Inspection·June 5, 2025

F 0774 Help the resident with transportation to and from laboratory services outside of the facility. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and facility policy review, the facility failed to ensure transportation to and from a planned physician appointment for Resident #94. This affected one (Resident #94) of three residents reviewed for transportation assistance. The facility census was 95. Residents Affected - Few Findings include: Review of the medical record revealed Resident #94 was admitted to the facility on [DATE]. Medical diagnoses included malignant neoplasm of right lung, malignant neoplasm of lower right lung, cerebrovascular disease, hypertension, vertigo, hyperlipidemia, anxiety, major depression, gastro esophageal reflux, and abnormal gait. Review of facility document dated 03/25/25, revealed Resident #94 was to have an appointment on 05/02/25 for a CT (computed tomography) of the chest, abdomen, pelvis and a Radiation Oncology appointment to establish a new patient. In addition, on 05/08/25 Resident #94 was to have an appointment with Hematology and Oncology to establish Resident #94 and infusion therapy. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #94's cognition was intact. Supervision was needed to transfer from bed to chair. Resident #94 did not have pain at present and life expectancy was not less than six months. Resident #94 received chemotherapy. Review of the care plan dated 04/19/25 revealed Resident #94 was at risk for complications related to the administration of chemotherapy. Interventions included encouraging fluids, following up with oncologist/hematologist, administering medication as ordered and monitoring for signs of activity intolerance such as fatigue, shortness of breath, pallor or cyanosis, vertigo, weakness. Review of facility document title Appointment Information dated 05/08/25 revealed Resident #94 was scheduled for a Hematology and Oncology visit for small cell right Atezolizumab (immunotherapy) infusion; but Resident #94 was documented as not seen. Review of facility Appointment Calendar dated May 2025, revealed Resident #94 was scheduled on 05/02/25 for an appointment with transportation, but no appointments were scheduled on 05/08/25. Review of Resident Grievance Form, dated 05/13/25, revealed Resident #94 had a concern regarding a missed appointment. Investigation findings revealed the appointment was missed due to transportation error. The resolution revealed the appointment was rescheduled. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 365691 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 06/05/2025 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)