Inspection·September 19, 2022

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the care plan for Resident #51 indicated the resident required the assistance of one staff for daily hygiene, grooming, dressing, oral care, and eating as needed. The resident also required assistance of two staff for transfers. Observation of Resident #51 on 09/12/22 at 12:01 P.M., the call light cord was observed hanging from the wall down to the floor. Interview with LPN #408 on 09/12/22 at 12:09 P.M. confirmed the call light cord for Resident #51 was hanging from the wall down to the floor. LPN #408 secured the call light cord to the resident's bed. Resident #51 was asked if she could access her call light cord and was able to activate the call light by pulling gently on the cord. 3. Review of the medical record for Resident #74 revealed an admission date of 11/09/18 with diagnoses including congestive heart failure, anxiety, unspecified dementia with behavioral disturbance, mild cognitive impairment, and articular cartilage disorder of the left hand. Review of the MDS 3.0 quarterly assessment dated [DATE] revealed Resident #74 had moderate to severe cognitive impairment, had impaired memory, problem solving, judgement, and safety awareness. The MDS assessment also revealed the resident required extensive assistance for most activities of daily living related to general weakness, impaired mobility, and poor safety awareness. Review of Resident #74's care plan revealed the resident required assistance from one staff member for daily hygiene, grooming, dressing, oral care, and eating as needed. The resident required assistance of two staff for bed mobility and Hoyer (mechanical) lift transfers. Observation of Resident #74 on 09/12/22 at 2:37 P.M. revealed the call light cord was observed attached to the bedding on the left lateral side of the mattress, near the bed frame. Resident #74 was informed where his call light was located and was asked to activate the call light. Resident #74 was lying supine in the bed and attempted to roll onto his left side to access the call light cord. The resident was unable to reposition himself in the bed to reach the call light cord. Interview with Nurse Aide #434 on 09/12/22 at 2:42 P.M. confirmed the call light cord was placed on Resident #74's bed in a location not accessible to the resident. Nurse Aide #434 repositioned and reattached the call light cord on Resident #74's bedding near the right side of his chest. Resident #74 was informed where the call light cord was positioned and was asked if he was able to pull the call light cord. The resident was able to locate and pull the call light cord to activate the call light. 4. Review of medical record for Resident #53 revealed an admission date of 11/27/12 and a readmission date of 07/29/22 with diagnoses including end stage renal disease, hemiplegia and hemiparesis following cerebral infarction affecting the right side, unspecified dementia without behavioral disturbance, anxiety, heart failure, and muscle weakness. Review of the MDS 3.0 quarterly assessment dated [DATE] for Resident #53 revealed the resident was rarely/never understood, required extensive assistance to complete activities of daily living. Review of Resident #53's care plan dated 09/09/22 revealed the resident had expressed interest in some activities but preferred to stay in bed for comfort. The resident required assistance of two staff for mobility, transfers with use of a Hoyer lift, locomotion, dressing, toileting, and hygiene. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365691 If continuation sheet Page 2 of 17 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 09/19/2022 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 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Observation of Resident #53 on 09/12/22 at 2:37 P.M. revealed the call light cord was observed hanging from the wall down to the floor. Interview with Nurse Aide #434 on 09/12/22 at 2:42 P.M. confirmed the call light cord for Resident #53 was hanging from the wall down to the floor. Nurse Aide #434 secured the call light cord to the resident's bedding near his chest. Resident #53 was asked if he was able to access the call light cord. The resident was not able to perform this task during the interview. Event ID: Facility ID: 365691 If continuation sheet Page 3 of 17 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 09/19/2022 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 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Based on record review, interview, and review of shower sheets revealed the facility failed to provide showers/bed baths as preferred. This affected two (Resident's #19 and #80) of five residents reviewed for showers. The facility census was 95. Findings include: 1. Review of the medical record for Resident #19 revealed an admission date of 12/27/19. Diagnoses included type two diabetes mellitus with diabetic nephropathy and major depressive disorder. Resident #19 had intact cognition. Interview on 09/12/22 at 10:20 A.M., Resident #19 stated she does not receive showers on a regular basis. Review of the shower sheets revealed Resident #19 received five showers in August and September 2022. Staff did not provide any documented evidence indicating the resident refused showers. Review of progress notes revealed no documented evidence related to Resident #19 refusing showers. 2. Review of the medical record for Resident #80 revealed an admission date of 06/23/21. Diagnoses included unspecified dementia and altered mental status. Resident #19 had intact cognition. Review of the shower sheets revealed Resident #80 received five showers in August and September 2022. Interview on 09/15/22 at 11:45 A.M., the Charge Nurse #405 verified the missing documentation indicating the residents received showers as preferred. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365691 If continuation sheet Page 4 of 17 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 09/19/2022 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on record review, observations, and interviews the facility failed to maintain a sanitary environment. This affected nine (Resident's #9, #19, #27, #32, #36, #67, #68, #69 and #81) of 51 residents residing on the 200/300 hall. The facility also failed to clean wheelchairs. This affected five (Resident's #15, #34, #56, #62 and #84) of 59 residents who utilize wheelchairs. The facility census was 95. Findings Include: 1. Review of the medical record for Resident #9 revealed an admission date of 02/26/22. Diagnoses included adult failure to thrive, diabetes mellitus, and major depressive disorder. Resident # 9 had intact cognition. Review of the medical record for Resident #19 revealed an admission date of 12/27/19. Diagnoses included type two diabetes mellitus with diabetic nephropathy and major depressive disorder. Resident #19 had intact cognition. Review of the medical record for Resident #27 revealed an admission date of 09/16/18. Diagnoses included bipolar disorder and anxiety disorder. Resident # 27 had intact cognition. Review of the medical record for Resident #32 revealed an admission date of 07/09/21. Diagnoses included unspecified dementia and heart failure. Resident # 32 had impaired cognition. Review of the medical record for Resident #36 revealed an admission date of 10/27/21. Diagnoses included type two diabetes mellitus with diabetic polyneuropathy, falls, and anxiety disorder. Resident #36 had intact cognition. Review of the medical record for Resident #67 revealed an admission date of 11/11/21. Diagnoses included major depressive disorder and migraines. Resident #67 had intact cognition. Review of the medical record for Resident #68 revealed an admission date of 05/12/22. Diagnoses included muscle weakness and age-related cognitive decline. Resident #68 had intact cognition. Review of the medical record for Resident #69 revealed an admission date of 08/12/22. Diagnoses included anxiety disorder and congestive heart failure. Resident #69 had intact cognition. Review of the medical record for Resident #81 revealed an admission date of 07/01/15. Diagnoses included multiple sclerosis and unspecified dementia. Resident #81 had impaired cognition. Initial observations on 09/12/22 from 11:25 A.M. through 12:35 P.M. revealed Resident's #9, #19, #36, #68, #69 and #81's room had debris covering the floor including food and paper. Observations on 09/12/22 at 3:09 P.M. revealed rooms for Resident's #9, #19, #36, #68, #69 and #81 were still dirty. Interview on 09/14/22 at 4:30 P.M., Licensed Practical Nurse (LPN) #406 verified the rooms for Resident's #9, #19, #68 and Resident #69 were dirty. Observations on 09/12/22 at 4:42 P.M. revealed Resident's #27, #32, #36, #67 and #81 room floors (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365691 If continuation sheet Page 5 of 17 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 09/19/2022 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 0584 had debris covering the floor including food and paper. Level of Harm - Minimal harm or potential for actual harm Interview on 09/14/22 at 4:30 P.M., LPN #409 verified the rooms for Resident's #27, #32, #36, #67 and #81 remained dirty. Residents Affected - Some Interview on 09/14/22 at 5:50 P.M., the Administrator stated the facility was currently looking for a housekeeping supervisor and two housekeepers. The Administrator stated she knew there were concerns with housekeeping services due to lack of staff. The Administrator stated they sometimes utilized aides to clean the rooms. 2. Observation on 09/12/22 at 2:00 P.M. during smoke break revealed five (Resident's #15, #34, #56, #62 and #84) had cigarette ashes and other debris on all horizontal surfaces of their wheelchairs. Interview on 09/12/22 at 2:05 P.M. with the Resident Assessment Coordinator (RAC) #417 and Licensed Practical Nurse (LPN) #415 confirmed Resident's #15, #34, #56, #62 and #84 had cigarette ashes and other debris on the horizonal surfaces of their wheelchairs. RAC #417 and LPN #415 revealed wheelchairs were to be cleaned on night shift and no one held night shift accountable to ensure wheelchairs were cleaned. Interview with the Administrator on 09/15/22 at 11:44 A.M. revealed housekeeping and night shift aides were to clean wheelchairs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365691 If continuation sheet Page 6 of 17 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 09/19/2022 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, review of the facility self-reported incident (SRI), and review of the facility policy the facility failed to ensure staff to resident verbal abuse did not occur. This affected one (Resident #50) of three residents reviewed for abuse. The facility census was 95. Findings include: Review of Resident #50's medical record revealed an admission date of 06/07/19 with diagnoses including idiopathic normal pressure hydrocephalus, dementia with behavioral disturbances, and hemiplegia (weakness) and hemiparesis (paralysis) following cerebral infarction affecting the left non-dominant side. Review of Resident #50's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #50 was cognitively intact and required extensive assistance of one staff for toilet use. Resident #50 was occasionally incontinent of urine and always incontinent of bowel. Resident #50 answered yes when questioned regarding feeling down, depressed, or hopeless, and had trouble falling or staying asleep, or sleeping too much. Review of Resident #50's care plan dated 08/11/22 included Resident #50 had bowel incontinence related to impaired mobility, impaired cognition, behaviors, and use of stool softeners. Interventions included Resident #50 would be maintained in as clean and dry dignified state as possible. Review of Resident #50's progress notes on 08/21/22 at 8:22 P.M. authored by Licensed Practical Nurse (LPN) #504 stated around 6:45 P.M. Resident #50 opened the door to his room. There was copious amount of bowel movement smeared all over the floor. Resident #50 went through his feces spreading it along down the hall, then he covered some of the feces with towels. When the nurse asked what happened, Resident #50 stated, I had an accident. I had a diarrhea. The feces didn't have a loose consistency. The incident was repetitive (the second day on a row), and the resident didn't have any sense of wrongdoing. Review of the facility SRI tracking number 225670, dated 08/21/22, included the second shift nurse (LPN #409) reported that a third shift nurse (Registered Nurse (RN) #402) verbally abused Resident #50. The Administrator received a message that LPN #409 wanted to report that RN #402 was verbally abusive to Resident #50 after he had an accident with bodily fluids. Review of the Witness Statement for RN #402, dated 08/24/22, revealed she thought she needed to contact a lawyer and would call back to provide a statement. Review of the Witness Statement for State Tested Nurse Aide (STNA) #425, dated 08/22/22 at 12:16 A.M., stated she arrived for work at 11:00 P.M. and was told by the second shift staff there was a mess in Resident #50's room. STNA #425 wrote there was feces all over Resident #50's room, including the walls and hall, on his wheelchair and on his person. STNA #425 stated RN #402 and I got upset and we can't leave patient room that way, and where is patient supposed to sleep? Resident #50 was told to wait in the hall numerous times while his room was being cleaned. Review of the Witness Statement for LPN #409, dated 08/24/22, stated she heard RN #402 tell (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365691 If continuation sheet Page 7 of 17 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 09/19/2022 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #50 his room was disgusting, and Resident #50 responded you are not my mom. RN #402 responded I am glad I am not your mom because your mom wouldn't want to clean up after you. RN #402 told Resident #50 he needed to stay in his room. LPN #409 heard RN #402 continuously talking over Resident #50 while he was trying to talk to her. RN #402 kept saying OK goodnight over and over. Observation on 09/15/22 at 10:30 A.M. of Resident #50 revealed he was sitting in a wheelchair near the nurse's station. Resident #50 was pleasant and answered questions. Resident #50 stated he did not remember any staff members talking to him in a rude manner. Interview on 09/15/22 at 2:06 P.M. with the Administrator revealed on 08/21/22 an incident occurred around the time of the transition from second shift to third shift. Resident #50 had an accident around 11:00 P.M. and the second shift STNA stated to leave the feces which was all over the bathroom and Resident #50's room for the day shift to clean up. The Administrator stated RN #402 was upset the STNA said to wait for day shift to clean up Resident #50's room, got loud, and stated we are not going to do that, the bowel movement needs cleaned now. RN #402 was yelling at the staff because she was upset, and LPN #409 thought RN #402 was yelling at Resident #50. The Administrator stated the statements from other staff members who were present during the incident did not indicated RN #402 was inappropriate towards Resident #50. The Administrator stated Resident #50 did not state RN #402 was mean or rude to him. Interview on 09/15/22 at 2:37 P.M. with LPN #504 revealed on 08/21/22 she worked second shift and Resident #50 had a bowel movement, and it was smeared all over the toilet bowl, the bathroom, and Resident #50's room including the floor. LPN #504 stated when the bathroom door opened it further smeared the bowel movement on the floor. LPN #504 stated Resident #50 covered the bowel movement with towels. LPN #504 stated after Resident #50 had the bowel movement he left his room and went to the dining room and bowel movement was noted on the floor in the hall. LPN #504 indicated she could not remember for sure but thought Resident #50 had the accident between 7:00 P.M. and 10:00 P.M. LPN #504 stated the second shift staff covered the bowel movement with towels but did not clean the bowel movement from the bathroom. LPN #504 stated I cannot say we cleaned everything, no we did not. LPN #504 indicated the bowel movement was noted on Resident #50's bed also. LPN #504 revealed 08/21/22 was a very busy night, there was not enough staff, and the residents residing on the hall Resident #50 resided on required a lot of help. LPN #504 stated she did not know who was going to clean up the mess and if it was going to be like that all night. Interview on 09/15/22 at 3:00 P.M. with LPN #409 revealed on 08/21/22 Resident #50 was in the hall and LPN #409 stated she heard RN #402 say she did not want Resident #50 out of his room. LPN #409 indicated RN #402 did not like Resident #50 out of his room because he gets on her nerves. LPN #409 stated she heard RN #402 tell Resident #50 she did not want to see him out here, she told him his room was disgusting, and Resident #50 stated well you are not my mother. RN #402 said I am glad I am not your mother, and your mother would not want to clean up after you. LPN #409 stated she felt bad for Resident #50 and heard STNA #425 tell Resident #50 he better go to his room because he knew how RN #402 was when he was out in the hall. LPN #409 stated STNA #512 was standing at the desk acting like it was ok for Resident #50 to be talked to that way. LPN #409 stated RN #402 was mad at Resident #50. LPN #409 stated a week earlier RN #402 told Resident #50 to go to his room, he was trying to talk to her, and RN #402 kept saying OK goodnight like ten times, like what he was saying did not mean anything, and get in your room I don't want to see you the rest of the shift. Interview on 09/15/22 at 3:10 P.M. with LPN #406 indicated LPN #406 could not remember the date but LPN #406 heard RN #402 very loudly talking to Resident #50 in a rude way and telling Resident #50 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365691 If continuation sheet Page 8 of 17 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 09/19/2022 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 0600 to go, go, go to your room, go, go. Level of Harm - Minimal harm or potential for actual harm Interview on 09/16/22 at 11:50 A.M. with RN #402 revealed on 08/21/22 she cleaned up the mess from Resident #50 but did not remember anything else. Residents Affected - Few Review of the facility policy titled Abuse, Neglect, and Intimate Partner Violence Inservice, dated 01/2019, included verbal abuse was defined as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to patients or their families, or within hearing distance, regardless of their age, ability to comprehend, or disability. It was the responsibility of every employee to be aware of possible signs of abuse and neglect and report concerns or suspicions to the supervisor immediately. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365691 If continuation sheet Page 9 of 17 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 09/19/2022 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 0602 Protect each resident from the wrongful use of the resident's belongings or money. Level of Harm - Minimal harm or potential for actual harm Based on record review, self-reported incident (SRI) review, and interview the facility failed to secure narcotics to prevent misappropriation. This affected two (Resident's #85 and #291) of 31 residents receiving narcotic medications. The facility census was 95. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #85 revealed an admission date of 02/18/22. Diagnoses included benign neoplasm of peripheral nerves and autonomic nervous system of the face, head, and neck, chronic pain syndrome, and schizoaffective disorder. Resident #85 had intact cognition. Review of the physician orders dated February through April 2022 revealed Resident #85 was ordered oxycodone 5 milligrams (mg) (opioid pain medication) 02/18/22 through 02/20/22. Review of the medication administration record (MAR) February through April 2022 revealed Resident #85 did not receive any oxycodone in March and April 2022. Review of SRI tracking number (#) 220000 dated 04/05/22 revealed facility staff observed two missing narcotic cards holding 30 pills of oxycodone 5 milligrams (mg). Two staff were counting the narcotics at shift change when the missing medications were revealed. Staff contacted the Director of Nursing (DON), and the facility initiated an investigation. 2. Review of the medical record for Resident #291 revealed an admission date of 04/07/17. Diagnoses included migraine without aura and major depressive disorder. Resident #291 had intact cognition. Review of the physician orders revealed Resident #291 was ordered oxycodone 5 mg from 04/01/22 through 04/07/22. Review of SRI #219997 dated 04/05/22 revealed facility staff observed one missing narcotic card holding 30 pills of oxycodone 5 mg. Two staff were counting the narcotics at shift change when the missing medications were revealed. Staff contacted the DON, and the facility initiated an investigation. The first shift nurse Alleged Perpetrator (AP) #600 left the facility without speaking with the unit managers. Interview on 09/13/22 at 10:50 A.M., the DON stated the narcotic medications for Resident #85 were discontinued on 02/20/22; however, staff did not remove the narcotic cards from the narcotic box until 04/05/22. The medications for Resident #291 were current due to physician order. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365691 If continuation sheet Page 10 of 17 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 09/19/2022 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to complete a Preadmission Screening and Record Review (PASARR) after a new serious mental disorder diagnosis. This affected one (Resident #51) of three resident records reviewed. The facility census was 95. Findings include: Review of the medical record for Resident #51 revealed an admission date of 08/12/13, and a re-admission date of 02/03/20 with diagnoses including chronic obstructive pulmonary disease, dementia with behavioral disturbance, dysarthria and anarthria, acute and chronic respiratory failure, schizoaffective disorder bipolar type, weakness, anxiety, bipolar disorder, current episode mixed, severe, with psychotic features, and mild cognitive impairment. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] for Resident #51 revealed the resident had moderate cognitive impairment, required limited to extensive assistance to complete activities of daily living related to the resident's physical limitations, impaired mobility, and pain. Review of the care plan for Resident #51 indicated the resident required the assistance of one staff for daily hygiene, grooming, dressing, oral care, and eating as needed. The resident also required assistance of two staff for transfers. A review of the medical records for Resident #51 revealed a new order, dated 07/06/22, to add a new diagnosis of schizoaffective disorder, bipolar type. The order was written by Nurse Practitioner #528. Medical records were absent of an updated PASARR for Resident #51 to coincide with the new diagnosis. The psychiatric assessment progress notes for Resident #51 dated 07/06/22 was absent of reference to the new diagnosis. Interview with Social Services Aide #466 on 09/13/22 at 11:27 A.M., it was reported a new PASARR should have been completed for Resident #51 due to the new diagnosis of schizoaffective disorder, bipolar type. In an interview with Registered Nurse (RN) #417, the MDS Nurse, on 09/13/22 at 11:39 A.M., confirmed Resident #51 was given a new diagnosis of schizoaffective disorder, bipolar type on 07/06/22. RN #417 verified there was no PASARR completed after the resident was given the new diagnosis on 07/06/22. Interview with the Director of Nursing (DON) on 09/14/22 at 9:46 A.M., confirmed there was no reference to the new diagnosis of schizoaffective disorder, bipolar type on the psychiatric assessment progress note dated 07/06/22 for Resident #51. Interview via telephone with Nurse Practitioner #528 on 09/15/22 at 11:19 A.M., confirmed Resident #51 received a new diagnosis of schizoaffective disorder, bipolar type on 07/06/22. Nurse Practitioner #528, while viewing the resident's records during the telephone conversation, reported she had failed to update the resident's records with the new diagnosis, and stated her assessment notes from the visit with Resident #51 on 07/06/22 did not reflect the new diagnosis. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365691 If continuation sheet Page 11 of 17 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 09/19/2022 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities 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 timely complete an initial Preadmission Screening and Record Review (PASARR) for one (Resident #51) of three resident records reviewed. The facility census was 95. Residents Affected - Few Findings include: Review of the medical record for Resident #51 revealed an admission date of 08/12/13, and a re-admission date of 02/03/20 with diagnoses including chronic obstructive pulmonary disease, dementia with behavioral disturbance, dysarthria and anarthria, acute and chronic respiratory failure, schizoaffective disorder bipolar type, weakness, anxiety, bipolar disorder, current episode mixed, severe, with psychotic features, and mild cognitive impairment. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] for Resident #51 revealed Resident #51 had moderate cognitive impairment, required limited to extensive assistance to complete activities of daily living related to the resident's physical limitations, impaired mobility, and pain. Review of care plan for Resident #51 indicated the resident required the assistance of one staff for daily hygiene, grooming, dressing, oral care, and eating as needed. The resident also required assistance of two staff for transfers. A record review for Resident #51 on 09/13/22 revealed there was no PASARR on file before 04/05/22. Interview with Social Services Aide #466 on 09/14/22 at 3:33 PM confirmed there was no PASARR on file in the electronic health records, nor the physical hard copy health records, for Resident #51 other than the PASARR dated 04/05/22. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365691 If continuation sheet Page 12 of 17 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 09/19/2022 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on record review, interview, and policy review the facility failed to assess residents before and after dialysis treatments. This affected one (Resident #36) of seven residents requiring dialysis. The facility census was 95. Residents Affected - Few Findings include: Review of the medical record for Resident #36 revealed an admission date of 10/27/21. Diagnoses included dependence on renal dialysis, falls, and anxiety disorder. Resident #36 had intact cognition. Review of the physician's orders for September 2022 revealed Resident #36 was to receive dialysis every Monday, Wednesday, and Friday. Review of the dialysis communication sheets and progress notes revealed the facility staff did not assess Resident #36 before and after dialysis treatments. Interview on 09/15/22 at 9:44 A.M., the Administrator and Director of Nursing stated facility staff were to assess the resident before and after dialysis and verified the missing documentation. Review of the undated facility policy titled Dialysis Guidelines revealed facility staff were to assess the resident before and after receiving dialysis treatments. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365691 If continuation sheet Page 13 of 17 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 09/19/2022 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 - Some 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 record review, observations, and interviews the facility failed to date and or document name on insulin vials/Kwik pens after opening. This affected six (Resident's #9, #18, #19, #36, #37 and #55) of 12 residents who required insulin. The facility census was 95. Findings include: 1. Review of the medical record for Resident #9 revealed an admission date of 02/26/22. Diagnosis included diabetes mellitus. Resident # 9 had intact cognition. Review of the physician orders revealed an order dated 08/21/22 for a Humalog mix 75/25 Kwik pen. 2. Review of the medical record for Resident #18 revealed an admission date of 06/23/21. Diagnosis included type two diabetes mellitus. Resident # 18 had intact cognition. Review of the physician orders revealed an order dated 06/28/22 for glargine insulin solution. 3. Review of the medical record for Resident #19 revealed an admission date of 12/27/19. Diagnoses included type two diabetes mellitus with diabetic nephropathy. Resident #19 had intact cognition. Review of the physician orders revealed an order dated 03/09/22 for glargine insulin solution. 4. Review of the medical record for Resident #37 revealed an admission date of 07/05/22. Diagnosis included type one diabetes mellitus. Resident # 37 had intact cognition. Review of the physician orders revealed an order dated 09/08/22 for insulin Lispro cartridge and insulin glargine solution pen-injector dated 7/22/22. Observations on 09/14/22 at 11:33 A.M. revealed opened vials and used Kwik pens that were not dated, two Kwik pens had no name or date. Interview immediately after observations, Licensed Practical Nurse (LPN) #412 verified the findings. 5. Review of the medical record for Resident #36 revealed an admission date of 10/27/21. Diagnoses included type two diabetes mellitus with diabetic polyneuropathy. Resident # 36 had intact cognition. Review of the physician orders revealed an order dated 08/24/22 for Lantus Solostar pen-injector and Basaglar pen-injector. 6. Review of the medical record for Resident #55 revealed an admission date of 01/31/22. Diagnosis included diabetes mellitus due to underlying condition. Resident # 55 had intact cognition. Review of the physician orders revealed an order dated 08/31/22 for Basaglar Kwik pen and Lispro pen-injector dated 09/01/22. Observations on 09/14/22 at 11:47 A.M. revealed four used Kwik pens that were not dated. Interview (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365691 If continuation sheet Page 14 of 17 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 09/19/2022 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 immediately after observations, LPN #410 verified the findings. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365691 If continuation sheet Page 15 of 17 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 09/19/2022 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 and interview the facility failed to maintain a clean and sanitary environment in the kitchen. This had the potential to affect all 95 residents provided food and beverages from the facility. The facility census was 95. Findings include: Observations on 09/12/22 from 10:10 A.M. to 10:24 A.M. during the initial tour of the kitchen with Dietary Manager #458 revealed the overhead vents above the grill top were greasy and dusty as was the back ledge behind the grill top, the light bulbs above the grill top, and the fire extinguisher nozzles. Inside the microwave was dirty. The sanitizer in one of the sanitizer buckets wasn't at a high enough concentration to be effective. The sanitizer was used for wiping down the counters. The ceiling had areas that were dirty/dusty. These findings were verified by Dietary Manager #458 at the time of the observations. On 09/14/22 at 12:20 P.M. [NAME] #454 used a gloved hand to reach into an open bag and place hamburger buns on the resident's plates. Use of a serving utensil was required. On 09/14/22 at 12:22 P.M. Dietary Manager #458 confirmed the cook was not using a utensil for the hamburger buns. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365691 If continuation sheet Page 16 of 17 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 09/19/2022 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, record review, and interview, the facility failed to ensure staff performed adequate hand hygiene during the provision of personal care for residents. This affected two (Resident's #20 and #51) of three residents observed for personal care. The facility census was 95. Residents Affected - Few Findings include: Review of the medical record for Resident #20 revealed an initial admission date of 11/21/19, and a re-admission date of 01/31/20 with diagnoses including hemiplegia and hemiparesis of the left non-dominant side, mild cognitive impairment, and dysphagia. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] for Resident #20 revealed the resident had moderate to severe cognitive impairment, required assistance with daily hygiene and oral care related to cerebral vascular accident- left sided hemiparesis. Review of the care plan for Resident #20 indicated the resident required assistance to bathe/shower, and daily hygiene, grooming, dressing, oral care, and eating as needed. The resident also required the assistance of two staff for bed mobility. Review of the medical record for Resident #51 revealed an admission date of 08/12/13, and a re-admission date of 02/03/20 with diagnoses including chronic obstructive pulmonary disease, dementia with behavioral disturbance, dysarthria and anarthria, acute and chronic respiratory failure, schizoaffective disorder bipolar type, weakness, anxiety, bipolar disorder, current episode mixed, severe, with psychotic features, and mild cognitive impairment. Review of the MDS 3.0 quarterly assessment dated [DATE] for Resident #51 revealed the resident had moderate cognitive impairment, required limited to extensive assistance to complete activities of daily living related to the resident's physical limitations, impaired mobility, and pain. Review of the care plan for Resident #51 indicated the resident required the assistance of one staff for daily hygiene, grooming, dressing, oral care, and eating as needed. The resident also required assistance of two staff for transfers. During an observation of incontinence care for Resident #20 on 09/14/22 at 3:39 P.M., Nurse Aide #521 was observed gathering supplies to perform incontinence care. Nurse Aide #521 was observed donning gloves prior to performing care. Proper technique was observed during the incontinence care as evidenced by maintaining one clean hand during care. Poor infection control technique was observed as Nurse Aide #521 used dirty gloves after the completion of incontinence care to redress Resident #20 and rearrange the resident's bedding. Nurse Aide #521 then disposed of the soiled brief and doffed her gloves. Nurse Aide #521, without performing hand hygiene, repositioned the cohabitating resident's television, Resident #51. The nurse aide also assisted Resident #51 by repositioning the bed and placing the bed remote into Resident #51's hand. Nurse Aide #521 exited the residents' room without performing hand hygiene. In an interview with Nurse Aide #521 on 09/14/22 at 3:58 P.M. confirmed proper hand hygiene was not performed while providing incontinence care for Resident #20, hand hygiene was not performed prior to assisting Resident #51, and hand hygiene was not performed prior to exiting the residents' room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365691 If continuation sheet Page 17 of 17