Health inspection·January 25, 2024

F 0558 Level of Harm - Minimal harm or potential for actual harm hallway. She also stated the call lights sounded like the alarm for the front door and another piece of portable equipment they used. Review of the facility policy titled Resident Call System, reviewed 01/15/24 revealed facility associates should always be aware of call lights. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365085 If continuation sheet Page 2 of 22 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 01/25/2024 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure accurate advanced directives were in place for Resident #110. This affected one resident (Resident #110) of 25 residents reviewed for advanced directives. Findings include: Record review for Resident #110 revealed an admission date of 11/09/23. Diagnosis included surgical aftercare following surgery on the digestive system, muscle weakness, cognitive communication deficit, moderate protein calorie malnutrition, hypertensive heart and chronic kidney disease with heart failure. Resident #110 was admitted to hospice services on 12/22/23. Record review of the Significant Change Minimum Data Set (MDS) dated [DATE] revealed Resident #110 was severely cognitively impaired. Resident #110 required assistants with activities of daily living. Resident #110 had medically complex conditions and had a condition or chronic disease that may result in life expectancy of less than six months. Record review of the physician order dated 11/09/23 in the Electronic Medical Record revealed Resident #110 had an order for Do Not Resuscitate, Comfort Care Arrest (DNRCC-A). Review of the care plan dated 11/09/23 revealed Resident #110 had the following Advanced Directives DNRCC-Arrest. Record review of the DNR order form in Resident #110's hard chart was the order dated 12/23/23 signed by Physician #807 and revealed Resident #110 was to be Do Not Resuscitate, Comfort Care (DNRCC). Interview and record review on 01/24/24 at 3:40 P.M. with Director of Nursing (DON) confirmed the written order dated 12/23/23 in Resident #110's hard chart did not match the orders in the electronic medical record and care plan. DON confirmed Resident #110's code status was changed on 12/23/23 and the medical records and care plan was not updated to reflect the current orders. DON revealed she would expect the code status to match. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365085 If continuation sheet Page 3 of 22 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 01/25/2024 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 - Few 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 observation, interview, and record review the facility failed to maintain clean and sanitary floors in a resident's room. This affected two residents (#7 and #32) of five residents reviewed for environment. The facility census was 118. Findings include: Observation on 01/22/24 at 10:34 A.M. of Resident #7 and #32's floor revealed under the sink a large dark stains that appeared like dirt and also along the edge of the molding. Follow-up observation on 01/24/24 at 11:17 A.M. of Resident #7 and #32's floor revealed the large black dirt like stain on still on the floor under sink. Observed Resident #32 and a visitor and interview at this time the visitor stated the sink had a leak a while ago, but it was fixed but after the stain came. Resident #32's visitor then stated he wondered if it was mold. Interview on 01/24/24 at 11:27 A.M. with Housekeeping Supervisor (HS) #393 revealed the housekeeping staff cleaned residents' rooms and the common areas daily. Observation on 01/24/24 at 11:30 A.M. with HS #393 of Resident #7 and #32's room floor revealed the large black stain under the sink. Interview at this time HS #393 stated it was stained. Further observation with HS #393 using the flashlight on her cell phone revealed using the tip of a pen the black dirt like material was easily scraped up. Further observation of the area under the sink revealed the black material along the molding back against the wall under the sink and along the walk behind the small trash located next to the sink. After the small trash can was moved away, there was a cobweb and dirt debris build-up. At this time HS #393 verified the observation and stated she will get it cleaned up. Interview on 01/24/24 at approximately 2:25 P.M. with the Administrator stated the area under the sink in Resident's #7 and #32's room was not mold but was waxed over dirt and it had been cleaned up. The Administrator stated had he known about it, it would have been cleaned up immediately. Reviewed policy Housekeeping- General Policy revised 02/24/22 revealed it is the responsibility of the executive director through the environmental services director to assure that housekeeping policies are implemented and followed. The facility must provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365085 If continuation sheet Page 4 of 22 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 01/25/2024 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility policy, the facility failed to investigate and report an allegation of missing money from Resident #2's purse. This affected one resident (Resident #2) of one resident reviewed for abuse, neglect, and misappropriation. Findings include: Record review for Resident #2 revealed an admission date of 12/18/16. Diagnosis included muscle weakness and need for assistants with personal care. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #2 was cognitively intact. Resident #2 had an impairment to one side of the upper extremity and used a wheelchair. Interview on 01/22/24 at 10:42 A.M. with Resident #2 revealed a few weeks ago she had $31.00 missing from her purse. Resident #2 revealed the administrator and social worker said there was nothing they could do about it and her money had to be in a locked box. Resident #2 revealed they provided her with a locked box. Observation revealed Resident #2 had a grey locked box in the second drawer of her nightstand. Record review of the Facility Reported Incidents (FRI) revealed there was no reported incident of Resident #2's missing money or an investigation related to missing money. Review of the facility concern/grievance log revealed no concerns were logged regarding Resident #2's missing money. Interview on 01/23/24 at 4:27 P.M. with Social Worker Director, Licensed Social Worker (LSW) #424 verified no concerns were logged regarding Resident #2's allegation of missing money. LSW #424 revealed Resident #2 had an issue with a State Tested Nursing Assistant (STNA) who she thought was taking her money. LSW #424 revealed they talked to her along with other staff as a group. When asked who the STNA was, LSW #424 revealed she did not want to talk anymore until she spoke with the administrator. Interview on 01/23/24 at 5:31 P.M. with Administrator and LSW #424 revealed per the Administrator they were never told Resident #2 had made a statement of missing money. Administrator revealed they provided Resident #2 with a locked box because she tends to keep everything on her table. Administrator revealed he thought LSW #242 was mixing up stories, Resident #2 never reported missing money, and the Administrator needed to know if she was reporting missing money. LSW #424 confirmed she was never told Resident #2 had missing money. Interview on 01/24/24 at 7:46 A.M. with Administrator revealed he spoke with Resident #2 the previous evening and Resident #2 told him she was missing $31.00, per Administrator this was the first time she reported this. Interview on 01/24/24 at 9:43 A.M. with Resident #2 revealed the Administrator and LSW #424 came in yesterday evening and talked to her about her missing money. Resident #2 revealed that was the second time they talked to her about it, the first time they gave her the locked box and now they say they didn't remember talking to her before. Resident #2 revealed well they did, they gave me the box. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365085 If continuation sheet Page 5 of 22 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 01/25/2024 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 01/24/24 at 9:47 A.M. with State Tested Nursing Assistant (STNA) #478 revealed the nurse, Registered Nurse (RN) #538 told her two or three weeks ago about Resident #2's $31.00 missing. STNA #478 revealed that was when LSW #424 gave Resident #2 the locked box. Interview on 01/24/24 at 10:10 A.M. with RN #538 revealed he was the nurse Resident #2 reported her missing money to. RN #538 revealed about three weeks ago Resident #2 told him about the $31.00 missing. RN #538 revealed he told LSW #424 the same day and that was when they gave Resident #2 the locked box. Interview on 01/24/24 at 10:32 A.M. with Administrator confirmed LSW #424 did not report to him Resident #2 had reported missing money prior to 01/23/24. Administrator revealed he would have expected her to report it. Interview on 01/24/24 at 2:49 P.M. with STNA #540 revealed Resident #2 told everyone about her $31.00 missing about three to four weeks ago. Record review of the facility policy titled, Abuse Prevention reviewed 07/18/23 revealed the facility will ensure reporting reasonable suspicion of crimes against a resident or individual receiving care from the facility within prescribed timeframe's to the appropriate entities. Each covered individual shall report immediately, but no later than two hours after forming the suspicion, if the events that cause the suspicion results in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365085 If continuation sheet Page 6 of 22 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 01/25/2024 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 0641 Ensure each resident receives an accurate assessment. 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 Minimum Data Set (MDS) assessments were accurate related to nutrition for Resident #8 and #99. This affected two residents (Resident #8 and #99) of 28 residents reviewed for comprehensive assessments. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #99 revealed an admission date of 10/05/22. Diagnoses included dementia with agitation, muscle weakness, dysphagia, and protein-calorie malnutrition. Review of the quarterly MDS assessment dated [DATE] revealed the resident had severely impaired cognition and had received tube feedings while as a resident. Further review of Resident #99's medical record revealed no documentation the resident had received tube feedings. Interview on 01/24/24 at 2:33 P.M. with Registered Dietitian (RD) #701 stated Resident #99 had never received tube feedings. Interview on 01/25/24 at 9:11 A.M. with MDS Nurse #311 verified she marked in error that Resident #99 received tube feedings on the MDS assessment. MDS Nurse #311 stated (RD) #701 brought it to her attention yesterday. 2. Review of the medical record for Resident #8 revealed an admission date of 07/02/21 with diagnoses including but not limited to unspecified protein-calorie malnutrition, type II diabetes mellitus, and stage III chronic kidney disease. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] for Resident #8 revealed the resident was cognitively intact and was independent for bed mobility, transfer and toileting and required supervision with set up for meals. Under section K0300, no significant weight changes were indicated. Review of the weights for Resident #8 revealed on 07/18/23 the resident was 120.6 pounds and on 01/17/24 she was 107.4 pounds which indicated a 13.4 pound loss which was an 11.1 percent weight loss over the past six months. Review of the quarterly nutrition assessment dated [DATE] timed at 5:27 for Resident #8 revealed no significant weight changes. Interview on 01/24/24 at 12:08 P.M. with Registered Dietitian #701 confirmed Resident #8 did have a significant weight loss over the past six months and the quarterly nutrition assessment and MDS dated [DATE] did not indicate a significant weight loss but should have. Interview on 01/25/24 at 9:11 A.M. with MDS Coordinator #311 confirmed Resident #8's MDS dated [DATE] did not indicate a significant weight loss as it should have and was marked in error. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365085 If continuation sheet Page 7 of 22 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 01/25/2024 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 0646 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure the appropriate state agency (The Ohio Department of Mental Health and Addiction Services) was notified of significant change in a residents Pre-admission Screen (PASRR). This affected one (Resident #49) of two residents reviewed for PASRR status. The facility census was 118. Findings include: Review of the medical record for Resident #49 revealed an admission date of 08/11/20. Diagnoses included but were not limited to schizophrenia, bipolar disorder, anxiety disorder, major depressive order, morbid obesity, rheumatoid arthritis, systemic lupus, and non-Hodgkin's lymphoma. Review of the most recent quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #49 was cognitively intact and required partial/moderate assistance for bathing and dressing, limited assistance of one for toileting, and supervision for bed mobility, transfer, and personal hygiene. No behaviors were noted. Review of section D question one of the PASRR screen dated 09/28/20 revealed Resident #49 had no mental health diagnosis of schizophrenia. Interview on 01/23/24 at 2:51 P.M. with Social Worker #424 verified no new PASRR was submitted to the state PASRR authority to address Resident #49's new mental health diagnosis of schizophrenia as required. Review of the diagnosis report for Resident #49 dated 01/24/24 revealed a Schizophrenia diagnosis was first reported on 11/08/20. Review of the nursing progress note dated 11/03/20 revealed Resident #49 was sent out to the hospital for evaluation related to abnormal lab values. Review of the nursing progress note dated 11/08/20 revealed Resident #49 returned to the facility from the hospital. Interview on 01/24/24 at 2:16 P.M. with Unit Manager #347 confirmed Resident #49 was first noted to have a diagnosis of schizophrenia following return from hospital on [DATE] and was unable to provide evidence of a PASSR following his diagnosis of schizophrenia. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365085 If continuation sheet Page 8 of 22 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 01/25/2024 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 #38 revealed an admission date of 05/13/22. Diagnoses included schizoaffective disorder, bipolar, type II diabetes, and Alzheimer's dementia. Residents Affected - Few Review of the quarterly Minimum Set (MDS) assessment dated [DATE] for Resident #38 revealed she had intact cognition and required partial to moderate assistance with showers. Review of the plan of care dated 01/03/24 revealed the resident has potential for declines in activities of daily living (ADL) and self-care related to Alzheimer's and schizophrenia. Intervention included offering and encouraging showers twice weekly. Review of the shower documentation for January revealed Resident #38 received a shower on 01/01/24, 01/04/24, 01/15/24 and 01/18/24, on 01/08/24 and 01/11/24 the shower was documented NA, meaning not applicable the shower did not occur, and on 01/22/24 the resident refused her shower. There was no documented evidence that Resident #38 received a shower from 01/05/24 through 01/14/24. Interview on 01/22/23 at 10:58 A.M. with Resident #38 stated she did not receive showers for nine days. Observation at this time revealed her hair was matted and greasy. Interview on 01/22/24 at 11:47 A.M. with the Director of Nursing (DON) verified there was no documentation that Resident #38 received a shower 01/05/24 through 01/14/24. The DON stated the NA reveals the resident did not receive a shower. Interview on 01/24/23 at 4:30 P.M. with State Tested Nursing Assistant (STNA) #427 revealed Resident #38 rarely will refuse a shower and will ask for a shower. Review of the policy titled Activities of Daily Living, dated 12/11/18 stated the resident will receive assistance as needed to complete ADLs. Any changes in the ability to perform ADLs will be documented and reported to the nurse. Based on interview, record review, and review of the facility policy, the facility failed to ensure Resident #38, Resident #50, Resident #43, and resident who receive hospice services received assistance with showers. This affected three residents (Resident #38, Resident #43, Resident #43) of three residents reviewed for showers and had the potential to affect 17 (Resident #5, #6, #31, #35, #42, #55, #59, #82, #84, #86, #94, #96, #101, #102, #110, #470, #473) who receive Hospice services. The facility census was 118. Findings include: 1. Record review revealed Resident #43 had an admission date of 09/24/21. Diagnosis included atrioventricular block, muscle weakness, schizophrenia, and chronic obstructive pulmonary disease. Record review of the physician orders revealed Resident #43 began receiving hospice services on 09/13/23. Record review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #43 was cognitively intact. Resident #43 required set up or clean up assist with eating, partial or moderate (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365085 If continuation sheet Page 9 of 22 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 01/25/2024 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few assist with upper body dressing, substantial/max assist with lower body dressing, personal hygiene, and bathing. Review of the care plan dated 12/05/23 revealed Resident #43 had an activities of daily living (ADL) self-care performance deficit. Interventions included to encourage resident to participate to the fullest extent possible with each interaction. Observation and interview on 01/22/24 at 5:09 P.M. with Resident #43 revealed Resident #43's shirt and pants had multiple food stains and crumbs. Resident #43's nails were long and jagged. Resident #43 revealed he changed his clothing on shower days and would prefer to wear the same clothing until his next scheduled shower. Resident #43 revealed he received two showers a week, he would like to receive more showers but there was not enough staff to provide more showers. Interview on 01/25/24 at 8:38 A.M. with DON confirmed Resident #43 received Hospice services. DON revealed the hospice aides shower Resident #43 two times a week. DON revealed once a resident signs up for hospice services, the resident is put on the hospice bathing schedule and the facility staff no longer bath or shower the resident unless hospice missed a day then they would. DON confirmed since the hospice resident received two baths a week by hospice, the facility did not do scheduled routine additional baths or showers for any hospice residents. Interview on 01/25/24 at 8:41 A.M. with Licensed Practical Nurse (LPN) #542 revealed if a resident received hospice services, hospice aides do the showers, the facility aides did not. Interview on 01/25/24 at 8:48 A.M. with Registered Nurse (RN) Unit Care Coordinator #347 revealed Resident #43 received his showers on Mondays and Fridays. The two showers a week were provided per hospice services. (RN) Unit Care Coordinator #347 revealed at times Resident #43 would refuse the male Hospice aide because he preferred females to bath him. If Resident #43 refused the Hospice aide, then a facility aide would bath him. (RN) Unit Care Coordinator #347 revealed for all hospice residents, the hospice staff normally provided all the baths/showers, the facility did not because the resident was already receiving their bathing per hospice. (RN) Unit Care Coordinator #347 revealed the Hospice aides fill out the facility shower sheets. Review of the shower sheets with (RN) Unit Care Coordinator #347 for Resident #43 revealed the last shower sheet completed was 12/21/23. (RN) Unit Care Coordinator #347 confirmed the last sheet completed was 12/21/23 and confirmed if showers were done, the shower sheet would be filled out. Interview on 01/25/24 at 10:24 A.M. with State Tested Nursing Assistant (STNA) #610 confirmed if a resident received hospice services, she did not have to bath or shower the resident because hospice did. STNA #610 revealed the STNA's do document the resident received a shower or bath because hospice completed the task for them. Interview on 01/25/24 at 2:10 P.M. with Hospice RN #809 confirmed she was Resident #43's Hospice Nurse. Hospice RN #809 revealed the Hospice aides visited and gave each hospice resident two baths/showers a week. Hospice RN #809 revealed she would expect the staff at the facility to also give their two baths/showers a week plus as needed. Hospice RN #809 confirmed Hospice Services were intended to be additional services provided to the resident along with the facility services provided. Interview on 01/25/24 at 2:30 P.M. with DON confirmed the facility had 17 additional hospice residents, Residents #35, #6, #84, #59, #473, #82, #470, #86, #102, #110, #5, #31, #96, #55, #101, #42, and #94. DON confirmed the facility did not provide routine scheduled baths/showers for any of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365085 If continuation sheet Page 10 of 22 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 01/25/2024 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 0677 hospice residents. Level of Harm - Minimal harm or potential for actual harm Interview on 01/25/24 at 3:45 P.M. with Administrator confirmed hospices services were intended to be additional services to the resident including bathing/showers. Residents Affected - Few Review of the facility policy titled, Activities of Daily Living issued 12/11/18 revealed the facility must provide care and services for activities of daily living to include bathing, dressing, grooming and oral care. 3. Resident #50's medical record revealed an admission date of 08/25/20 with diagnosis including: traumatic brain injury, hemiplegia affecting left dominant side, dementia with mood disorder, and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/14/24, revealed Resident #50 was dependent on staff for assistance with showers, and was severely impaired cognitively. Resident #50's care plan dated 01/03/24 revealed Resident #50 had a self-care deficit and staff were to provide assistance with showers twice a week. On 01/22/24 at 10:06 A.M., interview with Resident #50's Representative revealed concerns with personal hygiene not being completed on resident. Review of Resident #50's shower task sheets for bathing revealed resident prefers showers on Fridays. The task sheet for December 2023 revealed Resident #50 had refused a shower on 12/01/23, and 12/08/23. The shower task sheet revealed the shower was non- applicable on 12/15/23, 12/22/23 and 12/29/23. The shower task sheet for January of 2024 revealed resident's showers were non-applicable for 01/05/24, and 01/19/24. On 01/12/24 resident was marked refused on the shower sheet. Overall review of the shower sheets for November 2023, December 2023 and January 2024 revealed the last time Resident #50's had been washed was on 11/10/23 when a bed bath had been given. On 01/25/24 at 11:04 A.M., interview with STNA #604 verified non applicable on the shower sheet meant the shower was not given. STNA #604 reported the shower is usually not given because they do not have enough staff to give the shower. STNA #604 verified Resident #50 did not refuse showers for her. Review of the policy titled Activities of Daily Living, dated 12/11/18 stated the resident will receive assistance as needed to complete ADLs. Any changes in the ability to perform ADLs will be documented and reported to the nurse. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365085 If continuation sheet Page 11 of 22 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 01/25/2024 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, interview, record review and review of the facility policy, the facility failed to ensure Resident #2 was safely positioned while in bed, in a manner to prevent the resident from falling out of bed during personal care provided by staff. This affected one resident (Resident #2) of three residents reviewed for falls. The facility census was 118. Findings include: Record review for Resident #2 revealed an admission date of 12/18/16. Diagnosis included muscle weakness, need for assistants with personal care, chronic pain syndrome, and morbid severe obesity. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 required extensive assistants of two staff for bed mobility. Review of the most recent Quarterly MDS dated [DATE] revealed Resident #2 was cognitively intact. Resident #2 had an impairment to one side of the upper extremity and used a wheelchair. Resident #2 was always incontinent of bowel and bladder. Resident #2 was dependent for toileting and required substantial maximum assistant with personal hygiene and rolling left and right in bed. Resident #2 was unable to stand. Resident #2 was debilitated with cardiorespiratory conditions. Resident #2 had no falls since admission. Review of the care plan for Resident #2 dated 01/15/24 revealed Resident #2 had a self care and mobility deficit related to chronic conditions, morbid obesity, cardiac disease, respiratory disease, anxiety and depression. Interventions included Resident #2 required assistance with frequent repositioning each day and used quarter side rail to aid herself with bed mobility. Resident #2 was at risk for falls, was non-weight bearing, and non-ambulatory. Interventions included to monitor for good body alignment each shift, reposition as needed to keep centered and balanced well in chair and bed. The care plan did not identify how many people were needed to reposition the resident in bed. Record review of the progress note for Resident #2 dated 01/19/24 at 2:57 A.M. completed by Registered Nurse (RN) #347 included State Tested Nursing Assistant (STNA) was changing resident when resident stated that her legs were starting to slide and STNA then went to other side of bed. Resident's top of foot and ankle noted on floor. STNA then assisted with lowering her to the floor. Resident complained of sharp pain to the right lower extremity. Visible lump noted to the lateral aspect. Resident was assisted to bed by three nurses and three STNA's. The physician was notified and received orders to send the resident to the emergency room. Record review of the progress note for Resident #2 dated 01/19/24 at 6:52 P.M. completed by RN #538 included Resident #2 returned to the facility from the hospital. Per hospital records, Resident #2 had no fractures. Review of the electronic medical record documentation completed by STNA's for Resident #2 revealed on 01/19/24, under the bed mobility tab, Resident #2 required extensive assistants for bed mobility, staff provide weight bearing support. Interview and observation on 01/22/24 at 10:51 A.M. with Resident #2 revealed the previous week she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365085 If continuation sheet Page 12 of 22 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 01/25/2024 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 was pushed out of bed by an STNA. Resident #2 revealed it was in the middle of the night, she was incontinent of urine. The STNA came in to change her, and found she needed her sheets changed too. Resident #2 revealed while the STNA was changing her sheets, she kept pushing her over to the edge of the bed. Resident #2 revealed she kept telling the STNA she was on the edge of the bed, but the STNA kept pushing her on her back from the opposite side of the bed until she fell out of bed. Resident #2 revealed there were supposed to be two staff members when turning her in bed, but on this night, there was only one. Resident #2 revealed she really hurt her right leg and required her pain medication to be increased due to the pain in her right leg from the fall. Observation revealed Resident #2 was in a bariatric bed with a quarter rail. Resident #2 had a large, raised hematoma on the front of her right lower leg. Interview on 01/24/24 at 10:15 A.M. with RN #347 revealed Resident #2 only required one STNA to provide care including repositioning while in bed. RN #347 revealed while turning Resident #2 in bed, the STNA rocks Resident #2 back and forth to get momentum then rolls Resident #2 to her side with assistants from the STNA. RN #347 revealed Resident #2 then holds onto the rail while the STNA cleans her backside. RN #347 confirmed she was the charge nurse the night Resident #2 fell out of bed. RN #347 revealed STNA #347 was assisting Resident #2 with care when STNA #347 reported when she rolled Resident #2 (from the opposite side of the bed) her feet went off the bed, Resident #2's right leg was bracing the fall and STNA #347 went over and assisted her to lay down on the floor. Interview on 01/24/24 at 11:34 A.M. with Physical Therapist (PT) #310 revealed the therapy department had evaluated and treated Resident #2 for bilateral shoulder pain prior to the fall on 12/19/23. PT #310 revealed the therapy department never evaluated Resident #2 for bed mobility because she was in a bariatric bed and there was plenty of room as long as she was kept centered. PT #310 revealed if Resident #2 was in a regular sized bed, therapy would have had to evaluate her for bed mobility because she would have been on the edge of the bed, Resident #2's lower extremities were the weakest part of her body and once she was on the edge of the bed she would not have the strength to prevent a fall from bed if she began falling. Phone interview on 01/24/24 at 12:16 P.M. with STNA #347 confirmed she worked on night shift and on 01/19/24 and she was Resident #2's assigned STNA. STNA #347 revealed on 01/19/24 she went in to change Resident #2. Resident #2 required a full bed change because her sheets were also wet. Once she washed Resident #2 up, she rolled Resident #2 to her left side, (standing on the opposite side of the bed) using the bed pad to assist her to roll. STNA #347 revealed once Resident #2 gets rolling she can assist more holding onto the rail. Resident #2 grabbed the rail with her left arm. STNA #347 revealed she then washed her backside then began removing the sheet under Resident #2. STNA #347 revealed Resident #2 was lying on her left side on the edge of the bed holding the quarter side rail. STNA #347 revealed she was on the opposite side of the bed. STNA #347 revealed she tugged the sheet to remove it from under Resident #2 and once she tugged the sheet under Resident #2 it moved her, Resident #2, closer to the edge of the bed, she seen Resident #2's legs start to go off the bed, Resident #2 was saying she felt her legs sliding, they are sliding but it was too late, her legs went out first, it happened so fast. STNA #347 revealed by the time she got over to Resident #2, her legs were on the ground, and she began yelling for the nurses. STNA #347 confirmed Resident #2 did not have the strength to reposition herself in bed and revealed she needed two people to assist Resident #2 with repositioning in bed. Interview on 01/24/23 at 2:49 P.M. with STNA #540 confirmed she worked frequently with Resident #2. Prior to Resident #2's fall on 01/19/24, Resident #2 only required one person to assist with incontinence care as long as she was always kept in the center of the bed, it was important to keep her in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365085 If continuation sheet Page 13 of 22 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 01/25/2024 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 the center of the bed to prevent her from falling out of bed. Resident #2 was unable to reposition herself and required the assistants to reposition in bed. If Resident #2 required her sheets to be change, she would need two assistants because Resident #2 was so large and would need to be rolled more to the edge of the bed to change the sheets. Interview on 01/24/24 at 3:23 P.M. with DON confirmed Resident #2's care plan prior to 01/19/23 when Resident #2 fell out of bed, did not define how many people was to assist Resident #2 with incontinence care or changing linen while in bed. Review of the facility policy titled, Fall Management revised 09/22/23 revealed the facility will assess the resident upon admission/readmission, quarterly, with change in condition, and will identify appropriate interventions to minimize the risks of injury related to falls. Each resident receives adequate supervision and assistants devices to prevent accidents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365085 If continuation sheet Page 14 of 22 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 01/25/2024 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #49 revealed an admission date of 08/11/20. Diagnoses included but were not limited to bipolar disorder, schizophrenia, major depressive disorder, anxiety disorder. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #49 was cognitively intact and required moderate assistance of one for transfer, dressing, bathing and toileting and supervision for personal hygiene. Resident #49 was noted to be taking routine antipsychotic, antidepressant, opioid and hypoglycemic medications. No behaviors were indicated. Review of the physician orders for Resident #49 dated 12/30/23 revealed she was prescribed Lamictal (an anticonvulsant) 25 milligrams (mg) two tablets at bedtime for diagnosis of bipolar disorder, Venlafaxine Hydrochloride extended release (an antidepressant also known as Effexor) 150 mg capsule one time a day with one 75 mg capsule to make a total of 225 mg daily for diagnosis of depression, Vraylar (an antipsychotic) 4.5 mg capsule at bedtime for bipolar disorder, Hydroxyzine Pamoate ( an antihistamine also known as Vistaril ) 25 mg capsule twice daily and Hydroxyzine Pamoate 100 mg capsule at bedtime for anxiety. Review of the pharmacy consultation report dated 04/21/23 for Resident #49 revealed recommendations that Vraylar 4.5 mg at bedtime, Lamictal 50 mg at bedtime, Hydroxyzine Pamoate 25 mg twice daily, Hydroxyzine Pamoate 50 mg at nighttime for anxiety, and Effexor XR 187.5 mg once daily be considered for gradual dose reduction. Certified Nurse Practitioner #801 noted it was reviewed on 04/26/23 stating she sees her own psychiatrist. Review of the pharmacy consultation report dated 09/11/23 for Resident #49 revealed recommendations to discontinue Zyrtec 10 milligrams daily due to receiving two routine antihistamines: Cetirizine (Zyrtec) and Hydroxyzine Pamoate (Vistaril) 25 milligrams twice daily and 100 milligrams at bedtime. Undated response from CNP #801 stated Cetirizine (Zyrtec) 10 mg was used for allergies and Hydroxyzine Pamoate 25 mg twice daily and 100 mg at bedtime is used for anxiety per psych. Review of the nursing progress note dated 01/03/24 timed at 12:18 revealed Zyrtec 10 mg was discontinued. Interview on 01/25/24 at 2:35 P.M. with the Director of Nursing (DON) confirmed the facility was not able to provide evidence the facility followed up with pharmacy recommendations dated 04/21/23 and 09/11/23 with Resident #49's psychiatrist. Review of the facility policy last reviewed on 08/17/23 called; LTC Facility's Pharmacy Services and Procedures Manual revealed the attending physician should document in the resident's health record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. Based on record review and interview, the facility failed to ensure pharmacy recommendations were addressed by the physician in a timely manner. This affected two residents (Residents #49 and Resident #50) of five residents reviewed for unnecessary medications. The facility census was 118. Findings include: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365085 If continuation sheet Page 15 of 22 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 01/25/2024 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 1. Resident #50's medical record revealed an admission date of 08/25/20 with diagnosis including: traumatic brain injury, hemiplegia affecting left dominant side, dementia with mood disorder, and anxiety disorder. Resident #50 was receiving anti-psychotic medication and had behavioral symptoms such as yelling out, outbursts and exit seeking. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/14/24, revealed the resident had severe impaired cognition, and felt depressed. Review of the monthly pharmacy recommendations to the attending physician dated 12/12/23, revealed a recommendation for a gradual dose reduction of Tramadol (opioid pain medication). The record revealed the physician was notified on 01/24/24 by Licensed Practical Nurse (LPN) #511 of the pharmacist recommendation to taper and discontinue the Tramadol. On 01/25/24 at 10:46 A.M LPN #511 verified the first time the physician was notified of the 12/12/23 recommendation was on 01/24/24. LPN #511 was unaware of a timeline to notify the physician of a pharmacist recommendation. Review of Resident #50's medical record review on 01/24/24 revealed no documentation from the physician addressing the pharmacy recommendation from 12/12/23. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365085 If continuation sheet Page 16 of 22 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 01/25/2024 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #36 revealed an admission date of 12/23/23. Diagnoses included schizoaffective disorder, anxiety, depression, and psychotic disturbance. Review of the baseline assessment dated [DATE] for Resident #36 revealed she had impaired cognition and received an antidepressant and antipsychotic medication. Review of the base line plan of care dated 12/23/23 revealed the resident uses antipsychotic medications. Intervention included to observe and report any adverse reaction related to the medication. Review of the January physician order revealed orders for Sertraline (antidepressant medication) 25 milligram (mg) daily for depression and Seroquel (antipsychotic medication) 25mg two times a day for anxiety. Review of Resident #36's medical record revealed no evidence of behavior monitoring or the monitoring of medications for efficacy and adverse consequences. Interview on 01/25/24 at 10:19 A.M. with the Register Nurse (RN) #347, the unit manager, verified there was no monitoring for behaviors or monitoring of medications for efficacy and adverse consequences. Based on record review and interview the facility failed to ensure a stop date was added for Resident #99's as needed psychotropic medication, and failed to ensure behavior monitoring was completed for Resident #36 while receiving psychotropic medications. This affected two residents (#36 and #99) of five residents reviewed for unnecessary medications. Findings include: 1. Review of the medical record for Resident #99 revealed an admission date of 10/05/23. Diagnoses included dementia with agitation, dementia with mood disturbance, insomnia, and depression. Review of the Physician orders for January 2024 revealed an active order for Lorazepam (anti-anxiety medication) tablet 0.5 milligrams (mg) to give one tablet by mouth as needed (PRN) for anxiety/restlessness related to dementia with mood disturbance. May give once daily with a start date of 08/31/23 and no end date. Interview on 01/25/24 at 9:19 A.M. with the Director of Nursing (DON) verified the as needed Lorazepam physician order for Resident #99 did not have a stop date. Review of the facility policy titled Psychotropic Medication Use revised 10/24/23 revealed PRN psychotropic medications should be ordered for no more than 14 days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365085 If continuation sheet Page 17 of 22 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 01/25/2024 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 - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and interview the facility failed to maintain a clean and sanitary kitchen and nursing unit refrigerator. This had to the potential to affect 116 of 118 residents in the facility as Residents #4 and #425 received nothing by mouth. The facility census was 118. Findings include: During the initial tour of the kitchen on 01/22/24 from 9:09 A.M. to 9:45 A.M. with Dietary Manager (DM) #361 revealed the outside door of the reach in cooler had various food stains/smears and the inside of the cooler's bottom shelf had various food crumbs and debris. On the counter where the coffee machine was located were dried coffee stains on the counter and the along the side of the coffee maker. The floor by the oven was dirty with dried food and small bits of paper on the floor. Interview on 01/22/24 between 9:09 A.M. to 9:45 A.M. with DM #361 verified the above identified findings. Observation on 01/23/24 at 10:38 A.M. of the nursing unit refrigerators located on the House 2 unit revealed brownish food stain in butter dish, dried brownish food splatter along the inside refrigerator door, and the bottom inside shelf had various food splatter. Interview at this time with DM #361 verified observation and stated housekeeping was responsible for cleaning the refrigerator. Review of a list of facility resident diets revealed Residents #4 and #425 received nothing by mouth. Reviewed policy Sanitation and Maintenance revised 04/26/23 revealed food and nutrition services associates are trained in proper use, cleaning, and sanitation of all equipment. Physical facilities are cleaned as often as necessary to keep them clean. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365085 If continuation sheet Page 18 of 22 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 01/25/2024 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 0814 Dispose of garbage and refuse properly. Level of Harm - Potential for minimal harm Based on observations and interview, the facility failed to maintain a clean and sanitary area around the trash compactor. This had the potential to affect all 118 residents in the facility. Residents Affected - Many Findings include: Observation on 01/22/24 at 9:30 A.M. of the outside trash compactor revealed on the ground behind the compactor was a moderate amount of various trash and debris including three trash bags of trash, empty cans, and containers. Interview at this time with Dietary Manager (DM) #361 verified the observations and stated trash pickup was on Mondays and Fridays and the trash area was cleaned weekly by the maintenance department. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365085 If continuation sheet Page 19 of 22 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 01/25/2024 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, closed record review, and review of the facility policy, the facility failed to notify Hospice Services and collaborate continuation of care and treatment after discharge for Resident #120. This affected one resident (Resident #120) of three residents reviewed for notification. The facility census was 118. Findings include: Record review for Resident #120 revealed an admission date of 12/21/23 and a discharge date of 12/26/23. Diagnoses included Alzheimer's disease and hypertensive chronic kidney disease. Record review of the admission assessment dated [DATE] at 6:40 P.M. completed by Registered Nurse (RN) #538 revealed Resident #120 was admitted for Hospice Respite stay. Record review of the care plan dated 12/25/23 revealed Resident #120 had a break in skin integrity. The resident had a skin tear related to fragile skin, decreased intake and was on hospice services. Record review of the physician orders dated 12/25/23 for Resident #120 revealed an order for wound care to the right-hand skin tear. Clean with normal saline, apply alginate and foam dressing and change every three days and as needed. Additional orders dated 12/25/23 revealed wound care to the right elbow skin tear. Clean with normal saline, apply foam dressing and change every three days and as needed. Record review of the progress note dated 12/25/23 at 1:05 P.M. completed by RN #538 revealed the nurse was alerted that (Resident #120) sustained two skin tears during a shower. (Resident #120) was noted to have skin tears to the right elbow and the back of her right hand, both noted to have a small amount of serosanguineous drainage. (Resident #120) was noted to have very fragile skin, staff noted (Resident #120) brushed arm/hand on the shower chair. Areas were assessed cleansed, and dressings were applied. The skin tear to the right hand measured three centimeters (cm) in length by 1.5 cm in width by 0.1 cm in depth. The area to the right elbow measured 7.6 cm in length by 3.4 cm in width by 0.1 cm in depth. Record review of the progress note for Resident #120 dated 12/26/23 at 1:24 P.M. completed by RN #347 revealed discharge paperwork reviewed with Emergecny Medical Technicians (EMT's). All medications including narcotics given to EMT. Resident #120 was discharged via cot. Record review of the Discharge Return Not Anticipated Minimum Data Set (MDS) dated [DATE] revealed Resident #120 was rarely or never understood, dependent on staff for shower/bathing, upper and lower body dressing, personal hygiene, and substantial/max assist with rolling left to right. Record review of the medical records for Resident #120 from 12/25/23 through 12/26/23 revealed there was no documentation of Hospice Services being notified of the new wounds or treatment orders to Resident #120's right hand or elbow. Interview on 01/24/24 at 3:38 P.M. with DON confirmed Resident #120 was admitted to the facility on [DATE] for a Hospice Respite stay with a planned discharge of 12/26/23. Resident #120's stay was to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365085 If continuation sheet Page 20 of 22 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 01/25/2024 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 0849 Level of Harm - Minimal harm or potential for actual harm be from 12/21/23 through 12/26/23 then the resident was to be discharged back home with family with continued hospice services. The DON confirmed Resident #120 obtained skin tears to the right arm/hand on 12/25/23. The DON confirmed the injuries required continued treatments after discharge and there was no documentation or evidence the hospice provider was notified of the injuries prior to discharge home. The DON revealed the nurses were expected to notify the hospice nurse of changes and condition. Residents Affected - Few Interview on 01/25/24 at 2:10 P.M. with Hospice RN #805 revealed she provided continuum of care for Resident #120 while at home and during Resident #120's respite stay at the facility. Hospice RN #805 confirmed she was not notified by the facility of Resident #120's skin tears that occurred 12/25/23. Hospice RN #805 revealed the facility should have notified her of any change in condition for Resident #120 while at the facility and prior to discharge. Record review of the facility policy titled, Hospice Coordination of Care reviewed 08/23/23 revealed the facility must have a communication process between the Long-Term Care Facility (LTC) and the hospice provider to ensure that the needs of the resident are addressed and met 24 hours a day. The LTC facility immediately notifies the hospice about the following which included a significant change in the resident's physical, mental, social status and clinical complications that suggest a need to alter the plan of care. This deficiency represents non-compliance investigated under Complaint Number OH00149559. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365085 If continuation sheet Page 21 of 22 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 01/25/2024 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 observation, interview, and record review the facility failed to perform proper hand hygiene during medication administration. This affected two residents (Resident #111 and Resident #97) of four residents observed for medication administration. Residents Affected - Few Findings Include: Review of the medical record for Resident #111 revealed an admission date of 11/10/23. Diagnoses included fracture of lumbar vertebra, schizophrenia, chronic kidney disease and muscle weakness. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment for Resident #111, dated 12/08/23, revealed the resident had impaired cognition and received antipsychotic. Review of the January physicians order revealed the orders for Amlodipine 10 milligrams (mg) used to treat hypertension, Carvedilol 3.125 mg used to treat hypertension, and Fluphenazine 10 mg an antipsychotic used to treat schizophrenia, Review of the medical record for Resident #97 revealed an admission date of 02/02/24. Diagnoses included Alzheimer's Disease, hypertension, and insomnia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment for Resident #97, dated 12/08/23, revealed the resident had memory problems and received an antidepressant and a diuretic medication. Review of the January physicians order revealed the orders for Divalproex Sprinkles oral capsule 125 mg, Lasix 20 mg a diuretic, Seroquel 50 mg an antipsychotic. Observation of medication administration on 01/23/24 at 7:50 A.M. with Licensed Practical Nurse (LPN) #479 revealed she did not wash or sanitize her hands and began preparing Resident #111's morning medications. LPN #479 prepared and administered the morning medications to Resident #111. LPN #479 did not wash or sanitize her hands and continued her medication pass and started preparing Resident #97's morning medications. LPN #479 put Lasix and Seroquel into one cup and then put two Divalproex capsules into another cup. LPN #479 sanitized her hands and donned gloves; she opened two Divalproex capsules and poured them back into the medication cup and mixed them with pudding. LPN #479 administered all Resident #97's medications left the room and sanitized her hands. Interview with LPN #479, 01/23/24 at 8:10 AM verified she did not wash her hands prior to preparing Resident #111 medications and prior to preparing Resident #97's medications. LPN #479 stated she sanitized her hand prior to opening the Divalproex capsules. Review of the policy titled Hand hygiene, revised 06/13/23 stated associates will perform hand hygiene before and after contact with a resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365085 If continuation sheet Page 22 of 22