Health inspection·October 15, 2025

F 0678 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and the resident's head did not move from its position. A four-lead electrocardiogram (ECG) was taken and asystole (absence of heart rhythm which is incompatible with life). Resident #271's time of death was pronounced by EMS after collaboration with an outside emergency physician at 9:10 P.M. Review of Certified Nursing Assistant (CNA) #510's witness statement dated 09/30/25 stated about 8:10 P.M. she and CNA #509 proceeded to take Resident #271, who appeared to be sleeping, from the dining room to his room. Once they got Resident #271 into his room, they noticed his fingertips were blue, he was cold to touch and felt slightly hard. Following checking vitals, CNAs #509 and #510 ran to find RN #514. Upon RN #514 returning to the room with them, RN #514 started crying and panicking and stated, I don't do well with dead people. CNA #510 asked RN #514 if Resident #271 was a full code and RN #514 left the room to go check. About two minutes later, RN #514 returned and screamed put him in bed, we gotta do chest compressions. RN #514 asked CNAs #509 and #510 if they knew CPR and they said no. CNAs #509 and #510 put Resident #271 in bed and CNA #517 called EMS. RN #514 called RN #515 and screamed come over here and do chest compressions. CNA #510 stated Resident #271 did not have anything hard under his back. When RN #515 arrived, chest compressions were initiated until EMS arrived.Review of the witness statement from RN #515 dated 09/28/25 revealed while working on another unit, Unit Manager #516 received a phone call stating a code was called on the Fairmont unit. RN #515 and Unit Manager #516 rushed to Resident #271's room and found Resident #271 not breathing, without spontaneous movement of the chest, no audible sounds upon auscultation, no circulation, and eyes were fixed and dilated with no reaction to light. There was also no response to painful stimuli such as pressure applied to the supraorbital nerve. Code status was verified and RN #515 initiated CPR while paramedics were being called. Resident #271 was pronounced dead at 9:12 P.M.Review of the undated witness statement for Licensed Practical Nurse (LPN) #508 revealed Resident #271 refused medications three times when offered earlier in the day. Resident #271 only took two bites of lunch and refused to eat dinner on 09/27/25. LPN #508 stated Resident #271 was last seen in the dining room at the end of shift.Review of the 09/28/25 witness statement written by LPN #519 revealed she checked Resident #271 between 6:00 P.M. and 6:30 P.M. and the resident was noted to have his eyes open.Interview on 10/08/25 at 11:42 A.M. with LPN #508 revealed she worked the day shift of 09/27/25 and attempted to feed Resident #271 lunch and he only took a couple bites. Between 3:00 and 3:30 P.M., she rounded and noticed Resident #271 was sitting on the side of his bed and assisted the aide to change him. LPN #508 later attempted to feed Resident #271dinner but he refused. LPN #508 stated they kept Resident #271 near the nurses' station for safety, and she and the other nurse had commented on the color of his eyes just prior to leaving her shift around 6:30 P.M. LPN #508 stated she did not notice any concerns for Resident prior to leaving her shift at approximately 8:30 P.M.Interview on 10/08/25 at 11:57 A.M. with CNA #509 revealed he worked on 09/27/25 from 7:00 A.M. till almost 10:00 P.M. Around 7:30 P.M., CNA #509 left the unit with CNA #510 to get approval to work overtime on the unit. CNA #509 stated they came back around 8:00 P.M. and were both working on the hall Resident #271 resided on. Around 8:10 P.M., they proceeded to take Resident #271, who was in the dining room and appeared to be sleeping, to his room for bed. Once they got Resident #271 into his room, they realized he was unresponsive. Both CNAs #509 and #510 checked for a pulse. CNA #510 stated they noticed Resident #271's fingers were blue. CNAs #509 and #510 left the room to look for RN #514. Within two minutes they returned to Resident #271's room with RN #514. RN #514 told them to get vitals. CNA #509 stated RN #514 was nervous and stated she did not do well with dead people. CNA #510 told RN #514 to go check Resident #271's code status and she came back with the crash cart within several minutes. CNAs #509 and #510 proceeded to lay Resident #271 down in bed and RN #514 proceeded to call Unit Manager #516 and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365094 If continuation sheet Page 2 of 5 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 10/15/2025 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 0678 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few it was on speaker phone. Shortly thereafter, Unit Manager #516 and RN #515 came to Resident #271's room. RN #515 started to do chest compressions and less than five minutes after, EMS showed up.Interview on 10/08/25 at 12:23 P.M. with CNA #510 revealed around 8:00 P.M., CNA #509 and CNA #510 came back to the Fairmont unit to help cover a call off. Around 8:10 P.M., CNAs #509 and #510 approached Resident #271 in the dining room and told him they were going to get him ready for bed and proceeded to roll his wheelchair back to his room. As they were wheeling Resident #271, they noticed his legs were straight and he appeared unresponsive. CNA #509 checked his wrist and found no pulse. CNA #510 checked his neck and found no pulse and stated his neck was cool and appeared to be slightly hard. CNA #510 stated Resident #271's fingertips appeared to be blue. CNAs #509 and #510 left to find RN #514 and returned to the room with her in less than a minute. RN #514 told CNAs #509 and #510 to get the vitals machine and check his vitals. RN #514 left the room and returned shortly thereafter. She appeared nervous, scared, and stated she did not do well with dead people. CNA #510 asked RN #514 if Resident #271 was a full code and RN #514 left to go check and brought back the crash cart less than a minute or so later. CNAs #509 and #510 laid Resident #271 down in bed and RN #514 called Unit Manager #516. RN #514 asked CNAs #509 and #510 if they were CPR certified and neither of them were currently certified. CNA #510 stated RN #514 did not do chest compressions. When RN #515 arrived, chest compressions were initiated. Another (unnamed) CNA called EMS and was on speaker while RN #514 was explaining the situation. Unit Manager #516 arrived and switched off CPR with RN #514. CNA #510 left to go meet EMS in the lobby and then brought them back to Resident #271's room.Phone interview on 10/08/25 at 4:35 P.M. with RN #514 revealed she saw Resident #271 at the beginning of her shift shortly after 7:00 P.M. from a distance in the dining room but did not approach him as he appeared to be sleeping. CNAs #509 and #510 came to get her around 8:45-8:50 P.M. and stated Resident #271 was unresponsive. When RN #514 arrived at Resident #271's room she noticed he appeared to be sleeping, was noted to be unresponsive, had no pulse and was cyanotic (bluish in color), and had some skin mottling. RN #514 notified Unit Manager #516. RN #514 left the room to go get the crash cart. RN #514 confirmed she did not initiate CPR prior to RN #514 and Unit Manager #516 arriving at the room. RN #514 called 911 and they told her they were already enroute. RN #515 and Unit Manager #516 took turns doing chest compressions until EMS arrived and pronounced Resident #271 deceased at 9:10 P.M.Interview on 10/09/25 at 6:18 A.M. with RN #515 revealed during his night shift on 09/27/25, Unit Manager #516 was on his unit when she received a call from RN #514 stating Resident #271 was unresponsive. RN #515 and Unit Manager #516 both went to Resident #271's room. Unit Manager #516 arrived first and when RN #515 arrived, the crash cart was in the room, and they were setting up the bed for CPR. RN #515 noted Resident #271 was cool but not cold, his body was stiff, and fingertips were cyanotic. RN #515 asked RN #514 why CPR had not been started and RN #514 stated she had to go get the crash cart first. RN #515 stated they arrived at Resident #271's room within three to five minutes after the call was received since it is a big building. RN #515 started CPR immediately after arriving to Resident #271's room and continued until EMS arrived less than 10 minutes later. Interview on 10/09/25 at 6:41 A.M. with Unit Manager #516 revealed she was the Unit Manager the night of 09/27/25. The Fairmont unit was short a nurse and she was assisting to cover. Unit Manager #516 stated she needed to check all the units to make sure staff were covered and arrived at the unit around 8:30 P.M. to count meds with LPN #508 prior to her leaving. Following counting meds, she spoke with RN #514, CNA #509, CNA #510 and another aide about covering since she may need to step off the unit to handle concerns on other units. Around 8:45 P.M., Unit Manager #516 was on the unit RN #515 was working on and received a phone call from RN #514 stating Resident #271 was unresponsive. Unit Manager #516 and RN #515 both (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365094 If continuation sheet Page 3 of 5 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 10/15/2025 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 0678 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few responded to assist within two minutes. Unit Manager #516 stated upon arrival, Resident #271 was noted to be unresponsive, with no pulse or respirations. Resident #271 was cool to the touch and pupils were fixed and CPR had not been started yet. Unit Manager #516 stated she looked up Resident #271's code status and yelled he was a full code to RN #515, who then started CPR. RN #515 and Unit Manager #516 continued compressions until EMS arrived about six minutes later. Unit Manager #516 confirmed when she arrived the crash cart was in the hall outside the room and was unsure why RN #514 had not started CPR. Unit Manager #516 stated typically the protocol would be to check code status, yell for help, and start CPR.Phone interview on 10/09/25 at 11:58 A.M. with CNA #517 revealed around 8:45 P.M., CNAs #509 and #510 told her they thought Resident #271 was deceased and CNA #517 went to Resident #271's room with RN #514 and found Resident #271 unresponsive. RN #514 asked CNAs #509, #510, and #517 if they were CPR certified, and they told her no. CNA #517 stated RN #514 appeared to panic and did not know what to do. RN #514 then called RN #515. RN #514 did not initiate CPR and acted scared of a dead body. When RN #515 arrived a few minutes later, RN #515 initiated CPR.Phone interview on 10/14/25 at 8:11 A.M. with LPN #519 revealed she had discussed the pretty eye color of Resident #271 with LPN #508 and had observed Resident #271 alert in the dining room between 6:00 P.M. and 6:30 P.M.Phone interview on 10/14/25 at 8:40 A.M. with CNA #525 revealed she had last seen Resident #271 alert in the dining room around 7:00 P.M.A follow-up phone interview on 10/14/25 at 9:03 A.M. with CNA #510 revealed she worked from 7:00 A.M. to 3:00 P.M. on Fairmont and was called to another unit until 7:30 P.M. At 7:30 P.M., she went down to see if she could get overtime to assist on the Fairmont unit since there was a staff call off. Around 8:00 P.M., CNA #510 was given permission to help on Fairmont, and she proceeded to go to the unit shortly after 8:00 P.M. and sometime later found Resident #271 unresponsive.Interview on 10/14/25 at 9:08 A.M. with the Regional Clinical Director #499 revealed if a resident is found unresponsive, staff should immediately initiate CPR following confirmation of a full code status.Follow up phone interview on 10/14/25 at 10:09 A.M. with RN #515 confirmed when he arrived at Resident #271's room on 09/27/25, Resident #271 was lying in his bed and there was no board or hard surface underneath him. Resident #271's fingers appeared to be blue, and RN #514 had not initiated CPR. When RN #515 asked why she had not started CPR, RN #514 stated she had gone to get the crash cart and then called Unit Manager #516. RN #515 initiated CPR and continued till EMS arrived.Review of the facility employee Cardiopulmonary Resuscitation (CPR) report printed on 10/09/25 revealed RN # 515's CPR license expired as of 08/01/25.Observation on 10/14/25 at 10:45 A.M. of the cardiopulmonary resuscitation Basic Life Support (CPR BLS) card for RN #515 revealed it was renewed on 10/09/25. Interview at the time of observation with the Assistant Director of Nursing (ADON) confirmed RN #515's CPR certification was expired on 09/27/25 when CPR was performed on Resident #271.Phone interview on 10/15/25 at 7:30 A.M. with Paramedic #520 revealed when he arrived on the scene on 09/27/25, one staff member was doing CPR, and two other staff members were in the room but not assisting. No one was managing Resident #271's airway, no bag or AED were present. The staff member providing compressions was not doing them at the correct rate and a backboard was not present under Resident #271. Paramedic #520 stated he did not recall seeing the crash cart and upon seeing the ineffective CPR being performed, he promptly asked them to stop. Paramedic #520 assessed Resident #271 and found no signs of life and that rigor mortis (stiffening of the joints and muscles of a body which sets in a few hours after death) had set in. Paramedic #520 stated when the staff member was performing CPR, Resident #271's body was stiff and bent in the middle, and his head was off the pillow when staff was performing compressions. Upon stopping compressions, Resident #271's head remained in the raised position and did not fall back onto the pillow. Paramedic #520 stated staff kept (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365094 If continuation sheet Page 4 of 5 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 10/15/2025 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 0678 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete saying they had last seen the resident at 8:30 P.M., but the condition observed upon entrance at the scene did not reflect proof of life at 8:30 P.M. Paramedic #520 reported Resident #271 appeared to have been deceased for at least 2-3 hours prior to EMS arrival. Paramedic #520 stated upon arriving on scene, staff did not provide additional information about Resident #271 and appeared to not know how to appropriately handle the emergent situation.Review of the 01/03/25 reviewed facility policy called; Cardiopulmonary Resuscitation (CPR) Policy- Ohio Long Term revealed CPR (basic life support) includes chest compressions, ventilations and use of AED (as applicable) to restore circulation/respiration. The facility shall initiate CPR when a resident is found in cardiac arrest) absence of respirations or pulse), unless a valid advance directive or DNR order is present. If a resident is discovered unresponsive or without respirations/pulse, immediate action must be taken: call a ‘Code Blue', certified staff should begin CPR (compressions, ventilations) and/or use AED per training once it is safe to do so until arrival of EMS.This deficiency represents non-compliance investigated under Complaint Number 2635740. Event ID: Facility ID: 365094 If continuation sheet Page 5 of 5