Inspection·January 26, 2024

F 0600 Level of Harm - Actual harm Residents Affected - Few Review of a facility SRI and investigation dated 01/03/24 at 3:47 P.M. revealed Residents #20 and Resident #35 had a verbal argument in the common area of the facility secured memory care unit. Resident #20 walked away, and Resident #35 followed him to another resident 's (Resident #39) room. In Resident #39's room, Resident #20 hit Resident #35 on his right arm resulting in no injuries. Resident #39 then pulled Resident #35 towards her away from Resident #20. In response, Resident #20 struck Resident #39 who fell to the floor with no injury noted. Resident #39 then struck Resident #20 in return with no injuries noted. A visitor in Resident #39's during this altercation used a dust mop in attempt to break up Resident #20 and Resident #39 and inadvertently swung the dust mop hitting Resident #20 on the head. A staff member was present and intervened to separate all individuals. All three (#20, #35, and #39) residents involved were assessed with Resident #35 and Resident #39 sustaining no injuries. Resident #20 received an open area to the top of the head that was bleeding. Resident #20 was transported to a local emergency room (ER) for an evaluation, and the open area was treated in the ER with staples to close the wound. A computed tomography scan (commonly referred to as a CT scan used to obtain images of the internal portions of the body) completed in the ER revealed no negative results. Resident #20 returned to the facility and neurological checks continued without deficits. Immediately following the altercation, Resident #39's visitor denied hitting Resident #20 and reported she was trying to keep Resident #20 away from her mom (Resident #39). Resident #39's visitor was escorted out of the facility and the dust mop removed from the room. Staff remained with Resident #20 until he was transferred to the hospital. All physicians and responsible parties were notified for all three (#20, #35, and #39) residents involved in the altercation. The local police department was notified and arrived at the facility at 3:23 P.M. on 01/03/24. Interview with the Administrator on 01/26/24 at 9:55 A.M. verified all the events of the SRI dated 01/03/24 involving Resident #20, Resident #35, and Resident #39. Review of the policy titled, Abuse, Neglect, Exploitation & Misappropriation of Resident Property, dated 10/01/20, revealed the facility will not tolerate abuse, neglect, and exploitation of its residents or the misappropriation of resident property. As a results of the incident, the facility implemented the following corrective actions to correct the deficient practice by 01/04/24: • On 01/03/24 at approximately 2:15 P.M., Resident #39's visitor was instructed by the Director of Nursing (DON) to leave the facility and not to return pending the results of the investigation. Resident #39's visitor was escorted out the facility by the DON and the dust mop removed from Resident #39's room. • On 01/03/24, immediately following the incident Resident #20, Resident #35, and Resident #39 were assessed for injury. Resident #20 received a laceration to the head which was cleansed and covered with a foam dressing. The physician was notified, and Resident #20 was sent to the ER for an evaluation. Facility staff remained with Resident #20 until emergency services arrived at 2:26 P.M. A message was left for Resident #20's guardian to return call, and a return call was received at 7:05 P.M. and the guardian was made aware of the incident by the DON. Resident #20's guardian requested that charges be filed against Resident #39's family member. Resident #35 and Resident #39 were assessed with no injuries or concerns. Resident #35 and Resident #39's physicians and responsible parties were (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 01/26/2024 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 0600 notified of the incident with no new orders or concerns noted. Level of Harm - Actual harm • Residents Affected - Few On 01/03/24 at 3:57 P.M., an SRI was initiated and submitted to the State Survey Agency. • On 01/03/24 at approximately 2:30 P.M., the DON obtained staff statements of those involved in the incident • On 01/03/24, the local police department was notified of the event and arrived at the facility at 3:23 P.M. The local police department took necessary statements and stated they would follow up with the facility as needed. • On 01/03/24 at 3:30 P.M., the DON and Regional Director of Clinical Services (RDCS) #610 completed a review of current residents who have displayed aggressive behaviors. All resident care plans and interventions were reviewed, and necessary changes made as appropriate. • On 01/03/24, the DON and RDSC #610 completed skin assessments of all residents on the secured memory care unit with no abnormal findings. • On 01/03/24 at 6:21 P.M., Resident #20's room was changed to another location within the secured memory care unit. Resident #20's Guardian was notified on 01/03/24 and was in agreement with the room change. • On 01/03/24, the DON and designees began education with staff on resident altercations, recognizing triggers, and de-escalating/redirecting residents. The education of all staff members was completed by 01/04/24. • On 01/03/24, the DON and designees began education with families and responsible parties on allowing staff to intervene during any resident altercations. The families and responsible parties were educated on what to do during a resident altercation. All education was completed by 01/04/24. • On 01/04/24 at 6:30 A.M., Resident #20 returned to the facility with staples to the open area on (continued on next page) 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 01/26/2024 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 0600 Level of Harm - Actual harm the head and CT scans were negative in the ER. Resident #20 received orders to monitor staples to the resident's head. Resident #20 displayed no signs or symptoms of emotional distress, and a follow up skin assessment was completed with no additional findings. Residents Affected - Few • On 01/04/24, RDCS #610 completed an environmental observation to ensure no other dust mops or foreign objects were in resident rooms or out in resident areas unattended with no concerns noted. • On 01/04/24, a Quality Assurance and Performance Improvement (QAPI) meeting was held to review the incident and plans to prevent further incidents. • On 01/04/24, the DON or designee will audit five residents per week for four weeks to include residents who have aggressive behaviors to ensure care planned interventions are effective/appropriate. The results would be reviewed in QAPI meetings. There were no concerns with the audits noted. • On 01/04/24, Memory Care Coordinator (MCC) #600 or designee will complete observations on five resident interactions per week for four weeks to include resident-to-resident interactions, potential triggers, and staff interview on what to do if resident to resident altercations occur. The results would be reviewed in QAPI meetings. There were no concerns with the audits noted. • On 01/04/24, the Administrator or designee will complete interview and/or quiz five employees per week for four weeks related to visitor-to-resident altercations, if any have been observed, and how to handle visitor-to-resident altercations. The results would be reviewed in QAPI meetings. There were no concerns with the audits noted. • On 01/04/24, MCC #600 will complete environmental safety observation three times per week for four weeks to ensure no dust mops are in resident areas unattended. The results would be reviewed in QAPI meetings. There were no concerns with the observation audits noted. • On 01/26/24 between 8:30 A.M. and 12:00 P.M. random observations of interactions between residents and visitors revealed no abuse concerns. • Interviews on 01/26/24 between 8:30 A.M. to 12:00 P.M. with two random licensed practical nurses (LPNs) and three random state tested nurse aides revealed all staff interviewed were educated (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 01/26/2024 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 0600 regarding resident abuse and had appropriate knowledge of the facility's policies and procedures related to identifying and preventing resident abuse, neglect, and misappropriation. Level of Harm - Actual harm This deficiency represents noncompliance investigated under Complaint Number OH00150070. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365401 If continuation sheet Page 5 of 5