Inspection·August 4, 2022

F 0573 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of an email dated [DATE] at 9:03 A.M. revealed Admission/ SSD #600 emailed Resident #222's daughter and revealed she had just returned to work [DATE] and asked Resident #222's daughter if she received the medical records that Resident #222's daughter requested or if she needed to follow-up on the request. Review of an email dated [DATE] at 9:21 A.M. revealed Resident #222's daughter responded back to the Admission/ SSD #600 that she had not received the medical records and asked if they were sent in the mail or by email. Review of an email dated [DATE] at 9:44 A.M. revealed Admission/ SSD #600 responded that she would check and let Resident #222's daughter know. Review of the nursing note dated [DATE] at 1:44 P.M. authored by Admission/ SSD #600 revealed a copy of the email for the request for medical records for Resident #222 along with copies of the requested medical records were given to the Administrator. The nursing note revealed the Admission/ SSD #600 had not given the copy of the medical records to the guardian until it was authorized. Review of an email dated [DATE] at 11:58 A.M. revealed Resident #222's daughter emailed Admission/ SSD #600 and stated that she had not received Resident #222's medical records yet and requested the medical records to be sent to her. Resident #222's daughter provided her address that she wanted the records sent to or she requested the medical records be sent to her email. Review of an email dated [DATE] at 12:41 P.M. revealed Admission/ SSD #600 replied to Resident #222's daughter that she would notify the Administrator. Review of an email dated [DATE] at 12:41 P.M. revealed Admission/ SSD #600 forwarded the email from Resident #222's daughter to the Administrator and stated that Resident #222's daughter had not received the medical records she had requested, and that the Admission/ SSD #600 had put a copy of the email in her box. Interview on [DATE] at 9:59 A.M. with Resident #222's daughter revealed she contacted the Admissions/ SSD #600 in [DATE] and in [DATE] and requested Resident #222's medical records and that she still had not received the medical records as of today, [DATE]. Interview on [DATE] at 9:29 A.M. with Admission/ SSD #600 revealed Resident #222's daughter requested the medical records for Resident #222 on two different occasions- [DATE] and [DATE]. She revealed Resident #222's daughter emailed her the request that included all the medical records from [DATE] through [DATE] regarding Resident #222's care during this time frame. She revealed she forwarded both requests to the Administrator as she revealed the Administrator was the one who authorized if the medical records could be sent. She revealed she did not know if the medical records were sent to Resident #222's daughter per her request. Interview on [DATE] at 9:50 A.M. with the Administrator revealed she had not sent the medical records to the Resident #222's daughter. She revealed if the Admission/ SSD #600 had forwarded her the request, she had to be honest, she had failed to send the medical records and she stated that the request had fell through the cracks. She stated after reviewing the emails that she was in the loop and she was responsible to send the medical records to Resident #222's daughter but had not. Review of the undated facility procedure titled Medical Records, revealed the facility had a (continued on next page) 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 08/04/2022 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 0573 Level of Harm - Minimal harm or potential for actual harm processing fee of 15 dollars for medical records and the copying fees included one dollar for pages one to ten, 50 cents pages 11 through 50, and 20 cents for pages 51 and more. This deficiency substantiates Complaint Number OH00132734. Residents Affected - Few 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 08/04/2022 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, record review, and facility policy review the facility failed to ensure Resident #54's passive range of motion and splint for the right upper extremity was completed per the occupational therapy recommendation. This affected one resident (Resident #54) of one resident reviewed for use of splints. This had the potential to affect five residents (Resident's #1, #10, #18, #53, #54) that had occupational therapy recommendations for splints. The facility census was 65. Findings include: Review of the medical record for Resident #54 revealed an admission date of 01/10/18 and diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, hypertension, and cognitive communication deficit. Review of the care plan dated 04/27/20 revealed Resident #54 had multiple medical diagnoses including her right side was flaccid and right hemiparesis. Interventions included right hand splint as ordered. There were no interventions regarding passive range of motion to right hand and elbow. Review of the Occupational Discharge summary dated [DATE] and authored by Occupational Therapist (OT) #607 revealed Resident #54 received occupational therapy from 04/01/22 to 04/28/22. The discharge summary recommended a restorative program be established including a restorative range of motion program and a restorative splint and brace program. The summary revealed passive range of motion was to be completed to Resident #54's right hand and elbow and a right-hand splint was to be worn six to eight hours per day as tolerated. Review of the form labeled Therapy Follow-Up Treatment Program, dated 04/29/22, authored by OT #607 revealed Resident #54 had passive range of motion exercises to the right hand and elbow with extended stretch for three to five minutes and right finger and elbow extensions. The form revealed staff was to perform range of motion, cleanse right hand, pat dry, and apply the right-hand splint. The form revealed Resident #54 was to wear the right-hand splint daily, six to eight hours as tolerated. Review of the July 2022 physician orders revealed Resident #54 had an order dated 05/30/20 to apply a right-hand splint and right shoulder brace when out of bed as tolerated every day shift. There were no physician's orders regarding range of motion exercises to the right hand and elbow or to wear right hand splint six to eight hours per day as tolerated as per Occupational Discharge Summary or Therapy Follow-Up Treatment program. Review of the quarterly Minimum Data Set (MDS) 3.0 dated 07/15/22 revealed Resident #54 had impaired cognition and no behaviors. She required extensive assist of two staff for transfers and was unable to ambulate. She required limited assist of one staff with locomotion on the unit. The MDS revealed no restorative program was completed per the assessment period for passive range of motion and/or splint assistance. Interview and observation on 08/01/22 at 3:05 P.M. with Resident #54 revealed she was in bed, and she stated she had not worn her right-hand splint today, 08/01/22, and she stated staff had not completed passive range of motion. She revealed she was unsure when she was supposed to wear her splint. She revealed she had not worn her right-hand splint for a long time and could not remember when the (continued on next page) 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 08/04/2022 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 0688 last time she wore it as staff do not apply the right-hand splint. Level of Harm - Minimal harm or potential for actual harm Interview on 08/02/22 at 2:44 P.M. with State Tested Assistant (STNA) #602 revealed Resident #54 refused almost every day to get out of bed. She revealed she thought Resident #54 was only to wear her right-hand splint when she was up out of bed as she had never applied her splint when she was in bed. Residents Affected - Few Interview on 08/02/22 at 2:59 P.M. with Registered Nurse (RN) #603 revealed Resident #54 had an order to wear her right-hand splint only when she was out of bed. She revealed Resident #54 almost always refused to get out of bed, so she very rarely wore her splint. Interview on 08/03/22 at 1:46 P.M. with OT #607 revealed Resident #54 was to wear her right-hand splint in and/ out of bed. He revealed he discharged Resident #54 from occupational therapy on 04/29/22 and referred Resident #54 for restorative passive range of motion program and restorative splint program to her right upper extremity. He revealed he provided nursing with the Therapy Follow- Up Treatment program dated 04/29/22 with the new recommendations. He revealed Resident #54 was to wear her right-hand splint six to eight hours per day as tolerated and he had not heard Resident #54 was not wearing her right-hand splint or that passive range of motion was not being completed as he recommended per the Therapy Follow-Up Treatment Program. He revealed Resident #54's order on her July 2022 physician order for right hand splint and right shoulder brace when out of bed as tolerated every day shift was an old order and not per the last occupational therapy recommendation on 04/29/22. Interview on 08/03/22 at 1:52 P.M. with LPN #608 revealed she was the charge nurse for Resident #54 and only worked at the facility as needed and had not worked at the facility for several months. She revealed she signed off on the treatment administration record that the right-hand splint and right shoulder brace when out of bed as tolerated every day shift had been applied but she verified that this was in error as she had not seen the brace or splint on Resident #54 all day and did not know anything about her splint. Interview on 08/03/22 at 1:58 P.M. with STNA #609 revealed she was the aide for Resident #54 and was not aware when Resident #54 was to wear her right-hand splint, and she verified she had not applied her right-hand splint today, 08/03/22. Interview on 08/03/22 at 2:02 P.M. with the Director of Nursing revealed she had worked at the facility since November 2021 and since then the facility had not had any restorative programs. She revealed any referral received from therapy, nursing placed the order on the treatment administration record (TAR) including range of motion and splints for the nurse and the aide to complete on the floor for that resident. She verified the order on Resident #54's physician's order for the right-hand splint and right shoulder brace when out of bed as tolerated every day shift dated 05/20/20 was an old order and the new recommendations from the last occupational therapy discharge summary and Therapy Follow-Up Treatment Program dated 04/29/22 for passive range of motion and right-hand splint for six to eight hours per day as tolerated was not transcribed to Resident #54's orders. She verified she had no documented evidence passive range of motion was completed for Resident #54 as recommended. Review of the undated facility policy labeled Splint/ Brace Application revealed qualified nursing personnel would ensure that residents received correct application and care of splints and braces to promote proper joint alignment, healing, avoid complications of immobility while monitoring skin integrity and avoiding discomfort. The policy revealed a splint and brace was individualized to reflect resident needs and functional problems. The policy revealed the splint wearing schedule orders (continued on next page) 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 08/04/2022 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 0688 would be in the treatment record of the resident's chart. 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: 365487 If continuation sheet Page 6 of 6