Health inspection·November 8, 2023

F 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few confused, independent with ambulation, combative with staff and was wandering in other resident's rooms. Interventions attempted and failed were to offer drink, one to one supervision, expression of feelings. The CNP (Certified Nurse Practitioner) gave an order for Resident #172 to return to the local hospital psychiatric unit. Resident #172's Responsible Party was contacted and updated. Review of Resident #172's progress notes dated 11/02/23 at 2:53 P.M. included Resident #172 had a change in condition including behavioral symptoms of agitation and psychosis. Resident #172 was confused and independent with ambulation. Resident #172 was verbally and physically combative with staff, wandering to other units and exit seeking. Attempts to redirect Resident #172 caused increased agitation. During attempts at redirection Resident #172 shoved a staff member. The Nurse Practitioner was notified and Resident was sent via Emergency Medical Services to the local hospital for a psychological evaluation. Review of Resident #172's progress notes dated 11/03/23 at 1:29 A.M. revealed Resident #172 was discharged from the facility. There was no documentation a transfer notice was sent with Resident #172 when he left the facility and there was no documentation Resident #172's Responsible Party was provided a transfer notice. Interview on 11/08/23 at 10:26 A.M. of Family Member (FM) #590 revealed she was Resident #172's daughter and also his Responsible Party. FM #590 stated Resident #172 was admitted to the facility on [DATE] she was told he was doing well, she visited him and he was very happy and calm. FM #590 stated on 11/02/23 she was told Resident #172 was doing well and a short time later she was called and told she needed to pick his belongings because was at the local hospital. FM #590 stated the facility nurse told her Resident #172 was entering other resident rooms and the staff could not be chasing after him. FM #590 stated the nurse told her Resident #172 attacked two people and shoved someone else's shoulder. FM #590 stated Resident #172 didn't mean anything by his actions. FM #590 indicated Resident #172 was cared for by her daughter before he was admitted to the local hospital behavioral unit. FM #590 stated she admitted Resident #172 to the local hospital because the neighbor upset him and he hit her daughter. FM #590 stated she was not given a 30 day notice, a transfer notice or any paper. FM #590 stated she received no communication from the facility other than Resident #172 was being transported to the local hospital. FM #590 stated the situation was very upsetting to her. FM #590 indicated the facility called her and told her she needed to sign paperwork so the insurance could be billed. Interview on 11/08/23 at 11:34 A.M. of the Administrator revealed Resident #172 was recently admitted from the local hospital psychiatric unit and had a history of beating up his grandchild. The Administrator stated Resident #172 became combative and physically aggressive at the facility and was sent to the local hospital for evaluation. The Administrator stated Hospital Liaison and Marketing (HLM) #591 evaluated Resident #172 and said he was appropriate for admission to the facility. The Administrator stated Resident #172 probably needed alternative placement other than the facility and the hospital would have a conversation with the family. The Administrator stated the facility did not get Resident #172's referral back from the hospital and if Resident #172 was discharged to the hospital he would not be a bed hold. Interview on 11/08/23 at 1:53 P.M. of Registered Nurse (RN) #423 revealed she was working on 11/02/23 when Resident #172 was sent to the hospital via Emergency Medical Services. RN #423 stated Resident #172 was fine in the morning but later in the day he became verbally and physically aggressive and started wandering into other resident rooms. RN #423 stated Resident #172 was exit seeking and pushed an aide into the double door. RN #423 stated she updated FM #590 about the situation with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365706 If continuation sheet Page 2 of 10 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 365706 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Lake Villa 7260 Ridge Rd Parma, OH 44129 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 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #172 and told FM #590 that Resident #172 was going to be transported to the local hospital for evaluation. RN #423 stated she worked until 3:00 P.M. on 11/02/23 and told the daughter before she left the facility that Resident #172's belongings would stay in his room and she would lock his cell phone in the medication cart. RN #423 stated she went home and did not know what happened after that. Interview on 11/08/23 at 2:10 P.M. of Business Office Manager (BOM) #421 revealed Resident #172 had a medicaid insurance plan. BOM #421 stated she did not hold his bed or send a bed hold notice to Resident #172 or his Responsible Party because he did not have his admission paperwork signed and because he went to the hospital due to medical needs. BOM #421 indicated a transfer letter would have gone with the nurses packet. Interview on 11/08/23 at 2:32 P.M. of the Director of Nursing revealed Resident #172 was admitted to the facility on [DATE] from the local hospital psychiatric unit. The DON indicated on 11/02/23 Resident #172 was placed on one-to-one care because he was aggressive and yelling and walking into other resident rooms. The DON stated she knew Spanish and tried talking to Resident #172 in Spanish but he told her to get out of his room and slammed the door. The DON stated FM #590 was contacted and updated on the situation with Resident #172. The DON stated Resident #172 was not placed in the secured unit because he needed to be assessed before he was put on a unit of vulnerable residents. The DON stated Resident #172 was transported via Emergency Medical Services to the local hospital for evaluation. The DON confirmed a Transfer Letter should be located in Resident #172's electronic medical record and the Transfer Letter was not in the electronic medical record. Review of the facility policy titled Transfer or Discharge Notice reviewed 06/08/22 included the facility should provide a resident and, or the resident's representative (sponsor) with a thirty (30)-day written notice of an impending transfer or discharge. Except as specified below, a resident and, or his or her representative would be given a thirty (30)-day advance notice of an impending transfer or discharge from the facility: the transfer was necessary for the resident's welfare and the resident's needs could not be met at the facility; the safety of individuals in the facility was endangered; an immediate transfer or discharge was required by the resident's urgent medical needs; the resident had not resided in the facility for 30 days. The resident and, or the representative would be provided with the following information, including the reason for the transfer or discharge, the effective date of the transfer or discharge, the location to which the resident was being transferred or discharged , the name, address, and telephone number of the state long-term care ombudsman. This deficiency represents non-compliance investigated under Complaint Number OH00148150. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365706 If continuation sheet Page 3 of 10 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 365706 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Lake Villa 7260 Ridge Rd Parma, OH 44129 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and review of the facility policy the facility failed to ensure Resident #172 and his Responsible Party were given a bed hold notice and transfer notice when Resident #172 was transported from the facility via Emergency Medical Services to the local hospital for evaluation. This affected one resident (Resident #172) out of three residents reviewed for transfers and discharges. The facility census was 170. Findings include: Review of Resident #172's medical record revealed an admission date of 11/01/23 and diagnoses included unspecified dementia with agitation, restlessness and agitation, and type two diabetes mellitus. Resident #172 was discharged from the facility on 11/03/23. Review of Resident #172's admission Assessment and Baseline Care Plans dated 11/01/23 at 6:44 P.M. included Resident #172 had cognitive impairment with poor decision making skills and had a diagnosis of dementia. Resident #172 was alert, quiet and cooperative. Resident #172 could ambulate independently and did not have a history of elopement. Review of Resident #172's progress notes dated 11/01/23 at 3:24 P.M. included Resident #172 was transported from the local hospital to the facility. Resident #172 had dementia and Alzheimer's Disease with agitation. Resident #172 was alert and oriented to time, place, person and spoke mainly Spanish with very little English. Resident #172 was resting peacefully and safety measures were maintained. Review of Resident #172's progress notes dated 11/02/23 at 10:37 A.M. included Resident #172 was pacing to and from his room on the nursing unit earlier this morning. At this time Resident #172 was off the nursing unit and pressing elevator buttons. Resident #172 was redirected and returned to his room without incident. Resident #172 was alert to self, pleasant and cooperative. One-to-one initiated for monitoring. Resident #172's Responsible Party was notified and updated. Review of Resident #172's progress notes dated 11/02/23 at 10:50 A.M. completed by an Advanced Practice Nurse included Resident #172 had dementia with agitation, was sitting on the side of his bed and was alert and oriented times two. Resident #172 was Spanish speaking and understood some English. Nursing reported some manic behaviors and pacing in his room and hallways. Resident #172 was admitted from the local hospital behavioral unit and had increased confusion and agitation. Resident #172's family reported agitation, aggression and abusive patterns. Review of Resident #172's progress notes dated 11/02/23 at 12:07 P.M. included Resident #172 was confused, independent with ambulation, combative with staff and was wandering in other resident's rooms. Interventions attempted and failed were to offer drink, one to one supervision, expression of feelings. The CNP (Certified Nurse Practitioner) gave an order for Resident #172 to return to the local hospital psychiatric unit. Resident #172's Responsible Party was contacted and updated. Review of Resident #172's progress notes dated 11/02/23 at 2:53 P.M. included Resident #172 had a change in condition including behavioral symptoms of agitation and psychosis. Resident #172 was confused and independent with ambulation. Resident #172 was verbally and physically combative with staff, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365706 If continuation sheet Page 4 of 10 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 365706 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Lake Villa 7260 Ridge Rd Parma, OH 44129 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few wandering to other units and exit seeking. Attempts to redirect Resident #172 caused increased agitation. During attempts at redirection Resident #172 shoved a staff member. The Nurse Practitioner was notified and Resident was sent via Emergency Medical Services to the local hospital for a psychological evaluation. Review of Resident #172's progress notes dated 11/03/23 at 1:29 A.M. revealed Resident #172 was discharged from the facility. There was no documentation a transfer notice was sent with Resident #172 when he left the facility and there was no documentation Resident #172's Responsible Party was provided a transfer notice. Interview on 11/08/23 at 10:26 A.M. of Family Member (FM) #590 revealed she was Resident #172's daughter and also his Responsible Party. FM #590 stated Resident #172 was admitted to the facility on [DATE] she was told he was doing well, she visited him and he was very happy and calm. FM #590 stated on 11/02/23 she was told Resident #172 was doing well and a short time later she was called and told she needed to pick his belongings because was at the local hospital. FM #590 stated the facility nurse told her Resident #172 was entering other resident rooms and the staff could not be chasing after him. FM #590 stated the nurse told her Resident #172 attacked two people and shoved someone else's shoulder. FM #590 stated Resident #172 didn't mean anything by his actions. FM #590 indicated Resident #172 was cared for by her daughter before he was admitted to the local hospital behavioral unit. FM #590 stated she admitted Resident #172 to the local hospital because the neighbor upset him and he hit her daughter. FM #590 stated she was not given a 30 day notice, a transfer notice or any paper. FM #590 stated she received no communication from the facility other than Resident #172 was being transported to the local hospital. FM #590 stated the situation was very upsetting to her. FM #590 indicated the facility called her and told her she needed to sign paperwork so the insurance could be billed. Interview on 11/08/23 at 11:34 A.M. of the Administrator revealed Resident #172 was recently admitted from the local hospital psychiatric unit and had a history of beating up his grandchild. The Administrator stated Resident #172 became combative and physically aggressive at the facility and was sent to the local hospital for evaluation. The Administrator stated Hospital Liaison and Marketing (HLM) #591 evaluated Resident #172 and said he was appropriate for admission to the facility. The Administrator stated Resident #172 probably needed alternative placement other than the facility and the hospital would have a conversation with the family. The Administrator stated the facility did not get Resident #172's referral back from the hospital and if Resident #172 was discharged to the hospital he would not be a bed hold. Interview on 11/08/23 at 1:53 P.M. of Registered Nurse (RN) #423 revealed she was working on 11/02/23 when Resident #172 was sent to the hospital via Emergency Medical Services. RN #423 stated Resident #172 was fine in the morning but later in the day he became verbally and physically aggressive and started wandering into other resident rooms. RN #423 stated Resident #172 was exit seeking and pushed an aide into the double door. RN #423 stated she updated FM #590 about the situation with Resident #172 and told FM #590 that Resident #172 was going to be transported to the local hospital for evaluation. RN #423 stated she worked until 3:00 P.M. on 11/02/23 and told the daughter before she left the facility that Resident #172's belongings would stay in his room and she would lock his cell phone in the medication cart. RN #423 stated she went home and did not know what happened after that. Interview on 11/08/23 at 2:10 P.M. of Business Office Manager (BOM) #421 revealed Resident #172 had a medicaid insurance plan. BOM #421 stated she did not hold his bed or send a bed hold notice to Resident #172 or his Responsible Party because he did not have his admission paperwork signed and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365706 If continuation sheet Page 5 of 10 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 365706 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Lake Villa 7260 Ridge Rd Parma, OH 44129 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few because he went to the hospital due to medical needs. BOM #421 indicated a transfer letter would have gone with the nurses packet. Interview on 11/08/23 at 2:32 P.M. of the Director of Nursing revealed Resident #172 was admitted to the facility on [DATE] from the local hospital psychiatric unit. The DON indicated on 11/02/23 Resident #172 was placed on one-to-one care because he was aggressive and yelling and walking into other resident rooms. The DON stated she knew Spanish and tried talking to Resident #172 in Spanish but he told her to get out of his room and slammed the door. The DON stated FM #590 was contacted and updated on the situation with Resident #172. The DON stated Resident #172 was not placed in the secured unit because he needed to be assessed before he was put on a unit of vulnerable residents. The DON stated Resident #172 was transported via Emergency Medical Services to the local hospital for evaluation. The DON confirmed a Transfer Letter should be located in Resident #172's electronic medical record and the Transfer Letter was not in the electronic medical record. Review of the facility policy titled Transfer or Discharge Notice reviewed 06/08/22 included the facility should provide a resident and, or the resident's representative (sponsor) with a thirty (30)-day written notice of an impending transfer or discharge. Except as specified below, a resident and, or his or her representative would be given a thirty (30)-day advance notice of an impending transfer or discharge from the facility: the transfer was necessary for the resident's welfare and the resident's needs could not be met at the facility; the safety of individuals in the facility was endangered; an immediate transfer or discharge was required by the resident's urgent medical needs; the resident had not resided in the facility for 30 days. The resident and, or the representative would be provided with the following information, including the reason for the transfer or discharge, the effective date of the transfer or discharge, the location to which the resident was being transferred or discharged , the name, address, and telephone number of the state long-term care ombudsman. This deficiency represents non-compliance investigated under Complaint Number OH00148150. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365706 If continuation sheet Page 6 of 10 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 365706 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Lake Villa 7260 Ridge Rd Parma, OH 44129 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, record review, review of the facility policy and review of the Centers for Disease Control (CDC) and Prevention guidelines, the facility failed to maintain an adequate infection control program to prevent the spread of infection. The facility failed to ensure staff donned appropriate personal protective equipment (PPE) prior to entering the room of and providing wound care to Resident #156 who had tested positive for Carbapenem-resistant Acinetobacter baumannii (CRAB). Furthermore, the facility failed to ensure Resident #155, who tested positive for CRAB washed his hands before leaving his room. This affected two sampled residents (#156 and #155) who tested positive for CRAB and had the potential to affect 42 additional residents (#1, #4, #10, #12, #26, #33, #34, #40, #45, #46, #54, #55, #56, #59, #60, #67, #68, #74, #80, #83, #89, #90, #93, #97, #98, #100, #102, #106, #109, #110, #112, #115, #116, #119, #121, #129, #137, #148, #150, #159, #160, #170) residing on the unit Resident #156 resided on and 22 residents (#2, #13, #19, #25, #43, #71, #86, #88, #91, #95, #96, #122, #127, #133, #134, #145, #147, #151, #158, #161, #163, #167) residing on the nursing unit Resident #155 resided on. The facility census was 170. Residents Affected - Some Findings include: 1. Review of Resident #156's medical record revealed an admission date of 01/08/21 and diagnoses included dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, carrier of Carbapenem-resistant Acinetobacter baumannii (does not respond to common antibiotics and some are resistant to all available antibiotics), and unspecified intellectual disabilities. Review of Resident #156's annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #156 did not have a Brief Interview for Mental Status completed due to Resident #156 was rarely or never understood. Resident #156 required extensive assistance of one staff member for bed mobility, total dependence of two staff members for transfers, and extensive assistance of two staff members for toilet use and personal hygiene. Review of Resident #156's physician orders dated 10/03/23 revealed an order to cleanse areas to the left buttock extending to the right thigh with normal saline and pat dry with a four-by-four gauze, apply TRIAD (skin protectant) and leave open to air (LOTA). Line bed with a chuck (disposable pad), no (incontinence) brief. Monitor for pain, discomfort with treatment, use prn (as needed) meds and, or contact the physician or Nurse Practitioner. Further review revealed to cleanse areas to right buttock extending to the right thigh with normal saline and pat dry with a four-by-four gauze, apply TRIAD and LOTA, line bed with a chuck and no brief. Monitor for pain and discomfort with treatment, use prn meds and or contact the physician or Nurse Practitioner. Review of facility laboratory report results revealed a swab of Resident's #156's axilla and groin was collected from 10/16/23 through 10/18/23 and reported on 10/23/23. Resident #156's Carbapenem-resistant Acinetobacter baumanni colonization culture showed Acinetobacter baumannii (A), this isolate tested positive for OXA-24/40-like carbapenemases by PCR (polymerase chain reaction which detect genetic material from the virus). Review of Resident #156's care plan dated 10/24/23 included Resident #156 had a CRAB (Carbapenem-resistant Acinetobacter baumannii) infection. Resident #156's infection would resolve with no adverse reactions to treatment. Interventions included contact isolation precautions; follow facility protocols for contact isolation for duration of treatment, monitor for increased withdrawal, social (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365706 If continuation sheet Page 7 of 10 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 365706 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Lake Villa 7260 Ridge Rd Parma, OH 44129 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 isolation; monitor wound for changes in color, odor, inflammation, exudate, and complaints of pain. Level of Harm - Minimal harm or potential for actual harm Review of Resident #156's physician orders dated 10/24/23 revealed an order for contact precautions related to CRAB. Post a See Nurse Before Entering Sign on the door, provide personal blood pressure cuff, stethoscope, thermometer, wear gloves, mask, and gown as needed, and wash hands when touching environment and with direct patient care. Residents Affected - Some Review of Resident #156's progress notes dated 10/24/23 at 11:35 A.M. revealed the nurse practitioner was asked to see Resident #156 due to CRAB positive. Resident #156's plan was to continue infection prevention measures, hand hygiene, environmental cleaning and Resident #156 was placed on enhanced barrier precautions (EBP). Interview on 11/06/23 at 9:34 A.M. of Licensed Practical Nurse/Staff Development/Infection Preventionist (LPN/SD/IP) #526 revealed the facility had quite a few residents positive with CRAB, and it had been going on for months. LPN/SD/IP #526 stated the Cuyahoga County Board of Health and Ohio Department of Health visited the facility on 04/2023 and gave recommendations and guidance for CRAB. LPN/SD/IP #526 stated she received a call from the Ohio Department of Health and Cuyahoga County Board of Health on 09/26/23. LPN/SD/IP #526 stated she was advised by the Ohio Department of Health and the Cuyahoga County Board of Health to test all the residents in the facility for CRAB. LPN/SD/IP #526 indicated most of the residents (some refused) were tested for CRAB over a three-day period from 10/16/23 through 10/18/23. LPN/SD/IP #526 revealed eight residents (Resident #57, #61, #92, #101, #113, #114, #155 and #156) tested positive for CRAB and were placed in private rooms or cohorted in a semi-private room. LPN/SD/IP #526 stated none of the eight residents who tested positive for CRAB had symptoms. LPN/SD/IP #526 stated staff washed their hands and wore isolation gowns and gloves when providing resident care for residents positive for CRAB. LPN/SD/IP #526 stated the facility was going to retest the residents in six months for CRAB. Observation on 11/07/23 at 9:10 A.M. of Resident #156's room revealed there was a small red sign to the right of the door which stated to Ask the Nurse before entering the room. There were personal protective equipment (PPE) supplies on the door to the room including isolation gowns. Further observation revealed Wound Physician (WP) #588, Registered Nurse/Wound Nurse (RN/WN) #447 and Med Tech (MT) #487 walked in Resident #156's room and did not don PPE. Observation revealed WP #588 and RN/WN #447 were standing next to Resident #156's bed and had not donned PPE. MT #487 was wearing gloves, no isolation gown and was leaning over Resident #156's bed and applying cream to Resident #156's right and left buttocks and upper thighs. MT #487's clothing was touching Resident #156's bed while she applied the cream. When asked about the sign and PPE on the door to Resident #156's room MT #487 stated Resident #156 did not have CRAB and that was why she did not have an isolation gown on. WP #588 stated Resident #156's roommate (Resident #114, also positive for CRAB) had some kind of urine bacteria and that was what the PPE was for. WP #588 stated Resident #114 was not in the room, so it was not a problem. Observation revealed Resident #114 was not in the room. Interview on 11/07/23 at 11:04 A.M. of RN/WN #447 confirmed Resident #156 was CRAB positive and she should have donned PPE before entering Resident #156's room with WP #588 and MT #487 to provide wound care. Interview on 11/07/23 at 1:48 P.M. of Medical Director #589 revealed he was aware the facility had an increase in CRAB cases. Medical Director #589 stated he talked to the Director of Nursing about the increase in CRAB cases today (11/07/23) and agreed with the measures the facility was taking to control the spread of CRAB. Medical Director #589 stated he had no additional recommendations for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365706 If continuation sheet Page 8 of 10 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 365706 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Lake Villa 7260 Ridge Rd Parma, OH 44129 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 Residents Affected - Some measures the facility should take. When asked if there should have been additional testing, screening when there were CRAB positive cases in 05/2023 and 08/2023 Medical Director #589 stated he could not recall anything regarding what was done about CRAB in the facility, and he could not comment on the residents who were positive in May and August 2023, and he could not comment if screening should have been done because it was too long ago. Medical Director #589 stated he attended scheduled monthly meetings and more often if needed. Interview on 11/08/23 at 3:36 P.M. of the Administrator, the Director of Nursing and LPN/SD/IP #526 revealed when asked why Resident #156's door did not have a Contact Precaution sign on the door and had a small red sign to the right of door stating to Ask a Nurse before entering the room LPN/SD/IP #526 stated the red sign says to see a nurse and the nurse would tell the person Resident #156 was on Contact Precautions. LPN/SD/IP #526 stated that was the way the facility had always done it. 2. Review of Resident #155's medical record revealed an admission date of 08/11/21 and diagnoses included epilepsy, carrier of carbapenem-resistant Acinetobacter baumannii (CRAB), and alcoholic cirrhosis of the liver with ascites. Review of Resident #155's quarterly MDS 3.0 assessment dated [DATE] revealed Resident #155 was cognitively intact. Resident #155 required setup or clean-up assistance for toileting and walking in his room or a corridor. Resident #155 used a manual wheelchair or scooter. Review of Resident #155's care plan dated 10/24/23 included Resident #155 had a CRAB infection. Resident #155's infection would resolve with no adverse reactions to treatment. Resident#155 would follow facility protocols for contact isolation for duration of treatment, monitor for increased withdrawal, social isolation; utilize PPE (personal protective equipment) as appropriate. Interview on 11/07/23 at 8:05 A.M. of LPN/SD/IP #526 revealed Resident's #57, #61, #92, #101, #113, #114, #155 and #156's were instructed that they should wash their hands before leaving the rooms they resided in. Observation on 11/07/23 at 4:10 P.M. of Resident #155 revealed he used a wheeled walker, walked out of his room into the hall and into the common area used by other residents and did not wash his hands before leaving the room. Interview on 11/07/23 at 4:10 P.M. of Resident #155 revealed he shared a room with Resident #113 and confirmed there was PPE supplies hanging on the door to his room. Resident #155 stated the PPE was on the door because both he and Resident #113 were swabbed and tested positive for something in their arm pits. Resident #155 indicated a person came by with the results and told him he would be tested again. Resident #155 stated he was not told he should do anything like washing his hands before leaving his room or to do anything different than he had been doing before he tested positive. Resident #155 confirmed he did not wash his hands before leaving his room. Review of the facility policy titled Isolation Precautions dated 06/08/22 included it was the policy of the facility, when necessary, to prevent the transmission of infections within the facility using Isolation Precautions. The 2007 Centers for Disease Control and Prevention (CDC) guidelines for Isolation Precautions would be utilized in the facility with some modifications. In addition to Standard Precautions, use Contact Precautions for residents known or suspected to be infected with microorganisms that could be easily transmitted by direct or indirect contact, such as handling environmental surfaces or resident-care areas. In some instances, residents colonized with these organisms may (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365706 If continuation sheet Page 9 of 10 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 365706 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Lake Villa 7260 Ridge Rd Parma, OH 44129 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 Residents Affected - Some also require Contact Precautions. The above includes epidemiologically important organisms (multidrug-resistant organisms). Handwashing (hand hygiene) was the single most important precaution to prevent the transmission of infection from one person to another. Wash hands with soap and water before and after each resident contact and after contact with resident belongings and equipment. Alcohol-based hand rub could be used if hands were not visibly soiled. All personal protective equipment should be used once and discarded in either the trash or used linen receptacle before leaving the room. Review of the Centers for Disease Control and Prevention (CDC) Information for facilities titled CRAB Carbapenem-resistant Acinetobacter baumannii, An Urgent Public Health Threat included Acinetobacter baumannii was a species of bacteria that was an opportunistic pathogen. It could cause a variety of different types of infections. Infections caused by carbapenem-resistant A. baumannii (CRAB) don't respond to common antibiotics and some CRAB were resistant to all available antibiotics. Carbapenemase-producing CRAB had the potential to spread rapidly and was frequently associated with outbreaks. CRAB spreads through direct and indirect contact with patients infected or colonized with CRAB or contaminated environmental surfaces and equipment. It was usually transmitted from person to person, often via the hands of healthcare personnel or on contaminated shared medical equipment like blood pressure machines. CRAB could cause large outbreaks in healthcare facilities. Colonization meant that an organism was found in or on the body but was not causing any symptoms or disease. CRAB primarily colonized the digestive tract, respiratory tract, skin, and, or wounds but could colonize other body sites. Patients who were colonized with CRAB could be a source of spread to other patients. They were also at higher risk of developing CRAB infection than patients who were not colonized. And because patients colonized with CRAB don't have signs or symptoms, CRAB colonization could go undetected and contribute to silent spread of resistant bacteria. Colonization was detected by a screening test for patients and residents who were at risk of CRAB colonization or infection. Follow public health recommendations for CRAB colonization screening. Wear a gown and gloves when caring for patients with CRAB. CRAB could contaminate your hands and clothes while you care for a patient infected or colonized with CRAB or work in their environment. This puts the patients you care for afterward at risk of getting CRAB. Review of the CDC's Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) included Contact Precautions were intended to prevent transmission of infectious agents, like MDROs, that were spread by direct or indirect contact with the resident or the resident's environment. Contact Precautions required the use of gown and gloves on every entry into a resident's room. The resident was given dedicated equipment (e.g., stethoscope and blood pressure cuff) and was placed into a private room. When private rooms were not available, some residents (for example, residents with the same pathogen) may be cohorted, or grouped together. This deficiency represents non-compliance investigated under Complaint Number OH00147595. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365706 If continuation sheet Page 10 of 10