Inspection·February 2, 2024

F 0660 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few witnessed pushing the door open and walked outside the facility with the use of a walker and was not wearing shoes or a coat. LPN #503 stayed with Resident #98 while he was outside the facility. Resident #98's family was called and able to convince Resident #98 to return to the facility, and Resident #98 walked inside. Review of Resident #98's progress notes dated [DATE] at 6:52 P.M. included Resident #98 was safely inside the facility and Nurse Practitioner (NP) #603 was called and orders to give Haldol revealed Resident #98 was refusing medications. NP #603 gave orders to send Resident #98 to the local hospital for evaluation and a psych consult. The Administrator and Director of Nursing (DON) were made aware of the situation. The DON requested to speak with Resident #98's family to assist with transportation and care at the local hospital Emergency Department. FM #602 arrived and was notified Resident #98 was to be sent to the local hospital for evaluation related to combative aggressive behaviors with exit seeking. FM #602 proceeded to walk to Resident #98's room and soon after pushed Resident #98 to the front door in a wheelchair with his belongings. Education given on AMA and Resident #98 signed the AMA paperwork with FM #602 present. The Administrator, DON and NP #603 were notified. Review of Resident #98's Medication Administration Record (MAR) dated [DATE] revealed Resident #98's Insulin Lispro (one unit dial) subcutaneous solution pen-injector 100 units per milliliter (ml) due at 5:00 P.M. was not administered as ordered due to Resident #98 was out of the facility. Interview on [DATE] at 12:01 P.M. of Family member (FM) #601 revealed nothing good happened while Resident #98 resided at the facility. FM #601 stated Licensed Practical Nurse (LPN) #503 gave FM #602 Resident #98's insulin pen when the family was taking Resident #98 out of the facility AMA (against medical advice) on Christmas Eve ([DATE]). FM #601 stated FM #602 was told by LPN #503 she was unable to show her how to use the insulin pen. FM #601 indicated she had a conversation with the Administrator and the Administrator told her LPN #503 could not show the family how to use the insulin pen because of laws. FM #601 stated Resident #98 had an insulin pump which stopped working when he was sent to the hospital before he was admitted to the facility, and he was receiving insulin per sliding scale (based on blood sugar levels). Interview on [DATE] at 2:30 P.M. of the Director of Nursing (DON) revealed Resident #98 was verbally aggressive at times and FM #601 and #602 helped calm him down. The DON stated on [DATE] Resident #98 was combative, trying to hit the nurse with a cane or walker, was in and out of other resident rooms and NP #603 was contacted for orders. The DON indicated NP #603 gave orders for Resident #98 to be sent out to the local hospital to be evaluated if he did not calm down. The DON stated LPN #503 called her on [DATE] for guidance because Resident #98 was aggressive and unable to be redirected. The DON revealed LPN #503 saw Resident #98 walk out the front door, immediately followed him and stayed with him while she tried to redirect him back into the facility. LPN #503 was unable to redirect Resident #98 back into the facility, and while keeping him in sight at all times ran back to her medication cart to get her cell phone so she could call the family for assistance. FM #602 arrived to the facility and was able to bring Resident #98 back inside the facility, but FM #602 was irritated, started packing Resident #98's belongings, put Resident #98 in a wheelchair with his belongings and went out the front door. The DON stated LPN #503 asked FM #602 if Resident #98 should go to the hospital to be evaluated and FM #602 stated she was signing him out AMA. The DON stated the facility did their best to have something set up if a resident left AMA and NP #603 was notified. The DON stated we would print out a med list and LPN #503 gave a med list to the family and she gave Resident #98's insulin pen to the family because medications could not be returned to the pharmacy. Interview on [DATE] at 1:25 P.M. of LPN #503 revealed Resident #98 was forgetful at times. LPN #503 (continued on next page) 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 02/02/2024 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 0660 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated on [DATE] Resident #98 using a walker came out of his room around dinnertime, was not very steady and became belligerent if staff attempted to steady him or assist in any way. LPN #503 indicated staff stayed close to Resident #98 because they were worried he was going to fall. LPN #503 indicated Resident #98 went in a resident room and started yelling at him, left that room and went in a female resident room and started walking towards her and LPN #503, trying to keep both residents safe stood between Resident #98 and the female resident. LPN #503 stated Resident #98 hit her on her arms and legs before he was redirected out of the room. LPN #503 revealed she called FM #601 and FM #601 was able to calm Resident #98 down. LPN #503 indicated NP #603 was called and an order for Haldol (antipsychotic) was obtained and FM #601 was able to talk Resident #98 into taking it. LPN #503 stated on [DATE] Resident #98 was confused and at dinnertime she prepared to check his blood sugar, he was not in his room, she went looking for him and saw him pushing the door open and attempting to exit the facility via the front entrance. LPN #503 indicated she tried talking Resident #98 into coming back inside the facility, he did not have shoes or a jacket on, but was unable to redirect him back. LPN #503 stated keeping Resident #98 in sight she ran to her medication cart to get her cell phone, then ran back to Resident #98. LPN #503 revealed she called FM #601 while she was outside the door to the facility with Resident #98 and FM #601 was able to talk Resident #98 into going back inside and once inside he sat in a chair by the front door. LPN #503 stated she called the Administrator, the DON and NP #603 and NP #603 suggested sending Resident #98 to the local hospital for a psychiatric evaluation. LPN #503 indicated the DON said to wait until the family arrived to make the situation less traumatic for Resident #98. LPN #503 stated when FM #602 arrived she said she was taking Resident #98 out of the facility AMA and LPN #503 had AMA paperwork signed. LPN #503 stated she had FM #602 give Resident #98 his blood pressure medication, and she gave her Resident #98's insulin pen because he was a type one diabetic and she thought he needed it. LPN #503 indicated she did not remember FM #602 asking for Resident #98's medication list, but if they had she would have given it to them. Interview on [DATE] at 2:01 P.M. of FM #602 revealed on [DATE] when she arrived and took Resident #98 out of the facility AMA, she asked LPN #503 about his medications and LPN #603 said she could not legally tell her anything about the medications. FM #602 indicated LPN #503 told her to make sure Resident #98 received his medications, but she would not tell her how to give the insulin. FM #602 stated she did not know how to use the insulin pen, Resident #98 had always managed his own insulin until now and if Resident #98 was given the insulin he might have died. Interview on [DATE] at 2:17 P.M. of the DON revealed Resident #98 was on insulin previous to his admission to the facility and should have his pen. The DON stated FM #602 was told to call the family physician with any questions and FM #602 was in such a hurry to leave she might not have fully understood everything. Interview on [DATE] at 3:31 P.M. of LPN #503 revealed she gave FM #602 Resident #98's Lispro insulin pen-injector, and did not send written instructions with Resident #98 explaining how to use the pen-injector. LPN #503 stated she did not call Resident #98's physician or nurse practitioner to get an order to send the pen-injector with Resident #98 when he left. LPN #503 revealed she called NP #603 after Resident #98 left the facility and told her she sent Resident #98's Lispro insulin pen-injector with him when he left and NP #603 said ok. LPN #503 stated she told FM #602 Resident #98's insulin was based on what he eats, to follow up with Resident #98's primary care physician, and the family did not tell her they did not know how to use the insulin pen. Review of the facility policy titled Discharge Against Medical Advice Policy dated 12/2023 included it was the policy of the facility to assist the resident to discharge in the safest manner possible when the discharge was not recommended by the facility or the resident's physician. Orders would be (continued on next page) 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 02/02/2024 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 0660 Level of Harm - Minimal harm or potential for actual harm requested for Home Health services and equipment needs deemed appropriate, to facilitate a safer situation in the home environment. This deficiency represents non-compliance investigated under Master Complaint Number OH00149727 and Complaint Number OH00149724. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365267 If continuation sheet Page 4 of 4