Health inspection·October 1, 2024

F 0689 Level of Harm - Actual harm Residents Affected - Few Review of a physician order dated 08/20/24 revealed, while in bed, ensure there is a mat next to the bed. Review of the September 2024 physician orders revealed Resident #280 required two-person assistance for transfers. Additional review revealed the following orders: on 09/16/24 at 2:45 P.M. an x-ray of the right shoulder due to a fall with pain, 09/16/24 at 11:00 P.M. ice pack to right shoulder four times daily for 20 minutes, 09/17/24 at 6:00 P.M. air mattress with bolsters and 09/18/24 at 6:00 A.M. apply lidocaine patch to right clavicle and ribs daily. Review of an undated facility fall investigation revealed on 09/15/24 at 11:00 P.M., Resident #280 was calling for help and the nurse found the resident lying face down on the floor. Resident #280's head was turned towards the door, with her right arm positioned under her chest. The resident's lower extremities were tangled in the bedding, slightly elevated on the bed. The resident's bed rail was in the up position. Resident #280 stated she was attempting to turn and then rolled off the bed. Initial nursing assessment, while the resident remained on the floor, revealed the resident complained of pain to the right arm with no signs of deformity. A head-to-toe assessment was completed once the resident was put back in bed. Pain was noted to the right arm (rated) on a scale of three out of ten (with ten being the most severe pain). Resident #280 had limited range of motion to the bilateral upper extremities. The investigation indicated there were injuries to the top of the scalp and right upper arm. The investigation indicated the side rail was up but did not indicate the fall mat was in place at the time of the fall. It was noted Resident #280 had clutter in the bed and was too close to the right rail. The supervisor and hospice were notified. Further review revealed family was notified on 09/16/24 at 12:30 P.M. and the attending physician was notified on 09/17/24 at 7:15 A.M. Review of a nursing progress note dated 09/16/24 at 1:15 A.M. revealed an assessment was completed and Resident #280 had complaints of right arm pain with no signs of deformity. The resident denied neck pain on palpation. Resident #280 denied shortness of breath. Lungs were equal and clear bilaterally and abdomen was soft and non-tender. Resident #280 had limited ROM to upper and lower extremities, which was normal. Resident placed back in bed. Supervisor and hospice notified. The progress note did not indicate the assessment was completed as a result of Resident #280 falling from bed, nor did it include any additional details related to the fall. Review of a hospice e-mail correspondence dated 09/16/24 at 1:34 A.M. revealed the hospice on-call nurse communicated to the hospice team that she received a call from the facility reporting Resident #280 was turning in bed and had a fall. The fall was unwitnessed and there were no apparent injuries. The facility nurse was advised to continue neurological checks and report any concerns to hospice. Review of a hospice summary visit, dated 09/16/24, revealed Hospice Nurse Practitioner (HNP) #949 assessed Resident #280 with the chief complaint being a mechanical fall with injury to the right shoulder. Resident #280 was unable to move her right arm and complained of severe pain. The assessment indicated the resident's right shoulder had limited range of motion, was ecchymosis (bruising), swollen and tender with minimal touch. The note further stated the attending physician's nurse practitioner (NP), and the resident's daughter were notified. Review of the radiology imaging report dated 09/16/24 at 5:28 P.M. revealed Resident #280 had a fracture of the right clavicle and a fracture at the sixth and seventh ribs. Review of a late entry progress note, dated 09/19/24, revealed Resident #280 had one to two falls in the past three months. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365094 If continuation sheet Page 2 of 6 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 365094 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE King David Post Acute Nursing & Rehabilitation LLC 27100 Cedar Rd Beachwood, OH 44122 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Actual harm Residents Affected - Few Interview on 09/24/24 at 1:04 P.M. with Resident #280's daughter revealed she initially learned of the resident's fall the morning of 09/16/24, when hospice staff left her a voice mail indicating they ordered an x-ray due to her injuries. Resident #280's daughter stated the facility did not notify her of the fall until 09/16/24 at approximately 10:00 P.M., even though the fall had occurred the night prior. Resident #280's daughter confirmed the resident sustained a right clavicle fracture and fracture at the sixth and seventh ribs. The resident's daughter stated Resident #280 subsequently discharged from the facility on 09/19/24 to the hospice's inpatient facility. Interview on 09/25/24 at 11:00 A.M. with Hospice Case Manager (HCM) #498 revealed the facility nurse reported Resident #280's fall on the night it occurred to the on-call hospice nurse. HCM #498 stated the facility nurse indicated there were no apparent injuries at the time of the notification. The on-call hospice nurse sent out an email to the hospice team notifying them of a fall with no injuries and to follow up within 24 hours. HCM #498 stated if the facility nurse would have notified them of Resident #280's pain and/or injury, a hospice physician would have been notified at that time of the call for further orders. HCM #498 stated HNP #949 was unaware of the injury until she visited the resident the next day, 09/16/24, at approximately 10:00 A.M. HCM #498 stated an x-ray was ordered and an air mattress with bolsters was implemented. Interview on 09/25/24 at 2:59 P.M. with State Tested Nursing Assistant (STNA) #931 revealed she was assigned to provide care for Resident #280 on the night of her fall. STNA #931 stated she checked on the resident around 10:00 P.M. and the resident was sleeping. STNA #931 stated the nurse found the resident on the floor around midnight. STNA #931 stated she went to the resident's room and saw her on the floor, with her face positioned toward the door, her abdomen on the floor and her hips were turned to the side. STNA #931 stated Resident #280 had bruising to her right arm. STNA #931 verified there was no fall mat in place and further stated she was unaware of the fall mat intervention and there was no mat in the resident's room. Interview on 09/25/24 at 5:15 P.M. with STNA #829 revealed on the night Resident #280 fell, he went into the room and found the resident lying on the floor on her stomach. STNA #829 stated the resident's hips and torso were sideways and her right arm was bent at the elbow behind her hips. STNA #829 stated the resident's lower extremities were tangled in the bedding. STNA #829 stated when Resident #280 lifted her right arm, she had pain and there was bruising to her chest on the right side. STNA #829 verified there was no fall mat in Resident #280's room. Interview on 09/26/24 at 9:12 A.M. with HNP #949 revealed she received notification that Resident #280 had a fall with no injuries. HNP #949 stated she did not typically follow-up on a fall with no injuries, but stated she happened to in this case. HNP #949 stated she visited Resident #280 the morning of 09/16/24 and was surprised to see the resident had pain, bruising and swelling of the right shoulder. HNP #949 ordered an x-ray of the right shoulder and a sling. HNP #949 stated she notified the family of the fall and discussed treatment options. Interview on 09/26/24 at 1:50 PM with Registered Nurse (RN) #930 revealed she was off at the time of the resident's fall and could not verify if all fall interventions, including the fall mat, were in place. RN #930 stated the interventions in place would have been filled out on the fall investigation by the nurse on duty. Interview on 09/26/24 at 2:45 P.M. with the Director of Nursing (DON) revealed she could not verify if Resident #280's fall mat was in place at the time of the fall and stated she would have to investigate to determine that. The DON declined to review the fall investigation with the surveyor and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365094 If continuation sheet Page 3 of 6 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 365094 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE King David Post Acute Nursing & Rehabilitation LLC 27100 Cedar Rd Beachwood, OH 44122 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 stated the information was documented in the investigation. The DON stated it was her opinion the physician and family were notified timely. Level of Harm - Actual harm Residents Affected - Few Review of the facility policy titled Change in a Resident's Condition or Status, revised February 2021, revealed the facility promptly notified the resident, his or attending physician and the resident representative of change in the resident's medical/mental condition. Except in medical emergencies, notification would be made within twenty-four hours of a change occurring in the resident's condition. Review of the facility policy titled Falls and Fall Risk, Managing, revised March 2018, revealed in conjunction with the attending physician, staff would identify and implement relevant interventions to minimize serious consequences of falling. This deficiency represents noncompliance investigated under Master Complaint Number OH00158189 and Complaint Number OH00158027. This deficiency is an example of continued noncompliance from the survey completed 09/12/24. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365094 If continuation sheet Page 4 of 6 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 365094 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE King David Post Acute Nursing & Rehabilitation LLC 27100 Cedar Rd Beachwood, OH 44122 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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, staff interview and review of facility policy, the facility failed to ensure the nursing unit kitchenettes were maintained in a clean and sanitary manner. This had the potential to affect all residents except two (#105 and #193) who received nothing by mouth and 34 residents (#2, #8, #24, #30, #40, #46, #54, #64, #76, #78, #111, #116, #131, #132, #136, #138, #140, #150, #154, #155, #159, #177, #185, #195, #216, #221, #222, #225, #226, #232, #249, #255, #265 and #269) who resided on the [NAME] nursing unit. The facility census was 276. Findings include: Observations on 09/24/25 from 10:49 A.M. to 11:36 P.M. of the nursing unit kitchenettes with Dietary Manager (DM) #597 revealed the following: • Euclid pavilion 1 nursing unit kitchenette had food spillage on the bottom shelf of the refrigerator. The meat and dairy microwaves were dirty with various dried food splatter inside. Further observation revealed food crumbs on the counters and on the two toasters. • Euclid pavilion 2 nursing unit kitchenette's dairy and meat microwaves had various dried food splatter inside and accumulated food crumbs under the dairy microwave. Continued observation revealed various dried, dark brown splatter behind the coffee and ice/water machines. Lastly, food crumbs were observed in the condiment container. • Fairmont nursing unit kitchenette had crumbs on the counter around the toaster. Further observation revealed the refrigerator shelves had a dried, brown colored substance/spots throughout and cardboard was stuck to the bottom shelf. There was a clear container with three bags of brown sugar, with two of the bags opened. [NAME] sugar was spilled inside the plastic container and on the shelf around the container. Observation of a second refrigerator in the kitchenette revealed a dried, dark brown substance on the shelves. • Weinburg nursing unit kitchenette refrigerator had a plastic container with half of a wrap sandwich, which was not labeled or dated and a Styrofoam cup of grapes, not labeled or dated. Continued observation revealed the bottom of the refrigerator had various spots of dried substances and a dried, white spillage down the inside wall. The dairy microwave had dried flood splatter inside and under it was various debris, including a straw, margarine container and dried food splatter. The meat microwave had various dried food splatter inside. • (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365094 If continuation sheet Page 5 of 6 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 365094 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE King David Post Acute Nursing & Rehabilitation LLC 27100 Cedar Rd Beachwood, OH 44122 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Shaker nursing unit kitchenette refrigerator had a dried, dark brown substance on the shelves. The sink was dirty, with various splatter, and an unshelled hard boiled egg was laying in the sink. The counter next to the coffee maker had dried coffee stains and there was dried coffee spillage down the front of the cabinet and drawers near the coffee maker. On top of the coffee maker was dried coffee splatters and coffee grounds. On the counter, next to the sink, was a large blue bin with melting ice and two cups inside. At this time, DM #597 stated the bin was to go back to the kitchen to be refilled with ice for lunch service and should not be used. Continued observation revealed next to the blue bin, and in front of the toaster, was a piece of brown paper towel with two opened margarine containers and a spoon with margarine on it, a balled up clothing protector and a white balled up linen. • Beachwood nursing unit kitchenette meat microwave had a paper towel and various dried food splatter and crumbs inside. The dairy microwave had dried food splatter inside. • Heights 2 nursing unit kitchenette meat microwave had dried food crumbs inside. • Heights 1 nursing unit kitchenette refrigerator had a dark brown substance and food crumbs on the shelves and white substance on the inside bottom. The dairy microwave had various dried food splatter and the counter, near the coffee maker, had dried coffee stains. • [NAME] nursing unit kitchenette had no observed concerns. Interview on 09/23/24 between 10:49 A.M. and 11:36 A.M., during observations of the nursing unit kitchenettes, with DM #597 verified the above findings. DM #597 stated dietary staff stocked the kitchenettes, but nursing staff were responsible for cleaning them. Review of the facility policy titled Cleaning and Disinfection of Environmental Surfaces, revised August 2019, revealed housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled. Environmental surfaces will be disinfected (or cleaned) on a regular basis (e.g., daily, three times per week) and when surfaces are visibly soiled. This deficiency represents noncompliance investigated under Complaint Number OH00157980. This deficiency is an example of continued noncompliance from the survey dated 09/12/24. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365094 If continuation sheet Page 6 of 6