Inspection·August 31, 2023

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review the facility failed to ensure advanced directives were present in the electronic chart and failed to ensure physicians orders were in place for Resident #70's advanced directives. This affected one resident (#70) of one resident reviewed for advance directives. The facility census was 96. Findings include: Review of the medical record revealed Resident #70 was admitted to the facility on [DATE]. Diagnoses included esophagitis unspecified with bleeding, gastrointestinal hemorrhage, and severe protein-calorie malnutrition. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #70 was alert and oriented with cognitive impairment and required one-person physical extensive assist for activities of daily living (ADL). Review of the paper medical record identified a code status of Full Code. Review of the electronic medical record, located in Point Click Care (PCC) identified no evidence of Resident #70's advanced directives request. Review of the current physician orders for August 2023 revealed no physician orders to identify the request for a code status of Full Code. Interview on 08/29/23 at 10:19 A.M. with Licensed Practical Nurse (LPN) #844 confirmed the advanced directive wishes of each resident should be in both medical records (paper and electronic), and match. LPN #844 confirmed the electronic chart should have included a physician order, which identified each residents wishes so nursing staff can quickly access the information in the event of an emergency. Review of the facility document titled Advance Directive Protocol, dated December 2014, revealed the facility had a policy in place that residents had a right to make decisions regarding the extent of resuscitation they wish to have performed was respected, honored, and discussed at the time of admission and as indicated during the course of treatment. Further review of the policy revealed a physician's order would be obtained indicating the residents code status and entered into PCC. Review of the facility document revealed the facility did not implement the policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365267 If continuation sheet Page 2 of 4 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 365267 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE O'Neill Healthcare Lakewood 13900 Detroit Ave Lakewood, OH 44107 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, staff interview, and policy review the facility failed to ensure food was labeled, dated, and stored appropriately. This had the potential to affect 91 of 91 residents who received meals from the facility kitchen. The facility identified five residents (#52, #70, #86, #87 and #202) who received no food by mouth. The facility census was 96. Findings include: The following concerns were noted during the main initial kitchen tour conducted on 08/28/23 between 8:16 A.M. and 8:42 A.M. One bag of breadcrumbs, one bag of coconut flakes, and one bag of corn flakes were open to air and not properly sealed were located in the walk-in dry storage area, one bag of sugar cookies and one bag of chocolate chip cookies were open to air and undated located in the reach-in freezer, and four containers and/or baskets of strawberries with white, fuzzy, mold were located in the walk-in refrigerator. Interview and observation on 08/28/23 at 8:25 A.M., Dietary Manager (DM) #806 verified the above findings. Review of the facility document titled Food Storage, dated 2005, revealed the facility had a policy in place that sufficient storage would be provided to keep foods safe, wholesome, and appetizing and food would be stored, prepared, and transported at an appropriate temperature and by methods designed to prevent food contamination. Review of the document revealed the facility did not implement the policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365267 If continuation sheet Page 3 of 4 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 365267 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE O'Neill Healthcare Lakewood 13900 Detroit Ave Lakewood, OH 44107 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Level of Harm - Minimal harm or potential for actual harm Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. 2. Observation on 08/28/23 from 8:10 A.M. through 8:35 A.M. of the hallways and each resident room revealed heavily stained, spotted, and worn carpeting. Residents Affected - Many On 08/28/23 at 8:35 A.M. the Director of Nursing (DON) verified and stated the carpet was being replaced due to the stains and spots in each room and in the hallways. Based on observation and staff interview the facility failed to ensure 15 residents (#5, #14, #21, #22, #31, #36, #51, #61, #67, #68, #69, #70, #79, #84, and #87) had a clean privacy curtain and failed to maintain clean and sanitary carpeting throughout the resident rooms and hallways. This had the potential to affect all 96 residents currently residing in the facility. Findings include: 1. Observation on 08/29/23 at 7:33 A.M. with State Tested Nurse Assistants (STNAs) #887 and #900 verified Residents #5, #14, #21, #22, #31, #36, #51, #61, #67, #68, #69, #70, #79, #84 and #87 had privacy curtains that were stained and dirty. Interview on 08/29/23 at 7:36 A.M. with STNA #900 revealed housekeeping and laundry staff were responsible for cleaning and maintaining the privacy curtains in resident rooms. Interview on 08/31/23 at 10:15 A.M. with Office Staff (OS) #944 revealed housekeeping staff maintained the resident rooms and common areas daily and privacy curtains were cleaned on rotation once a month unless contaminated or during isolation precautions. An environmental tour was conducted on 08/31/23 between 10:20 A.M. and 10:30 A.M. with OS #944. The following concerns were observed and verified at the time of observation. The rooms belonging to Residents #5, #14, #21, #22, #31, #36, #51, #61, #67, #68, #69, #70, #79, #84 and #87 contained privacy curtains that were stained to various degrees by unknown substances that varied from red, brown, and yellow in color and brown crusted material. Review of the facility document titled Laundry Guidelines, undated, revealed the facility had a policy in place that all personnel would handle, store, process, and transport linen to prevent the spread of infection and an adequate supply of linen would be maintained for resident care. Review of the document revealed the facility did not implement the policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365267 If continuation sheet Page 4 of 4