Health inspection·October 26, 2023

F 0580 condition of the skin. Level of Harm - Minimal harm or potential for actual harm Interview on 10/17/23 at 10:08 A.M. with Resident #16 revealed she continued to have pain during incontinence care. Residents Affected - Few Interview on 10/17/23 at 4:02 P.M. with Resident #16 revealed she did not think the staff addressed her concern with the physician because nothing was done to relieve her pain with peri care. Interview on 10/17/23 at 4:06 P.M. with LPN #277 revealed she was Resident #16's charge nurse. LPN #277 revealed she was unaware of Resident #16 having any pain during incontinence care. Interview on 10/17/23 at 4:39 P.M. with STNA #202 revealed she was Resident #16's care giver, and Resident #16 had been complaining of pain with peri care and itching in the vaginal area a lot. STNA #202 revealed she did not report it to LPN #277 or any nurse because she thought they were aware. Interview and record review on 10/18/23 at 9:34 A.M. with CNP #600 revealed he was at the facility five days a week and cared for Resident #16. CNP #600 revealed he was not made aware Resident #16 had pain or itching in the vaginal area. Review of the physician orders with CNP #600 revealed CNP #600 confirmed Resident #16 received no new orders for care and treatment of the pain or itching in the vaginal area. Interview and record review on 10/18/23 at 10:05 A.M. with Clinical Manager LPN #275 verified after the observation on 10/16/23 of Resident #16 complaining of pain and itching in her peri area, there was no documentation, assessment, or physician notification to address Resident #16's complaints. Clinical Manager LPN #275 confirmed she did not document her observations or let the CNP, or physician know of Resident #16's concerns. Clinical Manager LPN #275 revealed she let the nurse on the floor know and confirmed the nurse did not follow through with the concern. Review of the facility policy titled, Notification of Change in Condition undated, revealed the center must inform the resident, consult with the resident's physician and or notify the residents representative, authorized family member, or legal power of attorney when there is a change requiring such notification. Circumstances requiring notification include but are not limited to circumstances that require a need to alter treatment which may include a new treatment. This deficiency represents non-compliance identified during the investigation of Complaint Number OH00146541. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365192 If continuation sheet Page 2 of 19 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 365192 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenbrier Health Center 6455 Pearl Rd Parma Heights, OH 44130 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation and staff and resident interview, the facility failed to maintain a sanitary and comfortable interior living environment. This affected seven residents (Resident #4, #16, #31, #38, #39, #78, and #103.) of the 125 residents living in the facility. Finding Include: 1. Observation on 10/17/23 at 8:15 A.M. of Resident #4's room revealed the heater unit on the floor had busted parts, was rusted and covered in dust. Three of three walls in the room were dirty with pealing paint and dried on staining from the ceiling to the floor. Interview with Resident #4 at the time of observation revealed she wished they would do something about the heater and dirty walls. 2. Observation on 10/16/23 at 5:03 P.M. of Resident #16's room revealed the bathroom door had four holes in the middle of the door and the privacy curtain had two holes in the top of the curtain. Interview at the time of observation with Resident #16 revealed the door had been that way since she moved into the room. 3. Observation on 10/16/23 at 11:52 A.M. of Resident #31's room revealed the television (TV) and TV shelf were dusty and the window blinds were covered in a thick layer of dust. Interview at time of the observation with Resident #31 revealed her room got mopped but did not get dusted. 4. Observation on 10/16/23 at 12:17 P.M. of Resident #103's room revealed peeling paint on the walls with large gouges with drywall showing. 5 . Observation on 10/16/23 at 4:41 P.M. of Resident #38's room revealed the TV, shelf and blinds were covered with a thick layer of dust and the wall behind her bed had the top layer of the wall peeling and flaking. Resident #38 stated housekeeping cleaned rooms but did not move anything to clean around. 6. Observation on 10/16/23 at 5:55 P.M. of Resident #78's room revealed the cushion on the top of the right siderail of the bed was ripped and torn. Interview on 10/16/23 at 6:00 P.M. with State Tested Nurse Assistant (STNA) #538 verified the bed rail for Resident #78 was not in good repair. 7. Observation on 10/17/23 8:50 A.M. of Resident #39's room revealed two of three walls with multiple areas of peeling paint, dark brown dried drips of liquid substance on the walls and an air conditioning unit covered with dust particles. Interview and observations on 10/18/23 at 2:31 P.M. with Maintenance Director (MD) #544 verified all above environmental concerns and housekeeping concerns. Review of the work orders for the last six months revealed no work orders for the areas of concern for Resident #4, #16, #31, #38, #39, #78, and #103. Review of the Deep Clean Checkout List revealed TVs and shelves should be wiped and dusted. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365192 If continuation sheet Page 3 of 19 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 365192 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenbrier Health Center 6455 Pearl Rd Parma Heights, OH 44130 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Level of Harm - Minimal harm or potential for actual harm Review of the deep cleaning schedule for September 2023 revealed Resident #31's room was to be deep cleaned and Resident #38's room should have been deep cleaned on 10/11/12. This deficiency represents non-compliance identified during the investigation of Complaint Number OH00146626. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365192 If continuation sheet Page 4 of 19 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 365192 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenbrier Health Center 6455 Pearl Rd Parma Heights, OH 44130 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 record review, review of the facility policy, observation and interview, the facility failed to provided daily and as needed nail care to Resident #78 who required staff assistance with his activities of daily living (ADL). This affected one resident (Resident #78) of three residents reviewed for activities of daily living. The facility census was 125. Residents Affected - Few Findings include: Record review for Resident #78 revealed an admission date of 04/29/21 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side and need for assistance with personal care. Record review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #78 was rarely or never understood. Resident #78 required extensive assistance of two for bed mobility, toilet use, personal hygiene, and extensive assistance of one for eating. Resident #78 had an indwelling catheter and was always incontinent of bowel. Record review of the care plan dated 05/07/21 revealed Resident #78 had an ADL self care performance deficit, required assistance with ADL's related to mobility, hemiplegia following cerebral infarction. Interventions included extensive assistance with hygiene. Observation on 10/16/23 at 12:18 P.M. revealed Resident #78 was lying in bed. Resident #78 did not respond verbally and was able to move her right hand freely. Resident #78 did not move her left hand. Observation revealed all the fingernails, including the thumb nail on the right hand were long in length and embedded with a thick dark black/brown substance. Observation and interview on 10/16/23 at 5:43 P.M. with State Tested Nursing Assistant (STNA) #538 confirmed Resident #78's nails on her right hand continued to be imbedded with a thick dark brown/black substance. STNA #538 revealed Resident #78 was at times able to feed herself but would use her fingers to eat instead of silverware. Observation and interview on 10/17/23 at 4:42 P.M. with STNA #202 confirmed Resident #78 continued to have a thick dark brown/black substance embedded under all of her nails on the right hand. STNA #202 revealed Resident #78 dug in her stool at times. Interview with the Director of Nursing (DON) on 10/24/23 at 12:10 P.M. revealed nail care was to be completed daily and as needed. Record review of the facility policy titled, Routine Resident Care undated, revealed Routine Resident Care was care that was not necessarily medically or clinically based but necessary for quality of life promoting dignity and independence. Additional procedures included to provide routine daily care by a certified nursing assistant with specialized training in rehabilitation/restorative which included implementing and maintaining programs for skin care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365192 If continuation sheet Page 5 of 19 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 365192 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenbrier Health Center 6455 Pearl Rd Parma Heights, OH 44130 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 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed medical record review, facility policy review and interview, the facility failed to collaborate care between nursing and physician services to identify and assess risk factors affecting quality of care and wellbeing of Resident #129 and placing Resident #129 at risk for the development of a blood clot and rehospitalization within 30 days of admission. Residents Affected - Few Actual harm occurred on 09/01/23 when Resident #129, who had a history of embolism (blood clot), was at high risk for developing blood clots and was non-ambulatory, insisted on being sent to the hospital because the facility was not doing anything to address his complaints of severe pain in his left leg which was being treated at the facility as neuropathic pain. Resident #129 was ordered the anti-coagulant medication Heparin from admission through 08/23/23. The facility failed to adequately assess the continued need for Heparin or any other type of anti-coagulant medication after 08/23/23. After being transported to the hospital on [DATE], the resident was diagnosed with a large blood clot in his leg and required intravenous (IV) Heparin and an oral anticoagulant (the resident was not a candidate for surgical intervention, the preferred treatment). This affected one resident (#129) of 34 residents reviewed for quality of care. The facility census was 125. Findings include: Review of Resident #129's closed medical record revealed the resident was admitted to the facility for rehabilitation on 08/05/23 after being hospitalized from [DATE] due to a motorcycle accident requiring trauma intensive care and emergency surgery. Resident #129 was his own responsible party. Review of a hospital history and physical for Resident #129, dated 06/30/23, revealed Resident #129 had been brought into the hospital emergency room following a motorcycle accident. Resident #129 arrived at the hospital emergency room with complaints of pain all over his body and was diagnosed with deep vein thrombosis (DVT)/blood clots in both proximal lower extremities and an open book fracture of the pelvis. Upon admission to the facility on [DATE] Resident #129 had diagnoses including embolism and thrombosis of iliac artery, fracture of other parts of pelvis, right side rib fracture, low back pain, surgical aftercare following surgery on the digestive system, obstructive and reflux uropathy, muscle weakness, need for assistance with personal care, contusion of unspecified part of neck, dysphagia, paralytic ileus, low back pain, hypertension, and neuralgia and neuritis. Review of the physician's orders revealed an order, dated 08/05/23 for Heparin sodium (Porcine) 5000 units subcutaneously (SQ) three times a day for circulation. On 08/08/23 this order was revised to read Heparin sodium injection 5000 units SQ every eight hours for circulation for 14 days and discontinue 08/21/23. Review of the care plan, dated 08/07/23, revealed Resident #129 was at risk for abnormal bleeding or hemorrhage due to anticoagulant use related to embolism and thrombosis of the iliac artery. Interventions included administering medications and observing side effects and effectiveness. Record review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 08/17/23, revealed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365192 If continuation sheet Page 6 of 19 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 365192 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenbrier Health Center 6455 Pearl Rd Parma Heights, OH 44130 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 - Actual harm Residents Affected - Few Resident #129 was cognitively intact and required extensive assistance of two staff for bed mobility, transfers and toilet use, extensive assist of one for dressing, personal hygiene, and supervision with eating. Resident #129 had impairment on both sides of the lower extremities, used a wheelchair for mobility and required set up help only for mobility. Resident #129 had an indwelling catheter, an ostomy, was frequently incontinent of bowel, had fractures, other multiple traumas, DVT, and septicemia. The MDS assessment revealed Resident #129 received anticoagulant therapy seven out of seven days and was receiving occupational and physical therapy services. Further review of the physician's orders revealed an order dated 08/21/23 for Heparin sodium (Porcine) 5000 units SQ every eight hours for circulation until 08/31/2023. However, this order was discontinued on 08/23/23 per Certified Nurse Practitioner (CNP) #600. Review of progress notes dated 08/14/23, 08/28/23 and 08/29/23 by the CNP revealed Resident #129 had suffered extensive injuries from a motorcycle accident, had bilateral nephrostomy tubes present, internal fixation of the anterior pelvis and percutaneous pinning of the posterior pelvis following pelvic fracture. The resident denied pain on 08/14/23 except when visitors were present the pain would elevate and would consist of sharp, shooting pain to his left lower leg. The resident was agreeable to try Gabapentin to treat neuropathic pain in addition to the other pain medications noted. On 08/28/23 the resident was seen for complaints of nausea; pain was low at a one out of 10 and he denied any other complaints. It was noted he had been prescribed an antibiotic, Sulfamethoxazole-trimethoprim on 08/23/23 to treat a urinary tract infection and was prescribed an anti-nausea medication at the visit. On 08/29/23 the resident was seen for acute, increase neuropathic pain to the bilateral legs which was noted to be present over the last several weeks since admission. The resident had no other complaints, and the vital signs were normal. Gabapentin was increased to treat the neuropathic pain and the resident agreed. The CNP noted the resident had chronic one-plus edema that showed no change at each visit. Review of a telehealth visit note dated 09/01/23 completed by CNP #606 revealed a telehealth visit was conducted due to Resident #129 complaining of increased pain stating it was above a 10 out of 10 although all vital signs were normal with no elevation in pulse, temperature or blood pressure and no non-verbal signs of pain noted. The note documented the resident appeared to be nontoxic and had been on the phone with his ex-wife about how the facility was not doing anything and he was not ready to come to the facility for rehab. He was currently on the phone with his ex-wife, both were making each other agitated and insisting on going to the emergency department (ED). According to the resident, no pain meds work for him, Tramadol or Oxycontin and he needed something stronger. Explained to resident and his ex-wife this was going to be a long process that involved trial and error, not something that was going to get resolved with a visit at 4:00 A.M. and that they need to speak with the appropriate team for their concerns. Both just want to go to ED, explained that ED was just going to send him right back after giving him one dose of pain meds, but they were both not listening and talking over staff. Note to send to ED per patient request. Review of the nurse's note, dated 09/01/23 at 4:23 A.M. revealed Resident #129 was complaining of severe pain, refusing to take a muscle relaxant, vital signs were obtained, telehealth was contacted and despite the explanation provided by convergence the resident was determined for a hospital transfer and therefore transferred to the hospital at 4:20 A.M. Review of the nurse's note dated 09/01/23 at 8:22 A.M. revealed Resident #129 was being admitted to the hospital with a diagnosis of DVT to the left lower extremity. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365192 If continuation sheet Page 7 of 19 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 365192 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenbrier Health Center 6455 Pearl Rd Parma Heights, OH 44130 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 Review of the discharge MDS 3.0 assessment, dated 09/01/23, revealed Resident #129 was discharged to an acute hospital and not expected to return to the facility. Level of Harm - Actual harm Residents Affected - Few Record review of the Physical Therapy Discharge summary dated [DATE] and completed by Physical Therapist (PT) #607 revealed Resident #129 was discharged from PT services due to going out to the hospital for a DVT. Resident #129 had been working with therapy though was making slow and steady progress due to his pain and complaints of dizziness when attempting to sit up. Resident #129 continued to be non-weight baring and had been maintaining this as Resident #129 had not been getting out of bed and had been declining attempts to try a sliding board since he was only able to sit at the edge of the bed for 30 seconds at a time due to dizziness. Interviews and medical record review were conducted intermittently with the Director of Nursing (DON) between 10/23/23 at 3:27 P.M. and 10/24/23 at 12:43 P.M. for Resident #129. The DON verified Resident #129 had a history of blood clots noted in the records. When asked if Resident #129 had a blood clot in his leg upon admission to the facility, the DON explained he had a history of blood clots but was not aware of a current blood clot when admitted to the facility. Interview on 10/23/23 at 3:39 P.M. with CNP #600 revealed he worked at the facility four to five days a week and verified he had discontinued the Heparin order on 08/23/23. There was no evidence the CNP considered the resident's risk for developing blood clots or need for continued anti-coagulant treatment after 08/23/23. Interview on 10/23/23 at 4:35 P.M. with Rehab Director (RD) #608 confirmed Resident #129 had been receiving physical therapy services and did not ambulate. RD #608 said Resident #129 had a history of blood clots but did not know of an active blood clot while at the facility. Interview on 10/23/23 at 5:23 P.M. with Resident #129 revealed he was at the facility for rehabilitation, had a history of blood clots in his legs and had not been able to get up and walk at the facility prior to being sent to the hospital on [DATE] at his own request. Resident #129 explained his legs started hurting and because the pain was severe, he wanted to go to the hospital; he was worried about blood clots, so he insisted they send him out. Resident #129 explained after he left the hospital, he went to a different care facility to receive rehabilitation and was up walking around now. Resident #129 did not specify how long he had been hospitalized for the DVT. Interview via phone on 10/24/23 at 1:35 P.M. with Primary Care Physician (PCP) #604 confirmed he cared for Resident #129 while Resident #129 resided at the facility. PCP #604 revealed he also cared for Resident #129 after he was transferred to the hospital on [DATE]. PCP #604 revealed Resident #129 was injured badly when he was hit on his motorcycle while going through an intersection and had an extensive pelvic fracture. PCP #604 explained Resident #129 had a blood clot that extended from the iliac femoral artery all the way down his leg, and this was confirmed in the hospital on [DATE]. PCP #604 revealed those types of clots were usually removed surgically but because of the resident's extensive fractures, that was not an option. PCP #604 explained Resident #129's treatment in the hospital consisted of a Heparin drip (intravenous) then an anticoagulant. PCP #604 revealed Heparin injections being given at the facility were used prophylactically to prevent further blood clots. PCP #604 explained if one dose a day was prescribed, then the person was at low risk for an embolism. If two doses were prescribed, the person was at moderate risk for developing a clot and if three doses a day were prescribed, they were at high risk. PCP #604 revealed Resident #129 was ordered three doses a day because he was at high risk for developing a blood clot. When asked about what could happen if Resident #129 had missed doses of the Heparin, PCP #604 revealed if Resident #129 received at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365192 If continuation sheet Page 8 of 19 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 365192 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenbrier Health Center 6455 Pearl Rd Parma Heights, OH 44130 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 - Actual harm Residents Affected - Few least one dose a day of the Heparin, it would be less likely to form a blood clot than missing all three doses in one day. PCP #604 verified the CNP was following the resident's care in the facility. PCP #604 indicated he could not recall if he was notified the Heparin was discontinued on 08/23/23 by the nurse practitioner and revealed the only reason why he personally would have discontinued the Heparin was if the resident was ambulatory. PCP #604 stated blood clots can be deadly. Interview was conducted via phone on 10/24/23 at 4:04 P.M. with the Regional Director of Clinical/Registered Nurse (RDC/RN) #900 who revealed Resident #129 was assessed by the CNP on 08/14/23 and was treated for neuropathic pain. Resident #129 was assessed again by the CNP on 08/28/23 and 08/29/23 and the RDC/RN did not believe there were signs of a new DVT. RDC/RN #900 said he had spoken with PCP #604 about the half-life of Heparin and PCP #604 informed him intermittent missed doses would not cause a DVT, but a DVT could occur if there were multiple missed doses for several days in a row. Interview via phone on 10/25/23 at 9:22 A.M. with CNP #600 revealed he had discontinued the Heparin dose for Resident #129 on 08/23/23, and thought it was possibly because he had started Resident #129 on an antibiotic on 08/23/23 and at times there could have been a drug interaction between the antibiotic and the Heparin. CNP #600 confirmed he did not document why he discontinued the Heparin for Resident #129 on 08/23/23. CNP #600 revealed Resident #129 was non-weight bearing but stated he did see Resident #129 transfer himself. CNP #600 explained he did not know the Heparin was supposed to continue (per the physician's order) until 08/31/23 because he did not look into the ins and outs of how many days the Heparin was ordered. When CNP #600 was asked about Resident #129 being diagnosed with a blood clot in the hospital on [DATE], CNP #600 did not respond to the question. Review of the undated facility policy titled Routine Resident Care revealed it was the policy of the facility to meet the total needs of the resident including the administration of medications. This deficiency represents non-compliance identified during the investigation of Complaint Number OH00146541. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365192 If continuation sheet Page 9 of 19 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 365192 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenbrier Health Center 6455 Pearl Rd Parma Heights, OH 44130 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility policy, the facility failed to ensure all smoking supplies were secured in a locked area when not in use by independent smokers. This affected two residents (Resident #106 and #65) of two residents reviewed for smoking. The facility identified 27 residents who independently smoked at the facility. The facility census was 125. Findings include: 1. Record review for Resident #106 revealed an admission date of 04/02/23. Diagnosis included nicotine dependence. Record review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #106 was cognitively intact. Record review of the care plan dated 04/11/23 revealed Resident #106 utilized nicotine products. Interventions included: complete smoking evaluation and educate resident / resident representative to facility smoking policy. Record review of the smoking assessment dated [DATE] revealed Resident #106 was an independent smoker. Observation on 10/19/23 at 3:10 P.M. revealed the facility provided an outdoor smoking area for residents, and near the exit door to the outside smoking area was a storage area containing several small locked boxes. Interview with Regional Director #603 revealed residents who were independent smokers were assigned a locked box and given a key to store their smoking supplies. Residents were to store their cigarettes' and lighter in the locked boxes when they were not smoking. Observation on 10/19/23 at 3:13 P.M. revealed Resident #106 was in the outdoor smoking area smoking independently with other residents also smoking outdoors. Resident #106 finished smoking and properly dispensed of the cigarette butt, walked past the storage area and headed back into the facility into the residential area of the facility. Observation and interview with Resident #106 confirmed she had her cigarettes and lighter in her pocket and did not lock them up before coming back into the facility. Resident #106 revealed she forgot to lock them up prior to leaving the area. Regional Director (RD) #603 was present and confirmed Resident #106 was supposed to lock her cigarettes and lighter in the locker prior to leaving the area and Resident #106 did not lock her smoking supplies prior to leaving the smoking area. 2. Record review for Resident #65 revealed an admission date of 01/19/23. Diagnosis included nicotine dependence. Record review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #65 was cognitively intact. Record review of the Smoking assessment dated [DATE] for Resident #65 revealed Resident #65 was independent for smoking. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365192 If continuation sheet Page 10 of 19 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 365192 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenbrier Health Center 6455 Pearl Rd Parma Heights, OH 44130 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 10/19/23 at 3:14 P.M. revealed Resident #65 was in the outdoor smoking area smoking independently with other residents also smoking outdoors. Resident #65 finished smoking and properly dispensed of the cigarette butt, walked past the storage area and headed back into the facility into the residential area of the facility. Observation and interview with Resident #65 confirmed he had his cigarettes and lighter in a pouch he was carrying. Resident #65 revealed sometimes he locked them up and sometimes he didn't. RD #603 was present and confirmed Resident #65 was supposed to lock his cigarettes and lighter in the locker prior to leaving the area and Resident #65 did not lock his smoking supplies prior to leaving. Record review of the facility policy titled, Resident/Patient Smoking dated effective 03/25/16 revealed facility staff will secure smoking materials in a locked area when not in use by the resident for both independent and supervised smokers. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365192 If continuation sheet Page 11 of 19 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 365192 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenbrier Health Center 6455 Pearl Rd Parma Heights, OH 44130 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm Based on record review, review of the facility policy and interview, the facility failed to follow the physician order for a gradual dose reduction (GDR) of a psychotropic medication as recommended by the licensed pharmacist for Resident #57. This affected one resident (Resident #57) of five residents reviewed for GDR of medications. The facility census was 125. Residents Affected - Few Findings include: Record review for Resident #57 revealed an admission date of 12/29/20. Record review of the census revealed Resident #57 resided at the facility from 08/10/22 through 10/19/23 with no hospital or discharge transfers out of the facility. Record review of the care plan dated 10/16/23 revealed Resident #57 was at risk for falls secondary to a history of falls, receiving antianxiety and antidepressant medications. Interventions included to observe medication for side effects that may increase risk for falls. Review of the Pharmacist Recommendation for the Prescriber report, dated 07/18/23, completed by Consultant Pharmacist (CP) #602 revealed Resident #57 was recently documented for multiple falls. After a review of current medications, the following medications can increase the risk for dizziness, sedation and therefore increase the risk for falls. Please review and discontinue or decrease medications if appropriate. Medications included Trazadone 150 milligrams (mg) by mouth every day. Included in the Pharmacist Recommendation for the Prescriber report dated 07/18/23 was the Pharmacist Recommendation Prescriber response dated 07/25/23. The Prescriber response was completed by Certified Nurse Practitioner (CNP) #600 on 07/25/23 and included decrease trazadone to 100 mg by mouth every night. Record review of the physician orders for Resident #57 revealed an order for Trazadone HCL (antidepressant) 150 mg initiated 10/31/22 and discontinued 08/21/23. The Trazadone 100 milligrams (mg) one tablet by mouth at bedtime for insomnia was initiated on 08/21/23 which was nearly one month after CNP #600 recommended to decrease Trazadone to the 100 mg dose. Record review of the Medication Administration Record (MAR) for Resident #57 for July and August 2023 revealed Resident #57 received trazadone 150 mg daily for July and August 2023 ending 08/20/23. On 08/21/23 Trazadone HCL 100 mg one tablet by mouth at bedtime for insomnia was initiated. Interview on 10/18/23 at 5:00 P.M. with the Director of Nursing (DON) confirmed the order to decrease Trazadone to 100 mg one tablet by mouth at bedtime was received on 07/25/23. The DON confirmed the order was not initiated until 08/21/23 and confirmed the order should have been initiated 07/25/23. Record review of the facility policy titled, Pharmacy and Therapeutics Committee Monthly Meeting undated, included to perform psychotropic medication evaluations for gradual dosage reduction (GDR). The Consultant Pharmacist provides overview on medication use within the facility based on monthly drug regimen reviews and brings forward any issues that are a pattern or trend within the facility. The DON assures all monthly Consultant Pharmacist Drug Regimen Review recommendations are addressed timely. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365192 If continuation sheet Page 12 of 19 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 365192 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenbrier Health Center 6455 Pearl Rd Parma Heights, OH 44130 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 0757 This deficiency represents non-compliance identified during the investigation of Complaint Number OH00146673 and OH00146541. 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: 365192 If continuation sheet Page 13 of 19 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 365192 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenbrier Health Center 6455 Pearl Rd Parma Heights, OH 44130 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 closed medical record review, facility policy review and interview, the facility failed to prevent a significant medication error for Resident #129, who had an admitting diagnosis of embolism and thrombosis of the iliac artery and history of deep vein thrombosis (DVT) in the bilateral lower extremities, when staff failed to administer Heparin (an anti-coagulant/blood thinner medication) according to the physician order. The facility also failed to notify the physician (PCP) and/or certified nurse practitioner (CNP) of missed doses of the medication. This affected one resident (#129) of six residents reviewed for medication administration. The facility census was 125. Residents Affected - Few Findings include: Review of Resident #129's closed medical record revealed the resident was admitted to the facility for rehabilitation on 08/05/23 after being hospitalized from [DATE] due to a motorcycle accident requiring trauma intensive care and emergency surgery. Resident #129 was his own responsible party. Review of the hospital history and physical for Resident #129, dated 06/30/23, revealed Resident #129 had been brought into the hospital emergency room following a motorcycle accident. Resident #129 arrived at the hospital emergency room with complaints of pain all over his body and was diagnosed with deep vein thrombosis (DVT)/blood clots in both proximal lower extremities and an open book fracture of the pelvis. Upon admission to the facility on [DATE] Resident #129 had diagnoses including embolism and thrombosis of iliac artery, fracture of other parts of pelvis, right side rib fracture, low back pain, surgical aftercare following surgery on the digestive system, obstructive and reflux uropathy, muscle weakness, need for assistance with personal care, contusion of unspecified part of neck, dysphagia, paralytic ileus, low back pain, hypertension, and neuralgia and neuritis. Review of the physician's orders revealed an order, dated 08/05/23 for Heparin sodium (Porcine) 5000 units subcutaneously (SQ) three times a day for circulation. On 08/08/23 this order was revised to read Heparin sodium injection 5000 units SQ every eight hours for circulation for 14 days and discontinue 08/21/23. Review of the care plan, dated 08/07/23, revealed Resident #129 was at risk for abnormal bleeding or hemorrhage due to anticoagulant use related to embolism and thrombosis of the iliac artery. Interventions included administering medications and observing side effects and effectiveness. Record review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 08/17/23, revealed Resident #129 was cognitively intact and required extensive assistance of two staff for bed mobility, transfers and toilet use, extensive assist of one for dressing, personal hygiene, and supervision with eating. Resident #129 had impairment on both sides of the lower extremities, used a wheelchair for mobility and required set up help only for mobility. Resident #129 had an indwelling catheter, an ostomy, was frequently incontinent of bowel, had fractures, other multiple traumas, DVT, and septicemia. The MDS assessment revealed Resident #129 received anticoagulant therapy seven out of seven days and was receiving occupational and physical therapy services. Further review of the physician's orders revealed an order dated 08/21/23 for Heparin sodium (Porcine) 5000 units SQ every eight hours for circulation until 08/31/2023. However, this order was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365192 If continuation sheet Page 14 of 19 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 365192 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenbrier Health Center 6455 Pearl Rd Parma Heights, OH 44130 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 discontinued on 08/23/23 per CNP #600. Level of Harm - Minimal harm or potential for actual harm Review of the Medication Administration Record (MAR) for Resident #129 for August 2023 revealed the Heparin sodium injection was scheduled to be administered at 6:00 A.M., 2:00 P.M. and 10:00 P.M. Review of the MAR revealed the medication was first administered on 08/05/23 at 10:00 P.M. and was administered three times a day as ordered until 08/15/23 at 10:00 P.M. Residents Affected - Few Review of the MAR revealed the following Heparin doses were not administered to Resident #129 as ordered: 08/15/23 at 10:00 P.M., 08/16/23 at 6:00 A.M. and 10:00 P.M., 08/17/23 at 6:00 A.M., 08/19/23 at 10:00 P.M., 08/20/23 and 08/21/23 at 6:00 A.M. and 10:00 P.M. and 08/22/23 at 6:00 A.M. Review of an electronic MAR note dated 08/17/23 at 12:00 A.M., 08/17/23 at 6:47 A.M., 08/19/23 at 10:00 P.M., 08/20/23 at 8:36 A.M., and 08/20/23 at 9:53 P.M. completed by Licensed Practical Nurse (LPN) #297 revealed the Heparin for Resident #129 was unavailable and awaiting pharmacy to deliver. Review of the electronic MAR note dated 08/22/23 at 12:29 A.M. and 08/22/23 at 5:55 A.M. completed by Registered Nurse (RN) #229 revealed the Heparin for Resident #129 was unavailable. Review of the medical record for Resident #129 from 08/15/23 through 09/01/23 revealed no documentation of a physician or CNP being notified of the missed doses of Heparin for Resident #129. Review of a telehealth visit note dated 09/01/23 completed by CNP #606 revealed a telehealth visit was conducted due to Resident #129 complaining of increased pain stating it was above a 10 out of 10 although all vital signs were normal with no elevation in pulse, temperature or blood pressure and no non-verbal signs of pain noted. The note documented: he appeared to be nontoxic and had been on the phone with his ex-wife about how the facility was not doing anything and he was not ready to come to the facility for rehab. He was currently on the phone with his ex-wife, both were making each other agitated and insisting on going to the emergency department (ED). According to the resident, no pain meds work for him, Tramadol or Oxycontin and he needed something stronger. Explained to resident and his ex-wife this was going to be a long process that involved trial and error, not something that was going to get resolved with a visit at 4:00 A.M. and that they need to speak with the appropriate team for their concerns. Both just want to go to ED, explained that ED was just going to send him right back after giving him one dose of pain meds, but they were both not listening and talking over staff. Note to send to ED per patient request. Review of the nurse's note, dated 09/01/23 at 4:23 A.M. revealed Resident #129 was complaining of severe pain, refusing to take a muscle relaxant, vital signs were obtained, telehealth was contacted and despite the explanation provided by convergence the resident was determined for a hospital transfer and therefore transferred to the hospital at 4:20 A.M. Review of the nurse's note dated 09/01/23 at 8:22 A.M. revealed Resident #129 was being admitted to the hospital with a diagnosis of DVT to the left lower extremity. Review of the discharge MDS 3.0 assessment, dated 09/01/23, revealed Resident #129 was discharged to an acute hospital and not expected to return to the facility. Record review of the Physical Therapy Discharge summary dated [DATE] and completed by Physical Therapist (PT) #607 revealed Resident #129 was discharged from PT services due to going out to the hospital for a DVT. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365192 If continuation sheet Page 15 of 19 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 365192 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenbrier Health Center 6455 Pearl Rd Parma Heights, OH 44130 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interviews and medical record review were conducted intermittently with the Director of Nursing (DON) between 10/23/23 at 3:27 P.M. and 10/24/23 at 12:43 P.M. for Resident #129. The DON verified Resident #129 did not receive his Heparin as ordered between 08/15/23 at 10:00 P.M. through the last dose on 08/23/23 at 6:00 A.M. The DON verified Resident #129 had a history of blood clots noted in the records. The DON explained the doses should not have been missed because the nurses had an option to reorder the Heparin on the electronic MAR and she was unsure why they did not and instead mark they did not have the medication. The DON confirmed some nurses pulled the Heparin for Resident #129 from the starter box when it was available and that was why some doses were missed and some doses were not missed. The DON confirmed the nurses did not notify any CNP or physician during that period when Resident #129 did not receive his Heparin as ordered and she would have expected the nurses to notify the physician when a medication was not available. Interview on 10/23/23 at 3:39 P.M. with CNP #600 revealed he worked at the facility four to five days a week and had discontinued the Heparin order on 08/23/23. CNP #600 stated he cared for Resident #129 and was never notified Resident #129 missed any doses of Heparin. CNP #600 revealed he would expect to be notified if medication was not available. Interview on 10/23/23 at 5:23 P.M. with Resident #129 verified he was at the facility for rehabilitation, had a history of blood clots in his legs and had not been able to get up and walk at the facility prior to being sent to the hospital on [DATE] at his own request. Resident #129 explained his legs started hurting and because the pain was severe, he wanted to go to the hospital; he was worried about the blood clots, so he insisted they send him out. Resident #129 explained after he left the hospital, he went to a different care facility to receive rehabilitation and was up walking around now. Resident #129 did not specify how long he had been hospitalized for the DVT. Interview via phone on 10/24/23 at 1:35 P.M. with PCP #604 confirmed he cared for Resident #129 while Resident #129 resided at the facility. PCP #604 revealed he also cared for Resident #129 after he was transferred to the hospital on [DATE]. PCP #604 revealed Heparin injections being given at the facility were used prophylactically to prevent further blood clots. PCP #604 explained if one dose a day was prescribed, then the person was at low risk for an embolism. If two doses were prescribed, the person was at moderate risk for developing a clot and if three doses a day were prescribed, they were at high risk. PCP #604 revealed Resident #129 was ordered three doses a day because he was at high risk for developing a blood clot. When asked about what could happen if Resident #129 had missed doses of the Heparin, PCP #604 revealed if Resident #129 received at least one dose a day of the Heparin, it would be less likely to form a blood clot than missing all three doses in one day. PCP #604 verified he was not notified of the missed Heparin doses for Resident #129 Interview via phone on 10/25/23 at 9:22 A.M. with CNP #600 revealed he recalled the DON telling him at morning meeting the Heparin was hard to get but stated he had not been informed of any missed Heparin doses for Resident #129. CNP #600 revealed heparin was a drug readily available and confirmed he was never told of any missed doses. Review of the facility undated policy titled Routine Resident Care revealed it was the policy of the facility to meet the total needs of the resident including the administration of medications. This deficiency represents non-compliance identified during the investigation of Complaint Number OH00146541 and OH00146673. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365192 If continuation sheet Page 16 of 19 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 365192 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenbrier Health Center 6455 Pearl Rd Parma Heights, OH 44130 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 0851 Level of Harm - Potential for minimal harm Residents Affected - Many Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Based on interview and record review, the facility failed to submit complete and accurate staffing information for the Payroll-Based Journal (PBJ) report to Centers for Medicare and Medicaid Services (CMS). This had the potential to affect all 125 residents in the facility. Findings include: Review of [NAME] PBJ Staffing data report revealed facility triggered for low weekend staffing and one star staffing for fiscal year quarter two of 2023. Interview on 10/19/23 at 1:45 P.M. with the Administrator revealed that they submit the facility staffing data to the corporate office who then reports it to CMS. Interview on 10/19/23 at 4:27 P.M. with Corporate Regional Director (CRD) #572 verified the facility triggered for low weekend staffing and one star for staffing for fiscal year quarter two of 2023. CRD #572 explained the facility staffing data was transposed inaccurately to the office responsible for sending the data to CMS resulting in the trigger of low weekend staffing and one star for staffing for quarter two of 2023. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365192 If continuation sheet Page 17 of 19 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 365192 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenbrier Health Center 6455 Pearl Rd Parma Heights, OH 44130 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 record review, review of the facility policy, observation and interivew, the facility failed to demonstrate appropriate use of Personal Protective Equipment (PPE) when entering and exiting the room of Resident #33 who resided on the second floor and was on transmission-based precautions for COVID-19. This had the potential to affect 46 residents (Resident #14, #78, #122, #100, #5, #53, #104, #113, #8, #16, #41, #29, #57, #81, #4, #10, #76, #63, #47, #46, #68, #89, #83, #112, #42, #24, #13, #18, #27, #55, #40, #30, #25, #6, #19, #38, #73, #98, #66, #32, #107, #90, #106, #31, #60, and #21 residing on the second floor. The facility census was 125. Residents Affected - Some Findings include: 1. Record review for Resident #33 revealed an admission date of 05/04/21. Diagnosis included COVID-19 dated 10/12/23. Record review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #33 was moderately cognitively impaired and required extensive assistance of one staff for bed mobility, transfers, dressing and toilet use. Resident #33 was frequently incontinent of bowel and bladder. Review of the physician order dated 10/12/23 for Resident #33 revealed and order for droplet precautions (use to prevent the spread of pathogens in respiratory secretions) maintained until 10/23/23 for COVID-19. Record review of the care plan dated 10/12/23 revealed Resident #33 was on droplet isolation precautions for a COVID-19 positive test. Interventions included droplet isolation precautions per physician's order and to determine appropriate barriers to apply based on isolation precaution category and activities to be performed e.g. masks, gowns, gloves, face shields. When leaving the isolation room, dispose of linen, trash, and disposable items using appropriate infection control procedures. 2. Record review for Resident #52 revealed an admission date of 04/10/17. Diagnosis included COVID-19 dated 10/12/23. Record review of the quarterly MDS assessment dated [DATE] revealed Resident #52 mental status was not assessed. Resident #52 required extensive assistance of two persons for bed mobility, transfers, dressing, extensive assist of one for personal hygiene, and total dependence for toilet use. Resident #52 had an indwelling catheter and was always incontinent of bowel. Record review of the care plan dated 10/12/23 revealed Resident #52 was on droplet isolation precautions for COVID-19. Interventions included droplet isolation precautions per physician's order, determine appropriate barriers to apply based on isolation precaution category and activities to be performed e.g. masks, gowns, gloves, face shields. Record review of the physician order dated 10/12/23 for Resident #52 revealed an order for droplet precautions maintained until 10/23/23 for COVID-19. Observation and record review revealed Resident #52 and Resident #33 were roommates. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365192 If continuation sheet Page 18 of 19 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 365192 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenbrier Health Center 6455 Pearl Rd Parma Heights, OH 44130 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 - Some Observation and interview on 10/16/23 at 1:13 P.M. revealed State Tested Nursing Assistant (STNA) #568 opened the door to exit Resident #52 and #33's room. STNA #568 indicated he was assigned to the second floor resident care areas. STNA #568 still had his N 95 mask, face shield, and gloves on and had not yet washed his hands before exiting the room. Regional Director (RD) #603 was also present near the surveyor and instructed STNA #568 to return to the room to remove his PPE and wash his hands. STNA #568 closed the door and once again opening the door, stepped out of the room and closed the door. STNA #568 was wearing the same N95 and face shield. RD #603 informed STNA #568 to return to the room, remove all PPE and wash his hands again. STNA #568 returned as instructed. Observation and interview on 10/16/23 at 5:59 P.M. revealed LPN #337 had her medication cart in front of the doorway of Resident #33 and #52. LPN #337 indicated she was the nurse on the second floor resident care area. Observation with RD #603 revealed LPN #337 opened the residents door, had full PPE on with exception of a face shield. LPN #337 had been wearing prescription glasses with no side pieces for protection. LPN #337 went back into the room, closed the door, removed her PPE then exited the room. LPN #337 confirmed she did not wear goggles or a face shield while caring for Residents #33 and 52. RD #603 confirmed LPN #337 should have worn the goggles or face shield while caring for residents with COVID-19. Review of the facility policy titled, Criteria for Covid 19 Requirements reviewed 05/11/23, revealed the process for isolation/covid room or unit if warranted included full PPE was required when entering a resident room which includes: N95 mask, eye protection, gown, and gloves. PPE is discarded before exiting the room. The receptacle for waist is placed inside the room at the exit. The eye protection may be discarded and new one applied or may be cleaned after each patient encounter. Perform hand hygiene per protocol before donning PPE and after doffing PPE. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365192 If continuation sheet Page 19 of 19