Inspection·April 9, 2024

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. Based on record review and interview the facility failed to complete quarterly smoking assessments as care planned to identify and to the extent possible eliminate foreseeable smoking hazards. This affected one (Resident #7) of three residents reviewed for smoking. Findings include: Review of the medical record for Resident #7 revealed an admission date of 08/09/21. Diagnoses included schizophrenia, bipolar disorder, and nicotine dependence. Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/22/24, revealed Resident #7 had impaired cognition and was independent for activities of daily living. Review of the plan of care dated 08/31/23 revealed Resident #7 had the potential for safety hazard or injury related to smoking. Resident #7 was able to smoke with staff or family supervision. Interventions included observing resident during smoke breaks and completing a smoking assessment quarterly. Review of the facility smoking assessments revealed the facility last completed an assessment on 08/15/23. Interview on 04/08/24 at 5:13 P.M., the Director of Nursing verified that no assessment was completed for 2024 and stated smoking assessments are completed annually and quarterly. Review of the facility policy titled Resident Smoking, dated 2021 revealed no documentation related to the frequency in which smoking assessments should be completed. 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 04/09/2024 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 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 record review, observations and interview the facility failed to ensure Resident #23 was provide nail care. This affected one (Resident #23) of three residents observed for activities of daily living. The census was 41. Residents Affected - Few Findings include: Review of the medical record for Resident #23 revealed an admission date of 06/03/22. Diagnoses included dementia, mild and Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed Resident #23 had impaired cognition, was dependent for toileting, and required moderate assistance with personal hygiene. Review of the the plan of care dated 06/22/24 revealed Resident #23 required assistance with choosing appropriate clothing, oral care, and showering. Observation on 04/08/24 at 7:53 A.M. revealed Resident #23 was dressed in street clothes and seated at a dining room table. Resident #23's nails were long and dirty with food and other brown debris noted under the nails. Interview on 04/08/24 at 1:43 P.M. with Memory Care Coordinator #101 confirmed Resident #23's nails were long and dirty. This deficiency represents non-compliance investigated under Complaint Number OH00151393. 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 04/09/2024 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 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm Based on record review, observation and interview the facility failed to ensure all residents were given opportunities to engage in activities and have opportunities for social interaction other than routine activities of daily living. This affected one (Resident #2) of seven residents observed for quality of life. Residents Affected - Few Findings include: Review of the medical record for Resident #2 revealed an admission date of 09/19/19. Diagnoses included malignant neoplasm of the uterus, unspecified dementia, anxiety disorder, senile degeneration of the brain, and muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment, dated 12/09/23, revealed Resident #2 had impaired cognition, required setup and cleanup for eating, and was dependent for toileting. Review of the plan of care dated 09/23/19 revealed Resident #2 required encouragement to participate in activities and assistance to escort to activities. Review of the nurse progress notes dated March 2024 through April 2024 revealed no documentation indicating Resident #2 refused to attend activities. Observations on 04/08/24 at 8:00 A.M. revealed Resident #2 was dressed and seated in wheelchair in the main hallway. Resident #2's wheelchair was placed approximately six inches from the wall facing toward the nurse's station which was approximately 15 feet away. Most staff and residents were congregated approximately 15 to 20 feet down the hall. Limited staff and residents traveled down the hall because the main entrance approximately 50 feet away was closed. An interview with Resident #2 was unsuccessful; she could not answer questions related to activities. Observation on 04/08/24 at 10:30 A.M. revealed Resident #2 seated in the same location in the hallway. Staff had placed a linen cart against the wall approximately three feet in front of Resident #2 blocking the view of the nurse's desk. Observations on 04/08/24 at 12:16 P.M. revealed Resident #2 was seated approximately six feet from the nurse's station eating her lunch. There were no staff interacting with Resident #2 during the meal. Interview with Licensed Practical Nurse (LPN) #100, during the observation, revealed Resident #2 was a slow eater and would not allow staff to assist her with eating. Interview on 04/08/24 at 2:15 P.M. with State Tested Nurse Assistant (STNA) #107 confirmed Resident #2 had not attended any organized activities on this date and also confirmed that Resident #2 had been sitting alone throughout the day. Interview on 04/08/24 at 2:20 P.M. with Activity Assistant #108 confirmed Resident #2 was not invited or encouraged to attend activities from 8:00 A.M. to 2:30 P.M. 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 04/09/2024 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 0921 Level of Harm - Minimal harm or potential for actual harm Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation and interview, the facility failed to ensure a sanitary environment for residents. This affected Residents #15 and #38 and had the potential to affect all 41 residents residing in the facility. Residents Affected - Many Findings include: Observation on 04/08/24 at 7:43 A.M. revealed the entire length of the floors on the two main hallways had scattered dried brown and orange colored liquid staining and dirt and other various debris. In addition there was a strong smell of urine in the hallways. Interview immediately after the observation with Licensed Practical Nurse (LPN) #100 verified the dried liquid, dirt an various other debris on the floor and strong smell of urine. Interview on 04/08/24 at 8:15 A.M. with Housekeeper #103 revealed she cleaned resident rooms and communal areas daily. Interview on 04/08/24 at 8:17 A.M. with Floor Technicians #109 and #110 revealed floor technicians did not work over the weekend (04/06/24 and 04/07/24). The Floor Technicians verified the flooring in the two main hallways were dirty. Observation of Resident #38's room on 04/08/24 at 8:26 A.M. revealed food debris, plastic bags, five unidentified medication tablets in the corner behind the bed, and a whole dinner roll under the sink. The observations were verified with LPN #102 who stated housekeeping was responsible for sweeping and mopping the floors daily. Observation of Resident #15's room on 04/08/24 at 1:50 P.M. revealed food, paper debris, ants, and four unidentified medication tablets on the floor. The observations were verified with Memory Care Coordinator #101 who stated when Resident #15 finished eating she went to her room an brushed the food crumbs from her clothing onto the floor. This deficiency represents non-compliance investigated under Complaint Number OH00151393. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365401 If continuation sheet Page 5 of 5