Inspection·October 7, 2025

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few then spreads to the limbs within three hours of death) had set in at the site of the mandible. No resuscitation efforts were performed by EMS. The medical director was called and provided time of death. The resident was DOA (dead on arrival). The resident's body was left at the facility and EMS returned to service. The run report listed the Call Nature as DOA/Body Found.Review of the written statement provided by RN #515 on [DATE] revealed she was called into Resident #116's room by CNA #401. The resident was unresponsive. RN #515 called out the resident's name, performed a sternal rub (a medical procedure used to assess a patient's level of consciousness and responsiveness) and the resident remained unresponsive. RN #515 indicated she assessed the resident, palpated the carotid area and radial artery for a pulse and was unable to find them. She was unable to obtain any vital signs (blood pressure, pulse, respirations, and oxygenation level). RN #515 notified LPN #507 to assess the resident. RN #515 established the resident's code status, initiated hands only CPR, called 911, and reassessed the resident the first round of compressions. No change was found and the DON was notified. EMS arrived and performed no interventions for the resident. The physician was notified as well as the family. On [DATE] the Administrator obtained a verbal statement from CNA #401 which indicated she was assigned to care for Resident #116 on the night shift of [DATE]. CNA #401 said the resident was anxious throughout the shift. When she checked on the resident she was not breathing so she called in RN #515 and RN #515 initiated chest compressions and CNA #401 then left the room. CNA #401 did not sign her statement, only the Administrator signed it.Interview with Police Officer (PO) #531 on [DATE] at 2:59 P.M. revealed she was the one dispatched to the facility call on [DATE]. PO #531 said typically the police do not respond to EMS calls but they requested an officer's presence at the scene as the call had been for a deceased body. She said the call was a bit unusual but would not elaborate. PO #531 confirmed there was no police file from the call. Interview with RN #515 on [DATE] at 10:15 A.M. revealed she always works on the first floor skilled unit. RN #515 said when a resident is found unresponsive she calls them by name, checks for a pulse, respirations, and code status. The second nurse is called to the room to verify her findings. If the second nurse confirms her findings they start cardiopulmonary resuscitation (CPR) and call 911. RN #515 said if she was unable to find a resident's code status in the chart she would contact the physician or the transferring hospital to determine code status. If they did not have one the resident would be treated as a full code (all life saving measures are to be implemented). To obtain help from the other floor she can call a direct line they have or overhead page a code. When asked when does CPR end RN #515 said she does a first round of compressions and then reassesses the resident. She does not provide rescue breathing or have the second nurse start rescue breathing as she feels compressions are more important. RN #515 said she typically does three rounds of compressions and reassesses to consider her options. Either she or the aide will call 911. When asked where she learned the method of three rounds of compressions RN #515 said she read it in a journal somewhere. The night the resident died, CNA #401 went in to start getting the resident ready for dialysis. RN #515 said she was preparing Resident #116's 6:00 A.M.'s morning medications. CNA #401 came and told her the resident did not look good. RN #515 said she went to the resident's room to assess the resident. RN #515 said the resident was not breathing and did not have a pulse. She said she did not provide any rescue breathing as she thought compressions were more important. RN #515 said she was the one who called 911 for an unresponsive resident. EMS did not do anything for Resident #116 after their arrival. RN #515 confirmed the police arrived with the squad. RN #515 confirmed she was not providing compressions when EMS arrived as she had completed her 3 cycles of compression. After each cycle she stopped and checked for a pulse. LPN #507 did not perform rescue breathing either.Interview with LPN #507 on [DATE] at 11:12 A.M. revealed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365267 If continuation sheet Page 2 of 7 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 10/07/2025 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few she has worked for the facility for about a year and typically works on the first floor skilled unit. LPN #507 said she does not remember Resident #116 as she was not on her hallway but does remember the code on [DATE]. RN #515 was the nurse assigned to Resident #116. LPN #507 said she was on break and sitting outside when RN #515 came to her and asked her to assess Resident #116 so they could pronounce her deceased . LPN #507 confirmed the resident had no vital signs but did not remember what time that was. The only other part she had in the code was letting EMS in when they and the police arrived. LPN #507 said she pointed EMS to the room and she then went back and finished her break. LPN #507 said the code did seem unusual to her as she did not know if the resident was a full or a Do Not Resuscitate (DNR provide no life saving interventions). She did not write a statement about the code as the only thing she did was assess for vitals in order the pronounce the resident deceased and let the squad in.Interview with the Administrator, the DON, and the Regional Director of Clinical Services (RDCS) #530 on [DATE] at 12:25 P.M. revealed the statements they received regarding Resident #116's death was different from the EMS run sheet and what the staff told them. RDCS #530 confirmed CPR and rescue breathing should have been continued until EMS arrived.Review of the American Heart Association (AHA) website CPR recommendations for healthcare providers revealed conventional CPR using chest compressions and mouth-to-mouth breathing at a ratio of 30:2 compressions-to breaths.Review of the facility's Cardiopulmonary Resuscitation (CPR) policy, last revised [DATE]), revealed the resident who is unresponsive should by checked by assessing airway, breathing, and circulation (ABCs). The airway is to be opened with the head tilt/chin lift maneuver. Check the airway by placing your ear over the resident's mouth and nose then look to see if the chest is rising and falling, listen for exhalation, and feel for exhaled air. Check for signs of breathing for no more than 10 seconds. Then check for a pulse for no more than 10 seconds. If the resident is pulseless and not breathing begin CPR. The resident should be on a firm, flat surface using a back board as needed when the resident is in bed. Perform 30 compressions at a rate of 100 per minute then give two breaths for five cycles before evaluating the resident. Once CPR is started do not discontinued unless there obvious signs of life (breathing), advanced medical help/EMS arrives, another trained rescuer takes over for you, you are presented with a valid DNR order, you are too exhausted to continue, a physician pronounces the resident dead and gives orders to discontinue CPR, or an automated external defibrillator (AED) is ready for use.Review of the facility's Death of a Resident Policy, last revised [DATE], revealed pronouncement of death may be by a licensed physician or two licensed nurses with prior authorization from a physician, in accordance with applicable state laws. Documentation must be recorded in the clinical record including date and time of death, name and title of the individual pronouncing the resident deceased , and any pertinent clinical observations.2. Resident #123 was admitted to the facility on [DATE] with diagnoses including CHF, COPD, chronic respiratory failure, cirrhosis of the liver, ESRD dependent on renal dialysis, dependence on supplemental oxygen, heart disease, presence of an automatic implantable defibrillator, and atrial fibrillation. Resident #123 died on [DATE].Review of the physician's orders for Resident #123 revealed orders dated [DATE] for a full code (life saving measures are to be performed); hemodialysis every Monday, Wednesday, and Friday; and oxygen at four liters per minute via nasal cannula continuous.Review of the quarterly comprehensive MDS 3.0 assessment, dated [DATE], revealed Resident #123 was cognitively intact. She needed staff assistance to set her up for eating, oral hygiene, toileting, and personal hygiene. She required supervision for showers. The resident was short of breath lying flat, and did not have a life expectancy of less than six months. The resident received oxygen, dialysis, and participated in rehabilitative therapy.Review of Resident #123's nurses' notes revealed on [DATE] at 2:08 A.M. LPN #509 was notified by (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365267 If continuation sheet Page 3 of 7 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 10/07/2025 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the resident she had received a call from the hospital she was transferred to the facility from advising her that they had a bed for her available so they could investigate an abnormal electrocardiogram (EKG) she had had while she was in the hospital. LPN updated the on-call nurse practitioner, arranged for transportation and the resident was transferred to the hospital at 2:10 A.M. The resident was readmitted to the facility on [DATE]. On [DATE] at 8:48 A.M. RN #460 documented Resident #123 was in pain and complained of back pain and was given an as needed order for Tramadol (a controlled medication for pain). The resident remained on her ordered oxygen of four liters oxygen per nasal cannula and had shortness of breath with exertion. Review of RN #460's documentation revealed at 12:32 P.M. CNA #409 noted Resident #123 was not breathing and notified RN #460. RN #460 assessed the resident and was not able to palpate a pulse, the resident was not breathing, and did not respond to a sternal rub. The resident had a code status of full code. An overhead page was made alerting staff to a Code Blue (an alert to staff a resident who was a full code was unresponsive and life saving measures were needed). RN #460 documented CPR was initiated, 911 was called, EMS services took over the code but were unable to revive her. EMS contacted their medical director who made the pronouncement of death. EMS left the resident's body with the facility and all notifications were made. Post-mortem care was provided by the facility.Review of the EMS run report for Resident #123, dated [DATE] revealed a call was received from the facility at 12:33:19 P.M. EMS was notified at 12:33:33 P.M. and was enroute to the facility at 12:35:33 P.M. EMS arrived at the resident's bedside at 12:39 P.M. The EMS narrative revealed they found Resident #123 in her bed and unresponsive with nurses performing CPR and had applied an AED to the resident's chest. Nursing stated the last known normal time for the resident was five minutes prior to finding her unresponsive. The resident's nurse said the resident had just been discharged from the hospital for a cardiac issue. EMS took over CPR and care of the resident. Resident #123's pupils were fixed and dilated. EMS provided ventilation through use of a Bag-Valve-Mask device (a life-saving resuscitation device that manually delivers oxygen to a patient's lungs when they cannot breathe adequately on their own which is also called an Ambu bag) and oxygen. EMS gave the resident Advanced Cardiac Life Support (an advanced medical protocol and certification for healthcare professionals to manage cardiopulmonary emergencies, building on Basic Life Support skills) and continued CPR. The resident did not respond to treatment. EMS contacted the medical director and time of death was 1:00 P.M. EMS left the resident for post-mortem care and left the facility.Review of the witness statements for Resident #123's code revealed statements were obtained from CNA #409, LPN #425, and LPN #467. CNA #409's statement was dated [DATE] revealed she was assigned to Resident #123 on day shift of [DATE]. She revealed she took Resident #123's tray in she noticed the resident was curled up with her back to her. CNA #409 called the resident's name but she did not respond. She walked over to the resident and touched her but the resident was unresponsive. CNA #409 immediately went to get the resident's nurse. RN #460 came to the room and told CNA #409 to call a code. CNA #409 left the room and called a code.LPN #425's witness statement was dated [DATE]. LPN #425 stated the code was called for Resident #123. LPN #425 brought the crash cart to the room. Upon entering the resident's room he saw another nurse providing chest compressions and the AED was being applied. After several minutes EMS arrived at the bedside.LPN # 467's witness statement was undated. LPN #467 heard a Code Blue called over the overhead page system and she went to Resident #123's room. As she rounded the corner to the east hallway where the resident resided an unnamed nurse told her to call 911 and give information to the operator. After doing that LPN #467 went to the resident's room to assist with compressions. LPN #467 was directed to get the resident's paperwork together for EMS and did so. Compressions continued, EMS arrived and took over from the staff.Interview with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365267 If continuation sheet Page 4 of 7 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 10/07/2025 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few RDCS #530 on [DATE] at 4:50 P.M. revealed the night shift staff are responsible for keeping the crash carts fully stocked. This stopped on [DATE] when they changed it to the current system of attaching a disposable lock that has a code on it and if the code matches what is on the audit sheet then the crash cart remains fully stocked. If the numbers do not match then they have to restock it, put a new lock on the cart, and document it on the audit sheet. RDCS #530 provided a copy of the old crash carts audits from August and [DATE]. Review of the audits indicated the crash cart on the second floor was fully stocked on [DATE] when Resident #123 coded.Interview with LPN #425 on [DATE] at 2:30 P.M. revealed when the code was called for Resident #123 he took the crash cart down to the resident's room and then went back to his unit. LPN #425 said he did not participate in the code. Interview with LPN #512 on [DATE] at 2:41 P.M. revealed she had been a nurse since [DATE] and has worked for the facility since [DATE]. She works in both the nursing home and the assisted living. LPN #512 said she was working in the Assisted Living the day Resident #123 coded. When she heard the overhead page for Resident #123 coding she ran out of the Assisted Living, ran around the building and into the nursing home. LPN #512 said when she arrived at the resident's room LPN #484 was performing compressions on Resident #123. LPN #512 said LPN #425 had originally started compressions but LPN #484 took over as LPN #425 was performing compressions over the resident's left breast and not over the sternum. LPN #425 offered to take over compressions but LPN #484 declined as he performed them incorrectly. LPN #512 kept asking for the Ambu bag in order to provide oxygen to the resident but there was not one on the crash cart. LPN # 512 said LPN #467 went to find an Ambu bag without success. LPN #512 said she took over compressions from LPN #484. LPN #425 again offered to take over compressions and she, LPN #484, and CNA #505 all told him no as he had provided compressions to the wrong area. LPN #512 said CNA #505 is certified in CPR so she assisted with compressions. LPN #512 said she told Regional Registered Nurse (RRN) #532 about her concerns with the code.Interview with LPN #467 on [DATE] at 3:04 P.M. revealed she had worked for the facility for three years and has been a nurse for five years. She said she typically works on the second floor on the second floor on day shift. LPN #467 said she heard the overhead page for a code but was unable to hear the room where it was located. She left the room she was in and saw RN #460 who told her to call 911 and give report to them as well as to get the paperwork together for EMS. Once she completed her task she went to Resident #123's room where staff were performing CPR. LPN #425 and LPN #484 were doing compressions and RN #460 was setting up the AED. LPN #512 was also in the room. CPR was continued until EMS arrived and took over. LPN #467 said EMS put the compression device on the resident. Eventually EMS contacted their medical director and pronounced the resident dead. EMS did not transport the resident to the ER. LPN #467 said RN #460 notified the family and post-mortem care was provided. LPN #467 said she was unable to see who was providing care but heard LPN #512 tell LPN #425 she was taking over CPR but was unsure why. LPN #467 said the night shift staff were responsible for stocking the crash cart. There was not an Ambu bag on the cart but there was an oxygen cannister. She looked for an Ambu bag to provide ventilation to Resident #123 but was unable to locate one.Interview with CNA #505 on [DATE] at 3:23 P.M. revealed she had worked for the facility for a little over a year but has been an aide for about 20 years. CNA #505 confirmed she was CPR certified. She responded to the coded and helped LPN #425 with bringing the crash cart to the room and placing the back board under the resident. When they arrived LPN #484 was providing compressions. CNA #505 said she took over compressions from LPN #484. When LPN #425 was doing compressions she noticed he was not performing them correctly. He was compressing the left breast but not over the breast bone. CNA #505 said she, LPN #512, and LPN #484 all told LPN #425 he was performing compressions incorrectly so the three of them took over all compressions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365267 If continuation sheet Page 5 of 7 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 10/07/2025 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few CNA #505 did tell the Administrator about her concerns with the code.Interview with LPN #484 on [DATE] at 3:37 P.M. revealed she works on the first floor skilled unit. When she heard the overhead page for a code she got the AED off the crash cart and took it upstairs. The crash cart had just arrived when she got there so she assisted rolling Resident #123 over so the backboard could be placed under her and then started compressions. When LPN #512 arrived she took over compressions from her. LPN #484 confirmed there was not an Ambu bag on the cart so there was no one providing ventilations to the resident. LPN #484 confirmed there were issues with the CPR provided to the resident. LPN #425 was initially doing compressions but not in the correct area. LPN #484 told him he was doing compressions incorrectly as did LPN #512 and CNA #505. LPN #425 eventually moved to the correct position over the sternum after so many people told him he was performing it incorrectly. The AED kept saying no shock advised. EMS arrived and took over care of Resident #123 and eventually pronounced the resident dead. LPN # 484 said she did not tell anyone what occurred and she was not asked for a statement regarding the code.Interview with the Administrator, the DON, and RDCS #530 on [DATE] at 4:50 P.M. revealed they were unaware three staff members had told LPN #425 he was performing chest compressions incorrectly. RDCS #530 said there were some personality conflicts among staff and she thinks that is where the statements were coming from. RDCS #530 said she spoke with RN #460 who was Resident #123's nurse on [DATE] and she voiced no concerns regarding the code. They did not ask RN #460 for a written statement as her documentation in the nurses' notes was her statement. RDCS #530 said they were not aware an Ambu bag was not on the crash cart. RDCS #530 said they did recently change the crash cart checks to adding a lock to the cart with a number on it and as long as the number on the lock matches the audit sheet then the cart is fully stocked.Interview with RN #460 on [DATE] at 10:46 A.M. revealed she last saw the resident a few minutes before CNA #409 notified her she had found Resident #123 unresponsive. When CNA #409 told her the resident was unresponsive she went to the resident's room and assessed her. After assessing her she told CNA #409 to overhead page a code. RN #460 said there was a good response from the staff. LPN #425 and LPN #512 started compressions and she had LPN #467 gather the paperwork and call 911. RN #460 said she had somebody hold the elevator door open on the first floor for when the squad arrived. The first floor nurse, LPN #484 brought the AED up with her and also assisted with compressions. RN #460 had the staff stop compressions so she could place the AED on the resident which advised no shock then CPR was resumed. RN #460 did not remember if she checked the oxygenation level for Resident #123. RN #460 said the resident was on continuous oxygen at four liters per minute per nasal cannula. RN #460 said the AED would sometimes state compression were not deep enough and staff would adjust and correct it. RN #460 said she did not remember if CNA #505 provided compressions for Resident #123. She denied noticing any problems with the code. RN #460 said she felt the code went well and the staff involved were great. RN #460 confirmed no ventilation was provided during the code, just compressions. RN #460 confirmed there was not an Ambu bag on the crash cart. When EMS arrived they took over the code from the facility staff. When EMS received no response from the resident they contacted their medical director who pronounced the resident dead. EMS said they would not be taking the body as the police had to inspect the scene.Review of the facility's crash cart supply list prior to changing to the lock system revealed the crash cart should contain an ambubag. Review of the American Heart Association (AHA) website CPR recommendations for healthcare providers revealed conventional CPR using chest compressions and mouth-to-mouth breathing at a ratio of 30:2 compressions-to breaths.Review of the facility's Cardiopulmonary Resuscitation (CPR) policy, last revised [DATE]), revealed the resident who is unresponsive should by checked by assessing airway, breathing, and circulation (ABCs). The airway is to be opened with the head (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365267 If continuation sheet Page 6 of 7 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 10/07/2025 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete tilt/chin lift maneuver. Check the airway by placing your ear over the resident's mouth and nose then look to see if the chest is rising and falling, listen for exhalation, and feel for exhaled air. Check for signs of breathing for no more than 10 seconds. Then check for a pulse for no more than 10 seconds. If the resident is pulseless and not breathing begin CPR. The resident should be on a firm, flat surface using a back board as needed when the resident is in bed. Perform 30 compressions at a rate of 100 per minute then give two breaths for five cycles before evaluating the resident. Once CPR is started do not discontinued unless there obvious signs of life (breathing), advanced medical help/EMS arrives, another trained rescuer takes over for you, you are presented with a valid DNR order, you are too exhausted to continue, a physician pronounces the resident dead and gives orders to discontinue CPR, or an automated external defibrillator (AED) is ready for use.This deficiency represents noncompliance investigated under Complaint Number 2621899. Event ID: Facility ID: 365267 If continuation sheet Page 7 of 7