Inspection·October 23, 2023

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of the facility policy, the facility failed to ensure Resident's #15, #26, #49 and #50 were supervised while they were smoking and failed to ensure Resident #15 was wearing a smoking apron while smoking. This affected four residents (#15, #26, #49 and #50) reviewed for smoking safety and had the potential to affect all 33 residents (Resident's #1, #2, #5, #6, #8, #9, #11, #13, #14, #15, #18, #23, #25, #26, #33, #36, #43, #49, #50, #54, #56, #58, #59, #61, #62, #64, #67, #74, #75, #80, #87, #89, #95) who smoked in the facility. The facility census was 91. Residents Affected - Some Findings include: 1. Review of Resident #15's medical record revealed an admission date of 03/29/23 and diagnoses included necrotizing fasciitis, acquired absence of left leg above the knee, type two diabetes mellitus without complications, arthritis due to other bacteria left hip and arthritis due to other bacteria right wrist. Review of Resident #15's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #15 was cognitively intact. Resident #15 required extensive assistance of one staff member for locomotion off the unit and personal hygiene. Resident #15 had upper extremity impairment on one side and lower extremity impairment on one side. Resident #15 used a wheelchair. Review of Resident #15's Smoking Safety assessment dated [DATE] included Resident #15 had cognitive loss, a visual deficit, and dexterity problems. Resident #15's plan of care was used to assure resident was safe while smoking. Resident #15 needed a smoking apron and supervision while smoking. Review of Resident #15's care plan dated 09/16/23 included Resident #15 was a cigarette smoker by personal choice. Resident #15 would not suffer an injury from unsafe smoking practices through the next review date. Interventions included to supervise and provide assistance as needed. Observation on 10/10/23 at 4:24 P.M. of Resident #15 revealed the resident was outside in a secured area smoking with other residents Resident's #15 was not wearing a smoking apron. Observation revealed there was no staff member supervising the residents while they smoked. Observation on 10/10/23 at 4:26 P.M. revealed Activities Aide (AA) #333 walked out of the facility and into the outside secured area. When asked if Resident #15 should be supervised while they smoked AA #333 said these residents do not need supervision while they smoked. Interview on 10/11/23 at 4:04 P.M. with the Director of Nursing (DON) revealed she expected residents to be supervised by staff while they were smoking. Interview on 10/12/23 at 2:40 P.M. with Administrator revealed today was the first day smoking break assignments were scheduled through workforce management software. The Administrator stated before 10/12/23 the activities and nursing departments covered smoke breaks. The Administrator indicated activities covered afternoon smoke breaks and nursing would cover the rest of the smoke breaks. The Administrator stated staff who smoked would usually volunteer to cover smoke breaks. Interview on 10/12/23 at 3:14 P.M. of Activities Director (AD) #305 revealed activities covered the 12:00 P.M. and 2:00 P.M. smoke breaks and nursing covered the other smoke break times. AD #305 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365129 If continuation sheet Page 2 of 15 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 10/23/2023 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some stated if nursing was unable to cover a smoke break then they would step in and supervise the smoke break. AD #305 stated the nursing department covered the 4:00 P.M. smoke break. 2. Review of Resident #26's medical record revealed an admission date of 02/02/23 and diagnoses included acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, anxiety disorder and need for assistance with personal care. Review of Resident #26's care plan dated 08/14/23 included Resident #26 was a cigarette smoker by personal choice. Resident #26 would not suffer injury from unsafe smoking practices through next review date. Interventions included to supervise and provide assistance as needed. Review of Resident #26's Quarterly MDS 3.0 assessment dated [DATE] revealed Resident #26 had severe cognitive impairment. Resident #26 required supervision of one staff member for locomotion on and off the unit. Resident #26 used a wheelchair. Observation on 10/10/23 at 4:24 P.M. of Resident #26 revealed the resident was outside in a secured area smoking with other residents. Observation revealed there was no staff member supervising the residents while they smoked. Observation on 10/10/23 at 4:26 P.M. revealed AA #333 walked out of the facility and into the outside secured area. When asked if Resident #26 should be supervised while they smoked AA #333 said these residents do not need supervision while they smoked. Interview on 10/11/23 at 4:04 P.M. with DON revealed she expected residents to be supervised by staff while they were smoking. Interview on 10/12/23 at 2:40 P.M. with Administrator revealed today was the first day smoking break assignments were scheduled through workforce management software. The Administrator stated before 10/12/23 the activities and nursing departments covered smoke breaks. The Administrator indicated activities covered afternoon smoke breaks and nursing would cover the rest of the smoke breaks. The Administrator stated staff who smoked would usually volunteer to cover smoke breaks. Interview on 10/12/23 at 3:14 P.M. of AD #305 revealed activities covered the 12:00 P.M. and 2:00 P.M. smoke breaks and nursing covered the other smoke break times. AD #305 stated if nursing was unable to cover a smoke break then they would step in and supervise the smoke break. AD #305 stated the nursing department covered the 4:00 P.M. smoke break. 3. Review of Resident #49's medical record revealed an admission date of 01/18/18 and diagnoses included hemiplegia (paralysis) and hemiparesis (weakness) following cerebral infarction affecting the left non-dominant side, ataxia (impaired coordination) following cerebral infarction, and muscle weakness. Review of Resident #49's Quarterly MDS 3.0 assessment dated [DATE] included Resident #49 had moderate cognitive impairment. Resident #49 required supervision of one staff member for locomotion on the unit and limited assistance of one staff member for locomotion off the unit. Resident #49 had upper and lower extremity impairment on one side. Resident #49 used a wheelchair. Review of Resident #49's care plan dated 09/16/23 included Resident #49 was a cigarette smoker by personal choice. Resident #49 would not smoke without supervision through the next review date. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365129 If continuation sheet Page 3 of 15 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 10/23/2023 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident #49 would not suffer injury from unsafe smoking practices through next review date. Interventions included to supervise and provide assistance as needed. Review of Resident #49's Smoking Safety assessment dated [DATE] included Resident #49 did not have cognitive loss, and had a visual deficit. Resident #49's plan of care was used to assure Resident #49 was safe while smoking. Resident #49 required supervision while smoking. Observation on 10/10/23 at 4:24 P.M. of Resident #49 revealed the resident was outside in a secured area smoking with other residents. Observation revealed there was no staff member supervising the residents while they smoked. Observation on 10/10/23 at 4:26 P.M. revealed AA #333 walked out of the facility and into the outside secured area. When asked if Resident #49 should be supervised while they smoked AA #333 said these residents do not need supervision while they smoked. Interview on 10/11/23 at 4:04 P.M. with the DON revealed she expected residents to be supervised by staff while they were smoking. Interview on 10/12/23 at 2:40 P.M. with Administrator revealed today was the first day smoking break assignments were scheduled through workforce management software. The Administrator stated before 10/12/23 the activities and nursing departments covered smoke breaks. The Administrator indicated activities covered afternoon smoke breaks and nursing would cover the rest of the smoke breaks. The Administrator stated staff who smoked would usually volunteer to cover smoke breaks. Interview on 10/12/23 at 3:14 P.M. with AD #305 revealed activities covered the 12:00 P.M. and 2:00 P.M. smoke breaks and nursing covered the other smoke break times. AD #305 stated if nursing was unable to cover a smoke break then they would step in and supervise the smoke break. AD #305 stated the nursing department covered the 4:00 P.M. smoke break. 4. Review of Resident #50's medical record revealed an admission date of 09/03/20 and diagnoses included muscle weakness, delusional disorders, and presence of right artificial hip joint. Review of Resident #50's care plan dated 03/14/23 included Resident #50 was a cigarette smoker by personal choice. Resident #50 would not smoke without supervision through the next review date. Resident #50 would not suffer injury from unsafe smoking practices through next review date. Interventions included to supervise and provide assistance as needed. Review of Resident #50's Annual MDS 3.0 assessment dated [DATE] revealed Resident #50 had severe cognitive impairment. Resident #50 required supervision of one staff member for locomotion on and off the unit. Resident #50 had lower extremity impairment on one side. Resident #50 used a wheelchair. Review of Resident #50's Smoking Safety assessment dated [DATE] included Resident #50 had cognitive loss. Resident #50's plan of care was used to assure Resident #50 was safe while smoking. Resident #50 required supervision while smoking. Observation on 10/10/23 at 4:24 P.M. of Resident #50 revealed the resident was outside in a secured area smoking with other residents. Observation revealed there was no staff member supervising the residents while they smoked. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365129 If continuation sheet Page 4 of 15 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 10/23/2023 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation on 10/10/23 at 4:26 P.M. revealed AA #333 walked out of the facility and into the outside secured area. When asked if Resident #50 should be supervised while they smoked AA #333 said these residents do not need supervision while they smoked. Interview on 10/11/23 at 4:04 P.M. with the DON revealed she expected residents to be supervised by staff while they were smoking. Interview on 10/12/23 at 2:40 P.M. with Administrator revealed today was the first day smoking break assignments were scheduled through workforce management software. The Administrator stated before 10/12/23 the activities and nursing departments covered smoke breaks. The Administrator indicated activities covered afternoon smoke breaks and nursing would cover the rest of the smoke breaks. The Administrator stated staff who smoked would usually volunteer to cover smoke breaks. Interview on 10/12/23 at 3:14 P.M. with AD #305 revealed activities covered the 12:00 P.M. and 2:00 P.M. smoke breaks and nursing covered the other smoke break times. AD #305 stated if nursing was unable to cover a smoke break then they would step in and supervise the smoke break. AD #305 stated the nursing department covered the 4:00 P.M. smoke break. Review of a list of residents who smoke revealed Resident's #1, #2, #5, #6, #8, #9, #11, #13, #14, #15, #18, #23, #25, #26, #33, #36, #43, #49, #50, #54, #56, #58, #59, #61, #62, #64, #67, #74, #75, #80, #87, #89, #95 smoked. Review of the facility policy titled Resident Smoking Policy undated included staff would supervise all smoking sessions to ensure safety regulations were met. This deficiency represents non-compliance investigated under Complaint Number OH00147268. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365129 If continuation sheet Page 5 of 15 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 10/23/2023 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Residents Affected - Few Based on closed medical record review, review of Emergency Department notes, review of facility investigative information, review of facility elopement and missing resident policy and procedures and interviews, the facility failed to provide adequate supervision to prevent Resident #92, who had cognitive impairment, wandering behaviors and diagnoses of schizophrenia and dementia, from eloping from the facility. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm on 08/18/23 at approximately 8:30 P.M. when Resident #92 walked through the secured third-floor nursing unit back hallway door leading to a stairwell without staff knowledge; the door alarm sounded and was turned off by Agency Licensed Practical Nurse (LPN) #210 who failed to check to make sure all the residents residing on the secured third-floor nursing unit were on the unit and failed to notify other staff members the alarm sounded and was turned off. Resident #92 proceeded to walk down the stairs to the secured second-floor nursing unit back entrance which led to the outside. Resident #92 walked outside, the door alarm sounded, and he walked out of the facility into the parking lot. STNA #278 heard the second-floor door alarm sound and went to check the door, she saw a man walking in the parking lot, but did not think it was a facility resident and did not go outside to further investigate who the man was. Resident #92 was found by railroad tracks (approximately a quarter mile from the facility, after he experienced a fall without loss of consciousness. Resident #92 was noted to have abrasions to his left elbow and forearm and was transported to the local hospital Emergency Department on 08/18/23 around 11:30 P.M. This affected one resident (#92) of three residents reviewed for elopement. On 10/10/23 at 3:29 P.M. the Administrator, [NAME] President of Operations #209 and [NAME] President of Clinical Services #211 were notified Immediate Jeopardy began on 08/18/23 at approximately 8:30 P.M. when Resident #92 opened two facility secured doors (alarms sounded for both doors), walked out of the facility and was found by railroad tracks around 11:00 P.M. after he experienced a fall. Staff were unaware the resident had eloped from the facility at the time of the incident. The Immediate Jeopardy was removed and corrected on 08/19/23 when the facility implemented the following corrective actions: • A resident head count was completed on 8/18/2023 at 11:00 P.M. by facility staff. • On 08/18/23 Resident #92 was evaluated in the Emergency Department and no medical treatment was warranted. The resident returned to the facility on [DATE] at 5:31 P.M. and was placed on one-on-one (staff) supervision until being discharged from the facility on 08/31/23. • Within two hours of notification that Resident #92 was missing from the facility, the Administrator physically verified and visualized that all door alarms, mag locks, secure care system, window (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365129 If continuation sheet Page 6 of 15 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 10/23/2023 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 0689 guards, and window stops were all in functioning order so no other residents were at risk for elopement. Level of Harm - Immediate jeopardy to resident health or safety • Residents Affected - Few A route cause analysis was completed on 8/19/2023 by the interdisciplinary team. The interdisciplinary team identified the root cause was Agency LPN #210 deactivated sounding door alarm to the D floor stairwell (secured third-floor nursing unit) without identifying the reason why the door was alarming. Agency LPN #210's shift ended on 08/18/23 at 11:00 P.M. The agency nurse was placed on a do not return (DNR) list following this shift. • Facility staff, including agency staff, nursing, activities, therapy, laundry, housekeeping, admissions, maintenance, and business office were educated on the proper response to facility door alarms and initial resident search expectations when door alarms were activated. • The Administrator or Designee educated all staff on missing resident policy and procedure for responding to the door alarm by 8/19/2023. • Beginning 08/19/23, the Administrator or Designee completed elopement drills on each shift for seven days and with a plan to continue to complete elopement drills monthly for four months. • The Administrator or Designee had agency staff review facility policies including elopement, missing resident procedure and the process for what to do when an alarm was activated. The education would be reviewed at the front desk or prior to entering the clinical area. The front desk was monitored by staff around the clock by 08/19/2023 to ensure all staff reviewed. • On 08/19/23 the Director of Nursing or Designee completed elopement risk assessments for all facility residents to ensure appropriate precautions and interventions were put in place. • The Director of Nursing or Designee reviewed all residents care plans who residents who were identified as high risk for elopement and revised as needed by 8/19/2023. • The facility residents identified as high risk for elopement plans of care were reviewed and revised as needed by the Director of Nursing or designee by 8/19/2023. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365129 If continuation sheet Page 7 of 15 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 10/23/2023 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 0689 • Level of Harm - Immediate jeopardy to resident health or safety Director of Nursing or Designee reviewed the elopement book and updated all Resident identification (photos, name, address, phone, etcetera) information by 8/19/2023. • Residents Affected - Few The Director of Nursing or Designee posted visual signs at the front, rear exit door alerting residents, families, and friends to notify staff when a resident is leaving the facility and need to sign out at the nurse's station by 8/19/2023. • The facility Administrator or Designee reviewed the Elopement Prevention-missing person policy and noted it would be updated as needed by 8/19/2023. • The VP (vice president) of Operations and VP of Clinical services reviewed the Abuse Prohibition policy by 8/19/2023. • The Administrator or Designee educated all facility staff on the Abuse Prohibition Policy by 8/19/2023. • The Administrator educated all facility staff on responding to any alarms in the building promptly and to do a visual resident observation if a resident exhibited exit seeking behavior or expressed a desire to leave LOA (leave of absence)/AMA (against medical advice) by 8/19/2023. • The Administrator or Designee completed education on the sign in, sign out procedure to residents and responsible party by 8/20/2023. • The Administrator/designee communicated with family and visitors concerning the purpose, use of alarmed exit doors, and risk for residents leaving by 8/20/2023. • The Administrator notified all resident representatives via broadcast message, educating them on the facility's process for unplanned LOA and personal outing by 8/20/2023. • (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365129 If continuation sheet Page 8 of 15 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 10/23/2023 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few The facility interdisciplinary team (IDT) conducted T Ad Hoc Quality Assessment Performance Improvement (QAPI) meeting to discuss the elopement incident and review the facility plan of correction by 08/21/2023. • Beginning 08/19/23 the facility began auditing elopement policy/review for current and agency staff. Audits consisted of three facility staff members and three agency staff members weekly for two weeks, two facility staff members and two agency staff members weekly for two weeks and one facility staff member weekly and one agency staff member for two weeks. Elopement drills would be audited every shift for seven days and then monthly times four weeks. Updates to the elopement book would be audited weekly for four weeks. All identified areas would be submitted to the Quality Assurance committee for additional analysis, review, and implementation of corrective actions, in-services, or modified policies and procedures. Findings include: Review of Resident #92's closed medical record revealed an admission date of 05/01/23 with diagnoses including schizophrenia, delusional disorder, diffuse traumatic brain injury without loss of consciousness, dementia, and epilepsy. Resident #92 was discharged from the facility on 08/31/23. Review of Resident #92's care plan dated 05/13/23 included Resident #92 was an elopement risk, wanderer related to history of attempts to leave facility unattended, impaired cognition, impaired safety awareness, new environment, traumatic brain injury (TBI), delusions and agitation. The goal developed with a target date of 08/20/23 indicated Resident #92 would not leave the facility unattended and Resident #92's safety would be maintained (through the review date). Interventions included to assess Resident #92's fall risk, identify pattern of wandering, (was wandering purposeful, aimless, or escapist, was resident looking for something, does wandering indicate the need for more exercise) and intervene as appropriate. On 07/18/23 the plan of care was updated to included safety checks every 15 minutes. initiated 07/18/23. Review of Resident #92's physician's orders revealed an order, dated 07/17/23 for every 15-minute checks for wandering. Review of Resident #92's Elopement Evaluation dated 07/13/23 revealed Resident #92 was at risk of elopement. Review of Resident #92's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #92 had severe cognitive impairment. The assessment revealed Resident #92 required supervision and a one-person (staff) physical assist for bed mobility, transfers, and locomotion on and off the unit. Resident #92 was not steady walking, but able to stabilize without staff assistance. Review of a nurse practitioner progress note, dated 08/11/23 included Resident #92 was still wandering. Further review revealed Resident #92 required a secure memory unit for safety due to TBI and bipolar disorder (psychiatry following in-house). Continue with meds (medications) and monitor. Review of a hospital emergency department note, dated 08/18/23 at 10:51 P.M. revealed Resident #92 arrived to the local hospital Emergency Department via ambulance and Emergency Medical Services (EMS) and was admitted due to a fall. Resident #92 told the Emergency Department staff he got lost on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365129 If continuation sheet Page 9 of 15 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 10/23/2023 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few his walk and tripped over a rock and fell backwards. Resident #92 was found by train the tracks. Resident #92 stated he hit his head but denied loss of consciousness. Review of a cat scan (CT) of the head, without contrast dated 08/19/23 at 2:38 A.M. revealed Resident #92 had an unwitnessed fall with head strike and findings included no acute intracranial hemorrhage or mass effect. Review of Resident #92's medical record/progress notes revealed no written documentation related to an actual elopement on 08/18/23. Review of Resident #92's progress notes dated 08/19/23 at 6:30 A.M. revealed the local hospital Emergency Department was contacted for an update on Resident #92. The notes included Resident #92 was being discharged and was awaiting transportation. The notes did not document why Resident #92 was transported to the local hospital Emergency Department. Review of Resident #92's Elopement Evaluation dated 08/19/23 revealed Resident #92 was at risk for elopement. Review of a facility investigation included a staff interview, dated 08/19/23 from Licensed Practical Nurse (LPN) #210 who revealed she was the nurse assigned to the secured third-floor memory unit (on 08/18/23) when Resident #92 eloped from the facility. LPN #210 stated she was completing medication administration for the residents and heard the back stairwell alarm sound. LPN #210 turned the door alarm off. LPN #210 stated the State Tested Nursing Assistant (STNA) was in a resident room providing resident care. LPN #210 stated she did not look for any residents and stated she did not tell the STNA about the alarm. Review of a facility investigation included a staff interview, dated 08/19/23 from STNA #204 who was assigned to the secured third-floor memory unit (on 08/18/23) when Resident #92 eloped from the facility. STNA #204 stated Resident #92 asked about a shower, and she told him she could help him with a shower. STNA #92 revealed the nurse left the unit and STNA #204 was redirecting another resident from trying to leave the unit. LPN #210 never told STNA #204 anything about the alarm. STNA #204 stated she did not know Resident #92 was missing or off the unit until around 10:30 P.M. to 10:45 P.M. when she could not find Resident #92 to help him into bed and immediately notified LPN #210 and Supervisor #265. A staff statement, dated 08/19/23 from Supervisor #265 revealed she was told Resident #92 was missing (on 08/18/23) at 11:15 P.M. Supervisor #265 stated LPN #210 never told her she heard an alarm going off. A search was immediately initiated for Resident #92. Supervisor #265 stated she was notified by local hospital staff that Resident #92 was in the Emergency Department. A staff statement, dated 08/19/23 revealed STNA #278 was assigned to the back hallway of the second-floor nursing unit when Resident #92 eloped from the facility. STNA #278 stated she heard an alarm sounding around 8:30 P.M. for the door leading outside to the back parking lot. STNA #278 checked the door, looked outside, and saw a man walking out of the parking lot. STNA #278 indicated she did not realize it was Resident #92 because people who were not residents in the facility always stood in the parking lot or lay in the grass. Review of Resident #92's Weekly Skin assessment dated [DATE] at 10:37 P.M. revealed a new area was found. The new area was an abrasion of the left outer forearm, in-house acquired on 08/18/23. Resident #92's abrasion measured a length of 1.0 centimeter (cm), width of 1.0 cm and depth was not applicable. The area had a scab covering it and no drainage or swelling was noted. The assessment stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365129 If continuation sheet Page 10 of 15 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 10/23/2023 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few soap and water were used to cleanse the area and there was no dressing. Resident #92's physician and responsible party were notified. Review of Resident #92's physician's orders dated 08/20/23 at 12:52 A.M. revealed an order to cleanse left elbow and forearm abrasions with soap and water and leave open to air, every shift for wound care. Review of an interdisciplinary team (IDT) care conference note dated 08/20/23 at 2:00 P.M. revealed the note was a late entry and on 08/18/20 at 8:30 P.M. Resident #92 exited the facility without informing staff. Resident #92 was wearing a t-shirt, shorts, blue jacket and footwear and the weather was approximately 68 degrees Fahrenheit, partly cloudy. Night rounds on 08/18/23 at 11:00 P.M. revealed Resident #92 was not in his room and a search was initiated. While the facility was being searched a call was received from Resident #92's sister stating the resident was in the Emergency Department for evaluation due to a fall while out of the building. The Administrator and Director of Nursing were notified on 08/18/23 at 11:15 P.M. and Resident #92's physician was notified by the Director of Nursing upon arrival to the facility. Resident head count revealed all other residents were accounted for, door alarm system testing completed by the Administrator revealed alarms were functioning per manufacturer's specifications. Windows were assessed by the Administrator and no issues were identified. Resident #92 returned to the facility on [DATE] via ambulance. 08/19/23. The Director of Nursing interviewed Resident #92 to determine purpose for leaving the facility and Resident #92 stated I was going to work. No psychosocial or emotional distress noted at the time of the assessment. The facility provided information from a public records request as part of their investigation. The record (requested by the facility on 08/21/23) included Resident #92 was picked up in the vicinity of a local road by railroad tracks and brought to the local hospital on [DATE] at approximately 11:00 P.M. Interview on 10/10/23 at 1:55 P.M. with [NAME] President of Clinical Services (VPCS) #211 verified Resident #92 eloped from the facility on 08/18/23. VPCS #211 stated staff were interviewed about when they last saw Resident #92 and when door alarms were heard. VPCS #211 indicated she was not in the facility at the time of the elopement but from the interviews it was determined Resident #92 was last seen on 08/18/23 at approximately 8:30 P.M. VPCS #211 stated Resident #92's sister called the facility regarding Resident #92's elopement around 10:30 P.M. to 11:00 P.M. which was about the same time Resident #92 was found to be missing (by staff). VPCS #211 stated Resident #92 resided on the third-floor secured nursing unit and residents did not wear wander guards. VPCS #211 revealed a code was needed to exit two stairwells which could be used to enter and exit the third-floor secured nursing unit. VPCS #211 indicated there was an elevator which was used to enter and exit the third-floor secured nursing unit, and a code was needed to use the elevator. VPCS #211 stated both stairwells had a 15-second egress and would alarm immediately and open after 15 seconds if an attempt was made to open the door without a code. VPCS #211 stated Licensed Practical Nurse (LPN) #210 was an agency nurse working on the secured third-floor nursing unit on 08/18/23 when Resident #92 eloped from the facility. VPCS #211 stated LPN #210 heard a door alarm and turned it off without notifying anyone. VPCS #211 stated she did not know why LPN #210 did not tell anyone or initiate a resident head count when she heard the alarm. VPCS #211 stated Resident #92 walked down a flight of stairs from the third-floor secured nursing unit back entry to the second floor back entry which also had an alarm and opened after 15-seconds to the outside at ground level. VPCS #211 stated the second-floor entrance door alarmed, and opened after 15 seconds, and Resident #92 walked out the second floor back entrance to the outside. VPCS #211 revealed an aide heard the alarm and turned off the alarm without realizing Resident #92 left the facility via the second-floor entrance. VPCS #211 stated the aide saw someone (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365129 If continuation sheet Page 11 of 15 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 10/23/2023 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 0689 standing in the parking lot but did not realize the person was Resident #92. Level of Harm - Immediate jeopardy to resident health or safety Interview on 10/11/23 at 12:36 P.M. of State Tested Nursing Assistant (STNA) #204 revealed 08/18/23 was the first time she worked on the secured memory unit. STNA #204 stated during the day shift on 08/18/23 she was assigned to a different nursing unit, and stayed after her regular shift ended at 7:00 P.M. to work on the secured nursing unit because the secured memory unit needed coverage from 7:00 P.M. until 11:00 P.M. STNA #204 stated she did not know the residents on the secured nursing unit and an agency nurse she did not know was also assigned to the secured memory care unit. STNA #204 stated the agency nurse did not give her a thorough report regarding which residents were elopement risks. STNA #204 stated she was completing documentation on a resident who was a fall risk, and the agency nurse left the unit for a break. STNA #204 stated the nurse came back from her break, used the back entrance of the secured nursing unit, and did not mention an alarm was sounding when she came back. STNA #204 stated she discovered Resident #92 was missing around 10:30 P.M. and could not remember the time she last saw Resident #92. STNA #204 indicated after Resident #92 was found to be missing the agency nurse told her when she came back from her break the door for the rear entrance of the secured nursing unit was alarming and she turned the alarm off. STNA #204 stated the agency nurse told her she did not think a resident eloped when the door was alarming and that was why she did not say anything. STNA #204 stated she completed rounds on the residents she was assigned to every two hours and did not remember Resident #92 seeking to leave the unit. STNA #204 revealed while they were searching for Resident #92 someone from the hospital emergency department called the facility and told them Resident #92 was being evaluated at the hospital. Residents Affected - Few Review of the facility undated policy titled Missing Resident revealed the purpose was to ensure missing residents were located quickly. A search of all rooms in the facility would be done if a resident was thought to be missing. Assign two personnel to check the area immediately outside the facility. Personnel should go around the facility in opposite directions. When they meet, they should return inside for reassignment. Review of the facility undated policy titled Elopement Prevention revealed it was the goal of the facility to provide a safe environment for all residents while using the least restrictive measures possible. Elopement occurred when a resident left the premises or safe area without authorization and, or necessary supervision to do so. A resident who left a safe area might be at risk of heat or cold exposure, dehydration, and, or other medical complications, drowning, or being struck by a motor vehicle. Residents would be assessed upon admission, quarterly, and with a significant change in condition using the facility designated assessment form to determine whether the resident was at risk for elopement. Once the risk assessment was completed, the IDT (interdisciplinary team) would review the assessment and make the determination if the resident should be identified at risk for wandering and, or elopement. The IDT would document their decision accordingly on the format provided and proceed with determining interventions to keep the resident safe. This deficiency represents non-compliance investigated under Complaint Number OH00146796. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365129 If continuation sheet Page 12 of 15 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 10/23/2023 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. **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 #67's right knee skin impairment was accurately documented to include wound type in the medical record. This affected one resident (Resident #67) out of three residents reviewed for wounds. The facility census was 91. Findings include: Review of Resident #67's medical record revealed an admission date of 06/21/23 and diagnoses included immersion foot, left foot (an injury caused by cold exposure to tissue not resulting in freezing), schizophrenia and type two diabetes mellitus without complications. Review of Resident #67's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #67 was cognitively intact. Resident #67 required supervision of one staff member for bed mobility, limited assistance of one staff member for transfers and locomotion off the unit, and Resident #67 was not steady but able to stabilize without staff assistance for walking. Resident #67 used a wheelchair and a walker. Review of Resident #67's Guardianship record dated 07/18/23 included Resident #67 was mentally impaired and had moderate mental retardation, developmental disabilities. The record further stated Resident #67 had mild schizophrenia. Resident #67 had difficulty with decision making and required repetition for learning. Review of Resident #67's Smoking Injury report dated 08/21/23 at 10:23 A.M. included while staff was providing care Resident #67 was observed with an intact blister to the right knee and measured length 2.8 centimeters (cm), width of 2.8 cm and depth was not applicable. Resident #67 reported he might have burned himself while smoking but was unsure. Resident #67 was alert and oriented to person, and confused to place, time, and situation. Resident #67 was unable to provide detail. Resident #67 was ambulatory with an assistive device and staff assist. Resident #67 locomotion with a wheelchair. No witnesses were found to the incident. Smoking assessment completed on 08/23/23 and smoking apron was initiated due to Resident #67's statement of being unsure if area was a burn from a cigarette. Based on review of Resident #67's room, wheelchair, walker, bed, diet, and foods on the menu, coffee consumption, clothing, modalities that would cause trauma during therapy sessions, it was determined that the non-pressure area was consistent with sleeping in the wheelchair. Would encourage Resident #67 not to sleep in wheelchair for prolonged periods of time. The documentation did not specify how the wheelchair caused the blister to Resident #67's right knee. Review of Resident #67's Wound Evaluation and Management Summary dated 08/28/23 included non-pressure wound of the right knee and etiology was undetermined, unknown was resolved. Anatomic location of previously existing wound examined today, epthelialized and resolved and follow up only as needed. Review of Resident #67's Wound Evaluation and Management Summary dated 09/04/23 included burn wound of the right knee, full thickness and etiology was burn and duration was greater than seven days. The objective was to maintain healing phase, cigarette burn. Measurements were length 2.0 cm, width 2.0 cm, and depth was 0.2 cm. A light serrous exudate was noted, granulation tissue was 60 percent. Dressing treatment plan was xeroform gauze, apply once daily for 30 days, and gauze border dressing, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365129 If continuation sheet Page 13 of 15 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 10/23/2023 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 apply once daily for 30 days. Level of Harm - Minimal harm or potential for actual harm Review of Resident #67's Wound Evaluation and Management Summary dated 09/25/23 included burn wound of right knee, full thickness and etiology was burn and duration was greater than 27 days. Measurements were length 0.8 cm, width 1.3 cm, and depth was 0.2 cm. Light serrous exudate was noted, and slough was 20 percent and granulation tissue was 80 percent. Further review revealed surgical excisional debridement procedure and the indication for the procedure was to remove necrotic tissue and establish the margins of viable tissue. The wound was cleansed with normal saline. A curette was used to surgically excise devitalized tissue including slough, biofilm, and non-viable muscle level tissues were removed at a depth of 0.2 cm and healthy bleeding tissue was observed. As a result of this procedure the non-viable tissue in the wound bed decreased from 20 percent to 0 percent. Dressing treatment plan xeroform gauze, three times per week and gauze border dressing, three times per week. Residents Affected - Few Review of Resident #67's Wound Evaluation and Management Summary dated 10/02/23 included burn wound of the right knee was resolved on 10/02/23. Anatomic location of previously existing wound was examined, epithelialized and resolved. Follow up only as needed. Review of the facility list of Resident's with Wounds dated 10/01/23 through 10/07/23 included Resident #67 had a right knee burn which was greater than 33 days and was now resolved. Interview on 10/12/23 at 12:03 P.M. of Registered Nurse/ Unit Manager (RN/UM) #200 revealed Resident #67 had a blister on his right knee. When he was asked how he got the blister Resident #67 stated he thought he burned himself while smoking. RN/UM #200 stated this made sense because of the location of the wound. RN/UM #200 stated Resident #67 was supervised while smoking, but not required to wear a smoking apron. RN/UM #200 stated the blister was observed during Resident #67's therapy appointment. Observation on 10/12/23 at 1:03 P.M. of Resident #67's right knee with Licensed Practical Nurse (LPN) #217 revealed the top of Resident #67's right knee had a pink area about the size of a fifty-cent piece, the area was not open and had no drainage. Resident #67 stated he burned himself on his right knee while he was smoking. Resident #67 stated the cigarette burned his right knee through his pants and he fell from his chair. Resident #67 stated he was outside smoking when the cigarette burn occurred and there were no other residents or staff with him. Interview on 10/12/23 at 1:25 P.M. of LPN #217 revealed she sometimes supervised smoking breaks. LPN #217 stated she was not aware Resident #67 had a burn on his leg. Interview on 10/12/23 at 4:27 P.M. of [NAME] President of Operations (VPO) #209 revealed it was speculation that Resident #67's right knee blister was caused from a burn. VPO #209 stated the area was too large to be a burn from a cigarette and was not consistent with a cigarette burn. VPO #209 did not state what caused the right knee blister. Review of Resident #67's Wound Physician (WP) #206's note revised on 10/24/23 at 1:37 P.M. for the date of service 08/21/23. The note stated Resident #67's right knee blister was classified as undetermined, unknown etiology to further investigate the cause. After further investigation it was determined that this was an injury from the wheel chair and resolved on 08/28/23. Inadvertently WP #206 forgot to change the etiology to trauma, injury prior to resolving the wound on 08/28/23. Resident #67's right knee wound opened up again and was evaluated on 09/04/23 and labeled as a burn wound due to miscommunication. In reality the wound opened up due to Resident #67 picking on the old site. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365129 If continuation sheet Page 14 of 15 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 10/23/2023 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 Etiology was trauma, injury and was self-inflicted. WP #206 did not state how the wheelchair caused the blister. Review of Resident #67's Registered Nurse/Unit Manager (RN/UM) #200 statement written on 10/24/23 revealed she documented Resident #67's right knee wound as a blistered area. Resident #67 stated he might have burned himself but was unsure. RN/UM #200 wrote her clinical judgement did not lead her to believe it was a cigarette wound due to the size of the wound. RN/UM #200 stated the size of the wound did not correlate with Resident #67 burning himself with a cigarette. RN/UM #200 did not state what caused the right knee blister. This deficiency represents non-compliance investigated under Complaint Number OH00147268 and OH00146796. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365129 If continuation sheet Page 15 of 15