signature was partially illegible, and this person was not on the all-staff roster for the facility) indicated they did not witness Resident #19 fall, and no other information was provided. There were no other witness statements included in the facility investigation. Review of the October 2024 Medication Administration Record (MAR), Treatment Administration Record (TAR), progress notes, nurse aide tasks, and resident evaluations revealed there was no documentation that the intervention to check Resident #19 between the hours of 10:00 P.M. and 12:00 A.M. was implemented and monitored. It was noted on the MAR that two tablets of acetaminophen (500 milligram tablets) were administered on 10/03/24 at 11:50 P.M. by LPN #690 (which was after the resident had fell in her room) for a pain level of six out of 10. Review of the facility document titled Medication Admin Audit Report, dated 10/03/24, for Resident #19 revealed on 10/03/24 at 11:10 P.M. CVS nasal spray and sodium chloride granules were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365046 If continuation sheet Page 25 of 55 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 11/08/2024 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 - Actual harm Residents Affected - Few administered to Resident #19 by LPN #690. The acetaminophen which had been noted in the MAR as being given on 10/03/24 at 11:50 P.M. was not on the audit report. However, an interview with LPN #690 (noted further down in this deficiency) revealed LPN #690 stated she was being trained by LPN #791 on how to add medication administration documentation into the electronic MAR at that time and did not actually administer any medications to Resident #19 at 11:10 P.M. nor provide any care for her at that time. Review of the progress note, created 10/04/24 at 2:51 A.M. with an effective date of 10/03/24 at 11:40 A.M. (this time was inaccurate in the medical record as it should have been 11:40 P.M.) authored by LPN #791 indicated Resident #19 had an unwitnessed fall, the nurse heard Resident #19 yelling from her room, Resident #19 was observed sitting against the wall on the bathroom floor with pants halfway down and the floor was wet, Resident #19 was assisted back to bed by three staff members, a head to toe assessment was completed, Resident #19 complained of right side pain of six out of 10 with tenderness to touch, an ice pack was applied, Tylenol (acetaminophen) was given, and no other injuries were noted. The note indicated Resident #19 was sent to the hospital at approximately 1:40 A.M. Review of the progress note, created 10/05/24 at 12:54 P.M. with an effective date of 10/03/24 at 11:57 P.M., authored by Unit Manager/LPN (UM/LPN) #789 revealed Resident #19 was screaming for help from her room and observed on the floor of the bathroom claiming she had hit her back. Resident #19 was assisted back to bed by three staff. Resident #19 complained of right-side pain and cried when her side was touched. Ice was applied and Tylenol was given. Resident #19 was sent to the hospital at 1:40 A.M. due to intense pain and crying. The note indicated Resident #19 was admitted to the ICU for rib fractures. Review of the hospital records dated 10/04/24 to 10/05/24 revealed Resident #19 arrived at the emergency room at 2:14 A.M. on 10/04/24 complaining of pain all over the right-side motioning broadly to the right flank extending to the base of the right side of the chest along the rib cage and she believes she fell tonight but could not elaborate. Baseline capacity was oriented to self only. Resident #19 appeared elderly, frail and in no acute distress while sitting up in the bed. The radiology report dated 10/04/24 at 3:48 A.M. concluded Resident #19 had displaced fractures of the right seventh through 12th ribs and a non-displaced sternal fracture. A diagnosis of pulmonary embolism (blood clot in the lung) was also diagnosed. The hospital plan of care recommendations included physical and occupational therapy and anticoagulant medication for treatment, however, the family declined and opted for comfort care with hospice services. Resident #19 was discharged back to the facility on [DATE]. On 10/28/24 at 3:07 P.M., an observation of Resident #19 revealed she was sitting in a reclining geriatric chair by the nurse's station. She was alert but unable to provide any valid responses to any simple or open-ended questions. On 10/31/24 at 11:01 A.M., an interview with Registered Nurse (RN) #661 revealed she was familiar with Resident #19 and stated Resident #19 had several falls in the facility due to ambulating without assistance. On 10/31/24 at 1:55 P.M., an interview with UM/LPN #789 revealed just because things were time stamped a certain time in the medication record did not mean that was when it was administered because the time stamp was just when it was documented in the chart. UM/LPN #789 verified there was a discrepancy between the MAR indicating the acetaminophen was given on 10/03/24 at 11:50 P.M. and the Medication Admin Audit Report. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365046 If continuation sheet Page 26 of 55 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 11/08/2024 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 - Actual harm Residents Affected - Few On 11/04/24 at 12:23 P.M., a follow-up interview with UM/LPN #789 revealed the progress note with an effective date of 10/03/24 at 11:40 A.M. was inaccurately documented because the fall incident of Resident #19 occurred on night shift not day shift. He further indicated he did not have a witness statement for LPN #791, who wrote the progress note documenting the incident. UM/LPN #789 also confirmed Resident #19 was not transferred to the hospital until two hours after the fall occurred. On 11/04/24 at 2:27 P.M., an interview with LPN #690 revealed on 10/03/24 she was sitting at the nurse's station, and she heard Resident #19 call for help and upon entering the room Resident #19 was observed on the floor. LPN #690 said they could not send Resident #19 to the hospital until they checked to see if she was on hospice, and it took a while to get in touch with hospice on night shift. LPN #690 said Resident #19 was complaining of pain and was ultimately sent to the hospital due to pain. LPN #690 could not recall when she had last seen Resident #19 prior to the fall on 10/03/24. On 11/04/24 at 2:41 P.M., an interview with LPN #791 revealed on 10/03/24 she was sitting at the nurse's station and heard Resident #19 screaming in her room. Upon entering the room, Resident #19 was observed on the bathroom floor. LPN #791 obtained Resident #19's vital signs and completed a head-to-toe assessment which revealed no bruising or swelling. Resident #19 complained of pain on her right side and LPN #791 administered as needed (PRN) Tylenol (acetaminophen) per physician's orders after the fall occurred. LPN #791 said it was about an hour and a half before Resident #19 was sent to the hospital because they had to determine if Resident #19 was on hospice or not. LPN #791 could not recall when she had last seen Resident #19 prior to the fall on 10/03/24. LPN #791 stated she did not complete a witness statement for the incident, she just wrote a progress note in the chart. On 11/05/24 at 8:11 A.M., an interview with the Director of Nursing (DON) confirmed Resident #19 had a fall on 09/26/24 and a new intervention was added to check on Resident #19 between 10:00 P.M. and 12:00 A.M. The DON verified the fall on 10/03/24 occurred within that 10:00 P.M. to12:00 A.M. time. The DON stated staff would not have documented those checks because it would have been a routine check. However, the DON verified there was no documented evidence this new intervention had been implemented for Resident #19. On 11/05/24 at 9:55 A.M., an interview with UM/LPN #789 revealed LPN #690 had administered medications on 10/03/24 at 11:10 P.M. as indicated by the documentation on the Medication Admin Audit Report. UM/LPN #789 confirmed he had previously stated the time stamps in the charts were not indicative of the time something was administered because the time stamp just reflected when it was documented. UM/LPN #789 confirmed he could not verify exactly when the medication administration occurred so there was no firm evidence Resident #19 had been checked by staff prior to the fall. UM/LPN #789 said the intervention of checking Resident #19 between 10:00 P.M. and 12:00 A.M., which was implemented after a fall on 09/26/24, was not documented in the chart because it was part of the routine two-hour check and changes. UM/LPN #789 also confirmed the progress note, authored by him, was created on 10/05/24 after the interdisciplinary team (IDT) had completed their investigation of the fall and he backdated the note to the time of the incident on 10/03/24. UN/LPN #789 stated again that LPN #791's progress note, dated 10/03/24 at 11:40 A.M., was inaccurately documented because it should have reflected a time of 11:40 P.M. On 11/05/24 at 1:15 P.M., an interview with Nurse Practitioner (NP) #839 revealed she could not confirm when the notifications were made for Resident #19's fall on 10/03/24. NP #839 verified there were no physician's orders in the medical record to send Resident #19 to the hospital on [DATE] or 10/04/24 and said residents could not be sent to the hospital without physician's orders. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365046 If continuation sheet Page 27 of 55 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 11/08/2024 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 - Actual harm Residents Affected - Few On 11/07/24 at 11:08 A.M., an interview with LPN #690 revealed she did not provide care for Resident #19 at all that evening of 10/03/24 until after the fall. She stated LPN #791 provided all care and services, but it was documented on the medication records under LPN #690's name because LPN #791 was showing her how to document it in the electronic record using LPN #690's log-in access. LPN #690 stated she was not able to verify if LPN #791 actually checked on Resident #19 for any reason prior to the fall that evening. Review of the facility policy titled Fall Protocol, dated 10/15/24, revealed each resident would be assessed for the risk of falling, would receive care and services to minimize the likelihood of falls, and the facility would conduct an in-depth root-cause analysis with each fall and would implement interventions appropriate to the resident and the situation. When any resident experiences a fall, the facility would assess the resident for injuries, complete an incident report, notify the physician, notify the family or Power of Attorney (POA), notify the nursing supervisor, document accordingly, review the resident's care plan, initiate an immediate intervention as indicated to decrease risk of further events, and document all assessments and actions in the progress notes including interventions implemented. The nursing department would review falls and conduct a root-cause analysis to include the following: a) all scheduled staff to write a statement of occurrence, b) the resident's statement of occurrence, c) any risk factors that contributed to the fall, d) identification of any high-risk medications, e) current interventions in place, f) the facility's immediate actions, and g) long term interventions to be implemented. Nursing staff would monitor for effectiveness and appropriateness of all new interventions. 2. Review of the medical record revealed Resident #68 was admitted to the facility on [DATE] with diagnoses including wedge compression fracture of first lumbar vertebrae, postherpetic polyneuropathy, enterocolitis, hypertensive heart disease with heart failure, type two diabetes mellitus, osteoarthritis, fracture of right lower leg, sciatica, and morbid obesity. Review of the care plan dated 02/07/24 revealed Resident #68 had activities of daily living (ADL) self-care performance deficit related to impaired mobility, hip fracture, pain and weakness and required assistance from two staff for all transfers. Review of the quarterly MDS 3.0 assessment completed on 10/07/24 revealed Resident #68 had intact cognition, had impaired range of motion (ROM) on one side of both her upper and lower extremities, and refused the assessment related to transfer ability. Further review of MDS assessments revealed the previous quarterly MDS completed on 09/16/24 and on 07/18/24 revealed Resident #68 was dependent for chair to bed transfers. Observation on 10/30/24 at 1:35 P.M. revealed a Hoyer lift (a mechanical device used to help transfer residents from one place to another) between Resident #68's wheelchair and bed. At the time of the observation, only one staff member, Certified Nursing Assistant (CNA) #810, was in Resident #68's room and he stated he had just finished putting her back to bed. Interview on 10/30/24 at 1:38 P.M. with CNA #810 confirmed he completed the transfer of Resident #68 from her wheelchair to her bed with a Hoyer lift without a second staff member present. During the interview, STNA #810 also confirmed he had performed one-person Hoyer transfers in the past, but knew two staff were required for all mechanical lift transfers. Interview on 10/30/24 at 1:43 P.M. with Resident #68 confirmed no other facility staff were present at the time she was transferred by STNA #810 with the Hoyer lift from her chair to her bed, and it (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365046 If continuation sheet Page 28 of 55 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 11/08/2024 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 was not the first time only one staff member was present when the Hoyer lift was used. Level of Harm - Actual harm Interview on 10/31/24 at 11:12 A.M. with Registered Nurse (RN) Unit Coordinator #814 confirmed two staff members were required during all Hoyer transfers. Residents Affected - Few Review of the policy titled Mechanical Lift Usage last revised October 2023 revealed a mechanical lift was to be used with two staff members. This deficiency represents non-compliance investigated under Complaint Numbers OH00158926, OH00158389 and OH00158882. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365046 If continuation sheet Page 29 of 55 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 11/08/2024 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on observation, interview, medical record review, and review of facility policy, the facility failed to ensure appropriate care and services were in place for Resident #111's enteral feeding tube. This affected one resident (Resident #111) of one reviewed for tube feeding concerns. The facility identified eleven residents ( #46, #63, #66, #79, #97, #98, #110, #111, #128, #137, and #148) who received enteral tube feedings. The facility census was 166. Findings include: Review of the medical record for Resident #111 revealed an initial admission date of 12/20/23 and a facility re-entry date of 01/31/24. Diagnoses included hypertensive urgency, hematuria, altered mental status, benign prostatic hyperplasia, oropharyngeal phase dysphagia, type two diabetes mellitus with diabetic neuropathy, unspecified dementia, pure red cell aplasia, vesicointestinal fistula, flaccid neuropathic bladder, stage three chronic kidney disease, acquired absence of the right and left leg above the knee, and attention to gastrostomy. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment completed on 07/26/24 revealed Resident #111 had intact cognition and exhibited no behaviors or rejection of care. Further review of the MDS revealed Resident #111 received his primary nutrition and hydration through a feeding tube. Review of the care plan dated 09/18/24 revealed Resident #111 required a PEG (percutaneous endoscopic gastrostomy) tube (a feeding tube inserted into the stomach which may be used for nutrition, hydration, and medication administration) secondary to dysphagia. Interventions included providing local PEG tube site care per orders and monitoring for signs and symptoms of infection. Review of all active physician orders revealed no orders related to care of Resident #111's PEG tube insertion site. Observation on 10/28/24 at 2:22 P.M. revealed the tube pump beeping hold error (a water flush had been infusing) and a PEG tube PEG dressing with several yellowish to yellow-brown stains which was dated 10/25/24. An interview with Resident #111 at the time of the observation confirmed the feeding pump had been beeping for 10 minutes, it beeps all the time, and staff take a long time to check to see why it is beeping. During the interview, Resident #111 stated he was uncertain how often his PEG tube dressing got changed because it tends to vary, but thought this one had been on since last week. Continued observation from the hallway revealed no staff entered the room of Resident #111 to check on the beeping feeding pump until 2:50 P.M., though one staff member was observed walking past the room twice. Interview on 10/28/24 at 2:50 P.M. with Certified Nursing Assistant (CNA) #841 confirmed the PEG tube dressing was dated 10/25/24 and confirmed she was on the way to let the nurse know the feeding pump had been beeping. Interview on 10/30/24 at 2:18 P.M. with Resident #111 revealed something around his abdomen was bothering him after his shower and he thought there might still be a dressing on his PEG tube insertion site. At the time of the interview, he began pulling at his gown and grabbing around the PEG tube stating he wanted it off. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365046 If continuation sheet Page 30 of 55 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 11/08/2024 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 10/30/24 at 2:24 P.M. with Licensed Practical Nurse (LPN) #795 confirmed her knowledge of Resident #111's PEG tube care was that if it is dirty, change it. LPN #795 further revealed nurses were to follow orders, adding if they have them. Observation on 10/30/24 at 2:36 P.M. of Resident #111 receiving PEG tube site care from LPN #795 revealed there was no dressing (he had just been showered within the hour), and the site appeared clean, dry, and intact. LPN #795 was observed cleaning the PEG site with moistened gauze, drying with a clean gauze pad, and applying a clean split gauze which was dated and initialed. An interview with LPN #795 after the PEG tube care was completed confirmed the gauze used to clean around the PEG tube insertion site was moistened with Dakin's solution (a strong topical antiseptic solution used to treat or prevent wound infections), but she was uncertain the strength of the solution she used and was unable to verbalize what the orders were for the PEG tube site care she just performed for Resident #111. Interview on 10/31/24 at 10:48 A.M. with LPN #715 confirmed Resident #111 had no orders regarding PEG site care. Interview on 10/31/24 at 11:20 A.M. with LPN Unit Manager #787 confirmed PEG tube site care should be done daily and as needed by cleaning and applying a clean split gauze. During the interview, LPN #787 confirmed Resident #111 had no orders related to PEG site care, just checking placement and residuals every eight hours. Review of the policy titled Peg Tube Care and Maintenance revised October 2017 revealed no creams, powders, or dressings were to be applied underneath the external anchor device unless ordered by a physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365046 If continuation sheet Page 31 of 55 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 11/08/2024 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 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** 2. Review of the medical record for Resident #50 revealed an admission date of 08/25/22 with diagnoses including end stage renal disease, dementia, congestive heart failure, and dependence on renal dialysis. Residents Affected - Few Review of the physician's orders for October 2024 identified orders for dialysis three times weekly on Tuesday, Thursday, and Saturday (ordered 02/21/24), perform pre-dialysis assessment once daily on dialysis days (ordered 12/02/23), and perform post-dialysis assessment every evening shift on dialysis days (ordered 12/03/23). Review of the quarterly MDS 3.0 assessment, dated 10/25/24, revealed Resident #50 had severe cognitive impairment and received dialysis treatments. Review of the medication administration records (MARs) for August 2024 through October 2024 revealed there were no pre-dialysis vital signs on 09/07/24 and 10/19/24, and there were no post-dialysis vital signs on 08/30/24, 09/05/24, 09/26/24, 10/08/24, 10/15/24, and 10/22/24. Review of Resident #50's dialysis assessment dated [DATE] revealed Resident #50 went to dialysis on 08/03/24 at 4:00 P.M. and returned from dialysis at 12:00 A.M. The pre-dialysis evaluation, first post-dialysis evaluation, and second post-dialysis evaluation (which the assessment indicated was four hours post-dialysis) all used the same vital signs, including a temperature, pulse, and oxygen saturation all dated 08/03/24 at 1:36 P.M., and a blood pressure dated 08/03/24 at 3:24 P.M. The first post-dialysis evaluation and second post-dialysis evaluation both included a pain level dated 07/30/24 at 6:38 P.M. and a respiration rate dated 08/01/24 at 11:16 P.M. The pre-dialysis weight, dated 07/26/24 at 1:44 A.M., was 142 pounds and there was no indication of a post-dialysis weight. Review of Resident #50's dialysis assessment dated [DATE] revealed Resident #50 went to dialysis on 08/08/24 at 4:30 P.M. and returned from dialysis on 08/08/24 at 11:00 P.M. The pre-dialysis evaluation included an oxygen saturation dated 08/06/24 at 10:49 P.M. The second post-dialysis evaluation (four hours post-dialysis) included a pain level dated 08/03/24 at 7:12 P.M., and a respiration rate and oxygen saturation both dated 08/06/24 at 10:49 P.M. Review of Resident #50's dialysis assessment dated [DATE] revealed Resident #50 went to dialysis on 08/13/24 at 9:00 A.M. and returned from dialysis on 08/13/24 at 4:00 P.M. The second post-dialysis evaluation (four hours post-dialysis) included a pain level dated 08/09/24 at 2:16 A.M. and a blood pressure dated 08/13/24 at 9:26 A.M., which was the same blood pressure included in the pre-dialysis evaluation. The pre-dialysis weight, dated 08/08/24 at 3:29 P.M., was 142 pounds and there was no indication of a post-dialysis weight. Review of Resident #50's dialysis assessment dated [DATE] revealed Resident #50 went to dialysis on 08/15/24 at 9:45 A.M. and returned from dialysis on 08/15/24 at 4:30 P.M. The pre-dialysis evaluation included a pulse and oxygen saturation both dated 08/14/24 at 1:36 A.M. The first post-dialysis evaluation and the second post-dialysis evaluation both included a respiration rate and pain level both dated 08/13/24 at 6:03 P.M., a temperature, pulse, and oxygen saturation all dated 08/14/24 at 1:36 A.M., and a blood pressure dated 08/15/24 at 9:17 A.M., which was the same blood pressure included in the pre-dialysis evaluation. The pre-dialysis weight, dated 08/08/24 at 3:29 P.M., was 142 pounds and there was no indication of a post-dialysis weight. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365046 If continuation sheet Page 32 of 55 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 11/08/2024 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 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #50's dialysis assessment dated [DATE] revealed Resident #50 went to dialysis on 08/17/24 at 9:00 A.M. and returned from dialysis on 08/17/24 at 4:00 P.M. The pre-dialysis evaluation included an oxygen saturation dated 08/14/24 at 1:36 A.M., a blood glucose dated 08/17/24 at 5:19 P.M., and a temperature, pulse, respiration rate, and pain level all dated 08/17/24 at 6:55 P.M. The first post-dialysis evaluation included a temperature dated 08/15/24 at 9:56 A.M., and a pain level dated 08/15/24 at 9:57 A.M. The second post-dialysis evaluation (four hours post-dialysis) included a temperature and respiration rate both dated 08/15/24 at 9:56 A.M., a pain level dated 08/15/24 at 9:57 A.M., and a blood pressure dated 08/17/24 at 9:56 A.M. The pre-dialysis weight, dated 08/08/24 at 3:29 P.M., was 142 pounds and there was no indication of a post-dialysis weight. Review of Resident #50's dialysis assessment dated [DATE] revealed Resident #50 went to dialysis on 08/20/24 at 9:45 A.M. and returned from dialysis on 08/20/24 at 5:00 P.M. The pre-dialysis evaluation included a pain level dated 08/17/24 at 6:55 P.M., and a respiration rate dated 08/17/24 at 10:39 P.M. The first post-dialysis evaluation and second post-dialysis evaluation both included a pain level dated 08/17/24 at 6:55 P.M., a respiration rate dated 08/17/24 at 10:39 P.M., and a temperature, pulse, and oxygen saturation all dated 08/20/24 at 3:56 P.M., which was the same temperature and oxygen saturation that was included in the pre-dialysis evaluation. The pre-dialysis weight, dated 08/08/24 at 3:29 P.M., was 142 pounds and there was no indication of a post-dialysis weight. Review of Resident #50's dialysis assessment dated [DATE] revealed Resident #50 went to dialysis on 08/22/24 at 8:30 A.M. and returned from dialysis on 08/22/24 at 4:00 P.M. The pre-dialysis evaluation included an oxygen saturation dated 08/22/24 at 7:34 P.M. The first post-dialysis evaluation included a pulse dated 08/20/24 at 11:42 P.M. The second post-dialysis evaluation (four hours post-dialysis) included a pain level dated 08/17/24 at 6:55 P.M., a respiration rate dated 08/17/24 at 10:39 P.M., an oxygen saturation dated 08/20/24 at 3:56 P.M., and a temperature and pulse both dated 08/20/24 at 11:42 P.M. The pre-dialysis weight, dated 08/08/24 at 3:29 P.M., was 142 pounds and there was no indication of a post-dialysis weight. Review of Resident #50's dialysis assessment dated [DATE] revealed Resident #50 went to dialysis on 08/27/24 at 8:00 A.M. and returned from dialysis on 08/27/24 at 3:55 P.M. The pre-dialysis evaluation included a respiration rate dated 08/24/24 at 10:29 P.M. The second post-dialysis evaluation (four hours post dialysis) included a pain level dated 08/22/24 at 4:37 P.M., a temperature, pulse, respiration rate, and oxygen saturation all dated 08/24/24 at 10:29 P.M., and a blood pressure dated 08/27/24 at 9:29 A.M., which was the same blood pressure that was included in the pre-dialysis evaluation. The pre-dialysis weight, dated 08/08/24 at 3:29 P.M., was 142 pounds and there was no indication of a post-dialysis weight. Review of Resident #50's dialysis assessment dated [DATE] revealed Resident #50 went to dialysis on 08/29/24 at 9:30 A.M. and returned from dialysis at 12:00 A.M. The first post-dialysis evaluation and second post-dialysis evaluation both included a pulse dated 08/27/24 at 3:56 P.M., a respiration rate and pain level both dated 08/27/24 at 3:57 P.M., a temperature and oxygen saturation both dated 08/28/24 at 1:13 A.M., and a blood pressure dated 08/29/24 at 9:34 A.M., which was the same blood pressure included in the pre-dialysis evaluation. The pre-dialysis weight, dated 08/08/24 at 3:29 P.M., was 142 pounds and there was no indication of a post-dialysis weight. Review of Resident #50's dialysis assessment dated [DATE] revealed Resident #50 went to dialysis on 08/31/24 at 9:00 A.M. and returned from dialysis on 08/31/24 at 4:00 P.M. The second post-dialysis evaluation (four hours post dialysis) included a pain level dated 08/29/24 at 9:36 A.M., a pulse, respiration rate, and oxygen saturation all dated 08/29/24 at 11:30 P.M., a temperature dated 08/31/24 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365046 If continuation sheet Page 33 of 55 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 11/08/2024 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 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few at 8:59 A.M., and a blood pressure dated 08/31/24 at 9:55 A.M., which were the same temperature and blood pressure included in the pre-dialysis evaluation. The pre-dialysis weight, dated 08/08/24 at 3:29 P.M., was 142 pounds and there was no indication of a post-dialysis weight. Review of Resident #50's dialysis assessment dated [DATE] revealed Resident #50 went to dialysis on 09/05/24 at 9:00 A.M. and returned from dialysis on 09/05/24 at 4:00 P.M. The pre-dialysis evaluation included a respiration rate dated 09/04/24 at 1:27 A.M. The second post-dialysis evaluation included a pain level dated 08/31/24 at 7:14 P.M., an oxygen saturation dated 09/01/24 at 4:08 A.M., a temperature, pulse, and respiration rate all dated 09/04/24 at 1:27 A.M., and a blood pressure dated 09/05/24 at 9:44 A.M., which were the same respiration rate and blood pressure included in the pre-dialysis evaluation. The pre-dialysis weight, dated 08/08/24 at 3:29 P.M., was 142 pounds and there was no indication of a post-dialysis weight. Review of Resident #50's dialysis assessment dated [DATE] revealed Resident #50 went to dialysis on 09/10/24 at 9:00 A.M. and returned from dialysis on 09/10/24 at 4:00 P.M. The pre-dialysis evaluation included a blood glucose dated 09/09/24 at 5:04 P.M. The second post-dialysis evaluation included a pain level dated 09/05/24 at 6:44 P.M., a temperature, pulse, respiration rate, and oxygen saturation all dated 09/08/24 at 12:19 A.M., and a blood pressure dated 09/10/24 at 5:07 A.M. The pre-dialysis weight, dated 08/08/24 at 3:29 P.M., was 142 pounds and there was no indication of a post-dialysis weight. Review of Resident #50's dialysis assessment dated [DATE] revealed Resident #50 went to dialysis on 09/14/24 at 9:30 A.M. and returned from dialysis on 09/14/24 at 4:00 P.M. The second post-dialysis evaluation (four hours post-dialysis) included a pain level dated 09/10/24 at 6:17 P.M., a temperature, pulse, respiration rate, and oxygen saturation all dated 09/12/24 at 10:44 P.M., and a blood pressure dated 09/14/24 at 9:35 A.M., which was the same blood pressure included in the pre-dialysis evaluation. The pre-dialysis weight, dated 08/08/24 at 3:29 P.M., was 142 pounds. Review of Resident #50's dialysis assessment dated [DATE] revealed Resident #50 went to dialysis on 09/19/24 at 9:00 A.M. and returned from dialysis on 09/19/24 at 4:00 P.M. The pre-dialysis evaluation included a temperature, pulse, and oxygen saturation all dated 09/19/24 at 1:07 P.M. The first post-dialysis evaluation included an oxygen saturation all dated 09/19/24 at 1:07 P.M., which was the same oxygen saturation included in the pre-dialysis evaluation. The post-dialysis weight, dated 09/14/24 at 6:12 P.M., was 146.4 pounds and there was no indication of a pre-dialysis weight. Review of Resident #50's dialysis assessment dated [DATE] revealed Resident #50 went to dialysis on 09/24/24 at 8:45 A.M. and returned from dialysis on 09/24/24 at 4:30 P.M. The second post-dialysis evaluation (four hours post-dialysis) included a pain level dated 09/20/24 at 12:36 A.M., a temperature, pulse, respiration rate, and oxygen saturation all dated 09/21/24 at 11:13 P.M., and a blood pressure dated 09/24/24 at 8:55 A.M., which was the same blood pressure included in the pre-dialysis evaluation. The post-dialysis weight, dated 09/14/24 at 6:12 P.M., was 146.4 pounds and there was no indication of a pre-dialysis weight. Review of Resident #50's dialysis assessment dated [DATE] revealed Resident #50 went to dialysis on 09/28/24 at 9:00 A.M. and returned from dialysis on 09/28/24 at 4:00 P.M. The second post-dialysis evaluation (four hours post-dialysis) included a pain level dated 09/24/24 at 4:32 P.M., a temperature, pulse, respiration rate, and oxygen saturation all dated 09/26/24 at 3:51 P.M., and a blood pressure dated 09/28/24 at 9:30 A.M., which was the same blood pressure included in the pre-dialysis evaluation. The post-dialysis weight, dated 09/14/24 at 6:12 P.M., was 146.4 pounds and there was no (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365046 If continuation sheet Page 34 of 55 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 11/08/2024 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 0698 indication of a pre-dialysis weight. Level of Harm - Minimal harm or potential for actual harm Review of Resident #50's dialysis assessment dated [DATE] revealed Resident #50 went to dialysis on 10/03/24 at 9:00 A.M. and returned from dialysis on 10/03/24 at 4:00 P.M. The pre-dialysis evaluation included a temperature, pulse, and blood glucose all dated 10/03/24 at 1:20 P.M., and a pain level dated 10/03/24 at 1:23 P.M. The second post-dialysis evaluation (four hours post-dialysis) included a respiration rate, oxygen saturation, and pain level all dated 09/28/24 at 4:00 P.M., a blood pressure dated 10/03/24 at 8:37 A.M., and a temperature and pulse both dated 10/03/24 at 1:20 P.M., which were the same blood pressure, temperature, and pulse included in the pre-dialysis evaluation. The post-dialysis weight, dated 09/14/24 at 6:12 P.M., was 146.4 pounds and there was no indication of a pre-dialysis weight. Residents Affected - Few Review of Resident #50's dialysis assessment dated [DATE] revealed Resident #50 went to dialysis on 10/08/24 at 9:00 A.M. and returned from dialysis on 10/08/24 at 4:00 P.M. The second post-dialysis evaluation (four hours post-dialysis) included a pain level dated 10/03/24 at 4:00 P.M., a temperature, pulse, respiration rate, and oxygen saturation all dated 10/05/24 at 11:48 P.M., and a blood pressure dated 10/08/24 at 8:37 A.M., which was the same blood pressure included in the pre-dialysis evaluation. The post-dialysis weight, dated 09/14/24 at 6:12 P.M., was 146.4 pounds and there was no indication of a pre-dialysis weight. Review of Resident #50's dialysis assessment dated [DATE] revealed Resident #50 went to dialysis on 10/12/24 at 9:00 A.M. and returned from dialysis on 10/12/24 at 4:00 P.M. The second post-dialysis evaluation (four hours post-dialysis) included a pain level dated 10/08/24 at 4:14 P.M., a temperature, pulse, respiration rate, and oxygen saturation all dated 10/10/24 at 9:58 P.M., and a blood pressure dated 10/12/24 at 8:26 A.M. The pre-dialysis weight, dated 10/10/24 at 8:00 A.M., was 143.5 pounds and there was no indication of a post-dialysis weight. Review of Resident #50's dialysis assessment dated [DATE] revealed Resident #50 went to dialysis on 10/15/24 at 10:00 A.M. and returned from dialysis on 10/15/24 at 4:00 P.M. The pre-dialysis evaluation, first post-dialysis evaluation, and second post-dialysis evaluation (which the assessment indicated was four hours post-dialysis) all used the same vital signs were dated 10/15/24 at 5:18 P.M., and the same pain level dated 10/12/24 at 4:07 P.M. The pre-dialysis weight, dated 10/10/24 at 8:00 A.M., was 143.5 pounds and there was no indication of a post-dialysis weight. Review of Resident #50's dialysis assessment dated [DATE] revealed Resident #50 went to dialysis on 10/17/24 at 12:00 A.M. and returned from dialysis on 10/17/24 at 4:00 A.M. The pre-dialysis evaluation and second post-dialysis evaluation (four hours post-dialysis) included the same pain level dated 10/12/24 at 4:07 P.M., and the same vital signs dated 10/17/24 at 11:57 A.M. The pre-dialysis weight, dated 10/10/24 at 8:00 A.M., was 143.5 pounds and there was no indication of a post-dialysis weight. Review of Resident #50's dialysis assessment dated [DATE] revealed Resident #50 went to dialysis on 10/19/24 at 9:00 A.M. and returned from dialysis on 10/19/24 at 4:18 P.M. The pre-dialysis evaluation, first post-dialysis evaluation, and second post-dialysis evaluation (which the assessment indicated was four hours post-dialysis) all included the same temperature, pulse, and respiration rate all dated 10/17/24 at 6:31 P.M., an oxygen saturation and pain level dated 10/17/24 at 6:32 P.M., a blood glucose dated 10/18/24 at 3:39 P.M., and a blood pressure dated 10/18/24 at 10:16 P.M. The pre-dialysis weight, dated 10/10/24 at 8:00 A.M., was 143.5 pounds and there was no indication of a post-dialysis weight. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365046 If continuation sheet Page 35 of 55 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 11/08/2024 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 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #50's dialysis assessment dated [DATE] revealed Resident #50 went to dialysis on 10/22/24 at 9:00 A.M. and returned from dialysis on 10/22/24 at 5:55 P.M. The pre-dialysis evaluation included a pain level dated 10/21/24 at 2:22 P.M. The second post-dialysis evaluation included a pulse, respiration rate, and oxygen saturation all dated 10/19/24 at 10:31 P.M., a temperature dated 10/21/24 at 9:07 A.M., a pain level dated 10/21/24 at 2:22 P.M., and a blood pressure dated 10/22/24 at 9:04 A.M., which was the same blood pressure included in the pre-dialysis evaluation. The pre-dialysis weight, dated 10/10/24 at 8:00 A.M., was 143.5 pounds and there was no indication of a post-dialysis weight. Review of Resident #50's dialysis assessment dated [DATE] revealed Resident #50 went to dialysis on 10/26/24 at 8:30 A.M. and returned from dialysis on 10/26/24 at 4:00 P.M. The first post-dialysis evaluation included a pulse dated 10/25/24 at 1:56 A.M. The second post-dialysis evaluation (four hours post-dialysis) included a temperature, pulse, respiration rate, and oxygen saturation all dated 10/25/24 at 1:56 A.M., a pain level dated 10/25/24 at 12:55 P.M., and a blood pressure dated 10/26/24 at 8:29 A.M. which was the same blood pressure included in the pre-dialysis evaluation. Review of Resident #50's dialysis assessment dated [DATE] revealed Resident #50 went to dialysis on 10/29/24 at 9:55 A.M. and returned from dialysis on 10/29/24 at 4:12 P.M. The pre-dialysis evaluation, first post-dialysis evaluation, and second post-dialysis evaluation (which the assessment indicated was four hours post-dialysis) all included the same pulse dated 10/26/24 at 11:38 P.M., a pain level dated 10/29/24 at 9:58 A.M., a blood pressure dated 10/29/24 at 10:26 P.M., and a temperature, respiration rate, and oxygen saturation all dated 10/29/24 at 11:20 P.M. The pre-dialysis weight, dated 10/26/24 at 8:25 A.M., was 145.2 pounds and there was no indication of a post-dialysis weight. On 10/30/24 at 9:28 A.M., an interview with the Director of Nursing (DON) confirmed the dialysis assessments on the MAR were not completed every dialysis day. The DON further stated staff were not required to complete the dialysis assessment information on the MAR because they completed the preand post-assessments in the resident evaluations. On 10/31/24 at 11:04 A.M., an interview with Registered Nurse (RN) #661 stated facility staff were supposed to obtain Resident #50's weight via hoyer lift before and after dialysis. On 10/31/24 at 1:08 P.M., an interview with Registered Nurse (RN) Supervisor #654 verified the information on pre- and post-dialysis assessments for Resident #50. RN Supervisor #654 also confirmed weights were not documented for all dialysis days. On 10/31/24 at 1:55 P.M., an interview with Unit Manager/Licensed Practical Nurse (LPN) #789 stated just because things were time stamped a certain time did not mean that was when it was completed, and that time stamp was just when it was documented in the chart. Unit Manager #789 stated the pre-assessment was to be completed before dialysis, the first post-dialysis assessment was to be completed upon return from dialysis, and the second post-dialysis assessment was to be completed four hours after returning from dialysis. Unit Manager #789 stated staff might need more training on how to complete the dialysis assessments, further stating he would be unable to provide education on all shifts because he did not work night shift. On 11/05/24 at 11:54 A.M., an interview with Licensed Practical Nurse (LPN) #714 stated all vital signs were supposed to be taken before residents leave for dialysis and after they returned from dialysis. She further stated if vital signs were not entered in the chart before the assessment was opened, the most recent vital signs would auto populate in the assessment and facility staff would have (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365046 If continuation sheet Page 36 of 55 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 11/08/2024 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 0698 to change them in the assessment after obtaining new vital signs. Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled End Stage Renal Disease, Care of a Resident with, dated September 2010, indicated the facility would assess residents pre- and post-dialysis and communicate any concerns with center staff, the physician, and the Registered Dietitian (RD). Residents Affected - Few 3. Review of the medical record for Resident #314 revealed an admission date of 10/22/24 with diagnoses including end stage renal disease, acute kidney failure, and dependence on renal dialysis. Review of the physician's orders for October 2024 identified orders for dialysis three times weekly on Mondays, Wednesdays, and Fridays (ordered 10/28/24). Review of the in-progress admission MDS 3.0 assessment, dated 10/19/24, revealed Resident #314 had no cognitive impairment. Review of Resident #314's dialysis assessment dated [DATE] revealed Resident #314 went to dialysis on 10/23/24 at 10:00 A.M. and the return time was not documented. The pre-dialysis evaluation, first post-dialysis evaluation, and second post-dialysis evaluation (which the assessment indicated was four hours post-dialysis) all used the same vital signs which were dated 10/22/24 at 11:52 P.M. The pre-dialysis weight, dated 10/22/24 at 5:46 P.M., was 132 pounds and there was no indication of a post-dialysis weight. Review of Resident #314's dialysis assessment dated [DATE] revealed Resident #314 went to dialysis on 10/25/24 at 8:30 A.M. and returned from dialysis on 10/25/24 at 4:40 P.M. The pre-dialysis evaluation included a weight of 132 pounds dated 10/22/24 at 5:46 P.M., and a temperature and respiration rate both dated 10/24/24 at 9:23 P.M. The second post-dialysis evaluation, four hours post-dialysis, included a blood pressure, temperature, pulse, respiration, and oxygen saturation all dated 10/22/24 at 9:23 P.M. and a pain level dated 10/25/24 at 12:18 A.M. Review of Resident #314's dialysis assessment dated [DATE] revealed Resident #314 returned from dialysis on 10/28/24 at 4:40 P.M. and the departure time for 10/28/24 was not documented. The pre-dialysis evaluation included a blood glucose dated 10/25/24 at 8:59 A.M. The second post-dialysis evaluation (four hours post dialysis) included an oxygen saturation dated 10/29/24 at 9:27 P.M. There was no dialysis assessment completed for Resident #314 on Wednesday 10/30/24. Review of Resident #314's dialysis assessment dated [DATE] revealed Resident #314 went to dialysis on 11/01/24 at 10:00 A.M. and returned from dialysis on 11/01/24 at 4:36 P.M. The pre-dialysis evaluation included a blood glucose dated 10/25/24 at 8:59 A.M. The second post-dialysis evaluation (four hours post dialysis) included a blood pressure, pulse, respiration rate, and oxygen saturation all dated 11/01/24 at 9:08 A.M., and a pain level dated 11/01/24 at 8:18 A.M., which were exactly the same as documented for the pre-dialysis evaluation. On 11/05/24 at 11:54 A.M., an interview with Licensed Practical Nurse (LPN) #714 confirmed Resident #314's dialysis assessments were not completed how they should have been. LPN #714 stated all vital signs were supposed to be taken before residents leave for dialysis and after they returned from dialysis. She further stated if vital signs were not entered in the chart before the assessment was opened, the most recent vital signs would auto populate in the assessment and facility staff would have to change them in the assessment after obtaining new vital signs. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365046 If continuation sheet Page 37 of 55 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 11/08/2024 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 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the facility policy titled End Stage Renal Disease, Care of a Resident with, dated September 2010, indicated the facility would assess residents pre- and post-dialysis and communicate any concerns with center staff, the physician, and the Registered Dietitian (RD). Based on medical record reviews, staff interviews, and review of facility policy, the facility failed to provide appropriate assessments and monitoring to ensure residents were free from complications before and after dialysis treatments. This affected three residents (Resident #50, Resident #126, and Resident #314) of three residents reviewed for dialysis. The facility identified three residents (#50, #126 and #314) as receiving dialysis. The facility census was 166. Findings include: 1. Review of the medical record for Resident #126 revealed an admission date of 08/15/24. Diagnoses included end stage renal disease, diabetes mellitus type one, and dependence on renal dialysis. Review of the significant change Minimum Data Set (MDS) 3.0 assessment completed on 10/08/24 revealed Resident #126 had intact cognition and required substantial to maximal assistance with chair to bed, toilet, and shower transfers. Further review of the MDS revealed Resident #126 was on dialysis. Review of the physician orders revealed an order dated 08/17/24 for Resident #126 to be transported to Centers for Dialysis Care (CDC) every Monday, Wednesday, and Friday to receive dialysis related to end stage renal disease. Review of the care plan dated 08/15/24 revealed Resident #126 required dialysis every Monday, Wednesday, and Friday at CDC related to renal failure. Interventions included monitoring and reporting complications related to dialysis. Further review of the care plan revealed Resident #126 had renal failure secondary to end stage renal disease. Interventions included monitoring for signs and symptoms of hyper or hypovolemia, dyspnea, increased heart rate, blood pressure changes, changes in peripheral pulses or skin temperature, and daily weight changes of two pounds. Review of the clinical assessment history in the electronic medical record (EMR) on 10/31/24 at 1:47 P.M. revealed only two assessments titled Monte-Dialysis - Pre and Post Communication Tool were present, one dated 08/16/24 with status listed as Errors and one dated 08/26/24 with status listed as In Progress. On 11/04/24, the EMR clinical assessment history revealed 15 pre and post dialysis assessments listed as Complete and two (dated 08/16/24 and 08/26/24) listed as In Progress. Of the additional 15 pre and post dialysis assessments, they were signed and locked on the following dates by the following staff: The pre dialysis assessments dated 09/04/24, 09/25/24, 09/27/24, and 10/25/24 were signed and locked by Registered Nurse (RN) #814 on 11/02/24 between 11:33 P.M. and 11:58 P.M. The pre dialysis assessment dated [DATE] was signed by Licensed Practical Nurse (LPN) #719 and the dialysis center and post dialysis evaluations were signed by RN #814 on 11/03/24. The pre and post dialysis evaluation information for dialysis dated 10/02/24 (7:36 P.M.) and 10/04/24 (7:48 P.M.) were signed and locked on 11/03/24 by LPN #719. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365046 If continuation sheet Page 38 of 55 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 11/08/2024 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 0698 Level of Harm - Minimal harm or potential for actual harm The pre and post dialysis evaluation information for dialysis dated 10/07/24 (10:58 P.M.), 10/09/24 (11:04 P.M.) , 10/16/24 (10:52 P.M.), and 10/21/24 (12:06 A.M.) were signed and locked on 11/03/24 by RN #814. The pre and post dialysis evaluation information for dialysis dated 10/11/24, 10/14/24, 10/18/24, and 10/23/24 were all signed and locked on 11/03/24 at 10:47 P.M. by LPN #719. Residents Affected - Few Review of all the dialysis assessments in the medical record revealed Resident #126 did not have a pre-dialysis or post-dialysis assessment completed on 08/19/24, 08/21/24, 08/23/24, 08/28/24, or 08/30/24. Review of Resident #126's dialysis assessment dated [DATE] revealed the pre-dialysis weight, dated 04/12/24 at 11:06 A.M., was 122.6 pounds and there was no indication of a post-dialysis weight. The first post-dialysis evaluation and the second post-dialysis evaluation (which the assessment indicated was four hours post-dialysis) each used the same vital signs, which were taken between 4:34 P.M. and 4:35 P.M.; however, the original copy of the pre and post dialysis assessment, obtained on 10/31/24, contained no record of a second post-dialysis assessment and had been incomplete in the In Progress status prior to receiving the completed copy on 11/04/24. Review of Resident #126's dialysis assessment dated [DATE] revealed the pre-dialysis evaluation, first post-dialysis evaluation, and second post-dialysis evaluation (which the assessment indicated was four hours post-dialysis) all used the same blood pressure, which was taken on 08/26/24 at 8:48 A.M The first post-dialysis assessment and the second post-dialysis assessment used the same temperature, pulse, and respirations, which were taken on 08/23/24 at 9:04 P.M. and the same pain assessment, which was assessed on 08/24/24 at 10:11 P.M. The pre-dialysis weight, dated 04/12/24 at 11:06 A.M., was 122.6 pounds and there was no indication of a post-dialysis weight. The original copy of the pre and post dialysis assessment from this date, obtained on 10/31/24, was an open document with missing assessment data, listed in the status of Errors. Review of Resident #126's dialysis assessment dated [DATE] revealed the pre-dialysis evaluation, first post-dialysis evaluation, and second post-dialysis evaluation (which the assessment indicated was four hours post-dialysis) all used the same blood pressure, which was taken on 09/04/24 at 8:52 A.M., and the same temperature, pulse, and oxygen saturations, which were taken on 08/26/24 between 10:42 A.M. and 10:43 A.M. The pre-dialysis assessment and the first post-dialysis assessment used the same respiratory rate assessment, which was taken on 08/26/24 at 10:43 A.M.; however, the second post-dialysis assessment had respirations recorded on 09/13/24 at 6:36 P.M., nine days after the dialysis was received on 09/04/24. The pre-dialysis weight, dated 08/28/24 at 11:06 A.M., was 128.3 pounds and there was no indication of a post-dialysis weight. Review of Resident #126's dialysis assessment dated [DATE] revealed the pre-dialysis evaluation, first post-dialysis evaluation, and second post-dialysis evaluation (which the assessment indicated was four hours post-dialysis) all used the same vital signs, which were dated 09/13/24 at 6:36 P.M. and the same pain assessment, which was taken on 09/18/24 at 8:59 A.M. The pre-dialysis weight, dated 09/04/24 at 6:47 P.M., was 106 pounds and there was no indication of a post-dialysis weight. Review of Resident #126's dialysis assessment dated [DATE] revealed the pre-dialysis evaluation, first post-dialysis evaluation, and second post-dialysis evaluation (which the assessment indicated was four hours post-dialysis) all used the same vital signs, which were dated 09/24/24 at 5:23 P.M. and the same pain assessment, which was taken on 09/25/24 at 8:47 A.M. The pre-dialysis weight, dated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365046 If continuation sheet Page 39 of 55 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 11/08/2024 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 0698 09/24/24 at 5:22 P.M., was 106 pounds and there was no indication of a post-dialysis weight. Level of Harm - Minimal harm or potential for actual harm Review of Resident #126's dialysis assessment dated [DATE] revealed the pre-dialysis evaluation, first post-dialysis evaluation, and second post-dialysis evaluation (which the assessment indicated was four hours post-dialysis) all used the same vital signs, which were dated 09/24/24 at 5:23 P.M. and the same pain assessment, which was taken on 09/27/24 at 8:34 A.M. The pre-dialysis weight, dated 09/24/24 at 5:22 P.M., was 106 pounds and there was no indication of a post-dialysis weight. Residents Affected - Few Review of Resident #126's dialysis assessment dated [DATE] revealed the pre-dialysis evaluation, pre-dialysis evaluation had an oxygen saturation of 98% that was taken on 10/02/24 at 7:24 P.M. (Resident #126 was sent to dialysis at 10:11 A.M.), a first post-dialysis oxygen saturation of 99% that was documented on 10/02/24 at 5:16 P.M., and second post-dialysis evaluation (which the assessment indicated was four hours post-dialysis) oxygen saturation of 99% that was documented on 10/02/24 at 4:34 P.M. The second post-dialysis pain assessment revealed the pain level taken on 09/30/24 at 9:19 A.M. The pre-dialysis weight, dated 10/02/24 at 9:22 A.M., was 106 pounds and there was no indication of a post-dialysis weight. Review of Resident #126's dialysis assessment dated [DATE] revealed the pre-dialysis evaluation, first post-dialysis evaluation, and second post-dialysis evaluation (which the assessment indicated was four hours post-dialysis) all used the same vital signs, which were dated 10/04/24 between 5:40 P.M. and 5:42 P.M. and a pre-dialysis and second post-dialysis pain level both taken on 10/07/24 at 11:33 A.M. The pre-dialysis weight, dated 10/04/24 at 9:36 FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365046 If continuation sheet Page 40 of 55 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 11/08/2024 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 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 observation, record review and interview the facility failed to ensure staff administered Resident #107's insulin as ordered by the physician. This affected one resident (#107) out of four residents observed for medication administration. The facility census was 166. Residents Affected - Few Findings include: Review of the medical record revealed Resident #107 was re-admitted on [DATE] with diagnoses including diabetes mellitus, and long term use of insulin. Resident #107's physician order dated 09/23/24 indicated to administer 21 units of Insulin Glargine Solution 100 units per milliliter (u/ml) subcutaneously (SQ) one time a day for diabetes mellitus. There were no parameters for holding the insulin medication in the order. An observation on 10/29/24 at 8:25 A.M. of Licensed Practical Nurse (LPN) #763 administering medications to Resident #107 revealed a failure to administer the Insulin Glargine Solution medication as ordered by the physician. The following medications were administered during the observation: Aspirin 81 milligrams (mg) orally, floranex (lactobacillus) one tablet orally, polysaccharide iron 150 mg orally, metformin 500 mg orally, metoprolol 25 mg orally, vitamin D3 2000 international units (IU) (50 mcg) orally and tagrisso 80 mg tab orally A review of Resident #107's Medication Administration Record (MAR) dated 10/01/24 to 10/31/24 indicated on 10/29/24 the Insulin Glargine Solution medication as ordered above was scheduled to be administered at 9:00 A.M. The documentation on the MAR indicated LPN #763 documented the Insulin Glargine Solution medication was not administered due to not available or not administered because was outside the parameters for pulse, blood pressure or blood sugar. An interview with LPN #763 on 10/29/24 at 10:13 A.M. verified the above findings and stated she thought the insulin should have been held due to the blood sugar measured 98 mg/dL (milligrams per diluent). LPN #763 agreed there were no blood sugar parameters written in the physician order to hold the Insulin Glargine Solution. LPN #763 said the insulin was a long acting insulin and was scheduled to be given once a day at 9:00 A.M. and should not have been held. The facility policy titled Administering Medications revised 12/2012 indicated the policy stated medications shall be administered in a safe and timely manner, and as prescribed. This deficiency represents non-compliance investigated under Complaint Number OH00159071. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365046 If continuation sheet Page 41 of 55 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 11/08/2024 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on record review, observation and interview, the facility failed to ensure all menu items were prepared in advance and menus and/or substitutions were followed for resident meal service. This had the potential to affect all 159 residents receiving meals from the kitchen excluding the seven residents (#44, #46, #97, #110, #111, #137, and #315) the facility identified as receiving nothing by mouth (NPO). The facility census was 166. Findings include: 1. Review of the facility menu for 10/30/24 lunch revealed the meal was to consist of tomato soup, grilled cheese on Texas toast, potato chips, oven roasted vegetables and banana cake. Review of the resident's menu extension sheets for 10/30/24 revealed residents on a regular and mechanical soft texture diet were to receive four ounces of an oven roasted vegetable, and residents on a puree texture diet should receive the equivalent of one pureed grilled cheese sandwich. Review of the recipe Grilled Swiss Cheese Sandwich, Puree undated, revealed the grilled cheese sandwich would be served with a four-ounce scoop. Observation on 10/30/24 at 11:58 A.M. of lunch meal service revealed tray line had begun and there was no evidence of oven roasted vegetables being served to the residents on regular and mechanical soft textured diets. There was also no evidence of pureed grilled cheese being served to the residents on puree textured diets. It was not until approximately halfway through tray line that [NAME] #684 brought out a cart with pans of Brussels sprouts and carrots. The facility had not identified pureed grilled cheese was not prepared for the tray line lunch meal until questioned by the surveyor. Interview on 10/30/24 12:36 P.M. with Dietary Director #813 and Dietary Manager #836 confirmed the vegetables were not served to the residents on regular and mechanical soft textured diets and pureed grilled cheese was not served to the residents on puree textured diets. It was not until 12:46 P.M. that pureed grilled cheese was available to serve. There was no evidence portions of vegetable or grilled cheese were sent for trays that were already served. 2. Review of the facility menu for breakfast on 10/30/24 revealed the meal was to consist of farina (hot cereal), vegetable and potato egg skillet, Danish and canned fruit. At the bottom of the menu was a section titled also available and for breakfast listed fresh fruit, assorted cold cereal, hard boiled eggs and yogurt as alternative options for the meal. Review of the menu substitution log for 10/30/24 breakfast revealed cereal, yogurt and banana would be served secondary to no cook scheduled. The original menu that was being substituted was not indicated on the substitution log and there were no additional substitutes listed for the yogurt or banana. Observation on 10/28/24 at 9:38 A.M. of resident breakfast meal service revealed Resident #81 was complaining about her meal and described the facility food as horrible all the time. Interview on 10/30/24 at 9:34 A.M. to 9:40 A.M. with Resident #81 revealed she had not yet received her breakfast tray and she was expecting to be served eggs because that was what was on the menu. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365046 If continuation sheet Page 42 of 55 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 11/08/2024 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 0803 Level of Harm - Minimal harm or potential for actual harm During the interview, Resident #81 received her breakfast, which did not include the eggs she expected. Further observation of the breakfast tray revealed Resident #81 received a Danish, applesauce, and farina instead of the eggs she expected. Review of the meal ticket revealed the meal Resident #81 was to receive that morning included a Danish, farina, yogurt, and a banana. There was no yogurt or banana served to Resident #81. Residents Affected - Many Interview on 10/30/24 at 9:44 AM with Certified Nursing Assistant (CNA) #845 confirmed Resident #81's meal ticket and food served on her meal tray did not match the meal ticket. CNA #845 verified Resident #81 should have received the yogurt and banana. CNA #845 also verified there were several residents who received applesauce instead of yogurt and a banana and she had only seen three resident trays with bananas on them during this meal tray pass. During this interview, CNA #845 stated several residents had asked her why they did not get eggs this morning because that was what they were expecting according to the original menu. CNA #845 was not sure if there were hard boiled eggs or any eggs available in the kitchen if a resident wished to have an egg for breakfast. A group interview on 10/31/24 2:55 P.M. with Residents #18, #20, #29, #43, #69, #78, and #96 revealed food served often did not match the menu and the food on their trays often did not match the meal tickets on their trays. All confirmed not being informed when there would be a substitution from what they expected to receive. Review of the policy Menu Substitutions last revised January 2023 revealed menus may be revised to accommodate unforeseen circumstances and should be recorded in the binder, indicating the food that was supposed to be served, the substituted food, and the reason for the substitution, and the residents should be notified as soon as possible. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365046 If continuation sheet Page 43 of 55 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 11/08/2024 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and food committee meeting minutes review, the facility failed to ensure palatable and appealing meals were served. This had the potential to affect all residents receiving meals from the kitchen. The facility identified seven Residents (#44, #46, #97, #110, #111, #137, and #315) as receiving nothing by mouth (NPO). The facility census was 166. Residents Affected - Many Findings include: 1. Interview on 10/30/24 at 1:26 P.M. with Dietary Director (DD) #813 revealed he had identified an issue with meal timeliness and keeping good temperatures. DD #813 indicated it would be easier and faster to serve from the pantry on each unit. DD #813 indicated the new facility ownership had changed the process from serving from the pantry to serving from the main kitchen. Observation on 10/30/24 at 1:37 P.M. of a test tray with DD #813 and Dietary Manager (DM) #836 revealed the tray was served to the last unit identified as [NAME] Two. All resident trays were passed prior to taking temperatures. The temperatures were taken using the facility's digital thermometer by DM #836. Final temperatures were 124 degrees Fahrenheit (F) for grilled cheese, 127 degrees F for carrots, and 120 degrees F for tomato soup. Taste test with DD #813 revealed the grilled cheese was soggy and not palatable. The sandwich consisted of two slices of bread and one piece of cheese. DD #813 confirmed there was not enough cheese on the sandwich and it would taste better with more cheese. Taste test of the carrots revealed no concerns. Taste test of the tomato soup revealed the soup was lukewarm and not palatable. DD #813 verified the soup was not palatable. Interview on 10/30/24 at 1:42 P.M. with DD #813 and DM #836 confirmed the food temperatures and palability were not acceptable for the grilled cheese and tomato soup. Review of Food Committee Meeting Minutes dated 08/16/24 revealed proper food temperatures and meal delivery was a focus of the meeting. 2. Interview on 10/29/24 at 11:22 A.M. with Resident #68 revealed she thought the food served by the facility was absolutely horrible and gave the following examples/descriptions: a cabbage roll burnt to (expletive), a baked potato that was so undercooked it was too hard to eat, chicken breast small, dry, and so hard it could not be cut. During the interview, Resident #68 revealed her son brought in food three times a week so she could get enough to eat. Observation and interview conducted on 10/30/24 at 9:18 A.M. revealed Resident #68 lifted the lid off of the plate to expose one piece of hard dry toast which she picked up and dropped back down onto the plate to demonstrate how hard the toast was, as it made a noise when it hit the plate. Resident #68 stated there was no butter or jelly to even put on the toast. Further observation of the meal tray revealed Resident #68 also received a container of non-fat yogurt, one banana, and farina (hot cereal). There were zero condiments on the tray. Resident #68 stated she did not like or eat hot cereal, would not eat anything on her tray, and would only drink her hot tea. Resident #81 stated the items she received were not what was listed on the menu for this date and residents were supposed to have access to an alternate menu, but she had never been given an alternate menu to review. Group interview on 10/31/24 2:55 P.M. with Residents #18, #20, #29, #43, #69, #78, and #96 confirmed they each had the following concerns related to dietary services and food palatability: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365046 If continuation sheet Page 44 of 55 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 11/08/2024 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 Level of Harm - Minimal harm or potential for actual harm Any food item that is breaded, such as chicken nuggets or patty's, all get overcooked, which made it too hard to eat. Resident #20 stated he would rather eat nothing at all than try to eat those overcooked breaded items. Breakfast was always boring and not filling. Residents Affected - Many Interview on 10/31/24 with Resident #18 at 3:00 P.M. revealed food was sometimes plated in a manner that allowed all the food to run together, which gave the appearance of dog food' on his lunch and dinner plates. This deficiency represents non-compliance investigated under Complaint Number OH00158389. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365046 If continuation sheet Page 45 of 55 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 11/08/2024 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation, interview, and recipe review, the facility failed to ensure appropriate puree preparation techniques were followed. This had the potential to affect 17 Residents (#17, #37, #42, #53, #62, #63, #74, #79, #80, #86, #88, #98, #105, #106, #113, #132, and #326) the facility identified as requiring a puree textured diet. The facility census was 166. Findings include: Observation on 10/30/24 from 10:19 A.M. to 10:55 A.M. of puree preparation by [NAME] #684 revealed preparation of puree cake, Brussels sprouts, sweet potatoes, and tomato soup. Dietary Director (DD) #813 and Dietary Manager (DM) #836 were also present for observation. [NAME] #684 did not refer to any recipes or diet manual during the preparation. [NAME] #684 indicated he was looking for a pudding like consistency. [NAME] #684 was noted to add large amounts of water and thickener (a powdered substance used to alter the texture of foods and beverages to allow for safe swallowing) to the Brussels sprouts, sweet potatoes, and tomato soup. After completing the puree preparation [NAME] #684 was observed to add a seasoning to the Brussels sprouts and tomato soup. The seasoning was not powdered and had large chunks of what appeared to be dried garlic, onion, and other spices. There was no additional check to ensure appropriate consistency. Interview on 10/30/24 at 10:55 A.M. with [NAME] #684, DD #813, and DM #836 confirmed findings of excessive use of water to thin, excessive use of powdered thickener, and use of chunky seasoning. [NAME] #684 confirmed he had not referred to the puree recipes or diet manual during puree preparation. [NAME] #684 indicated he had been working at the facility for some time and knew the texture he was looking for. Review of recipe Mashed Sweet Potatoes undated revealed the sweet potatoes were prepared with milk, margarine, ground cinnamon, and ground nutmeg. None of which was added to the mixture. Review of recipe Sweet Potatoes, Puree undated revealed the sweet potatoes were prepared with apple juice and food thickener as needed. Review of recipe Garlic Brussels Sprouts, Puree undated revealed the Brussels sprouts were prepared with broth or gravy. It was noted food thickener should be added as needed and gradually only until desired consistency is reached. Review of recipe Tomato Soup undated revealed tomato soup was appropriate as prepared for puree texture and did not require thickening or seasoning. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365046 If continuation sheet Page 46 of 55 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 11/08/2024 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 - Many 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure meals were served in a timely manner. This had the potential to affect all residents receiving meals from the kitchen. The facility identified seven Residents (#44, #46, #97, #110, #111, #137, and #315) as receiving nothing by mouth (NPO). The facility census was 166. Findings include: Review of the facility meal times revised on 04/10/24 revealed breakfast was served from 7:45 A.M. to 8:55 A.M., lunch was served from 11:45 A.M. to 12:50 P.M., and dinner was served from 5:00 P.M. to 6:00 P.M. The identified order of serving was first [NAME] One Unit, [NAME] Unit, [NAME] Three Unit, [NAME] Two Unit, and last [NAME] Two Unit. It was noted meal times were based on census and may deviate 15 minutes from scheduled time. Review of Food Committee Meeting Minutes dated 07/16/24 revealed meal times were reviewed and the committee discussed reasons for delays in meal delivery. Review of Food Committee Meeting Minutes dated 08/16/24 revealed residents reviewed the focus on meal times and proper food temperatures. Review of Food Committee Meeting Minutes dated 10/22/24 revealed concerns remained with meal times and the times were reviewed. Residents were notified deviation can occur by 15-20 minutes as the census was growing. The meal times were planned to be revised if the census consistently stayed above 150 and the attending residents agreed. Residents also requested the Administrator attend next meeting as there was a motion to consider resuming dining room steam table meal service. Interview on 10/28/24 at 10:01 A.M. with Resident #40 stated the meals were always served late and she had not even had breakfast yet. Observation on 10/28/24 at 10:08 A.M. revealed Resident #40's breakfast tray was delivered. Interview on 10/28/24 at 10:14 A.M. with Licensed Practical Nurse (LPN) #787 confirmed the breakfast trays were being delivered at that time. LPN #787 further stated they were at the mercy of the kitchen and delivered meal trays whenever the kitchen brought them to the unit. Observation during an interview with Resident #147 on 10/28/24 at 10:20 A.M. revealed her breakfast tray was passed at this time. Observation on 10/28/24 at 10:24 A.M. revealed two staff passing general breakfast trays on Resident #147's unit. Interview with Certified Nursing Assistant (CNA) #740 at this time revealed this was the usual time for breakfast trays to be passed on the unit. Observation on 10/28/24 at 10:28 A.M. revealed the breakfast meal service was in progress. Staff were delivering the meal trays to the residents in their room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365046 If continuation sheet Page 47 of 55 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 11/08/2024 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 - Many Interview with LPN #768 on 10/28/24 at 10:30 A.M. revealed the breakfast trays were routinely delivered late on the secured dementia unit. LPN #768 stated the lunch meal was usually served at approximately 1:00 P.M. which was later than the time scheduled to be delivered for both breakfast and lunch. Interview on 10/30/24 at 11:42 A.M. with Dietary Supervisor #676 revealed with the increased census the meal times needed revised. Observation on 10/30/24 at 12:30 P.M. revealed Resident #13 and Resident #24 were seated in the dining room waiting for their lunch to be served. Both residents stated they often had to wait an extended period of time for meals to be served. The meal cart arrived in the dining room at 1:04 P.M. and the staff started to serve the meal trays to the residents. All the meal trays were delivered to the residents and Resident #13 and Resident #24 did not receive their meal. Residents were not served at the same time who were seated together. Resident #13 and Resident #24 stated they were not informed why their meal tray was late and thought they were not going to receive a meal tray for lunch. At 1:34 P.M. Resident #13 and Resident #24 received their meal tray. Interview on 10/30/24 at 1:26 P.M. with Dietary Director (DD) #813 revealed he had identified an issue with meal timeliness and keeping good temperatures. DD #813 indicated it would be easier and faster to serve from the pantry on each unit. DD #813 indicated the new facility ownership had changed the process from serving from the pantry to serving from the main kitchen. DD #813 indicated he has noted an improvement since he started in September 2024 however was still not able to always serve meals on time. Observation on 10/30/24 at 1:37 P.M. revealed the last meal tray had been served on [NAME] Two unit which was identified as the last unit served. Observation on 10/31/24 at 8:15 A.M. revealed a breakfast tray cart arrived on [NAME] Three unit and a second cart was delivered at 8:20 A.M. Observations revealed CNAs did not completed tray pass until 9:37 A.M. Interview on 10/31/24 at 9:49 A.M. with CNA #607 confirmed tray pass took over an hour to complete. CNA #607 indicated the other two aides on shift were agency and were stopping in the middle of tray pass to provide morning care. Interview on 10/31/24 at 11:07 A.M. with Registered Nurse (RN) #661 stated there was no consistency with meal times. Interview on 11/04/24 at 8:55 A.M. with Registered Dietitian (RD) #711 revealed there had been three dietary managers since June 2024. RD #711 reported concerns with meal times had been identified. RD #711 indicated the issue was both from the kitchen and with staff passing trays. RD #711 indicated the meal times were based on census of 150 and they had a 15-20 minute leeway however indicated they were considering revising. RD #711 indicated the residents have been requesting to go back to dining room service and noted we had good customer satisfaction with serving from the pantry. RD #711 indicated she had mentioned this multiple times from June 2024 to October 2024 and the concern had been mentioned formally in food committee. RD #711 indicated the Administrator was aware of the concerns. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365046 If continuation sheet Page 48 of 55 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 11/08/2024 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, interview, and record review, the facility failed to ensure kitchen staff followed appropriate food safety and handling techniques including equipment cleaning and sanitation, glove use, handwashing, hairnet use. This had the potential to affect all 159 residents receiving meals from the kitchen. The facility identified seven residents (#44, #46, #97, #110, #111, #137, and #315) as receiving nothing by mouth (NPO). The facility census was 166. Findings include: Observation on 10/30/24 at 8:51 A.M. revealed Mashgiach #837 (a person in the Judaism religion who supervises the kosher status of a food establishment) in the kitchen area. Mashgiach #837 was not wearing a hair net. Dietary Director (DD) #813 asked Mashgiach #837 to wear a hair net and Mashgiach refused and stated she was wearing a wig, so she does not need to. Observation on 10/30/24 at 10:19 A.M. to 10:55 A.M. of [NAME] #684 preparing pureed cake revealed [NAME] #684 adjusted his beard net with gloved hands and did not change gloves or wash hands. [NAME] #684 used the food processor and a rubber spatula during pureed cake preparation. [NAME] #684 used gloved hands to scoop pureed cake from food processor into a pan. [NAME] #684 transferred the pureed cake back into processor from the pan and continued to puree. [NAME] #684 scooped cake with gloved hand back into pan. [NAME] #684 removed gloves and tossed soiled gloves at a trash can across the kitchen, missed, and picked up gloves off the floor and put into trash. [NAME] #684 did not wash his hands and donned another pair of gloves. [NAME] #684 rinsed the food processor parts and a rubber spatula used to demonstrate texture in a preparation sink under running water. The water from the sink was observed to splash into the pan with pureed cake. [NAME] #684 used the rinsed spatula in the pureed cake then set aside the pureed cake. [NAME] #684 did not allow the food processor time to dry before next use. There was visible residue on the food processor from pureed cake. [NAME] #684 then moved on to preparing pureed Brussels sprouts. [NAME] #684 used the food processor, a whisk, a rubber spatula, and a scoop during preparation. [NAME] #684 transferred pureed Brussels sprouts from food processor to a pan. [NAME] #684 used gloved hand to sift through puree and pull-out large chunks of brussels sprouts. [NAME] #684 rinsed his gloved hands in sink and continued wearing wet gloves. [NAME] #684 whisked in food thickener and checked texture using a scoop then removed gloves. [NAME] #684 walked over to hand wash sink and wiped the sweat from his face with paper towel then donned new gloves without washing hands. [NAME] #684 again rinsed food processor parts, spatula, scoop, and whisk in sink. [NAME] #684 was wearing gloves throughout rinsing and did not change when wet. [NAME] #684 left food processor parts in sink at this time. The spatula, scoop, and whisk were not allowed time to dry before next use. [NAME] #684 then moved on to preparing pureed sweet potatoes. [NAME] #684 drained two large cans of sweet potatoes in the sink. The liquid from the cans was drained over the food processor parts in the sink. [NAME] #684 then re-rinsed food processor and did not allow time to dry then added sweet potatoes and water from sink to food processor. While sweet potatoes were pureeing in the food processor [NAME] #684 walked over to the dairy pot washing area and grabbed a pitcher off of a cart of what appeared to be dirty dishes. [NAME] #684 then rinsed pitcher in the sink with water then used to scoop tomato soup into a pan. [NAME] #684 added water from the sink to the soup then whisked thickener into the soup. The mixture was not run through food processor. [NAME] #684 rinsed whisk, spatula and scoop in sink. [NAME] #684 had not yet changed gloves. [NAME] #684 used gloved hands to scoop sweet potatoes into pan and whisked in food thickener. [NAME] #684 then rinsed scoop and demonstrated final texture. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365046 If continuation sheet Page 49 of 55 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 11/08/2024 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 Interview on 10/30/24 at 10:55 A.M. with [NAME] #684, DD #813, and Dietary Manager (DM) #836 confirmed above findings during puree preparation. [NAME] #684 confirmed he had not properly cleaned and sanitized equipment in dish machine or three compartment sink. [NAME] #684 confirmed he had not allowed the equipment time to dry between uses. Observation on 10/30/24 at 11:04 A.M. revealed Mashgiach #837 in the area of the dairy dish machine washing dishes. Mashgiach #837 continued to not wear a hair net. Interview on 10/30/24 at 11:45 A.M. with DM #836 confirmed observations of Mashgiach #837 not wearing a hair net in the kitchen area. DM #836 indicated he worked at a sister facility and had no issues with his Mashgiach wearing a hair net in the kitchen area. Review of facility policy, Hair and [NAME] Restraints, revised January 2023 revealed hair restraints must be worn at all times in the kitchen. Review of facility policy, Hand Washing, revised January 2023 revealed staff would wash hands frequently to ensure safe food handling. Hands should be washed after using a handkerchief or disposable tissue, after handling soiled equipment or utensils, during food preparation to remove soil and contaminants, when changing tasks, and after engaging in any activity that may soil or contaminate hands. Review of facility policy, General Safe Food Handling, revised February 2024 revealed kitchen equipment was to be cleaned after each use. Review of facility policy, Disposable Gloves, revised May 2024 revealed single-use disposable gloves shall be used for only one task and discarded when damaged or soiled and when interruptions occur in task completion. Hands were to be washed before and after wearing disposable gloves. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365046 If continuation sheet Page 50 of 55 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 11/08/2024 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the medical record revealed Resident #15 was admitted on [DATE] with diagnoses including chronic kidney disease, dementia, diabetes mellitus, malnutrition, high blood pressure, dysphagia (trouble swallowing), prosthetic heart valve, aortic valve stenosis, hypothyroidism, and gastroesophageal reflux disease. A review of Resident #15's clinical record revealed an assessment dated from 05/2024 to 10/2024 which indicated Resident #15 had a high risk for falls. Resident #15's plan of care indicated Resident #15 was at risk for falls. A review of Resident #15's fall investigations dated 03/2024 to 11/2024 revealed Resident #15 had sustained nine falls during the review period. Five of the investigations referred to nursing progress notes that were not entered at the time of the fall. There was no indication the progress note was written at a different time than when the fall actually occurred. There was no late entry to indicate the fall occurred at a different time than what was indicated in the nursing progress note. The fall investigation indicated the fall occurred on 09/15/24 at 7:25 P.M. The nursing progress note documented the fall on 09/16/24 at 7:15 A.M. The fall investigation indicated a fall occurred on 07/20/24 at 9:10 P.M. The nursing progress note documented the fall on 07/20/24 at 4:20 A.M. The fall investigation indicated a fall occurred on 05/23/24 at 7:50 A.M. The nursing progress note documented the fall on 05/23/24 at 4:18 P.M. The fall investigation documented the fall occurred on -5/09/24 at 2:40 A.M. The nursing progress note documented the fall on 05/09/24 at 4:59 P.M. The fall investigation indicated a fall occurred on 03/04/24 at 9:30 P.M. The nursing progress note indicated the fall occurred on 03/05/24 at 12:31 A.M. An interview with Licensed Practical Nurse (LPN) #767 on 11/05/24 at 10:38 A.M. verified the above findings. This deficiency represents non-compliance investigated under Complaint Number OH00159071 and OH00158882. Based on medical record review, review of the facility's fall investigations, and interview, the facility failed to ensure documentation was complete and accurate for Resident #15, #19 and #50. This affected three residents (#15, #19, and #50) of 43 records reviewed. The facility census was 166. Findings include: 1. Review of the medical record for Resident #19 revealed an admission date of 04/29/18 with diagnoses including age-related osteoporosis, presence of left artificial shoulder joint, major depressive disorder, presence of right artificial hip joint, hypothyroidism, and a history of falling. Review of the facility's fall investigation dated 10/03/24 at 11:40 P.M. revealed Resident #19 had an unwitnessed fall while self-ambulating, complained of six out of ten pain to the right side, was administered acetaminophen and an ice pack, and was sent to the hospital around 1:40 A.M. on 10/04/24, two hours after the fall occurred. There was no witness statement for Licensed Practical Nurse (LPN) #791, who wrote a progress note for the incident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365046 If continuation sheet Page 51 of 55 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 11/08/2024 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the progress note, created 10/04/24 at 2:51 A.M. with an effective date of 10/03/24 at 11:40 A.M., and authored by LPN #791 indicated Resident #19 had an unwitnessed fall, the nurse heard Resident #19 yelling from her room, Resident #19 was observed sitting against the wall on the bathroom floor with pants halfway down and the floor was wet, Resident #19 was assisted back to bed by three staff members, a head to toe assessment was completed, Resident #19 complained of right side pain six out of 10 with tenderness to touch, an ice pack was applied, Tylenol was given, and no other injuries were noted. The note indicated Resident #19 was sent to the hospital at approximately 1:40 A.M. Review of the progress note, created 10/05/24 at 12:54 P.M. with an effective date of 10/03/24 at 11:57 P.M., revealed Resident #19 was screaming for help from her room and observed on the floor of the bathroom claiming she had hit her back. Resident #19 was assisted back to bed by three staff. Resident #19 complained of right side pain and cried when her side was touched. Ice was applied and Tylenol was given. Resident #19 was sent to the hospital at 1:40 A.M. due to intense pain and crying. The note indicated Resident #19 was admitted to the intensive care unit (ICU) for rib fractures. Review of the physician's orders for October 2024 revealed there were no physician's orders to send Resident #19 to the hospital on [DATE] or 10/04/24. On 11/04/24 at 12:23 P.M., an interview with Unit Manager/LPN #789 stated the progress note with an effective date of 10/03/24 at 11:40 A.M. was inaccurately documented because the incident documented in the note occurred on night shift not day shift. Unit Manager #789 also stated he did not have a witness statement for LPN #791, who wrote the progress note documenting the incident. On 11/04/24 at 2:41 P.M., an interview with LPN #791 stated she did not complete a witness statement for the incident, she just wrote a progress note in the chart. On 11/05/24 at 9:55 A.M., an interview with Unit Manager #789 confirmed the progress note, authored by him, was created on 10/05/24 after the interdisciplinary team (IDT) had completed their investigation of the fall and he back-dated the note to the time of the incident on 10/03/24. Unit Manager #789 stated again that LPN #791's progress note, dated 10/03/24 at 11:40 A.M., was inaccurately documented because it should have reflected a time of 11:40 P.M. On 11/05/24 at 1:15 P.M., an interview with Nurse Practitioner (NP) #839 verified there were no physician's orders in the medical record to send Resident #19 to the hospital on [DATE] or 10/04/24. 2. Review of the medical record for Resident #50 revealed an admission date of 08/25/22 with diagnoses including end stage renal disease, dementia, congestive heart failure, and dependence on renal dialysis. Review of the physician's orders for October 2024 identified orders for dialysis three times weekly on Tuesday, Thursday, and Saturday (ordered 02/21/24), perform pre-dialysis assessment once daily on dialysis days (ordered 12/02/23), and perform post-dialysis assessment every evening shift on dialysis days (ordered 12/03/23). Review of the medication administration records (MARs) for August 2024 through October 2024 revealed there were no pre-dialysis vital signs on 09/07/24 and 10/19/24, and there were no post-dialysis vital signs on 08/30/24, 09/05/24, 09/26/24, 10/08/24, 10/15/24, and 10/22/24. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365046 If continuation sheet Page 52 of 55 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 11/08/2024 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #50's dialysis assessments for August 2024 through October 2024 revealed pre- and post-dialysis assessments were not always completed on all dialysis days and the time stamps for some of the vital signs were while the resident was out of the facility at dialysis. On 10/30/24 at 9:28 A.M., an interview with the Director of Nursing (DON) confirmed the dialysis assessments on the MAR were not completed every dialysis day. The DON further stated staff were not required to complete the dialysis assessment information on the MAR because they completed the preand post-assessments in the resident evaluations. On 10/31/24 at 1:08 P.M., an interview with Registered Nurse (RN) Supervisor #654 verified the information on pre- and post-dialysis assessments for Resident #50. RN Supervisor #654 also confirmed weights were not documented for all dialysis days. On 10/31/24 at 1:55 P.M., an interview with Unit Manager/Licensed Practical Nurse (LPN) #789 stated just because things were time stamped a certain time did not mean that was when it was completed, and that time stamp was just when it was documented in the chart. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365046 If continuation sheet Page 53 of 55 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 11/08/2024 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of facility policy and interview the facility failed to maintain infection control standards during care for Resident #107 during medication administration and Resident #111 during gastronomy tube site care. This affected one resident (#107) out of four residents reviewed for medications administration and one resident (#111) out of one resident reviewed for tube feeding. The facility census was 166. Residents Affected - Few Findings include: 1. Resident #107 was re-admitted on [DATE] with diagnoses including heart failure, iron deficiency anemia, diabetes mellitus, high white blood cell count, lung cancer, Alzheimer's dementia, aortic valve stenosis, fractured right femur, high blood pressure, leiomyoma of uterus (uterine fibroids), vascular dementia, cerebral vascular disease with transient ischemic attack (TIA) and stroke, high cholesterol, lymphoma, and long term use of insulin. An observation 10/29/24 at 8:25 A.M. of Licensed Practical Nurse (LPN) #763 administering medications to Resident #107 revealed a failure to maintain infection control standards to prevent possible cross contamination of germs. LPN #763 assisted Resident #107 to a seated position and did not sanitize or wash her hands prior to obtaining medications from medication cart containing other residents medications. LPN #763 proceeded to dispense the medications in a medication cup. While dispensing the medications from the bubble card packaging LPN #763 touched the tagrisso 80 mg tablet with her bare thumb and placed the table in the medication cup. LPN #763 removed the polysaccharide iron 150 mg capsule and pulled apart the capsule to dispense the medication in the cup of other crushed medications with her bare hands. LPN #763 entered Resident #107's room and when leaning over to administer the medications her long braided hair fell from her shoulder/back to her front hanging down and touching Resident #107's chest. LPN #763 pushed/tossed her hair braids to remove it from her face seven times during the task. When handing the cup of water to Resident #107 she placed forefinger inside of cup of water. An interview with LPN #763 on 10/29/24 at 10:13 A.M. verified the above findings and confirmed she failed to follow infection control standards. The facility policy titled Handwashing/Hand Hygiene revised August 2019 indicated all personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Staff should use an alcohol-based hand rub containing at least 62% alcohol or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: before and after coming on duty, direct contact with residents, preparing or handling medications, any non-surgical invasive procedures, handling an invasive device (e.g., urinary catheters, IV access sites), before donning sterile gloves, handling clean or soiled dressings, gauze pads, etc., moving from a contaminated body site to a clean body site during resident care, contact with a resident's intact skin, contact with blood or bodily fluids, after handling used dressings, contaminated equipment, etc., after removing gloves, after contact with objects (e.g., medical equipment) in the immediate vicinity of the resident, before and after entering isolation precaution settings. Hand hygiene is the final step after removing and disposing of personal protective equipment. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365046 If continuation sheet Page 54 of 55 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 11/08/2024 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 - Few 2. Review of the medical record for Resident #111 revealed an initial admission date of 12/20/23 and a facility re-entry date of 01/31/24. Diagnoses included hypertensive urgency, hematuria, altered mental status, benign prostatic hyperplasia, oropharyngeal phase dysphagia, type two diabetes mellitus with diabetic neuropathy, unspecified dementia, pure red cell aplasia, vesicointestinal fistula, flaccid neuropathic bladder, stage three chronic kidney disease, acquired absence of the right and left leg above the knee, and attention to gastrostomy. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment completed on 07/26/24 revealed Resident #111 had intact cognition. Further review of the MDS revealed Resident #111 had an indwelling urinary catheter and received nutrition and hydration through a feeding tube. Review of the physician orders revealed an order dated 04/16/24 for enhanced barrier precautions. Review of the care plan dated 09/18/24 revealed Resident #111 required a PEG tube (percutaneous endoscopic gastrostomy, a feeding tube inserted into the stomach which may be used for nutrition, hydration, and medication administration) secondary to dysphagia. Interventions included maintaining enhanced barrier precautions (EBP) while performing high-contact resident care activities. Observation on 10/30/24 at 2:30 P.M. revealed Licensed Practical Nurse (LPN) #795 performed PEG tube site care for Resident #111. During the observation, LPN #795 donned gloves to perform the procedure, but not a gown. There were also no gowns noted near the outside or inside of Resident #111's room. Interview on 10/30/24 at 2:46 P.M. with LPN #795 confirmed Resident #111 was in enhanced barrier precautions because of the PEG tube and urinary catheter and when providing the PEG site care, a gown should have been worn. Further interview with LPN #795 confirmed she did not wear a gown to perform PEG care for Resident #111 and did not see any available in his room. Interview on 10/31/24 at 11:20 A.M. with LPN Unit Manager #787 confirmed staff were supposed to wear a gown and gloves to perform PEG tube care. Review of the policy titled Enhanced Barrier Precautions revised August 2022 revealed gloves and a gown were to be worn while performing high contact resident care activities which included care of a feeding tube. This deficiency represents non-compliance investigated under Complaint Number OH00158550. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365046 If continuation sheet Page 55 of 55