Inspection·September 13, 2019

F 0585 Level of Harm - Potential for minimal harm Residents Affected - Many Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on record review, observation and interviews, the facility did not ensure the members of Resident Council (Residents #21, #29, #37, #38, #52, #72, #89, #109 ) were well informed and had access to information on how to file an official grievance or complaint with the facility administration. This had the potential to affect all residents in the facility. The facility census was 109. Findings include: Interviews were conducted on 09/11/19 from 10:30 A.M. to 10:59 A.M. with Residents #21, #29, #37, #38, #52, #72, #89 and #109 as part of the Resident Council meeting with the state surveyor during the annual survey. All the residents at the meeting were alert and oriented and actively participated in the meeting. When the residents were asked if they knew how to file a grievance or official complaint with administration, they unanimously responded they did not know how to file a grievance. When the residents were asked if they had seen or knew where to find information on how to file a grievance, they unanimously responded they did not know where to find that information. Record review was conducted of the facility documents titled Resident Council Minutes, dated 09/27/18, 10/28/18, 11/29/18, 12/27/18, 01/31/19, 02/28/19, 03/28/19, 04/25/19, 05/30/19, 06/27/19, 07/25/19 and 08/29/19. There was no evidence in the documents the residents were provided information on how to file a grievance or where to find that information in the facility. An interview and observation were conducted on 09/11/19 from 3:18 P.M. to 3:24 P.M. with the Administrator regarding where the facility posted information on how to file a grievance. The Administrator pointed out a poster in the main entrance hallway. The white poster, measuring approximately 20 inches long by 12 inches wide had printed black font so small it was illegible from a one foot distance. The poster was hung at standing eye level so if a resident was seated in a wheelchair, it could not be read. The small, printed words which addressed multiple topics covered the entire poster and at the very bottom were a few small lines about the name and phone number of the Administrator with instructions to call with any concerns. The Administrator verified the poster was in two locations on the facility walls, were the only postings regarding how to launch a complaint or concerns and was not legible by anyone in a wheelchair or visually challenged due to the placement on the wall and the font size. The Administrator added he was just about to post new information specific to the residents right to know how to file a grievance, and it would be reader friendly and easily accessible to the residents. The Administrator explained he was the Grievance Officer and had no resident representative on the grievance committee. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365691 If continuation sheet Page 2 of 27 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 365691 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mentor Hills Post Acute 8200 Mentor Hills Drive Mentor, OH 44060 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Record review was conducted for Resident #68 who was admitted to the facility on [DATE] with diagnoses including stroke and major depression. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated Resident #68 had cognitive impairment and required extensive assistance of two staff for bed mobility, transfers and toileting. Residents Affected - Many An interview was conducted on 09/10/19 at 10:36 A.M. with Resident #97 who was the room mate of Resident #68. During the annual survey's resident screening process, Resident #97 was asked if she had ever been abused, neglected or made to feel humiliated or degraded by anyone in the facility. Resident #97 responded with I have not, but I reported something that happened to my room mate. She went on to say one of the aides, STNA #829, a few weeks ago told Resident #68 she refused to change her dirty brief and told her she would have to wait until the next shift came on because she did not have time to change her. Resident #97 further explained her room mate sat in a soiled disposable brief from approximately 9:00 P.M. to 11:30 P.M. when the next shift came on and a different STNA finally changed her. Resident #97 said she reported it to RN #830 the next day saying STNA #829 refused to change her room mates soiled brief. Observation and interview was conducted on 09/11/19 at 2:30 P.M. of Resident #68 who asked to be interviewed at a later time due to her wanting to watch television and use the bathroom. Resident #68 appeared calm, clean, free from odors and wetness and had her personal items and call light within reach. An interview was conducted on 09/12/19 at 9:39 A.M. with Resident #68 who was alert and oriented to the conversation. When asked if anyone in the facility had ever made her feel humiliated, degraded or abused she responded that one aide she identified by name as STNA #829 had changed her soiled brief one night. Just after changing her brief Resident #68 had moved her bowels again and put her light on to get help from staff. STNA #829 answered her call light and said to her that she just changed her, she did not have time to change her again and she would have to wait until the next shift came on. Resident #68 stated she felt ashamed and embarrassed and afraid to ask STNA #829 for help from that point forward. Resident #68 mentioned that STNA #829 seemed very stressed out and had been telling her and her room mate that she worked a lot and was tired. Resident #68 said she felt safe in the facility, did not think that STNA #68 meant to abuse her but did leave her sitting in a bowel movement for over one and one half hours until the next shift came on. Resident #68 said she was afraid to refuse care from STNA#829 because she did not want to cause any problems since she was bedridden and totally dependent on staff to care for her. An interview was conducted on 09/12/19 at 12:02 P.M. with RN #830 who verified Resident #97 had reported to her STNA #829 did not provide care to Resident #68 and told Resident #68 she was not going to change her. RN #830 said she did not think it was abusive because that was STNA #829's personality to say things like that to residents and sometimes STNA #829 would tell Resident #68 she had to stop pooping so much. RN #830 revealed she did not report this to the administrator as alleged neglect. An interview was conducted on 09/12/19 at 1:12 P.M. with the Administrator and Director of Nursing (DON) who verified this had not been brought to their attention as a concern until the present day so they would immediately open an investigation related to alleged neglect. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365691 If continuation sheet Page 3 of 27 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 365691 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mentor Hills Post Acute 8200 Mentor Hills Drive Mentor, OH 44060 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many An interview and record review were conducted on 09/13/19 from 9:42 A.M. to 9:48 A.M. with the Administrator who stated he had not yet filed the allegation with the state licensing agency as a Self Reported Incident (SRI) but was going to do so today. The Administrator filed the SRI#180394 at 9:48 A.M. Record review was conducted of the facility document titled Patient Protection. Abuse, Neglect, Exploitation, Mistreatment and Misappropriation Prevention, dated 11/08/16, revealed the facility must identify and thoroughly investigate suspected abuse, neglect, exploitation and misappropriation and report allegations no later than two hours after the allegation is made. Based on record review and staff interview, the facility failed to develop and implement a comprehensive abuse policy and procedure to ensure adequate screening systems were in place for all employees prior to hire. The facility failed to implement their abuse policy to ensure all employees were checked against the Nurse Aide Registry for findings concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property, obtain reference checks and ensure a complete criminal background check log was maintained. This affected 62 employees hired between 08/16/18 and 09/13/19 whose personnel files were reviewed. Also, the facility failed to implement their abuse policy for potential abuse for one resident (Resident #68) of one resident reviewed for abuse. This had the potential to affect all 109 residents residing in the facility. Findings included: 1. Review of personnel files of employees hired between 08/16/18 through 09/13/19 revealed the following employees currently employed did not have record of being checked against the Nurse Aide Registry: Dietary Manager #610, Occupational Therapy Assistant #628, Physical Therapists #625, #642, Dietary Aides #620, #621, #626, #627, #631, #644, #646, General Clerk #632, Cooks #633, #647, #900, and Housekeeping #643. The following employees hired after 08/16/18 and worked at the facility during the time frame between 08/16/18 to 09/13/19 but do not continue to work at the facility did not have record of being checked against the Nurse Aide Registry: Hospitality Aides #802, #815, #816, and Social Service Designee (SSD) #813. Interview on 09/12/19 at 4:52 P.M. with Human Resource Director #700 verified she only checked State Tested Nurses' Aides (STNA's) against the Nurse Aide Registry for findings concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. She revealed she did not know she needed to check all employees prior to hire against the registry. 2. Review of personnel file for STNA #629 with a hire date of 09/26/18 revealed she did not have any reference checks in her record prior to hire. Review of personnel file for Registered Nurse (RN) #616 with a hire date of 05/22/19 revealed she did not have any reference checks in her record prior to hire. Review of personnel file for Licensed Practical Nurse (LPN) #649 with a hire date of 05/22/19 revealed she did not have any reference checks in her record prior to hire. Review of personnel file for Certified Nursing Assistant (CNA) #617 with a hire date of 07/03/19 revealed she did not have any reference checks in her record prior to hire. Interview on 09/12/19 at 4:52 P.M. with Human Resource Director #700 verified RN #616, LPN #649, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365691 If continuation sheet Page 4 of 27 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 365691 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mentor Hills Post Acute 8200 Mentor Hills Drive Mentor, OH 44060 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 0607 STNA #629, and CNA #617 did not have reference checks completed upon hire. Level of Harm - Minimal harm or potential for actual harm 3. Review of form titled, Background Check Tracking Log, revealed the facility's log was only from 03/29/19 to current 09/13/19. Residents Affected - Many Review of personnel files of employees hired between 08/16/18 through 09/13/19 revealed the following employees currently employed were not on the background check log as they were hired from 08/16/18 through 03/29/19 and the facility did not have a log during this time frame that included these employees: RN #636, LPN #623, #630, #637, STNA #622, #629, #634, #635, #638, #639, #640, #641, #645, #648, General Clerk #632, Physical Therapist #642, and Dietary Aide #644. The following employees no longer work at the facility but were hired after 08/16/18 and were not on the background check log: RN #801, #818 LPN #800, #804, #806, #812, #819,#820, Hospitality Aide #802, #815, #816, STNA #803, #805, #807, #809, #810, #811, #814, #817, #821, #822, #824, #825, #826, #827, #828, CNA #808, #823 and SSD #813. Interview on 09/12/19 at 2:51 P.M. with Human Resource Director (HRD) #700 revealed she started March 2019 and discovered the previous background check logs which were hand written were missing. She verified they do not have a background check log from 08/16/18 through 03/29/19. She revealed background checks were completed they just do not have a log for this time period. Interview on 09/13/19 at 7:55 A.M. with the Administrator revealed the previous HRD maintained a handwritten background check log and when she became disgruntled upon separation of the facility the background check log came up missing as well as other items in the personnel files. He verified they did not have a background check log from 08/16/18 through 03/29/19. Review of facility policy titled, Patient Protection Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation Prevention, dated 2016, revealed the facility failed to implement their policy as the facility was to screen employees by checking with previous and current employees, checking state licensing boards for nursing assistants and registries and criminal background check checks to identify and verify any history of abuse, neglect, exploitation, mistreatment or misappropriation of patient property to reduce the risk that no one was hired who was likely to abuse residents. The policy did not identify that all employees must be checked against the Nurse Aide Registry. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365691 If continuation sheet Page 5 of 27 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 365691 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mentor Hills Post Acute 8200 Mentor Hills Drive Mentor, OH 44060 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility failed to report an allegation of neglect for Resident #68 within two hours of the allegation being made. This affected one of two residents reviewed for abuse. The facility census was 109. Findings include: Record review was conducted for Resident #68 who was admitted to the facility on [DATE] with diagnoses including stroke and major depression. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated Resident #68 had cognitive impairment and required extensive assistance of two staff for bed mobility, transfers and toileting. An interview was conducted on 09/10/19 at 10:36 A.M. with Resident #97, who was the room mate of Resident #68. During the annual survey's resident screening process Resident #97 was asked if she had ever been abused, neglected or made to feel humiliated or degraded by anyone in the facility. Resident #97 responded with I have not, but I reported something that happened to my room mate. She went on to say one of the aides, State Tested Nursing Assistant (STNA) #829, a few weeks ago told Resident #68 she refused to change her dirty brief and told her she would have to wait until the next shift came on because she did not have time to change her. Resident #97 further explained her room mate sat in a soiled disposable brief from approximately 9:00 P.M. to 11:30 P.M. when the next shift came on and a different STNA finally changed her. Resident #97 said she reported it to Registered Nurse (RN) #830 the next day saying STNA #829 refused to change her room mates soiled brief. Observation and interview was conducted on 09/11/19 at 2:30 P.M. of Resident #68 who asked to be interviewed at a later time due to her wanting to watch television and use the bathroom. Resident #68 appeared calm, clean, free from odors and wetness and had her personal items and call light within reach. An interview was conducted on 09/12/19 at 9:39 A.M. with Resident #68 who was alert and oriented to the conversation. When asked if anyone in the facility had ever made her feel humiliated, degraded or abused she responded that one aide she identified by name as STNA #829 had changed her soiled brief one night. Just after changing her brief, Resident #68 had moved her bowels again and put her light on to get help from staff. STNA #829 answered her call light and said to her that she just changed her, she did not have time to change her again, and she would have to wait until the next shift came on. Resident #68 stated she felt ashamed and embarrassed and afraid to ask STNA #829 for help from that point forward. Resident #68 mentioned that STNA #829 seemed very stressed out and had been telling her and her room mate that she worked a lot and was tired. Resident #68 said she felt safe in the facility, did not think that STNA #68 meant to abuse her but did leave her sitting in a bowel movement for over one and one half hours until the next shift came on. Resident #68 said she was afraid to refuse care from STNA #829 because she did not want to cause any problems since she was bedridden and totally dependent on staff to care for her. An interview was conducted on 09/12/19 at 12:02 P.M. with RN #830 who verified Resident #97 had reported to her STNA#829 did not provide care to Resident #68 and told Resident #68 she was not going to change her. RN #830 said she did not think it was abusive because that was STNA #829's personality to say things like that to residents, and sometimes STNA #829 would tell Resident #68 she had to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365691 If continuation sheet Page 6 of 27 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 365691 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mentor Hills Post Acute 8200 Mentor Hills Drive Mentor, OH 44060 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stop pooping so much. RN #830 revealed she did not report this to the administrator as alleged neglect. RN #830 said she believed it happened approximately three weeks ago. An interview was conducted on 09/12/19 at 1:12 P.M. with the Administrator and DON who verified this had not been brought to their attention as a concern until the present day so they would immediately open an investigation related to alleged neglect. An interview and record review were conducted on 09/13/19 from 9:42 A.M. to 9:48 A.M. with the Administrator who stated he had not yet filed the allegation with the state licensing agency as a Self Reported Incident (SRI) but was going to do so today. The Administrator filed the SRI #180394 at 9:48 A.M. Record review was conducted of the facility document titled Patient Protection. Abuse, Neglect, Exploitation, Mistreatment and Misappropriation Prevention, dated 11/08/16. The document stated the facility must identify and thoroughly investigate suspected abuse, neglect, exploitation and misappropriation and report allegations no later than two hours after the allegation is made. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365691 If continuation sheet Page 7 of 27 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 365691 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mentor Hills Post Acute 8200 Mentor Hills Drive Mentor, OH 44060 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 - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure accurate assessments regarding hospice for Resident #30. This affected one of two residents reviewed for hospice. The facility census was 109. Residents Affected - Few Findings include: Review of the record revealed Resident #30 was admitted to the facility on [DATE] with diagnoses including spinal stenosis, major depression and depression. The resident was sent to the hospital on [DATE] for increase in pain, returning on 06/29/19. A hospice consult was written on 07/02/19, and the resident was admitted to hospice services on 07/05/19. Review of a significant change Minimum Data Set (MDS) 3.0 assessment dated [DATE] did not indicate the resident was on hospice. An interview with the assessment nurses, Registered Nurses (RN) #613 and RN #614 on 09/11/19 at 8:33 A.M. verified the resident was receiving hospice services, which should have been marked on the significant change assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365691 If continuation sheet Page 8 of 27 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 365691 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mentor Hills Post Acute 8200 Mentor Hills Drive Mentor, OH 44060 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 interview, record review and policy review, the facility failed to implement fall interventions per the comprehensive care plan for Resident #72. This affected one resident (Resident #72) of four residents reviewed for falls and accidents. The facility census was 109. Findings include: Record review for Resident #72 revealed an admission date of 10/05/13 and diagnoses including urinary tract infection, diabetes, psychosis, dementia, muscle weakness and multiple sclerosis. Review of fall investigation dated 07/09/19 at 10:43 A.M. revealed Resident #72 had a fall on 07/09/19 as she was trying to get out of bed to use the restroom. She had no injuries, and the bed bolsters were removed from the bed as intervention. Review of fall investigation dated 08/01/19 at 9:21 A.M. revealed on 07/31/19 Resident #72 returned to the facility and had a fall as she became confused with environmental changes. She was provided frequent redirection as intervention. Review of care plan with a revision date of 08/01/19 revealed Resident #72 was at risk for falls due to unsteady gait, potential medication side effects, cognitive impairment, history of falls and occasional incontinence. Interventions included a bladder diary, provide assistance to transfer and ambulate as needed, and reinforce need to call for assistance. Review of care plan with a revision date of 08/01/19 revealed Resident #72 had urinary incontinence related to disease process of multiple sclerosis, Alzheimer's, and diabetes, impaired mobility, behaviors, non-compliance and medications. Interventions included adjust toileting times to meet patient needs, identify voiding patterns and establish toileting program, provide assistance with toileting, remind and assist as needed with toileting at routine times such as before bedtime with routine care rounds and as needed. Review of significant change Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #72 had impaired cognition and required extensive assist of one person with bed mobility and extensive assist of two persons with transfers. She was unable to ambulate and was frequently incontinent of urine and occasionally incontinent of bowel. Review of nursing note dated 08/27/19 at 11:49 A.M. revealed the nurse went in to Resident #72's room to obtain blood sugar and observed Resident #72 on the floor with her back to the dresser. She had attempted to walk to the bathroom and was soiled with bowel and urine. Review of fall investigation dated 08/29/19 at 1:06 P.M. revealed Resident #72 had a fall on 08/27/19 as she self -transferred herself to the restroom and slipped and fell. She was incontinent of bowel and urine. Intervention per investigation was to complete a bladder diary to verify bladder pattern. Review of form titled, Bladder Diary for Resident #72 revealed the instructions on the bladder diary were to be completed for three successive days. Review of the diary revealed there was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365691 If continuation sheet Page 9 of 27 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 365691 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mentor Hills Post Acute 8200 Mentor Hills Drive Mentor, OH 44060 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 documentation on 08/29/19 from 4:00 P.M. to 10 P.M., 08/30/19 from 6:00 A.M. to 8:00 A.M. and from 4:00 P.M. to 10:00 P.M., and on 08/31/19 from 6:00 A.M. to 2:00 P.M. There was no other documentation. Interview on 09/11/19 at 11:38 A.M. with State Tested Nursing Assistant (STNA) #605 revealed Resident #72 was at risk for falls as she attempted to self-ambulate multiple times as she attempted to toilet herself. She revealed she was confused and did not ring for assistance. She revealed she was not aware of a scheduled toileting program in place. Interview on 09/11/19 at 4:19 P.M. with Registered Nurse (RN) Unit Manager #607 revealed Resident #72 frequently attempts to self-transfer especially to the restroom. She revealed they had implemented a bladder diary after her last fall on 08/27/19 to obtain a voiding pattern and see if there was a change with her voiding pattern to prevent falls as she was attempting to self- transfer to the restroom multiple times. RN Unit Manager #607 verified the bladder diary was to be completed for three days but the bladder diary was incomplete. She verified the facility did not re-evaluate the bladder diary after the bladder diary was to be completed to see that the bladder diary was incomplete or to review for possible voiding pattern or change in voiding pattern to prevent falls. She verified Resident #607 was not on a scheduled toileting program per care plan which had revealed the facility was to identify voiding patterns and establish toileting program. Interview on 09/12/19 at 11:52 A.M. with Licensed Practical Nurse (LPN) #605 revealed Resident #72 gets confused and attempts to self-ambulate. She revealed the staff attempted to remind Resident #72 frequently, but she continued to attempt to self-ambulate, especially to the restroom. Review of facility policy titled, Falls Practice Guide Flowsheet, dated 2011, revealed the facility did not implement their policy to assess, plan, implement, and evaluate fall interventions per comprehensive care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365691 If continuation sheet Page 10 of 27 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 365691 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mentor Hills Post Acute 8200 Mentor Hills Drive Mentor, OH 44060 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide adequate care and treatment to manage diabetes and ensure physician orders were followed related to insulin administration and blood sugar levels. This affected one resident (Resident #57) out of three resident reviewed for blood sugar monitoring. Residents Affected - Few Findings include: Resident #57 was admitted on [DATE] with diagnoses including displaced bimalleolar (ankle) fracture of right lower leg, diabetes mellitus and obesity. A review of resident #57's clinical record indicated a physician order dated 11/08/19 for Humalog insulin (to treat high blood sugar levels), 100 units per milliliter inject 27 units subcutaneously before meals for diabetes mellitus and to hold the administration of the insulin if the blood glucose level was less than 200 milligrams (mg) per deciliter (dL). A review of Resident #57's November 2019 Medication Administration Record (MAR) revealed on 11/10/19 at 8:00 A.M. the blood sugar measured 174 mg/dL, on 11/14/19 at 8:00 A.M. the blood sugar measured 195 mg/dL and on 11/12/19 at 4:00 P.M. the blood sugar measured 128 mg/dL. The nurse initialed on these dates and times indicating the Humalog insulin, 27 units, was subcutaneously administered even though the blood sugar was below 200 mg/dL. A physician order dated 11/14/19 directed nursing staff to administer 27 units of Humalog insulin, 100 units per milliliter, subcutaneously before meals for diabetes mellitus. The insulin was to be held for blood glucose measurement of less than 200 mg/dL. A review of the November 2019 MAR revealed on 11/16/18 at 8:00 A.M. the blood sugar measured 175 mg/dL , at 11:00 A.M. the blood sugar measured 124 mg/dL, and at 4:00 P.M. the blood sugar measured 118 mg/dL, on 11/17/19 at 8:00 A.M. the blood sugar measured 133 mg/dL, at 11:00 A.M. the blood sugar measured 176 mg/dL and at 4:00 P.M. the blood sugar measured 166 mg/dL, on 11/18/19 at 8:00 A.M. the blood sugar measured 176 mg/dL and on 11/19/19 at 11:00 A.M. the blood sugar measured 185 mg/dL. The MAR indicated the nurses initialed the boxes, indicating the Humalog insulin was administered on these dates and times when Resident #57's blood sugar measured less than 200 mg/dL. An interview with Director of Nursing on 11/19/19 at 4:00 P.M. verified the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365691 If continuation sheet Page 11 of 27 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 365691 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mentor Hills Post Acute 8200 Mentor Hills Drive Mentor, OH 44060 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure an accurate pain assessment was completed for Resident #30. This affected one of two residents reviewed for pain. The facility census was 109. Residents Affected - Few Findings include: Review of the record revealed Resident #30 was admitted to the facility on [DATE] with diagnoses including spinal stenosis, major depression and depression. Review of her quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she was moderately cognitively impaired and had no symptoms or complaints of pain. Review of a nursing note dated 06/23/19 at 4:30 P.M. revealed the resident told a staff member that she fell yesterday and had told the other nurse. She denied hitting her head or any injury. Review of the medication administration record and computerized nursing notes dated 06/24/19 at 11:18 A.M. indicated the resident was given Tylenol, two tablets, which was ordered for an elevated temperature. The note indicated the resident refused repositioning or ice packs. Review of another linked medication administration note and computerized nursing note revealed the medication was effective. The record did not contain any further assessment of the reason for the administration of the Tylenol, assessment of the resident regarding an elevated temperature or any other reason that she could have received the Tylenol. Review of an order dated 06/24/19 at 11:59 A.M. revealed x-rays of the lumbar and thoracic spine were ordered stat for diagnostics. Review of a geri-psychiatric note dated 06/24/19 at 1:10 P.M. revealed the resident complained of level 5 pain in her back, and the psychologist explored pain management strategies, especially relaxation techniques. Review of the next nursing note on 06/24/19 at 11:23 P.M. revealed the nurse called the radiology service to see their location and was told they should be in route. A nursing note dated 06/25/19 at 1:49 A.M. revealed the resident was resting in bed with eyes closed. The next note was dated 06/25/19 at 12:38 P.M. and indicated an order was given for a stat x-ray of the lumbar spine and thoracic spine for status two days post fall. The order for that x-ray was entered on 06/25/19 at 12:31 P.M. Review of the x-ray, which was obtained on 06/25/19 (no time given), revealed the resident had multi-level compression deformities, age indeterminate of the lumbar spine and diffuse degenerative intervertebral disc space narrowing of the thoracic spine. The medication administration record indicated the resident received Tylenol on 06/25/19 at 4:32 P.M. for pain of eight on a scale of ten being the worst pain and another dose of Tylenol on 06/25/19 at 10:10 P.M. for pain, again at a level of eight. The record did not initially contain computerized documentation from the nurse practioner or physician regarding the incident of pain, but a handwritten note was provided to the surveyor upon questioning, dated 06/25/19, which indicated the resident had fallen on 06/22/19 with no injury initially, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365691 If continuation sheet Page 12 of 27 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 365691 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mentor Hills Post Acute 8200 Mentor Hills Drive Mentor, OH 44060 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 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few but had increased reports of low back pain, and the resident had refused to get out of bed due to the pain which was described as sharp pain at a level of eight. Review of the record revealed a pain assessment was completed on 06/26/19 which indicated the resident had pain up to a level of ten almost constantly over the past five days over her upper and lower back. The assessment indicated over the counter medication, relaxation and warm or cool compresses were effective. Another handwritten note by the nurse practioner dated 06/27/19 revealed the resident continued with unrelieved pain due to intervertebral disc degeneration, spinal stenosis and compression deformities of the lumbar region with topical relief measures ordered, including Aspercreme, an over the counter pain medication and a medicated pain patch. The resident continued receiving Tylenol and Aspercreme to her back. On 06/28/19 at 9:45 A.M., a note indicated the nurse practioner was notified of uncontrolled pain and the resident was sent to the hospital and admitted for observation, returning on 06/30/19. Licensed Practical Nurse (LPN) #612, who wrote the note regarding the order on 06/25/19, was interviewed on 09/11/19 at 9:00 A.M. She indicated she remembered the resident had increased pain after the fall, and as the resident did not frequently complain of anything, she felt the pain was probably bad if the resident was relaying it to staff. She stated she did not remember hearing anything about the x-ray ordered on 06/24/19, regarding why it was not done, or if there were concerns with the order, but stated she put in a new order stat as ordered by the nurse practioner. She verified she did not document an assessment of the resident regarding the increase in pain. An interview with Resident #30 on 09/11/19 at 9:15 P.M. revealed her in her room slightly confused, but appeared comfortable. She did not remember the fall or how she felt after, but indicated she was comfortable at the time of the interview. An interview with LPN #611 on 09/12/19 at 1:30 P.M. revealed she had medicated Resident #30 on 06/23/19 for complaints of pain to her back. She stated the resident was hurting with every movement, but she verified she did not document an assessment of the pain or it's affect on the resident. She said she called the nurse practioner to let her know about the pain, which seemed to be related to the fall. She verified she was given an order for x-rays. She stated she entered the x-ray orders in the computer, but could not remember for sure if they were ordered as stat or if entering them as stat was a mistake. The nurse who wrote the note on 06/24/19 at 11:23 P.M. no longer worked at the facility and could not be interviewed. An interview with the unit manager, Registered Nurse (RN) #607 on 09/12/19 at 10:15 A.M. verified the record did not contain documentation of any type of pain assessment or notes regarding the resident's condition and the development of pain after the fall on 06/22/19 through 06/26/19. She stated the resident did not have pain until 06/24/19, when she told staff about pain in her back. RN #607 verified the record did not indicate where the resident's pain was, how it was affecting her, or even that the Tylenol was given for pain, as it was ordered for elevated temperature, and a pain level was not indicated on 06/24/19. She verified the order for the x-ray on 06/24/19 was ordered stat meaning it should be done without delay. She verified the the note by the nurse on 06/24/19 at 11:23 P.M. indicated the x-ray had not yet been done, but the record did not indicate the resident's condition (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365691 If continuation sheet Page 13 of 27 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 365691 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mentor Hills Post Acute 8200 Mentor Hills Drive Mentor, OH 44060 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 0697 Level of Harm - Minimal harm or potential for actual harm while she was waiting for the x-ray or reasons why the radiology service did not come to the facility to do the x-ray stat. She verified the medication administration record indicated the resident had pain of a level eight on 06/25/19, but no nursing notes indicated how the pain was affecting the resident or other interventions attempted to help the resident with the pain. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365691 If continuation sheet Page 14 of 27 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 365691 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mentor Hills Post Acute 8200 Mentor Hills Drive Mentor, OH 44060 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 0725 Level of Harm - Minimal harm or potential for actual harm Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on observation, interview and record review, the facility failed to ensure staff were available to meet the needs of residents. This had the potential to affect all 109 residents who resided in the facility. Residents Affected - Many Findings include: 1. The surveyor entered the facility on 09/11/19 at 6:45 A.M. A resident, who identified herself as Resident #20, was sitting in a wheelchair in the lobby. She told the surveyor she was waiting for a bus to pick her up to take her to dialysis and asked the surveyor if she could ask the staff on the 100/200/300 unit to come talk to her about what time the bus was to come. The surveyor walked toward the 100/200/300 unit. The unit was dimly lit and quiet. Staff were noted in the three halls as the surveyor approached. When the surveyor walked toward the large nursing station desk, a staff member, later identified as State Tested Nursing Assistant (STNA) #617, was noted behind the approximately four foot high wall around the desk, sitting in a chair with her head on the desk. The surveyor stated to the staff member, Excuse me, and Good morning, and the employee did not raise her head. The surveyor walked around the desk, toward the 200 hall, where a nurse was walking toward the nursing station. The nurse, Registered Nurse (RN) #615, walked toward the surveyor and into the nursing station and after asked about Resident #20, stated she didn't know details about the transportation and went into the medication room. STNA #617 was still sitting at the desk with her head down as RN #615 walked by her. The surveyor walked down the 100 hall toward a nurse, RN #616. She stated she would check on Resident #20's transportation and walked toward the nurse's station with the surveyor. STNA #617 was still at the desk with her head down, but as RN #616 and the surveyor walked away, she was noted to sit up in her chair and stretch her arm as if she was waking up. The surveyor returned to the unit on 09/11/19 at 6:55 A.M. STNA #617 was in the hall. She verified she had been sitting at the desk previously and may have fallen asleep, but said she had been on break. She said she probably should have taken her break in another area. An interview with RN #615 at 6:58 A.M. revealed she was unaware of the breaks taken by STNA #617 because she was not assigned to her hall and stated she had not seen her sleeping at the desk. She verified she had walked through the nurse's station, and saw STNA #617 sitting there, but didn't notice that she was sleeping. She verified employees should not sleep at the desk. An interview with RN #616 at 7:05 A.M. revealed she did not see STNA #617 sleeping desk. She said she was not assigned to her hall. She stated she had talked to STNA #617 in the past about sleeping on her breaks. She verified employees should not sleep at the desk. An interview with Licensed Practical Nurse (LPN) #618 on 09/11/19 at 7:10 A.M. revealed STNA #617 was assigned to his unit. He said she had breaks earlier in the shift, and although she had taken out the trash around 6:30 A.M., he had not been told she was taking a break and verified she should not have been sleeping at the desk. He stated he did not witness this, as he was at the end of the hall passing medications. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365691 If continuation sheet Page 15 of 27 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 365691 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mentor Hills Post Acute 8200 Mentor Hills Drive Mentor, OH 44060 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 0725 Level of Harm - Minimal harm or potential for actual harm Review of the facility policy on on meal and rest breaks, dated 09/19/18, revealed meal breaks should be taken in an area away from their normal work station if possible. The observation was verified with the Director of Nursing on 09/11/19 at 8:45 A.M. She verified STNA #617 should not have been sleeping at the nursing station desk. Residents Affected - Many 2. An interview with Resident #12 on 09/09/19 at 10:07 A.M. revealed he felt the facility could use more staff. An interview with Resident #38 on 09/09/19 at 10 :40 A.M. revealed delays in call light response at times. An interview with Resident #60 on 09/09/19 at 1:02 P.M. revealed she had to wait for her call light to be answered for over an hour at times. An interview with Resident #22 on 09/09/19 at 1:26 P.M. revealed she had long waits for call lights and thought staffing had been decreased recently. An interview with the Director of Nursing on 09/11/19 at 8:45 A.M. confirmed residents had concerns with staffing and call light response times. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365691 If continuation sheet Page 16 of 27 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 365691 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mentor Hills Post Acute 8200 Mentor Hills Drive Mentor, OH 44060 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure Resident #84 was free of significant medication error as he received the incorrect pain medication on medication administration observation. This affected one resident (Resident #84) of eight residents reviewed for medication administration. The facility census was 109. Residents Affected - Few Findings include: Record review for Resident #84 revealed an admission date of 08/09/19 and diagnoses that included lower abdominal pain, osteomyelitis of vertebra lumbar region, chronic kidney disease and osteoarthritis. Review of care plan for Resident #84 dated 08/09/19 revealed he had pain to his back related to osteomyelitis of his thoracic vertebrae. Interventions included offer re-positioning, cold pack to the area, quiet environment, warm liquids to promote comfort and administer pain medications per physician orders. Review of Resident #84's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he had intact cognition and was on a scheduled pain medication regimen. He had pain present with a pain intensity score listed as an eight per the MDS. Review of Nurse Practitioner #830's progress note dated 09/09/19 revealed Resident #84 had chronic pain with a seven out of ten on the pain scale. He had pain radiating around his trunk of his body towards his abdomen. She recommended to discontinue Resident #84's Oxycodone (narcotic pain medication) and start Percocet (narcotic pain medication) 5-325 milligram (mg) two tablets three times a day. Review of Resident #84's physician order dated 09/09/19 revealed he had an order for Percocet Tablet 5-325 milligram (mg) give two tablets by mouth three times a day at 9:00 A.M., 2:00 P.M., and 9:00 P.M. for chronic spinal osteomyelitis for 14 days. He did not have an order for Oxycodone on his physician orders. Observation of medication pass by Licensed Practical Nurse (LPN) #600 on 09/11/19 at 8:19 A.M. with Resident #84 revealed she administered Oxycodone Hydrochloride five mg by mouth with water. Review of nursing note written by LPN #600 dated 09/11/19 at 8:46 A.M. for Resident #84 revealed she completed a pain evaluation prior to medication administration, and his pain was a seven out of ten on the pain scale with stabbing in his right flank and back. Resident #84 stated it can shoot to a ten if he moves. She administered his Oxycodone per routine order. Interview on 09/11/19 at 8:56 A.M. with LPN #600 verified she gave the wrong medication to Resident #84. She verified she gave Resident #84 Oxycodone five mg instead of administering Percocet 5-325 milligram two tablets per physician order. Review of nursing note written by LPN #600 dated 09/11/19 at 9:02 A.M. revealed Resident #84 received Oxycodone 5 mg this morning instead of his two Percocet as ordered. The physician was notified, and family were notified. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365691 If continuation sheet Page 17 of 27 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 365691 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mentor Hills Post Acute 8200 Mentor Hills Drive Mentor, OH 44060 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 0760 Level of Harm - Minimal harm or potential for actual harm Review of facility policy titled, Medication and Treatment Administration Guidelines, dated 2018, revealed the nurses were to administer medications in accordance with following rights of medication administration including right medication, and right dose. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365691 If continuation sheet Page 18 of 27 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 365691 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mentor Hills Post Acute 8200 Mentor Hills Drive Mentor, OH 44060 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview and record review, revealed the facility failed to ensure medications were dated when opened prior to use affecting Residents #36 and #78. This affected one resident (Resident #78) of eight residents reviewed for medication administration and one cart with undated medications for Resident #36 and #78 of four medication carts reviewed for medication storage and labeling. The facility census was 109. Findings include: 1. Observation of medication administration on 09/09/19 at 5:10 P.M. with Licensed Practical Nurse (LPN) #601 revealed she administered Resident #78's Timolol Maleate (glaucoma eye drop medication) 0.5 percent one drop to each eye. The Timolol Maleate bottle was not dated when opened and was not in the manufactures box. The expiration date on the bottle was unable to be located. Interview on 09/09/19 at 5:13 P.M. with LPN #601 verified the Timolol Maleate eye medication was not dated, and she was unsure when the bottle was opened. She verified she did not have the box the medication came in. She verified the eye drops should have been dated when they were opened. 2. Observation on 09/11/19 at 1:38 P.M. of the 300- hall cart with LPN #602 revealed Resident #36 had an opened undated Lantus (insulin) 100 units per milliliter vial in the medication cart. LPN #602 verified the vial was not dated, and she verified Lantus was only good for 28 days after the vial was opened. She revealed she did not know when the vial was opened. Resident #78 continued to have the same eye medication drop bottle- Timolol Maleate 0.5 percent solution in the cart opened and undated and unable to read the expiration date on the bottle, and the bottle was not in the manufactures box or the manufactures box in the cart. LPN #602 verified Resident #78's eye drops were opened and undated. Review of manufacture guidelines insert for Lantus revealed the insulin was good for 28 days after it was opened or until the expiration date on the bottle, whichever came first. Review of facility policy labeled, Storage and Expiration Dating of Drugs, Biologicals, Syringes, and Needles revealed the facility did not follow their policy as nursing staff should record the date opened on the medication container when the medication had a shortened expiration date once opened. The facility should, once any drug was opened, follow the manufactures guidelines with respect to expiration dates for opened medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365691 If continuation sheet Page 19 of 27 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 365691 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mentor Hills Post Acute 8200 Mentor Hills Drive Mentor, OH 44060 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review and interview, the facility failed to ensure food was served at an appetizing temperature and acceptable palatability. This had the potential to affect 106 residents who received meals in the facility. The facility identified Residents #23, #51 and #59 as receiving no food from the kitchen. The facility census was 109. Residents Affected - Many Findings include: An interview conducted on 09/09/19 at 10:42 A.M. with Resident #38 revealed the food sits too long on the delivery cart and was cold whenever it was delivered. An interview was conducted on 09/09/19 at 12:06 P.M. with Resident #373 who revealed she received burnt toast everyday it is on the menu, the eggs were served cold regularly, and the foods that are suppose to be hot are never hot. Resident #373 added the food being cold had caused her to not want to eat, and she knew she had lost weight because of it. An interview conducted on 09/09/19 at 1:45 P.M. with Resident #10 revealed the food served to her in her room was cold when it should be hot, the soup was only lukewarm, and the macaroni and cheese was usually cold. An interview was conducted on 09/09/19 at 1:48 P.M. with Resident #366 who revealed her eggs are always served cold, the cream of wheat is always served to her cold and the toast is always burnt on one side. An interview was conducted on 09/09/19 at 3:10 P.M. with Resident #97 who revealed the pork and beef were usually too tough to chew, and hot foods were not served hot. Resident #97 explained she received an early breakfast at 7:00 A.M. most days, and the oatmeal was always served cold to her, and she had come to expect the hot foods would not be served hot. An interview was conducted on 09/09/19 at 5:21 P.M. with Resident #4 who revealed food was not hot when served to her in her room. An interview was conducted on 09/10/19 at 9:15 A.M. with Resident #70 who reported the vegetable soup served on 09/09/19 was served cold, the cauliflower that was suppose to be served hot had been served cold to her, and she had requested a grilled chicken sandwich that was also served cold. An interview was conducted on 09/11/19 at 9:09 A.M. with Resident #4 who revealed the eggs served on a breakfast tray to the resident's room tasted cold. Observation of the lunch meal on 09/10/19 at 11:01 A.M. of [NAME] #609 as she checked the temperatures of the food prior to food service revealed the spaghetti was 196 degrees Farenheit (F), and the meat sauce was 210.9 degrees F. The Italian vegetables were 167 degrees F. The garlic bread had been taken out of the oven and was in stainless steel container on the top of the steam table. Juice was placed on the resident trays after it was obtained from an open reach-in cooler near the serving line. The cooler door remained open throughout the tray service. Tray service for the dining room and hall trays began at 11:32 A.M. The surveyors observed the last tray cart for hall trays for the 600 unit completed at 12:40 P.M., (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365691 If continuation sheet Page 20 of 27 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 365691 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mentor Hills Post Acute 8200 Mentor Hills Drive Mentor, OH 44060 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 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many and a test tray was requested and placed on the cart. The cart was moved to the 600 hall, arriving at 12:47 P.M. The last tray was passed to residents, and the test tray was removed at 12:52 P.M. and taken to a small coffee room with two surveyors and Dietary Manager (DM) #610. DM #610 checked the temperatures of the food as the surveyor tasted the food for temperature and palatability. The spaghetti and meat sauce temperature was 137.5 degrees F and tasted lukewarm. The Italian vegetables temperature was 122.7 degrees F and tasted cool. The garlic bread was room temperature, having been placed on the plate with the hot food, but was slightly tough. The orange juice tasted cool and the temperature was 58.3 degrees F. DM #610 verified the food would not be hot, based on the temperatures obtained but declined to taste the food. She also verified the juice had been obtained from an open cooler in the refrigerator. She stated the facility had started keeping milk in ice tubs separate from the meal trays, but verified the juice, which had been obtained from the refrigerator that was kept open and then transported in the closed cart, was not on ice prior to service. She verified the food should taste hot when served. A test tray was completed for the breakfast meal on 09/11/19 at 7:15 A.M. based on resident complaints of food temperatures for breakfast. [NAME] #609 had already checked the temperatures of the food on the steam table. The scrambled eggs temperature was 184 degrees F, and the cream of wheat was 198 degrees F. Toast was observed in a stainless steel container on the top of the steam table. Meal trays started for the dining room at 7:20 A.M. During observation of the preparation of meal carts for the floor, [NAME] #609 indicated that she needed to make more toast. She put bread through a toasting machine, but approximately nine pieces of toast were burned and discarded. [NAME] #609 indicated that it was difficult to regulate the temperature controls of the toaster to obtain toast that was toasted lightly but not burned. She indicated she had written toaster on a white board where supplies and food items were marked that were needed or needed to be ordered. She indicated it was well known that the toaster was difficult to use and verified the delay in trying to get the right amount of brown toast that was not burned often delayed the food line. The surveyors observed the last tray made for the last cart for the 600 unit and requested a test tray. The cart left the kitchen at 8:04 A.M. and arrived on the unit at 8:06 A.M. The last tray was served at 8:19 A.M. The test tray was removed to the coffee room to check temperatures with [NAME] # 609 at 8:20 A.M. The scrambled eggs temperature was 118 degrees F and the cream of wheat temperature was 109.6 degrees F. The eggs tasted lukewarm, and the cream of wheat was cool. The toast was toasted darkly, and the outside edge was rimmed with a dark streak that tasted burned. Cook #609 declined to taste the food but verified based on the temperatures, the food would not be hot. She also verified the toast was darkly toasted and had a dark edge that could be burned. An interview with DM #610 on 09/11/19 at 9:15 A.M. verified the concerns identified during the breakfast meal service with temperatures. She denied knowledge of on-going concerns related to food temperatures. She stated the facility had been checking food temperatures and had had no concerns. She also indicated she was unaware of any concerns related to the toaster or any resident complaints of burned toast. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365691 If continuation sheet Page 21 of 27 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 365691 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mentor Hills Post Acute 8200 Mentor Hills Drive Mentor, OH 44060 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 0804 Level of Harm - Minimal harm or potential for actual harm Review of the facility policy dated September 2014 regarding food temperatures at point of service, revealed food should be palatable, attractive and at the proper temperature as determined by the type of food to ensure the patient's satisfaction. It also indicated patient acceptance should be used a guide. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365691 If continuation sheet Page 22 of 27 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 365691 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mentor Hills Post Acute 8200 Mentor Hills Drive Mentor, OH 44060 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure pureed foods were prepared in the appropriate consistency affecting Resident #55. This affected one resident (Resident #55) out of seven residents with pureed consistency diet texture and had the potential to affect 106 residents receiving meals from the kitchen excluding Resident #23, #51, and #59 as they received nothing by mouth. Finding included: Record review for Resident #55 revealed an admission date of 06/28/18 with diagnoses including cerebrovascular disease, dementia with behavioral disturbances, and aphasia following cerebral aphasia. Review of care plan dated 07/08/18 revealed Resident #55 was at nutritional and hydration risk related to swallowing difficulty related to terminal condition of Alzheimer's. Interventions included report signs and symptoms of diet texture intolerance, and encourage and assist as needed to consume foods and fluids. Review of significant change Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #55 had impaired cognition and required extensive assist of one person with eating. She had a mechanically altered diet. Review of nutritional assessment dated [DATE] revealed Resident #55 had a pureed diet texture with moderate thick liquids. She had functional problems affecting her ability due to her swallowing and inability to perform activities of daily living without significant physical assistance. She had dementia and required a mechanically altered diet. Review of physician orders for September 2019 revealed Resident #55 had a diet order for pureed texture. Interview on 09/09/19 at 11:58 A.M. with Resident #55's sister revealed she comes in everyday to assist Resident #55 with her lunch and several times the pureed consistency was not appropriate as there was chunks in the puree, and the puree was not blended thoroughly. She revealed the corn and peas often contain the shells and skins, and one time there was a piece of [NAME] in the puree meat. She revealed she was concerned her sister may choke and had brought up her concern to the facility several times. Observation of Resident #55 on 09/11/19 at 8:57 A.M. who was assisted by State Tested Nursing Assistant (STNA) #608 with her breakfast revealed the eggs appeared to have lumps and did not appear in a smooth puree consistency. STNA #608 verified the eggs had lumps and were not of smooth consistency. STNA #608 revealed she had other issues with the pureed food not being of appropriate consistency especially with the meats as she had previously found chunks of meat in the pureed food. She revealed she usually went through the pureed food with a fork and removed any chunks out of the meat or attempted to mash up the pureed food further. Interview on 09/11/19 at 11:38 A.M. with STNA #605 revealed she had issues previously with the pureed texture not being the correct consistency. She revealed about two weeks ago she had to take back eggs to the kitchen because they were regular scrambled eggs and not pureed. She revealed this had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365691 If continuation sheet Page 23 of 27 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 365691 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mentor Hills Post Acute 8200 Mentor Hills Drive Mentor, OH 44060 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 0805 happened a few times. Level of Harm - Minimal harm or potential for actual harm Observation on 09/12/19 at 8:22 A.M. revealed Resident #55 received her tray, and the eggs were in regular scrambled texture not pureed. Residents Affected - Few Interview on 09/12/19 at 8:29 A.M. with [NAME] #609 verified the eggs on Resident #55's tray were regular scrambled eggs and not pureed. Interview on 09/12/19 at 2:44 P.M. with Dietitian #619 verified the cook had revealed Resident #55 received regular scrambled eggs instead of pureed eggs. She verified Resident #55 had a diet order to have pureed texture and the eggs were to be in pureed texture. Review of facility policy titled, Pureed Diet, dated 2019 revealed the facility did not follow the policy as the pureed texture was to be used for patients with swallowing and chewing difficulties designed for residents with moderate to severe dysphagia. Pureed foods should be smooth in texture and free of whole, minced, or ground pieces. Scrambled eggs and all other eggs were to be in pureed texture. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365691 If continuation sheet Page 24 of 27 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 365691 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mentor Hills Post Acute 8200 Mentor Hills Drive Mentor, OH 44060 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, record review and interview, the facility failed to maintain a clean and sanitary kitchen area. This had the potential to affect 106 residents who received meals in the facility. The facility identified Resident #23, #51 and #59 as receiving no food from the kitchen. The facility census was 109. Findings include: Observation of the kitchen during the initial tour with Dietary Manager (DM) #610 on 09/09/19 between 9:35 A.M. and 10:20 A.M. revealed three reach-in coolers and one reach-in freezer across from the steam table with food debris and dirt build up around the doors and door seals. Dried spills, splashes and dirt build up was observed on the outside doors of the three reach-in coolers and one reach-in freezer. Dried brown residue and brown dirt build-up was observed around the dispenser nozzles and drainage catchers of the two coffee makers. Food debris, dried spills, and brown dirt build-up were observed on surfaces and in corners and crevices, and on the sides of the two red and five black service carts. The floor in the dry storage room was observed to have numerous large spots of dirt build-up and food debris underneath the food storage racks, including a bag of potato chips, packages of crackers, an unused coffee filter, two sugar packets, a package containing an object for knife storage, and a snack package of cookies. A large amount of ice build-up was observed inside the walk-in freezer on the fan located on the back wall. The walk-in freezer and walk-in cooler floors were observed to have food debris, dirt, and dirt build-up. A substance was observed on the walk-in cooler floor which caused an adherence with shoes when walked upon. Interview with DM #610 during the kitchen tour confirmed all observations. Review of facility procedures, dated September 2014, entitled Daily Cleaning Schedule - Example, revealed the dry storage room, walk-in cooler, walk-in freezer, work stations, equipment and utility carts were to be swept, cleaned and/or sanitized daily. Review of facility procedures, dated September 2014, entitled Weekly Cleaning Schedule - Example, revealed the reach-in coolers (including gaskets), coffee maker, dry storage room floor, walk-in cooler floor, walk-in freezer floor, walk-in cooler & freezer gaskets were to be swept, mopped, cleaned or deep cleaned weekly. Review of facility procedures, dated September 2014, entitled Monthly/As Needed Cleaning Schedule Example, revealed the floors, walk-in cooler, dry storage room, and walk-in freezer were to be cleaned or deep cleaned monthly or as needed. Review of pest control report dated 08/02/19 from an outside company revealed a recommendation to remove accumulation of food product from damaged goods, and packets of crackers and other packaged food off of the food pantry floor to prevent ant activity. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365691 If continuation sheet Page 25 of 27 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 365691 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mentor Hills Post Acute 8200 Mentor Hills Drive Mentor, OH 44060 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 0838 Level of Harm - Potential for minimal harm Residents Affected - Many Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Based on record review and interview, the facility did not develop a staffing plan to support the acuity needs on the Facility Assessment according to the regulation requirements. This had the potential to effect all residents living in the facility. The facility census was 109. Findings included: A record review was conducted of the Facility Assessment with the Administrator on 09/13/19 from 10:11 A.M. to 10:19 A.M. In the section titled General Staffing Guidelines for nursing there were no specifications for how many direct care licensed nurses or state tested nursing assistants (STNA) were needed to meet acuity needs of the resident population. That section identified one, full-time Director of Nursing, three full-time unit nurse managers and four other nurses administrative positions were needed but left the remaining information regarding licensed direct care nurses and STNA blank. The Facility Assessment was last updated on 09/06/19. An interview was conducted on 09/13/19 at 10:19 A.M. with the Administrator who verified the section General Staffing Guidelines for nursing were incomplete. The Administrator stated he would make sure that information was added to the Facility Assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365691 If continuation sheet Page 26 of 27 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 365691 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mentor Hills Post Acute 8200 Mentor Hills Drive Mentor, OH 44060 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** Based on observation, interview and record review, the facility failed to ensure Resident #74's indwelling urinary Foley catheter (a flexible tube into the bladder to drain urine) drainage bag and catheter drainage emptying spout was not touching the floor. This affected one resident (Resident #74) of one resident reviewed with an indwelling urinary Foley catheter. This had the potential to affect 15 residents that had urinary Foley catheters at the facility. Residents Affected - Few Findings include: Record review for Resident #74 revealed an admission date of 08/03/19 with diagnoses including urinary tract infections, sepsis, neuromuscular dysfunction of the bladder and multiple sclerosis. Review of care plan dated 08/03/19 for Resident #74 revealed he had an indwelling urinary catheter due to the diagnosis of neurogenic bladder. Review of admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #74 had impaired cognition and required extensive assist of two persons with bed mobility, transfers and toileting. He was unable to ambulate and had an indwelling catheter. Observation on 09/09/19 at 11:08 A.M. revealed Resident #74 was in bed with his bed in a low position. He had an indwelling urinary Foley catheter drainage bag and catheter emptying drainage spout both touching the floor without a dignity pouch. Interview on 09/09/19 at 11:10 A.M. with State Tested Nursing Assistant (STNA) #603 verified Resident #74's catheter drainage bag and emptying drainage spout was touching the floor. Observation on 09/10/19 at 10:32 A.M. revealed Resident #74 was in bed with his bed in a low position. He had an indwelling urinary Foley catheter drainage bag and catheter emptying drainage spout both touching the floor without a dignity pouch. Interview on 09/10/19 at 10:34 A.M. with Licensed Practical Nurse (LPN) #604 verified Resident #74's catheter drainage bag was on the floor as well as the catheter emptying drainage spout was not in the holder on the bag and was touching the floor. Review of undated facility policy titled, Catheter Care: Indwelling Catheter revealed the facility did not follow their policy as staff were to check that the tubing was not kinked, looped, clamped, or positioned above the level of the bladder and not on the floor. The staff was to place the drainage bag in a catheter dignity bag. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365691 If continuation sheet Page 27 of 27