Inspection visit

InspectionMarch 17, 2022

EASTBROOK HEALTHCARE CENTERCMS #36512932 citations on this visit

32 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 32 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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, medical record review, and facility policy review the facility failed to ensure residents' code status (level of medical interventions a resident wishes to have performed in the event they experienced an absence of a heartbeat or breathing) entered in the electronic medical record matched the State of Ohio Do Not Resuscitate (DNR) written documents for three residents (#31, #57, and #67) of nine residents reviewed for advanced directives. The facility census was 85. Findings include: 1. Review of the medical record for Resident #31 revealed an admission date of [DATE]. Diagnoses included orthopedic care following surgical amputation, local infection of the skin and subcutaneous (under the skin) tissue, type 2 diabetes, chronic obstructive pulmonary disease (COPD), moderate protein calorie malnutrition, hemiplegia and hemiparesis following cerebral infarction, Methicillin-resistant staphylococcus aureus (MRSA) of unspecified site, idiopathic aseptic necrosis of left toes, acquired absence of right leg above knee, major depressive disorder, and chronic viral hepatitis C. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 11/15 indicating moderate cognitive impairment. He required the extensive assistance of one staff member for bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing. Review of the State of Ohio DNR form revealed Resident #31 had a DNR Comfort Care-Arrest (DNRCC-A) in place. This meant treatments and medications to sustain life would be provided up until the resident's heart or breathing stopped. At that time, no further life saving measures would be provided including cardiopulmonary resuscitation (CPR). This form was signed by the physician on [DATE]. Review of the physician orders dated [DATE] identified an order that Resident #31 was a full code. This meant the resident was to receive CPR in the event his heart stopped beating or he stopped breathing. Interview on [DATE] at 1:46 P.M. with the Director of Nursing (DON) verified the physician order for full code entered in the electronic medical record did not match the State of Ohio DNR form in the resident's chart (hard copy). 2. Review of the medical record for Resident #57 revealed an admission date of [DATE]. Diagnoses included COVID-19, hemiplegia/hemiparesis left side following cerebral infarction, chronic respiratory failure with hypoxia, chronic kidney disease stage 3, dysphagia (difficulty swallowing), type 2 (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 44 Event ID: 365129 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 365129 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastbrook Healthcare Center 17322 Euclid Ave Cleveland, OH 44112 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 - Some diabetes, dementia, aphasia (difficulty speaking), hypertension, and gastrostomy (a tube in the stomach for feeding). Review of the quarterly MDS 3.0 assessment, dated [DATE], revealed the resident had severe cognitive impairment. She required the extensive of assistance of two staff members for all activities of daily living (ADLs) had an indwelling urinary catheter, and a gastrostomy. Review of the State of Ohio DNR form revealed Resident #57 had a DNR Comfort Care (DNRCC) in place which was signed by the physician on [DATE]. Review of the physician orders dated [DATE] identified an order that Resident #57 was a full code. Interview on [DATE] at 1:26 P.M. with Social Service Designee (SSD) #252 verified the physician order for full code entered in the electronic medical record did not match the State of Ohio DNR form in the resident's chart. 3. Review of the medical record revealed Resident #67's hard chart contained a full code status. Review of Resident #67's electronic medical records revealed an order for a DNR-CC. Interview with Licensed Practical Nurse (LPN) #209 on [DATE] at 9:43 A.M. confirmed the conflicting code status for Resident #67. Review of the facility policy titled Advanced Directives revised [DATE], revealed the facility would display information in the medical record about whether or not the resident had executed an advance directive. The plan of care for each resident would be consistent with his or her documented treatment preference and/or advance directive. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365129 If continuation sheet Page 2 of 44 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 365129 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastbrook Healthcare Center 17322 Euclid Ave Cleveland, OH 44112 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 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to complete a Minimum Data Set (MDS) 3.0 assessment as required upon resident discharge to the hospital. This affected one (Resident #2) of one resident reviewed for MDS accuracy. The facility census was 85. Findings include: Review of the medical record for Resident #2 revealed the resident was admitted to the facility on [DATE] with diagnoses that included dementia, dysphagia and high blood pressure. Review of the progress note dated 09/30/21 revealed Resident #2 was sent to a local acute care hospital due to pulling out his feeding tube. Resident #2 ultimately did not return to the facility and the facility ceased billing the resident for bed hold days on 10/01/21. Review of the MDS data for Resident #2 revealed the last MDS assessment completed was an admission assessment dated [DATE]. No discharge MDS assessment was completed as required. On 03/09/22 at 9:56 A.M. interview with MDS Nurse #218 verified no discharge assessment was completed as required. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365129 If continuation sheet Page 3 of 44 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 365129 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastbrook Healthcare Center 17322 Euclid Ave Cleveland, OH 44112 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 staff interview the facility failed to accurately code the pre-admission screening and resident review (PASRR) accurately on the Minimum Data Set (MDS) 3.0 assessment. This affected five (Residents #24, #52, #61, #64 and #76) of six residents reviewed for accuracy of PASRR coding of MDS assessments. The facility identified twelve residents as having a level two mental illness. Residents Affected - Some Findings include: 1. Resident #24 was admitted to the facility on [DATE] with diagnoses that included schizophrenia, bi-polar disorder and major depressive disorder. Review of the level two determination from the Ohio Department of Mental Health dated 03/09/20 revealed Resident #24 had a serious mental illness. Review of the section A of the most recent comprehensive Minimum Data Set (MDS) 3.0 assessment for Resident #24 dated 08/17/21 revealed the facility answered no to the question, Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? 2. Resident #52 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder, psychosis and high blood pressure Review of the level two determination from the Ohio Department of Mental Health dated 03/20/16 revealed Resident #52 had a serious mental illness. Review of section A of the most recent comprehensive MDS 3.0 assessment for Resident #52 dated 12/07/21 revealed the facility answered no to the question, Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? 3. Resident #61 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder, violent behavior and high cholesterol Review of the level two determination from the Ohio Department of Mental Health dated 09/16/16 revealed Resident #61 had a serious mental illness. Review of section A of the most recent comprehensive MDS 3.0 assessment for Resident #61 dated 11/17/21 revealed the facility answered no to the question, Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? 4. Resident #64 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder, cirrhosis of the liver and high blood pressure. Review of the level two determination from the Ohio Department of Mental Health dated 11/18/11 revealed Resident #64 had a serious mental illness. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365129 If continuation sheet Page 4 of 44 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 365129 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastbrook Healthcare Center 17322 Euclid Ave Cleveland, OH 44112 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of section A of the most recent comprehensive MDS 3.0 assessment for Resident #64 dated 11/24/21 revealed the facility answered no to the question, Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? 5. Resident #76 was admitted to the facility on [DATE] with diagnoses that schizophrenia, mild intellectual disabilities and dementia. Review of the level two determination from the Ohio Department of Mental Health dated 11/23/11 revealed Resident #76 had a serious mental illness. Review of section A of the most recent comprehensive MDS 3.0 assessment for Resident #76 dated 11/12/21 revealed the facility answered no to the question, Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? On 03/09/22 at 11:12 A.M. Social Service Director #252 verified the incorrect assessment coding regarding PASRR status for all five residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365129 If continuation sheet Page 5 of 44 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 365129 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastbrook Healthcare Center 17322 Euclid Ave Cleveland, OH 44112 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities 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 staff interview the facility failed to ensure the pre-admission screen and resident review (PASRR) was accurate and reflective of current mental healthcare needs. This affected one (Resident #66) of twelve residents reviewed for PASRR status. The facility census was 85. Residents Affected - Few Findings include: Resident #66 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease, schizophrenia and bi-polar disorder. Review of the physicians orders for the current month (March 2022) revealed an order dated 01/29/22 for Resident #66 to receive Quetiapine Fumarate (anti-psychotic medication) 50 milligrams (mg) in the morning and 25 mg in the evening to address depression and behaviors. Review of the PASRR dated 01/28/22 revealed the answer was indicated as no to the question, Does the individual have a diagnosis(es) of any of the mental disorders listed below (schizophrenia was listed as choice) and no to the question, In the past SIX (6) months, has the individual been prescribed any psychotropic medications, with one of the choices being Anti-psychotics (i.e., Haldol, Loxitane, Thorazine, Mellaril, Moban, Zyprexa, Risperdal, Clozaril, etc.) Interview with Social Service Director #252 on 03/14/22 at 11:19 A.M. verified the PASRR screen in place did not address resident's schizophrenia diagnosis or anti-psychotic medication use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365129 If continuation sheet Page 6 of 44 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 365129 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastbrook Healthcare Center 17322 Euclid Ave Cleveland, OH 44112 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to develop resident specific care plans to address residents individual needs and to implement care planned interventions as required. This affected six (Residents #31, #35, #65, #66, #435 and #436) of 24 sampled residents. The facility census was 85. Findings Include: 1. Resident #66 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease, bi-polar disorder and schizophrenia. Review of the care plan initiated 02/01/22 revealed the care plan contained the following information. Resident has potential and desires to be discharged to No destination was noted. Resident is at risk for isolation. No cause of isolation risk was given. Resident is at risk for constipation. The goal for this problem was noted as The resident will pass soft, formed stool at the preferred frequency of (SPECIFY FREQUENCY) through the review date. No frequency was specified. Resident is at risk for skin impairment. The goal for this problem was noted as The resident will have no complications related to (SPECIFY skin injury type) of the (SPECIFY location) through the review date. No injury type or location was specified. 2. Resident #435 was admitted to the facility on [DATE] with diagnoses that included anemia, high blood pressure and chronic respiratory failure Review of the care plan initiated 02/01/22 revealed the care plan contained the following information. Resident has potential and desires to be discharged to to the community after therapy rehabilitation. The goal for this problem was noted as Staff will work with resident and responsible party to facilitate a safe discharge to: No specific discharge destination was noted in the care plan and no interventions were noted to address this care plan item. 3. Resident #436 was admitted to the facility on [DATE] with diagnoses that included left femur fracture, schizophrenia and bi-polar disorder. Review of the care plan initiated 02/12/22 revealed the care plan contained the following information. Resident has potential and desires to be discharged to: Undetermined. No interventions were noted in the care plan to address this problem. The resident will have improved mood state (SPECIFY: happier, calmer appearance, no s/sx of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365129 If continuation sheet Page 7 of 44 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 365129 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastbrook Healthcare Center 17322 Euclid Ave Cleveland, OH 44112 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some depression, anxiety or sadness) through the review date. No specific goals were stated in the care plan for this area. The resident will have improved sleep pattern by reporting (SPECIFY adequate rest or fewer documented episodes of insomnia) through the review date. No specific sleep goals were stated in the care plan for this area. 4. Resident #65 was admitted to the facility on [DATE]. Admitting diagnoses included anemia, mild calorie malnutrition, hemiplegia and hemiparesis, cerebral infarction, atrial fibrillation, absence of left leg above the knee, schizophrenia affect disorder and insertion of gastrostomy tube. Review of this resident's Minimum Data Set Assessment (MDS) dated [DATE] revealed the resident had severe cognitive impairment. Functionally, this resident was totally dependent on two staff member for a majority of activities of daily living (ADLs) including transfers, locomotion on and off the unit, dressing, eating, toilet use and personal hygiene. Review of the resident's physician order dated 12/21/22 revealed the resident was to receive Aquaphor advanced therapy ointment (an ointment applied to the skin to boost rash healing and minimize discomfort) to be applied to the resident's face topically every day shift for skin integrity. Review of this resident's plan of care from admission to present revealed no plan of care for treating the resident's rash on his face. MDS Nurse #218 verified the lack of care planned resident specific goals and interventions for all of the above residents in an interview on 03/09/22 at 9:49 A.M. 5. Review of the medical record for Resident #31 revealed an admission date of 08/22/19. Diagnoses included orthopedic care following surgical amputation, local infection of the skin and subcutaneous (under the skin) tissue, type 2 diabetes, chronic obstructive pulmonary disease (COPD), moderate protein calorie malnutrition, hemiplegia and hemiparesis following cerebral infarction, Methicillin-resistant staphylococcus aureus (MRSA) of unspecified site, idiopathic aseptic necrosis of left toes, acquired absence of right leg above knee, major depressive disorder, and chronic viral hepatitis C. Review of the quarterly MDS 3.0 assessment, dated 01/03/22, revealed the resident had moderate cognitive impairment as indicated by a Brief Interview for Mental Status (BIMS) score of 11/15. He required extensive assistance of one staff member for bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing. Review of the care plan revised on 09/01/21 revealed Resident #31 was at risk for falls related to gait and balance problems, impaired mobility, fidgeting, and agitation. Interventions included a low bed, a perimeter mattress, keeping the bed control at the foot of the bed, a floor matt to the open side of the bed, non-skid footwear to be worn at all times, placing one side of the bed against the wall, and placing a call before you fall sign on the wall. Observation on 03/07/22 at 12:44 P.M. of Resident #31's room revealed a lack fall interventions as stated in the plan of care. There was no floor matt to the open side of the bed, the resident was not wearing non-skid footwear, and one side of the bed was not placed against the wall. There was also a lack of a call before you fall sign posted in the room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365129 If continuation sheet Page 8 of 44 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 365129 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastbrook Healthcare Center 17322 Euclid Ave Cleveland, OH 44112 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 03/07/22 at the time of the observation at 12:44 P.M. with State Tested Nurse Aide (STNA) #276 verified the lack of fall interventions as stated above for Resident #31. She did not think he was a fall risk. Review of the incident logs dated 03/07/21 to 03/07/22 revealed Resident #31 had falls on 08/08/21, 08/25/21, 08/27/21, 09/03/21, 09/06/21, 11/12/21, 11/15/21, 11/26/21, and 01/20/22. 6. Review of the medical record for Resident #35 revealed an admission date of 02/25/21. Diagnoses included COVID-19, acute kidney failure, type 2 diabetes with diabetic neuropathy, essential hypertension, cellulitis of right lower limb, and acute peptic ulcer. Review of the annual MDS 3.0 assessment dated [DATE] revealed the resident had intact cognition as indicated by a BIMS score of 15/15. He required the extensive assistance of two staff members for bed mobility and the extensive assistance of one staff member for transfers, dressing, toilet use, personal hygiene, and bathing. Review of the care plan dated 02/26/21 revealed Resident #35 was resistant to care related to personal choice in refusing showers. Interventions included allowing the resident to make decisions about care and treatment regime to provide a sense of control. Further review of the care plan identified interventions to provide consistency in care and ADLs. Review of the physician orders dated 12/06/21 identified an order for Resident #35 to have weekly skin checks and showers on Wednesday and Saturday during the day shift. Interview on 03/09/22 at 8:18 A.M. with Resident #35 revealed he received a bed bath last week. He usually received a bed bath per choice once a week but was supposed to get a bath twice a week. Review of the shower sheets for Resident #35 from 12/02/21 through 03/07/22 revealed bed baths were given on 12/02/21, 12/13/21, 12/20/21, 12/27/21, 01/03/22, 01/17/22, 01/24/22, 01/31/22, 02/07/22, 02/14/22, 02/21/22, 02/28/22, and 03/04/22. Bed baths were given weekly, not twice a week as ordered and per resident preference. Interview on 03/16/22 at 12:39 P.M. via phone, revealed the Director of Nursing (DON) verified Resident #35's care plan revealed documentation to provide consistent routines and ADL care per resident preferences. She also verified the shower sheets for Resident #35 revealed bed baths once a week, instead of twice a week as per the resident's preference and physician orders. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365129 If continuation sheet Page 9 of 44 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 365129 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastbrook Healthcare Center 17322 Euclid Ave Cleveland, OH 44112 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on observation, interview, and medical record review the facility failed to develop a person-centered care plan for Resident #31. This affected one of six residents reviewed for care plan timing and revision. The facility census was 85. Review of the medical record for Resident #31 revealed an admission date of 08/22/19. Diagnoses included orthopedic care following surgical amputation, local infection of the skin and subcutaneous (under the skin) tissue, type 2 diabetes, chronic obstructive pulmonary disease (COPD), moderate protein calorie malnutrition, hemiplegia and hemiparesis following cerebral infarction, Methicillin-resistant staphylococcus aureus (MRSA) of unspecified site, idiopathic aseptic necrosis of left toes, acquired absence of right leg above knee, major depressive disorder, and chronic viral hepatitis C. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 01/03/22, revealed the resident had moderate cognitive impairment as indicated by a Brief Interview for Mental Status (BIMS) score off 11/15. He required the extensive assistance of one staff member for bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing. Review of the care plan revised 02/21/22 revealed lack of interventions regarding the physician order dated 02/21/22 to apply a compression stocking/shrinker to the right above the knee amputation every morning and to remove at bedtime. Observations on 03/07/22, 03/08/22, 03/09/22, and 03/14/22 revealed Resident #31 did not have the compression stocking/shrinker on the right above the knee amputation on any day. Interview on 03/14/22 at 10:45 A.M. with the Director of Nursing (DON) revealed if an order was received for a compression stocking, therapy would provide the stocking and the orders would be implemented. Interview on 03/16/22 at 12:39 P.M. via phone, revealed the DON verified the care plan lacked documentation or interventions regarding the compression stocking/shrinker. Review of the facility policy titled Care Planning-Interdisciplinary Team revised September 2013, revealed the facility's care planning/interdisciplinary team was responsible for the development of a comprehensive care plan for each resident. The care plan was based on the comprehensive assessment and would include, but limited to, the attending physician, and a registered nurse caring for the patient, and therapy services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365129 If continuation sheet Page 10 of 44 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 365129 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastbrook Healthcare Center 17322 Euclid Ave Cleveland, OH 44112 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** Based on observation and interview the facility failed to ensure routine turning and positioning for Resident #67 and adequate nail care for Residents #65 and #30. This affected three (Residents #67, #65 and #30) of six residents reviewed who were dependent for activities of daily living care. The facility census was 85. Residents Affected - Few Findings include: 1. Review of Resident #67's medical record revealed an admission date of 09/15/21 with diagnoses that included right and left leg amputations. Review of the care plan dated 09/22/21 revealed the resident had a potential for alteration in comfort and interventions included reposition as needed for comfort. Review of the Minimum Data Set (MDS) dated [DATE] revealed the resident required extensive assistance with bed mobility. Observation on 03/08/22 at 7:18 A.M. revealed Resident #67 was positioned on his back in bed. The resident was non-verbal. Observation on 03/08/22 at 8:25 A.M. revealed #67 remained in bed on his back. Observation on 03/08/22 at 10:09 A.M. revealed Resident #67 remained in the same position as during previous observations. Interview with State Tested Nursing Assistant (STNA) #223 at 10:12 A.M. confirmed Resident #67's position and she stated she had not provided care for the resident yet and stated she had not turned or repositioned him. STNA #223 further stated the resident required assistance with turning and should be turned at least every two hours.2. Resident #65 was admitted to the facility on [DATE]. Admitting diagnoses included anemia, mild calorie malnutrition, hemiplegia and hemiparesis, cerebral infarction, atrial fibrillation, absence of left leg above the knee, and schizophrenia affect disorder. Review of the MDS dated [DATE] revealed the resident had severe cognitive impairment. Functionally, the resident was totally dependent on two staff for activities of daily living (ADLs) personal hygiene. Observation on 03/07/22 at 9:30 A.M. of Resident #65 revealed the resident was lying in bed with his left hand partially open. The nails of his thumb and index finger were very long nails with black dirt underneath the nails. Observation on 03/08/22 at 9:00 A.M. with STNA #235 and #250 revealed when STNA #235 opened the resident's left hand all nails on that hand were extremely long with dirt underneath the nails. STNA #235 also opened his right hand and all fingernails were also long with dirt underneath. Both STNAs verified the resident's nails were long and dirty and had not been recently cleaned or trimmed. 3. Review of the medical record for Resident #30 revealed an admission dare of 08/09/17 with a readmission date of 12/14/21. Diagnoses included hemiplegia and hemiparesis of dominant right side following cerebral infarction, hypotension of hemodialysis, severe protein calorie malnutrition, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365129 If continuation sheet Page 11 of 44 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 365129 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastbrook Healthcare Center 17322 Euclid Ave Cleveland, OH 44112 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 ulcerative colitis, epilepsy, major depressive disorder, hypertensive chronic kidney disease (CKD) with stage 5 CKD, end stage renal disease, dysphagia, and dependence on renal dialysis. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed the resident had intact cognition indicated by a BIMS score of 15/15. The resident required the extensive assistance of one staff member for transfers, dressing, personal hygiene, toileting, and bathing. Observation and interview on 03/08/22 at 1:38 P.M. with Resident #30 revealed all of his fingernails were long and had brown residue underneath the nails. He stated he did not like them that long and could not recall the last time his nails were cut or cleaned. Interview on 03/09/22 at 1:54 P.M. with STNA #201 revealed she was supposed to trim residents' nails when they received showers or baths. Nail care was to be documented on the shower sheets and signed by the Unit Manager. STNA #201 verified Resident #30's nails were long and dirty and had not been trimmed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365129 If continuation sheet Page 12 of 44 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 365129 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastbrook Healthcare Center 17322 Euclid Ave Cleveland, OH 44112 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure heel pressure offloading devices (PODs) were appropriately applied and routine repositioning was completed to promote the healing of existing pressure ulcers for Resident #18 and failed to provide adequate wound care for Resident #66. This affected two (Resident #18 and #66) of four residents reviewed for pressure ulcers. The facility census was 85. Residents Affected - Few Findings include: 1. Review of medical record for Resident #18 revealed admission date of 09/13/17. Diagnoses included type II diabetes mellitus, severe protein calorie malnutrition, mild intellectual disabilities, post-traumatic stress disorder, pressure ulcer of right heel, pressure ulcer of left heel, chronic osteomyelitis of right ankle and foot, and benign neoplasm of colon. Review of Medicare Discharge Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 required total staff assistance for bed mobility, transfers, toileting, personal hygiene, bathing, and eating. Resident #18 had severely impaired decision making. The assessment indicated Resident #18 had one or more unhealed pressure ulcers. Review of facility Admission/readmission Packet dated 02/16/22 revealed Resident #18 had severe decrease in food intake over past three months and had skin impairments. No identification of skin impairments was noted in the assessment. Review of the Skin/Wound Note dated 02/16/22 revealed upon return from a 01/25/22 to 02/16/22 hospitalization Resident #18 presented with multiple new pressure areas acquired while hospitalized and some which were present prior to hospitalization. There was a total of 11 noted pressure areas. Review of Braden Scale for Predicting Pressure Sore Risk assessment dated [DATE] revealed Resident #18 was bedfast, completely immobile, frequently slid down in bed, and required moderate to maximum assistance in moving. The Braden scale indicated Resident #18 was at moderate risk for pressure sores. Review of Resident #18's care plan with a review date of 02/26/22 revealed Resident #18 had activities of daily living (ADL) performance deficits. Interventions included provide extensive one staff assistance for bed mobility and toileting and reposition the resident every two hours for wounds. Resident #18 was at nutritional risk related to impaired skin integrity and a history of weight changes. Interventions included to provide a nutrition supplement twice daily, provide a snack at bedtime, monitor skin status, weigh monthly, and monitor needs for healing with reassessments as necessary. Resident #18 had actual skin impairment. Interventions included wound treatments as ordered, ensure pressure off loading devices (PODs) were properly placed on both lower extremities, ensure good nutrition to promote healthy skin, encourage repositioning, and keep skin clean and dry. Review of current physician orders for March 2022 revealed cleanse, apply Dakins (solution used to prevent and treat skin and tissue infections) and cover with abdominal pad wrapped with Kerlix (bandage wrap) every day for left heel, right heel, and left knee; pad and protect every Monday, Wednesday, and Friday for left scapula, right lower extremity, right wrist, left buttock, mid sacrum, right sacrum, left sacrum; monitor and leave open to air for right knee and left calf. Other orders (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365129 If continuation sheet Page 13 of 44 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 365129 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastbrook Healthcare Center 17322 Euclid Ave Cleveland, OH 44112 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few included pressure a reducing cushion, pressure reducing mattress, house barrier cream after incontinence episodes, and weekly skin checks. Review of the Wound Evaluation Flow Sheet for right heel revealed an in house acquired pressure injury was noted on 12/01/21 and remained to 03/07/22 review. A right heel wound was described as a deep tissue injury (DTI - a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue due to pressure and/or shear, area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue) and measured 4.5 centimeters (cm) long by 4.5 cm wide by 0.1 cm deep. The tissue was necrotic (dead) and had 100 percent (%) eschar (a dry dark scab) coverage. Wound treatment orders were changed to Santyl (ointment that removes dead tissue) with foam pad covering on 03/07/22, continued use of heel offloading devices, and repositioning. Wound status was noted as chronic. Review of the Wound Evaluation Flow Sheet for the left heel revealed an in house acquired pressure injury was noted on 12/01/21 and remained to 03/07/22 review. The left heel wound was a DTI and measured 8.0 cm long by 6.0 cm wide by 0.1 cm deep. The tissue was necrotic and had 100% eschar coverage. Wound treatment orders were changed to Santyl with a foam pad covering on 03/07/22, continued use of heel offloading devices, and repositioning. Wound status was noted as chronic. Review of the Wound Evaluation Flow Sheet for the left shoulder blade revealed an in house acquired pressure injury was noted on 12/17/21 and remained to 03/07/22 review. The left shoulder blade wound was a stage 1 injury (intact skin with non-blanchable redness of a localized area usually over a bony prominence) and measured 5.5 cm long by 8.0 cm wide by 0.1 cm deep. The tissue had 100% granulation with moderate amount of drainage. Wound treatment orders were changed to Santyl with a foam pad covering on 03/07/22 and repositioning. Wound status was noted as chronic. Review of the Wound Evaluation Flow Sheet for the left buttock revealed an in house acquired pressure injury was noted on 12/28/21 and remained to 03/07/22 review. The left buttock wound was a DTI and measured 10 cm long by 8.5 cm wide by 0.1 cm deep. The tissue was necrotic and had 100% eschar coverage. Wound treatment orders were changed to Santyl with a foam pad covering on 03/07/22, repositioning, and debridement needed. Wound status was noted as chronic. Review of the Wound Evaluation Flow Sheet for the left sacrum revealed an in house acquired pressure injury was noted on 12/28/21 and remained to 03/07/22 review. The left sacrum wound was a DTI and measured 5.0 cm long by 5.5 cm wide by 0.1 cm deep. The tissue was necrotic and had 100% eschar coverage. Wound treatment orders were changed to Santyl with a foam pad covering on 03/07/22, repositioning, and debridement needed. Wound status was noted as chronic. Review of the Wound Evaluation Flow Sheet for a sacral slit revealed an in house acquired pressure injury was noted on 12/28/21 and remained to 03/07/22 review. The sacral slit wound was a DTI and measured 2.0 cm long by 0.5 cm wide by 0.3 cm deep. The tissue was necrotic and had 80% eschar and 20% slough coverage. Wound treatment orders were changed to Santyl with a foam pad covering on 03/07/22, repositioning, and debridement needed. Wound status was noted as chronic. Review of the Wound Evaluation Flow Sheet for the right knee revealed present on readmission the pressure injury was noted on 02/16/22 and remained to 03/07/22 review. The right knee wound was a DTI and measured 3.0 cm long by 4.6 cm wide by 0.0 cm deep. The tissue had 100% eschar coverage. Wound treatment orders were changed to leave open to air on 03/07/22, repositioning, and debridement needed. Wound status was noted as worsening. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365129 If continuation sheet Page 14 of 44 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 365129 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastbrook Healthcare Center 17322 Euclid Ave Cleveland, OH 44112 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 0686 Level of Harm - Minimal harm or potential for actual harm Review of the Wound Evaluation Flow Sheet for the right wrist revealed present on readmission the pressure injury was noted on 02/16/22 and remained to 03/07/22 review. The right wrist wound was a DTI and measured 4.5 cm long by 1.0 cm wide by 0.1 cm deep. The tissue was necrotic and had 100% eschar coverage. Wound treatment orders were changed to Santyl with a foam pad covering on 03/07/22, repositioning, and debridement needed. Residents Affected - Few Review of the Wound Evaluation Flow Sheet for the left knee revealed present on readmission the pressure injury was noted on 02/16/22 and remained to 03/07/22 review. The left knee wound was a DTI and measured 2.8 cm long by 3.0 cm wide by 0.1 cm deep. The tissue was necrotic and had 100% eschar coverage. Wound treatment orders were changed to Santyl with a foam pad covering on 03/07/22, repositioning, and operative debridement needed. Review of the Wound Evaluation Flow Sheet for the left calf revealed present on readmission the pressure injury was noted on 02/16/22 and remained to 03/07/22 review. The left calf wound was a DTI and measured 3.0 cm long by 2.5 cm wide by 0.1 cm deep. The tissue was necrotic and had 100% eschar coverage. Wound treatment orders were changed to leave open to air, repositioning, and operative debridement needed. Review of the Wound Evaluation Flow Sheet for the right lateral lower extremity revealed present on readmission the pressure injury was noted on 02/16/22 and remained to 03/07/22 review. The right lateral lower extremity wound was a DTI and measured 17 cm long by 1.4 cm wide by 0.1 cm deep. The tissue was black necrotic and had 100% eschar coverage. Wound treatment orders were changed to Santyl with a foam pad covering on 03/07/22, repositioning, and operative debridement needed. Review of the Wound Evaluation Flow Sheet for the right medial lower extremity revealed present on readmission the pressure injury was noted on 02/16/22 and remained to 03/07/22 review. The right medial lower extremity wound was a DTI and measured 1.9 cm long by 1.8 cm wide by 0.1 cm deep. The tissue was necrotic and had 100% eschar coverage. Wound treatment orders were changed to Santyl with a foam pad covering on 03/07/22, repositioning, and operative debridement needed. Review of the wound evaluation by the wound physician dated 03/04/22 revealed Resident #18 had extensive ulcerations with severe exacerbation of multiple wounds upon readmission from the hospital. Resident #18 would require hospitalization with extensive debridement and discussion of possible lower extremity amputation. Additional wound evaluations by the wound physician were noted on 03/01/22, 02/18/22, 01/23/22, 01/19/22, and 01/14/22 with weekly wound rounds. Review of physical therapy notes from 02/20/22 to 03/07/22 revealed Resident #18 required total staff assistance for bed mobility. Observation on 03/09/22 at 7:46 A.M. revealed Resident #18 lying in bed on his back slouched down and to the left side with sheet over top of him. The head of bed was raised slightly. Resident #18's eyes were closed, and he appeared to be sleeping. Observation on 03/09/22 at 10:39 A.M. revealed Resident #18 was in the same position as prior observation. The head of Resident #18's bed remained slightly raised and Resident #18 was slouched down on the air mattress causing his heels to press against the footboard of the bed. Further observation revealed Resident #18's pressure reducing devices were improperly attached around the upper calf so they were not preventing the heels from touching the mattress for offloading. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365129 If continuation sheet Page 15 of 44 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 365129 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastbrook Healthcare Center 17322 Euclid Ave Cleveland, OH 44112 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 03/09/22 at 10:59 A.M. with STNA #250 indicated there were only two aides on the hall and they had not gotten to Resident #18 to provide morning care and repositioning. STNA #250 confirmed PODs were not appropriately applied. STNA #250 assisted to pull Resident #18 up in bed to move his heels away from the footboard and reapplied the pressure reducing devices to offload pressure from the heels. STNA #250 confirmed Resident #18's call light was hanging off the bed out of reach, however, she did not replace the call light upon exiting the room. Interview on 03/09/22 at 11:04 A.M. with STNA #235 revealed they had started the shift at seven in the morning and confirmed they had not provided care to Resident #18 yet. Observation on 03/09/22 at 12:39 P.M. revealed Resident #18 remained in bed in the same positioning as prior observation and his call light remained out of reach. Observation on 03/09/22 at 12:48 P.M. revealed Resident #18 remained sleeping in the same position with his call light out of reach. Observation on 03/09/22 at 3:22 P.M. revealed Resident #18 remained in bed in the same position with his call light out of reach. Resident #18 nodded when asked if staff came in to visit and provide care. Review of the Nursing Note dated 03/10/22 revealed Resident #18 was sent to hospital for operative debridement of wounds on 03/09/22. Review of facility policy Pressure Ulcer Prevention and Risk Identification undated revealed the facility would establish measures to prevent development or further decline of pressure ulcers. Residents' pressure ulcer risk would be assessed to include evaluation of resident nutrition status, laboratory values, and mobility status. 2. Review of Resident #66's medical records revealed an admission date of 01/28/22 with diagnoses that included a stage four (full thickness tissue loss with exposed bone, tendon or muscle; slough may be present on some parts of the wound bed) pressure ulcer of the sacrum (tailbone). Review of the care plan dated 02/01/22 revealed the resident had a stage three (full thickness tissue loss, subcutaneous fat may be visible but bone, tendon or muscle are not exposed, slough may be present but does not obscure the depth of tissue loss) pressure ulcer to his sacrum that was present on admission and interventions included administer treatments as ordered. Review of the MDS dated [DATE] revealed the resident had intact cognition and required extensive assistance with toileting and personal hygiene and was incontinent of bowel and bladder. Review of physician orders for March 2022 revealed to cleanse the sacral wound with normal saline and pack with calcium alginate (wound dressing) and cover with a foam pad every Monday, Wednesday and Friday and also as needed if soiled. Observation of wound care for Resident #66 on 03/14/22 at 11:50 A.M. with Licensed Practical Nurse (LPN) #205 revealed the resident had a heavily soiled foam dressing to his sacral area with a date of 03/11/22 that LPN #205 stated she had done. LPN #205 confirmed the dressing was heavily soiled and stated the resident's wounds drained often and in large amounts. LPN #205 further stated the resident's dressing was to be changed if soiled. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365129 If continuation sheet Page 16 of 44 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 365129 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastbrook Healthcare Center 17322 Euclid Ave Cleveland, OH 44112 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 0687 Provide appropriate foot care. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure ancillary podiatry visits were provided and adequate foot care was administered to Resident #65. This affected one (Resident #65) of three residents reviewed for ancillary services. The facility census was 85. Residents Affected - Few Findings include: Resident #65 was admitted to the facility on [DATE]. Admitting diagnoses included anemia, mild calorie malnutrition, hemiplegia and hemiparesis, cerebral infarction, atrial fibrillation, absence of left leg above the knee, schizophrenia affect disorder and insertion of gastrostomy tube. Review of the Minimum Data Set Assessment (MDS) dated [DATE] revealed the resident had severe cognitive impairment. Functionally, the resident was totally dependent on two staff for transfers, locomotion on and off the unit, dressing, eating, toilet use and personal hygiene. Observation on 03/08/22 at 9:30 A.M. with State Tested Nursing Assistant (STNA) #235 revealed all five toe nails were thick, yellow colored and some were curling up on his right foot. The third digit the toenail was excessively long and was curling under his toe. STNA #235 verified these findings at the time of the observation. Interview with Social Worker (SW) #252 on 03/08/22 at 11:40 A.M revealed she was able to provide physician notes from dental and optometry services but not from the podiatrist. Interview with the Podiatry Nurse Practitioner on 03/09/22 at 10:00 A.M. revealed that she did not have Resident #65 on her list to be seen. She further stated she was not familiar with the resident. A second interview with the Podiatry Nurse Practitioner on 03/09/22 at 2:00 P.M. revealed SW #252 had obtained approval and Resident #65 would be seen today. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365129 If continuation sheet Page 17 of 44 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 365129 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastbrook Healthcare Center 17322 Euclid Ave Cleveland, OH 44112 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to provide adequate care for the use of an indwelling urinary catheter. This affected one (Resident #67) of one resident observed for catheter care. The facility census was 85. Findings include: Review of Resident #67's medical record revealed an admission date of 09/15/21 with diagnoses that included bladder dysfunction. Review of the care plan dated 09/22/21 revealed the resident had an indwelling urinary catheter related to bladder dysfunction but lacked any indication or interventions regarding providing catheter care. Review of the Minimum Data Set (MDS) dated [DATE] revealed the resident had no recorded cognition score, and required extensive assistance with toileting and personal hygiene. Review of physician orders for March 2022 revealed the resident was to receive catheter care every shift and as needed. Observation on 03/08/22 at 10:12 A.M. of Resident #67 with State Tested Nursing Assistant (STNA) #210 revealed the resident's urinary catheter appeared to be dirty with debris around the insertion site. Interview with STNA #210 confirmed the dirty catheter and she stated she had not provided catheter care and was unable to state when it had last been done. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365129 If continuation sheet Page 18 of 44 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 365129 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastbrook Healthcare Center 17322 Euclid Ave Cleveland, OH 44112 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of facility policy the facility failed to ensure Resident #18 was assessed for nutritional needs and to implement new interventions to address a significant unplanned weight loss and failed to ensure the resident was provided feeding assistance with meals. This affected one of eight residents reviewed for nutritional status. The facility census was 85. Residents Affected - Few Findings include: Review of medical record for Resident #18 revealed admission date of 09/13/17. Diagnoses included type II diabetes mellitus, severe protein calorie malnutrition, mild intellectual disabilities, pressure ulcer of the right and left heel, chronic osteomyelitis of the right ankle and foot, and benign neoplasm of the colon. The medical record indicated Resident #18 was hospitalized from [DATE] to 02/16/22 for altered mental status and sepsis. While hospitalized Resident #18 developed Clostridium Difficile (a bacterial infection that causes severe diarrhea) and Coronavirus. Review of the discharge Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #18 required total staff assistance for bed mobility, transfers, toileting, personal hygiene, bathing, and eating. Resident #18 had severely impaired decision making. A significant change in condition MDS was initiated on 02/26/22 and was still in progress. Review of the facility Admission/readmission Packet dated 02/16/22 revealed Resident #18 had severe decrease in food intake over past three months and had multiple areas of skin impairment. Review of the Skin/Wound Note dated 02/16/22 revealed upon return after being hospitalized from [DATE] to 02/16/22 the resident presented with multiple new and old pressure areas. There was a total of 11 pressure areas. Physician's orders dated 02/18/22 revealed the resident was ordered a regular diet with minced and moist texture. There were no orders for protein or nutritional supplements. Review of State Tested Nurse Aide Tasks revealed from 02/16/22 through 02/24/22 intakes were 50 - 75%. Beginning 02/25/22 through 03/02/22 intakes dropped below 50% with none recorded since 03/02/22. Review of Medication Administration Records for February and March 2022 revealed no evidence of high calorie or protein supplements provided. Review of Resident #18's plan of care with a review date of 02/26/22 revealed Resident #18 had an activities of daily living (ADL) performance deficit, actual skin impairment, and was at nutritional risk related to a history of weight changes. Interventions included to provide assistance for ADLs, monitor for decline in functioning, monitor for weight changes, and provide diet and supplementation as ordered. Review of the Nutrition assessment dated [DATE] revealed Resident #18 was reviewed for readmission from the hospital. The assessment indicated multiple pressure areas, the need for a mechanically altered diet, and current intakes of 50-75 percent. There was no evidence of evaluation of Resident #18's current nutritional needs nor any changes to the nutritional care plan. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365129 If continuation sheet Page 19 of 44 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 365129 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastbrook Healthcare Center 17322 Euclid Ave Cleveland, OH 44112 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the Weight Change Note dated 03/07/22 completed by Registered Dietitian (RD) #294 revealed Resident #18 weighed 149.0 pounds. Resident #18 experienced a 9.9% weight loss in three months. The note indicated no change in the nutritional care plan. Review of the weight summary revealed Resident #18 weighed 149.0 pounds on 03/01/22, there was no February 2022 weight, 165.2 pounds on 01/10/22, 165.4 pounds on 12/13/21, and 159.0 pounds on 09/08/21. Resident #18 had a 9.9% unplanned significant weight loss in the last three months that was not addressed. Observation on 03/09/22 at 12:39 P.M. revealed Resident #18 in bed with his eyes closed and he appeared to be sleeping. STNA #293 delivered a lunch tray. She placed it on the bedside table, then left the room without waking the resident and continued to pass lunch trays to other residents. Observation on 03/09/22 at 12:48 P.M. revealed Resident #18 remained in the same position with his eyes closed. His meal remained on the bedside table untouched and out of his reach. Observation on 03/09/22 at 12:54 P.M. revealed STNA #293 walked past Resident #18's room and looked into the open doorway. She did not enter the room. No attempt was made to provide encouragement, assistance or repositioning to facilitate eating. Observation on 03/09/22 at 12:58 P.M. revealed STNA #293 entered Resident #18's room and asked if he was finished. Resident #18 nodded his head and STNA #293 removed the untouched lunch tray. Resident #18 was not offered any encouragement, feeding assistance or alternate menu items. On 03/09/22 at 1:00 P.M. interview with STNA #293 revealed she thought Resident #18 was able to feed himself and required no assistance. She confirmed Resident #18 had not eaten any of his lunch meal, and she had not offered any encouragement, assistance, or an alternate menu item. Interview on 03/09/22 at 2:41 P.M. with RD #294 revealed Resident #18 had decline in meal intake in March 2022. RD #294 indicated the resident had multiple wounds and significant weight loss. RD #294 indicated she was unsure when the resident's last assessment for estimation of nutritional needs was completed. RD #294 indicated the resident received a magic cup (nutritional supplement) twice daily with breakfast and dinner but she did not know how well the resident accepted the supplement. When informed there was no current order and it was not seen on his lunch tray RD #294 confirmed he had an order in place prior to hospitalization but it must have dropped off. Interview on 03/10/22 at 9:39 A.M. with RD #294 revealed the last estimation of nutritional needs for Resident #18 was completed in August 2021. RD #294 verified no evaluation of needs was completed related to readmission from a hospital stay with 11 pressure wounds on 02/16/22 nor upon identification of significant unplanned weight loss on 03/07/22. The facility policy regarding nutrition and weight loss was requested but not provided. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365129 If continuation sheet Page 20 of 44 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 365129 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastbrook Healthcare Center 17322 Euclid Ave Cleveland, OH 44112 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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on record review and interview the facility failed to ensure the services of a Registered Nurse (RN) were maintained for at least eight hours a day, seven days a week. This had the potential to affect all 85 residents currently residing in the facility. Findings include: Review of the schedule from 03/02/22 through 03/08/22 revealed there was no RN scheduled to work for eight consecutive hours on 03/05/22 and 03/06/22. This was verified by Manager (MNGR) #300 on 03/09/22 at 4:30 P.M. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365129 If continuation sheet Page 21 of 44 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 365129 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastbrook Healthcare Center 17322 Euclid Ave Cleveland, OH 44112 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 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation, record review and interview the facility failed to ensure posted staffing information was updated daily. This had the potential to affect all 85 residents. Residents Affected - Many Findings include: Observation on 03/07/22 at 6:05 A.M. revealed the facility staffing information which indicated the census and number of nursing staff scheduled for the day that was posted at the receptionist's desk was dated 03/01/22. Interview on 03/07/22 at 6:06 A.M. with the Director of Housekeeping and Laundry revealed the staffing information should be updated and posted daily. She verified the posted information was dated 03/01/22. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365129 If continuation sheet Page 22 of 44 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 365129 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastbrook Healthcare Center 17322 Euclid Ave Cleveland, OH 44112 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to ensure medications were administered with an error rate of less than 5%. A total of 12 errors out of 27 opportunities observed resulted in a 44.4% medication error rate. This affected one resident (#40) of three (#41, #49 and #40) observed for medication administration. The facility census was 85. Residents Affected - Few Findings include: Review of Resident #40's medical records revealed an admission date of 09/23/21 with diagnoses that included gastrostomy (feeding tube placement), tracheostomy and respiratory failure. Review of care plan dated 09/24/21 revealed the resident required the use of a feeding tube related to dysphasia (difficulty swallowing) and interventions included, check tube for residual (amount of stomach content remaining after administration of feeding solution or medications). Review of the Minimum Data Set (MDS) dated [DATE] revealed resident had intact cognition and required extensive total dependence with transfers, toileting and personal hygiene. Review of physician orders for March 2022 revealed resident was to have nothing by mouth (NPO), check for residual of tube every shift prior to feeds, and medications were ordered to be administered via feeding tube. Observation of medication administration on 03/07/22 at 10:56 A.M. with Licensed Practical Nurse (LPN) #500 for Resident #40 revealed LPN #500 took the following medications out of their packaging and placed the tablets in a medication cup; Diflucan (antifungal medication), clonodine (blood pressure medication), amlodipine (blood pressure medication), doxcycline (antibiotic), famotidine (heartburn medication), prednisone (steroid), hydrochlorothiazide (diuretic), zyprexa (antipsychotic), senna (laxative) and omeprazole (heartburn medication). LPN #500 then placed all the medications in a plastic sleeve used to crush medications and opened the omeprazole capsule. LPN #500 put the crushed medications in a drinking cup and placed it on her medication cart. LPN #500 then proceeded to measure 5 milliliters (mL) of liquid nystatin (medication used to orally treat thrush) and placed the 5 ml nystatin in a drinking cup and placed it on her medication cart. LPN #500 then proceeded to take both drinking cups into Resident #40's room and filled each with an undetermined amount of water. Interview with LPN #500 at time of observation revealed she measured the amount of water added to the medications by looking at it and stated, I eye ball the amount until it looks about right. LPN #500 then proceeded to Resident #40's bedside. The tube feeding was turned off and the tubing was disconnected and a syringe was inserted into tube to administer medications. LPN #500 did not check for residual prior to administering the medications. The medications were not flowing through the tube and LPN #500 had to manually use a plunger on the end of the syringe to push the medications through Resident #40's feeding tube. LPN #500 completed the medication administration, reconnected Resident #40's tube feed and exited the room. Interview with LPN #500 at time of observation revealed she was not aware medications given via a feeding tube could not be crushed or administered together, and she further confirmed she should have checked for residual prior to medication administration. Interview on 03/09/22 at 7:33 A.M. with Director of Nursing (DON) revealed medications administered through a tube feeding tube were to be crushed and administered separately and nurses were required to check for residual prior to medication administration. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365129 If continuation sheet Page 23 of 44 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 365129 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastbrook Healthcare Center 17322 Euclid Ave Cleveland, OH 44112 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 0759 Review of facility policy titled Administering Medications Through an Enteral Tube revised November 2018 revealed medications were to be administered separately and a flush was to be done in between. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365129 If continuation sheet Page 24 of 44 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 365129 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastbrook Healthcare Center 17322 Euclid Ave Cleveland, OH 44112 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents were free of significant medication errors. This affected one (Resident #40) of three observed for medication administration. The facility census was 85 Residents Affected - Few Findings include: 1. Review of Resident #40's medical records revealed an admission date of 09/23/21 with diagnoses that included gastrostomy (feeding tube placement), tracheostomy and respiratory failure. Review of care plan dated 09/24/21 revealed the resident required the use of a feeding tube related to dysphasia (difficulty swallowing) and interventions included, check tube for residual (amount of stomach content remaining after administration of feeding solution or medications). Review of the Minimum Data Set (MDS) dated [DATE] revealed resident had intact cognition and required extensive total dependence with transfers, toileting and personal hygiene. Review of physician orders for March 2022 revealed resident was to have nothing by mouth (NPO), check for residual of tube every shift prior to feeds, and medications were ordered to be administered via feeding tube. Observation of medication administration on 03/07/22 at 10:56 A.M. with Licensed Practical Nurse (LPN) #500 for Resident #40 revealed LPN #500 took the following medications out of their packaging and placed the tablets in a medication cup; Diflucan (antifungal medication), clonodine (blood pressure medication), amlodipine (blood pressure medication), doxcycline (antibiotic), famotidine (heartburn medication), prednisone (steroid), hydrochlorothiazide (diuretic), zyprexa (antipsychotic), senna (laxative) and omeprazole (heartburn medication). LPN #500 then placed all the medications in a plastic sleeve used to crush medications and opened the omeprazole capsule. LPN #500 put the crushed medications in a drinking cup and placed it on her medication cart. LPN #500 then proceeded to measure 5 milliliters (mL) of liquid nystatin (medication used to orally treat thrush) and placed the 5 ml nystatin in a drinking cup and placed it on her medication cart. LPN #500 then proceeded to take both drinking cups into Resident #40's room and filled each with an undetermined amount of water. Interview with LPN #500 at time of observation revealed she measured the amount of water added to the medications by looking at it and stated, I eye ball the amount until it looks about right. LPN #500 then proceeded to Resident #40's bedside. The tube feeding was turned off and the tubing was disconnected and a syringe was inserted into tube to administer medications. LPN #500 did not check for residual prior to administering the medications. The medications were not flowing through the tube and LPN #500 had to manually use a plunger on the end of the syringe to push the medications through Resident #40's feeding tube. LPN #500 completed the medication administration, reconnected Resident #40's tube feed and exited the room. Interview with LPN #500 at time of observation revealed she was not aware medications given via a feeding tube could not be crushed or administered together, and she further confirmed she should have checked for residual prior to medication administration. Interview on 03/09/22 at 7:33 A.M. with Director of Nursing (DON) confirmed medications administered through a tube feeding tube were to be crushed and administered separately and nurses were required to check for residual prior to medication administration. The DON verified LPN #500 crushed, combined and administered 12 medications. The medications should have been administered separately with a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365129 If continuation sheet Page 25 of 44 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 365129 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastbrook Healthcare Center 17322 Euclid Ave Cleveland, OH 44112 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 0760 water flush between each to avoid possible drug interactions. Level of Harm - Minimal harm or potential for actual harm Review of facility policy titled Administering Medications Through an Enteral Tube revised November 2018 revealed medications were to be administered separately and a flush was to be done in between. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365129 If continuation sheet Page 26 of 44 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 365129 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastbrook Healthcare Center 17322 Euclid Ave Cleveland, OH 44112 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation and interview the facility failed to ensure medications were secured, not expired and medications carts did not contain loose unidentifiable medications. This had the potential to affect all 85 residents currently residing in the facility. Findings include: 1. Observation on 03/07/22 at 8:37 A.M. revealed Licensed Practical Nurse (LPN) #502's medication cart contained an unidentified white powder in the top drawer, a bottle of ibuprofen with an expiration date of 02/22, and 22 unidentifiable loose pills in various compartments of the medication cart. Further observation revealed Resident #24's Humalog insulin pen had an open date of 01/10/22, Residents #70, #19, #49 and #229's insulin pens did not have an open date and Resident #22's insulin had an unreadable open date. Interview with LPN #502 confirmed the observations and stated expired medications should be discarded and insulin pens were to have a date of open due to insulins expired 30 days after opening. 2. Observation of the medication storage room on 03/07/22 at 1:00 P.M. with LPN #209 revealed various intravenous (IV) starter kits with expirations dates between 12/31/21 and 01/31/22, as well as a medication refrigerator that contained various IV medications with a temperature reading of 54 degrees Fahrenheit. Observations were confirmed with LPN #209 and she stated expired supplies should be discarded and the refrigerator temperature reading should be lower than 54 degrees, however, she was unable to state the required temperature. 3. Observation on 03/08/22 at 12:33 P.M. revealed four blister packs of medications left on the counter at the D floor nursing station which was located in the dining room. The D floor was the secured unit. The station was open on one side and accessible to anyone wanting to enter. There were eight residents in the dining room at the time (Residents #32, #34, #36, #44, #45, #52, #53 and #59) three of which were ambulatory and five using a wheelchair. The residents were as close as three feet to where the medications were sitting. There were nine additional residents on the secured unit with the ability to be mobile throughout the unit via wheelchair or ambulation. The residents on this unit had impaired cognition and judgement. Interview on 03/08/22 at 12:38 P.M. with State Tested Nursing Assistant (STNA) #216 revealed the nurse was on the C floor where she was also assigned to work and split her time throughout the day. Interview on 03/08/22 at 12:41 P.M. with STNA #221 revealed the pharmacist spoke to her about the medications then placed the medications at the station. Interview, observation and record review on 03/08/22 at 12:45 P.M. with the Housekeeping/Laundry Director (HDL) #262 verified the medications were laying on the nursing station counter. She picked up the medications to reveal what the labels said. The medications were for Resident #15 and included Galantamine 4 milligram (mg), Pravastatin 20 mg, Divalproex 500 mg and Galantamine 4 mg. HDL #262 took the medications with her. Interviews on 03/08/22 at 12:45 P.M. with STNA #211 and #221 revealed the pharmacist left around 10:00 A.M. STNA #221 verified the nurse was not on the floor since around 10:00 A.M. She stated LPN (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365129 If continuation sheet Page 27 of 44 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 365129 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastbrook Healthcare Center 17322 Euclid Ave Cleveland, OH 44112 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many #209 passed medications on D floor before going to C floor. STNA #211 stated it was her first day. She stated the pharmacist told her about the medications while at the nursing station and left the medications there. Interview on 03/08/22 at 1:00 P.M. with LPN #209 revealed she was unsure what time she left D floor but stated she did not see the pharmacist at any point. She was not aware of medications left on the counter at the nursing station. Interview via phone on 03/08/22 at 2:18 P.M. with Pharmacist #291 revealed he was at the facility on this date. He stated he saw the medications tucked into the chart rack at the nursing station and said he gave them to the nurse stating they could not go there and needed to be returned to the pharmacy. He was not aware of the name of the nurse but said it was her first day. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365129 If continuation sheet Page 28 of 44 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 365129 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastbrook Healthcare Center 17322 Euclid Ave Cleveland, OH 44112 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 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on observation and interview the facility failed to employ a designated person to serve as director of food services who meets qualifications. This had the potential to affect 77 residents who received meals in the facility. The facility identified Residents #11, #12, #21, #40, #65, #67, #57, and #434 as receiving no food from the kitchen. The facility census was 85. Findings include: Observation of the kitchen during the initial tour on 03/07/22 at 6:58 A.M. revealed one staff member in the kitchen who was identified as functioning dietary manager. Initial tour was completed with Dietary Manager #259 and findings were reviewed. Interview on 03/07/22 during initial tour of kitchen with DM #259 revealed DM #259 had signed up for ServSafe program (food safety training and certification courses) on 03/04/22. DM #259 indicated they were not a certified dietary manager (CDM) and did not meet any of requirements to serve in such position. Interview on 03/08/22 at 7:59 A.M. with Registered Dietitian (RD) #294 revealed she covered the facility two days per week and did not work full time in the facility. Interview on 03/09/22 at 7:10 A.M. with RD #294 confirmed DM #259 was not a CDM and did not hold any other certifications to meet the requirements. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365129 If continuation sheet Page 29 of 44 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 365129 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastbrook Healthcare Center 17322 Euclid Ave Cleveland, OH 44112 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation and resident and staff interview the facility failed to ensure foods were served at a palatable temperature and were visually pleasing. This affected six (Residents #5, #39, #66, #74, #435 and #438) of six residents reviewed for food and had the potential to affect and additional 71 residents who received meals prepared by the kitchen. The facility identified Residents #11, #12, #21, #40, #65, #67, #57, and #434 as receiving no food from the kitchen. The facility census was 85. Residents Affected - Many Findings include: 1. Interview with Resident #66 on 03/07/22 at 8:44 A.M. revealed the facility served food that was bland, tasteless and always cold. 2. Interview with Resident #435 on 03/07/22 at 9:05 A.M. revealed the food is never hot. 3. Interview with Resident #438 on 03/07/22 09:20 A.M. revealed the food tastes like dog food. 4. Interview with Resident #39 on 03/07/22 12:08 P.M. revealed the food tastes terrible and it always served cold. 5. Interview with Resident #74 on 03/08/22 at 7:01 A.M. revealed the food is awful and the color of the meat served was questionable. Resident #74 felt dogs ate better then the residents. 6. Observation of Resident #5 on 03/07/22 01:08 P.M. revealed his lunch tray arrived in the dinning room at 1:08 P.M. (the facility meal schedule noted lunch was to be served at 12:30 P.M.) Resident #5 uncovered his tray to reveal a pork cutlet that was gray in color and unrecognizable as pork. Resident #5 asked the surveyor to come over and look at his tray and try the food. The pork cutlet was cold in temperature, the mashed potatoes had the consistency of a paste like substance and were noticeably cold and the cauliflower was hard and undercooked. Temperature of the food was taken with a kitchen thermometer, another surveyor, and State Tested Nursing Assistant (STNA) #750 on 03/07/22 at 1:11 P.M. The following readings were noted and verified by STNA #750 • Pork cutlet 72 degrees Fahrenheit • Mashed potatoes 77 degrees Fahrenheit • (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365129 If continuation sheet Page 30 of 44 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 365129 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastbrook Healthcare Center 17322 Euclid Ave Cleveland, OH 44112 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 0804 Cauliflower 68 degrees Fahrenheit. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365129 If continuation sheet Page 31 of 44 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 365129 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastbrook Healthcare Center 17322 Euclid Ave Cleveland, OH 44112 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation, taste test and diet manual review the facility failed to prepare pureed foods at the proper consistency. This had the potential to affect two (Residents #280 and #432) of two residents prescribed a pureed diet. The facility census was 85. Findings include: Observation on 03/08/22 at 7:51 A.M. revealed [NAME] #302 was preparing pureed waffles for the breakfast meal. [NAME] #302 was noted to use water as a thinning agent. Taste test of the pureed waffles revealed it was very thick and not smooth with chunks of waffle throughout the mixture. Dietary Manager #259 confirmed the consistency of the pureed waffles. Confirmed with Registered Dietitian #294 thinning pureed foods with water was not an appropriate practice and not according to the recipe on 03/08/22 at 7:59 A.M. Review of a resident diet list revealed Residents #280 and #432 were prescribed a pureed diet. Review of Pureed Bread Products recipe (undated) revealed broth, milk, or juice should be used to thin during processing of pureed bread products including waffles. The recipe indicated to ensure the mixture achieves a moist mashed potato or pudding-like consistency. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365129 If continuation sheet Page 32 of 44 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 365129 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastbrook Healthcare Center 17322 Euclid Ave Cleveland, OH 44112 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review the facility failed to maintain a clean and sanitary kitchen area. This had the potential to affect 77 residents who received meals in the facility. The facility identified Residents #11, #12, #21, #40, #65, #67, #57, and #434 as receiving no food from the kitchen. The facility census was 85. Findings include: Observation of the kitchen during the initial tour with Dietary Manager (DM) #259 on 03/07/22 at 6:58 A.M. revealed a dishwashing area with two backed up sinks filled with approximately three to five inches of orange colored liquid and old food floating within. Observed dust and food residue coating the top of the dish machine. Observation of the dish machine cycle revealed adequate level of sanitizing chemicals, however, the temperature gauge was not in working order. DM #259 indicated it had been broken for a while and they did not know the actual temperature the dish machine was reaching. The floor and walls by the dish machine were covered with a dark colored food residue and food particles. Observed an uncovered trash can in the dish machine area. Observation of the food preparation area during initial tour revealed dark colored food residue and food particles on floors and walls behind the oven, steamer, and three compartment sink. Observed a steamer resting on a table covered in sticky food residue. Observed inside of the microwave food residue and food particles stuck to the sides. Observed the food preparation cart sitting next to the steamer with a bag of shredded cheese on top. The cart had three levels all which were covered in food residue and food particles. Observed dried grease had run down the back of the kitchen hood from the filter grates. Observed a plastic container of sweet chili sauce sitting on a food preparation table that was about half full with no date. Observed a second uncovered trash can in the food preparation area. Observation of a sprinkler system head with caged metal surrounding and an air conditioning unit in a window revealed both to be covered in dust. Observation of food storage areas during initial tour revealed a bag of dried spaghetti pasta that was wrapped in cling wrap with no date in the dry storage area. In the walk-in cooler, observed an open bag of lettuce wrapped in cling wrap, open sliced cheese wrapped in cling wrap, unopened deli turkey, and a tray of covered biscuits all with no dates. Observed open unwrapped deli ham and an unidentifiable unwrapped portion of a brown chunk of food both did not have a date. DM #259 indicated the unidentifiable food was a beef roast. Interview with DM #259 during the kitchen tour confirmed all observations. Follow up observations throughout the annual survey on 03/08/22 and 03/10/22 revealed continued issues with kitchen cleanliness as previously noted during initial tour. Interview on 03/08/22 at 7:59 A.M. with Registered Dietitian #294 and [NAME] President of Operations #301 confirmed sanitation concerns. Observation on 03/10/22 at 8:06 A.M. revealed [NAME] #302 using gloved hands to rinse off a food processor blade in the sink. [NAME] #302 use gloved hands to rub off stuck on food debris. [NAME] #302 then went over to the stove with the same gloved hands and reached in bag of cheese to add to scrambled eggs. DM #259 then walked up to [NAME] #302 and handed her a new pair of gloves. No hand (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365129 If continuation sheet Page 33 of 44 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 365129 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastbrook Healthcare Center 17322 Euclid Ave Cleveland, OH 44112 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 washing was observed between doffing and donning the new gloves. Confirmed findings with Registered Dietitian #294 at 8:13 A.M. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365129 If continuation sheet Page 34 of 44 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 365129 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastbrook Healthcare Center 17322 Euclid Ave Cleveland, OH 44112 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 - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to properly dispose of garbage and refuse in the dumpster. This had the potential to affect all 85 residents currently residing in the facility. Residents Affected - Many Findings include: Observation on 03/10/22 at 11:45 A.M. revealed dirt, debris, used gloves, and pop cans laying on the ground between two dumpsters. An old truck tire was sitting outside the dumpster enclosure. Interview on 03/10/22 at 12:10 P.M. confirmed findings with Dietary Manager #259. Dietary Manager #259 indicated maintenance will be made aware for cleanup. Review of facility policy Food-Related Garbage and Refuse Disposal dated October 2017 revealed outside dumpsters provided by garbage pickup service will be free of surrounding litter. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365129 If continuation sheet Page 35 of 44 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 365129 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastbrook Healthcare Center 17322 Euclid Ave Cleveland, OH 44112 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on interview, observation, and medical record review the facility failed to ensure accurate documentation was contained in the medical record. This affected two (Residents #31 and #47) of six residents reviewed for accurate documentation. The facility census was 85. Findings include: 1. Review of the medical record for Resident #31 revealed an admission date of 08/22/19. Diagnoses included orthopedic care following surgical amputation, local infection of the skin and subcutaneous (under the skin) tissue, type 2 diabetes, chronic obstructive pulmonary disease (COPD), moderate protein calorie malnutrition, hemiplegia and hemiparesis following cerebral infarction, Methicillin-resistant staphylococcus aureus (MRSA) of unspecified site, idiopathic aseptic necrosis of left toes, acquired absence of right leg above knee, major depressive disorder, and chronic viral hepatitis C. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 01/03/22, revealed the resident had moderate cognitive impairment as indicated by a Brief Interview for Mental Status (BIMS) score of 11/15. He required the extensive assistance of one staff member for bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing. Review of the physician orders dated 02/21/22 identified and order for a compression stocking/shrinker to the right above the knee amputation to be applied in the morning and removed at bedtime every shift for wound management. Observations on 03/07/22, 03/08/22, 03/09/22, and 03/14/22 revealed Resident #31 did not have the compression stocking/shrinker on the right above the knee amputation on any day. Observation and interview on 03/14/22 at 9:55 A.M. with Licensed Practical Nurse (LPN) #297 verified Resident #31 did not have a compression stocking/shrinker on the right above the knee amputation. She searched the resident's room and was unable to locate the stocking. The physician's order to apply the compression stocking in the morning was verified and LPN #297 confirmed that she signed for the application of the compression stocking in the Medication Administration Record on 03/14/22 and did not confirm that the stocking/shrinker was actually on the resident. Interview on 03/14/22 at 10:45 A.M. with the Director of Nursing (DON) revealed if an order was received for a compression stocking, therapy would provide the stocking. A substitute would be used if it was being laundered. The stocking/shrinker would be worn daily in the morning through bedtime until an order was received to discontinue it. Interview on 03/16/22 at 12:39 P.M. via phone, revealed the DON verified the compression stocking was signed for on 03/07/22, 03/08/22, 03/09/22, and 03/14/22 and was not in place. Therapy provided Resident #31 with a compression stocking on 03/16/22. 2. Review of the medical record for Resident #47 revealed an admission date of 08/31/21. Diagnoses included unspecified atrial fibrillation (irregular fast heartbeat), morbid obesity, chronic systolic congestive heart failure, obstructive sleep apnea, difficulty walking, major depressive disorder, and acute transverse myelitis of the central nervous system. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365129 If continuation sheet Page 36 of 44 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 365129 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastbrook Healthcare Center 17322 Euclid Ave Cleveland, OH 44112 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 0842 Level of Harm - Minimal harm or potential for actual harm Review of the quarterly MDS 3.0 assessment revealed the resident had intact cognition with a BIMS score of 15/15. She exhibited behaviors that included screaming out and disruptive sounds. She was always incontinent of bowel and bladder and required the extensive assistance of two staff members for bed mobility, transfers, and toileting. The extensive assistance of one staff member was required for dressing and bathing. Residents Affected - Few Interview on 03/09/22 at 1:56 P.M. with Unit Manager LPN #205 verified the shower sheet for Resident #47 was marked that she received a shower on 03/08/22. LPN #205 confirmed that the resident did not receive a shower on 03/08/22 but her signature was on the shower sheet that indicated a shower was given. Review of facility policy titled Charting and Documentation revised July 2017, revealed documentation in the medical record would be objective, complete, and accurate. Entries would be recorded in the resident's medical record by licensed personnel in accordance with state law and facility policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365129 If continuation sheet Page 37 of 44 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 365129 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastbrook Healthcare Center 17322 Euclid Ave Cleveland, OH 44112 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and policy review the facility failed to follow appropriate infection control procedures during provision of incontinence care for Resident #31 and medication administration for Resident #40. This affected one (Residents #31) of three residents observed for personal care and one (Resident #40) of three residents observed for medication administration. The facility census was 85. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #31 revealed an admission date of 08/22/19. Diagnoses included orthopedic care following surgical amputation, local infection of the skin and subcutaneous (under the skin) tissue, type 2 diabetes, chronic obstructive pulmonary disease (COPD), moderate protein calorie malnutrition, hemiplegia and hemiparesis following cerebral infarction, Methicillin-resistant staphylococcus aureus (MRSA) of unspecified site, idiopathic aseptic necrosis of left toes, acquired absence of right leg above knee, major depressive disorder, and chronic viral hepatitis C. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 01/03/22, revealed the resident had moderate cognitive impairment indicated by a Brief Interview for Mental Status (BIMS) score of 11/15. He required the extensive assistance of one staff member for bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing. Observation on 03/07/22 at 11:43 A.M. of incontinence care for Resident #31 by State Tested Nurse Aide (STNA) #276 revealed care was performed according to the standards of nursing practice. Upon completion of care, STNA #276 continued to apply a clean brief, cover the resident with a sheet, place the call light within reach of the resident, turn the television toward him, and use the bed controls to adjust the height and head of the bed. STNA #276 touched the items in the resident's environment without performing hand hygiene or changing gloves after providing incontinence care. Interview on 03/07/22 at 12:48 P.M. with STNA #276 verified the above observation. 2. Review of Resident #40's medical record revealed an admission date of 09/23/21 with diagnoses that included gastrostomy (feeding tube placement), tracheostomy and respiratory failure. Review of the care plan dated 09/24/21 revealed the resident required the use of a feeding tube related to dysphagia (difficulty swallowing) and interventions included, check tube for residual (amount of stomach contents remaining after administration of feeding solution or medications). Review of the Minimum Data Set (MDS) dated [DATE] revealed the resident had intact cognition and required extensive total dependence with transfers, toileting and personal hygiene. Review of physician orders for March 2022 revealed the resident was to have nothing by mouth (NPO), check for residual of the feeding tube every shift prior to feeds, and medications had been ordered to be administered via the resident feeding tube. Observation of medication administration on 03/07/22 at 10:56 A.M. with Licensed Practical Nurse (LPN) #500 for Resident #40 revealed LPN #500 took the following medications out of their packaging, placed the tablets into her bare hands and then placed them inside a medication cup; Diflucan (antifungal medication), clonodine (blood pressure medication), amlodipine (blood pressure medication), (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365129 If continuation sheet Page 38 of 44 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 365129 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastbrook Healthcare Center 17322 Euclid Ave Cleveland, OH 44112 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few doxcycline (antibiotic), famotidine (heartburn medication), prednisone (steroid), hydrochlorothiazide (diuretic), zyprexa (antipsychotic), senna (laxative) and omeprazole (heartburn medication). LPN #500 then placed all the medications into a plastic sleeve used to crush medications and also used her bare hands to open the omeprazole capsule and added the contents to the plastic sleeve. LPN #500 completed the medication administration and exited the room. Interview with LPN #500 at the time of the observation revealed she had not performed proper hand hygiene prior to handling Resident #40's medications with her bare hands. Review of facility policy titled Handwashing/Hand Hygiene revised August 2019, revealed staff would wash hands using an alcohol-based hand rub containing at least 62% alcohol, or soap and water before moving from a contaminated body site to a clean body site during resident care, as well as after contact with resident's intact skin, and or contact with blood or bodily fluids. Gloves were to be used along with routine hand hygiene. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365129 If continuation sheet Page 39 of 44 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 365129 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastbrook Healthcare Center 17322 Euclid Ave Cleveland, OH 44112 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm Based on interview, medical record review, and policy review the facility failed to provide documentation that residents and/or their representatives were provided educational information regarding the risks and benefits, and informed consent/refusal for influenza and pneumococcal vaccinations. This affected five (Residents #12, #13, #67, #429, and #439) of seven residents reviewed for influenza and pneumococcal immunizations. The facility census was 85. Residents Affected - Some Findings include: 1. Review of the medical record for Resident #12 revealed an admission date of 02/21/21. Diagnoses included chronic respiratory failure, type 2 diabetes, anoxic (lack of oxygen) brain damage, dysphagia (difficulty swallowing), hypertension, epilepsy, and anxiety disorder. The resident had a legal guardian due to cognitive impairment. Review of the immunization record revealed the resident refused consent for the influenza vaccine with no date documented. There was no documentation regarding the pneumococcal vaccine. Further review of the medical record lacked evidence regarding Resident #12 and/or their representative receiving educational information including risks and benefits, informed consent, or refusal of consent for the influenza or pneumococcal vaccine. 2. Review of the medical record for Resident #13 revealed an admission date of 12/10/21. Diagnoses included Wernicke's encephalopathy, dysphagia following cerebral vascular disease, atrial fibrillation (irregular fast heartbeat), osteoarthritis, and delusional disorders. The resident was her own responsible party. Review of the immunization record lacked documentation regarding the pneumococcal vaccine. Further review of the medical record lacked evidence regarding Resident #13 receiving educational information including risks and benefits, informed consent, or refusal of consent for the pneumococcal vaccine. 3. Review of the medical record for Resident #67 revealed an admission date of 09/15/21 and a discharge date of 03/14/22. Diagnoses included acute and chronic respiratory failure, encounter for attention to tracheostomy (opening in the throat for a breathing tube), type 2 diabetes, hypertension, and pneumonia. The resident was his own responsible party. Review of the immunization record revealed the resident received the flu vaccine on 10/01/20 but refused consent upon admission with no date documented. Further review of the medical record lacked evidence regarding Resident #67 receiving educational information including risks and benefits, informed consent, or refusal of consent for the influenza or pneumococcal vaccines. 4. Review of the medical record for Resident #429 revealed an admission date of 02/14/22. Diagnoses included hemiplegia and hemiparesis of the right dominant side following cerebral infarction, type 2 diabetes, atherosclerosis of coronary artery bypass grafts, and hypertension. The resident was his own responsible party. Review of the immunization record lacked documentation regarding the influenza or pneumococcal vaccines. Further review of the medical record lacked evidence regarding Resident #429 receiving educational information including risks and benefits, informed consent, or refusal of consent for the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365129 If continuation sheet Page 40 of 44 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 365129 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastbrook Healthcare Center 17322 Euclid Ave Cleveland, OH 44112 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 0883 influenza or pneumococcal vaccines. Level of Harm - Minimal harm or potential for actual harm 5. Review of the medical record for Resident #439 reveled an admission date of 01/21/22. Diagnoses included chronic obstructive pulmonary disease, anxiety disorder, schizophrenia, Crohn's disease, type 2 diabetes, and epilepsy. The resident was her own responsible party. Residents Affected - Some Review of the immunization record lacked documentation regarding the influenza or pneumococcal vaccines. Further review of the medical record lacked evidence regarding Resident #439 receiving educational information including risks and benefits, informed consent, or refusal of consent for the influenza or pneumococcal vaccines. Interview on 03/15/22 at 12:25 PM with the Director of Nursing (DON) revealed vaccination information was part of the admission questionnaires and was built into the admission assessment. Unit Managers were to complete vaccination information prior to entering the facility and the information was to be entered into immunization tab in the electronic medical record. She verified the lack of influenza and pneumococcal vaccination documentation in the immunization record for Resident #12, #13, #67, #429, and #439. She also verified the lack of documentation in the medical record regarding residents and/or their representatives receiving educational information, informed consent, or refusal of consent for the influenza and pneumococcal vaccines for Resident #12, #13, #67, #429, and #439. Review of the facility policy titled Vaccination of Residents revised October 2019, revealed the facility would offer all residents vaccines, including the influenza and pneumococcal vaccines, that aid in preventing infectious diseases unless the vaccine is medically contraindicated, or the resident had already been vaccinated. Prior to receiving vaccinations, the resident or their legal representative would be provided information and education regarding the benefits and potential side effects of the vaccinations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365129 If continuation sheet Page 41 of 44 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 365129 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastbrook Healthcare Center 17322 Euclid Ave Cleveland, OH 44112 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 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Based on interview, medical record review, and facility policy review, and review of the Centers for Medicare and Medicaid (CMS) guidance the facility failed to provide documentation that residents and/or their representatives were provided educational information including risks and benefits, and informed consent/refusal for COVID-19 vaccinations. This affected three (Residents #67, #429, and #439) of seven residents reviewed for COVID-19 immunizations. The facility census was 85. Findings include: 1. Review of the medical record for Resident #67 revealed an admission date of 09/15/21 and a discharge date of 03/14/22. Diagnoses included acute and chronic respiratory failure, encounter for attention to tracheostomy (opening in the throat for a breathing tube), type 2 diabetes, hypertension, and pneumonia. The resident was his own responsible party. Review of the immunization record lacked documentation regarding the COVID-19 vaccination. Further review of the medical record lacked evidence regarding Resident #67 receiving educational information including risks and benefits, informed consent, or refusal of consent for the COVID-19 vaccinations. 2. Review of the medical record for Resident #429 revealed an admission date of 02/14/22. Diagnoses included hemiplegia and hemiparesis of the right dominant side following cerebral infarction, type 2 diabetes, atherosclerosis of coronary artery bypass grafts, and hypertension. The resident was his own responsible party. Review of the immunization record lacked documentation regarding the COVID-19 vaccination. Further review of the medical record lacked evidence regarding the resident receiving educational information including risks and benefits, informed consent, or refusal of consent for the COVID-19 vaccinations. 3. Review of the medical record for Resident #439 reveled an admission date of 01/21/22. Diagnoses included chronic obstructive pulmonary disease, anxiety disorder, schizophrenia, Crohn's disease, type 2 diabetes, and epilepsy. The resident was her own responsible party. Review of the immunization record lacked documentation regarding the COVID-19 vaccination. Further review of the medical record lacked evidence regarding the resident receiving educational information including risks and benefits, informed consent, or refusal of consent for the COVID-19 vaccinations. Interview on 03/15/22 at 12:25 PM with the Director of Nursing (DON) revealed vaccination information was part of the admission questionnaires and was built into the admission assessment. Unit Managers were to complete vaccination information prior to entering the facility and the information was to be entered into immunization tab in the electronic medical record. She verified the lack of COVID-19 vaccination documentation in the immunization record for Resident #67, #429, and #439. She also verified the lack of evidence in the medical record regarding residents and/or their representatives receiving educational information including risks and benefits, informed consent, or refusal of consent for the COVID-19 vaccines for Resident #67, #429, and #439. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365129 If continuation sheet Page 42 of 44 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 365129 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastbrook Healthcare Center 17322 Euclid Ave Cleveland, OH 44112 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 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the facility policy titled COVID-19 Vaccination dated 03/26/21, revealed the facility would offer and provide the COVID-19 vaccination as recommended by the Centers for Disease Control(CDC), and other regulatory bodies to minimize the risk of residents and staff acquiring, transmitting, or experiencing complications of COVID-19. A consent form would be completed at that time. It was recommended that any resident who was not exhibiting signs or symptoms of COVID-19 and did not have a positive test should be offered the COVID-19 vaccination. The facility would record the receipt, refusal, or contraindications within the medical record and/or the electronic medical record system. Review of the Centers for Medicare and Medicaid (CMS) Quality /Quality, Safety and Oversight Group (QSO-21-19-NH), dated 05/11/21 revealed on 05/11/2021 CMS published an interim final rule. This rule established Long-Term Care (LTC) Facility Vaccine Immunization Requirements for Residents and Staff. This included new requirements for educating residents or residents representatives and staff regarding the benefits and potential side effects associated with the COVID-19 vaccine and offering the vaccine. Furthermore, LTC facilities must report COVID-19 vaccine and therapeutic treatment information to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network. If the vaccine was unavailable in the facility, the facility should provide information on obtaining vaccination opportunities (e.g. Health Department or local pharmacy). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365129 If continuation sheet Page 43 of 44 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 365129 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastbrook Healthcare Center 17322 Euclid Ave Cleveland, OH 44112 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Level of Harm - Minimal harm or potential for actual harm Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation and staff interview the facility failed to ensure it maintained a clean and sanitary environment. This had the potential to affect all 85 residents currently residing in the facility. Residents Affected - Many Findings include: An environmental tour was conducted on 03/08/22 between 2:15 P.M. and 3:02 P.M. the following was observed and verified by Housekeeping Director #262 in an interview on 03/08/22 at 3:33 P.M. -The baseboard heating boards throughout the facility in the three facility dinning rooms and resident rooms showed various significant levels of scraping, scuffing, rust and paint chipping - In the 3rd floor dinning room the light fixtures above resident eating areas were encased in dust and other debris. A simple light tap of the fixtures would cause significant dust and debris to fall down to the resident eating area -The third floor hand rails showed significant paint chipping and peeling. -The main elevator had significant food stains on the floor of the elevator. -The room belonging to Resident #9 revealed the air conditioner was missing a filter cover. -The room belonging to Residents #34 and #52 revealed the lights above their beds were cracked or missing. -The side table in Resident #52's room was missing drawers. -The fall mats utilized by Residents #7, #53 and #75 were significantly torn and tattered and stained with various unknown substances. -The tube feed poles utilized by Residents #12 #29, #65 and #67 were significantly covered with various levels of dried residual tube feed. -Resident #28 had no privacy curtain for her side of the room. -Resident #23 was sleeping on a pillow case that was light brown in color. -Resident #27's room had no cover to the overhead ceiling light. -Residents #62's room had significant scraps, gouges and paint chips on the wall. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365129 If continuation sheet Page 44 of 44

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Citations

32 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0511GeneralS&S Epotential for harm
Have properly installed electrical wiring and gas equipment.
0225GeneralS&S Epotential for harm
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
0232GeneralS&S Epotential for harm
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
0311GeneralS&S Epotential for harm
Have an enclosure around a vertical opening shaft.
0331GeneralS&S Epotential for harm
Construct fire resistant interior walls.
0363GeneralS&S Epotential for harm
Install corridor and hallway doors that block smoke.
0641GeneralS&S Epotential for harm
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
0645GeneralS&S Dpotential for harm
F645 - Preadmission Screening for individuals with a mental disorder and individuals
PASARR screening for Mental disorders or Intellectual Disabilities
0656GeneralS&S Epotential for harm
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
0677GeneralS&S Dpotential for harm
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
0686GeneralS&S Dpotential for harm
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
0687GeneralS&S Dpotential for harm
F687 - Foot care
Provide appropriate foot care.
0690GeneralS&S Dpotential for harm
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
0692GeneralS&S Dpotential for harm
F692 - Assisted nutrition and hydration
Provide enough food/fluids to maintain a resident's health.
0727GeneralS&S Fpotential for harm
F727 - Except when waived under paragraph (f) or (g) of this section, the
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
0732GeneralS&S Cno actual harm
F732 - Nurse Staffing Information
Post nurse staffing information every day.
0759GeneralS&S Dpotential for harm
F759 - Medication Errors
Ensure medication error rates are not 5 percent or greater.
0761GeneralS&S Fpotential for harm
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
0801GeneralS&S Fpotential for harm
F801 - Staffing
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
0804GeneralS&S Fpotential for harm
F804 - Food and drink
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
0805GeneralS&S Dpotential for harm
F805 - Food and drink
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
0812GeneralS&S Fpotential for harm
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
0883GeneralS&S Epotential for harm
F883 - Influenza and pneumococcal immunizations
Develop and implement policies and procedures for flu and pneumonia vaccinations.
0887GeneralS&S Epotential for harm
F887 - Infection control
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
0921GeneralS&S Fpotential for harm
F921 - Other Environmental Conditions
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
0636GeneralS&S Dpotential for harm
F636 - Resident Assessment
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
0657GeneralS&S Dpotential for harm
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
0814GeneralS&S Fpotential for harm
F814 - Food Safety Requirements
Dispose of garbage and refuse properly.
0578GeneralS&S Epotential for harm
F578 - The right to request, refuse, and/or discontinue treatment, to participate in or
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.
0760GeneralS&S Dpotential for harm
F760 - Residents are free of any significant medication errors
Ensure that residents are free from significant medication errors.
0842GeneralS&S Dpotential for harm
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
0880GeneralS&S Dpotential for harm
F880 - Infection Control
Provide and implement an infection prevention and control program.

FAQ · About this visit

Common questions about this visit

What happened during the March 17, 2022 survey of EASTBROOK HEALTHCARE CENTER?

This was a inspection survey of EASTBROOK HEALTHCARE CENTER on March 17, 2022. The surveyor cited 32 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at EASTBROOK HEALTHCARE CENTER on March 17, 2022?

Yes, 32 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Have properly installed electrical wiring and gas equipment."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed June 15, 2026. If you believe any information is inaccurate, report it here.

Inspection·March 17, 2022