Health inspection·October 2, 2023

F 0600 pinning the resident. STNA #205 noted she held Resident #17's shirt sleeves during the procedure. Level of Harm - Minimal harm or potential for actual harm STNA #204 noted Resident #17's draw string was too tight and thought the resident got agitated because it hurt when trying to take off her pants. Following the event, the facility suspended STNA #204 and STNA #205 and began an investigation which substantiated the abuse allegation. Residents Affected - Few Further review of the medical record including progress notes revealed there was no related progress note entry on 09/13/23. Interview with Resident #17 on 10/02/23 at 8:24 A.M. revealed she recalled her hands were bruised recently, but she did not recall how. She did not recall being attacked or grabbed by anyone, and appeared to be in good spirits. Observation of Resident #17's skin at the time of the above-noted interview revealed no clear evidence of current bruising or other injury on her hands and forearms. Interview with the Administrator on 10/02/23 at 9:02 A.M. revealed STNA #203 reported an allegation of abuse of Resident #17 on 09/14/23, the day after it occurred, claiming two other aides were grabbing a resident and shouting during care. STNA #203 also said when she left the room, she heard one aide stay behind warning the resident to not dare to follow them. The two alleged perpetrators were suspended, then terminated. Bruising was identified on Resident #17's hands, and x-rays revealed no evidence of fracture. The Administrator verified as a result of the investigation the abuse allegation was substantiated. Interview with STNA #204 on 10/02/23 at 9:24 A.M. revealed (on 09/13/23) she attempted to give incontinence care for Resident #17, who was initially cooperative. When she tried to pull down the resident's pants, she found the resident had knotted the drawstring (of the pants) very tightly and it was difficult to get them down past her hips. The resident then grew agitated and started hitting her. STNA #205 then came in and held Resident #17's hands so the resident would stop hitting them (staff). They (STNA #204 and #205) and STNA #203 then finished the care. STNA #204 believed her behaviors were a reaction to discomfort from trying to take her tight pants off, and expressed regret she did not bring scissors to remove them easily. Interview with STNA #205 on 10/02/23 at 9:33 A.M. revealed on 09/13/23 she heard STNA #204 yelling at Resident #17 to not hit her. She entered the room and found Resident #17 very upset, bending over with her pants partway down as STNA #204 attempted to give care. STNA #205 stated she held the resident by her shirt sleeves to prevent her from hitting as STNA #203 and STNA #204 provided care. STNA #205 indicated all three staff left the room at the same time. Interview with STNA #203 on 10/02/23 at 1:26 P.M. revealed while showering another resident, she heard Resident #17 screaming for roughly four minutes. She investigated to find Resident #17 in bed with STNA #205 on top of her with her knee on the resident's abdomen and holding the resident's hands into the bed above Resident #17's head. STNA #204 was holding the resident's ankles. The two said they were trying to get Resident #17 changed and STNA #203 said to let her do it. STNA #203 had them assist the resident to a stand then left the room to get a brief, and upon her return found the other two had shoved the resident back down. During the procedure STNA #204 and STNA #205 were constantly yelling at the resident to stop trying to hit them, and the resident did kick STNA #203 in the stomach during the procedure. After completing the change, she left the room thinking the other aides were following her, but then saw STNA #205 pointing at the resident's face telling her to not ever (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365290 If continuation sheet Page 2 of 5 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 10/02/2023 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few touch her again and to not follow them from the room. STNA #203 reported the other aides were 'pretty aggressive' to the nurse, who seemed to shrug it off. STNA #203 then reported the incident as an alleged abuse event to management the next day after seeing Resident #17's hands were bruised. She confirmed she should have reported the event immediately and explicitly, but did not because she knew the nurse was friends with the other STNAs. She also confirmed when residents were resistant to care, the proper action was to provide space and re-approach rather than continuing to give care. Review of the facility undated abuse and neglect policy revealed the definition of abuse included willful infliction of injury with resulting harm, pain, or anguish. Employees were to immediately report any alleged violations. The deficient practice was corrected on 09/16/23 when the facility implemented the following corrective actions: • Protection of immediate resident safety by suspending STNA #204 and #205, and educating STNA #203 on appropriate abuse prohibition on 09/14/23. • Education for all staff in all departments on abuse prohibition began on 09/14/23. Education was provided by the Unit Managers (UM), the Director of Nursing (DON), the Therapy Director (TD), the Housekeeping Manager (HM) and the Administrator. 62 of 62 staff members were educated in-person on abuse and reporting by 09/15/2023. 54 of 54 staff were educated via telephone on abuse and reporting by a UM by 09/15/2023. The TD educated nine of nine therapy staff in-person on abuse and reporting completed by 09/15/23. The HM completed education by 09/15/23 for five of five housekeeping staff. • Resident audits for abuse prohibition including skin checks for non-interviewable residents and resident interviews were completed on all residents by 09/16/23. • Weekly ongoing audits on 10 random residents to be conducted twice a week for four weeks to ensure ongoing compliance to abuse prohibition. These audits were ongoing at the time of the survey and there were no further residents experiencing abuse through the date of the survey on 10/02/23. • A Quality Assurance Performance Improvement (QAPI) plan was put in place to oversee the facility's response to this incident. This deficiency represents noncompliance investigated under Control Number OH00146668. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365290 If continuation sheet Page 3 of 5 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 10/02/2023 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Residents Affected - Few Based on record review, review of a facility self-reported incident, facility policy review and interview, the facility failed to effectively implement their abuse policy to prevent and timely report an incident of abuse involving Resident #17. This affected one resident (#17) of three residents reviewed for abuse prohibition. The total census was 125. Findings include: Record review revealed Resident #17 was admitted to the facility 06/23/23 with diagnoses including dementia, delusional disorders, generalized anxiety disorder, and major depressive disorder. Review of a facility self-reported incident (SRI), dated 09/14/23 revealed the facility reported an allegation of physical abuse to the State agency involving Resident #17 on 09/14/23 at 4:30 P.M. Staff were made aware of the event at 8:00 P.M. on 09/13/23, and the administrator was informed on 09/14/23 at 4:30 P.M. A witness statement by State Tested Nursing Assistant (STNA) #203 revealed on 09/13/23 at 7:30 P.M. she heard screaming and ran out of the shower room to see STNA #205 on top of Resident #17 with one knee on her stomach and holding down both hands, while STNA #204 held her legs. They said they were trying to change her and kept screaming at Resident #17 to not hit them. STNA #203 attempted to calm the situation and assist with care, but the other two aides kept yelling at the resident despite her asking them to stop yelling. She thought they all left the room together after the care, but then turned and saw STNA #205 pointing at the resident and yelling at her to not follow or hit her, and to leave her alone. Interview with the Administrator on 10/02/23 at 9:02 A.M. verified the incident was not reported to administration until 09/14/23. Interview with STNA #203 on 10/02/23 at 1:26 P.M. revealed she did not report the incident as an alleged abuse event to managment until the next day. Review of the facility undated abuse and neglect policy revealed the definition of abuse included willful infliction of injury with resulting harm, pain, or anguish. Employees were to immediately report any alleged violations. Review of a facility bulletin dated 07/17/23 revealed when residents were combative, staff were to stop hands-on care, ensure safety, attempt other interventions, and document the event. The deficient practice was corrected on 09/16/23 when the facility implemented the following corrective actions: • Protection of immediate resident safety by suspending STNA #204 and #205, and educating STNA #203 on appropriate abuse prohibition on 09/14/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365290 If continuation sheet Page 4 of 5 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 10/02/2023 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 0607 • Level of Harm - Minimal harm or potential for actual harm Education for all staff in all departments on abuse prohibition began on 09/14/23. Education was provided by the Unit Managers (UM), the Director of Nursing (DON), the Therapy Director (TD), the Housekeeping Manager (HM) and the Administrator. 62 of 62 staff members were educated in-person on abuse and reporting by 09/15/2023. 54 of 54 staff were educated via telephone on abuse and reporting by a UM by 09/15/2023. The TD educated nine of nine therapy staff in-person on abuse and reporting completed by 09/15/23. The HM completed education by 09/15/23 for five of five housekeeping staff. Residents Affected - Few • Resident audits for abuse prohibition including skin checks for non-interviewable residents and resident interviews were completed on all residents by 09/16/23. • Weekly ongoing audits on 10 random residents to be conducted twice a week for four weeks to ensure ongoing compliance to abuse prohibition. These audits were ongoing at the time of the survey and there were no further residents experiencing abuse through the date of the survey on 10/02/23. • A Quality Assurance Performance Improvement (QAPI) plan was put in place to oversee the facility's response to this incident. This deficiency represents noncompliance investigated under Control Number OH00146668. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365290 If continuation sheet Page 5 of 5