Health inspection·July 20, 2023

F 0584 This deficiency represents non-compliance investigated under Master Complaint Number OH00144714 and Complaint Number OH00143997. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365290 If continuation sheet Page 2 of 12 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 365290 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kirtland Woods of Journey 9685 Chillicothe Rd Kirtland, OH 44094 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 on observation, record review, and interview the facility failed to provide appropriate oral care for Resident #71 and failed to document refusals. This affected one resident (#71) of three residents reviewed for activities of daily living. The census was 117. Residents Affected - Few Findings include: Observation of Resident #71 on 07/17/23 at 11:35 A.M. revealed Resident #71 sitting in a common room. She had brown teeth with a noticeable moist film on them and a crusty orange substance on her teeth and lips. She was not interviewable. Record review of Resident #71 revealed she was admitted [DATE] with diagnoses including dementia, macular degeneration, and anxiety disorder. Review of the Minimum Data Set (MDS) assessment on 06/14/23 revealed Resident #71 was rarely or never understood, required extensive assistance for personal hygiene, and received hospice services. She was care planned for refusing oral care; however, review of the progress notes and hygiene care documentation revealed no documented evidence of refusals of care in the last month. Oral hygiene was last documented as completed for her before the above observation on 07/17/23 at 1:10 A.M. The surveyor confirmed the above findings with the Director of Nursing (DON) on 07/17/23 at 11:42 A.M. Interview with State Tested Nurse Aide (STNA) #238 on 07/17/23 at 11:57 A.M. revealed Resident #71 refused oral care that morning. She said the resident had the orange debris in her mouth since before breakfast. This deficiency represents noncompliance investigated under Complaint Number OH00144133 and Complaint Number OH00143997. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365290 If continuation sheet Page 3 of 12 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 365290 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kirtland Woods of Journey 9685 Chillicothe Rd Kirtland, OH 44094 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 - Some 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 record review, interview, and facility policy review the facility failed to ensure Resident #162 was transferred according to the physician's order and failed to ensure Resident #107's fall investigations were completed to ensure fall prevention interventions were in place as well as new interventions implemented. This finding affected two residents (#107 and #162) of three residents reviewed for transfers and falls. The facility census was 117. Findings include: 1. Review of Resident #162's medical record revealed she was admitted on [DATE] with diagnoses including other Alzheimer's disease, chronic obstructive pulmonary disease, and overactive bladder. Review of Resident #162's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment and required extensive two person assist for transfers and toileting. Review of Resident #162's physician orders revealed an order dated 06/30/23 for two staff member assist during transfers every shift. Interview on 07/18/23 at 1:54 P.M. with Resident #162's daughter indicated Resident #162 was still in bed and in her pajamas on 07/16/23 at 1:00 P.M. with the breakfast tray in front of her. Resident #162's daughter confirmed State Tested Nurse Aide (STNA) #265 then transferred the resident by himself from the bed to her wheelchair and then to the bathroom. She stated she was aware Resident #162 required two-person assist with transfers. Interview on 07/18/23 at 2:24 P.M. with the Administrator confirmed Resident #162's daughter provided a photograph revealing STNA #265 transferred the resident by himself on 07/16/23 from the bed to the wheelchair and then the wheelchair to the bathroom. The Administrator confirmed Resident #162 required two-person assist for transfers and toileting. Interview on 07/19/23 at 8:28 A.M. with Social Services Designee (SSD) #225 indicated Resident #162's daughter came into her office on 07/16/23 around 2:00 P.M. to tell her that the resident was still in bed, still in her pajamas, and her incontinence brief was wet with urine. 2. Review of Resident #107's medical record revealed he was admitted on [DATE] with diagnoses including muscle weakness, repeated falls, and hyperlipidemia. Review of Resident #107's MDS 3.0 assessment dated [DATE] revealed he exhibited moderate cognitive impairment and required total dependence of two staff for transfers. Review of Resident #107's care plan dated 04/18/23 revealed he was at risk for falls related to new environment, history of falls, weakness, balance problem, and history of episodes of incontinence. Review of the facility incident reports dated from 07/12/22 to 07/17/23 revealed Resident #107 had falls on 04/18/23, 04/20/23, 04/29/23, 05/16/23, 05/25/23, 05/30/23, 05/31/23, 06/06/23, 06/13/23, 06/30/23 and 07/18/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365290 If continuation sheet Page 4 of 12 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 365290 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kirtland Woods of Journey 9685 Chillicothe Rd Kirtland, OH 44094 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 - Some Review of Resident #107's progress notes from 04/18/23 to 07/19/23 revealed the resident sustained falls on 04/18/23, 04/20/23, 04/29/23, 05/16/23, 05/25/23, 05/30/23, 05/31/23, 06/06/23, 06/13/23, 06/30/23 and 07/18/23. Review of Resident #107's medical record and fall investigations did not reveal evidence fall investigations were conducted for the falls dated 04/18/23, 04/20/23, 05/16/23, 05/25/23, 05/31/23, 06/06/23, 06/13/23, and 06/30/23 including if fall prevention interventions were in place at the time of the falls and if new fall prevention interventions were implemented following the fall to prevent further falls. Interview with 07/19/23 at 12:03 P.M. with the Director of Nursing (DON) verified the facility was unable to locate the fall investigations for 04/18/23, 04/20/23, 05/16/23, 05/25/23, 05/31/23, 06/06/23, 06/13/23, and 06/30/23. Review of the 11/08/22 revised facility policy titled Falls revealed the facility failed to complete a thorough investigation which included identifying the hazard, evaluating, and analyzing hazard, implement interventions to reduce hazards and risk, monitor for effectiveness, and modify interventions when necessary. This deficiency represents noncompliance investigated under Complaint Number OH00144133. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365290 If continuation sheet Page 5 of 12 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 365290 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kirtland Woods of Journey 9685 Chillicothe Rd Kirtland, OH 44094 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and facility policy review the facility failed to ensure Resident #99 was provided timely care. This finding affected one resident (#99) of three residents reviewed for incontinence care. Findings include: Review of Resident #99's medical record revealed he was admitted on [DATE] with diagnoses including unspecified dementia, malignant neoplasm of the prostate, anxiety disorder, and major depressive disorder. Review of Resident #99's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he exhibited a memory problem and required extensive one person assist for bed mobility, dressing, and personal hygiene as well as extensive two person assist for transfers and toilet use. Observation on 07/17/23 at 10:09 A.M. revealed Resident #99 was in the common television lounge on the secured memory care unit (SMCU). He was observed in a reclined Broda chair sleeping with music on the television. Observation on 07/17/23 at 12:12 P.M. revealed Resident #99 was moved from the common lounge to the main dining room on the SMCU for the lunch meal. Observation on 07/17/23 at 1:32 P.M. revealed Resident #99 was returned to the common lounge in the Broda chair. Incontinence care was not provided at this time. Interview on 07/17/23 at 1:54 P.M. with Licensed Practical Nurse (LPN) #242 indicated State Tested Nursing Assistants (STNAs) were required to check residents and provide incontinence care every two hours and as needed. Interview on 07/17/23 at 1:57 P.M. revealed Resident #99 was still in the common lounge in the Broda chair. Interview on 07/17/23 at 2:10 P.M. with STNA #299 indicated she worked the 7:00 A.M. to 7:00 P.M. shift and the last time Resident #99 was provided incontinence care was around 7:20 A.M. She stated she was the only STNA from 7:00 A.M. to 8:30 A.M. and then another STNA arrived on the unit. She stated she was unable to provide incontinence care to Resident #99 every two hours due to lack of staffing, and was she was unable to provide Resident #99's incontinence care for over six hours. Observation on 07/17/23 at 2:20 P.M. with LPN #239, STNA #299, and STNA #300 of Resident #99's incontinence care revealed the resident was assisted to the bed with the assistance of two staff members and incontinence care provided. Resident #99's incontinence brief was saturated with urine, and he had a bowel movement. Observation of Resident #99's left buttock revealed reddened excoriation. Interview on 07/17/23 at 2:30 P.M. with LPN #239 confirmed Resident #99 had reddened excoriation of his left buttock which could have been from incontinence care not being completed timely. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365290 If continuation sheet Page 6 of 12 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 365290 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kirtland Woods of Journey 9685 Chillicothe Rd Kirtland, OH 44094 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Review of the Supporting Activities of Daily Living policy, revised 03/18, indicated residents who were unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, personal and oral hygiene. This deficiency represents non-compliance investigated under Master Complaint Number OH00144714 and Complaint Number OH00143997. Event ID: Facility ID: 365290 If continuation sheet Page 7 of 12 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 365290 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kirtland Woods of Journey 9685 Chillicothe Rd Kirtland, OH 44094 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and policy review the facility failed to ensure adequate staffing to meet the needs of the residents. This finding affected Residents #99 and #162 and had the potential to affect all 43 residents residing on the secured memory care unit (SMCU) including Residents #4, #6, #7, #8, #11, #12, #17, #20, #29, #30, #32, #36, #37, #38, #41, #48, #50, #52, #53, #55, #64, #68, #69, #70, #76, #77, #78, #80, #83, #85, #88, #89, #91, #93, #95, #97, #99, #102, #105, #106, #109, #162 and #163. Findings include: 1. Review of Resident #99's medical record revealed he was admitted on [DATE] with diagnoses including unspecified dementia, malignant neoplasm of the prostate, anxiety disorder and major depressive disorder. Review of Resident #99's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he exhibited a memory problem and required extensive one person assist for bed mobility, dressing, and personal hygiene as well as extensive two person assist for transfers and toilet use. Observation on 07/17/23 at 10:09 A.M. revealed Resident #99 was in the common television lounge on the SMCU. He was observed in a reclined Broda chair sleeping with music on the television. Observation on 07/17/23 at 12:12 P.M. revealed Resident #99 was moved from the common lounge to the main dining room on the SMCU for the lunch meal. Observation on 07/17/23 at 1:32 P.M. revealed Resident #99 was returned to the common lounge in the Broda chair. Incontinence care was not provided at this time. Interview on 07/17/23 at 1:54 P.M. with Licensed Practical Nurse (LPN) Unit Manager #242 indicated State Tested Nursing Assistants (STNAs) were required to check residents and provide incontinence care every two hours and as needed. LPN Unit Manager #242 stated there was not enough staff on her unit at times for timely resident care. Observation on 07/17/23 at 1:57 P.M. revealed Resident #99 was in the common lounge in the Broda chair. Interview on 07/17/23 at 2:10 P.M. with STNA #299 indicated she worked the 7:00 A.M. to 7:00 P.M. shift and the last time Resident #99 was provided incontinence care was around 7:20 A.M. She stated she was the only STNA from 7:00 A.M. to 8:30 A.M. and then another STNA arrived on the unit. She stated she was unable to provide incontinence care to Resident #99 every two hours due to lack of staffing, and was she was unable to provide Resident #99's incontinence care for over six hours. Observation on 07/17/23 at 2:20 P.M. with LPN #239, STNA #299 and STNA #300 of Resident #99's incontinence care revealed the resident was assisted to the bed with the assistance of two staff members and incontinence care provided. Resident #99's incontinence brief was saturated with urine, and he had a bowel movement. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365290 If continuation sheet Page 8 of 12 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 365290 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kirtland Woods of Journey 9685 Chillicothe Rd Kirtland, OH 44094 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 0725 Level of Harm - Minimal harm or potential for actual harm Interview on 07/17/23 at 2:30 P.M. with LPN #239 confirmed Resident #99's incontinence care was not completed timely. 2. Review of Resident #162's medical record revealed she was admitted on [DATE] with diagnoses including other Alzheimer's disease, chronic obstructive pulmonary disease, and overactive bladder. Residents Affected - Some Review of Resident #162's admission MDS 3.0 assessment dated [DATE] revealed she exhibited severe cognitive impairment, required extensive two person assist for transfers and toileting, and was frequently incontinent of bowel and bladder. Review of a text message provided by Resident #162's daughter revealed a text message dated 07/16/23 at 2:08 P.M. from admission Director #215 to the daughter which stated managers have been working on it since this morning. We had a rough day for staffing. It happens sometimes but I can promise you this was not our normal. I have [Social Services Designee (SSD) #225] reaching out to you about it. It's been a day. Review of a text message provided by Resident #162's daughter revealed a text message dated 07/16/23 at 2:12 P.M. from the daughter to admission Director #215 which stated I imagine it has. My mother sitting in urine from 7:00 P.M. until 1:00 P.M. was not ok. Review of a text message provided by Resident #162's daughter revealed a text message dated 07/16/23 at 2:22 P.M. from Resident #162's daughter to admission Director #215 stated the STNA today was simply awful. The STNA did not want to get [Resident #162] dressed and the resident did not want to go to breakfast so she let her sit there all day in soaking wet pajamas. Interview on 07/19/23 at 8:28 A.M. with SSD #225 confirmed Resident #162's daughter had reported the resident was soiled with urine and they started a grievance form related to the concern. She stated Resident #162's daughter came into her office around 2:00 P.M. to report the concern. She denied concerns with staffing and indicated she did not check on the resident following the concern on 07/16/23 to determine the needs of the resident. Interview on 07/19/23 at 11:44 A.M. with Admissions Director #215 confirmed he received a text message from Resident #162's daughter on 07/16/23 which stated the resident was in bed, in her pajamas and had a soiled incontinence brief on. He confirmed he replied in a text to Resident #16's daughter that they had staffing challenges and the facility was working on it. He indicated the concern was fixed when she sent him the text, but he contacted Social Services Designee #225, who was the manager on duty, to let her know of the concern. Review of the Resident #162's Grievance/Concern form dated 07/16/23 indicated the toothbrush (brought in on admission on [DATE]) was unopened, the incontinence brief was dirty and soaked, the breakfast tray was in the room and the resident was in bed at 11:30 A.M., hangers were taken out of the room, clothing was removed from the room, and the STNAs did not know how to talk to dementia residents. Review of the Activities of Daily Living (ADL) policy, revised 03/18, indicated appropriate care and services would be provided for residents who were unable to carry out ADL independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene, mobility, elimination, dining and communication. 3. Interview on 07/17/23 at 12:00 P.M. with Resident #163's daughter indicated the facility was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365290 If continuation sheet Page 9 of 12 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 365290 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kirtland Woods of Journey 9685 Chillicothe Rd Kirtland, OH 44094 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 0725 short staffed at times. Level of Harm - Minimal harm or potential for actual harm Interview on 07/17/23 at 12:29 P.M. with Resident #88's daughter indicated the facility did not have enough staff for resident care. Residents Affected - Some Interview on 07/17/23 at 2:55 P.M. with STNA #238 indicated there was not enough staff, and the staff did the best they could. Review of the census revealed 43 residents reside on the SMCU including Residents #4, #6, #7, #8, #11, #12, #17, #20, #29, #30, #32, #36, #37, #38, #41, #48, #50, #52, #53, #55, #64, #68, #69, #70, #76, #77, #78, #80, #83, #85, #88, #89, #91, #93, #95, #97, #99, #102, #105, #106, #109, #162 and #163. This deficiency represents non-compliance investigated under Master Complaint Number OH00144714 and Complaint Number OH00144133. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365290 If continuation sheet Page 10 of 12 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 365290 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kirtland Woods of Journey 9685 Chillicothe Rd Kirtland, OH 44094 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and facility policy review the facility failed to serve meals at a palatable temperature. This had the potential to affect all residents in the facility. The facility census was 117. Residents Affected - Many Findings include: Interview on 07/17/23 at 10:19 A.M. with Resident #100 revealed food was not very warm at times. Interview on 07/17/23 at 11:00 A.M. with Resident #61 revealed food was not always warm enough. Observation on 07/18/23 at 7:03 A.M. revealed the breakfast tray line started. The last cart of resident trays left the kitchen at 8:03 A.M. and arrived on the 100 unit at 8:05 A.M. The last resident food tray was passed at 8:21 A.M. A test tray conducted on 07/18/23 at 8:22 A.M. with Food Service Director (FD) #228 revealed the scrambled eggs were 107 degrees Fahrenheit. FD # 228 confirmed she wished the scrambled eggs were hotter. Review of facility food council meeting minutes from 04/17/23 to 07/17/23. Some initial concerns related to taste and temperature were expressed on 04/17/23. Review of the revised facility policy dated October 2017 titled Food and Nutrition Services revealed each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365290 If continuation sheet Page 11 of 12 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 365290 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kirtland Woods of Journey 9685 Chillicothe Rd Kirtland, OH 44094 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 Based on interview and record review, the facility failed to have a building-specific legionella assessment in place. This had the potential to affect all 117 residents in the facility. Residents Affected - Many Findings include: Review of the facility legionella prevention documentation revealed the facility did not have a building-specific assessment identifying where legionella and other opportunistic waterborne pathogens could grow and spread in the facility water system. These findings were verified with the Administrator on 07/20/23 at 2:09 P.M. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365290 If continuation sheet Page 12 of 12