Inspection·February 20, 2020

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to develop comprehensive care plans for Resident #34 related to transmission-based precautions and for Resident #54 related to a wanderguard. This affected two of 18 residents reviewed for care plans. Findings include: 1. Record review of Resident #34 revealed a re-entry date of 01/04/20. Diagnoses included congestive heart failure and amputation of right toes. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition, required extensive assistance of two staff for bed mobility and transfers, and was totally dependent on two staff for toilet use. Resident #34 was always incontinent of bowel and bladder and was not on isolation precautions. Review of the nursing notes dated 01/19/20 at 4:19 P.M. revealed Resident #34 was acting slightly sluggish and eating little. The physician was notified of his condition and tests were ordered including a stool sample. Review of the laboratory results for a stool sample collected on 01/19/20 revealed results dated 01/20/20 indicating Resident #34 was positive for Clostridium difficile (C. diff). An inflammation of the colon caused by C. diff bacteria. A physician order dated 1/20/20 at 7:27 P.M. revealed Vancomycin HCl solution (an antibiotic), 25 milligrams (mg) per milliliter (ml), 125 mg by mouth four times a day was ordered as an antibiotic for 10 days for the C. diff. Review of the physician orders for February 2020 revealed no orders for transmission base precautions, but revealed orders for Vancomycin HCl capsule, 125 milligrams (mg) by mouth, two times a day for diarrhea for seven days until 02/24/20. And a physician order for Vancomycin HCl capsule, 125 mg by mouth, once a day for seven days for diarrhea until 03/02/20. Review of Resident #34's current care plan contained no information related to the need for transmission-based precautions for C. diff. Interview of 02/18/20 at 11:06 A.M. with Licensed Practical Nurse (LPN) #430 revealed Resident #34 was on transmission-based precautions for C. diff. Observation at that time revealed a cart with drawers outside of Resident #34's room but no sign indicating transmission-based precautions. Review of Resident #34's care plan on 02/19/20 at 3:25 P.M. with the Director of Nursing verified there was no care plan in place for Resident #34 related to transmission-based precautions for C. diff. 2. Record review of Resident #54 revealed an admission date of 04/29/19. Diagnoses included dementia without behavioral disturbance, vascular dementia without behavioral disturbance, and mixed receptive-expressive language disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition, required staff supervision with set-up help only for bed mobility, transfers, and toilet use and used a wander guard alarm daily. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365702 If continuation sheet Page 2 of 7 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 365702 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE O'Neill Healthcare Middleburg Heights 7250 Old Oak Blvd Middleburg Heights, OH 44130 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the Elopement Data Tool assessment dated [DATE] revealed Resident #54 had a history of wandering per family and history, a diagnosis of dementia, and a wanderguard was put in place. Review of the nursing notes dated 4/29/19 at 3:21 P.M. revealed Resident #54 was admitted to the facility after being found wandering into her neighbors' yards and was admitted to the hospital for change in mental status and alcohol abuse. Resident #54 was alert and oriented to herself only and very pleasant. Resident #54 has a wander guard in placed to the right ankle to prevent her from leaving the facility unassisted. Review of Resident #54's February 2020 physician orders were silent for the use of a wanderguard. Review of the current care plan revealed no information related to the use of a wanderguard. Observation on 02/18/20 at 2:14 P.M. revealed Resident #54 walking around the facility wearing a wanderguard to her right ankle. Interview on 02/19/20 at 2:50 P.M. with Registered Nurse (RN) #342 revealed he checked to ensure Resident #54's wanderguard was in place and working. RN #342 stated Resident #54 wandered around the facility but did not have exit seeking behaviors. Interview and review of the Resident #54's care plan on 02/19/20 at 3:25 P.M. with the Director of Nursing verified there were no physician orders or care plan for Resident #54's wanderguard. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365702 If continuation sheet Page 3 of 7 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 365702 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE O'Neill Healthcare Middleburg Heights 7250 Old Oak Blvd Middleburg Heights, OH 44130 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the closed medical record for Resident #680 revealed an admission date of [DATE] with diagnoses of acute respiratory failure, acute and chronic kidney failure, atrial fibrillation (rapid/irregular heart rate), and kidney dialysis. The care plan dated [DATE] revealed an advance directive for a full code status to be implemented and communicated to staff. Review of the nurse's note dated [DATE] at 7:30 P.M. revealed Resident #680 was found unresponsive by a State Tested Nursing Assistant (STNA). The nurse was unable to get a pulse, heart rate and vitals. A note at 7:45 P.M. indicated the Administrator, physician, Power of Attorney and family were notified. The funeral home was contacted to come for Resident #680. The nursing notes lacked pertinent information regarding all care and treatment provided to Resident #680, including if cardiopulmonary resuscitation (CPR) was initiated, as the resident was a full code. Review of the Physician Discharge summary dated [DATE] revealed Resident #680 had sepsis, multiple hospitalizations and a complicated pressure ulcer. The cause of death was cardiopulmonary arrest (heart stopped) and the resident was discharged to the funeral home. The summary contained no information to indicate resuscitation measures, including CPR, were attempted. Interview with Licensed Practical Nurse #451 on [DATE] at 4:44 P.M. revealed the nurse aide notified him that Resident #680 was unresponsive. LPN #451 stated he went into the room and immediately started CPR and 911 was called. He said emergency responders took over CPR and care when they arrived at the facility. Interview with the Director of Nursing on [DATE] at 4:54 P.M. verified the above findings and verified the medical record did not accurately reflect all care and treatment provided to Resident #680, including CPR. Based on observation, record review and interview, the facility failed to ensure accurate and complete documentation in the medical records for Residents #34 and Resident #680. This affected two residents (#34 and #680) of 18 residents whose medical records were reviewed. Findings include: 1. Record review of Resident #34 revealed a re-entry date of [DATE]. Diagnoses included (congestive) heart failure, amputation of right toes, and infectious disease. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition, required extensive assistance of two staff for bed mobility and transfers, and was totally dependent on two staff for toilet use. Resident #34 was always incontinent of bowel and bladder and was not on isolation precautions. Review of the nursing notes dated [DATE] at 4:19 P.M. revealed Resident #34 was acting slightly sluggish and eating little. The physician was notified of his condition and tests were ordered including a stool sample. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365702 If continuation sheet Page 4 of 7 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 365702 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE O'Neill Healthcare Middleburg Heights 7250 Old Oak Blvd Middleburg Heights, OH 44130 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the laboratory results for a stool sample collected on [DATE] revealed results dated [DATE] indicating Resident #34 was positive for Clostridium difficile (C. diff). An inflammation of the colon caused by C. diff bacteria. A physician order dated [DATE] at 7:27 P.M. revealed Vancomycin HCl solution (an antibiotic), 25 milligrams (mg) per milliliter (ml), 125 mg by mouth four times a day was ordered as an antibiotic for 10 days for the C. diff. Review of notes written by Nurse Practitioner (NP) #454, dated [DATE], revealed Resident #34 was positive for C. diff and the plan was to start oral Vancomycin for a of 10 days, contact precautions per facility protocol, and monitor closely for resolution of diarrhea. The note dated [DATE] revealed Resident #34 continued on oral Vancomycin for C. difficile and nursing reported the diarrhea was resolved. The plan for C. diff was to continue oral Vancomycin. Review of the physician orders for February 2020 revealed no orders for transmission base precautions, but revealed orders for Vancomycin HCl capsule, 125 milligrams (mg) by mouth, two times a day for diarrhea for seven days until [DATE]. And a physician order for Vancomycin HCl capsule, 125 mg by mouth, once a day for seven days for diarrhea until [DATE]. Review of Resident #34's current care plan contained no information related to the need for transmission-based precautions for C. diff. Interview of [DATE] at 11:06 A.M. with Licensed Practical Nurse (LPN) #430 revealed Resident #34 was on transmission-based precautions for C. diff. Observation at that time revealed a cart with drawers outside of Resident #34's room but no sign indicating transmission-based precautions. Review of Resident #34's care plan on [DATE] at 3:25 P.M. with the Director of Nursing verified there was no care plan in place for Resident #34 related to transmission-based precautions for C. diff. Interview of [DATE] at 11:06 A.M. with Licensed Practical Nurse (LPN) #430 revealed Resident #34 was on transmission-based precautions for C. diff. Observation at that time revealed a cart with drawers outside of Resident #34's room, but no sign indicating transmission-based isolation precautions were in place for Resident #34. Interview on [DATE] at 4:00 P.M. with the Director of Nursing (DON), stated the nurses were to complete skilled nursing assessments under the assessments tab in the electronic medical record in relation to Resident #34 being on transmission-based precautions for C. diff. Review of the skilled nursing assessments dated [DATE], [DATE], and [DATE] indicated Resident #34 was not on antibiotics or on any isolation precautions. There were no other skilled assessments dated after [DATE]. Review of the note by NP #454 dated [DATE] revealed Resident #34 had recently completed treatment for C. diff and staff reported some persistent diarrhea. The plan for C. diff with return of diarrhea was to resume the antibiotics and then go for tapering dose over the next 4 weeks and continue isolation precautions for now. Interview on [DATE] at 9:00 A.M. with NP #454 revealed she could not remember when Resident #54 was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365702 If continuation sheet Page 5 of 7 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 365702 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE O'Neill Healthcare Middleburg Heights 7250 Old Oak Blvd Middleburg Heights, OH 44130 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 0842 Level of Harm - Minimal harm or potential for actual harm first diagnosed with C. diff, but he did not clear after the first round of antibiotics and they had to start him on a longer treatment of Vancomycin Interview on [DATE] at 3:46 P.M. with the DON verified the skill nursing assessments noted above were inaccurate and no further assessments were completed after [DATE]. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365702 If continuation sheet Page 6 of 7 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 365702 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE O'Neill Healthcare Middleburg Heights 7250 Old Oak Blvd Middleburg Heights, OH 44130 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 and interview and record review the facility failed properly alert staff, visitors and other residents to see nursing staff prior to entering the room of Resident #117, who was on isolation precautions. This affected one of two residents reviewed for isolation precautions. Residents Affected - Few Finding include: Record review for Resident #117 revealed an admission date of 01/28/20 with diagnosis of a dementia, depression, high blood pressure and malnutrition. The admission Minimum Date Set (MDS) assessment dated [DATE] revealed Resident #117 was cognitively impaired and required extensive assistance from staff for bed mobility, transfers and toileting. The resident was incontinent of bowel and bladder. Review of February 2020 physician orders revealed an order dated 02/17/20 for Vancomycin, an antibiotic, for clostridium difficile (C. diff) infection, a highly contagious infection which causes diarrhea and inflammation of the colon. Observation on 02/18/20 at 9:30 A.M. of Resident #117's room revealed a cart sitting outside the room containing person protective equipment (PPE), such as gloves, gowns and face masks, used for isolation precautions. There was no sign posted on the doorway or outside the door to alert all staff, visitors or other residents to see the nurse prior to entering the room. Observation of Resident #117's room on 02/19/20 at 10:22 A.M. and 4:30 P.M. revealed sign posted to alert people to see the nurse before entering the room. Interview with License Practical Nurse (LPN) #448 on 2/20/20 at 10:22 A.M. confirmed Resident #117 was in isolation for C. diff infection and was on contact isolation precautions. These are precautions used for residents with infections/diseases which are spread to others by touching the person or objects in their room. LPN #448 was unaware there was no sign posted on Resident #117's door to alert visitors, all staff and other residents to see the nurse before entering. LPN #448 verified this concern at that time. Interview with the Director on Nursing (DON) on 02/20/20 at 3:30 P.M. revealed she was unaware the isolation rooms did not have proper signs posted. The DON verified they have signs that are posted on the resident's door to see the nurse before entering the room. The DON said the bottom half of the signs they use identify the type of precautions in effect and the person protective equipment (PPE) needed before entering the room. The DON said they were getting more signs made because housekeeping had been disposing of the signs when cleaning the rooms. Review of the undated facility policy titled, Isolation-Categories of Transmission-Based Precautions, revealed under the category of Contact Precautions, step 8 Signs, the facility will implement a system to alert staff to the type of precaution the resident requires. The facility utilized the following system for identification of Contact Precautions for staff and visitors; there were to two lines left blank for the facility to fill in the type of alert system before entering the room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365702 If continuation sheet Page 7 of 7