Health inspection·June 14, 2023

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few orders and the Advanced directives in Resident #35's medical record and hard medical record and revealed she would treat Resident #35 as a full code and perform cardiopulmonary resuscitation (CPR) if Resident #35 went into cardiac arrest. Interview on record review on [DATE] at 10:04 A.M., with Director of Nursing (DON) confirmed Resident #35's physician orders dated [DATE] revealed his code status was a full code. The section under Advanced Directives in the hard medical record revealed Resident #35 was a full code. DON also confirmed Resident #35's hard medical record revealed the Hospice Comprehensive Assessments and Plan of Care located in front of the record, dated [DATE] through [DATE] revealed Resident #35 had a directive for Do Not Resuscitate (DNR)-Arrest. DON revealed Resident #35 was to have a DNR-Arrest code status and not a full code. DON confirmed Resident #35's physician orders and Advanced Directives in the hard medical record were not updated to reflect the accurate code status. Record review of the policy titled, Advance Directives revised [DATE] revealed information about whether the resident has executed an advanced directive shall be displayed prominently in the medical record. Changes or revocations of a directive must be submitted in writing to the Administrator. The Administrator may require new documents if changes are extensive. The care plan team will be informed of such changes and or revocations so that appropriate changes can be made in the resident assessment and care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365392 If continuation sheet Page 2 of 34 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 365392 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rocky River Gardens Rehab and Nursing Ctr 4102 Rocky River Dr Cleveland, OH 44135 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 0603 Protect each resident from separation (from other residents, his/her room, or confinement to his/her room). Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident interviews, staff interviews, medical record review, admission agreement review, smoking policy review, review of the Secured Unit Agreement, and resident rights policy review, the facility failed to ensure residents were free from involuntary seclusion when cognitively intact residents were not afforded the opportunity to go outside without an escort of staff or interference. This resulted in actual psychosocial harm for two Residents (#57 and #252) were not allowed to freely go outside at will. This resulted in cognitively intact Resident #57 expressing wanting to leave the facility and was told by staff he could not leave. The resident was so distraught and resorted to physically removing the screen from his window, taking his wheeled walker and oxygen tank through the window, and leaving the facility to go to the store. Resident #252, who is cognitively intact and was assessed in activities as being very important to him to go outside to get fresh air when the weather was good, was told he could no longer go outside alone. Resident #252 stated he felt like he was in prison and there was nothing he could do about it. In addition, the facility failed to ensure two cognitively intact Residents (#17 and #19) were not being confined to a secured second floor nursing unit. This also affected two Residents (#69 and #24) that were not at harm level of 37 residents reviewed for involuntary seclusion. The facility census was 103. Residents Affected - Few Findings include: Observations from 06/05/23 at 8:00 A.M. through 06/13/23 at 3:00 P.M. revealed the entrance doors were always secured and could only be opened with the receptionist pushing the hand- held remote to open the door. Review of the facility admission agreement revealed no criteria of the facility being locked and residents requiring an escort to go outside of the facility. Interview on 06/06/23 at 1:30 P.M., with the Administrator, revealed people drive fast in the front parking lot. To keep the residents safe, all residents need to have supervision when they go outside, and they cannot go outside unassisted. Interview and observation on 06/07/23 at 10:54 A.M., with Administrator and [NAME] President of Operations #622 revealed two sitting areas outside the facility, one smoking area and one next to the smoking area, that was not in the pathway of the driveway and had an exit door of the facility leading directly to the area. [NAME] President of Operations #622 revealed she was unaware of residents not being allowed to sit outside unsupervised, staff would be updated on resident rights, and alert and oriented residents should be allowed to go outside unassisted. Interview on 06/07/23 between 4:32 P.M. and 4:36 P.M., with State Tested Nursing Assistant (STNA) #436, #570, and Licensed Practical Nurse (LPN) #575 revealed all residents must have an escort to go outside the facility. Interview on 06/12/23 at 3:36 P.M., with Social Worker (SW) #598 revealed he was gone from 05/18/23 to 05/24/23. When he returned, he was told no residents were able to leave the interior of the facility, even to just sit outside, without an escort or facility staff, and the escort had to show identification before going outside with the resident. SW #598 revealed he never received a written policy, but some residents were upset they could not go outside any longer unless someone was with them. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365392 If continuation sheet Page 3 of 34 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 365392 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rocky River Gardens Rehab and Nursing Ctr 4102 Rocky River Dr Cleveland, OH 44135 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 0603 Level of Harm - Actual harm Residents Affected - Few Interview on 06/12/23 at 4:05 P.M., with Receptionist #593 and #607 revealed the doors to the facility were locked 24 hours a day, seven days a week. Residents were not allowed to go outside to even sit outside or leave the premises unless they had a staff member with them, or they had an escort that showed an identification (ID). The facility was in lockdown. Receptionist #593 and #607 revealed at no time did they, or were they asked to monitor residents sitting outside. Interview on 06/12/23 at 4:25 P.M., with the Director of Nursing (DON) revealed the building was secure and no residents were allowed outside unless they had an escort. DON revealed she and other staff members told residents verbally that residents were no longer allowed to go outside the facility without an escort. DON confirmed staff did not document in residents charts that residents were notified they were no longer allowed to go outside the facility without an escort. DON revealed she also educated all the staff residents were not allowed to go outside, even to sit unless they had an escort on 05/23/23. Interview on 06/13/23 at 9:16 A.M., with the Administrator confirmed all exit doors to the facility were secured, residents or visitors cannot exit the facility without a staff member assisting them with the code to open the door. Review of the policy titled, Residents Rights, dated December 2016, revealed residents have the right to be free from corporal punishment or involuntary seclusion, physical or chemical restraints not required to resident's symptoms. 1. Review of Resident #57's medical record revealed an admission date of 01/10/23, with diagnoses including: chronic obstructive pulmonary disease, muscle weakness, gait abnormalities, lack of coordination and need for personal care. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/01/23, revealed the resident had intact cognition and was independent with mobility. No behaviors were noted. The resident does not have a legal guardian. Review of Resident #57's nurse progress notes, dated 05/18/23, revealed at approximately 7:00 P.M., the receptionist called Resident #57's nurse telling her he was leaving the facility without a leave of absence (LOA). The nurse and two aides came to the lobby to assess the situation. Resident #57 was observed walking back from the store. He stopped to sit in a field next to the facility. The nurse went out to check on Resident #57 and he reassured her he did not fall, he just wanted to sit in the sunshine for a bit. The sister of Resident #57 was called to redirect him to come inside, which she did. The resident returned with no injuries. Review of Resident #57's nurse progress notes, dated 05/20/23, revealed around 2:00 P.M., the resident wanted to walk to the store. The nurse checked for an LOA order from his physician and did not find one. The nurse informed Resident #57 that he could not leave the facility and he got very upset, yelled, and went back to his room. The nurse called Resident #57's sister about his request and she was planning to come to the facility with some items for Resident #57. Approximately at 2:30 P.M., the nurse received a phone call from Resident #57's sister stating the resident had climbed out his window. The nurse immediately checked Resident #57's room and discovered the screen had been removed and the resident was gone. Resident #57 did take his wheeled walker and his oxygen with him. The resident returned on his own and was not injured. Review of the form titled Elopement Review dated 05/25/23 completed by Registered Nurse (RN) #596 revealed Resident #57 was low risk for elopement. Review of the plan of care revealed no behavior or elopement care plans. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365392 If continuation sheet Page 4 of 34 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 365392 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rocky River Gardens Rehab and Nursing Ctr 4102 Rocky River Dr Cleveland, OH 44135 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 0603 Interview on 06/12/23 at 2:59 P.M., with Resident #57 stated he was pissed off, that he was not allowed to go outside without an escort. Resident #57 stated that was why he climbed out his window the other day. Level of Harm - Actual harm Residents Affected - Few 2. Review of Resident #252's medical record revealed an admission date of 10/12/21. Diagnoses included end stage renal disease and abnormalities of gait and mobility. This resident does not have a legal guardian. Review of the Annual MDS assessment dated [DATE] revealed Resident #252 required extensive assistants of two for bed mobility, transfers, extensive assistants of one for locomotion, and set up help only with eating. Resident #52 had no impairment of the upper or lower extremities and used a wheelchair for mobility. Resident #252's hearing was adequate, speech was clear, vision was adequate, made self-understood, and was able to understand. No behaviors were exhibited. Resident #252's favorite activities were very important to him. Review of Resident #252's nurse progress notes for the past six months, revealed no concern related to the resident going on LOA's or outside on smoke breaks. Record review the form titled Elopement Review dated 05/25/23 completed by RN #596 revealed Resident #252 was low risk for elopement. Review of the plans of care for Resident #69 revealed no evidence of elopement risk or behaviors. Review of the Brief Interview of Mental Status (BIMS) score dated 05/26/23 completed by Social Service Director (SS) #598 revealed Resident #252 was cognitively intact. Review of the Activity assessment dated [DATE] completed by Activities Director #503 revealed it was very important to Resident #252 to go outside to get fresh air when the weather was good. Interview on 06/05/23 at 10:42 A.M., with Resident #252, stated he liked to go sit outside, that was what he enjoyed, and he use to sit outside nearly all day because he loved it. Resident #252 stated, staff told him he couldn't go outside anymore without an escort, and they don't have one to go with him. Resident #252 stated he felt like he was in prison and there was nothing he could do about it. Interview 06/07/23 10:46 A.M., with Activities Director #503 revealed Resident #252 loved to go outside. Resident #252 would set out all day and he has never tried to leave the facility grounds. Activities Director #503 revealed all residents needed an escort to go outside, even to sit. Activities Director #503 revealed she did not know why; she was just told the policy changed and that was how it was. Activities Director #503 revealed there was a patio that was not near the driveway where residents could sit. Activities Director #503 confirmed there were times Resident #252 requested to go sit outside and there were no staff available to take him. 3. Review for Resident #69's medical record revealed an admission date of 03/31/20, with diagnoses including: paraplegia, muscle weakness, major depressive disorder, and generalized anxiety. This resident does not have a legal guardian. Record review of the quarterly MDS assessment dated [DATE] revealed Resident #69 was cognitively intact. Resident #69 was total dependent for transfers and extensive assistants of two with locomotion. Resident #69 used a wheelchair for mobility, had no impairment of upper extremities, and was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365392 If continuation sheet Page 5 of 34 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 365392 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rocky River Gardens Rehab and Nursing Ctr 4102 Rocky River Dr Cleveland, OH 44135 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 0603 impaired on both sides of lower extremities. Level of Harm - Actual harm Review of the care plan dated 04/12/23 revealed Resident #69 was a smoker. Interventions included Resident #69 would be educated on smoking policy and was aware of smoke times. Review of the plans of care for Resident #69 revealed no evidence of elopement risk or behaviors. Residents Affected - Few Review of Resident #69's nurse progress notes, for the past six months, revealed no concern related to the resident going on LOA's or outside on smoke breaks. Review of the form titled Elopement Review dated 05/25/23 completed by Registered Nurse (RN) #596 revealed Resident #69 was low risk for elopement. Interview on 06/05/23 at 11:39 A.M., with Resident #69 revealed the facility cut the smoke breaks down to two smoke breaks a day on weekends because someone eloped. Resident #69 stated he felt that was not right and that was upsetting to him. Resident #69 continued to state, he thinks it was not right that we are not allowed to go outside to get fresh air when we want, and we must be supervised just to sit outside. I feel confined. It made me mad and upset they can do that to us. Interview on 06/07/23 at 9:17 A.M., with the DON and Administrator revealed there were designated smoking times and all residents who smoked must be supervised. The Administrator revealed the housekeepers monitor the smoke breaks; smoking times on the weekend were decreased from three a day to two a day last month due to consistency of staffing with agency on the weekend and safety. Administrator revealed the residents were notified of the change and signed the new policy. Administrator confirmed there were 18 residents residing in the facility who smoked cigarettes and some residents were upset resulting in one resident leaving the facility. The Administrator also confirmed the decrease in resident smoking breaks was due to available staffing for the weekends. Review of the form titled, I have been advised of the change in smoke break and understand the new time parameters. 05/13/23 revealed 18 residents signed the form dated 05/13/23. Interview on 06/13/23 at 1:38 P.M., with Environmental Service Director #502 revealed the same day residents signed the change in smoking times, Saturday, 05/13/23, was the same day the residents not being allowed outside independently was initiated. Review of the undated admission packet area titled, Rocky River Gardens Smoking Policy, revealed residents were permitted to smoke as per the below facility smoking policy. All smokers will be supervised by an employee of the facility. Smoke breaks will take place on the back patio only during the designated smoke break times. The policy revealed there were three smoking breaks per day that were scheduled between 9:00 A.M. and 7:50 P.M. for 20 minutes per smoking break. Review of an undated policy titled, Rocky River Gardens Smoking Policy revealed smoking times Monday through Friday occurred three times a day starting at 9:30 A.M. and ending at 7:50 P.M. Saturday and Sunday two smoke breaks per resident were scheduled per day starting at 9:30 A.M. and ending at 2:50 P.M. for 20 minutes per smoking break. 4. Review for Resident #19's medical record revealed an admission date of 08/14/20, with diagnoses including chronic obstructive pulmonary disease (COPD), diabetes mellitus, and muscle weakness. This resident does not have a legal guardian. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365392 If continuation sheet Page 6 of 34 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 365392 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rocky River Gardens Rehab and Nursing Ctr 4102 Rocky River Dr Cleveland, OH 44135 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 0603 Level of Harm - Actual harm Record review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #19 was cognitively intact. Resident #19 required extensive assistants of one person for transfers, supervision with locomotion and eating. Resident #19 had no impairment of the upper or lower extremities and utilized a wheelchair for mobility. Residents Affected - Few Review of the form titled Elopement Review dated 04/25/23 completed by RN #596 revealed Resident #19 was at low risk for elopement. Interview on 06/08/23 at 2:25 P.M., with Resident #19 revealed he wanted to go outside just to sit and to enjoy the fresh air whenever he wanted. Resident #19 revealed the residents including himself, used to be able to go and sit outside whenever they wanted, then a couple people ruined that by leaving and now everyone was being punished and had to suffer. Resident #19 revealed it made him feel sad and angry. 5. Review of Resident #17's medical record revealed an admission date of 02/01/22, with diagnoses including major depressive disorder, generalized anxiety disorder, and unspecified dementia. Resident #17 was her own responsible party. Resident #17 was admitted to the secured nursing unit on 02/01/22. Review of Resident #17's admission Wandering Risk assessment dated [DATE] revealed Resident #17 was at low risk for wandering. Review of Resident #17's admission Secured Unit Screener dated 02/01/22 revealed Resident #17 was not appropriate for the secured unit. Review of Resident #17's progress notes dated 02/26/22 revealed Resident #17's daughter was contacted because Resident #17 attempted to leave the facility. Resident #17's daughter was alright with a one-to-one care intervention, and Resident #17's Nurse Practitioner and the facility management staff were notified. One to one supervision by facility staff was terminated after a wanderguard was placed on Resident #17's right ankle. Review of Resident #17's Elopement Review dated 02/26/22 revealed Resident #17 was a high risk for elopement. Review of Resident #17's Secured Unit Screener dated 02/26/22 revealed Resident #17 was appropriate for admission to the secured unit. Review of Resident #17's Secured Unit Screener revealed from 02/27/22 through 06/07/23 Resident #17 did not have a Secured Unit Screener completed. On 06/08/23 Resident #17's Secured Unit Screener revealed a continued stay on the secured unit. Review of Resident #17's physician orders dated 02/28/22 revealed wanderguard in place to right ankle. Check for placement every shift, and check skin integrity around wanderguard every shift. Every shift for safety, secured unit. Review of Resident #17's Elopement Review dated 08/26/22, 11/22/22, 02/26/23 and 05/26/23 revealed Resident #17 was a low risk for elopement. Review of Resident #17's Quarterly MDS assessment dated [DATE] revealed Resident #17 was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365392 If continuation sheet Page 7 of 34 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 365392 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rocky River Gardens Rehab and Nursing Ctr 4102 Rocky River Dr Cleveland, OH 44135 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 0603 Level of Harm - Actual harm Residents Affected - Few cognitively intact. Resident #17 required supervision of one staff member for bed mobility, transfers, locomotion on and off the unit, and for activities of daily living (ADL's). Resident #17 was not feeling down, depressed, or hopeless and had no thoughts of harming herself. Review of Resident #17's care plan revised 05/03/23 included Resident #17 was an elopement risk, wanderer related to disoriented to place. Resident #17 had impaired safety. Resident #17's safety would be maintained through the review date. Interventions included Resident #17 had a wander alert (wanderguard) to ankle, check placement and function every shift, Resident #17 resided on a secured unit. identify pattern of wandering, divert as needed and intervene as appropriate. Interview on 06/07/23 at 7:28 A.M., with LPN #550 revealed all residents who resided on the second floor wore a wanderguard. LPN #550 stated some of the residents were alert and oriented but if they were outside the facility, they were unable to find their way back in and back to the second floor. LPN #550 stated Resident #17's son did not want her to leave the facility unless he or another family member escorted her. LPN #550 stated the other alert and oriented residents who resided on the secured second floor nursing unit needed an escort to leave. Interview on 06/06/23 at 1:30 P.M., with the Administrator revealed residents residing on the secured second floor nursing unit could not leave the unit unescorted. The Administrator stated there was no policy for admission to the secured nursing unit, but the residents or the legal representative signed an agreement for placement on the secured nursing unit. Observation on 06/05/23 at 3:38 P.M., of Resident #17 revealed she was sitting in a chair in her room and had a wanderguard on her right ankle. Interview on 06/05/23 at 3:38 P.M., with Resident #17 revealed she usually stayed in her room, and a couple of the residents who resided on the second-floor nursing unit upset her. Resident #17 stated the lady who lived in the room next to her cursed loudly all the time, and she could hear the cursing through the walls. Resident #17 did not know the resident's name. Resident #17 stated Resident #96 was always walking around the nursing unit and would come in her room four to five times daily and it really upset her. Resident #17 stated last night he came in her room around 3:00 A.M. and she yelled at him to leave her room. Interview on 06/08/23 at 9:26 A.M., with Nurse Practitioner (NP) #612 revealed Resident #17 was on the secured unit when started working at the facility. NP #612 stated she was not sure why Resident #17 was on the secured unit. NP #612 stated if Resident #17 was not an elopement risk she did not need to be on the secured unit. NP #612 stated she had no reports from the nursing staff that would make her think she was at risk and did not see any reason for her to be on a secured unit. NP #612 stated Resident #17 should have a much more detailed exam per psychiatric services, but it had not been done. Interview on 06/08/23 at 10:18 A.M., with State Tested Nursing Assistant (STNA) #589 revealed the second-floor nursing unit was a secured unit. STNA #589 stated no residents were allowed to leave the unit unescorted. STNA #589 stated when a resident wearing a wanderguard was near the elevator the elevator sounded an alarm but would still work. STNA #589 stated sometimes the residents used the elevator to leave the unit. STNA #589 stated the staff often needed to go to other areas of the facility to find residents who had left the floor. STNA #589 indicated some of the residents knew how to lift the plastic cover for the elevator and push the call button. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365392 If continuation sheet Page 8 of 34 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 365392 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rocky River Gardens Rehab and Nursing Ctr 4102 Rocky River Dr Cleveland, OH 44135 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 0603 Level of Harm - Actual harm Residents Affected - Few Observation on 06/08/23 at 10:20 A.M., of the of the secured second floor nursing unit revealed an elevator, and the elevator call button had a plastic cover that needed to be lifted to push the button to have the elevator come to the floor. An electronic control panel was noted near the elevator and STNA #589 stated it was for the wanderguard system. Observation of doors leading to stairways revealed electronic panels that needed a code before the door would open. Interview on 06/08/23 10:31 A.M., with Resident #17 revealed Resident #17 stated someone cut the wanderguard off her right ankle this morning. Observation revealed there was no wanderguard on the resident. Interview on 06/08/23 at 1:50 P.M., with Resident #17 revealed the situation with Resident #96 coming into her room uninvited was better because she would slide her dresser in front of her door to keep him from coming in. Resident #17 stated she liked to keep her door closed. Resident #17 stated when she first arrived at the facility she wanted to go to the store and did not know she was not allowed to leave. Resident #17 indicated the staff stopped her from leaving before she crossed the street on her way to the store. Resident #17 stated she wished she could leave this floor and it bothered her that she could not leave unless she was accompanied by her family. Resident #17 stated she really wanted to be able to go outside and had not been outside recently. Review of Resident #17's undated form titled Secured Unit Assessment revealed the form was not signed by Resident #17. Resident #17's daughter signed the form which included this resident had been assessed by his or her interdisciplinary care team, and such assessment revealed that he or she had specific medical symptoms and or needs that warrant placement on the facility's secured unit, which was a specialized secured unit that restricted resident freedom of movement throughout the facility. The secured unit included the possibility of reduced social contact and benefits. 6. Review of Resident #24's medical record revealed an admission date of 02/17/23, with diagnoses including unspecified dementia with other behavioral disturbance, post-traumatic stress disorder, and hemiplegia (weakness) affecting the left non-dominant side. Resident #24 was his own representative. Resident #24 was admitted to the secured nursing unit. Review of Resident #24's physician orders dated 02/17/23 revealed wanderguard to right ankle. Check placement and function every shift. Check skin integrity around wander guard every shift. Review of Resident #24's Elopement Review dated 02/17/23 revealed Resident #24 was at high risk for elopement. Review of Resident #24's progress notes dated 02/20/23 revealed Resident #24 did not need a wanderguard and could leave the unit without supervision. Wanderguard was removed from the right ankle. Review of Resident #24's progress notes dated 02/21/23 revealed he was alert and oriented to time, place, person and requested to utilize the campus for fresh air. Resident #24 was oriented to the residential sitting areas and mentioned how close the store was. Resident #24 was informed that he did not currently have a leave of absence order and was not permitted to leave the healthcare campus. Resident #24 was seen off campus in a motorized wheelchair. Facility staff proceeded to resident's current location and Resident #24 was transported back to the facility. Resident #24 was notified as self-representative and educated again regarding the leave of absence protocol. Certified Nurse Practitioner was notified of unauthorized leave of absence and a wanderguard was placed on Resident #24's left ankle. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365392 If continuation sheet Page 9 of 34 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 365392 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rocky River Gardens Rehab and Nursing Ctr 4102 Rocky River Dr Cleveland, OH 44135 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 0603 Level of Harm - Actual harm Residents Affected - Few Review of Resident #24's Secured Unit assessment dated [DATE] revealed it was not signed by Resident #24. Resident #24's brother signed the form which included this resident had been assessed by his or her interdisciplinary care team, and such assessment revealed that he or she had specific medical symptoms and or needs that warrant placement on the facility's secured unit, which was a specialized secured unit that restricted resident freedom of movement throughout the facility. The secured unit included the possibility of reduced social contact and benefits. Review of Resident #24's Quarterly MDS assessment dated [DATE] revealed Resident #24 was cognitively intact. Resident #24 required extensive assistance of two staff members for bed mobility, transfers, and personal hygiene. Resident #24 required supervision of one staff member for locomotion on and off the unit, Resident #24 used a wheelchair. Resident #24 felt down, depressed, or hopeless, and did not have thoughts that he would be better off dead or hurting himself in some way. Interview on 06/12/23 at 9:23 A.M., with Resident #24 revealed he was placed on the secured nursing unit because he escaped, was by himself, got turned around and a civilian helped him find his way back to the facility. Resident #24 stated he was not alright with being on the secured nursing unit and not being allowed to leave the unit when he wanted to. Resident #24 stated he hated that he could not even go to the vending machine by himself. Resident #24 indicated that was why he got so upset a couple days ago and fought the staff when he was at the vending machine, and they tried to make him go back to the secured unit. Resident #24 stated he just wanted a drink out of the vending machine. Resident #24 stated he did not sign a paper saying he agreed to be on the secured unit. Interview on 06/12/23 at 9:43 A.M., with STNA #585 revealed the second floor was a secured unit and residents were not allowed to leave without escort. Interview on 06/13/23 at 11:18 A.M., with Regional Director of Operations #616 revealed Resident #24 represented himself, did not have a guardian and was getting moved off the secured nursing unit and would be residing on the third-floor nursing unit. This deficiency represents non-compliance investigated under Complaint number OHO0143495. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365392 If continuation sheet Page 10 of 34 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 365392 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rocky River Gardens Rehab and Nursing Ctr 4102 Rocky River Dr Cleveland, OH 44135 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review for Resident #252 revealed an admission date of 10/12/21. Resident #252 was discharged to the hospital on [DATE] and returned 05/25/23. Diagnoses included type two diabetes mellitus, end stage renal disease, and peripheral vascular disease. Review of the progress note dated 05/01/23 at 2:23 P.M., completed by Licensed Practical Nurse (LPN) #563 revealed Resident #252 was admitted to the hospital per the podiatry department. Review of the progress note dated 05/25/23 at 6:50 P.M., revealed Resident #252 was re-admitted to the facility from the hospital with a diagnosis of osteomyelitis of the second toe on the right foot. Resident #252 had the toe amputated, a stent placed through the right groin and a pacemaker. Resident #252 was reported to have complained of pain eight out of 10 to the surgical area. Review of the physician orders for Resident #252 for June 2023 revealed Dakin's 1/4 strength external solution apply to the right second toe amputation topically every day shift. Oxycodone -acetaminophen oral tablet 7.5-3.25 milligrams (mg) by mouth every six hours as needed for pain. Hydrocodone acetaminophen oral tablet 5-325 mg give one tablet by mouth two times a day for pain, and oxycodone HCL 7.5 mg every six hours as needed for severe pain. Review of the care plan for Resident #252 revealed there was no care plan initiated for Resident #252 related to the newly amputated toe, dressing changes to the wound, or pain management related to the pain to the newly amputated toe. Interview on 06/05/23 at 10:59 A.M., with Resident #252 revealed he had pain to the right foot second toe amputation that hurt on and off. Resident #252 revealed the nurse medicated him for pain which was effective but at times it felt like his toes that were cut off hurt. Interview on 06/12/23 10:18 A.M., with the Minimum Data Set (MDS) Nurse #533 confirmed several care plans for residents were not completed. MDS Nurse #533 confirmed Resident #252 did not have a care plan related to the surgical procedure to the right foot second toe (amputation) which would have included dressing changes and pain management. Based on record reviews, resident interviews and staff interviews, the facility failed to ensure care plans reflected resident needs. This affected three (#57, #14, and #252) of 32 resident records reviewed. The facility census was 103. Findings include: 1. Review of Resident #57 medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD), protein calorie malnutrition (PCM), muscle weakness, gait abnormalities, lack of coordination, and need for assistance for personal care. Review of Resident #57's physician orders revealed the resident was to have behaviors assessed every shift. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365392 If continuation sheet Page 11 of 34 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 365392 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rocky River Gardens Rehab and Nursing Ctr 4102 Rocky River Dr Cleveland, OH 44135 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #57's quarterly Minimum Data Set (MDS) assessment, dated 04/01/23, revealed the resident had intact cognition. Review of nurses notes for Resident #57 dated 05/18/23 at 9:27 P.M., revealed a temporary agreement was made with the Director of Nursing (DON) to move him to a first-floor room. This decision was made after the resident went to the store without having a leave of absence (LOA) order from a physician. Review of Resident #57's care plans revealed no evidence of plans for elopement risk and behaviors. 2. Review of Resident #14's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included hemiplegia, hemiparesis, non-traumatic intracerebral hemorrhage affecting left dominant side, cerebral infarction, dysphagia following cerebral infarction, cognitive communication deficit, speech disturbance, major depressive disorder, chronic kidney disease (CKD), and gastrostomy. Review of Resident #14's physician orders, dated 01/20/22, revealed to check the resident for placement of hearing aids every shift. Review of Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #14 has hearing aids for communication. Review of Resident #14's care plan dated 04/18/23 revealed no evidence of a plan for care and placement of hearing aids for communication. Interview with MDS Nurse #533 on 06/12/23 at 10:18 A.M., confirmed Resident #57 and Resident #14 did not have evidence of needed care plans. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365392 If continuation sheet Page 12 of 34 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 365392 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rocky River Gardens Rehab and Nursing Ctr 4102 Rocky River Dr Cleveland, OH 44135 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, staff interviews, record review, and review of policy, the facility failed to provide bathing/showers for two dependent residents. This affected two (#35 and #73) of three residents reviewed for bathing/showers. The facility census was 103. Residents Affected - Few Findings include: 1. Review of Resident #35's medical record revealed an admission date of 06/17/22. Diagnoses included chronic obstructive pulmonary disease (COPD), and dementia, unspecified without behavioral disturbances. Review of the care plan dated 07/15/22 revealed Resident #35 had an activity of daily living self-care performance deficit related to dementia. Interventions included assistants needed of one staff member for bathing/showering. The care plan dated 11/03/22 revealed Resident #35 received hospice care need due to the diagnosis of end stage COPD. Interventions included Hospice staff to visit and provide care, assistance, and/or evaluation in addition to facility staff. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35 was severely cognitively impaired. Resident #35 required supervision of one-person physical assistants for bed mobility, transfers, ambulation, and toileting. The MDS included bathing itself did not occur. Resident #35 received hospice care. Review of the physician order dated 01/16/23 revealed Resident #35 was admitted to Hospice with a diagnosis of lung cancer. Review of the facility tasks sheets revealed Resident #35 received her showers/baths on Wednesdays and Saturdays, third shift, 11:00 P.M. to 7:00 A.M. The tasks revealed the last shower Resident #35 received was 05/25/23 at 12:16 A.M. Review of the posted shower schedule located at the nurse's station revealed Resident #35 was to receive showers every Tuesday and Friday on day shift. Observation on 06/05/23 at 9:00 A.M., revealed Resident #35 was ambulating in the hall. Resident #35's hair was very oily and unkept. Resident #35 revealed she did not know if she received baths or showers. Interview on 06/05/23 at 9:04 A.M., with State Tested Nursing Assistant (STNA) #589 confirmed Resident #35's hair was oily and unkept. Observation on 06/05/23 at 2:29 P.M., revealed Resident #35 was lying in bed. Resident #35's hair was very oily and unkept. Resident #35 requested no interview. Interview on 06/06/23 at 3:04 P.M., with Unit Manager Licensed Practical Nurse (LPN) #574 revealed residents admitted to the facility will automatically go with the schedule located at the nurse's station. LPN #574 confirmed Resident #35 should have received her showers every Tuesday and Friday. LPN #574 revealed when showers were offered, a shower sheet for the resident would be completed by the STNA which included the shower was either completed or refused. LPN #574 revealed every resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365392 If continuation sheet Page 13 of 34 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 365392 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rocky River Gardens Rehab and Nursing Ctr 4102 Rocky River Dr Cleveland, OH 44135 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 should have a shower sheet completed for every scheduled shower day. Level of Harm - Minimal harm or potential for actual harm Interview on 06/06/23 at 3:14 P.M., with STNA #589 revealed she went by the shower schedule located at the nurse's station to determine if a resident was scheduled for a shower. If the shower or bath was given or offered, she would complete a shower sheet for that resident. STNA #589 revealed there were times there was not enough staff to complete showers and agency staff frequently did not complete their showers. STNA #589 revealed she tried but when she couldn't finish everything before the end of her shift, showers usually were the task not done. Residents Affected - Few Review of the shower sheets for Resident #35 revealed from 03/01/23 through 06/06/23, Resident #35 received a shower or bath on 03/04/23, 03/07/23, 03/31/23, 04/29/23, 05/16/23, 05/30/23, and 06/06/23. Resident #35 did not receive the remaining 23 scheduled baths/showers from 03/01/23 through 06/06/23. Review on 06/07/23 at 3:30 P.M., of the facility tasks and shower sheets provided by the Director of Nursing (DON) revealed in the facility tasks, Resident #35 refused a shower on 03/19/23 and 03/26/23. DON confirmed the shower sheets provided for Resident #35 were all that were available and revealed there was no further documentation available to verify if Resident #35 received her baths/showers as scheduled by the facility. DON confirmed when a bath or shower was given to a resident, the confirmation would be placed on the shower sheet or in the facility tasks. DON confirmed there was no further documentation available to verify if Resident #35 received her baths/showers as scheduled by the facility. DON revealed if a resident was receiving hospice services, the facility staff were not expected to give showers. Interview on 06/07/23 between 4:32 P.M. and 4:36 P.M., with STNA #570, #621, LPN #575 revealed there were times staff didn't have time to complete showers. If a resident received hospice services, the facility staff did not have to provide the resident's showers. Interview on 06/13/23 at 3:00 P.M., with DON revealed there was no further documentation in Resident #35's medical record to verify when hospice services provided Resident #35 with a bath or shower. 2. Review of Resident #73's medical record revealed an admission date of 07/22/20 and a readmission date of 02/24/23. Resident #73's diagnoses included catatonic schizophrenia, psychotic disorder with delusions due to known physiological condition, and immune effector cell-associated neurotoxicity syndrome, grade unspecified (neuropsychiatric syndrome that can occur following administration of certain types of immunotherapies). Review of Resident #73's Activity Interview for Daily and Activity Preferences dated 07/23/20 included it was very important for Resident #73 to choose between a tub bath, shower, bed bath or sponge bath. Review of Resident #73's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #73 did not have a Brief Interview for Mental Status conducted due to Resident #73 was rarely or never understood. Resident #73 required extensive assistance of two staff members for bed mobility, transfers, toilet use and personal hygiene. Resident #73 had total dependence of one staff member for bathing. Review of Resident #73's care plan revised 05/02/23 included Resident #73 had a self-care deficit related to past living arrangements, schizophrenia. Resident #73 would be clean, well-groomed and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365392 If continuation sheet Page 14 of 34 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 365392 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rocky River Gardens Rehab and Nursing Ctr 4102 Rocky River Dr Cleveland, OH 44135 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few would have no decline from admission. Interventions included Resident #73 required one to two staff assist with bed mobility, encourage daily bathing and weekly shower, Resident #73 required extensive to dependent assist of one staff for bathing, and one assist for grooming and hygiene. Review of Resident #73's shower sheets from 05/01/23 through 06/05/23 revealed only one bed bath was given on 05/10/23. There was no documentation Resident #73's hair was washed. Review of Resident #73's electronic aide charting from 05/10/23 through 06/05/23 revealed Resident #73 received bed baths on 05/10/23, 05/12/23, and 05/15/23. No further showers or bed baths were documented in the medical record. Observation on 06/06/23 at 8:46 A.M., of Resident #73 revealed her hair was very greasy with many white flakes noted throughout. Interview on 06/06/23 at 2:24 P.M., with State Tested Nursing Assistant (STNA) #582 revealed Resident #73 was scheduled for showers on the night shift and was not on her schedule to give a shower today. STNA #582 confirmed Resident #73's hair was greasy with white flakes throughout. STNA #582 stated Resident #73 was due for a shower tonight and her hair would look better after it was washed. STNA #582 stated she did not put gel in Resident #73's hair today or any day. Interview on 06/06/23 at 2:27 P.M., with Assistant Director of Nursing/Licensed Practical Nurse (ADON/LPN) #529 confirmed Resident #73's hair looked greasy and had white flakes throughout. Interview on 06/06/23 at 4:19 P.M., with STNA #570 revealed she just gave Resident #73 a shower and washed her hair. STNA #570 stated Resident #73's hair was dirty and needed washed. Review of the second-floor shower schedule revealed Resident #73 was scheduled to have a bed bath or shower Tuesdays and Fridays on night shift. Review of the policy titled Shampooing Hair revised October 2010, included the purpose was to clean the resident's hair and scalp. Notify the supervisor if the resident refuses the care. Review of the policy titled Shower, Tub Bath revised October 2010, included the purpose of the procedure was to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365392 If continuation sheet Page 15 of 34 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 365392 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rocky River Gardens Rehab and Nursing Ctr 4102 Rocky River Dr Cleveland, OH 44135 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, staff interviews, and policy review, the facility failed to timely assess newly identified skin areas and seek new treatment. This affected one (#80) of two residents reviewed for pressure ulcers. The facility identified four residents with pressure ulcers. The facility census was 103. Residents Affected - Few Findings include: Review of the medical record for Resident #80 revealed an initial admission date of 05/10/22 and a recent readmission on [DATE]. Diagnoses included but were not limited to unspecified hydro nephrosis, neuromuscular dysfunction of bladder, unspecified severe protein-calorie malnutrition, anoxic brain damage, dysphagia, need for assistance with personal care, and quadriplegia. Review of 04/15/23 quarterly Minimum Data Set (MDS) assessment for Resident #80 revealed severe cognitive impairment. Resident #80 was noted to need extensive assist of one for bed mobility, locomotion on and off the unit, dressing, eating, toileting, and personal hygiene. Resident #80 was noted to be totally dependent upon staff for transfer. A stage IV pressure ulcer was noted to be present upon admission. Review of Resident #80's care plan dated 06/01/23 revealed he had a pressure ulcer related to decreased mobility. Interventions included administering medications as ordered, administer treatments as ordered and monitor for effectiveness. Follow facility protocols for the prevention and treatment of skin breakdown. Monitor, document, and report as needed any changes in skin status, appearance, color, wound healing or signs and symptoms of infections, and wound size. Review of the 05/03/23 Braden scale (tool for predicting pressure ulcer risk) revealed Resident #80 was at high risk for pressure ulcers. Review of Resident #80's physician orders dated 03/20/23 revealed a treatment to the coccyx: cleanse with normal saline, pat dry, apply dermaseptin to peri-wound skin, calcium alginate to wound bed, ABD (wound dressing) to cover areas and tape to secure. Treatment to be completed every evening for wound care. Review of Resident #80's physician orders dated 03/21/23 revealed a treatment to the right buttock: cleanse with normal saline, pat dry, apply dermaseptin to peri-wound skin, calcium alginate to wound bed, ABD pad to cover area and tape to secure. Treatment to be completed every evening for wound care. Review of the 06/05/23 facility weekly skin assessment for Resident #80 revealed a stage four pressure wound on his coccyx with measures of 14 centimeters (cm) in length, 14 cm in width and 0.6 cm in depth and a stage three pressure wound on his right buttock which measured two and a half cm in length by 0.5 cm in width and 0.2 cm in depth. Review of the June 2023 Treatment Administration Record for Resident #80 revealed no treatment for the new identified area of the right lower buttock that presented with red cluster area prior to the 06/08/23 observation during wound care. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365392 If continuation sheet Page 16 of 34 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 365392 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rocky River Gardens Rehab and Nursing Ctr 4102 Rocky River Dr Cleveland, OH 44135 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 06/08/23 at 3:14 P.M., with Wound Care Nurse Licensed Practical Nurse (LPN) #563 and LPN #564 provide wound care to Resident #80's pressure wounds to the coccyx and right buttocks (located directly above the coccyx wound) revealed an additional wound was observed with no dressing by the surveyor to Resident #80's right hip area. The additional wound was open tissue, the wound bed was red, oval shaped, and the surrounding tissue was slightly reddened. After the wound care to the pressure wounds to the coccyx and right buttocks were completed, LPN #563 and #564 repositioned Resident #80 for comfort and confirmed the care for Resident #80's wounds were complete. Observation revealed no treatment was applied to the observed wound on Resident #80's right hip area that was visible during care. Surveyor interview and observation with Wound Care Nurse LPN #563 and #564 of the wounds to the right hip area confirmed this was a new wound and there were no treatment orders. Wound Care Nurse LPN #563 revealed she will report the new wound to hospice, and they will come out to assess, measure and provide a treatment order for the area. Wound Care Nurse LPN #563 confirmed that was hospices job. Interview on 06/08/23 at 3:59 P.M. with Regional Nurse #617, [NAME] President of Clinical Services #620, and DON revealed the nurse finding the new wound on Resident #80 should have immediately assessed the wound at the time it was found and notified the physician for care and treatment. The nurse would then notify hospice services of the new wound and treatment provided. Review of the 06/08/23 facility weekly skin assessment completed at 4:50 P.M. for Resident #80 revealed a new clustered red area on his right buttock which measured seven and a half cm in length by four cm in width. Review of 06/08/23 physicians ordered timed at 5:15 P.M. for Resident #80 revealed a new treatment to right lower buttock to cleanse with normal saline, pat dry then apply barrier cream. Review of the undated policy called; Wound and Skin Care revealed each resident will have a weekly skin assessment completed by a licensed nurse. Any alteration in skin integrity will be assessed, communicated to the physician, treatment order obtained, initiated and responsible party notified. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365392 If continuation sheet Page 17 of 34 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 365392 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rocky River Gardens Rehab and Nursing Ctr 4102 Rocky River Dr Cleveland, OH 44135 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 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy and procedure review and interview, the facility failed to provide Resident #30 adequate supervision and ensure proper footwear while ambulating to prevent a fall with injury. The facility also failed to complete a thorough fall investigation following the fall with injury. Actual harm occurred on 02/23/23 when Resident #30, who was severely cognitively impaired, at risk for falls and required (staff) supervision with ambulation fell while ambulating independently and sustained a fractured right clavicle and right hip requiring surgical intervention. This affected one (#30) of three residents reviewed for falls. The facility census was 103. Findings include: Review of Resident #30's medical record revealed an admission date of 05/06/22 and re-admission [DATE], with diagnoses including asthma, dementia, and congenital kyphosis unspecified region. Review of Resident #30's care plan dated 12/20/22 included Resident #30 had a self-care deficit related to dementia. Resident #30 would be clean, well groomed, and would have no decline from admission. Interventions included Resident #30 required supervision for ambulation and assistance of one staff member for grooming and hygiene. Further review revealed Resident #30 was at risk for falls. The goal developed was for Resident #30 to be free of falls (through review date). Interventions included to ensure Resident #30 was wearing appropriate footwear and to specify and describe correct client footwear, for example brown leather shoes, tartan bedroom slippers, black non-skid socks when ambulating. Review of Resident #30's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #30 had severe cognitive impairment. The assessment revealed Resident #30 required supervision of one staff member for bed mobility, transfers, toilet use and locomotion on the unit. Review of Resident #30's progress note, dated 02/23/23 at 3:37 P.M., documented the nurse heard a loud noise, a State Tested Nursing Assistant (STNA) yelled for help and Resident #30 was found on the floor in the doorway to her room. Resident #30 was bleeding from her head, 911 was called, pressure was applied to head wound. Vital signs were taken. Resident #30 stated she lost her balance and tripped over her shoe. Resident #30 complained of pain to her right leg, right shoulder, pelvis, and head. Resident #30 had a laceration to the right eyebrow and a hematoma to the right side of her forehead. Resident #30 was transported to the local hospital Emergency Department. The Director of Nursing (DON), the Nurse Practitioner, and Resident #30's guardian were notified. Review of Resident #30's progress notes dated 02/24/23 at 9:31 A.M., revealed Resident #30 was admitted to the hospital with a fractured right clavicle and had surgery, open reduction, and internal fixation right hip. Interview on 06/08/23 at 8:46 A.M., with Regional Nurse #617 revealed she read the investigation report of Resident #30's fall. The investigation report revealed the nurse heard a loud noise, the STNA called for help, Resident #30 was on floor and said she tripped over her shoe. Two nurses and an aide assisted Resident #30. Resident #30 was bleeding, pressure applied to her head wound, 911 was called, vital signs were stable and blood pressure was 166/97. Resident #30 was confused with impaired (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365392 If continuation sheet Page 18 of 34 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 365392 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rocky River Gardens Rehab and Nursing Ctr 4102 Rocky River Dr Cleveland, OH 44135 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 - Actual harm Residents Affected - Few memory. The Nurse Practitioner, Director of Nursing (DON) and responsible party were notified. A head-to-toe assessment was completed and Resident #30 was unable to state if she had pain in the past five days. Interview on 06/08/23 at 8:46 A.M., with Assistant Director of Nursing/Licensed Practical Nurse (ADON/LPN) #529 revealed she watched the camera footage of Resident #30's fall. ADON/LPN #529 stated Resident #30's shoes were not all the way on her feet, and she was walking on the back of the shoes and tripped. ADON/LPN #529 stated she believed Resident #30 was high functioning for activities of daily living (ADL)'s and was able to put her own shoes on. ADON/LPN #529 stated Resident #30 was walking out of her room and tripped. ADON/LPN #529 indicated Resident #30 took naps throughout the day. ADON/LPN #529 stated the aide was charting three doors down from Resident #30 when she fell. Interview on 06/08/23 at 10:08 A.M., with State Tested Nursing Assistant (STNA) #597 revealed he knew Resident #30 well and took care of her most days when he worked. STNA #597 stated he was not working on the nursing unit Resident #30 resided on the day she fell. STNA #597 stated before her fall Resident #30 needed assistance getting dressed, putting her pants and undergarments on. STNA #597 stated he had to put Resident #30's shoes on, and she could not do it herself. Interview on 06/08/23 at 11:19 A.M., with Regional Nurse #617 revealed she read the witness statements from Licensed Practical Nurse (LPN) #565 and STNA #625 and the notes confirmed the progress note documentation. Regional Nurse #617 confirmed the investigation notes did not reveal the events leading up to the fall or if staff assisted Resident #30 with her shoes (prior to the incident/fall). Regional Nurse #617 confirmed the investigation did not state if Resident #30 was trying to use the bathroom, if she was alone or with other residents, or which shoes were on her feet. Interview on 06/08/23 at 11:29 A.M., with LPN #565 revealed on 02/23/23 she was sitting at the nurse's station and saw Resident #30 walking back to her room. LPN #565 stated she heard a loud bang, ran to Resident #30 to assist her, and stayed with Resident #30 because she thought she fractured her hip by the way it looked. LPN #565 stated the DON was notified of Resident #30's fall. LPN #565 indicated Resident #30 tripped over her shoe when she was turning to enter her room. LPN #565 stated she could not remember if it was the right or left shoe, but stated one of her shoes was off and laying in the doorway. LPN #565 stated Resident #30 could walk independently, and she could not remember if Resident #30's shoes had shoelaces. LPN #565 indicated the fall occurred between lunch and dinner, and Resident #30 told her she was going to use the bathroom. LPN #565 stated the aide who assisted Resident #30 after the fall no longer worked at the facility. Interview on 06/08/23 at 11:44 A.M., with ADON/LPN #529 revealed she only looked at the camera footage at the point of Resident #30's fall and could not tell if Resident #30 was walking in or out of her room. ADON/LPN #529 stated she just wanted to make sure no one pushed Resident #30 or if there was any obstruction in her path. ADON/LPN #529 did not know if Resident #30 was lying down before the fall, did not know what Resident #30 was doing before the fall, and if staff assisted her with her shoes or Resident #30 had tried to put her shoes on herself. Interview on 06/08/23 at 12:52 P.M., with Regional Nurse #617 revealed no staff were interviewed to determine who (if anyone) put Resident #30's shoes on and helped her dress that day. Regional Nurse #617 indicated the investigation did not reveal if staff were interviewed about Resident #30 ambulating by herself. Review of the policy titled Assessing Falls and Their Causes revised October 2010 included the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365392 If continuation sheet Page 19 of 34 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 365392 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rocky River Gardens Rehab and Nursing Ctr 4102 Rocky River Dr Cleveland, OH 44135 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 - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete purpose of the procedure was to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall. After an observed or probable fall, the staff would clarify the details of the fall, such as when the fall occurred and what the individual was trying to do at the time the fall occurred. Within 24 hours of the fall the nursing staff would begin to try to identify possible or likely causes of the incident. Staff would evaluate chains of events or circumstances preceding a recent fall including what the resident was doing, whether the resident was among other persons or alone and whether the resident was trying to get to the toilet. Event ID: Facility ID: 365392 If continuation sheet Page 20 of 34 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 365392 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rocky River Gardens Rehab and Nursing Ctr 4102 Rocky River Dr Cleveland, OH 44135 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and review of policy, the facility failed to ensure monthly and weekly weights were completed and monitored for residents. This affected two (#73 and #3) of three residents reviewed for weight loss. The facility census was 103. Residents Affected - Few Findings include: 1. Review of Resident #73's medical record revealed an admission date of 07/22/20 and a readmission date of 02/24/23. Resident #73's diagnoses included catatonic schizophrenia, psychotic disorder with delusions due to known physiological condition, severe protein-calorie malnutrition and immune effector cell-associated neurotoxicity syndrome, grade unspecified (neuropsychiatric syndrome that can occur following administration of certain types of immunotherapies). Review of Resident #73's care plan dated 07/27/20 and revised 06/01/23 included Resident #73 was at risk for impaired nutritional status related to mental status, medical diagnosis of hypertension, malnutrition and vitamin B deficiency, shellfish allergy and need for enteral nutrition. On 05/11/23, the resident had a significant weight loss for six months. Resident #73 would maintain adequate nutritional status as evidenced by maintaining weight without significant weight changes, and no signs and symptoms of malnutrition. Interventions included to monitor weights per protocol. Review of Resident #73's physician orders dated 12/04/22 revealed weight weekly for four weeks, one time a day every Thursday for post admit weight for four weeks. Review of Resident #73's progress notes dated 12/08/22 at 12:56 P.M., written by Registered Dietician (RD) #626 revealed per nursing Resident #73 was having poor oral intake related to difficulty chewing, swallowing food, Resident #73 was pocketing food in cheeks. Speech Therapy is currently seeing Resident #73. Current body weight was 166 pounds, appears weight stable and no significant weight loss observed. Possible discrepancy in current body weight taken. Would request additional weights to confirm. Diet order was regular diet, pureed texture, thin. Oral intake 50 to 100 percent. No nutritional supplements currently in place. Would follow up upon additional weights. Further review of Resident #73's progress notes did not reveal a follow up note from RD #626. Review of Resident #73's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #73 did not have a Brief Interview for Mental Status conducted due to Resident #73 was rarely or never understood. Resident #73 required extensive assistance of two staff members for bed mobility, transfers, toilet use and personal hygiene. Resident #73 required supervision of one staff member for eating. Review of Resident #73's weight on 12/01/22 was 166.0 pounds, and Resident #73's weight on 12/22/22 was 147.2 pounds. This was a 11.33 percent weight loss. Weekly weights on 12/08/23, 12/15/23, and 12/29/23 were not documented per physician orders. There was no documentation Resident #73's weight was rechecked for accuracy on 12/23/23. Review of Resident #73's progress notes dated 12/28/22 at 4:37 A.M., revealed staff notified Resident #73's nurse that resident was pocketing all medications and food. Staff cleaned Resident #73's mouth. There was no documentation Resident #73's physician was notified. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365392 If continuation sheet Page 21 of 34 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 365392 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rocky River Gardens Rehab and Nursing Ctr 4102 Rocky River Dr Cleveland, OH 44135 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #73's progress notes from 12/22/22 through 01/19/23 did not reveal documentation Resident #73's physician was notified of weight loss of 11.33 percent. Review of Resident #73's progress notes dated 01/19/23 at 9:05 A.M., revealed the nurse spoke with Certified Nurse Practitioner (CNP) #612 about residents current state. Resident #73 did not swallow morning medication and did not have nutritional intake on 01/19/23. Resident #73 was pocketing food and sitting in a slumped over posture. Vital signs stable. CNP #612 ordered labs to be drawn immediately and would be in to evaluate Resident #73. Review of Resident #73's weight documentation did not reveal a weight was documented from 12/22/22 through 01/19/23 when Resident #73 was hospitalized . Review of Resident #73's progress notes dated 01/19/23 at 10:39 P.M. revealed Resident #73 was at the hospital. Review of Resident #73's progress notes dated 01/20/23 at 11:56 A.M. revealed Resident #73 was admitted to the local hospital with catatonia. Review of Resident #73's After Visit Summary for a hospital stay from 01/19/23 through 02/24/23 included the reason Resident #73 was admitted to the hospital was catatonia and malnutrition. Observation on 06/06/23 at 8:46 A.M., of Resident #73 revealed she was sitting in a wheelchair in the common area and her hair was very greasy with many white flakes noted throughout. Resident #73 was unable to be interviewed. Interview on 06/07/23 at 11:01 A.M., with RD #618 revealed he started working at the facility in February of 2023 and had been on a leave of absence for seven weeks. RD #618 stated RD #627 covered for him while he was away. RD #618 stated when he started working, he did not look back at previous weights because Resident #73 was receiving a tube feeding in February and the tube feeding was calculated as meeting Resident #73's current needs, her weight was stable, and no intervention was necessary. RD #618 stated RD #626 was the dietician in December of 2022 and no longer worked for the facility. When RD #618 was asked about the December weight loss he stated the facility could have rechecked the weight or received education on weighing in a consistent manner. Interview on 06/08/23 at 1:46 P.M., with the Director of Nursing (DON) revealed the facility had risk meetings daily and weight issues were addressed during the meetings. The DON stated she had worked at the facility a couple weeks and was not in facility in December 2022. When asked about Resident #73's weight loss and weights not checked as ordered the DON indicated she would try to find the notes from the December 2022 risk meetings. The DON was unable to find the documentation. Interview on 06/14/23 at 10:52 A.M., with Certified Nurse Practitioner (CNP) #612 revealed she remembered Resident #73 had a weight loss, but she did not remember the details. CNP #612 stated Resident #73 had an exacerbation of her schizophrenia. CNP #612 stated the Psychiatric Nurse Practitioner was supposed to be seeing her, but she did not know the frequency of the visits. CNP #612 stated she did not remember the facility staff reporting a weight loss to her for Resident #73. 2. Review of the medical record for Resident #3 revealed an admission date of 09/13/22. Diagnoses included congestive heart failure, type II diabetes, unspecified severe protein-calorie, hemiplegia, and hemiparesis following cerebral infarction affecting left non-dominant side, atrial fibrillation, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365392 If continuation sheet Page 22 of 34 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 365392 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rocky River Gardens Rehab and Nursing Ctr 4102 Rocky River Dr Cleveland, OH 44135 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 0692 Level of Harm - Minimal harm or potential for actual harm adult failure to thrive, mental disorder not otherwise specified, major depressive disorder, and generalized anxiety disorder. The resident was admitted to hospice on 11/25/22. Review of physician's order dated 09/13/22 revealed weekly weights times four weeks and then monthly. There were no current physician orders for weekly weights. Residents Affected - Few Review of Resident #3's weights revealed 111.8 pounds (#s) on 04/07/23 and 89.6 #s on 05/05/23 which indicated a 22.2 # weight loss over a 30-day interval. Resident #3 refused to be weighed for June 2023. Review of the nutrition notes dated 04/20/23 and 05/19/23 assessed the resident and implement nutritional interventions, including recommendations for medication changes, increasing supplements and protein intakes and weekly weights for four weeks for weight monitoring. Review of the May and June 2023, Medication Administration Record and Treatment Administration Record for Resident #3 did not reveal weekly weight monitoring was being completed. Review of the May 2023 State Tested Nurse Assistant (STNA) task assignment for monthly weight monitoring for Resident #3 revealed no weights were recorded. Interview on 06/13/23 at 2:20 P.M., with the Director of Nursing (DON) confirmed weekly weights were not ordered or completed for Resident #3 following the nutrition progress note recommendations on 05/19/23. Review of the policy titled Weight Assessment and Intervention updated 01/10/23 included the multidisciplinary team would strive to prevent, monitor, and intervene for undesirable weight loss for our residents. Monthly weights would be completed by the tenth of each month and weekly weights would be completed on a designated day each week at the facilities discretion. Weights will be recorded in the electronic medical record. Any weight change of five percent or more since the last weight assessment would be retaken the next day for confirmation. If the weight was verified, nursing would immediately notify the dietician in writing, Verbal notification must be confirmed in writing. Significant weight changes are identified as five percent weight loss in one month, seven and a half percent in three months and ten percent loss in six months. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365392 If continuation sheet Page 23 of 34 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 365392 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rocky River Gardens Rehab and Nursing Ctr 4102 Rocky River Dr Cleveland, OH 44135 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 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of policy, the facility failed to ensure physician orders included the time frame intravenous fluids were to be administered and the percentage of the solution to be administered. This affected one resident (#73) of three residents reviewed for physician orders. The census was 103. Residents Affected - Few Findings include: Review of Resident #73's medical record revealed an admission date of 07/22/20 and a readmission date of 02/24/23. Resident #73's diagnoses included catatonic schizophrenia, psychotic disorder with delusions due to known physiological condition, and immune effector cell-associated neurotoxicity syndrome, grade unspecified (neuropsychiatric syndrome that can occur following administration of certain types of immunotherapies). Review of Resident #73's physician orders dated 10/06/22 at 2:00 P.M., revealed per a telephone order from the Nurse Practitioner to insert a peripheral intravenous (IV), insert midline, two liters normal saline bolus. The order did not specify the length of time to administer the two liters bolus and no clarification of the percentage of saline of the normal saline bolus. Review of Resident #73's physician orders in the electronic medical record dated 10/06/22, revealed normal saline flush solution (sodium chloride flush), use two- liter intravenously one time only for hydration for one day. There was no length of time specified to administer the two-liter bolus or clarification of the percentage of saline of the bolus. Review of Resident #73's Medication Administration Record (MAR) dated 10/06/22 at 6:20 P.M., revealed normal saline flush solution (sodium chloride flush), use two liters intravenously one time only for hydration for one day was administered. There was not length of time specified to administer the two liters bolus or clarification of the percentage of saline of the bolus. Review of Resident #73's laboratory results dated [DATE] revealed a sodium level of 162 milliequivalents per liter and the normal range was 136 to 145 milliequivalents per liter. Interview on 06/12/23 at 3:06 P.M., with Certified Nurse Practitioner (CNP) #628 revealed it was possible for the two liters saline bolus to cause Resident #73's sodium level to be elevated to 162 milliequivalents per liter depending on the solution administered. CNP #628 stated there were so many unknowns in the intravenous normal saline bolus orders. Interview on 06/12/23 at 4:30 P.M., with the Director of Nursing confirmed the intravenous orders did not state the time frame for administering the normal saline IV bolus, and there was no clarification of the normal saline solution used for the bolus. The Director of Nursing confirmed Resident #73's sodium level was 162 milliequivalents per liter and that was high. Review of the policy titled Administering Medications revised 12/2012 included medications should be administered in a safe and timely manner, and as prescribed. If a dosage was believed to be inappropriate or excessive for a resident, or a medication was identified as having potential adverse consequences for the resident or was suspected of being associated with adverse consequences, the person preparing or administering the medication should contact the resident's Attending Physician or the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365392 If continuation sheet Page 24 of 34 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 365392 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rocky River Gardens Rehab and Nursing Ctr 4102 Rocky River Dr Cleveland, OH 44135 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 0694 facility's Medical Director to discuss the concerns. Level of Harm - Minimal harm or potential for actual harm This deficiency represents non-compliance investigated under Complaint number OHO0143495. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365392 If continuation sheet Page 25 of 34 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 365392 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rocky River Gardens Rehab and Nursing Ctr 4102 Rocky River Dr Cleveland, OH 44135 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on record review, staff interview, and policy review, the facility failed to ensure a licensed pharmacist completed monthly medication review (MMR). This affected two (#14 and #69) of the five residents reviewed for unnecessary medications. The facility census was 103. Findings include: 1. Review of Resident #14's medical record revealed an admission date of 07/01/19, with diagnoses including: hemiplegia, hemiparesis, non-traumatic intracerebral hemorrhage affecting left dominant side, cerebral infarction, dysphagia following cerebral infarction, cognitive communication deficit, speech disturbance, major depressive disorder, and chronic kidney disease. Review of Residents #14's medical record from June 2022 through May 2023 revealed no evidence of monthly pharmacy reviews being completed. 2. Review for Resident #69's medical record revealed an admission date of 03/31/20, with diagnoses including: paraplegia, muscle weakness, major depressive disorder, and generalized anxiety. Review of Residents #69's medical record from April 2023 through May 2023 revealed no evidence of monthly pharmacy reviews being completed. Interview on 06/13/23 at 10:00 A.M., with the Director of Nursing (DON) revealed the MMR's were not completed for Residents #14 and #69. Review of the policy titled Medication Regimen Review Policy, revised April 2007, revealed the Consultant Pharmacist will perform a monthly medication review (MRR) for every resident in the facility and routine reviews will be done monthly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365392 If continuation sheet Page 26 of 34 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 365392 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rocky River Gardens Rehab and Nursing Ctr 4102 Rocky River Dr Cleveland, OH 44135 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure each resident's Gradual Dose reduction (GDR) recommendations from the pharmacist was followed up by their physician. This affected four (#3, #30, #24, and #69) of the five residents reviewed for unnecessary medications. The facility identified 31 residents on psychotropic medications. The facility census was 103. Findings include: 1. Record review for Resident #69 revealed an admission date of 03/31/20. Diagnosis included schizophrenia. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #69 was cognitively intact. Resident #69 had a diagnosis of schizophrenia and received antipsychotic medication. Review of the care plan dated 04/12/23 revealed Resident #69 used psychotropic medication related to schizophrenia. Interventions included to consult with the pharmacy, physician to consider dosage reduction when clinically appropriate at least quarterly. Review of the Consultant Pharmacist Recommendation to Physician dated 03/25/23 completed by Registered Pharmacist #614 revealed the resident (#69) has been taking abilify 10 milligrams (mg) daily since 11/22/22 without a gradual dose reduction (GDR). Could we attempt a dose reduction at this time to verify this resident is on the lowest possible dose, if not please indicate response below. Review of the GDR revealed the form had no response documented from the physician. Review of the Medication Administration Record (MAR) for March 2023 through June 2023 revealed Resident #69 had no reduction of abiliy (aripiprazole) during that time frame. Interview on 06/13/23 at 8:05 A.M., with the Director of Nursing (DON) confirmed the Consultant Pharmacist Recommendation for Resident #69 was not initiated or completed. Resident #69 did not receive the recommended dose reduction of abilify. 2. Review of Resident #24's medical record revealed an admission date of 02/17/23, with diagnoses including unspecified dementia with other behavioral disturbance, post-traumatic stress disorder, and hemiplegia (weakness) affecting the left non-dominant side. Review of Resident #24's physician orders dated 02/17/23 revealed risperidone 0.25 milligram (mg), one tablet by mouth twice daily. Review of Resident #24's care plan dated 03/02/23 included Resident #24 used psychotropic medications. Resident #24 would remain free of psychotropic drug related complications. Interventions included to administer psychotropic medications as ordered by the physician and monitor for side effects and effectiveness every shift. Review of Resident #24's Consultant Pharmacist Recommendation to Physician dated 03/25/23 included Resident #24 had a new order to receive the following antipsychotic medication risperidone 0.25 mg (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365392 If continuation sheet Page 27 of 34 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 365392 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rocky River Gardens Rehab and Nursing Ctr 4102 Rocky River Dr Cleveland, OH 44135 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some twice a day. To comply with the new CMS initiative regarding the use of antipsychotic agents please verify the diagnosis as being valid, current, and appropriate. Further review of the Pharmacist Recommendation to the Physician revealed the form was not completed and not signed by the physician. Review of Resident #24's Quarterly MDS assessment dated [DATE] revealed Resident #24 was cognitively intact. Resident #24 required extensive assistance of two staff members for bed mobility, transfers, and personal hygiene. Resident #24 required supervision of one staff member for locomotion on and off the unit, Resident #24 used a wheelchair. Resident #24 felt down, depressed, or hopeless, and did not have thoughts that he would be better off dead or hurting himself in some way. Interview on 06/13/23 at 8:15 A.M., with Regional Nurse #617 revealed Resident #24 did not have a diagnosis of schizophrenia or a schizoaffective disorder, as asked on the GDR (gradual dose reduction) form. Regional Nurse #617 stated Resident #24 was receiving an antipsychotic without an approved diagnosis. Regional Nurse #617 confirmed the Pharmacist Recommendation to the Physician dated 03/25/23 for Resident #24 was not addressed and completed or signed by the physician. 3. Review of Resident #30's medical record revealed an admission date of 05/06/22, with diagnoses including asthma, dementia, and congenital kyphosis unspecified region. Review of Resident #30's physician orders dated 08/26/22 revealed quetiapine fumarate (Seroquel) tablet 25 mg, give 0.5 mg tablet by mouth three times a day for antianxiety. Review of Resident #30's care plan dated 12/20/22 included Resident #30 used psychotropic medications. Resident #30 would remain free of psychotropic drug related complications. Interventions included to administer psychotropic medications as ordered by the physician and monitor for side effects and effectiveness every shift. Review of Resident #30's Quarterly MDS assessment dated [DATE] revealed Resident #30 had severe cognitive impairment. Resident #30 required supervision of one staff member for bed mobility, transfers, toilet use and locomotion on the unit. Interview on 06/13/23 at 11:30 A.M., with Regional Nurse #617 revealed a Gradual Dose Reduction (GDR) for Seroquel was not attempted for Resident #30. 4. Review of medical record for Resident #3 revealed an admission date of 09/13/22, with diagnoses including mental disorder not otherwise specified, major depressive disorder, and generalized anxiety disorder. Review of the quarterly MDS assessment dated [DATE] revealed Resident #3 was severely cognitively impaired. Review of Resident #3's care plan dated 11/17/22 revealed Resident #3 had impaired cognitive function/dementia or impaired thought process related to impaired decision making. Interventions included reviewing medications and record possible causes of cognitive deficit, new medications or dosage increases, anticholinergics, opioids, benzodiazepines, drug interaction, errors or adverse drug reaction, drug toxicity. Review of the facility Consultant Pharmacist Recommendation to Physician form for Resident #3 dated 03/25/23 revealed the resident (#3) had been taking hydroxyzine 50 mg at bedtime (HS) since (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365392 If continuation sheet Page 28 of 34 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 365392 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rocky River Gardens Rehab and Nursing Ctr 4102 Rocky River Dr Cleveland, OH 44135 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 11/08/22 without a gradual dose reduction (GDR). Could we attempt a dose reduction at this time to verify this resident is on the lowest possible dose? If not, please indicate response below. Review of the GDR revealed the form had no response documented from the physician. Record review of the Medication Administration Record (MAR) for March 2023 to June 2023 revealed Resident #3 had no reduction of hydroxyzine during that time frame. Interview on 06/13/23 at 2:20 P.M., with the Director of Nursing (DON) confirmed the Consultant Pharmacist Recommendation for Resident #3 was not initiated or completed. Resident #3 did not receive the recommended dose reduction of hydroxyzine. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365392 If continuation sheet Page 29 of 34 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 365392 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rocky River Gardens Rehab and Nursing Ctr 4102 Rocky River Dr Cleveland, OH 44135 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, hospice staff interviews and staff interview, the facility failed to coordinate care with hospice services in providing care for residents. This affected two (#35 and #80) of three residents reviewed who received hospice services. The facility census was 103. Findings include: 1.Record review for Resident #35 revealed an admission date of 06/17/22. Diagnosis included chronic obstructive pulmonary disease (COPD), and dementia, unspecified without behavioral disturbances. Record review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #35 was severely cognitively impaired. Resident #35 received hospice care. Record review of the care plan dated 07/15/22 revealed Resident #35 had an activity of daily living self care performance deficit related to dementia. Interventions included assistants needed of one staff member for bathing/showering. The care plan dated 11/03/22 revealed Resident #35 received hospice care need due to the diagnosis of end stage COPD. Interventions included Hospice staff to visit and provide care, assistance, and/or evaluation in addition to facility staff. Record review of the physician order dated 01/16/23 revealed Resident #35 was admitted to Hospice (#625) with a diagnosis of lung cancer. Record review of the posted shower schedule located at the nurses station revealed Resident #35 was to receive showers every tuesday and friday on day shift. Observation on 06/05/23 at 9:00 A.M. revealed Resident #35 was ambulating in the hall. Resident #35's hair was very oily and unkept. Resident #35 revealed she did not know if she received baths or showers. Observation on 06/05/23 at 9:04 a.m. with State Tested Nursing Assistant (STNA) #589 confirmed Resident #35 's hair was oily and unkept. Record review of the shower sheets for Resident #35 revealed from 03/01/23 through 06/06/23 showers/baths were not consistently completed as scheduled. Interview on 06/07/23 at 3:30 P.M. with DON revealed if a resident was receiving hospice services, the facility staff were not expected to give showers. Interview on 06/07/23 between 4:32 P.M. and 4:36 P.M. with STNA #570, #621, LPN #575 revealed if a resident received hospice services, the facility staff did not have to provide the residents showers. Record review of the hospice Certification and Plan of Care dated 05/11/23 located in the front of Resident #35's chart revealed no documentation of when scheduled shower/bathing days occurred. Interview on 06/13/23 at 3:00 P.M. with DON revealed there was no documentation in Resident #35's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365392 If continuation sheet Page 30 of 34 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 365392 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rocky River Gardens Rehab and Nursing Ctr 4102 Rocky River Dr Cleveland, OH 44135 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few medical record to verify when hospice services provided Resident #35 with a bath or shower. DON confirmed the facility did not meet with hospice as a team when residents were admitted to hospice to collaborate care for residents. Phone interview on 06/13/23 at 4:20 P.M. with Hospice Nurse RN #623 from Hospice Service #625 for Resident #35 revealed the hospice staff provided supplemental care for Resident #35, the facility staff was to continue to provide routine care including showers. Hospice Nurse RN #623 revealed she did not sit with facility staff to coordinate care, she placed the care plan in the residents chart for the facility staff to review. Hospice Nurse RN #623 revealed she was not aware when Resident #35 received showers provided by the facility but when the hospice staff provided bathing, that was to be considered extra bathing. 2. Record review for Resident #80 revealed and admission date of 05/10/22. Diagnosis included anoxic brain damage, cognitive communication deficit, need for assistants with personal care, and hemiplegia and hemiparesis. Record review of the quarterly Minimum Data Set, dated [DATE] revealed Resident #80 was severely cognitively impaired. Resident #80 was at risk for pressure ulcers and had two stage four pressure ulcers. Record review of the care plan for Resident #80 dated 06/01/23 revealed Resident #80 had a pressure ulcer or potential for a pressure ulcer developing related to decreased mobility. Interventions included to administer treatment as ordered. Record review of the physician order dated 06/07/23 revealed an order for Resident #80 admitted to Hospice 06/01/23 with diagnosis of anoxic brain damage. Observation on 06/08/23 at 3:14 P.M. with Wound Care Nurse Licensed Practical Nurse (LPN) #563 and LPN #564 provide wound care to Resident #80's pressure wounds to the coccyx and right buttocks (located directly above the coccyx wound) revealed an additional wound was observed with no dressing by the surveyor to Resident #80's right hip area. The additional wound was open tissue, the wound bed was red, oval shaped, and the surrounding tissue was slightly reddened. After the wound care to the pressure wounds to the coccyx and right buttocks were completed, LPN #563 and #564 repositioned Resident #80 for comfort and confirmed the care for Resident #80's wounds were complete. Observation revealed no treatment was applied to the observed wound on Resident #80's right hip area that was visible during care. Surveyor interview and observation with Wound Care Nurse LPN #563 and #564 of the wound to the right hip area confirmed this was a new wound and there were no treatment orders. Wound Care Nurse LPN #563 revealed she will report the new wound to hospice, and they will come out to assess, measure and provide a treatment order for the area. Wound Care Nurse LPN #563 confirmed that was hospices job. Interview on 06/08/23 at 3:59 P.M. with Regional Nurse #617, [NAME] President of Clinical Services #620, and DON revealed the nurse finding the new wound on Resident #80 should have immediately assessed the wound at the time it was found and notified the physician for care and treatment. The nurse would then notify hospice services of the new wound and treatment provided. Interview on 06/13/23 at 3:00 P.M. with DON confirmed the facility did not meet with hospice as a team when residents were admitted to hospice to collaborate care for residents. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365392 If continuation sheet Page 31 of 34 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 365392 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rocky River Gardens Rehab and Nursing Ctr 4102 Rocky River Dr Cleveland, OH 44135 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Phone interview on 06/13/23 at 4:40 P.M. with Hospice RN #624 from Hospice Service #626 for Resident #80 revealed hospice staff take over the residents care plan and would collaborated with the staff on the unit at the time of the visit. The nurses were expected to notify hospice first with any change in condition including finding a new wound. Hospice RN #624 revealed the nurse at the facility would not notify the physician first because the physician would not know the hospice formulary including for wound care. The nurse would be expected to just put a dressing over the wound until the hospice nurse could come and assess the wound and determine the treatment. Hospice RN #624 verified she was unsure how long it may take for a hospice nurse to arrive to assess the resident but that was how it should be done. Event ID: Facility ID: 365392 If continuation sheet Page 32 of 34 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 365392 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rocky River Gardens Rehab and Nursing Ctr 4102 Rocky River Dr Cleveland, OH 44135 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, staff interview, record review, and review of policy, the facility failed to maintain infection control practiced during a wound dressing change. This affected one (#80) of two residents observed during wound dressing changes. The facility census was 103. Residents Affected - Few Findings include: Record review for Resident #80 revealed and admission date of 05/10/22, with diagnoses including anoxic brain damage, cognitive communication deficit, need for assistants with personal care, and hemiplegia and hemiparesis. Review of the quarterly Minimum Data Set, dated [DATE] revealed Resident #80 was severely cognitively impaired. Resident #80 was at risk for pressure ulcers and had two stage four pressure ulcers. Review of the care plan for Resident #80 dated 06/01/23 revealed Resident #80 had a pressure ulcer or potential for a pressure ulcer developing related to decreased mobility. Interventions included to administer treatment as ordered. Record review of the physician order dated 06/07/23 revealed an order for Resident #80 admitted to Hospice 06/01/23 with diagnosis of anoxic brain damage. Review of the physician orders for June 2023 for Resident #80 revealed the treatment to the coccyx included cleans with normal saline pat dry, apply dermaseptine to peri wound skin, calcium alginate to wound bed, abdominal pad to cover areas and tape to secure. The treatment to the right buttocks included cleans with normal saline pat dry, apply dermaseptine to peri wound skin, calcium alginate to wound bed, abdominal pad to cover areas. Observation on 06/08/23 at 3:14 P.M., with Wound Care Nurse Licensed Practical Nurse (LPN) #563 and LPN #564 provide wound care to Resident #80's pressure wounds to the coccyx and right buttocks (located directly above the coccyx wound) revealed the old dressing (covering both wounds) dated 06/08/23 was saturated with yellow/brown drainage on the outside of the dressing and there was a large amount of thick, mucousy yellow/brown drainage covering the inside of the dressing. Wound Care Nurse LPN #563 verified the dressing removed was saturated. Wound Care Nurse LPN #563 removed the old dressings covering both wounds, cleansed both wounds, applied the new dressings completing the dressing changes. Observation revealed during the dressing changes, Wound Care Nurse LPN #563 did not remove her gloves and/or wash her hands after removing the soiled dressings and before applying the clean dressings. Interview on 06/08/23 at 3:41 P.M., with LPN #564 confirmed Wound Care Nurse LPN #563 did not change her gloves or wash her hands during the dressing change with Resident #80. Interview on 06/08/23 at 3:41 P.M. with Wound Care Nurse LPN #563 confirmed she did not wash her hands or change her gloves after removing the soiled dressing on Resident #80's wounds to the coccyx and right buttocks and before applying the clean dressings during the dressing change. Review of the policy titled, Wound Care dated October 2010, revealed the purpose of the procedure is to provide guidelines for the care of wounds to promote healing. The steps in the procedure (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365392 If continuation sheet Page 33 of 34 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 365392 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rocky River Gardens Rehab and Nursing Ctr 4102 Rocky River Dr Cleveland, OH 44135 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 included to put on exam glove. Loosen tape and remove dressing. Pull glove over dressing and discard into appropriate receptacle. Wash and dry hands thoroughly. Put on gloves. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365392 If continuation sheet Page 34 of 34