Inspection·November 8, 2023

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. Based on record review and interview, the facility failed to ensure orders for antipsychotic medications to be administered as needed (PRN) were limited to 14 days for Resident #34. This affected one (#34) of three residents reviewed. The census was 39. Findings include: Review of the open medical record for Resident #34 (Alleged Perpetrator) revealed an admission date of 09/09/22. Diagnoses included paranoid schizophrenia, altered mental status, hypertension, chronic obstructive pulmonary disease, and moderate protein-calorie malnutrition. Review of the annual Minimum Data Set (MDS) Assessment, dated 09/21/23, revealed Resident #34 had severely impaired cognition. The assessment indicated Resident #34 had physical and verbal behaviors directed toward others during the seven-day lookback period, which put others at significant risk of physical injury and significantly disrupted the care or living environment. The assessment indicated Resident #34's behaviors were worsening. Review of the progress note dated 09/28/23 at 1:28 P.M. revealed Resident #34 hit another resident in the face and was screaming at the other resident. Resident #34 was sent to a psychiatric hospital for evaluation. Review of the progress note dated 10/23/23 at 4:45 P.M. revealed Resident #34 returned to the facility and re-admission medication orders were verified by a physician. Review of the physician's orders for November 2023 identified orders for Haloperidol (an antipsychotic medication) 10 milligrams (mg) every six hours as needed (PRN) for agitation beginning on 10/23/23 with no stop date. Review of the electronic medication administration record (eMAR) revealed Resident #34 had not received any doses of the PRN Haloperidol since it was ordered. Review of the pharmacy recommendation, dated 11/01/23, revealed a recommendation was made to discontinue the order for PRN Haldol (Haloperidol) due to PRN antipsychotics were not generally recommended to manage behaviors and federal regulations limited the use of PRN antipsychotics to 14 days with a re-evaluation every 14 days for subsequent renewals. On 11/07/23 at 1:35 P.M., interview with Senior Director of Nursing (DON) #100 verified Resident #34 had a PRN order for Haloperidol (an antipsychotic medication) with no stop date. Senior DON #100 stated 14-day stop dates were only required for residents receiving antipsychotic medications without an appropriate diagnosis and no stop date was necessary for Resident #34 because he had appropriate diagnoses for the use of an antipsychotic medication. Review of the facility policy titled Use of Psychotropic Medication, dated 10/01/22, indicated PRN orders for all psychotropic drugs would be used only when the medication is necessary to treat a diagnosed specific condition that was documented in the clinical record, and for a limited duration. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365401 If continuation sheet Page 2 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365401 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage Health Care Center 24613 Broadway Avenue Oakwood Village, OH 44146 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 This deficiency was an incidental finding identified during the investigation of Complaint Number OH00148024. 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: 365401 If continuation sheet Page 3 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365401 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage Health Care Center 24613 Broadway Avenue Oakwood Village, OH 44146 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on record review and interview, the facility failed to ensure Resident #33 and Resident #34's medical record was accurate and complete. This affected two residents (Resident #33 and Resident #34) of three residents reviewed for medical records. Findings include: 1. Review of the open medical record for Resident #34 revealed an admission date of 09/09/22 and re-admission date of 10/30/23. Diagnoses included paranoid schizophrenia, altered mental status, hypertension, chronic obstructive pulmonary disease, and moderate protein-calorie malnutrition. Review of the annual Minimum Data Set (MDS) Assessment, dated 09/21/23, revealed Resident #34 had severely impaired cognition. The assessment indicated Resident #34 had physical and verbal behaviors directed toward others during the seven-day lookback period, which put others at significant risk of physical injury and significantly disrupted the care or living environment. The assessment indicated Resident #34's behaviors were worsening. Review of the physician's orders for November 2023 identified orders for Haloperidol (an antipsychotic medication) 10 milligrams (mg) every six hours as needed (PRN) beginning on 10/23/23 with no stop date. Review of the psychiatric progress note dated 10/30/23 revealed Psychiatric Nurse Practitioner (NP) #106 assessed Resident #34 and made no recommendations for the PRN Haloperidol order. Review of the assessment titled Physician's Progress Note, dated 10/30/23, indicated there was a stop date of 11/13/23 for the PRN Haloperidol order. On 11/08/23 at 11:03 A.M., interview with Psychiatric NP #106 confirmed she assessed Resident #34 on 10/30/23 and stated she did not assess the use of PRN Haloperidol at that visit. She stated the assessment that was opened in the electronic health record (EHR) was just added on 11/07/23, backdated to 10/30/23 because she saw the resident that day, and that she usually did not document her notes in the facility's EHR. Psychiatric NP #106 further stated the assessment was only opened on 11/07/23 because Senior Director of Nursing (DON) #100 asked her to document a stop date for the PRN Haloperidol order. She again stated that she never assessed Resident #34 for the use of PRN Haloperidol on 10/30/23. On 11/08/23 at 11:30 A.M. with Senior DON #100 denied telling Psychiatric NP #106 to document something that she never assessed, but he did verify that he asked her to clarify a stop date for the PRN Haloperidol order. 2. Review of Resident #34's progress note in the medical record dated 10/29/23 at 4:23 P.M., revealed Resident #34 used verbally abusive language and Resident #33 was temporarily relocated to another room for safety reasons. Review of the medical record for Resident #33 revealed an admission date of 05/06/09 with diagnoses including dementia, schizophrenia, psychosis, major depressive disorder, anxiety, and Alzheimer's disease. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365401 If continuation sheet Page 4 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365401 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage Health Care Center 24613 Broadway Avenue Oakwood Village, OH 44146 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Further review of the medical record for Resident #33 revealed there was no documentation pertaining to the incident that occurred on 10/29/23 involving Residents #33 and #34. On 11/07/23 at 2:50 P.M., interview with the Administrator, Director of Nursing (DON), and Senior DON #100 stated the incident that occurred on 10/29/23 involving Residents #33 and #34 was not documented in Resident #33's record because there was no affect on Resident #33 other than temporarily relocating him to another room for safety reasons. Review of the facility policy titled Documentation in Medical Record, dated 09/01/22, revealed each resident's medical record would contain complete, accurate, and timely documentation. This deficiency was an incidental finding identified during the investigation of Complaint Number OH00148024. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365401 If continuation sheet Page 5 of 5