Health inspection·September 12, 2019

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview the facility failed to ensure Resident #59 and Resident #114 received a Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) upon skilled services ending. This affected two residents (#59 and #114) of three residents reviewed for liability notices. Residents Affected - Few Findings include: 1. Review of Resident #59's Notice of Medicare Non Coverage (NOMNC) form revealed his skilled services ended 07/09/19. Resident #59 remained in the facility upon skilled services ending. There was no evidence Resident #59 received a Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN). Interview on 09/11/19 at 9:03 A.M. with Administrator confirmed Resident #59 did not receive a SNFABN. 2. Review of Resident #114's NOMNC form revealed her skilled services ended 05/02/19. Resident #114 remained in the facility upon skilled services ending. There was no evidence Resident #114 received a SNFABN. Interview on 09/11/19 at 9:03 A.M. with Administrator confirmed Resident #114 did not receive a SNFABN. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365085 If continuation sheet Page 2 of 9 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 365085 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Medina 2400 Columbia Rd Medina, OH 44256 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 #13 received adaptive equipment to assist her during meals to maintain her highest practicable level of independence with eating. This affected one resident (#13) of four residents reviewed for nutrition. Residents Affected - Few Findings include: Record review revealed Resident #13 was admitted to the facility on [DATE] with diagnoses including hypertension, diabetes mellitus, stage three chronic kidney disease, cognitive communication deficit, and muscle weakness. Resident #13's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed her cognition was severely impaired and she required supervision assistance of one person with eating. Resident #13's active comprehensive care plan for nutritional risk revealed she required adaptive equipment at meals. Interventions on the care plan included a sippy cup (two handled cup), and built up utensils. Observation on 09/11/19 at 11:35 A.M. revealed Resident #13 was eating lunch in her room, without built up silverware. The grips to build up the silverware were located on her tray, but not on the silverware. Resident #13's two handled cup was upside down, with a regular cup full of milk on her tray Resident #13 was holding the knife attempting to cut her food. Registered Nurse (RN) #203 joined the observation and confirmed she did not have her built up silverware and her milk was in a normal cup. Observation on 09/12/19 at 11:59 A.M. revealed Resident #13 was eating her lunch in her room. Resident #13 had a carton of milk with a straw inside, with no two handled cup on the tray. Resident #13 had a mug with a lid on it, with no liquid inside. Food Service Director #114 and Registered Nurse (RN) #202 joined the observation and confirmed the above observation. Food Service Director #114 revealed the resident should have been served tea in the mug but was not. Food Service Director #114 revealed the kitchen ran out of two handled cups. Interview on 09/12/19 at 2:30 P.M. with RN #202 revealed Resident #13 needed the two handled cup to help prevent spillage and the built up utensils were to help with gripping the utensils better. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365085 If continuation sheet Page 3 of 9 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 365085 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Medina 2400 Columbia Rd Medina, OH 44256 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 0679 Provide activities to meet all resident's needs. 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 develop and implement a comprehensive and individualized activity program to meet the total care and activity interest and needs of Resident #60. This affected one resident (#60) of two residents reviewed for activities. Residents Affected - Few Findings include: Record review revealed Resident #60 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including pressure ulcer of left buttock, left knee and right knee contractures, major depressive disorder and anxiety disorder. Resident #60's annual Activity Evaluation, dated 03/14/19 revealed she finds strength in Baptist religion and her current interests included animals, beauty, events and news, movies, radio, religious studies, sing a longs, and television. Resident #60's frequency of activity preference was two to three times a week in her own room. Resident #60's was identified to be interested in life/activities, had a cooperative attitude, declines invitation, and was non-ambulatory/bedfast. The comments section of the evaluation indicate the resident was seen for one on one interventions and she declined any group invitations by staff. Resident #60's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed her cognition was moderately impaired, and required extensive two person assistance with transfers and was totally dependent on staff for locomotion. Resident #60's active comprehensive care plan for activities revealed the resident exhibited a reluctance to be out of room for group activities, as evidenced by frequent refusal of invitations and preference to stay in her room in bed. The care plan indicated the resident would accept one on one interventions three times per week and the facility would continue to monitor the resident for one on one interventions. Review of Resident #60's July 2019 activity record progress notes revealed evidence of only one, one on one (1:1) activity for the entire month. Resident #60's Individual Resident Daily Participation Record (independent activities) revealed no evidence the resident was offered religious study activities. Review of Resident #60's August 2019 1:1 Activity/Recreation Program Documentation revealed the week of 08/04/19 she only received one, one on one activity and the week of 08/18/19 she did not receive any one on one activities. Resident #60's activity documentation contained no evidence she was offered the radio or religious studies activities. Review of Resident #60's September 2019 1:1 Activity/Recreation Program Documentation revealed from 09/01/19 through 09/12/19, she only received one on one activity. Observation on 09/09/19 at 11:08 A.M., on 09/10/19 at 11:02 A.M., 2:22 P.M., 3:48 P.M., and on 09/11/19 at 8:00 A.M. revealed Resident #60 was lying in her bed. A radio was not observed playing in the resident's room. Interview on 09/12/19 at 9:28 A.M. with Activities Director (AD) #210 revealed the facility was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365085 If continuation sheet Page 4 of 9 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 365085 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Medina 2400 Columbia Rd Medina, OH 44256 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 0679 Level of Harm - Minimal harm or potential for actual harm revamping the one on one activities. AD #210 confirmed Resident #60 should receive two to three, one on one activities a week in her room. AD #210 confirmed the above findings from the residents activity participation records. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365085 If continuation sheet Page 5 of 9 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 365085 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Medina 2400 Columbia Rd Medina, OH 44256 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview the facility failed to ensure Resident #98's vital signs were monitored and physician guidelines were followed when administering medications. This affected one resident (#98) of five residents reviewed for medications. Residents Affected - Few Findings include: Review of the medical record for Resident #98 revealed an admission date of 07/18/19 with a diagnosis including hypertension. Review of the physician orders revealed an order, dated 08/20/19 for Metoprolol Tartrate 25 milligrams (mg) by mouth twice a day with parameters to hold if systolic blood pressure (SBP) less than 110 or if heart rate was below 60 beats per minutes (bpm) and Amlodipine Besylate 5 mg once daily for hypertension with parameters to hold if SBP is less than 110. Review of the vital sign records revealed from 08/20/19 to 09/02/19 Resident #98's blood pressure and pulse were not recorded twice a day for five of the days. There was no blood pressure or pulse recorded from 09/03/19 to 09/11/19. From 08/20/19 to 09/02/19 there were five times when the resident's pulse was below the 60 bpm guideline and Metoprolol Tartrate 25 mg was given. Review of the Medication Administration Record (MAR) for August and September 2019 revealed the Metoprolol Tartrate 25 mg was given twice daily and the Amlodipine Besylate 5 mg was given once daily and were not held on any day from 08/20/19 to 09/11/19. Review of the nursing progress notes from 08/20/19 to 09/11/19 revealed no documentation of vital signs or that medications were held due to not meeting the parameters set by the physician. Interview on 09/11/19 at 10:40 A.M. with Registered Nurse #300 revealed vital signs should be taken with each medication administration, if ordered by the physician. RN #300 stated Resident #98 had orders for Metoprolol Tartrate 25 mg to be held if heart rate was less than 60 bpm and if systolic blood pressure is less than 110. RN #300 verified from 08/20/19 to 09/02/19 the resident's blood pressure and pulse had not been checked each time Resident #98 received the hypertension medications. RN #300 verified Resident #98's heart rate was below the parameter on 08/23/19, 08/24/19, 08/26/19, 08/29/19 and 08/30/19 and she still received her Metoprolol Tartrate 25 mg for hypertension. RN #300 verified there was no documentation of blood pressures or heart rate being taken prior to Resident #98 receiving her medication from 09/02/19 to 09/11/19. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365085 If continuation sheet Page 6 of 9 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 365085 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Medina 2400 Columbia Rd Medina, OH 44256 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure Resident #80's fall precautions were in place at all times. This affected one resident (#80) of one resident reviewed for falls. Findings include: Record review revealed Resident #80 was admitted to the facility on [DATE] with diagnoses including unspecified injury of head, contractures of left and right knees, repeated falls, difficulty walking, muscle weakness, and cognitive communication deficit. Review of Resident #80's Event Follow-up and Recommendation Form dated 03/17/19 revealed Resident #80 was found lying on his back in front of his wheelchair in his room. As a result of this fall, staff were not to leave the resident unattended in his room. Resident #80's physician order dated 03/17/19 revealed the resident was not to be left unattended in room when up in the wheelchair. Resident #80's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognition was severely impaired and the resident required two person extensive assistance while transferring and toileting. Observation on 09/09/19 at 2:24 P.M. and at 3:30 P.M. revealed Resident #80 was sitting in his wheelchair in his room unattended. Interview on 09/09/19 at 3:30 P.M. with Registered Nurse (RN) #202 confirmed this observation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365085 If continuation sheet Page 7 of 9 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 365085 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Medina 2400 Columbia Rd Medina, OH 44256 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview the facility failed to implement a Legionella prevention program. This had the potential to affect all 113 residents residing in the facility. Residents Affected - Many Findings include: Review of the facility Water Management Program from the Environment of Care Manual, reviewed 06/26/19, revealed the purpose of the program was to protect the health and safety of residents, visitors, and associates by formulating a water management plan that identified and controlled hazardous conditions that support the growth and spread of bacterial organisms, such as Legionella. Review of the program revealed no evidence the facility implemented the policy and procedures of the water management system. Interview on 09/12/19 at 10:32 A.M. confirmed the facility had not implemented the Water Management Program to assist with Legionella Prevention. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365085 If continuation sheet Page 8 of 9 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 365085 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Medina 2400 Columbia Rd Medina, OH 44256 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure the antibiotic stewardship program was effective to prevent the administration of an antibiotic for Resident #80 after the medication had been discontinued. This affected one resident (#80) of three residents reviewed for infections. Residents Affected - Few Findings include: Record review revealed Resident #80 was admitted to the facility on [DATE] with diagnoses including heart failure, chronic kidney disease and peripheral vascular disease. Review of Resident #80's nurse practitioner note, dated 09/03/19 revealed the resident had a vascular wound infection to his right lateral ankle and was ordered the antibiotic, Keflex 500 milligrams (mg) three times a day for seven days. Review of the handwritten telephone order, dated 09/03/19, confirmed the Keflex was ordered on 09/03/19 for seven days. Review of the order entered into the electronic medication system, dated 09/03/19, revealed a stop date of seven days was not included in the order. Review of Resident #80's Medication Administration Record (MAR) from 09/01/19 through 09/12/19 revealed the resident was administered Keflex on 09/03/19 at bedtime through midday on 09/12/19, eight days from the start date. On 09/11/19, Resident #80 did not receive Keflex during the morning or midday because he was at the hospital. Review of Resident #80's medical record revealed no evidence the physician assessed Resident #80 to extend the use of Keflex or evidence an extension past seven days was ordered. Interview on 09/12/19 at 3:15 P.M. with Registered Nurse (RN) #200 revealed Resident #80 received four extra doses of Keflex past the seven days it was ordered. RN #200 confirmed the order in the computer did not have a stop date. RN #200 confirmed the Keflex was not reviewed for extended use until surveyor intervention. Review of the facility Antibiotic Stewardship program outline, issued 03/2017 revealed tracking antibiotic stewardship included the completeness of prescribing documentation to include duration for use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365085 If continuation sheet Page 9 of 9