Health inspection·July 11, 2023

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few broken and felt it had been broken ever since they gave him the chair but stated, it had been broken since the beginning of June 2023. She revealed he continuously slid down in the chair, and he could not properly sit upright like he did in his personal chair. She revealed she was upset as she brought up this concern several times and that they still refused to accommodate by providing a chair that was not broken and that he would not slide down in. She revealed the staff then do not get Resident #14 out of bed and/ or they lay him back down early because he constantly slides down which then causes him to become restless in bed. She revealed he then attempts to climb out of bed because he does not want to lay in bed all the time. She revealed Resident #14 had three falls attempting to get out of bed within the last month and felt it was because he cannot be up in a wheelchair as long as he was used to. She revealed the facility was attempting to get a new chair as it had been submitted and awaiting insurance approval but that the process had already taken a long time, and the facility had no knowledge how much longer he would have to go without a proper chair. Observation on 07/10/23 at 10:01 A.M. revealed State Tested Nursing Assistant (STNA) #601 assisted Resident #14 out of bed to his wheelchair by placing his wheelchair next to his bed and assisted Resident #14 to stand and pivot to his chair. During observation STNA #601 stated Resident #14's left leg rest was broken, and she felt it was unsafe. She revealed the leg rest does not lock in place, so it continuously opens and swings outward and inward causing a safety concern in the hallway for other residents walking by, as they could possibly trip over it and/ or as the leg rest opens and closes continuously non-stop, Resident #14 slides down in his chair. She revealed they reposition him frequently but that Resident #14 continuously slides down because the leg rest goes outward and then the leg rest was not able to support his weight. She revealed she felt this was a fall/ safety concern and revealed that he appeared uncomfortable in the wheelchair as he does not appear to fit well in it. She revealed for several months it had been like that and that therapy knew that the footrest was broken but it does not get repaired. Observation on 07/10/23 from 10:25 A.M. to 11:15 A.M. revealed Resident #14 sitting in front of the nursing station. Observation revealed his left foot/ leg continuously caused the footrest to swing back and forth causing Resident #14 to slide down in his chair. Resident #14 was observed to lose contact with the footrest and attempt to search for the footrest with his leg/ foot causing Resident #14 to further slide down in his chair. During the observation staff was observed repositioning him back up in his wheelchair but then the process of the leg rest swinging in and out began again with him sliding down in the chair. During the observation he appeared to clench his jaw and facial grimace as he tried to support his positioning; however, because of the left leg rest being broke he slid down. Interview on 07/10/23 at 10:33 A.M. with Licensed Practical Nurse (LPN) #606 verified the left footrest was broken as it was unable to lock in place. She also verified Resident #14 appeared uncomfortable as he kept sliding down in his chair. Observation on 07/10/23 at 10:48 A.M. with Speech Therapist (ST) #607 and Physical Therapy Assistant #608 were walking by Resident #14 and saw that he was sliding down in his chair. They attempted to reposition him back up in his chair. Interview on 07/10/23 at 10:48 A.M. with ST #607 and PTA #608 revealed the left footrest had been broken and stated maybe two to three months that it had been broken. They revealed the facility was attempting to get Resident #14 a new wheelchair and were awaiting on insurance approval. They verified that the broken footrest was causing the leg rest to open and close continuously back and forth which as a result Resident #14 slid down in his chair and required frequent staff repositioning. PTA (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365594 If continuation sheet Page 2 of 11 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 365594 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens of Euclid Beach 16101 Euclid Beach Blvd Cleveland, OH 44110 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 0558 #608 revealed, not sure what else we can do as we are waiting for approval on a new chair. Level of Harm - Minimal harm or potential for actual harm Interview on 07/10/23 at 11:06 A.M. with Rehabilitation Director #609 verified the left leg rest of Resident #14's wheelchair was broken causing the leg rest to continuously go in and out as Resident #14 attempted to support himself. He verified Resident #14 continuously slid down in the chair and needed frequently staff assistance to pull him back up in his chair. He revealed that the facility had the footrest repaired/ replaced maybe six weeks ago but that the leg rest almost immediately breaks again because of how he sits and pushes against the leg rest. He revealed that he had his own custom wheelchair but that possibly during the transition from a previous facility to this facility it was lost, but this was before he was hired, so he knew no details regarding his personal custom specialty chair. He revealed Resident #14 was in one of the facility chairs as a backup and had been for several months. He revealed they submitted for a new wheelchair but were awaiting insurance approval, and he was not aware how long that was going to be as sometimes is a lengthy process especially since he was not actually due for a new chair through his insurance as his old one was only a few years old. He revealed that the facility could not keep replacing the footrests especially since they had a new chair on order, he could not see the facility paying for repairs on the old chair that was not even his. He was asked if he felt it was the facility responsibility to reasonably accommodate Resident #14 with a wheelchair that functioned, and he stated that was something to discuss with the facility administration but that the facility currently could not just keep getting his leg rests repaired as they seemed to break again. Residents Affected - Few Interview on 07/10/23 at 12:36 P.M. with Rehabilitation Director #609 verified the last time his left leg rest was repaired was on 03/03/23. He revealed he had no documented evidence when the leg rest had broken again, and he revealed he had not ordered a new leg rest and/ or contacted the outside vendor to repair instead he stated again since a new chair was on order, they were not going to repair the leg rest on his old chair. He verified the new chair was awaiting insurance approval and had no idea how long it would be to get a new chair, at times this process can be timely. He also verified he had no other documentation regarding Resident #14's wheelchair. Observation on 07/10/23 from 2:07 P.M. to 2:18 P.M. revealed Resident #14 continued to sit in front of the nursing station, and his left footrest continued to swing in and out, and Resident #14 continued to slide down in her chair. Observation on 07/10/23 at 2:17 P.M. revealed Registered Nurse (RN) #611 stated to STNA #601 that they needed to lay down Resident #14 as he kept sliding down as she said that they had pulled him up multiple times and it was not helping as he kept sliding down because of the broken footrest. They proceeded to lay Resident #14 down. Interview on 07/10/23 at 4:55 P.M. with the Administrator and Director of Rehabilitation #609 verified per their facility policy it stated the facility would provide devices such as wheelchairs to assist with a resident mobility. Interview on 07/10/23 at 5:00 P.M. with STNA #601 verified RN #611 and STNA #601 laid down Resident #14 because he continuously slides down in his chair because of the broken footrest. She revealed Resident #14 did not like to be in bed as then he attempted to climb out of bed and has had falls in the past because he attempted to get out of bed. She re-verified Resident #14's left leg rest had been broken for at least a couple months. Review of the facility policy labeled, Assistive Devices and Equipment dated January 2020, revealed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365594 If continuation sheet Page 3 of 11 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 365594 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens of Euclid Beach 16101 Euclid Beach Blvd Cleveland, OH 44110 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 0558 Level of Harm - Minimal harm or potential for actual harm the facility maintained and supervised the use of assistive devices and equipment for residents. The policy revealed certain devices and equipment that assist with a resident mobility, safety, and independence were provided for the residents such as wheelchairs, walkers, and canes. This deficiency represents non-compliance investigated under Master Complaint Number OH00144102. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365594 If continuation sheet Page 4 of 11 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 365594 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens of Euclid Beach 16101 Euclid Beach Blvd Cleveland, OH 44110 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 0602 Protect each resident from the wrongful use of the resident's belongings or money. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, record review, and facility policy review the facility did not ensure Resident #14's legal guardian's allegation of misappropriation was investigated and/ or followed up on in a timely manner. This affected one resident (#14) out of three residents reviewed for misappropriation. The facility census was 56. Residents Affected - Few Findings include: Review of the medical record revealed Resident #14 had an admission date of 07/29/22 with diagnoses including Parkinson's disease, diabetes, hemiplegia, and hemiparesis following cerebral infarction affecting left and right side, dementia, and history of falling. There was nothing documented in his medical record regarding Resident #14 legal guardian's concern of misappropriation of his personal wheelchair made in June 2023. There was no documented evidence in his medical record that a personal inventory was completed on admission. Review of the care plan dated 02/03/23 revealed Resident #14 had an activities of daily living deficit related to dementia, impaired balance, frequent falls, epilepsy, and left and right hemiparesis related to cerebrovascular accident. Intervention included transfer with mechanical lift with two staff assist. The care plan did not include the form/ ability of locomotion such as wheelchair. Review of the grievance log dated 05/01/23 to 07/10/23 revealed no grievances regarding Resident #14's missing wheelchair. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident 14's cognition was not assessed. He required extensive assistance of two staff with bed mobility and was totally dependent of two staff with transfers. He was unable to ambulate, and locomotion of his wheelchair required total dependence of one staff. Interview on 07/10/23 at 9:33 A.M. and on 07/11/23 at 8:43 A.M. with Resident #14's legal guardian revealed Resident #14 was admitted to the facility on [DATE] and that he came from another facility. She revealed when he was admitted she had followed the other facilities van as they transported him to the current facility and that he was in his own personal customized wheelchair. She revealed the facility then at some point lost Resident #14's wheelchair and she had reported it numerous times, but the facility had frequent turnover of management staff and never seemed to investigate/ follow-up on his missing wheelchair. She revealed she had contacted the Administrator at the beginning of June 2023 and had an approximate 40-minute conversation regarding her concern that the facility had lost his wheelchair after he had moved into the facility, and previous management consistently stated they would investigate the situation but felt she was getting the run around as nobody would get back to her with a resolution. She revealed after her conversation with the Administrator the beginning of June 2023, the Administrator told her that she was new at the facility and that she would investigate and research his missing wheelchair. She revealed she contacted the Administrator again approximately two and a half weeks later and she still had done nothing about the missing chair: no investigation and/ or nothing to resolve the situation. She revealed it seemed like the same thing continued to occur as the management changed frequently and they say they were new and always say they do not know anything about the incident and/ or in her opinion resolve the situation. She revealed she was upset as it only left Resident #14 to continue to not have a wheelchair that was safe and well fitting. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365594 If continuation sheet Page 5 of 11 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 365594 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens of Euclid Beach 16101 Euclid Beach Blvd Cleveland, OH 44110 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 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 07/10/23 at 4:55 P.M. with the Administrator revealed Resident #14's legal guardian contacted her approximately two weeks ago regarding Resident #14's missing wheelchair. She verified she had not completed an investigation regarding Resident #14's missing wheelchair. She revealed she had no documentation a previous investigation had ever been completed regarding the missing wheelchair. She verified there had been no personal inventory completed on admission so was unable to determine if a wheelchair came with him. She also verified there was nothing placed on the grievance log regarding Resident #14's legal guardian's concerns voiced regarding the misappropriation. Observation on 07/10/23 at 10:01 A.M. revealed State Tested Nursing Assistant (STNA) #601 assisted Resident #14 out of bed to his wheelchair by placing his wheelchair next to his bed and assisted Resident #14 to stand and pivot to his chair. During the observation STNA #601 stated Resident #14's left leg rest was broken and that she felt it was unsafe. She revealed the leg rest does not lock in place so continuously opens and swings inward and outward causing a safety concern in the hallway for other residents walking by, as they could possibly trip over it and/ or as the leg rest swings opened and closes continuously non-stop, he slides down in his chair. She revealed they reposition him frequently, but Resident #14 continues to slide down because the leg rest goes outward, and it was not able to support his weight. She revealed she felt this was a fall/ safety concern and revealed that he appeared uncomfortable in the wheelchair as he does not appear to fit well in it. She revealed for several months it had been like that, and therapy knew it was broken but it does not get repaired. Observation on 07/10/23 from 10:25 A.M. to 11:15 A.M. revealed Resident #14 sitting in front of nursing station. Observation revealed his left foot/ leg continuously caused the footrest to swing back and forth causing Resident #14 to slide down in his chair. Resident #14 was observed to lose contact with the footrest and attempt to search for the footrest with his leg/ foot causing Resident #14 to further slide down in his chair. During the observation staff was observed repositioning him back up in his wheelchair but then the process of the leg rest swinging in and out began again with him sliding down in the chair. During the observation he appeared to clench his jaw and facial grimace as he tried to support his positioning; however, because of the left leg rest being broken, he slid down. Review of the facility policy labeled, Personal Property, dated September 2012, revealed the resident's personal belongings shall be inventoried and documented upon admission. The policy revealed the facility would promptly investigate any complaints of misappropriation or mistreatment of resident property. Review of the facility policy labeled, Resident Abuse, last revised 02/01/17, and revealed misappropriation of resident property was the deliberate misplacement, exploitation or wrongful, temporary, or permanent use of resident's belongings without the resident's consent. The policy revealed the abuse coordinator, or his designee shall investigate all reports or allegations. The policy revealed upon completion of the investigation a detailed report shall be prepared. Review of the facility policy labeled, Assistive Devices and Equipment, dated January 2020, revealed the facility maintained and supervised the use of assistive devices and equipment for residents. The policy revealed if residents provide their own assistive devices these items were documented as personal property and made available fir that resident's use only. This deficiency represents non-compliance investigated under Master Complaint Number OH00144102. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365594 If continuation sheet Page 6 of 11 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 365594 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens of Euclid Beach 16101 Euclid Beach Blvd Cleveland, OH 44110 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 interview, observation, record review, and facility policy review the facility did not ensure Resident #14 was transferred by use of a mechanical lift as ordered by the physician, care plan, and State Tested Nursing Assistant (STNA) report sheet. This affected one resident (#14) out of three residents (#14, #25 and #34) reviewed for staff assistance with transfers and had the potential to affect 22 residents (#2, #3 #4, #5, #6, #8, #14, #21, #24, #26, #30, #32, #34, #36, #37, #41, #43, #44, #45, #46, #49, and #54) who required staff assistance with transfers. The facility census was 56. Residents Affected - Few Findings include: Review of the medical record revealed Resident #14 had an admission date of 07/29/22 with diagnoses including Parkinson's disease, diabetes, hemiplegia, and hemiparesis following cerebral infarction affecting left and right side, dementia, and history of falling. Review of the care plan dated 02/03/23 revealed Resident #14 had an activities of daily living deficit related to dementia, impaired balance, frequent falls, epilepsy, and left and right hemiparesis related to cerebrovascular accident. Intervention included transfer with mechanical left with two staff assist. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident 14's cognition was not assessed. He required extensive assist of two staff with bed mobility and was totally dependent of two staff with transfers. He was unable to ambulate, and locomotion of his wheelchair required total dependence of one staff assistance. Review of the July 2023 Physician Orders revealed Resident #14 had a physician order dated 03/03/23 to transfer with a mechanical lift. Review of undated facility form (STNA report sheet) labeled; Crystal [NAME] Important Information revealed Resident #14 was to be transferred with a mechanical lift. Observation on 07/10/23 at 10:01 A.M. revealed STNA #601 assisted Resident #14 out of bed to his wheelchair by placing his wheelchair next to his bed and assisted Resident #14 to stand and pivot to his chair. Interview on 07/10/23 at 10:27 A.M. with STNA #601 verified that she did not realize Resident #14 had a physician order for a mechanical lift and the care plan and STNA report sheet stated to transfer Resident #14 with a mechanical lift. She revealed she had worked at the facility several months and had never transferred Resident #14 with a mechanical lift, and she had always used just one staff assist. Interview on 07/10/23 at 12:36 P.M. with Rehabilitation Director #609 revealed that Resident #14 had a physician order to be transferred with a mechanical lift. He stated, since he had a physician order he should have been transferred in that manner. However, he revealed he felt it also depended on if the STNA was strong and experienced they could possibly transfer Resident #14 with one assist as they had been working with him in therapy, but that it also depended on Resident #14's status, if he was tired and/ or if the staff was not experienced and/ or strong, then he should be transferred with a mechanical lift. He revealed he stated, I know that does not answer the question regarding how (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365594 If continuation sheet Page 7 of 11 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 365594 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens of Euclid Beach 16101 Euclid Beach Blvd Cleveland, OH 44110 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few staff should safely transfer Resident #14 so really, they should go by the physician order and/ or nursing should then decide. Interview on 07/10/23 at 1:56 P.M. with Licensed Practical Nurse (LPN) #606 revealed the STNA's were to go by the STNA report sheet on how residents were to be transferred. She verified Resident #14 had a physician order to transfer with a mechanical lift and that it also stated Resident #14 required a mechanical lift on the STNA report sheet. Interview on 07/10/23 at 4:21 P.M. with the Director of Nursing verified Resident #14 had a physician order to be transferred with a mechanical lift, and that it was identified in the care plan as well as on the STNA report sheet to use a mechanical lift. She revealed that staff should not use discretion instead should follow the physician order, and/ or care plan. Review of the facility policy labeled, Safe Lifting and Movement of Residents, dated July 2017, revealed in order to protect the safety and wellbeing of staff and residents and to promote quality of care the facility used appropriate techniques and devices to lift and move residents. The policy revealed nursing staff in conjunction with rehabilitation staff shall assess individual resident's needs for transfer assistance on an ongoing basis. The policy revealed staff would document needs in the care plan. This deficiency represents non-compliance investigated under Master Complaint Number OH00144102. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365594 If continuation sheet Page 8 of 11 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 365594 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens of Euclid Beach 16101 Euclid Beach Blvd Cleveland, OH 44110 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, record review, and facility policy review the facility did not ensure Resident #14 and Resident #55 had their fall prevention interventions in place as identified in their plan of care and/ or physician orders. This affected two residents (#14 and #55) out of three residents reviewed for falls. The facility census was 56. Findings include: 1. Review of the medical record revealed Resident #14 had an admission date of 07/29/22 with diagnoses including Parkinson's disease, diabetes, hemiplegia, and hemiparesis following cerebral infarction affecting his left and right side, dementia, and history of falling. Review of the care plan last revised 02/03/23 revealed Resident #14 was at risk for injury related to falls due to recurrent falls, balance problem, incontinence, impulsivity with poor safety awareness, risk of medication side effects, diagnosis of epilepsy, left and right hemiparesis due to cardiovascular accident, and dementia. Interventions included bed against the wall, call light within reach, appropriate footwear when transferring, mat to right side of bed, and parameter mattress. Review of the undated facility form labeled State Tested Nurse Aide (STNA) report sheet, [NAME] Important Information revealed Resident #14's wheelchair was to be kept in the hallway. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident 14's cognition was not assessed. He required extensive assistance of two staff with bed mobility and was totally dependent of two staff with transfers. He was unable to ambulate, and locomotion of his wheelchair required total dependence of one staff. Review of the Fall Risk assessment dated [DATE] revealed Resident #14 was at high risk for falls because he had a history of falls, he had diagnoses that placed him at risk for falls, and he overestimated or forgot his limits. Review of the July 2023 physician orders revealed Resident #14 had a physician order dated 08/23/22 to have his wheelchair in the hallway at all times when he was in his bed. Observation on 07/10/23 at 8:05 A.M. revealed Resident #14 was in his bed and his wheelchair was positioned inside his room within Resident #14's eyesight. Observation on 07/10/23 at 10:01 A.M. revealed STNA #601 assisted Resident #14 out of bed to his wheelchair that had continued to be in his room. Interview on 07/10/23 at 10:27 A.M. with STNA #601 verified that Resident #14's wheelchair was in his room at the start of her shift and that it had continued to remain in his room until she got him up at 10:01 A.M. She verified he had a physician order to keep his wheelchair in the hallway because when he sees it, he attempts to get out of bed to get to his wheelchair which then can result in him falling. Interview on 07/10/23 at 4:21 P.M. with the Director of Nursing verified Resident #14 had a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365594 If continuation sheet Page 9 of 11 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 365594 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens of Euclid Beach 16101 Euclid Beach Blvd Cleveland, OH 44110 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few physician order and a fall intervention to keep his wheelchair in the hallway when he was not in the wheelchair as he attempted to try to get out of bed to his wheelchair. 2. Review of the medical record for Resident #55 revealed an admission date of 04/24/23 with diagnoses including traumatic brain injury, diabetes, muscle weakness, aphasia, hemiplegia affecting right dominant side, epilepsy, and repeated falls. Review of the Fall Investigation dated 04/24/23 revealed Resident #55 was found on the floor in the hallway. The long-term intervention listed on the investigation was to add a sign, Call Don't Fall reminder to his room. Review of the Fall Investigation dated 04/29/23 revealed Resident #55 had fallen out of his chair at the nursing station. Resident #55 stated he was trying to lock the locks on his chair, and he leaned to the side too much. The investigation revealed non-slip Dycem (a rubber like surface that was non-slip material used to prevent sliding) was added to his wheelchair seat. Review of the Medicare five-day MDS assessment dated [DATE] revealed Resident #55 had impaired cognition. He required extensive assistance of two staff with bed mobility, transfers, dressing, and toileting. He was unable to ambulate. Review of the care plan dated 05/01/23 revealed Resident #55 was at risk for injury related to falls due to history of frequent falls, impaired cognition with impulsivity and poor safety awareness, gait and balance problems, and diagnoses included traumatic brain injury and right hemiplegia with foot drop. Interventions included call light in reach, a Call Don't Fall sign as a reminder to call for assistance, non-slip Dycem to wheelchair seat, and bedside commode in room. Review of the Fall Risk assessment dated [DATE] revealed Resident #55 was at high risk for falls due to history of falls, he had diagnoses that were high risk for falls, and he overestimated and forgot his limits. Observation and interview on 07/10/23 at 1:26 P.M. revealed Resident #55 were lying in bed in his room. His wheelchair was to the side of his bed without Dycem in place and a sign, Call Don't Fall was not located in his room. Resident #55 then was observed to get into his wheelchair and self-propel to the bathroom without the Dycem to his wheelchair. Interview with Resident #55 revealed he had cognitive impairment and went from subject to subject and could not provide details regarding his falls and/ or fall interventions. Interview on 07/10/23 at 1:56 P.M. with Licensed Practical Nurse (LPN) #606 verified Resident #55 did not have the following fall interventions as identified in his care plan in place: a sign in his room reminding to call for assistance and Dycem in his wheelchair. Interview on 07/10/23 at 4:21 P.M. with the Director of Nursing verified Resident #55 had care planned fall preventative interventions including: Dycem to wheelchair and a sign reminding him not to self-ambulate in his room. Review of the facility policy labeled, Falls- Clinical Protocol, last revised March 2018, revealed for a resident who had fallen the staff and practitioner would begin to try to identify possible causes. The policy revealed based on the assessment the staff and physician would identify pertinent interventions to try to prevent subsequent falls and address the risks of clinically significant (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365594 If continuation sheet Page 10 of 11 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 365594 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens of Euclid Beach 16101 Euclid Beach Blvd Cleveland, OH 44110 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 Level of Harm - Minimal harm or potential for actual harm consequences of falling. The policy revealed the staff and physician would monitor and document the individual's response to interventions intended to reduce falling. This deficiency represents non-compliance investigated under Master Complaint Number OH00144102. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365594 If continuation sheet Page 11 of 11