Health inspection·November 13, 2023

F 0623 Level of Harm - Minimal harm or potential for actual harm discharge date of 09/29/23. Resident #42 was admitted with diagnoses of myotonic muscular dystrophy, atrioventricular block, alcoholic hepatitis, alcohol dependence, and dementia. Review of the nursing progress notes revealed on 09/29/23 Resident #42 was discharged and transported by to another facility. Residents Affected - Few Interview on 11/08/23 at 3:00 P.M. with the Administrator revealed Resident #42 was discharged to another nursing home on [DATE]. The Administrator was unable to provide evidence the Ombudsman was notified of Resident #42's discharge to another facility. Review of the 2023 facility policy Transfer and Discharge (including AMA) revealed a transfer/discharge notice was to be provided to the resident/representative and Ombudsman as indicated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365452 If continuation sheet Page 2 of 9 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 11/13/2023 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 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 medical record review, staff and resident interviews and review of facility policy, the facility failed to ensure residents requiring assistance with activities of daily living received showers/bathing as scheduled. The affected two of three residents (Resident #23 and Resident #30) reviewed for showers/bathing. The facility census was 39. Residents Affected - Few Findings Included: 1. Review of the medical record for Resident #23 revealed an admission date of 02/22/23. Diagnoses included but were not limited to dementia, stage III chronic kidney disease and nontraumatic intracranial hemorrhage and seizures. Review of the plan of care dated 02/23/23 revealed Resident #23 had a self-care deficit related to confusion, limited mobility and limited range of motion and required total dependence of two staff for showers twice weekly. Resident #23 was noted to be resistant to care at times. Review of the comprehensive Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed Resident #23 was cognitively intact and required total dependence of two staff for bathing. Review of the facility shower list revealed Resident #23 was to be bathed on Wednesday and Saturday. Review of Resident #23's shower sheet documentation from August 2023 to October 2023 revealed out of 26 scheduled shower days, 13 days (08/09/23, 08/16/23, 08/19/23, 08/30/23, 09/13/23, 09/16/23, 09/20/23, 10/04/23, 10/07/23, 10/14/23, 10/18/23, 10/21/23, and 10/28/23) did not indicate shower/bathing was completed. Review of nursing progress notes from August 2023 to November 8, 2023, revealed two bathing refusals 08/05/23 and 08/12/23. Interview on 11/06/23 at 10:55 A.M. with Resident #23 revealed she preferred to receive showers two times a week and it had been three weeks since she had a shower/bath. Resident #23 stated staff offered to provide bathing/showers but then did not return to provide the shower/ bath. Interview on 11/08/23 at 9:20 A.M. with the Director of Nursing (DON) confirmed 13 shower sheets for Resident #23 from August to October 2023 indicated showers were not completed as scheduled. 2. Review of the medical record for Resident #30 revealed an admission date of 04/06/23. Diagnoses included but were not limited to amputation of right lower leg below knee, type I diabetes mellitus with diabetic retinopathy, chronic heart failure, legal blindness, and Alzheimer's dementia. Review of the plan of care dated 04/06/23 revealed Resident #30 had an activities of daily living self-care performance deficit related to activity intolerance, confusion, impaired balance, and limited mobility. Interventions included extensive assist of one staff for bathing twice weekly. Review of the comprehensive MDS 3.0 quarterly assessment dated [DATE] for Resident #30 revealed Resident #30 had intact cognition and required extensive assist of one for bathing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365452 If continuation sheet Page 3 of 9 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 11/13/2023 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 0677 Review of the facility shower list revealed Resident #30 was to have showers on Sundays and Thursdays. Level of Harm - Minimal harm or potential for actual harm Interview on 11/06/23 at 10:21 A.M. with Resident #30 revealed it had been about four weeks since he had a bath/shower. Residents Affected - Few Review of Resident #30's shower sheet documentation from August 2023 to October 2023 revealed out of 27 shower days, 12 days (08/06/23, 08/09/23, 08/13/23, 08/13/23, 08/27/23, 09/03/23, 09/07/23, 09/13/23, 09/29/23, 09/24/23 10/04/23 and 10/18/23) did not indicate showers or bed baths were completed. Review of the nursing progress notes from August 2023 through October 2023 revealed Resident #30 had refused showers on four days (08/23/23, 08/30/23, 09/06/23 and 10/08/23). Interview on 11/08/23 at 9:20 A.M. with the DON confirmed 12 shower sheets indicated showers/baths were not completed as required. Review of the 2022 revised facility policy Resident Showers revealed residents would be provided showers as per request or as per facility schedule protocols. This deficiency represents non-compliance investigated under Complaint Number OH00147716. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365452 If continuation sheet Page 4 of 9 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 11/13/2023 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of the medical record for Resident #14 revealed an admission date of 02/09/23. Diagnoses included alcohol induced dementia, vascular dementia, hearing loss, and chronic obstructive pulmonary disease. Residents Affected - Many Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #14 had impaired cognition. Review of the nurses' notes dated 10/30/23 at 4:30 P.M. revealed Resident #14 tested positive for Covid-19 this afternoon. Resident #14 was immediately placed on contact/droplet precautions. Resident 14's guardian was updated on the situation. The certified nurse practitioner was notified and entered orders. Review of the physician orders for November 2023 revealed orders for contact and droplet isolation (transmission based precautions) related to Covid-19 every shift until 11/10/23. Observation on 11/07/23 at 4:56 P.M. revealed Resident #14, who independently ambulated, sitting in the dining room. Resident #14's N95 mask was not placed over her mouth and nose and she was sitting next to (less than six feet) Resident #20 who was eating. Continued observation revealed Stated Tested Nurse Aide (STNA) #520 telling Resident #14 to pull her face mask up over her mouth and nose. Interview with STNA #520, at the time of the observation, revealed Resident #14 was supposed to be in isolation but would not stay in her room, and although Resident #14 was taken back to her room she returned to the dining room. STNA #520 confirmed Resident #14 was sitting at the table with Resident #20 who was negative for Covid-19. Observation of smoke break on 11/08/23 at 9:37 A.M. revealed Resident #14 outside sitting at the same table (less six feet) with Resident #33. Resident #14 was wearing a N95 face which she pulled down when talking to Resident #33. STNA #528 gave Resident #14 a cigarette and lit the cigarette. Resident #14 smoked the cigarette while seated at the same table with Resident #33. Interview on 11/08/23 at 9:39 A.M. with STNA #528 revealed other residents outside smoking during the smoke break included Resident #9, #12, and #13. STNA #528 stated she was told by the Director of Nursing that she could encourage but could not force Resident #14 to stay in her room. STNA #528 stated she was not given instructions on precautions to take when a resident who tested positive for Covid-19 was smoking, only that she could not refuse Resident #14 the right to smoke. Continued observation revealed at 9:43 A.M. Resident #33 informed STNA #528 that Resident #14 touched her cigarette and Resident #33 wanted another cigarette. STNA #528 stated she did not have any more and Resident #33 stated it was okay and went back into the facility. STNA #528 said she knew Resident #14 had to keep her hands down, not touch, and staff were to have their N95 masks on when lighting her cigarettes. Interview on 11/08/23 at 2:06 P.M. with Infection Control Preventionist (ICP) #503 revealed all staff were educated regarding Covid-19 protocols and when Covid-19 positive residents were out of their rooms staff were to ensure they were kept separated or an appropriate distance away from other residents and wore a face masks; however, they could only encourage. Based on observation, record review, facility policy review, and interview the facility failed to maintain proper infection control practices/procedures to prevent the potential spread of Covid-19. This had the potential to affect all 39 residents residing in the facility. (#1, #2, #3, #4, #5, #6, #7, #8, #9, 12, #13, #14, #16, #17, #18, #19, #20, #21,#23, #24, #25, #26, #27, #29, #30, #31, #32, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365452 If continuation sheet Page 5 of 9 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 11/13/2023 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 #33, #34, #36, #37, #38, #39, #40, #41, #45, #46, #245, and #246). Level of Harm - Minimal harm or potential for actual harm Findings include: Residents Affected - Many 1. Observation on 11/06/23 at 9:33 A.M. revealed five residents (Residents #5, #6, #14, #21, and #39) on the second floor in isolation for Covid-19. Personal Protective Equipment (PPE) was observed hanging on the doors of the rooms of the residents or in cabinets placed just outside the entrance of each room. There was no signage on or near the residents' doors indicating the type of isolation or what PPE should be donned prior to entering the rooms. Interview on 11/06/23 at 9:33 A.M. with State Tested Nurse Aide (STNA) #525 and Registered Nurse (RN) #505 confirmed there were no signs on or near the doors of Residents #5, #6, #14, #21 and #39 indicating the type of isolation or what PPE was required. Interview on 11/06/23 at 11:04 A.M. with the Administrator revealed signage should be posted on the doors of all residents in isolation indicating the type of isolation and PPE to be worn. Interview on 11/08/23 at 1:56 P.M. with Infection Preventionist (IP) #503 revealed the facility was in Covid-19 outbreak status. IP #503 verified there should be signs posted on the doors of residents who were Covid-19 positive indicating the type of isolation and PPE required. Interview on 11/13/23 at 7:32 A.M. with the Director of Nursing (DON) revealed staff entering a room of a Covid-19 positive resident were to wear a N95 masks, eye protection, gown, and gloves. Staff were to doff the N95 mask, gown, eye protection, and gloves upon exiting the room and apply a new N95 mask. The DON also verified there should be signage on the door indicating the type of isolation precautions and PPE to be used. Review of facility policy, Coronavirus (COVID-19) Prevention and Management (An Addendum to the infection Control Manual), revised 01/03/23, revealed instructional signage was to be posted. 2. Review of the medical record for Resident #6 revealed an admission date of 08/11/15. Resident #6 was diagnosed with Covid-19 on 11/02/23. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 had intact cognition and required supervision to touch assistance with bed mobility, dressing, toileting, and personal hygiene. Review of physician orders dated 11/02/23 revealed Resident #6 was to be placed in contact and droplet isolation (Transmission Based Precautions) related to Covid-19 for ten days. Observation on 11/06/23 at 9:52 A.M. revealed State Tested Nurse Aide (STNA) #525 donning PPE to enter Resident #6's room including gown, N95, and gloves. STNA #525 did not don eye protection. STNA #525 entered Resident #6's room and closed the door. A few minutes later, STNA #525 opened the door and yelled out for another STNA to assist. As STNA #530 was approaching, STNA #525 was asked why she was not wearing eye protection. STNA #525 responded I forgot and left at nurses' station. STNA #525 then yelled out to STNA #530 to bring her a face shield. STNA #530 brought a face shield to Resident #6's room and gave it to STNA #525. Observation on 11/06/23 at 10:17 A.M. revealed STNA #525 exiting Resident #6's room wearing a N95 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365452 If continuation sheet Page 6 of 9 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 11/13/2023 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many mask and walking down the hallway. Interview with STNA #525, at the time of the observation, verified she did not don eye protection when she entered Resident #6 room and upon exiting the room she did not doff the N95 mask. Further observation at 10:21 A.M. revealed STNA #525 removing the N95 mask and donning a new N95 mask. STNA #525 did not secure the bottom strap of the N95 mask but left the strap hanging below her chin. At the time of the observation, STNA #525 verified incorrect N95 mask placement and said I forgot. Interview on 11/06/23 at 11:04 A.M. with the Administrator revealed staff were to wear full PPE including eye protection, N95 mask, gown, and gloves when entering a Covid-19 positive room and doff all PPE before exiting the room including the N95 mask. Staff were to get a new N95 upon exiting the room. Interview on 11/08/23 at 1:56 P.M. with Infection Preventionist #503 revealed the facility was in Covid-19 outbreak status and staff were to wear full PPE including N95 masks, eye protection, gown, and gloves when entering a Covid-19 positive room. Before exiting the Covid-19 positive room staff were to doff the PPE including the N95 mask. Staff were to get a new N95 upon exiting the room. Interview on 11/13/23 at 7:32 A.M. with the Director of Nursing verified staff were to wear N95 masks, eye protection, gown, and gloves upon entering a Covid-19 positive room. Before exiting the Covid-19 room staff were to doff the PPE including the N95 mask and upon exit get a new N95 mask. Review of facility policy, Personal Protective Equipment, dated 2023, revealed eye protection was to be worn and staff were not to reuse single-use-only respirators. 3. Observation on 11/07/23 at 7:41 A.M. revealed State Tested Nurse Aide (STNA) #530 enter Resident #6's room with full PPE to answer the call light. Upon exiting the room STNA #530 removed all PPE except the N95 mask and started walking down the hall. At 7:44 A.M., STNA #530 verified she should have changed her N95 mask and got a new one before heading down the hall. STNA #530 reported I forgot. Interview on 11/06/23 at 11:04 A.M. with Administrator verified staff were to doff all PPE before exiting a Covid-19 positive room including the N95 mask. Staff were to get a new N95 upon exiting the room. Interview on 11/08/23 at 1:56 P.M. with Infection Preventionisit #503 revealed staff were to discard all PPE before exiting a Covid-19 positive room including the N95 mask. Staff were to get a new N95 upon exiting the room. Interview on 11/13/23 at 7:32 A.M. with the Director of Nursing verified before exiting a Covid-19 room staff were to doff all PPE including N95 mask and upon exiting the room get a new N95 mask. Review of facility policy, Personal Protective Equipment, dated 2023, revealed eye protection was to be worn and staff were not to reuse single-use-only respirators. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365452 If continuation sheet Page 7 of 9 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 11/13/2023 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observations, interviews, and record review, the facility failed to maintain a clean and sanitary environment. This affected three residents (#30, #38, and #45) of three residents reviewed for physical environment. The census was 39. Findings include: Interview on 11/06/23 at 9:45 A.M. with Resident #45 revealed no one cleaned his room. Observation at the time of interview revealed the bathroom floor had dirt buildup in the four corners of floor and there was feces in the toilet bowl. There was a buildup of dirt behind the entrance door to Resident #45's room. Observation of Resident #30's room on 11/07/23 at 9:39 A.M. revealed crumbs on the floor under and behind the bed, and near the sink area. Behind the entrance door into Resident #30's room there was a buildup of dirt. In Resident #30's bathroom there was a dirty, dry towel at the base of the pipe of the toilet and on the floor at the base of the toilet there was a tan colored stain. There was also dirt buildup in the four corners of the bathroom floor. Observation on 11/07/23 at 11:54 A.M. revealed Housekeeper (HSK) #553 outside of Resident #45's room with a housekeeping cart. Interview with Resident #45, at the time of the observation, revealed it was the first time Resident #45 had seen housekeeping. Further observation revealed the floor in the bathroom and behind Resident #45's door still looked dirty, but the feces was cleaned from the toilet. Tour on 11/07/23 from 1:51 P.M. to 2:10 P.M. with HSK #553 verified the dirt buildup behind Resident #45's door and in the corners of the bathroom floor. HSK #553 stated the floor tiles were old and he had cleaned Resident #45's room about 30 minutes ago. Observation of Resident #30's room with HSK #553 verified the various crumbs and stains on floor near and under the bed, under and along the edges of the floor around sink area, as well as the dirt buildup behind the entrance door. Observation of the Resident #30's bathroom with HSK #553 verified the dirty towel on the toilet pipe, the tan colored stained at the base of the pipe on the toilet, and dirt buildup in the corners of the bathroom floor. HSK #553 stated he did not know why the towel was there and that Resident #30 did not use the bathroom. HSK #553 stated he did not work on 11/06/23 and he was not sure what the part timer did. HSK #533 verified the dirt buildup in the four corners of Resident #38's bathroom floor. HSK #553 stated it was hard to complete deep cleaning and get all the resident rooms cleaned. HSK #553 stated sometimes the floors did not look clean after they had been mopped and the mop did not hit the corners of the floor. HSK #553 stated he would have to use something different for the corners, like a brush. Review of the facility's undated Daily Cleaning Procedures for Healthcare Maintenance Program, revealed under procedure at room staff were to apply bowl cleaner to bowl swab and start in a circular motion at top rim of toilet working down to the bottom of bowl. After that, spray and wipe exterior portions of toilet fixture with germicidal detergent. Under cleaning floors the procedure indicated to check general appearance of room, using a treated duct mop, pick up all loose dirt on floor. Using germicidal solution in a mop bucket, start in the furthest corner of room and mop or spray floor, also covering bathroom floor. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365452 If continuation sheet Page 8 of 9 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 11/13/2023 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 0921 This deficiency represents non-compliance investigated under Complaint Number OH00146691. 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: 365452 If continuation sheet Page 9 of 9