Health inspection·August 29, 2019

F 0606 Not hire anyone with a finding of abuse, neglect, exploitation, or theft. Level of Harm - Minimal harm or potential for actual harm Based on record review and staff interview the facility failed to check all potential new hires against the State Nurse Aide Registry (NAR) to ensure no employee had a finding entered into the NAR concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property. This had the potential to affect all 88 residents currently residing in the facility. Residents Affected - Many Findings include: Review of a document titled Phone List by Department, revealed the record reflected 75 State Tested Nurse Aides (STNAs) currently employed at the facility, 32 of which worked on an as needed (PRN) basis. These employees were checked against the State NAR. Review of a document titled New Hires Last 12 Months, dated 08/29/19 revealed the record reflected 14 Licensed Practical Nurses (LPN) #820, #825, #830, #835, #840, #845, #850, #855, #860, #875, #880, #885, #890, and #895. There were four Registered Nurses (RN) #800, #805, #810, and #815. Three housekeeping and laundry staff (Housekeeper) #945, #950, and #955. Seven dietary staff (Dietary) #905, #910, #915, #920, #925, #930, and #935. One activity staff #960 and one receptionist #940. All were hired in the last 12 months. Record review revealed no evidence these employees had been checked against the State NAR. On 08/29/19 at 4:01 P.M. interview with the Administrator and Human Resources (HR) #900 verified she had not been checking all potential new hires against the NAR. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365487 If continuation sheet Page 2 of 6 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 365487 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mount Saint Joseph Rehab Center 21800 Chardon Road Euclid, OH 44117 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure comprehensive assessments were accurate. This affected three (Residents #19, Resident #46, and Resident #64) of four residents reviewed for Pre-admission Screen - Resident Review. The facility census was 88. Residents Affected - Some Findings include: 1. Review of Resident #19's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including major depressive disorder, anxiety disorder, diabetes and heart failure. Review of Resident #19's medical record revealed the Minimum Data Set (MDS) 3.0 assessment, dated 05/07/19, revealed Section A did not indicate a mental illness as identified by Ohio Mental Health and Addiction Services. 2. Review of Resident #46's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia with Lewy bodies, major depressive disorder, anxiety disorder, and Parkinson's disease. Review of Resident #46's medical record revealed the MDS 3.0 assessment, dated 07/09/19, revealed Section A did not indicate a mental illness as identified by Ohio Mental Health and Addiction Services. 3. Review of Resident #64's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including delusional disorders, generalized anxiety disorder, post-traumatic stress disorder, and unspecified psychosis. Review of Resident #64's medical record revealed the MDS 3.0 assessment, dated 11/23/18, revealed Section A did not indicate a mental illness as identified by Ohio Mental Health and Addiction Services. On 08/29/19 at 11:25 A.M. an interview with MDS Nurse #895 verified the comprehensive assessments for Residents #19, #46, and #64 did not accurately reflect their mental health status. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365487 If continuation sheet Page 3 of 6 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 365487 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mount Saint Joseph Rehab Center 21800 Chardon Road Euclid, OH 44117 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility failed to ensure Resident #41's care plan was revised and updated to meet her individual needs. This affected one (Resident #41) out of 27 residents whose care plans were reviewed. Findings include: Resident #41 was admitted to this facility on 07/24/18. Her admitting diagnoses included vascular dementia, fracture of left femur, dementia, and blindness. Her Minimum Data Set Assessment 3.0 (MDS) dated [DATE] showed this resident had severe cognitive impairment. She needed extensive assistance for bed mobility, toilet use and personal hygiene. For all other activities of daily living she was totally dependant on staff. Her skin assessment from this MDS revealed she was at risk for pressure ulcer development and did at the time of this MDS have skin tears on her legs and arms. This resident resided on the dementia unit and received Hospice services. Review of the resident's plan of care dated 07/25/18 revealed the resident had a potential for actual skin impairment and or development of pressure ulcers related to her diagnoses of hypothyroidism, hypertension and being legally blind. Interventions included: keeping the skin clean and dry; provide a pressure relieving air mattress; provide pressure reducing cushion to char; pad corners of dressers, night stand and food board; provide a Roho cushion; and to use caution during transfers and bed mobility to prevent striking arms, legs and hands against any sharp or hard surface. Observation of Resident #41's bilateral upper and lower extremities revealed brushing on bilateral elbows and a skin tear on the lower left arm. The bilateral lower extremities showed bruising in several areas on bilateral legs and a skin tear noted to her left shin/calf area with a dressing. These bruises and skin tears were verified by Licensed Practical Nurse (LPN) #459 on 08/28/19 at 10:06 A.M. She stated the resident had a habit of forcibly moving her legs and arms over the sides of the wheelchair and while in bed. She stated that was the reason for the dermal sleeves for the arms and legs. Observation of the resident's room on 08/28/19 at 11:06 A.M. revealed there was no padding noted on the dresser or the nightstand. The food board of the bed was not padded and the food board of the wheelchair was not padded. Interview with LPN #459 on 08/28/19 at 11:15 A.M. verified that the dressers and the food boards were not padded. LPN #459 revealed those interventions did not really apply to the resident at the present time because the resident was now non ambulatory and was unable to move around. When asked about striking her arms/legs against objects and padding them for protection she stated that Hospice changed the orders. The orders were changed to a perimeter mattress with extra padding attachments to the perimeters of the bed to prevent the resident from striking her arms/legs when in bed. Resident #41 was also ordered to wear the derma sleeves to extremities for extra protection. LPN #459 verified present interventions including the perimeter mattress and the dermal sleeves were not listed on the current care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365487 If continuation sheet Page 4 of 6 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 365487 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mount Saint Joseph Rehab Center 21800 Chardon Road Euclid, OH 44117 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 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure appropriate interventions to prevent a fall with injury for Resident #18. Actual Harm occurred when State Tested Nurse Aide (STNA) #301 propelled Resident #18 in a wheel chair, without footrests. The resident's foot dropped to the floor and she fell, resulting in a hematoma of the forehead and transfer to the hospital. This affected one resident (Resident #18) of one resident reviewed for falls. Findings include: Resident #18 was admitted to the facility on [DATE] with diagnoses including dementia, physical debility, and osteoarthritis. The Minimum Data Set assessment dated [DATE] revealed the resident had severe cognitive impairment and required the extensive assistance of one person for all activities of daily living, including locomotion, via wheel chair. The resident was sent to the hospital on [DATE]. Observation on 08/28/19 at 8:06 A.M. revealed an STNA (unidentified) approached Registered Nurse (RN) #302 on the 500-unit hallway and informed her Resident #18 had fallen in the dining room. RN #302 went to the dining room and found Resident #18 sitting upright in her wheelchair with a hematoma across her forehead. No other nurse was noted on the scene. RN #302 promptly removed Resident #18 to her room for assessment. Interview with RN #302 on 08/28/19 at 8:17 A.M. revealed when a resident fell, unlicensed staff should wait until a nurse assessed the resident before getting them up. Interview with STNA #301 on 08/28/19 at 8:25 A.M. verified he was pushing Resident #18 in the wheelchair when her foot caught on the floor (no footrests were on the wheel chair) and she fell forward, hitting her head, resulting in a bruise across her forehead. He revealed he got the resident back into the wheelchair before a nurse arrived and confirmed he should not have moved the resident until she was assessed by the nurse Interview with the Director of Nursing (DON) on 08/28/19 at 9:36 A.M. confirmed the resident fell during transport in a wheel chair without footrests in place and fallen residents should not be moved until a nurse assessed them for injury. The DON revealed Resident #18 was sent to the hospital for evaluation following the fall. Record review of the facility's fall prevention protocol (undated) revealed staff was not to move a fallen resident until a nurse assessed them for injury. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365487 If continuation sheet Page 5 of 6 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 365487 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mount Saint Joseph Rehab Center 21800 Chardon Road Euclid, OH 44117 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 0844 Level of Harm - Potential for minimal harm Follow rules about disclosure of ownership requirements and tell the state agency about changes in ownership and/or administrative personnel. Based on record review and interview, the facility failed to inform the Ohio Department of Health when it hired a new Director of Nursing (DON). The total census was 88. Residents Affected - Many Findings include: Interview with the Administrator on 08/29/19 at 4:35 P.M. revealed their Director of Nursing (DON) began work in the facility in January of 2019. They did not know if information regarding her hire had been communicated to the Ohio Department of Health (ODH). Review of the DON's employee file revealed her hire date was 01/30/19. Review of both that file and the ODH secured website for provider communications revealed no evidence the DON's hire had been communicated to ODH. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365487 If continuation sheet Page 6 of 6