Health inspection·March 12, 2025

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility policy, the facility failed to ensure Resident #129 received proper incontinence care. This affected one resident (Resident #129) of three residents reviewed for incontinence. The facility census was 152. Findings include: Review of the medical record for Resident #129 revealed an admission date of 03/14/24. Diagnosis included but were not limited to COVID-19, dysphagia, cirrhosis of Iver, nontraumatic intracerebral hemorrhage, hemiplegia affecting right dominant side, and sickle-cell disease. Review of the Care Plan dated 12/10/24 revealed Resident #129 had bladder and bowel incontinence. Interventions included offer to toilet resident upon waking, before and after meals, at bedtime and as needed (PRN) and provide peri-care after each episode of incontinence. Review of the quarterly Minimal Data Set (MDS) dated [DATE] revealed Resident #129 had severely impaired cognition. Review of the bladder and bowel section revealed Resident #129 was always incontinent of bladder and bowel. Observation on 03/05/25 at 08:07 A.M. of perineal (peri) care (incontinence care) for Resident #129 revealed Wound Nurse # 581 gathered supplies, provided privacy, washed hands in bathroom and applied gloves. Wound Nurse #581 positioned Resident #129 on her right side and removed her brief. Wound Nurse #581 began to clean her buttocks area first with a warm washcloth with soap and water. When she removed the washcloth there was a small amount of stool on the washcloth after wiping. Wound Nurse #581 got another soapy washcloth and cleansed buttocks, then a rinse wash cloth, and then she patted area dry. Wound Nurse #581 removed the dressing to Resident #129's sacrum for the Wound Nurse Practitioner (NP) #700 to measure a pressure ulcer. After Wound NP #700 measured the pressure area Wound Nurse #581 did the pressure ulcer treatment. After completion of wound treatment Wound Nurse #581 then applied new brief, repositioned resident and ensured call light was in reach. Before leaving the room Wound Nurse #581 removed her gloves and washed her hands. Resident #129's front genital area was not cleansed. Interview on 03/05/25 at 8:24 A.M. with Wound Nurse #581 verified she provided peri-care/incontinence care incorrectly. Wound Nurse #581 reported she forgot to cleanse Resident #129's front genital peri area and she was to provide peri care to the front first then do the buttocks. Interview on 03/05/25 at 8:53 A.M. with Director of Nursing (DON) revealed procedure for peri care is to clean the front peri area first then the buttocks. DON verified Wound Nurse #581 performed peri care incorrectly. Review of facility policy, Perineal Care, dated August 2009, revealed the purpose of the procedure is to provide cleanliness and comfort. For female residents wash perineal area then wash the rectal area thoroughly. This deficiency represents non-compliance investigated under Complaint Number OH00161455. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365046 If continuation sheet Page 2 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365046 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Daughters of Miriam Center for Nursing & Rehabilit One David N Myers Parkway Beachwood, OH 44122 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, medical record review, staff interviews, and policy review, the facility failed to secure and store medications appropriately. This affected one resident (Resident #136) out of three residents reviewed for secured medications. The facility census was 152. Findings include: Review of Resident #136 medical record revealed the following medications were due for administration the morning of 03/04/25: Amiodarone Hydrochloric Acid (HCI) 200 milligram (mg) give one by mouth (po) once a day (qd) for heart rate, Jardiance 25 mg give 1 tablet po for diabetes mellitus, Metoprolol Succinate extended release (ER) 24 hour 25 mg, give ½ tablet 12.5 mg PO qd for blood pressure, Potassium Chloride ER 20 milliequivalent (MEQ) give 1 tablet po qd for hypokalemia, sodium chloride oral tablet give 1 gram qd po for supplement, Vitamin C 500 mg give 1 tablet qd for anemia, and Acyclovir 400 mg give 1 tablet twice a day (BID) for prevention. Observation and interview on 03/04/25 at 11:52 A.M. with Resident #136 revealed a medicine cup on the overbed tray with 6 ½ pills in the cup. Resident #136 reported the nurse left the medications there for them to take. Resident#136 verified these were his morning medications. Interview and observation on 03/04/25 at 12:03 P.M. with supervisor LPN #583 confirmed a medicine cup with 6 ½ medications were left in Resident #136's room on his over the bed tray. LPN #583 verified medications are not to be left in a resident room. LPN #583 confirmed there were 6 ½ pills in the medicine cup and removed the medicine cup, with medications. Interview on 03/04/25 at 12:15 P.M. with Director of Nursing (DON) verified mediations were not to be left unattended in a residents room. Interview on 03/04/25 at 12:26 P.M. with LPN # 322 verified she left the medications at Resident #136's bedside. LPN #322 confirmed medications were not to be left at bedside. LPN #322 confirmed the medications were his morning medications and there were 6 ½ pills in the medicine cup. Review of facility policy, Medication Administration, dated 09/14/20 revealed to provide guidance for medication administration and administer medications as ordered and stay with until consumed/refused. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365046 If continuation sheet Page 3 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365046 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/12/2025 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** Based on record review, interview, and policy review, the facility failed to ensure Resident #201's medical record accurately reflected confirmation of the resident's death. This affected one resident (Resident #201) out of three resident reviewed for death in the facility. The facility census was 152. Findings include: Review of the medical record for Resident #201 revealed an admission date of [DATE] with diagnosis including but not limited to malignant neoplasm of nasopharynx, respiratory failure, severe protein-calorie nutrition, congestive heart failure, history of transient ischemic attack (TIA), adult failure to thrive, tracheostomy status, gastrostomy, and mood affective disorder. Resident #201 expired at the facility on [DATE]. Review of the progress note dated [DATE] at 12:00 A.M. authored by Licensed Practical Nurse (LPN) #579 revealed LPN #579 checked on Resident #210 and was unable to obtain vital signs. Resident #201 did not respond to verbal and tactile stimuli. Nursing supervisor was made aware, family and physician notified. LPN #579 contacted the funeral home where they received the body at 11:50 P.M. Interview on [DATE] at 8:54 A.M. with LPN #579 revealed she found Resident #201 deceased and checked for vital signs, and he didn't have any. LPN #579 reported she informed Nursing Supervisor Registered Nurse (RN) #706 and she came and verified no vital signs. Interview on [DATE] at 9:40 A.M. with Director of Nursing (DON) confirmed Resident #201's medical record did not contain documentation of the RN confirming the resident's death. Review of facility policy, Death of a Resident Documenting, undated, revealed all information pertaining to a resident's death (i.e. date, time of death, the name and title of the individual pronouncing the resident death, etc.) must be recorded on the nurses' noted. Review of the facility policy, Charting/Documenting Policy, undated, revealed the purpose of the guidelines is to ensure complete comprehensive and timely document and timely documentation of the resident's/patient's care, treatment, response to care, signs, symptoms, change of condition as well as the progress of the resident/patient. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365046 If continuation sheet Page 4 of 4