Health inspection·August 29, 2023

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 medical record review, emplyee time sheet review, employee disciplinary review and staff interviews, the facility failed to ensure all resident records had accurate documentation. This affected one (#45) of six residents reviewed for accurate medical records. The census was 44. Finding include: Review of the closed medical record for Resident #45 revealed an admission date of 08/17/23. Diagnosis included bacterial endocarditis. Review of the physician orders revealed an order for Ampicillin-Sulbactam Sodium (antibiotic) intravenous (IV) every six hours. Keep central line dressing intact. Review of the Medication Administration Report for August 2023 revealed on 08/12/23 Ampicillin-Sulbactam Sodium doses given at 8:00 A.M., 12:00 P.M. and 4:00 P.M., were signed off by the Former Director of Nursing (DON). Review of the Ampicillin-Sulbactam Sodium administration details revealed on 08/12/23 at 8:00 A.M., Licensed Practical Nurse (LPN) #313 had signed off the medications and then it was strike out on 08/12/23 at 11:20 A.M. by LPN #313, reason declined order and then was signed out at 8:00 A.M., 12:00 P.M. and 4:00 P.M. by former DON at 5:25 P.M Interview on 08/28/23 at 8:01 A.M., with former DON stated she was on vacation on 08/12/23 and was not in the facility at all. She was notified by LPN #313 that Resident #45 needed his IV antibiotic and there was no Registered Nurse (RN) in the facility. She was told that RN #374 was notified but was not able to come in because the Administrator told her she was not allowed to. Former DON verified she got on the electronic charting remotely and signed off three doses of Resident #45's IV antibiotic even though she did not administer the medication. Interview on 08/28/23 at 10:30 A.M., with LPN #313 verified she administered Resident #45's medication Ampicillin-Sulbactam Sodium in a central line. She only remembers doing one dose. LPN #313 stated she was not sure if she could administer IV medications in a central line. So, she did look it up, thought she could under the supervision of an RN, but no RN was in the building at this time. No other LPN working was IV certified. LPN #334 instructed LPN #313 to go ahead and administer since she was IV certified. LPN #334 informed LPN #313 she had talked to RN #374, who was in charge. The former DON did not directly tell LPN #313 to administer the medications. LPN #313 stated she signed the medication off for the one time she gave it. Interview on 08/28/23 at 4:00 P.M., with LPN #334 stated she was working on 08/12/23, on the day shift. Resident #45 had an IV antibiotic that needed to be hung. There was no RN in the building and LPN #313 was IV certified, so we looked up if she was allowed to hang the IV antibiotic, so she hung the antibiotic and signed it off. LPN #334 stated she called RN #374 to see if she was coming in to give Resident #45's antibiotic, RN #374 stated she was not scheduled and did not know if she was allowed to come in. Review of the timesheet for Former DON for 08/12/23 revealed she was not clocked in on 08/12/23. She was not working. Review of the undated policy Documentation in Medical Records, revealed false documentation should not be documented. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365452 If continuation sheet Page 2 of 4 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 365452 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearlview Rehab & Wellness Ctr 4426 Homestead Dr Brunswick, OH 44212 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 FORM CMS-2567 (02/99) Previous Versions Obsolete Review of former DON employee discipline form dated 08/21/23 revealed former DON was terminated for getting on the electronic charting from a remote location and signing off medication that she did not administer. This deficeincy represents non-compliance investigated under Master Complaint Number OH00145870 and Complaint Number OH00145362. Event ID: Facility ID: 365452 If continuation sheet Page 3 of 4 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 365452 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearlview Rehab & Wellness Ctr 4426 Homestead Dr Brunswick, OH 44212 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 Based on observation, staff interview, medical record review and review of policy, the facility failed to maintain appropriate hand hygiene during the tracheostomy (trach) care. This affected one (#43) of two residents identified as having a trach. The facility census was 44. Residents Affected - Few Findings include: Review of the medical record for the Resident #43 revealed an admission date of 01/24/23 and a readmission date of 07/17/23. Diagnoses included diffuse traumatic brain injury, diabetes mellitus, acute respiratory failure with hypoxia, and hydrocephalus. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/21/23, revealed the resident was in a persistent vegetative state. The resident required total dependence with two staff for activities of daily living except eating was total dependence of one staff. Review of the physician's order for August 2023 revealed Resident #43 revealed an order for trach care every shift and as needed. Observation of trach care on 08/28/23 at 5:56 A.M., with Registered Nurse (RN) #340 and Licensed Practical Nurse (LPN) #306 revealed RN #340 placed the trach kit on the table, washed his hands then donned gloves. He opened the trach care kit and took out Resident #43's reusable unclean trach tube. RN #340 then proceeded to clean the trach tube with the brush that was provided in the kit. RN #340 then took off gloves, donned the gloves that were in the kit and proceeded to put the cleaned cannula in, and placed a new split sponge around the trach. RN #340 did not need to suction Resident #43. RN #304 verified that he did not perform hand hygiene before putting on the second pair of gloves and stated that it's not a sterile procedure. Review of the undated policy titled Hand Hygiene, revealed that if a task requires gloves, perform hand hygiene prior to donning gloves. This deficiency represents non-compliance investigated under Master Complaint Number OH00145870 and Complaint Number OH00145362. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365452 If continuation sheet Page 4 of 4