Inspection·December 18, 2019

F 0559 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Interview on 12/18/19 at 4:13 P.M. with Social Worker #376 verified she completed the room change form on the electronic medical record when a room change was made but did not provide it to the residents or have residents sign it. Review of facility policy, Resident Room Change Policy, dated 05/30/19, revealed Social Service was to complete Notification of Room Change and New Roommate Notification forms in the medical record. Review of this form revealed a Resident's Signature area. Event ID: Facility ID: 365711 If continuation sheet Page 2 of 19 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 365711 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chardon Center 620 Water Street Chardon, OH 44024 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 record review, interview and policy review, the facility failed to ensure Resident #10 and Resident #29 were free from physical abuse. This affected two residents (Residents #10 and #29) of three residents (Residents #10, #29 and #131) reviewed for abuse and neglect. The facility census was 77. Findings include: 1. Record review revealed Resident #10 was admitted to the facility on [DATE] with diagnoses including muscular dystrophy, weakness, and bilateral primary osteoarthritis of knee. Review of the most recent quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/01/19 revealed Resident #10 had no cognitive impairment. Review of the care plan dated 06/26/19 revealed Resident #10 has a behavior problem related to bully-like, disrespectful behaviors towards other residents, and she tends to manipulate, and verbally express unsolicited, negative comments to peers. Record review revealed Resident #131 was admitted to the facility on [DATE] with dementia with behavioral disturbance, persistent mood (affective) disorder, and major depressive disorder. Review of the most recent annual MDS 3.0 assessment, dated 07/30/19 revealed Resident #131 was cognitively impaired. Review of the care plan dated 05/03/18 revealed target behaviors of delusions, inappropriate language, aggressiveness, and disruptive to others. The care plan also reflected a history of resident to resident altercation in the dining room initiated on 01/18/17 and resolved on 10/16/17. Resident #131 was discharged from the facility on 09/07/19. Review of the facility self reported incident (SRI) tracking number 174612 dated 06/04/19 revealed Resident #131 punched Resident #10 in the back while passing behind her in the dining room. Resident #131 was removed from the dining room and staff were directed to keep both residents separated. Local law enforcement was not contacted. Resident #131's medications were reviewed by the Consultant Pharmacist on 06/06/19. Resident #10's skin was assessed and identified no bruising or swelling but complaints of pain and tenderness below the left shoulder blade. She received counseling services on 06/10/19. Staff were inserviced on Abuse, Neglect, and Re-directing Residents on 06/05/19. Interview on 12/18/19 at 7:29 A.M. with the Director of Nursing verified the findings of the above SRI. Reviewed the facility Abuse, Neglect and Misappropriation policy, dated 09/02/16, revealed with resident to resident altercation, the facility would separate the residents, conduct appropriate assessments on each resident, may place the aggressive resident in a quiet area to reduce stimulation, notify the physician, update the care plan, make appropriate referrals, and complete a thorough investigation following the initial report. 2. Record review revealed Resident #29 revealed an admission date of 08/31/18 with diagnoses that included intellectual disabilities, cognitive communication deficit, generalized anxiety disorder, and major depressive disorder. Review of the most recent quarterly MDS 3.0 assessment dated [DATE] revealed the resident had no cognitive impairment and required staff supervision and set-up assistance with with activities of daily living (ADL). Review of the care plan, dated 09/05/18, revealed Resident #29 had impaired cognitive function/dementia or impaired thought processes related to MRDD (Mentally Retarded Developmentally Disabled), and he can get argumentative at times and get in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365711 If continuation sheet Page 3 of 19 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 365711 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chardon Center 620 Water Street Chardon, OH 44024 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 altercations. Level of Harm - Minimal harm or potential for actual harm Record review revealed Resident #10 was admitted to the facility on [DATE] with diagnoses including muscular dystrophy, weakness, and bilateral primary osteoarthritis of knee. Review of the most recent quarterly MDS 3.0 assessment, dated 10/01/19 revealed Resident #10 had no cognitive impairment. Review of the care plan dated 06/26/19 revealed Resident #10 has a behavior problem related to bully-like, disrespectful behaviors towards other residents, and she tends to manipulate, and verbally express unsolicited, negative comments to peers. Residents Affected - Few Review of SRI tracking number 184597 dated 11/30/19 revealed upon investigation Resident #29 and #10 had a witnessed verbal argument which resulted in Resident #10 striking Resident #29 on the face. Both residents were immediately separated. Resident #10 was placed on safety checks for supervision through 12/01/19. Upon assessment, Resident #29 had no injury. Local law enforcement was contacted, and no police report was filed. Interview on 12/18/19 at 7:29 A.M. with the Director of Nursing verified the findings of the above SRI. Reviewed facility Abuse, Neglect and Misappropriation policy, dated 09/02/16, revealed with resident to resident altercation, the facility would separate the residents, conduct appropriate assessments on each resident, may place the aggressive resident in a quiet area to reduce stimulation, notify the physician, update the care plan, make appropriate referrals, and complete a thorough investigation following the initial report. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365711 If continuation sheet Page 4 of 19 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 365711 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chardon Center 620 Water Street Chardon, OH 44024 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on record review, interview and policy review, the facility failed to implement the policy and procedure for reporting alleged physical abuse for Resident #29. This affected one Resident (#29) of three residents reviewed for abuse and neglect. The facility census was 77. Residents Affected - Few Findings include: Review of the medical record for Resident #29 revealed an admission date of 08/31/18. Diagnoses included intellectual disabilities, cognitive communication deficit, generalized anxiety disorder, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/23/19, revealed the resident had no cognitive impairment. The resident required staff supervision and set-up assistance with bed mobility, transfers, walking, locomotion, dressing, eating, toileting, personal hygiene, and bathing. Review of the care plan, dated 09/05/18, revealed Resident #29 had impaired cognitive function/dementia or impaired thought processes related to MRDD (Mentally Retarded Developmentally Disabled), and he can get argumentative at times and get in altercations. Interventions included to keep his routine consistent, provide consistent caregivers, use task segmentation, and encourage activity programs consistent with his interests. Review of the progress note dated 07/08/19 at 6:02 P.M. indicated resident had a bruise to the left thigh measuring six by eleven. The unit of measurement was not noted. Review of the progress note dated 08/06/19 at 4:05 A.M. indicated resident had returned from a leave of absence and a skin check revealed the right side of the cheek and jaw was slightly swollen, the right arm, abdomen, left foot and lower back had scratches. Review of the progress note dated 10/24/19 at 12:33 P.M. indicated resident had returned from a leave of absence and the staff observed a bruise to the left upper back measuring 26 centimeters (cm) by 5 cm, and a bruise to the left upper extremity measuring 7 cm by 3 cm. Interview on 12/17/19 at 4:36 P.M. with Social Worker (SW) #376 verified Resident #29 had taken multiple leave of absences to visit home, and the injuries on 07/08/19, 08/06/19 and 10/24/19 were each after one of those visits. She confirmed the facility's interdisciplinary team had concerns about the injuries, discussed those concerns, and decided Resident #29 would start counseling services. SW #376 also verified there were concerns of abuse, but Resident #29 was minimizing it and so the concerns were shared with the counselor. SW #376 confirmed she had not discussed it with anyone else or reported it to anyone else. Interview on 12/18/19 at 10:50 A.M. with SW #376 verified the Director of Nursing (DON) and Licensed Practical Nurse (LPN) #335 were included in the interdisciplinary meeting to discuss Resident #29 after the last injury on 10/24/19. SW #376 confirmed she expressed concerns about abuse. Interview on 12/18/19 at 10:50 A.M. with the DON and LPN #335 verified there was an interdisciplinary meeting held after Resident #29's injury was discovered on 10/24/19 to discuss concerns, and verified abuse was discussed at the meeting. The DON verified there was a different administrator for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365711 If continuation sheet Page 5 of 19 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 365711 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chardon Center 620 Water Street Chardon, OH 44024 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 0607 the facility at the time who was aware. Level of Harm - Minimal harm or potential for actual harm Interview on 12/18/19 at 10:50 A.M. with the Administrator confirmed it was the facility's policy with any allegation or suspicion of abuse to report it and investigate. Residents Affected - Few Review of the facility policy on Abuse, Neglect and Misappropriation, dated 09/02/16, revealed all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365711 If continuation sheet Page 6 of 19 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 365711 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chardon Center 620 Water Street Chardon, OH 44024 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on record review, interview and policy review, the facility failed to report alleged physical abuse for Resident #29. This affected one Resident (#29) of three residents reviewed for abuse and neglect. The facility census was 77. Findings include: Review of the medical record for Resident #29 revealed an admission date of 08/31/18. Diagnoses included intellectual disabilities, cognitive communication deficit, generalized anxiety disorder, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/23/19, revealed the resident had no cognitive impairment. The resident required staff supervision and set-up assistance with bed mobility, transfers, walking, locomotion, dressing, eating, toileting, personal hygiene, and bathing. Review of the care plan, dated 09/05/18, revealed Resident #29 had impaired cognitive function/dementia or impaired thought processes related to MRDD (Mentally Retarded Developmentally Disabled), and he can get argumentative at times and get in altercations. Interventions included to keep his routine consistent, provide consistent caregivers, use task segmentation, and encourage activity programs consistent with his interests. Review of the progress note dated 07/08/19 at 6:02 P.M. indicated resident had a bruise to the left thigh measuring six by eleven. The unit of measurement was not noted. Review of the progress note dated 08/06/19 at 4:05 A.M. indicated resident had returned from a leave of absence and a skin check revealed the right side of the cheek and jaw was slightly swollen, the right arm, abdomen, left foot and lower back had scratches. Review of the progress note dated 10/24/19 at 12:33 P.M. indicated resident had returned from a leave of absence and the staff observed a bruise to the left upper back measuring 26 centimeters (cm) by 5 cm, and a bruise to the left upper extremity measuring 7 cm by 3 cm. Interview on 12/17/19 at 4:36 P.M. with Social Worker (SW) #376 verified Resident #29 had taken multiple leave of absences to visit home, and the injuries on 07/08/19, 08/06/19 and 10/24/19 were each after one of those visits. She confirmed the facility's interdisciplinary team had concerns about the injuries, discussed those concerns, and decided Resident #29 would start counseling services. SW #376 also verified there were concerns of abuse, but Resident #29 was minimizing it and so the concerns were shared with the counselor. SW #376 confirmed she had not discussed it with anyone else or reported it to anyone else. Interview on 12/18/19 at 10:50 A.M. with SW #376 verified the Director of Nursing (DON) and Licensed Practical Nurse #335 were included in the interdisciplinary meeting to discuss Resident #29 after the last injury on 10/24/19. SW #376 confirmed she expressed concerns about abuse. Interview on 12/18/19 at 10:50 A.M. with the DON and LPN #335 verified there was an interdisciplinary meeting held after Resident #29's injury was discovered on 10/24/19 to discuss concerns, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365711 If continuation sheet Page 7 of 19 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 365711 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chardon Center 620 Water Street Chardon, OH 44024 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 0609 Level of Harm - Minimal harm or potential for actual harm verified abuse was discussed at the meeting. The DON verified there was a different administrator for the facility at the time who was aware. Interview on 12/18/19 at 10:50 A.M. with Administrator confirmed it was the facility's policy with any allegation or suspicion of abuse to report it and investigate. Residents Affected - Few Review of the facility policy on Abuse, Neglect and Misappropriation, dated 09/02/16, revealed all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported; in the event an allegation is made, the facility will take measures to protect residents from harm during an investigation; and accurate and timely reporting of incidents, both alleged and substantiated, will be sent to officials in accordance with the state law. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365711 If continuation sheet Page 8 of 19 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 365711 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chardon Center 620 Water Street Chardon, OH 44024 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 0610 Respond appropriately to all alleged violations. 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 policy review, the facility failed to thoroughly investigate a physical abuse incident involving Resident #10 and Resident #29. This affected two Residents (#10 and #29) of three residents reviewed for abuse and neglect. The facility census was 77. Residents Affected - Few Findings include: Record review revealed Resident #29 revealed an admission date of 08/31/18 with diagnoses including intellectual disabilities, cognitive communication deficit, generalized anxiety disorder, and major depressive disorder. Review of the most recent quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had no cognitive impairment and required staff supervision and set-up assistance with with activities of daily living (ADL). Review of the care plan, dated 09/05/18, revealed Resident #29 had impaired cognitive function/dementia or impaired thought processes related to MRDD (Mentally Retarded Developmentally Disabled), and he can get argumentative at times and get in altercations. Record review revealed Resident #10 was admitted to the facility on [DATE] with diagnoses including muscular dystrophy, weakness, and bilateral primary osteoarthritis of knee. Review of the most recent quarterly MDS 3.0 assessment, dated 10/01/19 revealed Resident #10 had no cognitive impairment. Review of the care plan dated 06/26/19 revealed Resident #10 has a behavior problem related to bully-like, disrespectful behaviors towards other residents, and she tends to manipulate, and verbally express unsolicited, negative comments to peers. Review of the facility self-reported incident (SRI) tracking number 184597 dated 11/30/19 revealed upon investigation Resident #29 and #10 had a witnessed verbal argument which resulted in Resident #10 striking Resident #29 on the face. Both residents were immediately separated. Resident #10 was placed on safety checks for supervision through 12/01/19. Upon assessment, Resident #29 had no injury. Local law enforcement was contacted, and no police report was filed. Interview on 12/15/19 at 10:36 A.M. with Resident #29 revealed he was living in the room next to Resident #10 and did not remember how long ago the incident took place. He stated Resident #10 said bad things about him, his family, and his wife to be so he got mad and called her names in return, then she punched him in the jaw. Resident #29 indicated Resident #10 picks on him by sitting in places where he likes to go and sticks her middle finger up at him. He confirmed the police talked with him about the incident and encouraged him to not press charges so he did not. Interview on 12/15/19 at 11:06 A.M. with Resident #10 revealed there were issues between her and Resident #29 building prior to the incident on 11/30/19. She indicated Resident #29 was living in the room next to hers and walked around her, watched her, and taunted her by calling her names. She stated on the day of the incident he walked over to her, leaned down into her face, and called her a [expletive], so she hit him in the mouth. She expressed Resident #29 was intimidating since she was in a wheelchair and he was not. Resident #10 indicated she told the police that Resident #29 harassed her, and the police talked Resident #29 out of pressing charges. Resident #10 further explained right after the incident Resident #29 sang a song in her face to get rid of evil he has to cut me like a goat, then he cracked his knuckles and had his fists clenched around her which caused her to feel scared and worried. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365711 If continuation sheet Page 9 of 19 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 365711 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chardon Center 620 Water Street Chardon, OH 44024 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 12/17/19 at 5:32 P.M. with Administrator confirmed no additional residents or staff assigned to the area where Resident #10 and #29 reside and the incident took place were interviewed. He also confirmed Resident #10 was not interviewed in detail about the effects of the incident and no follow-up interviews with Resident #10 and Resident #29 were conducted. Interview on 12/18/19 at 7:29 A.M. with Director of Nursing verified no additional residents or staff assigned to the area where Resident #10 and #29 reside and the incident took place were interviewed. She also confirmed Resident #10 was not interviewed in detail about the effects of the incident and no follow-up interviews with Resident #10 and Resident #29 were conducted. Interview on 12/18/19 at 9:56 A.M. with State Tested Nursing Assistant (STNA) #330 verified Resident #29 sang a song to Resident #10 that ended with off with her head, then looked at Resident #10, grinned and laughed, so she told Resident #10 to stay by the nurses station and reported it to the nurse on duty. STNA #330 stated Resident #29 likes to instigate and start things with other residents. Review of the progress notes dated 12/4/2019 at 4:51 P.M. confirmed Resident #29 was observed ambulating in hallway, pacing back and fourth around the nursing station with his headphones around his neck, singing explicit alleged song lyrics taunting Resident #10 while staring at her and verbalizing vulgar language and violence. Interview on 12/18/19 at 10:00 A.M. with Registered Nurse (RN) #315 verified Resident #29 usually kept to herself, and Resident #10 did not know personal space or boundaries and gets very close to people. Review of the facility policy on Abuse, Neglect and Misappropriation, dated 09/02/16, revealed following the initial report of the alleged violation the facility will complete a thorough investigation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365711 If continuation sheet Page 10 of 19 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 365711 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chardon Center 620 Water Street Chardon, OH 44024 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 record review, interview and policy review, the facility failed to ensure Pre-admission Screening and Resident Review (PASRR) recommendations were incorporated into Resident #53's plan of care. This affected one (Resident #53) of two residents reviewed for PASRR status. The facility census was 77. Findings include: Record review revealed Resident #53 was admitted to the facility on [DATE]. Diagnoses included schizoaffective disorder, bipolar type, a history of bullet to the brain with fragmentation, and diabetes mellitus type 2. Review of the PASRR determination from the Ohio Department of Mental Health dated 05/03/19 revealed Resident #53 was approved for a sixty day nursing facility stay to expire on 07/02/19, and that any further stay beyond sixty days would require a new PASRR request and subsequent approval by the Ohio Department of Mental Health. Review of the PASRR determination from the State Department of Mental Health revealed Resident #53 had a history of serious mental illness and noted a list of recommendations for services, supports and linkages which included ongoing medication review, medication education, socialization and recreation activities, coordinate discharge with the county Mental Health board, refer to Opportunities for Ohioans with Disabilities for vocational services, Case Management, and Behavioral Health Services. Review of the care plan dated 07/15/19 revealed no evidence of the PASRR recommendations included into the care plan. Interview on 12/18/19 at 12:29 P.M. with Registered Nurse #345 verified Resident #53's care plan did not reflect the PASRR determination recommendations including discharge planning for return to the community. Review of facility policy entitled, Plan of Care Overview, dated 05/30/19, revealed care plan documents are resident specific/resident focused and reflect resident/representative opportunities for participation and preferences. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365711 If continuation sheet Page 11 of 19 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 365711 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chardon Center 620 Water Street Chardon, OH 44024 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 record review and interview, the facility failed to ensure a valid Pre-admission Screen and Resident Review (PASRR) was in place for Resident #53. This affected one (Resident #53) of two residents reviewed for PASRR status. The facility census was 77. Residents Affected - Few Findings include: Record review revealed Resident #53 was admitted to the facility on [DATE]. Diagnoses included schizoaffective disorder, bipolar type, a history of bullet to the brain with fragmentation, and diabetes mellitus type 2. Review of the PASRR determination from the Ohio Department of Mental Health dated [DATE] revealed Resident #53 was approved for a sixty day nursing facility stay to expire on [DATE], and that any further stay beyond sixty days would require a new PASRR request and subsequent approval by the Ohio Department of Mental Health. Review of the medical record revealed no evidence a new PASRR was submitted for approval to the State agency prior to admission on [DATE]. Interview on [DATE] at 4:36 P.M. with Social Worker #376 verified a new PASRR was not requested for Resident #53 when it expired on [DATE], and no valid PASRR was currently in place for Resident #53's continued stay at the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365711 If continuation sheet Page 12 of 19 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 365711 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chardon Center 620 Water Street Chardon, OH 44024 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 0660 Plan the resident's discharge to meet the resident's goals and needs. 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 ensure Resident #52 had a current discharge plan of care and failed to have documented evidence of care plan meetings. This affected one (Resident #52) of two (Residents #52 and #79) reviewed for discharge. The facility census was 77. Residents Affected - Few Findings include: Review of the medical record for Resident #52 revealed an admission date of 02/02/19. Diagnoses included dementia, diabetes, difficulty in walking, acute embolism and thrombosis of left lower extremity. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 11/03/19, revealed the resident required the extensive assistance of one person for bed mobility, dressing, toilet use and personal hygiene. Extensive assistance of two people was needed for transfers. Supervision was needed for locomotion in a wheelchair. Review of the annual MDS 3.0 assessment, dated 10/11/19, revealed the resident had impaired cognition. Review of the care plans for Resident #52 revealed there was no discharge plan in place. Review of the medical record for Resident #52 revealed no documented evidence of care plan meetings. Review of the nursing progress note on 09/19/19 at 11:18 A.M. the interdisciplinary team (IDT) revealed Resident #52's original admission was 10/18/18, the resident was discharged home. Resident #52 was readmitted from home on [DATE]. The resident's family had not managed the resident at home, and Resident #52 was Long-Term Care (LTC) with a guardian. Review of the Baseline Care Plan signed 02/04/19 revealed the original discharge plan was for the resident to discharge home. Interview on 12/15/19 at 11:07 A.M. with Resident #52 revealed the resident wanted to know when she would be able to go back home to live with her children. Interview on 12/17/19 at 6:08 P.M. Licensed Social Worker (LSW) #376 stated Resident #52's children were not able to take care of her. The resident had a guardian appointed on 06/11/19. Interview on 12/18/19 at 3:05 P.M. LSW #376 verified there was no current discharge plan in the medical record, and there had been no documented care plan meetings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365711 If continuation sheet Page 13 of 19 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 365711 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chardon Center 620 Water Street Chardon, OH 44024 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure timely assessments were completed and adequate interventions were implemented to prevent the development of three unstageable pressure ulcers for Resident #55. Residents Affected - Few Actual Harm occurred on 12/05/19 when Resident #55, who was bedfast and required extensive assistance to total dependence on staff for activity of daily living care, including bed mobility and transfers developed unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough [yellow, tan, gray, green or brown tissue] and/or eschar [tan brown or black tissue] in the wound bed) pressure ulcers to the right heel, left heel and coccyx. This affected one Resident (#55) of two residents reviewed for pressure ulcers. The facility identified three current residents with pressure ulcers. Findings include: Record review revealed Resident #55 was admitted to the facility on [DATE] with diagnoses including type two diabetes mellitus without complications, dementia, congestive heart failure and chronic obstructive pulmonary disease. Review of the physician's orders revealed the following orders: A diet order on 07/02/19 for a consistent carbohydrate diet, no added salt. On 08/13/19 a physician order for Med Plus no sugar added (NSA) four ounces twice a day as a nutritional supplement. On 10/18/19 fortified foods three times a day were added to the resident meals along with a 2:00 P.M. snack and bedtime (HS) snack. Review of Resident #55's care plan initiated 07/02/19 revealed Resident #55 had a potential for actual impairment to skin integrity due to fragile skin, edema to her lower extremities, a deficit in self care performance related to dementia, incontinent of urine and stool and was at nutritional risk for weight loss and dehydration. The interventions included apply barrier cream to buttocks and peri area after each incontinent episode, encourage good nutrition and hydration in order to promote healthier skin, provide and serve snacks and supplements as ordered, pressure relieving devices to bed and wheelchair, turn and reposition every two hours and elevate legs in bed. Record review revealed Resident #55 was discharged to the hospital on [DATE] with diagnoses of urinary retention and exacerbation of chronic obstructive pulmonary disease. The resident returned to the facility on [DATE]. Review of the 11/04/19 admission Evaluation completed by Licensed Practical Nurse (LPN) #352 upon the resident's return from the hospital revealed Resident #55 could not walk, did not stand or sit in a chair, used a mechanical lift for transfers and was dependent on staff to roll in the bed from back to sides and sides to back. The Braden Observation Tool dated 11/04/19 and authored by LPN #352 revealed Resident #55's skin was very moist, she was confined to bed, had potential problems with friction and shearing of the skin and very limited mobility being unable to independently make significant changes in body position. The tool scored the resident at moderate risk for skin breakdown with interventions listed as encourage turn and reposition, float heels, elevate legs above heart while in bed and place a blanket between resident and mechanical lift. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365711 If continuation sheet Page 14 of 19 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 365711 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chardon Center 620 Water Street Chardon, OH 44024 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 0686 Level of Harm - Actual harm Review of the physician orders, dated 11/04/19 revealed the resident was ordered to be non weight bearing (NWB), pressure reduction mattress to the bed, encourage and assist resident to float heels in bed, encourage and assist her to turn and reposition every two hours and a consistent carbohydrate, no added salt diet. The Med Plus NSA nutritional supplement was not reordered by the physician upon readmission. Residents Affected - Few Review of a progress note dated 11/05/19 and authored by Certified Registered Nurse Practitioner (CRNP) #900 revealed Resident #55 had been recently in the hospital for urinary retention, had a decrease in weight following the hospital stay of 12.4 pounds (weight noted at 160 pounds) and trace edema to the bilateral extremities. Review of the facility document titled MD Progress Note, dated 11/08/19, authored by Primary Care Physician (PCP) #901 revealed Resident #55 had an elevated blood sodium level at 149, her weight was stable at 174 pounds and she may have been dehydrated. The quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated Resident #55 had cognitive impairment, did not reject care, was at risk for pressure ulcers requiring pressure reducing devices to her bed and chair, was always incontinent of bowel and bladder and required total assistance by two staff for transfers and extensive assistance of two staff for bed mobility, dressing, toileting and hygiene. A physician order dated 11/12/19 revealed an order for Prafo boots (specialized boots used to relieve pressure to the heels in people who spend most of the time in bed ) while in bed. Review of a progress note dated 11/13/19 and authored by CRNP #900 revealed Resident #55 had not been eating well, would not sit up in bed more than 30 degrees, had trace edema and needed fluids encouraged due to high blood sodium levels being monitored by the CRNP. Review of the Braden Observation Tool dated 11/17/19 indicated Resident #55 was chair fast, had very limited mobility, adequate nutrition and was low risk for skin impairment. Review of the MD Progress Note dated 11/22/19 and authored by PCP #901 revealed Resident #55 had decreased by mouth intake of meals and was at risk for weight loss and dehydration so a diet downgrade would be considered because she refused to sit upright for meals. Review of the documented titled Skid Grid Non Pressure, dated 11/24/19, revealed the resident had developed on 11/17/19 an abrasion to her left front thigh from improper briefing. The abrasion was described as no skin loss, red in color, no exudate and size of 10.0 centimeters (CM) length by 10.0 cm width and 0.0 depth. Review of the Weekly Skin Check document dated 11/26/19 revealed new areas since the last skin check. A progress note dated 11/27/19 authored by Registered Dietitian (RD) #373 revealed the resident's weight was up three percent (%) and nursing staff reported her by mouth intakes were increased. RD #373 added the RN was made aware of the weight gain and current interventions would continue along with monitoring. There was no assessment of actual percentage of meal intakes or implementation of any supplements or meal fortifiers (foods used to provided a concentrated source of calories and protein) for nutritional support during this review by RD #373. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365711 If continuation sheet Page 15 of 19 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 365711 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chardon Center 620 Water Street Chardon, OH 44024 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 0686 Review of the Weekly Skin Check documented dated 12/03/19 indicated there were no new skin areas. Level of Harm - Actual harm Review of the facility documents titled Skin Monitoring Comprehensive CNA Shower Review, from 11/07/19 to 12/05/19 revealed the resident was provided bed baths due to shower refusals during that time frame, there were no skin impairment areas identified to the heels or coccyx and the sheets were signed and dated by the charge nurses. Residents Affected - Few Review of a progress note dated 12/06/19 at 7:54 P.M. revealed while Resident #55 was being moved with the mechanical lift from the bed to the shower chair it was identified the resident had discoloration to her bilateral heels, an area to the right lateral foot, an abrasion to left third toe and discoloration to coccyx. The note continued to describe the right heel had a deep tissue injury measuring four centimeters (cm) in length by five cm, the left heel had deep tissue injury measuring 2.5 cm in length by 5.8 width, the coccyx had an unstageable ulceration measuring 1.2 cm by 1.5 cm and third toe had an abrasion. The physician and daughter were made aware of the ulcers and treatments were ordered at that time. Review of the document titled Skin Grid Pressure, dated 12/06/19 and authored by LPN #370 revealed an in-house acquired right heel pressure ulcer identified on 12/05/19 measuring 4.0 cm length by 5.0 cm width with an undetermined (UTD) depth and suspected deep tissue injury (SDTI). The ulcer was assessed to have indistinct edges, red color with granulation tissue present, no drainage or pain. The treatment order was paint with betadine (an anti-septic solution used to prevent infection) and cover with a foam dressing daily. Review of the document titled Skin Grid Pressure, dated 12/06/19, and authored by LPN #370 revealed an in-house acquired left heel pressure ulcer identified on 12/05/19 measuring 2.5 cm length by 4.8 cm width with an undetermined (UTD) depth and suspected deep tissue injury (SDTI). The ulcer was assessed to have indistinct edges, eschar (tan, brown or black color) with necrotic (dead) tissue present, no drainage or pain. The treatment order was paint with betadine (an anti-septic solution used to prevent infection) and cover with a foam dressing daily. Review of the document titled Skin Grid Pressure, dated 12/06/19 and authored by LPN #370 revealed an in-house acquired coccyx pressure ulcer identified on 12/05/19 measuring 1.2 cm length by 1.5 cm width with an undetermined (UTD) depth and unstageable. The ulcer was assessed to have distinct edges, with yellow slough (dead skin tissue that may have yellow or white appearance) present, bloody drainage and no odor. The treatment order was for medihoney and a foam dressing daily. On 12/16/19 at 1:31 P.M. RN #375 and LPN #335 were observed completing wound care for Resident #55. Proper infection control procedures were followed and the resident denied pain before starting the dressing changes. Upon positioning the resident to expose the coccyx there was no dressing in place and a small area of dry pink and dark color skin was noted on the coccyx. A dressing dated 12/15/19 was removed from the right heel. The right heel was observed to have a large purple and black colored area which was covered with eschar. A dressing dated 12/15/19 was removed from the left heel. The left heel appeared calloused with purple dotted areas of deep injury. The resident retracted her left foot during cleansing and complained of extreme tenderness to the left heel. All ordered treatments were implemented and dated 12/16/19. On 12/17/19 at 11:01 A.M. observation and interview with Resident #55 revealed she appeared pale and tired, as she closed her eyes a few times during the conversation. The resident was able to have reciprocal conversation remaining oriented to the situation. She was laying on her back on a pressure (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365711 If continuation sheet Page 16 of 19 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 365711 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chardon Center 620 Water Street Chardon, OH 44024 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 0686 Level of Harm - Actual harm Residents Affected - Few reducing mattress, head elevated to approximately 30 degrees and her heels were wrapped in white bandages and elevated on a bolster. Resident #55 had been watching television while waiting for her lunch. She was alert with some confusion, as she said she did not remember why she had bandages on her feet. She indicated she preferred to stay in bed only occasionally getting up to a chair and did not have a good appetite. On 12/17/19 at 4:54 P.M. during an interview with Certified Dietary Manager (CDM) #372, CDM #372 revealed prior to her going to the hospital on [DATE] the resident had been receiving fortified foods that consisted of fortified cereal, fortified potato and fortified pudding but it was not restarted when she returned from the hospital on [DATE]. CDM #372 said it was up to the registered dietitian to implement the fortified foods. She added the resident did receive snacks twice a day as before she went to the hospital. On 12/18/19 from 9:56 A.M. to 10:27 A.M. interview with RD #373 verified she had not completed a comprehensive nutritional assessment on the resident when she returned to the facility on [DATE] but instead did a progress note on 11/27/19 addressing the three percent weight gain with no new recommendations. RD #373 identified Resident #55 as a nutritional risk prior to her hospitalization on 11/01/19, had put her on fortified foods three times a day and Med Plus NSA supplement four ounces twice a day with snacks twice a day. RD #373 verified the Med Plus NSA and fortified foods were not restarted for the resident upon return to the facility on [DATE]. RD #373 shared she implemented a Promod (protein) supplement on 12/06/19 after the multiple in-house acquired pressure ulcers were reported to her at the weekly meeting but as of 12/18/19 she had still not done a comprehensive nutritional assessment of the resident with the last one being 09/25/19 when her quarterly review was due. On 12/18/19 at 1:11 P.M. interview with LPN #314 who reviewed the Skin Monitoring Comprehensive CNA Shower Review documents from 12/01/19 and 12/05/19 verified the documents indicated there were no skin impairment areas notated on them. LPN #314 added she would assume the resident's skin was intact during that time period based on the documents reviewed. On 12/18/19 at 4:02 P.M. interview with the Director of Nursing (DON) and RN #375 both verified Resident #55 developed pressure related wounds to her bilateral heels and coccyx in the facility. The DON revealed she believed the wounds were caused because Resident #55 had edema in her legs and was wearing Prafo boots in bed which caused the pressure on her heels. She had no comment regarding how the ulcer on the resident's coccyx developed or how it first identified as an unstageable pressure ulcer. On 12/18/19 at 4:41 P.M. during an interview with RN #375, the RN indicated she believed the coccyx pressure ulcer developed from prolonged pressure as a result of the resident having the head of her bed elevated, edema in her heels and keeping her legs elevated put pressure on the coccyx. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365711 If continuation sheet Page 17 of 19 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 365711 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chardon Center 620 Water Street Chardon, OH 44024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview and record review, the facility failed to ensure Resident #52 was wearing a wander/elopement alarm per physician's order. This affected one (Resident #52) of two (Residents #52 and #8) reviewed for wandering/elopement. The facility census was 77. Findings include: Review of the medical record for Resident #52 revealed an admission date of 02/02/19. Diagnoses included dementia, diabetes, difficulty in walking, acute embolism and thrombosis of left lower extremity. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 11/03/19, revealed the resident required the extensive assistance of one person for bed mobility, dressing, toilet use and personal hygiene. Extensive assistance of two people was needed for transfers. Supervision was needed for locomotion in a wheelchair. A wander/elopement alarm was used daily. Review of the annual MDS 3.0 assessment, dated 10/11/19, revealed the resident had impaired cognition. Review of the Wandering Observation Tool dated 10/15/19 revealed the resident was at risk for elopement. Review of the plan of care dated 07/15/19 revealed the resident was at risk for elopement/wandering behavior related to an attempt to exit out the front door. Interventions included to apply a code alert bracelet, check function every shift, check placement every shift, assess for hunger, thirst, ambulation or toileting needs when found attempting to exit and provide diversionary activities. Review of the physician's orders for 12/2019 identified orders for a code alert bracelet (a bracelet that alerts staff if a resident attempts to exit the facility). Observation and interview on 12/17/19 at 1:41 P.M. revealed Resident #52 was not wearing a code alert bracelet. The Assistant Director of Nursing (ADON)/ Registered Nurse (RN) #375 checked the resident for wander guard/code alert bracelet placement and verified it was not on the resident. Interview on 12/17/19 at 3:32 P.M. with RN #375 revealed Resident #52's wander guard/code alert bracelet was just found in the laundry. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365711 If continuation sheet Page 18 of 19 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 365711 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chardon Center 620 Water Street Chardon, OH 44024 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on record review, observation and interviews, the facility did not ensure foods were served at palatable temperatures. This had the potential to affect all residents in the facility except for one Resident (#35) who did receive food by mouth. The facility census was 77. Residents Affected - Many Findings included: Resident interviews were conducted on 12/15/19 from 9:06 A.M. to 12:45 P.M. with Residents #25, #27, #39, #45 and #52. The residents consistently reported that hot foods were not hot and it could be at any meal the food was not hot. Resident #52 said she expected to get cold eggs when they were ordered. Resident #45 shared he did not eat a full meal a lot of times due to the hot foods being too cool, and he had lost weight. Resident #39 said the longer the trays sit in the hall waiting to get passed the colder the food was to him. Record review was conducted of the Food Committee Meeting Minutes dated 06/2019 which indicated foods were served at the proper temperature based on the floor staffing. On 09/19/19 the minutes reflected foods were served at the proper temperatures most of the time, but the meal carts took too long to pass. On 11/14/19 a comment was noted regarding eggs being cold in the morning. Observation was conducted on 12/18/19 at 10:59 A.M. of the lunch trayline food temperatures in the kitchen with Certified Dietary Manager (CDM) #372. CDM #372 used a calibrated, digital touch point thermometer to obtain the following food temperatures: balsamic pork - 209.5 degrees Fahrenheit (F), roasted potato 176 degrees F, zucchini - 169.5 degrees F and scalloped apples - 31.3 degrees F. Tray line service began at 11:11 A.M. with CDM #372 serving. She placed the foods onto a plate that had been warmed in a stainless steel plate warming unit. The plates were then placed onto a plastic thermal base and covered with a plastic thermal dome cover. The thermal bases and dome covers were noted to be aged to the point the plastic was starting to separate forming a scale like appearance to the domes and bases. The cart going to the 100 unit for room trays was loaded with 12 trays and the last tray, a test tray, at 11:19 A.M. At 11:22 A.M. the cart left the kitchen and arrived on the 100 unit at 11:23 A.M. District Dietary Manager (DDM) #371 followed the cart to the unit with the surveyor. Using a calibrated, digital touch point thermometer DDM #371 began taking test tray temperatures at 11:32 A.M. when the last tray, the test tray, was passed by the unit staff. The test tray temperatures were as followed: milk - 37 degrees F, scalloped apples 40.7 degrees F, balsamic pork 104.3 degrees F, roasted potato 113.5 degrees F and zucchini 113.9 degrees F. The food flavor and texture were good, however, the food temperature palpability of the pork, potato and zucchini felt barely warm in the mouth. These temperatures were verified with DDM #371 at the time of the observation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365711 If continuation sheet Page 19 of 19