Inspection·December 27, 2022

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and policy review the facility to ensure medications were always secure from unauthorized access. This affected one (Resident #26) of four (Residents #1, #26, #35 and #58) observed for medication administration. The facility census was 70. Findings include: Review of the medical record for Resident #26 revealed an admission date of 09/01/21 with diagnoses including major depressive disorder, pulmonary fibrosis, chronic obstructive pulmonary disease, and hypotension. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #26 was severely cognitively impaired. Review of the December 2022 physician's orders revealed orders for Depakote (Divalproex Sodium) 125 milligrams (mg) three times a day for depression. Observation on 12/18/22 at 9:40 A.M. revealed an orange oblong pill with a plastic cup with water in Resident #26's room. Resident #26 could not state what date the pill was from. Observation and interview on 12/18/2 at 9:50 A.M. with Licensed Practical Nurse (LPN) #289 revealed an orange oblong pill with UL-125 on it sitting on Resident #26's nightstand. LPN #289 stated she was passing medications and had not been into Resident #26's room yet, and the pill was probably from last night. Review of the website titled, Medscape (https://reference.medscape.com/drug/depakote) revealed UL-125 was identified as Divalproex Sodium, a mood stabilizer. Review of the facility policy titled Oral Solid Medication Administration, dated 08/11/14, revealed residents should be observed taking medications to ensure the resident swallows all medications given. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365702 If continuation sheet Page 2 of 5 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 12/27/2022 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 0807 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. Based on observations, medical record review, and staff interviews, the facility failed to ensure a resident received the correct thickened consistency of fluids per physician orders. This affected two Residents (#124 and #129) of two residents reviewed for thickened liquids. The facility identified four Residents (#45, #124, #129 and #130) who received thickened liquids. The facility census was 70. Findings include: 1. Review of Resident #124's medical record revealed and admission date of 12/07/22 with diagnoses including pneumonia, multiple sclerosis, and atrial fibrillation. Review of the admission Minimum Data Set (MDS) 3.0 assessment revealed the assessment was in progress. Review of the physician's orders for December 2022 revealed Resident #124's diet order was a no added salt, mechanical soft with ground meat texture, and nectar thickened liquids consistency. Observation on 12/20/22 at 7:26 A.M. revealed a 16-ounce (oz) Styrofoam cup filled halfway filled with thin liquids on the Resident #124's nightstand. This was verified at the time of the observation by Central Supply #233. 2. Review of Resident #129's medical record revealed and admission date of 12/03/22 with diagnoses including COVID-19, dementia, and depression. Review of the admission MDS 3.0 assessment revealed the assessment was in progress. Review of the physician's orders for December 2022 revealed Resident #129's diet order was two-gram sodium low concentrated sweets, mechanical soft texture, and nectar thickened liquids consistency. Observation on 12/20/22 at 7:34 A.M. revealed regular (thin) water in a plastic mug sitting on Resident #129's nightstand with straw. This was verified at the time of the observation by Licensed Practical Nurse (LPN) #291. Review of the facility's diet list revealed that Resident #124 and Resident #129 were on nectar consistency liquids. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365702 If continuation sheet Page 3 of 5 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 12/27/2022 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, staff interview, review of resident records, review of infection control policy and procedures, review of the facilities Influenza timeline for December 2022, the Center for Disease Control (CDC) Interim Guidance for Influenza Outbreak Management in Long Term Care Facilities, dated 11/21/22, the facility failed to maintain acceptable infection control practices in the area of isolation procedures for influenza outbreaks after Resident #24 tested positive for Influenza A (highly contagious respiratory infection) by placing her in the dining room at the table with Resident #45. This affected two (Residents #24 and #45) and had the potential to affect all 70 residents residing in the facility. Residents Affected - Few Findings include 1. Review of the medical record for Resident #24 revealed an admission date of 09/09/22. Diagnosis included dementia, acute kidney failure, and heart failure. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #24 was severely impaired cognitively. Resident #24 required one to two staff assistance for activities of daily living (ADL). Further review of the MDS assessment revealed Resident #24 was totally dependent for locomotion, eating, and toileting. Resident #24 required a mechanical lift for all transfers. Review of the physician orders dated 12/18/22 revealed an order to swab for Respiratory Syncytial Virus (RSV) and/or influenza due to cough. Review of the progress note dated 12/18/22 at 5:49 P.M. revealed Resident #24 was placed on isolation precautions pending results of the Influenza/RSV swab. Review of the progress notes dated 12/19/22 at 3:44 P.M. revealed Resident #24's swab returned positive for Influenza A. Review of the physician orders dated 12/19/22 revealed an order to maintain droplet isolation for Influenza A every shift until 24-hours symptom free. Review of the physician orders dated 12/20/22 revealed an order for Resident #24 to receive one capsule by mouth, one time a day, of Tamiflu capsule 75 milligrams (mg) for Influenza A, for five days. 2. Review of the medical record for Resident #45 revealed an admission date of 04/27/20. Diagnosis included acute kidney failure, Alzheimer's, and vascular dementia. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #45 was severely impaired cognitively. Resident #45 required one to two staff assistance for ADL. Further review of the MDS assessment revealed Resident #45 was a totally dependent for locomotion. Review of the progress notes dated 12/20/22 at 3:04 P.M. revealed Resident #45 was swabbed for Influenza/RSV due to cough. Further review revealed Resident #45's results were negative. Observation on 12/18/22 to 12/20/22 from 8:00 A.M. to 5:00 P.M. revealed Resident #24 was observed in her room on isolation precautions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365702 If continuation sheet Page 4 of 5 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 12/27/2022 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 Level of Harm - Minimal harm or potential for actual harm On 12/21/22 at 9:10 A.M., Resident #24 was observed in the dining room sitting across from Resident #45 for the breakfast meal. Resident #24 was observed to be yelling loudly without a protective face covering. Resident #45 was observed to be sitting at the table without a protective face covering. Resident #45 was previously swabbed for RSV and Influenza A on 12/20/22 at 3:04 P.M. and the results were reported as negative. Resident #45 was on oral antibiotics for pneumonia. Residents Affected - Few Interview on 12/21/22 at 9:11 A.M. with Licensed Practical Nurse (LPN) #266 stated she was involved in a medical emergency and did not realize Resident #24 was sitting in the dining area located on the southwest unit. LPN #266 was unaware how Resident #24 had been transported to the location. Interview on 12/21/22 at 9:12 A.M., with State Tested Nurse Aide (STNA) #286 revealed she walked into the dining room and found Resident #24 sitting at the table and stated she was unaware of her isolation status and how she got to the dinging area. On 12/21/22 at 9:15 A.M., Resident #24 was observed to be transported back to her room by STNA #286. Interview on 12/21/22 at 9:23 A.M., with STNA #287 stated she did not transport Resident #24 to the dining room. STNA #287 stated it was her first day and she was instructed to feed Resident #24. STNA #287 denied bringing Resident #24 to the dining room. Interview on 12/21/22 at 9:26 A.M., with LPN #228 revealed Resident #24 was not on her assignment but she was aware that she was positive for the Influenza A. LPN #228 stated Resident #24 was seated in the dining area across from Resident #45. LPN #228 was not aware how she was transported there. On 12/21/22 at 9:25 A.M., the Director of Nursing (DON) was informed of infection control concerns. The DON stated residents on isolation precautions who require feeding assistance, are to be fed inside their rooms. Review of the undated facility policy titled Policy for Isolation revealed the policy was to prevent the spread of infection within the facility using isolation precautions. The facility failed to implement this policy for compliance. Review of the CDC guidelines for Interim Guidance for Influenza Outbreak Management in Long-Term Care Facilities, dated 2017, revealed droplet precautions should be implemented to prevent further exposure to other residents and should continue for seven days after illness onset or until 24 hours after the resolution of fever and respiratory symptoms, whichever is longer. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365702 If continuation sheet Page 5 of 5