Health inspection·August 5, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 8:00 P.M. Resident #12 had fallen out of bed during patient care. She was assessed and complained of right shoulder and jaw pain. The note revealed that staff stated she hit her head. PCP #900 was notified and ordered Resident #12 to go to the ER for further evaluation. The note revealed the fall intervention included that staff (CNA #611) was educated. Review of the Employee Counseling Form dated 07/28/25 revealed CNA #611 received a disciplinary action form from the Director of Nursing (DON) as he failed to follow a resident's care plan and Kardex resulting in a fall. CNA #611 was re-educated on use of Kardex and would follow the Kardex to ensure resident safety. Review of the Kardex as of 07/30/25 revealed Resident #12 was to be offered toileting on rounds and upon request and provided incontinence care on rounds and upon request. The Kardex revealed Resident #12 required total dependence of two staff for bed mobility and toileting. Observation on 07/30/25 at 3:17 P.M. revealed CNA #607 walked into Resident #12's room to provide incontinence care. She proceeded to don gloves, pulled back the sheet and rolled Resident #12 over towards the window. CNA #12 provided incontinence care and then rolled her back until she was lying flat on her back. Interview on 07/30/25 at 3:25 P.M. with CNA #607 verified she had turned Resident #12 and provided incontinence care by herself. She revealed she always completed Resident #12's care, including bed mobility and toileting hygiene, by herself. Interview on 07/30/25 at 3:31 P.M. and 3:45 P.M. with LPN/ Unit Manager #610 revealed on 07/25/25 at approximately 8:00 P.M. CNA #611 was providing incontinence care and rolled Resident #12 away from him towards the window resulting in Resident #12 falling out of bed onto the floor hitting her head. She revealed RN #601 assessed Resident #12 and she had complained of right shoulder and jaw pain; therefore, RN #601 sent Resident #12 to the ER per PCP #900's order for further evaluation. She revealed she had returned with no injury, including no fractures. She verified Resident 12's Kardex and care plan stated there were to be two staff always assisting Resident #12 with bed mobility, and toileting and that CNA #611 should not have completed her incontinence care by himself. She revealed CNA #611 received disciplinary action for not following the Kardex and care plan resulting in Resident #12's fall out of bed. LPN/ Unit Manager #610 was informed during observation on 07/30/25 at 3:17 P.M. of incontinence care for Resident #12, CNA #607 turned her towards the window away from her and provided incontinence care by herself. LPN/ Unit Manager #610 again verified per Resident #12's care plan and Kardex stated that two staff always were to assist with bed mobility and incontinence care for safety to prevent falls. Interview on 07/30/25 at 3:38 P.M. with RN #601 revealed she was the nurse on duty on 07/25/25 at approximately 8:00 P.M. when CNA #611 yelled up the hall as she was passing medications that Resident #12 had fallen out of bed while he was turning her. She verified CNA #611 turned her by himself to provide incontinence care, and she fell out of bed on the other side landing on her right side. She revealed the bed was approximately waist high as he was changing her. She revealed Resident #12 complained of right shoulder and jaw pain and had hit her head during the incident. She revealed her pain was a seven on a pain scale of zero to ten, ten being the worst pain. She revealed she contacted PCP #900 who ordered to send Resident #12 to the ER for further evaluation. Interview on 07/30/25 at 4:40 P.M. with CNA #611 revealed he had worked at the facility for approximately three months. He revealed on 07/25/25 at approximately 8:00 P.M. he went into Resident #12's room to change her. He revealed he elevated the height of the bed to waist high and rolled Resident #12 away from him towards the window, and her leg went over her other leg causing her to roll off the bed onto the floor. He revealed Resident #12 hit her head on the floor and he yelled for the nurse. He verified he turned her to provide incontinence care by himself, and no other staff was in the room. He revealed he was never previously trained on how to use a Kardex or care plan to know that Resident #12 was to be a two-person assist with bed mobility and toileting. He revealed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365305 If continuation sheet Page 2 of 8 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 365305 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willoughby Post Acute 37603 Euclid Ave Willoughby, 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 - Few FORM CMS-2567 (02/99) Previous Versions Obsolete he always felt she needed to be a two-person assist but when he asked other staff to assist him, they would never help him, so he usually always changed her by himself. He revealed he never reported to management that other staff would not assist him with Resident #12's care. He revealed after the incident he was educated on how to utilize a Kardex. Review of the facility policy labeled, Fall Risk Assessment, dated 2001, revealed the nursing staff in conjunction with the attending physician and others would seek to identify and document risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information. Review of the facility policy labeled, Activities of Daily Living (ADL), Supporting, dated 2011, revealed residents who were unable to carry out activities of daily living independently received the services necessary to maintain good nutrition, grooming and personal hygiene. The policy revealed care, and services were provided in accordance with the plan of care including the appropriate support and assistance with including hygiene, and mobility. This deficiency represents non-compliance investigated under Complaint Number OH001276912 (OH00167179). Event ID: Facility ID: 365305 If continuation sheet Page 3 of 8 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 365305 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willoughby Post Acute 37603 Euclid Ave Willoughby, 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, review of manufacture guidelines and facility policy review, the facility failed to ensure residents were free from significant medication error. This affected two (Residents #133, and #137) out of seven residents observed and/or reviewed for medication administration. The facility census was 136. Findings include: 1. Review of the closed medical record for Resident #137 revealed an admission date of 06/28/25, and he was discharged home on [DATE]. His diagnoses included motor-vehicle accident with multiple fractures, diabetes and hypertension. Review of the After Visit Summary revealed on 06/28/25 Resident #137 was discharged from the hospital to the facility with the following medication orders: lispro insulin 100 units per milliliter (ml) inject zero to ten units subcutaneously (SQ) three times a day before meals as directed per insulin instructions. The last dose given at the hospital per the discharge instructions was on 06/28/25 at 1:24 P.M. The orders also included Lantus insulin 100 units per ml inject 10 units SQ once daily at bedtime. The last dose was given at the hospital on [DATE] at 9:15 P.M. Review of the nursing note dated 06/28/25 at 11:36 P.M. and completed by Licensed Practical Nurse (LPN) #606 revealed Resident #137 was admitted at approximately 6:30 P.M. He had an allergy to penicillin and had multiple fractures including to his bilateral femurs and nasal bone. Vital signs were obtained, but there was no documentation a blood sugar was taken. There was no documentation regarding Resident #137's insulin and that the orders were verified with Primary Care Physician (PCP) #900. Review of the blood sugars from admission on [DATE] to discharge on [DATE] revealed the first blood sugar documented for Resident #137 was on 06/30/25 at 9:29 A.M., and it was 165. Review of Nurse Practitioner (NP) #901's progress note dated 06/30/25 at 12:13 P.M. revealed Resident #137 had a diagnosis of diabetes, and she ordered lispro insulin before meals SQ per sliding scale and Lantus 10 units SQ at night. Review of Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #137 had intact cognition, and he received insulin. Interview on 07/30/25 at 1:55 A.M. with the Director of Nursing (DON) verified per the After Visit Summary from the hospital Resident #137 was to be on lispro insulin 100 units per ml inject zero to ten units SQ three times a day before meals as directed per insulin instructions and Lantus insulin 100 units per ml inject 10 units SQ once daily at bedtime. She verified these orders were not transcribed, and there was no documentation in the medical record that PCP #900 was contacted upon Resident #137's admission and verified there was no documentation stating Resident #137's insulin was discontinued. She verified the first documentation Resident #137's blood sugar was checked was on 06/30/25 at 9:29 A.M. and he had not received insulin until 06/30/25 (two days after he was admitted ). Interview on 07/30/24 at 2:08 P.M. and 3:58 P.M. with LPN #606 revealed she did not remember anything regarding Resident #137's admission including if she contacted PCP #900 to verify Resident 137's admission orders, and/or anything regarding his insulin orders from the hospital including what was on the After Visit Summary. LPN #606 revealed she did not know why Resident #137's insulin orders were not transcribed on admission. She revealed she did not remember day to day as she went from unit to unit. She revealed if it was not documented that she contacted PCP #900 then she probably did not. 2. Review of the medical record for Resident #133 revealed an admission date of 08/03/23 with diagnoses including dementia, diabetes, and hypertension. Review of the July 2025 physician orders revealed Resident #133 had an order for metoprolol succinate extended release (ER) give 25 milligram (mg) tablet one time a day for hypertension. There was no physician order to crush her medication. Review of the annual MDS assessment dated [DATE] revealed Resident #133 had impaired cognition. Observation on 07/30/25 at 8:35 A.M. revealed LPN #600 crushed Resident #133's medications including the Metoprolol Extended Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365305 If continuation sheet Page 4 of 8 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 365305 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willoughby Post Acute 37603 Euclid Ave Willoughby, 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Release (ER) 25 mg. The only medication she did not crush was her ferrous sulfate which she placed whole in applesauce. She then placed the crushed medications in the applesauce and administered them to Resident #133 at 8:41 A.M. Interview on 07/30/25 at 8:43 A.M. with LPN #600 verified she had crushed Resident #133's metoprolol ER and that it was ER, and there was no order to crush it. She also verified there was nothing in the medical record that the physician had approved Resident #133's metoprolol ER to be crushed. Review of the Federal Drug Administration package insert labeled, Metoprolol Succinate Extended- Release Tablets, dated December 2007, revealed Metoprolol succinate ER were intended for daily administration for the treatment of hypertension and angina (chest pain). Metoprolol succinate ER tablets were scored and can be divided; however, the whole or half tablet should be swallowed whole and not chewed or crushed. Review of the facility policy labeled, Crushing Medications, dated 2001, revealed medications shall be crushed only when it is appropriate and safe to do so, consistent with physician orders. The nursing staff shall notify the attending physician who would give an order to crush a drug that the manufacturer states shall not be crushed, for example long acting or enteric coated medications. The policy revealed the physician must document why crushing the medication would not adversely affect the resident. Review of the facility policy labeled, Administering Medications, dated 2001, revealed medications were administered in a safe and timely manner. Medications were administered in accordance with prescriber orders. Review of the undated facility policy labeled, Nursing admission Assessment and Examination revealed the purpose of the policy was to ensure a comprehensive, timely and person-centered admission assessment was completed. The policy revealed the nurse was to confirm the accuracy of the medication list, names, and dosages of the medications by reconciling all medications promptly using the electronic data confirmation. This deficiency represents non-compliance investigated under Complaint Number OH001276910 (OH00165788) and OH001276912 (OH00167179). Event ID: Facility ID: 365305 If continuation sheet Page 5 of 8 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 365305 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willoughby Post Acute 37603 Euclid Ave Willoughby, 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, review of medical record and review of facility policy revealed the facility did ensure proper infection control during incontinence care. This affected one Resident (#12) out of five residents reviewed for incontinence care. This had the potential to affect 70 residents (#1, #2, #4, #7. #9, #10, #12, #13, #15, #19, #20, #22, #25, #27, #29, #30, #31, #33, #37, #38, #39, #40, #41, #45, #46, #47, #48, #53, #54, #56, #57, #58, #60, #61, #62, #71, #57, #77, #80, #81, #83, #84, #89, #90, #91, #93, #95, #96, #97, #98, #100, #101, #102, #104, #106, #107, #111, #112, #114, #115, #116, #119, #122, #124, #129, #131, #132, #133, #134, and #125) identified by the facility as incontinent.Review of the medical record for Resident #12 revealed an admission date of 06/27/24 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, congestive heart failure, and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 had impaired cognition and was dependent on staff for most of her activities of daily living (ADL) including toileting hygiene and rolling left and right in bed. She was frequently incontinent of urine and always incontinent of bowel. Review of the care plan dated 05/21/25 revealed Resident #12 had bladder and bowel incontinence. Interventions included observing for changes in skin integrity and providing incontinence care on rounds and upon request. There was nothing in the care plan regarding staff applying two incontinence briefs at once. Review of the Kardex as of 07/30/25 revealed Resident #12 was to be offered toileting on rounds and upon request and provided incontinence care on rounds and upon request. There was nothing in the Kardex regarding Resident #12 wearing two incontinence briefs. Observation on 07/30/25 at 3:17 P.M. revealed Certified Nursing Assistant (CNA) #607 walked into Resident #12's room to provide incontinence care. CNA #607 revealed she had changed Resident #12 before lunch. She proceeded to don gloves, take one towel and place the towel under the faucet, wetting both ends of the towel. She did not apply soap to the towel. She then pulled back the sheet, and Resident #12 was wearing two white incontinence briefs. The first brief was moderately saturated in urine. CNA #607 denied applying two incontinent briefs when she changed her before lunch but was unable to identify who else would have changed her. CNA #607 proceeded to roll Resident #12 over towards the window and removed both incontinence briefs. She then proceeded to use one end of the towel and cleansed her buttock region which had a small amount of bowel movement. Resident #12 continued to smear bowel movement as CNA #607 wiped; therefore, CNA #607 continued to wipe with the same end of the towel. CNA #607 then, without drying Resident #12's buttocks, proceeded to apply barrier cream with her gloved hand to her buttock and rolled her back until she was lying flat on her back. CNA #607 then proceeded with the same gloved hands to take the same towel but the other end of the towel and wiped the front of her perineal area using three swipes in an upward motion. The other side of the towel that had the smears of bowel movement on it was lying on Resident #12's bilateral thighs. After she wiped the front of her perineal area, she proceeded to take her hand and in a fanning type motion went back and forth in a motion as if she was trying to air dry the area for a few seconds. She then proceeded to take barrier cream and apply to the front of her perineal area, closed her incontinent brief and proceeded to cover her up. She then proceeded to remove her gloves and perform hand hygiene. Interview on 07/30/25 at 3:25 P.M. with CNA #607 verified she used one towel to perform perineal care for Resident #12. CNA #607 was asked why she did not use soap, and she stated, I did. (This was not observed as it was only observed that she stuck the towel under the faucet to wet both ends). She verified she wet both ends of the towel. She was asked how she washed, rinsed and dried if she used the same end of the towel but CNA #607 just looked at the surveyor and did not Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365305 If continuation sheet Page 6 of 8 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 365305 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willoughby Post Acute 37603 Euclid Ave Willoughby, 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete respond. She later stated, I flipped the towel but would not provide any other details. She verified that she had cleansed her buttock first that had bowel movement then proceeded to clean the front of her perineal area with the same gloved hands. She also verified she had applied barrier cream to her buttocks and then with the same gloved hands proceeded to clean the front of her perineal area and apply barrier cream. Interview on 07/30/25 at 3:31 P.M. and 3:45 P.M. with Licensed Practical Nurse (LPN)/ Unit Manager #610 verified Resident #12 was not to have two incontinence briefs on and to her knowledge CNA #607 was the aide assigned to her so would have been the one that most likely put the two briefs on as she could not think of anyone else who would of changed her. She also verified during perineal care that CNA #607 should not have used only one towel to provide incontinence care as she should have first started with the front and provided perineal care including washing, rinsing and drying with different washcloths and/or towel and then proceeded to cleanse her buttock area in the same manner. Interview on 07/30/25 at 3:38 P.M. with Registered Nurse (RN) #601 revealed she was the nurse for Resident #12, and that CNA #607 was assigned as her aide. To her knowledge, CNA #607 was the only one throughout the day that had performed incontinence care, so she would have been the aide that applied the two incontinence briefs. She verified Resident #12 was to only have one brief on. Review of the facility policy labeled, Perineal Care, dated 2001, revealed the purpose of the policy was to provide cleanliness and comfort to the residents, prevent infection, prevent skin irritation, and observe the resident's skin condition. The policy revealed the following equipment, and supplies were necessary when performing the procedure including wash basin, towels, washcloth, soap, and personal protective equipment. The steps to the policy included fill the wash basin one half full of warm water, wet the washcloth, apply soap and wash the perineal area by wiping front to back. Then staff were to rinse the perineum area thoroughly in same direction using fresh water, clean washcloth and then gently dry the perineum area. After the perineal area was cleansed staff were to turn resident to side and wash, rinse and dry the rectal area. This deficiency represents non-compliance investigated under Complaint Number OH001276910 (OH00165788) and OH001276912 (OH00167179). Event ID: Facility ID: 365305 If continuation sheet Page 7 of 8 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 365305 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willoughby Post Acute 37603 Euclid Ave Willoughby, 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and facility policy review, the facility did not ensure the carpeting in the hallways of all units was maintained in a clean manner. This had the potential to affect all 136 residents residing in the facility. Findings include: Observation on 07/30/25 from 8:23 A.M. to 9:23 A.M. revealed the carpeting in the hallways of all units were discolored and contained multiple black, brown stains throughout. Interview on 07/31/25 at 9:13 A.M. with Environmental Service Manager #613 revealed she was aware there were multiple stains on the carpeting on all the units. She revealed the facility had a floor technician who cleaned the carpeting routinely, but the carpeting was old, and the stains did not come up even after cleaned. She stated, the carpeting needs to be replaced. She revealed she was unsure if there were any quotes on getting the carpeting replaced or where the facility was at regarding replacing the carpeting. Environmental tour on 07/31/25 from 9:30 A.M. to 9:44 A.M. with Environmental Service Manager #613 and Administrator verified the following findings: A. Med Ridge unit revealed the carpeting near the double doors had approximately two large three feet by four feet black oblong stains. B. Entrance by the door of room [ROOM NUMBER] revealed the carpeting had a large black- brown stain approximately three feet by four feet. C. In front of room [ROOM NUMBER] it was revealed the carpeting had a black stain approximately six feet by four feet and another stain approximately three feet by three feet next to the other stain. D. In front of room [ROOM NUMBER] it was revealed the carpeting had a large brown stain circular in nature approximately three feet by three feet. E. Entrance by the doors of rooms [ROOM NUMBERS] revealed the carpeting contained large black, brown stains. F. Arcadia unit lounge area revealed the carpeting had multiple stains. G. Willow unit outside of elevator revealed the carpeting had dark, brown stains extending in front of both elevators. H. In front of room [ROOM NUMBER] the carpeting had a medium brown circular stain in the center of rug I. Near the double doors on Willow unit revealed the carpeting had approximately five feet by four feet black discolored stain. J. Entrance into the soiled utility, and stair well door entrance on Willow unit revealed the carpeting had large black discolorations K. Entrance by rooms [ROOM NUMBERS] revealed the carpeting had large black discolorations. L. Lakeside unit revealed the carpeting had black discolorations throughout the hallway of unit including the entry to the soiled utility room. M. Entrance by rooms 218, 219, 220, 221, 222, and 223 revealed there were large black discolorations on the carpeting. N. Courtside unit revealed the carpeting had discolorations throughout the hallway including outside the dining room had darker black stains. O. Entrance by rooms [ROOM NUMBER] revealed the carpeting had large black discolorations. P. Ridge unit carpeting contained black stains throughout the hallway including outside of the recreational therapy door entrance, and rooms 209, 210, 214, and 217. Interview with Administrator on 07/31/25 from 9:30 A.M. to 9:44 A.M. verified the above findings and revealed the carpeting does need replaced, and she was going to work on getting quotes. She verified she had not obtained any quotes currently nor did the facility have any active plans in process to replace the carpeting. Review of the facility policy labeled, Homelike Environment, dated 2001, revealed residents were to be provided safe, clean, comfortable and homelike environment. The facility staff and management maximize to the extent as possible a clean, sanitary and orderly environment. This deficiency represents non-compliance investigated under Complaint Number OH001276910 (OH00165788). Event ID: Facility ID: 365305 If continuation sheet Page 8 of 8