Health inspection·September 24, 2021

F 0572 Give residents a notice of rights, rules, services and charges. Level of Harm - Potential for minimal harm Based on record review and resident and staff interview the facility failed to ensure residents were informed of their rights on an ongoing basis. This had the potential to affect all 101 residents currently residing in the facility. Residents Affected - Many Findings include: Completion of the resident council portion of the annual survey on 09/22/21 between 3:00 P.M. and 3:25 P.M. with Residents #58, #67, #84 and #347 revealed there was no ongoing review of residents rights during the resident council meeting or in any other fashion at the facility. Review of the residents council meeting minutes from August 2020 through August 2021 revealed no evidence that residents rights were reviewed during the resident council meeting. Interview with Activity Director #700 on 09/22/21 at 3:30 P.M. verified residents rights were not reviewed during resident council meetings and she was unaware of any other mechanisms in place at the facility to review residents rights on an ongoing basis. 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 09/24/2021 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on resident interview, observation and staff interview the facility failed to ensure a homelike environment that is free from excessive unnecessary clutter in the common shower room on the 600 unit. This affected one (Resident #40) of twenty five sampled residents and had the potential to affect an additional 25 (Residents #2, #6, #7, #8, #10, #11, #13, #29, #31, #36, #37, #42, #44, #47, #52, #54, #61, #65, #72, #76, #80, #81, #92, #93 and #94) who resided on the 600 unit. The facility census was 101. Findings include: Interview with Resident #40 on 09/20/21 at 10:11 A.M. revealed concerns related to the clutter in the shower room on the 600 unit. Resident #40 stated the shower room was full of junk and it made taking a shower feel cramped and uncomfortable. Observation of the 600 hall shower room revealed the shower room contained the following: - Two wheelchairs (one of which was a large geri chair) - One wheeled walker. - Four wheelchair legs - An unused trash can Approximately 40% to 50% of the shower room was occupied by the above noted items. Infection Preventionist #526 verified the unnecessary clutter caused by the above mentioned items in the shower room during interview on 09/22/21 at 11:25 A.M. 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 09/24/2021 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to administer insulin according to physicians orders. This affected one Resident (#58) of six residents reviewed (#20, #32, #36, #51 and #57) for medication administration. The facility census was 104. Residents Affected - Few Findings include: Review of Resident #58's medical record revealed an admission date of 12/18/16 with diagnoses that included diabetes, long term use of insulin and morbid obesity. Review of Resident #58's Minimum Data Set (MDS) dated [DATE] revealed the resident had intact cognition. Review of Resident #58's care plan dated 08/07/21 revealed the resident was dependant on insulin related to diabetes. Interventions included administer insulin and monitor blood sugars as ordered by the physician. Review of physician orders for September 2021 revealed Resident #58 was to receive 24 units of Humalog (fast acting insulin) with each meal. Observation on 09/20/21 at 12:05 P.M. of medication administration revealed Licensed Practical Nurse (LPN) #602 had checked Resident #58's blood sugar. The reading was 264 (normal range 70-100). LPN #602 obtained the resident's insulin injectable pen and dialed a dose of 12 units. LPN #602 had the resident's Medication Administration Record (MAR) open and had confirmed the physician orders were for 24 units. LPN #602 stated due to the resident consuming less food she was going to give the resident 12 units instead of the ordered 24 units. LPN #602 denied she had contacted the physician and stated she had given less insulin several times before and had not contacted the physician, she documented the 12 units given in a progress note each time she had given it. LPN #602 entered the resident's room and administered the 12 units of Humalog insulin in the resident's left lower abdominal area. Interview with LPN #632 on 09/21/21 at 9:13 A.M. revealed she had administered 24 units of Humalog to Resident #58. She denied being aware of the resident receiving an amount of insulin other than what was physician ordered. She verified insulin should be administered as ordered unless directed otherwise by the physician. Interview with Resident #58 on 09/21/21 at 9:50 A.M. revealed LPN #602 was the only nurse who had given her a decreased dose of insulin. She stated she had not requested to receive a smaller dose and stated she had informed LPN #602 she wanted to receive the full dose. Review of progress notes authored by LPN #602 revealed on 08/08/21, 08/09/21, 08/12/21, 09/04/21 at 4:33 P.M. and 12:12 P.M., and on 09/20/21 Resident #58 had received only 10 out of 24 units of Humalog insulin ordered by the physician. 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 09/24/2021 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 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, staff interview, and review of facility drug storage policy and manufacturer's instructions the facility failed to ensure medications and supplements wee stored according to manufacture guidelines. This had the potential to affected 58 residents (#2, #4, #5, #6, #7, #9, #10, #11, #13, #14, #15, #17, #18, #19, #21, #25, #27, #29, #31, #32, #36, #37, #40, #41, #42, #43, #44, #45, #47, #49, #51, #54, #58, #60, #61, #64, #65, #67, #68, #69, #70, #71, #73, #75, #76, #77, #78, #80, #81, #84, #87, #91, #92, #94, #99, #147, #148 and #149) that resided on the 600, 700 and 800 units. The facility census was 104. Findings include: 1. Observation on 09/22/21 at 8:58 A.M. with Licensed Practical Nurse (LPN) #632 of the 800-unit medication cart revealed one opened box of Culturelle probiotics, used to support digestive balance with an expiration date of November 2020. Interview 09/22/21 at 9:05 A.M. with LPN #632 revealed there were no residents with current orders for probiotics. 2. Observation on 09/22/21 at 9:16 A.M. of the medication room for the 600, 700, and 800 units revealed an unopened bottle of calcium 600 milligram (mg) with vitamin D3 with with an expiration date of November 2020 and an unopened bottle of vitamin B6 with an expiration date of July 2021. The refrigerator revealed an opened multi use vial of tuberculin purified protein derivative (PPD) solution, used to detect Tuberculosis disease, with an expiration date of November 2023. The bottle contained it was dated when opened. Interview on 09/22/21 at 9:20 A.M. with LPN #632 revealed once a multi vial of tuberculin solution was opened the nurse was to document the date on the vial. Review of the manufacturer's instructions for tuberculin (PPD) solution revealed the vial should be refrigerated and protected from light. Vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency. Review of the policy titled Storage and Expiration dating of Medications, Biologicals, Syringes and Needles, dated 12/01/07 stated the facility should follow manufacture guidelines with respect to expiration dates for opened medications. Once any medication or biological package is opened, the facility should follow manufacture guidelines with respect to expiration dates for opened medications. Staff should record the date opened on the primary medication container /vial when the medication has a shortened expiration date once opened. Interview on 09/22/21 at 3:57 P.M. with the Director of Nursing (DON) verified the above findings. 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 09/24/2021 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 observation, interview and menu spreadsheet review the facility failed to follow the menus for residents receiving a pureed diet. This affected 11 residents (Residents #4, #5, #8, #23, #53, #56, #70, #73, #83, #89 and #93) receiving a pureed diet. The facility census was 101. Findings include: Review of the menu and spreadsheet corresponding to the lunch meal on 09/21/21 revealed a meal consisting of Italian meat sauce, spaghetti pasta, Italian vegetable blend, garlic bread, peach cream pudding and choice of beverage. An alternate meal of creamy mushroom chicken, glazed carrots and rice pilaf was listed on the spreadsheet. Residents on a pureed diet were to receive a #8-scoop of pureed meat sauce, a #8-scoop of pureed spaghetti, a #8-scoop of pureed Italian vegetables and a #16-scoop of pureed bread. Observation of the lunch meal on 09/21/21 starting at 10:48 A.M. revealed a meal consisting of spaghetti pasta, meat sauce, mixed vegetables, breadstick and a fruit cup as well as alternate food items. There were metal pans containing pureed meat sauce, pureed bread and pureed mixed vegetables and mashed potatoes. No pureed spaghetti pasta was noted on the steam table. On 09/21/21 at 11:05 A.M. the first pureed meal was being plated and the pureed meat sauce was being served on top of the mashed potatoes as the entree. Interview on 09/21/21 at 11:54 A.M. with Food Service Director (FSD) #543 verified the spreadsheet indicated residents receiving a pureed diet were to receive pureed spaghetti pasta with their pureed meat sauce and not mashed potatoes. FSD #543 confirmed they did not follow the menu extension for residents receiving a pureed diet during the lunch meal on 09/21/21. Review of the facility diet list dated 09/20/21 indicated 11 residents (Residents #4, #5, #8, #23, #53, #56, #70, #73, #83, #89 and #93) received a pureed diet. 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 09/24/2021 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 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and review of facility food storage and labeling policies the facility failed to ensure foods were labeled and stored appropriately. This affected 99 residents receiving food from the kitchen; two residents (Resident #51 and Resident #94) were ordered nothing-by-mouth. The facility census was 101. Findings include: Observation of the kitchen on 09/20/21 from 9:19 A.M. to 9:47 A.M. with Food Service Director (FSD) #543 revealed in the cooler, there was corned beef that expired on 09/18/21 and in the freezer, there was a bun that was freezer-burned. The tour continued to the facility's two nourishment rooms. House Three's nourishment refrigerator revealed two bags of resident food that were unlabeled and undated. House Two's nourishment refrigerator revealed a container in the freezer labeled with Resident #4's name and dated 08/08/21, an undated and unlabeled bag of [NAME] takeout, a bag of Taco Bell take out dated 09/12/21 with no label and two additional containers that were unlabeled and undated. Interview on 09/20/21 at 9:47 A.M. with FSD #543 revealed the facility's expectations for labeling and dating resident food items were posted on the nourishment refrigerators for staff to reference and included labeling the food item with who the food belonged to, what the food was, when it was placed in the refrigerator and when the food had to be used by. FSD #543 confirmed the above items were not labeled or stored appropriately and shared night shift nursing assistants often helped to monitor the nourishment refrigerators to ensure food was not expired. Review of a policy, Food Safety, revised 11/28/17 revealed food was stored and maintained in a clean and sanitary manner following federal, state and local guidelines to minimize contamination and bacterial growth. Prepackaged food was placed in a leak-proof, pest-proof, non-absorbent sanitary container with a tight-fitting lid. The container is labeled with the name of the contents and the date (when the item is transferred to the new container). Use by date is noted on the label or product when applicable. The use by date guide is easily accessible to all associates involved with resident food storage. Food is labeled with the date received if the date received is not on the item. Leftovers are dated properly and discarded after 72 hours unless otherwise indicated. Review of a handout, For Guests: Keeping Food Safe for the Residents in [Facility Name] no date revealed food requiring refrigerated storage must be placed in a container that is covered securely and must contain a label that has the name of the resident, what the items is, the date it was stored and the use by date (72 hours from the storage date). Food brought in by guests may not be stored in the food service department. During rounds, any food found not to be stored properly will be discarded. When to discard food guidance included if there was an off smell or taste and if there was no date on the food item and it was questionable if it was safe to eat. Review of a facility policy, Food Brought into Facility from Outside Sources, dated 10/04/19 revealed food was stored, prepared and distributed in accordance with professional standards for food safety. To ensure food remains properly stored, assign daily rounds to a facility associate. Food items not stored/labeled properly or food that is expired will be discarded. Facility associates will ensure each food item is properly labeled with the name of the item and the name of the person providing the item. 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 09/24/2021 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation and staff interview the facility failed to maintain a clean and well maintained environment. This affected 31 residents (#1, #4, #7, #8, #9, #12, #22, #24, #25, #28, #33, #36, #37, #38, #39, #42, #51, #52, #54, #59, #69, #75, #76, #80, #81, #83, #85, #91, #93, #94 and #95) and had the potential to affect all 101 residents currently residing in the facility. Findings include: An environmental tour was conducted on 09/21/21 between 10:30 A.M. and 11:00 A.M. with Environmental Service Director (ESD) #561 and Assistant Maintenance Director (AMD) #606. The following concerns were observed and verified at the time of observation. 1. The tube feed poles and bases for Residents #51, #69 and #94 were stained significantly with dried tube feed solution. 2. The privacy curtain separating Residents #42 and #80 was significantly stained with an unknown black substance. 3. Residents #33 and #38's room had a significant crack in the window sill. 4. The wall directly beneath the air conditioning in Resident #81's room was crumbled to the point of exposing the bare wall. 5. The bathroom floors in Resident #7, #28, #39, #54, #75 and #76's rooms were significantly discolored to various degrees with numerous unknown substances. 6. The based board in Resident #76's room had come off the wall. 7. The walls in the Resident #4, #12, #22, #91 and #93's rooms were significantly scuffed with noticeable degrees of markings on the walls and paint was chipped and coming off the walls around said markings in various areas in the room. 8. The fall mats utilized by Residents #1, #8, #25, #36, #52, #59, #69, #83, #85 and #95 were all significantly stained, tattered and in poor condition. This deficiency substantiates Complaint Number OH00114316. 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 09/24/2021 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 0922 Have enough backup water supply for essential areas of the nursing home. Level of Harm - Minimal harm or potential for actual harm Based on policy review and staff interview the facility failed to develop an emergency water source policy and procedure with all required information. This had the potential to affect all 101 residents currently residing in the facility. Residents Affected - Many Findings include: Review of the policy entitled Water Service Disruption or Contamination of Water Supply dated 07/22/20 on 09/21/21 at 10:20 A.M. revealed the facility had developed a policy to provide food and water for staff or other persons which will stay during an emergency but had no procedure to verify the water on hand could provide the necessary three days of emergency water per it's policy. Interview with the Assistant Maintenance Director (AMD) #606 verified the finding at the time of the policy review. AMD #606 did an audit of the on hand supply and counted 360 gallons on site. The minimum required for the number of beds and staff for the facility was 518 gallons. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365085 If continuation sheet Page 9 of 9