Inspection·November 27, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation, interview, and record review ,the facility failed to ensure a clean, sanitary, and well maintained environment in good repair. This affected five residents (#4, #30, #33, #34, and #38) of seven residents reviewed for physical environment. The facility census was 38. Findings include: 1. Observation on 11/20/23 at 10:21 A.M. of Resident #30's room revealed a hole in the wall behind the dresser that appeared to be the size of at least a baseball of what was able to be observed without moving the dresser. Interview at this time with Resident #30 revealed that hole had been there since she was admitted to the facility about two months ago. Observation on 11/20/23 at 10:26 A.M. of Resident #33's room revealed the windowsill in disrepair and lifted up. Also observed two holes in the bathroom door. Interview at this time with Resident #33 revealed it had been that way for a while. Observation on 11/20/23 at 10:33 A.M. of Resident #34's room revealed under the sink area was a large hole in the wall and also various dried brownish stains throughout this wall. Observed in the upper left side corner a thin, metal beam that's between the ceiling tile was hanging. Observation on 11/20/23 at 10:41 A.M. of Resident #4's room revealed a large upside T shaped opening in back wall next to call light. Observed a small hole inside the the upside down T shaped opening. Observed behind Resident #4's bed the wallpaper was scratched up and coming off the wall and there were several holes in the wall as well. Observed a large brownish stain in the corner ceiling tile in the upper right corner of this wall near the resident's bed. Tour on 11/21/23 from 8:24 A.M. to 8:37 A.M. with Director of Maintenance (DOM) #256 verified the identified observations in the rooms of Resident #4, #30, #33, and #34 and stated he was not aware of all of the observations except the T shaped opening in the wall of Resident #4's room was when her removed an old pipe about a month ago and forgot about it. During the tour observation of Resident #30's room, DOM #256 removed the dresser from the wall to reveal the hole was much larger. DOM #256 stated he was in charge of two buildings and recently within two weeks hired an assistance. DOM #256 stated nursing was to inform him of any maintenance repairs, and he would get to them as fast as he could. Observation on 11/21/23 at 9:23 A.M. of Resident #34's room with Housekeeping Supervisor #305 verified the dried, brownish stains on the wall and around the sink area. Housekeeping Supervisor #305 stated they would get that cleaned up. Reviewed policy TELS/Maintenance Work Orders, dated 04/17/23 revealed all maintenance works are to be completed by the Maintenance Director or designee. The maintenance director has a week (5-7 days) to acknowledge and make corrective actions. Review of the policy Routine Cleaning and Disinfection, revised 11/29/22 revealed routine cleaning and disinfection of frequently touched or visibly soiled surfaces will perform in common areas, resident rooms, and at the time. Cleaning of walls, blinds and windows will be conducted when visibly soiled. 2. Observation on 11/20/21 at 9:43 A.M. of Resident #38's room revealed a drain pipe was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365401 If continuation sheet Page 2 of 16 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 11/27/2023 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some missing from underneath the sink. Observation of the running faucet revealed the water drained onto the floor. Further observation of Resident #38's vanity area revealed no signage was posted and the sink faucet was able to be turned on. Interview on 11/20/21 at 9:43 A.M. of Resident #38 revealed he used the sink of the adjoining residents room to wash. Resident #38 was cognitively impaired and resided on the memory care unit. Resident #38 stated the sink has not had a drain for three months. Interview on 11/20/21 at 9:48 A.M. of State Tested Nurse Assistant (STNA) #303 verified the water drain was missing from underneath the sink and needed to be replaced. STNA #303 stated a work order ticket had been placed for the repair on 11/19/23 when Resident #38 removed the sink drain. Interview on 11/21/23 at 11:42 A.M. of the Maintenance Director (MD) #256 revealed he was unaware of Resident #38's sink drain and stated a work order had not been entered into the electronic system for repair. MD #256 stated clinical staff informed him of the sink drain this morning and he was able to replace the drain timely. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365401 If continuation sheet Page 3 of 16 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 11/27/2023 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 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** 2. Review of Resident #12's medical record revealed an admission date of 10/06/23 and diagnoses including unspecified severe protein-calorie malnutrition, dementia in other diseases without behavioral disturbance, hypertension, anemia and atrial fibrillation. Residents Affected - Few Review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 was moderately cognitively impaired, did not have upper or lower extremity impairment and required partial/moderate assistance for showering/bathing. Resident #12 did not reject care. Review of Resident #12's nurses' notes since admission revealed no documentation relative to showers. Review of the undated facility document, Station Two Shower Schedule and Wheelchair Cleaning Schedule, revealed Resident #12 was to have showers on Tuesdays and Fridays. Review of point-of-care documentation for October 2023 revealed Resident #12 had showers on 10/11/23, 10/12/23, 10/16/23 and refused a shower on 10/22/23. Documentation was not available for 10/20/23 (Friday), 10/24/23 (Tuesday), 10/27/23 (Friday) and 10/31/23 (Tuesday). Review of point-of-care documentation for November 2023 revealed Resident #12 had showers on 11/05/23, 11/11/23, 11/12/23 and 11/13/23. Documentation was not available for 11/03/23 (Friday), 11/10/23 (Friday) and 11/17/23 (Friday). Interview on 11/20/23 at 11:13 A.M. with Resident #12 and her family member revealed she received one shower a week but she wanted two showers per week. Interview on 11/21/23 at 12:46 P.M. with the Director of Nursing (DON) verified Resident #12's showers were not completed twice a week as scheduled. Review of the facility policy, Resident Showers, dated 07/01/22 revealed the facility would assist residents with bathing to maintain proper hygiene. Residents will be provided showers as per request or as per facility schedule protocols and based on resident safety. Based on interview, observation, and record review, the facility failed to provide necessary services to maintain personal hygiene and grooming for two residents (Resident #12 and #18) out of two residents reviewed for activities of daily living. The facility census was 38. Findings include: 1. Review of the medical record for Resident #18 revealed an admission date of 06/09/23 with a diagnosis of non-Alzheimer's dementia and traumatic brain injury. Resident #18 was cognitively impaired and dependent on staff for hygiene and grooming. Review of the plan of care dated 09/07/23 for Resident #18 revealed assistance needed for activities of daily living (ADLs) related to cognitive impairment and dementia. Interventions included staff to assist as needed with daily hygiene and assist with showering resident per facility policy weekly. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365401 If continuation sheet Page 4 of 16 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 11/27/2023 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 11/20/23 at 1:11 P.M. with Resident #18's legal guardian revealed Resident #18's finger nails needed to be cleaned and trimmed. Observation of Resident #18's finger nails on 11/20/23 at 2:43 P.M. and on 11/21/23 at 3:54 P.M. revealed the fingernails of all digits belonging to both the left and right hand were observed to be thick and overgrown. Resident #18's fingernails presented with moderate debris and random particles visible under the nail beds, brown nail staining observed to first and fifth digit of right hand. Further observation of Resident #18 revealed the resident required staff assistance for grooming of fingernails due to cognitive impairment. Interview on 11/21/23 at 3:54 PM with the State Tested Nurse Assistant (STNA) #303 verified Resident #18 required his nails to be cleaned and trimmed. Interview on 11/21/23 at 3:54 P.M. with Licensed Practical Nurse (LPN) #222 revealed the nursing staff was responsible for cleaning and trimming the residents fingernails. LPN #222 was unable to provide the date Resident #18's fingernails were last cleaned and trimmed. Review of the facility policy titled Resident Care revised 06/18/22, revealed the residents will be given nursing care and supervision based upon individual needs. Typical personal hygiene for a resident will include but not limited to: care of the skin to include routine bathing/foot care, shampoo and grooming of the hair per resident preference, oral hygiene, shaving and beard trimming per resident preference, removal of women's facial hair when requested, and cleaning and cutting of fingernails and toenails. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365401 If continuation sheet Page 5 of 16 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 11/27/2023 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and facility policy review, the facility failed to have a comprehensive system in place for communication and collaboration with the dialysis facility. This affected one resident (Resident #97) of one resident reviewed for dialysis. The facility census was 38 residents. Residents Affected - Few Findings include: Review of Resident #97's medical record revealed an admission date of 10/17/23 and diagnoses including type two diabetes, osteomyelitis, chronic kidney disease, dependence on renal dialysis, depression and glaucoma. Review of an admission minimum data set (MDS) 3.0 assessment dated [DATE] revealed it was still in progress. Review of Resident #97's physician's orders revealed an order dated 10/31/23 for Monday/Wednesday/Friday dialysis resident to be up front of [sister facility next door] for 5:30 A.M. pick up and an order dated 11/01/23 for dialysis at [facility name]. Review of Resident #97's October 2023 and November 2023 Medication Administration Records (MARs) and Treatment Administration Records (TARs) revealed no documentation relative to pre-dialysis or post-dialysis assessments. Review of a nurses' note dated 11/20/23 revealed Resident #97 did not go to dialysis that day. Review of electronic assessments revealed pre-dialysis assessments completed on 11/01/23, 11/02/23, 11/06/23, 11/15/23 and 11/16/23. These assessments lacked post-dialysis assessment. Review of Resident #97's care plan dated 10/17/23 revealed Resident #97 was at risk for complications related to diagnosis of renal failure/end stage renal disease requiring dialysis treatment. Resident #97 attended [facility name] Mondays, Wednesdays and Fridays with a pick up time of 5:45 A.M. Listed interventions included nurse to utilize dialysis communication form for pre-dialysis assessment including vitals signs and communication with dialysis center staff regarding plan of care, lab values, diet/fluid restriction recommendations, etc. Interview on 11/21/23 at 9:15 A.M. with Licensed Practical Nurse (LPN) #222 revealed there was a book for vitals before and after dialysis but she could not find the book. At 9:36 A.M., LPN #222 provided the dialysis book to the surveyor. Review of a paper dialysis book revealed three post-dialysis assessments for 11/08/23 and 11/13/23. The last assessment lacked a date. Interview on 11/21/23 at 9:38 A.M. with the Director of Nursing (DON) and Senior Director of Nursing (SDON) #302 revealed when Resident #97 went to dialysis on Mondays, Wednesdays and Fridays he was supposed to go with a paper dialysis sheet. Night shift nurses were responsible for ensuring Resident #97 went with the paper and day shift staff were responsible for ensuring the paper returned with him to the facility and for completing the post-dialysis assessment electronically. If the paper did not come back to the facility, nurses were to get vitals and a weight. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365401 If continuation sheet Page 6 of 16 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 11/27/2023 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 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Follow-up interview on 11/21/23 at 4:46 P.M. with the DON and SDON #302 verified no other dialysis documentation was available for review for Resident #97 and verified there was only a pre-dialysis assessment completed 11/01/23, no documentation for 11/03/23, a pre-dialysis assessment completed on 11/06/23, a post-dialysis assessment completed on 11/08/23, no documentation for 11/10/23, a post-dialysis assessment completed on 11/13/23, a pre-dialysis assessment completed on 11/15/23 and no documentation completed on 11/17/23. Review of the facility policy, Dialysis Care, dated January 2016 revealed there should be a source of communication between the facility and the dialysis unit with each visit (Utilize the dialysis communication form). Talk with your dialysis unit and explain the importance of this communication. The nurse will complete a head to toe assessment of the resident prior to leaving for each visit to the dialysis unit) complete the skin observation prior to discharge/transfer/leave of absence. Upon return the communication form sent to the dialysis unit for any new orders. in the event the dialysis unit refuses and/or fail to provide communication with the resident visit, document in the clinical record, the dialysis unit did not provide any communication on the communication form provided. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365401 If continuation sheet Page 7 of 16 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 11/27/2023 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 0727 Level of Harm - Minimal harm or potential for actual harm Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on record review and interview the facility failed to ensure eight hours of Registered Nurse (RN) coverage as required. This affected all 38 residents in the facility. Residents Affected - Many Findings include: 1. Review of the facility's payroll based journal (PBJ) data and posted daily staffing sheets on 11/21/23 starting at 11:34 A.M. with Human Resource Manager (HRM) #255 revealed the following: • On 04/22/23, no RN was scheduled on the daily staffing sheet and there were no RN hours recorded in the PBJ. • On 05/07/23, one RN was scheduled for eight hours on the daily staffing sheet but only 7.7 RN hours were recorded in the PBJ. • On 05/20/23, no RN was scheduled on the daily staffing sheet and there were no RN hours recorded in the PBJ. • On 05/21/23, two RNs were scheduled for 15 hours on the daily staffing sheet but no RN hours were recorded in the PBJ. • On 06/03/23, no RN was scheduled on the daily staffing sheet and there were no RN hours recorded in the PBJ. • On 06/04/23, no RN was scheduled on the daily staffing sheet and there were no RN hours recorded in the PBJ. • On 06/17/23, no RN was scheduled on the daily staffing sheet and there were no RN hours recorded in the PBJ. • On 06/18/23, two RNs were scheduled on the daily staffing sheet but only 7.37 RN hours were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365401 If continuation sheet Page 8 of 16 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 11/27/2023 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 0727 recorded in the PBJ. Level of Harm - Minimal harm or potential for actual harm Interviews on 11/21/23 starting at 11:34 A.M. with HRM #255 verified the facility did not have an RN for at least eight hours as required on 04/22/23, 05/07/23, 05/20/23, 05/21/23, 06/03/23, 06/04/23, 06/17/23 and 06/18/23. Residents Affected - Many 2. Review of schedules and posted staffing from 11/14/23 to 11/20/23 revealed no evidence an RN worked in the facility on 11/18/23. Interview on 11/20/23 at 5:05 P.M. with Scheduler/State Tested Nursing Assistant (STNA) #303 verified there was no RN in the facility on 11/18/23. Follow-up interview on 11/21/23 at 11:34 A.M. with HRM #255 verified the facility did not have an RN onsite on 11/18/23 as the scheduled RN had called off of work. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365401 If continuation sheet Page 9 of 16 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 11/27/2023 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 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and policy review, the facility failed to ensure monitoring for medication effects and potential adverse consequences was completed for residents who were receiving psychotropic medications. The facility also failed to document a rationale for extending an as-needed (PRN) anti-anxiety medication. This affected two residents (Residents #21 and #24) out of five residents reviewed for unnecessary medications. The facility census was 38 residents. Findings Include: 1. Review of Resident #24's medical record revealed an admission date of 10/07/16 and diagnoses including depression, dementia, hypertension and COVID-19. Review of a plan of care dated 10/19/16 for Resident #24's potential for adverse side effects of psychotropic drug use - anti-depressant daily for depression revealed interventions of document side effects of medication: dry mouth, dizziness, drowsiness, constipation, extrapyramidal symptoms, seizures and notify physician of any changes; observe and document any abnormal behavior and moods; observe, document and report to physician as needed signs and symptoms of drug-related complications: cognitive/behavioral impairment, drug-related discomfort, gait disturbance, hypotension and movement disorder. Review of a plan of care dated 09/07/17 for Resident #24's potential for mood and behavioral issues that may fluctuate related to depression, dementia with behaviors, anxiety, psychosis with use of anti-depressant and interventions of administer medications as ordered, observe for effectiveness and adverse reactions; attempt non-pharmacological interventions such as one on one, change in position or scenery, offer food or fluids, redirect, activity of choice, toileting, diversional activities, etc. Review of a quarterly minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #24 had a memory problem and received an anti-depressant six out of the seven days in the lookback period on the assessment. Review of Resident #24's current physician's orders as of 11/21/23 revealed an order dated 04/13/23 for Citalopram Hydrobromide, give 7.5 milligrams (mg) once a day for depressive disorder. Review of Resident #24's medical record including nurses' notes, Medication Administration Records (MARs) and Treatment Administration Records (TARs) revealed no evidence of monitoring for signs and symptoms of depression or side effects related to Resident #24's anti-depressant. Review of a plan of care dated 09/09/23 for Resident #24 exhibiting depressive behaviors included interventions of monitoring for increased side effects if psychotropic medications have been increased or decreased and notify physician; administer medications as ordered, observe for effectiveness and adverse reactions; attempt non-pharmacological interventions such as one on one, change in position or scenery, offer food or fluids, redirect, activity of choice, toileting, diversional activities, etc. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365401 If continuation sheet Page 10 of 16 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 11/27/2023 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 11/21/23 at 1:38 P.M. with Licensed Practical Nurse (LPN) #222 reviewed Resident #24's electronic medical record including the MAR and TAR with the surveyor and verified no monitoring of side effects or behaviors pertaining to anti-depressant use was available in the record. Interview on 11/21/23 at 4:46 P.M. with the Director of Nursing (DON) and Senior Director of Nursing (SDON) #302 revealed if there was no supplemental documentation on the MAR and TAR regarding medication monitoring then there was no other documentation to review regarding Resident #24's antidepressant relative to symptoms and side effects. SDON #302 agreed Resident #24 should have this supplemental documentation and was not sure why the orders for monitoring were not already in place. Review of Use of Psychotropic Medication dated 10/01/22 revealed the indications for initiating, withdrawing, or withholding medications as well as the use of non-pharmacological approaches, will be determined by- assessing the residents' underlying condition, current signs, symptoms, expressions and preferences and goals for treatment. For psychotropic drugs that are initiated after admission to the facility, documentation shall include non-pharmacological interventions that have been attempted and the target symptoms for monitoring shall be included in the documentation. The effects of the psychotropic medications on a resident's physical, mental, and psychosocial well-being will be evaluated on an ongoing basis such as in accordance with nurse assessments and medication monitoring parameters consistent with clinical standards of practice, manufacturer's specifications and the resident's comprehensive plan of care.2. Review of the medical record for Resident #21 revealed an admission date of 09/20/19. Diagnoses included uterine cancer, dementia, and anxiety disorder. Review of the pharmacy recommendation dated 03/03/23 revealed Ativan 0.5 mg every four hours as needed (prn) must document clinical rationale for extended use and duration of treatment. Please note hospice is not exempt from this requirement. Suggest adding a stop date of 180 days. Noted under clinical rationale for continuation was handwritten 03/08/23 noted by psych. Review of pyscho therapies note dated 03/08/23 provided by the facility revealed a highlighted portion of the note that read, GDR contraindicated at this time. Tapering current meds would interfere with the desired therapeutic effects. Current dose is necessary to maintain or improve resident's functioning elbowing, safety, and quality of life. The note did not indicate a rationale for extending the Ativan greater than 14 days. The resident was also noted to be receiving an antidepressant. Review of the pharmacy recommendation dated 05/03/23 for revealed Ativan 0.5 mg every four hours prn must document clinical rationale for extended use and duration of treatment. Please note hospice is not exempt from this requirement. Suggest adding a stop date of 180 days. Noted under clinical rationale for continuation was handwritten continue Ativan 0.5 every 4 hours prn for 12 m. Review of the physician orders for November 2023 revealed active orders for Ativan (antianxiety) oral tablet 0.5 milligrams (mg). Give 0.5 mg via percutaneous endoscopic gastrostomy (PEG) tube every four hours as needed for anxiety related to anxiety disorder for 180 days with a start date of 06/02/23. Further review of Resident #21's medical record revealed no documentation indicating a rationale to extend the Ativan greater than 14 days. Interview on 11/21/23 at 5:09 P.M. with Senior Director of Nursing (SDON) verified there was no documentation in Resident #21's medical record documenting the rational for extending the as needed Ativan greater than 14 days as indicated on the pharmacy recommendations dated 03/03/23 and 05/03/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365401 If continuation sheet Page 11 of 16 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 11/27/2023 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 Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled Medication Regimen Review, dated 09/30/22 revealed the pharmacist shall communicate any recommendations and identified irregularities via written communication within 10 days working days of the review. Facility staff shall act upon all recommendations according to procedures for addressing medication regimen review irregularities. Residents Affected - Few This deficiency is an example of continued non-compliance from the surveys dated 11/08/23. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365401 If continuation sheet Page 12 of 16 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 11/27/2023 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm 4. Review of the facility's Legionella Environmental Assessment Form dated 06/18/18 revealed it was named and completed for the separately licensed sister facility next door to the facility. No flow diagram was included in the document. The plan indicated occupancy varied throughout the year but did not detail what staff would do with vacant rooms to prevent biofilm growth. The plan indicated the facility had a water safety plan. The question regarding testing for Legionella was left blank. The area to describe the testing plan was also left blank. The plan indicated the facility would monitor incoming water parameters but no logs, pH (measure of acidity or alkalinity), temperature ranges or disinfectant residual information was provided. The plan stated there was a recirculation system but the area where the system was supposed to be described with delivery/return temperatures was left blank. The plan indicated the thermostatic mixing valves were used but no details about the location of mixing valves were provided. The plan indicated the facility would monitor cold water at points of use but no logs were attached. The plan question regarding potable water disinfectant levels (such as chlorine) was left blank. Test results from a residential test kit dated 02/22/23 and 09/16/23 were included, however, no further information on what the test had tested for aside from the results being negative was available for review. Residents Affected - Many Interview on 11/27/23 at 8:15 A.M. with Director of Maintenance (DOM) #256 revealed he was not knowledgeable on the facility's water management documentation and DOM #256 stated, I have never seen this plan. DOM #256 stated he flushed vacant rooms in the secured unit twice a month but did not document this process. DOM #256 was unaware of any other water management plans to review as the provided plan was for the sister facility next door and not this facility but did share the facilities had separate water lines. DOM #256 also stated he never took cold water temperatures even though the water management plan stated the facility would monitor these at point of use. Follow up interviews on 11/27/23 at 10:02 A.M. and 10:24 A.M. with DOM #256, the Director of Nursing (DON) and the Administrator verified multiple areas on the water management plan with a yes answer had no further information provided thus the plan was not complete and the plan also did not meet the guidance from the Centers for Disease Control (CDC). The DON and the Administrator were made aware the provided plan was not for this facility and no further documentation relative to the water management plan was provided by the time of exit. The Administrator indicated control measures for the facility were hot and cold water but the facility was not capturing cold water temperatures or recording them. Review of the policy, Legionella Surveillance, dated 08/01/23 revealed the facility to establish primary and secondary strategies for the prevention and control of Legionella infections. Physical controls included non-potable water systems shall be routinely cleaned and disinfected. Temperature controls were to be maintained including cold water to be stored and distributed below 68 degrees F. Hot water shall be stored above 140 degrees Fahrenheit (F) and circulated at a minimum return temperature of 124 degrees F. The policy did not define control measures, lacked any information about how the facility would intervene when control measures were not met, did not detail any baseline or routine testing outside of an outbreak of Legionnaire's disease and failed to address ongoing monitoring of the plan's effectiveness. Review of the CDC webpage revealed guidance under the title of, Overview of Water Management Programs, and revealed water management programs identify hazardous conditions and take steps to minimize the growth and transmission of Legionella and other waterborne pathogens in building water systems. Developing and maintaining a water management program is a multi-step process that requires (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365401 If continuation sheet Page 13 of 16 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 11/27/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many continuous review. Such programs are now an industry standard for many buildings in the United States. Further review of the webpage under the subsection titled, Key Elements, revealed there were seven key elements of a Legionella water management program which included to establish a water management program team, describe the building water systems using text and flow diagrams, identify areas where Legionella could grow and spread, decide where control measures should be applied and how to monitor them, establish ways to intervene when control limits are not met, make sure the program is running as designed (verification) and is effective (validation), and document and communicate all the activities. Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented related to handwashing with medication pass, proper personal protective equipment (PPE) before entering a COVID-19 positive room, and did not fully develop and implement a comprehensive water management program to prevent Legionella. This had the potential to affect all residents. The facility census was 38. Findings include: 1. Review of the medical record for Resident #5 revealed an initial admission date of 12/15/22. Diagnoses included congestive heart failure (CHF), morbid obesity, chronic obstructive pulmonary disease (COPD), and lymphedema. Review of the physician orders for November 2023 revealed active orders for contact and airborne precautions due to COVID 19 positive two times a day for 10 Days with a start date of 11/20/23. Observation on 11/20/23 at 9:56 A.M. of Resident #5's room door closed with signage on the door indicating contact and air borne precautions, and personal protective equipment (PPE) outside of the door that included, N95 facemask, disposable gowns, and gloves. No eye protection was observed. Observation on 11/20/23 at 12:03 P.M. of Housekeeper (HSK) #307 entering Resident #5's room wearing a N95 facemask and gloves. Observed HSK #307 take trash out of the room and observed the resident's floor was wet. Observed HSK #307 take a new clear trash back into the resident's room and place in the trash bin near door. Interview on 11/20/23 at 12:03 P.M. with HSK #307 verified he was only wearing a N95 facemask and gloves when he cleaned Resident #5's room. HSK #307 stated only the nurses had to put on the gown and everything when they went into the resident room. HSK #307 stated when he had cleaned rooms like that in past he had to put on the gown, glove, and everything but was not too familiar with Resident #5 being in transmission based precautions. 2. Review of the medical record for Resident #16 revealed an admission date of 08/14/23. Diagnoses included agoraphobia with panic disorder, major depressive disorder, muscle weakness, and Huntington's disease. Review of the physician orders for November 2023 revealed orders for airborne and contact isolation precautions every shift for isolation with a start date of 11/17/23. Observation dated 11/20/23 at 10:16 A.M. revealed room door was opened with signage on the door indicating contact and air borne precautions, and personal protective equipment (PPE) outside of the door that included, N95 facemask, disposable gowns, and gloves. No eye protection was observed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365401 If continuation sheet Page 14 of 16 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 11/27/2023 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 0880 Observed red and yellow biohazard bins in the resident's room. Level of Harm - Minimal harm or potential for actual harm Observation on 11/21/23 at 8:34 A.M. of Housekeeper (HSK) #306 put on a gown and gloves but no eye protection. HSK #306 was observed wearing a N95 facemask and entered Resident #16's room. Residents Affected - Many Observation on 11/21/23 at 8:38 A.M. of HSK #306 cleaning Resident #16's room with the N95 facemask not completely on her face with the bottom strap hanging off chin. No eye protection was observed on while HSK #306 was mopping out of the resident room toward the hallway. HSK #306 then closed the door behind her and doffed the gown and placed it in a clear trash bag in the housekeeping cart outside of Resident #16's door. HSK #306 the doffed the gloves into the trash bin. Interview on 11/21/23 at 8:43 A.M. with HSK #306 verified she did not wear eye protection and her N95 face mask was not on correctly. HSK #306 stated it was hard to breathe with it on. HSK #306 verified there was no eye protection available in the PPE cart for her to wear. Observation and interview on 11/21/23 at 8:49 A.M. with Infection Control Preventionist (ICP) #302 verified there was no eye protection available in the PPE bins outside of the transmission based precautions (TBP) rooms. ICP #302 stated they will be provided. Reviewed policy COVID-19 Prevention, Response and Reporting dated 05/10/23 revealed HCP who enter the room of a resident with suspected or confirmed SARS-CoV-2 infection should adhere to standard precautions and a NIOSH-approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection. 3. Observation on 11/20/21 at 9:15 A.M. of medication administration with Licensed Practical Nurse (LPN) #304 revealed the LPN #304 prepared five pills with water for Resident #34 and administered the medication. LPN #304 was not observed to perform hand hygiene prior to administering medications and was not wearing gloves. LPN #304 returned to the medication cart at 9:20 A.M. and prepared four pills with water for Resident #16 and administered the medications to the resident. LPN #304 was not observed to perform hand hygiene prior to medication administration or between Residents #34 and #16. Interview on 11/20/21 at 9:22 A.M., of LPN #304 revealed the LPN #304 performs hand hygiene at the residents sink. LPN #304 verified that he forgot to perform hand hygiene before and after medication administration. LPN #304 confirmed that he did not have alcohol based hand sanitizer available on the medication cart. Review of the facility policy titled Medication Administration, revised on 08/22/23 revealed medications are administered by licensed nurses as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Guidelines include keep medication cart clean, organized, and stocked with adequate supplies; Cover and date fluids and food used with medication pass; Identify resident; Wash hands prior to administering medication per facility protocol and product; Knock. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365401 If continuation sheet Page 15 of 16 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 11/27/2023 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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm Based on observation and interview the facility did not ensure a working call system was in place for Resident #17. This affected one resident (Resident #17) of one resident whose call light was not working. The facility census was 38. Residents Affected - Few Findings include: Observation on 11/21/23 at 10:09 A.M. of a beeping noise. Interview at this time with the Administrator when asked about the call lights lighting up outside of the residents' rooms and she stated she did not know what the noise was. The Administrator then went to get Director for Maintenance (DOM) #256. Interview on 11/21/23 at 10:10 A.M. with DOM #256 revealed call lights lit up outside the residents' room and stated he could pull the call light in Resident #17's room. Observation at this time of DOM #256 pull the call light in Resident #17's room and it did not light up outside of the resident's room. DOM #256 verified the observation. Observation on 11/21/23 at 10:13 A.M. with DOM #256 of the call light board at the nurse's station revealed the light did not light on the call light board. At this time DOM #256 verified the observation and stated it might be a bulb that burnt out. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365401 If continuation sheet Page 16 of 16