Inspection·August 15, 2023

F 0921 The above observation was verified by the Director of Nursing (DON) on 08/15/23 at 11:50 A.M. Level of Harm - Minimal harm or potential for actual harm -Resident #18's room had several wheel tread scuff marks on the floor, holes in the wall along the base of the wall by the sink area, and rusty and broken heating vents. The bathroom vent located on the ceiling had a thick layer of dust with a rusty heating vent, torn/stained wallpaper, and gouges in the wood on the bathroom door. Residents Affected - Some - Resident #19's room had a sticky floor with dull dark stains and the heating vent was rusty and broken. The bathroom had peeling paint, stained floor tiles and gouges in the wood of the door. An interview with Resident #19 at the time of the observation revealed he tried not to look around his room and when laying in bed. Resident #19 stated he would only look at the ceiling or television to avoid observing the areas of the room in need of repair. - Resident #26's room had gouges in the bathroom door, heating vent covers falling off the wall, and damaged torn wallpaper on every wall of the room. An interview with Housekeeper (HK) #60 on 08/15/23 at 11:55 A.M. revealed the facility was in need of many repairs and there had been no major repairs completed in the resident rooms and common areas on the second floor of the facility. The floor scrubber was in need of repair for several months and the floors could not be cleaned properly. HK #60 stated Maintenance Director (MD) #61 was not able to complete all the work due to the amount of work needed in the facility. HK #60 confirmed the facility was in a general state of disrepair. HK #60 verified the above observations of Resident #18's, Resident #19's, Resident #26's room. - Resident #8's room had heating vents falling off the wall, gouges in the doors of the clothing closet and chipped tiles on the floor. An interview with Resident #8 at the time of the observation on 08/15/23 at 12:09 P.M. revealed she had noticed ants crawling on her sink and there was black mold located on the wall by her bed which the facility had covered with a square of plastic material. -Resident #23's room had peeling wallpaper with black stains along the wall above the floor molding, dull scuffed stained floors, gouges in the wood of the bathroom door, molding on the base of the wall along the floor was pulled away from the wall. -The hallway for room numbers 260 to 271 had two missing wood strips on the post and wall by the recreation room. - The four common hallways had ground in stains, with damaged molding along the base of the walls, and had several areas of damaged, peeling wallpaper. -The activity room had a dull, sticky floor. - An interview with Resident #3 on 08/15/23 at 12:10 P.M. indicated he had resided in the facility for one year and seven months and there had been no major changes in the appearance of the facility during his stay at the facility. - On 08/15/23 at 12:15 P.M. and interview with State Tested Nursing (STNA) #62 verified Resident #2's room had paint chipping with the bare plaster exposed on the walls, damaged, stained wallpaper, gouges in the wood of the bathroom door, rusty heating vent and the bathroom floor was dull with ground in stains. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365594 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 365594 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2023 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some - Resident #38's room had a sticky floor, wallpaper and molding was damaged, chipped tiles on the floor, gouges in the wood of the bathroom door, and the tiles on the floor at the entrance of the bathroom had been replaced with gaps in the seams between the tiles. An interview with Resident #38 on 08/15/23 at 12:17 P.M. revealed he had lived in the facility for one year and there had been little change regarding repairs of the facility and his room. - Resident #43's room had peeling wallpaper, gouges in the wood of the bedroom door, and curtains falling off the curtain rod. - There were gouges in the wood of Resident #31's, Resident #8's, Resident #48's, Resident #28's, Resident #58's, and Resident #1's bedroom doors. - Resident #32's and Resident #57's room had damaged walls and floors. - Resident #14's room had peeling, stained wallpaper. - Resident #52's room had missing floor molding and peeling wallpaper. An interview with STNA #63 on 08/15/23 at 12:25 P.M. verified the observations of Resident #38's, Resident #43' Resident #32's Resident #14's and Resident #52's room. STNA #63 stated she had worked in the facility for one year and there had been no major repairs completed in the resident rooms. - Resident #56's room had curtains falling off the rod. - Resident #36's room had the heating vents falling off the wall, bedside table damaged with gouges, chips of wood missing. - Resident #42's room had stained, sticky bathroom floor and gouges in the wood of the bathroom door and paint chipping on the frame of the bathroom door. - Resident #25's room had missing molding under the heating vent with debris accumulated under the heating vent. An interview with Assistant Director of Nursing (ADON) #64 on 08/15/23 at 12:50 P.M. verified the observation in Resident #56's, Resident #36's, Resident #42's and Resident #25's room. An interview with MD #61 on 08/15/23 at 2:26 P.M. indicated he was hired during the month of 04/2023 and the previous maintenance director had not maintained the work orders accurately to determine what repairs needed completed in the facility. MD #61 indicated he was unable to complete all the repairs and renovation projects in the building due to the amount of repairs needed and additional emergent repairs that had priority over the general repair needs in the facility. MD #61 stated the facility had a crew of maintenance workers from their sister facilities come in to assist for a short period of time to assist with repairing the floor tiles around the nursing station located on the second floor. MD #61 stated the amount of work needed to complete all the repairs needed in the facility was overwhelming. MD #61 confirmed the facility was generally in a state of disrepair. MG #61 stated he was only able to handle so much work at one time. MD #61 stated it was impossible for one person to complete all the repairs needed in the building. MD #61 indicated he had informed the Administrator of the need for additional maintenance personnel to assist with the major and minor repairs in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365594 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 365594 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2023 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the facility. MD #61 indicated the facility needed to obtain estimates from an outside company and then obtain approval from the owner. MD #61 stated he had not had time to call the outside companies to have estimates completed for the required repair projects. An interview with Housekeeping Director (HD) #65 on 08/15/23 at 2:56 P.M. indicated the facility had a floor scrubber which needed repaired since 04/2023 and had completely stopped working approximately three weeks ago. HD #61 stated the facility was currently awaiting delivery of a new floor scrubber. HD #65 agreed the facility needed many repairs. This deficiency represents non-compliance investigated under Complaint Number OH00145395 and is an example continued non-compliance from the surveys dated 07/26/23, 06/22/23, and 04/06/23. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365594 If continuation sheet Page 4 of 4