Inspection·March 18, 2024

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the physical therapy evaluation and plan of treatment dated 02/01/23 revealed Resident #57 was using a power wheelchair. Review of the MDS 3.0 quarterly assessment dated [DATE] revealed Resident #57 was cognitively intact and used a wheelchair for mobility. Review of the pest control invoice dated 02/01/23 revealed treated chair from (Residents #56 and #57's room) for bed bugs. Review of the pest control invoice dated 02/03/23 revealed treated chair for bed bugs. Review of the pest control invoice dated 02/06/23 revealed treated (Residents #56 and #57's room) for bed bugs and also treated both electric chairs. Interview on 03/11/24 at 2:05 P.M. with Social Service Designee (SSD) #8 revealed Resident #56 shared a room with her son (Resident #57) and their room kept getting infested with bed bugs so two weeks after arriving at the facility, their power wheelchairs were moved outside. Observation on 03/11/24 at 2:10 P.M. outside and behind the facility by the dumpster and facility garage with SSD #8 revealed two power wheelchairs sitting side by side. The chair backs of both the power wheelchairs were covered with plastic bags however the rest of the power wheelchairs were exposed to the elements including the batteries and toggle controls. There was approximately one inch of snow sitting on both power wheelchairs and the metal frames had portions of rust. Interview, during the observation, with SSD #8 verified the power wheelchairs were uncovered and left outside to the elements and temperature. Interview on 03/11/24 at 2:15 P.M. with the Administrator revealed both Resident #56 and #57's wheelchairs were infested with bed bugs and cockroaches when they arrived at the facility. After numerous pest control treatments, both electric power wheelchairs were pushed out of the building. Observation on 03/11/24 at 3:15 P.M. of the outside and back of the facility by the dumpster and garage with the Administrator revealed of the power wheelchairs covered with snow. Interview, during the observation, with Administrator verified the power wheelchairs were uncovered and exposed to precipitation and temperature. Interview on 03/11/24 at 3:45 P.M. with former Resident #56 revealed she had a stroke and mainly used her power wheelchair for mobility. The power wheelchairs worked when her and her son arrived at the facility. However, the power wheelchairs were placed outside in the snow and rain due to bed bugs. This deficiency represents non-compliance investigated under Complaint Number OH00151533. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365731 If continuation sheet Page 2 of 11 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 365731 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE East Park Care Center 8 East Park Circle Brook Park, OH 44142 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 observation, review of the Self-Reported Incident (SRI) log, personnel record review, court docket review, facility policy review, and interview, the facility failed to implement their abuse policy and procedure regarding reference checks. This had the potential to affect all residents who resided in the facility. The census was 55. Residents Affected - Many Findings include: Review of the personnel record for State Tested Nurse Aide (STNA) #2 revealed a hire date of 09/27/22. Review of the Application for Employment dated 09/26/21 revealed STNA #2 answered no to the question of have you ever plead guilty to or been convicted of a crime other than a driving-related misdemeanor? There were two Verification of Employment forms referencing STNA #2's current and past skilled nursing facility (SNF) employers. The two Verification of Employment forms were incomplete and there was no evidence the forms were sent to the two employers to answer. Review of the State Nurse Aide Registry license verification form revealed STNA #2 was not eligible to work and was not in good standing due to committing abuse, neglect or misappropriation and could not be employed by a long-term facility in any capacity. Review of the Court of Common Pleas for Cuyahoga County court docket revealed STNA #2 pleaded guilty to identity fraud, misuse of credit cards, fraud, aggravated theft and telecommunications fraud on 08/02/16 and pleaded guilty to identify fraud and aggravated theft on 03/02/23. Review of the State Nurse Aide Abuse Listing document revealed STNA #2 was added to registry for findings of abuse, neglect, misappropriation or exploitation on 02/01/24. Review of the facility's SRI Log from September 2022 to March 2024 revealed there were 23 resident misappropriation allegations on the following dates: 10/03/22, 10/16/22, 10/18/22, 10/21/22, 10/25/22, 10/31/22, 11/14/22, 11/24/22, 12/30/22, 01/28/23, 03/09/23, 03/15/23, 03/17/23, 04/04/23, 05/20/23, 05/22/23, 07/02/23, 07/17/23, 08/30/23, 09/10/23, 01/18/24, 01/22/24 and 02/17/24. Observation on 03/11/24 at 9:37 A.M. revealed STNA #2 was working and assisting residents on the North Hall. Interview on 03/11/24 at 9:53 A.M. with STNA #2 revealed she had been employed at the facility since September 2022. Interview on 03/11/24 at 10:30 A.M. with the Administrator revealed when reviewing STNA #2's personnel record on this date, it was found that STNA #2's registry verification form was not in her personnel record and when the STNA registry verification was searched on this date, it was found that STNA #2 was not in good standing with the State. The Administrator asked STNA #2 if she had any inclination of why she was not in good standing with the State, STNA #2 replied that she did not know and she was not notified by the State she was not in good standing. The Administrator revealed STNA #2 was suspended pending investigation. A follow-up interview on 03/11/24 at 11:00 A.M. and on 03/12/24 at 2:25 P.M. with the Administrator verified there was no evidence that reference checks were completed for STNA #2. The Administrator also verified there had been several SRIs of allegations of misappropriation since STNA #2 began employment at the facility. The Administrator verified the facility's abuse policy was not followed in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365731 If continuation sheet Page 3 of 11 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 365731 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE East Park Care Center 8 East Park Circle Brook Park, OH 44142 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 regards to thoroughly screening new staff hired by completing reference checks. Level of Harm - Minimal harm or potential for actual harm Review of the facility's Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property dated 10/06/22 revealed it was the facility's policy to undertake background checks of all employees and to retain on file applicable records of current employees regarding such checks. The facility would do the following prior to hire of a new employee: conduct a criminal background check in accordance with Ohio law and the facility's policy, and verify that the applicant had not been found guilty of abuse, neglect, exploitation, misappropriation of property or mistreatment by a court of law or had been convicted of an offense that otherwise prohibited employment .and attempt to obtain information from previous employers or current employers. Residents Affected - Many This deficiency represents non-compliance investigated under Complaint Number OH00151533 and OH00150574. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365731 If continuation sheet Page 4 of 11 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 365731 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE East Park Care Center 8 East Park Circle Brook Park, OH 44142 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 0624 Prepare residents for a safe transfer or discharge from the nursing home. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed medical record review, policy review and interview, the facility failed to provide an orderly discharge for former Resident #56. This affected one (Resident #56) of three former residents reviewed for discharging against medical advice (AMA). The census was 55. Residents Affected - Few Finding include: Review of the closed medical record for former Resident #56 revealed an admission date of 01/31/23, discharge date of 12/12/23 with diagnoses of hemiplegia and hemiparesis, muscle weakness, cognitive communication deficit, reduced mobility, and homelessness. Review of the hospital social work assessment and discharge plan dated 01/25/23 revealed Resident #56 and Resident #56's son (Resident #57) were evicted that morning. Resident #56's case manager was told to present to the emergency department to help with placement. Resident #56 had applied to multiple apartments since getting the eviction notice and was on multiple wait lists and unable to stay with friends or family as there were not any in the community. Resident #56 was agreeable to respite care at skilled nursing facility. Review of the social history assessment dated [DATE] revealed Resident #56 used Paratransit for transportation and anticipated discharge plan/goals were to give strength/time to find affordable, adequate housing. Review of the discharge care plan dated 02/11/23 revealed Resident #56 had a return to the community referral and desired to talk to the State designated local contact agency about resources available for returning to the community. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed Resident #56 was cognitively intact, needed supervision or touching assistance with transferring from bed-to-chair, and used a wheelchair for mobility. Resident #56 was actively participating in the active discharge plan to return to the community and a referral had been made to the local contact. Review of the plan of care note dated 10/05/23 authored by Social Services Designee (SSD) #8 revealed care a conference was held with SSD #8 and representative from Home Choice for both Resident #56 and #57 to discharge plan. They were at the end of the 180-day period for Home Choice and the representative was recommending the case be closed at this time due to Resident #57's lack of cooperation and to failure to communicate with the representative. Residents #56 and #57 could reapply at a later time. Resident #56 had all required information and could choose to leave without Resident #57 if her name came up on the Cuyahoga Metropolitan Housing Authority (CMHA) waiting list. Review of nurse practitioner (NP) progress note dated 11/16/23 revealed Resident #56 was homeless, and her son (Resident #57) was her roommate. Review of the Notice of Discharge and Transfer letter dated 12/06/23 revealed Resident #56 would be discharged and transferred from the facility on 01/04/24 because the resident had failed, after reasonable and appropriate notice, to pay current and past due patient liability for the care provided by the community. It was proposed for Resident #56 to be discharged to an extended stay hotel. The letter was signed by the Administrator; Resident #56 refused to sign the letter. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365731 If continuation sheet Page 5 of 11 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 365731 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE East Park Care Center 8 East Park Circle Brook Park, OH 44142 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 0624 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of NP #7's progress note dated 12/11/23 revealed Resident #56 was requesting leave of absence (LOA) tomorrow (12/12/23) to go to the store. Resident #56 was wheelchair dependent and had a history of a cerebrovascular accident (CVA) with left sided weakness. The progress noted indicated Resident #56 could only go on LOA if family accompanied secondary to debility. Review of the health status note dated 12/11/23 revealed after Nurse Practitioner (NP) #7 interaction/interview with Resident #56, NP #7 ordered that resident may go on LOA with family member or friend if she wished to go on LOA. This information was provided to resident. Review of the December 2023 physician orders revealed Resident #56 may have LOA only if family accompanying secondary to debility. Review of the plan of care note dated 12/12/23, timed 11:44 A.M. authored by SSD #8 revealed Resident #56 was insistent that she was going to leave to go to a phone store via Paratransit. SSD #8 offered to get her a battery on her behalf for her phone. She declined. She arranged her own transportation through Paratransit. Her Brief Interview for Mental Status (BIMS) was 15 (cognitively intact). She was her own responsible party. The Administrator explained several times to her that the nurse practitioner indicated that if she chose to leave today without assistance that she would be discharged against medical advice (AMA) and unable to return. She was educated that this did not appear to be a safe plan and that she should reconsider leaving at this time. She refused to sign AMA form and left via Paratransit. Review of the health status note dated 12/12/23 timed 12:15 P.M. revealed Resident #56 stated to the nurse that she was going out and she had called Paratransit for transport. This nurse stated to resident that she would need an escort when leaving the facility. Resident refused escort and was directed over to the social services and Administrators office. Resident #56 continued to state that she was leaving the facility and refused to sign the AMA form. Resident #56 left on Paratransit around 11:00 A.M. Review of the Facility Discharge Against Medical Advice letter dated 12/12/23 revealed the Administrator and two witnesses signed the letter; however, Resident #56 refused to sign the letter. Interview on 03/11/24 at 1:10 P.M. with NP #7 revealed NP #7 ordered Resident #56 to have a LOA with family/friend because of NP #7's concern for Resident #56's debility as the resident was in a wheelchair. Interview on 03/11/24 at 2:05 P.M. with SSD #8 revealed Resident #56 wanted to go on a LOA so the nurse practitioner wrote an LOA with a family/friend order yet the resident proceeded to go on the LOA by herself. Resident #56 attempted to return to the facility that same day (12/12/23) however the Administrator spoke to the resident and explained that she had discharged AMA so Resident #56 was taken to a hotel. Interview on 03/11/24 at 2:15 P.M. and 3:30 P.M. with the Administrator revealed Resident #56 had wanted to go the store to purchase a battery for her cell phone so the nurse practitioner wrote an order for a supervised LOA due to concerns that Resident #56 had difficulty getting around in her wheelchair. Resident #56 notified the staff that her ride via Paratransit would be arriving soon however the facility wasn't able to get a staff member to escort her in such short notice. Resident #56 was adamant on going and refused to sign the AMA paperwork. Resident #56 came back to the facility a few hours later around 3:30 P.M. The Administrator had Resident #56 sign in as a visitor to see (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365731 If continuation sheet Page 6 of 11 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 365731 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE East Park Care Center 8 East Park Circle Brook Park, OH 44142 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 0624 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #57 and educated her that she had been discharged . An hour later, Resident #56 reported she didn't have a ride from the facility and wanted to spend the night at the facility so the Administrator secured her a room at a nearby hotel and dropped her off the hotel that evening. The following day (12/13/23), the facility tried to contact Resident #56 at the hotel for her medication list but the resident had already checked herself out of the hotel. The Administrator verified Resident #56's intent was to go on a LOA to purchase a cell phone battery not to discharge from the facility. Interview on 03/11/24 at 3:45 P.M. with former Resident #56 revealed when she returned from the store on the bus, Resident #56 was greeted by the Administrator and told, you can't stay here, you need someone to come pick you up. Resident #56 stated she didn't have any place to go so the Administrator drove her to a hotel. The only reason the resident went to the hotel was because the Administrator wouldn't allow her to stay at the facility. Resident #56 revealed her and her son (Resident #57) had been living in an extended hotel ever since discharging from the facility. Interview on 03/12/24 at 12:50 P.M. with the Administrator verified Adult Protective Services were not notified of Resident #56's discharge. Review of the facility's undated Leave of Absence policy revealed the facility recognized there would be times a resident wished to leave the facility. Residents who wished to leave the facility for a LOA could do so but were asked to follow the LOA procedures. Upon return to the facility, the nurse would document the date and time of the return, and the general health status of the resident at the time of the return. A resident who did not return within 24 hours of the expected date and time of return and did not communicate with the facility; or who notified the staff they were not returning, would be discharged . The physician would be notified to determine if a discharge order would be given. If the physician refused to give a discharge order the discharge would be considered to be AMA. Residents who left on an LOA and notified staff they were not returning would be encouraged to return to the facility to allow a safe discharge plan to be implemented. Review of the facility's Discharge Against Medical Advice policy dated February 2024 revealed to notify Adult Protection Services, or other entity, as appropriate if self-neglect was suspected. Document accordingly. This deficiency represents non-compliance investigated under Complaint Number OH00151533. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365731 If continuation sheet Page 7 of 11 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 365731 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE East Park Care Center 8 East Park Circle Brook Park, OH 44142 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 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, infection control log review and interview, the facility to timely obtain lab services for Resident #43. This affected one (Resident #43) of three residents reviewed for infections. The census was 55. Residents Affected - Few Findings include: Review of the medical record for Resident #43 revealed an admission date of 01/30/24 with diagnoses of parkinsonism, history of falling, rhabdomyolysis, metabolic encephalopathy and Clostridium difficile (C.diff) diarrhea. Review of the health status note dated 01/30/24 timed 5:45 P.M. revealed Resident #43 arrived via cot with admission diagnosis of C-difficile (a bacteria that causes diarrhea and colitis). Review of the health status note dated 01/30/24 timed 8:02 P.M. revealed contact precautions in effect for C.diff. Review of the Minimum Data Set (MDS) 3.0 admission assessment dated [DATE] revealed Resident #43 was cognitively intact, needed partial/moderate assistance with toileting and was always incontinent of bowel. Review of the health status note dated 02/09/24 revealed Resident #43 had completed oral Vancomycin (antibiotic) therapy for C.diff. No reported loose stools. Review of the physician progress note dated 02/16/24 revealed diarrhea had improved somewhat. Review of the health status note dated 02/16/24 revealed Resident #43 continued to have loose stools with incontinence. Required assistance with toileting hygiene. Review of the health status note dated 02/17/24 revealed Resident #43 remained on contact precautions related to positive C.diff. Resident reported he was still having loose stools. Review of the physician order dated 02/19/24 revealed send stool for C.diff/do not use urine cup. Review of the health status note dated 02/20/24 revealed stool sample for C.diff collected and sent to lab. Review of the nurse practitioner progress note dated 02/21/24 revealed Resident #43 was seen as follow up for diarrhea and history of C. difficile. Repeat stool sample sent in wrong medium. Order to be placed to send again. The progress note indicated the plan was to resend stool sample. Review of the physician order dated 02/21/24 revealed please resend stool for C.diff - was in the wrong specimen cup. Review of the nursing progress notes from 02/21/24 to 02/26/24 revealed there was no evidence of attempt(s) to obtain stool sample from Resident #43. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365731 If continuation sheet Page 8 of 11 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 365731 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE East Park Care Center 8 East Park Circle Brook Park, OH 44142 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 0770 Level of Harm - Minimal harm or potential for actual harm Review of the nurse practitioner progress note dated 02/26/24 revealed Resident #43 seen as follow up with history of C.diff. Resident with continuous loose stools. Will send repeat stool sample. The progress note indicated the plan was to send repeat sample. Review of the physician order dated 02/26/24 revealed please resend stool for C.diff. Residents Affected - Few Review of the health status note dated 02/26/24 timed 2:05 P.M. revealed the nurse practitioner was in to see Resident #43. See new order to recollect stool specimen to sent to lab to rule out C.diff. The previous specimen was not in correct container and was rejected by the lab. Review of the health status note dated 02/27/24 timed 4:17 A.M. revealed stool specimen for C.diff collected and already sent to lab. Review of the health status note dated 03/01/24 revealed positive C.diff results reported to nurse practitioner. See new orders. Review of the physician order dated 03/01/24 revealed Resident #34 was ordered Vancomycin HCl oral suspension give 125 milligrams by mouth every six hours for positive C.diff for 14 days. Review of the facility's Infection Control Log from March 2024 revealed Resident #43 had continued signs and symptoms of gastrointestinal C.diff. Vancomycin was started on 03/02/24 through 03/15/24. Observation on 03/11/24 at 11:15 A.M. revealed there was a Velcro Stop sign across Resident #43's doorway with a sign to see nurse and a personal protective equipment (PPE) bin outside the doorway. Resident #43 was standing in his room with a walker. Interview on 03/11/24 at 4:15 P.M. with Licensed Practical Nurse (LPN) #1 revealed the wrong container was used when Resident #43's stool was initially collected. LPN #1 verified there was a delay in recollecting the resident's stool sample. LPN #1 stated she was unaware Resident #43 was incontinent of stool, so she kept putting a hat (a specimen collection device) inside his toilet rather than trying to obtain the stool sample from his incontinence brief. Interview on 03/12/24 at 10:25 A.M. with the Director of Nursing (DON) (who was also one of the facility's Infection Control Preventionist) revealed the facility's lab days were Tuesday's and Friday's. The DON verified there was no evidence of nursing attempting to collect Resident #43's stool from 02/21/24 to 02/26/24. The DON verified Resident #43's stool should have been collected and sent to the lab on 02/23/24 (Thursday) which in turn delayed the positive C.diff lab result and delayed the start of antibiotics. This deficiency represents non-compliance investigated under Complaint Number OH00151451. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365731 If continuation sheet Page 9 of 11 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 365731 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE East Park Care Center 8 East Park Circle Brook Park, OH 44142 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed medical record review, Centers for Disease Control (CDC) website review, pest control invoices review, policy review and interview, the facility failed to eradicate bed bugs in a resident room prior to Resident #60 being admitted to the room. This affected one (Resident #60) of eight residents reviewed for bed bugs. The census was 55. Residents Affected - Few Findings include: Review of the closed medical record for Resident #62 revealed an admission date 01/04/24, discharge date to home of 02/04/24 with diagnoses of fracture of left femur, respiratory syncytial virus pneumonia, alcohol dependence and chronic embolism and thrombosis deep veins of left lower extremity. Resident #62 resided in private room [ROOM NUMBER] during his entire stay. Review of the closed medical record for Resident #60 revealed an admission date of 02/06/24, discharge date to home of 02/21/24 with diagnoses of cerebral infarction, aphasia, and hemiplegia and hemiparesis affecting left dominant side. Review of the Minimum Data Set (MDS) 3.0 admission assessment dated [DATE] revealed Resident #60 was moderately cognitively impaired and required substantial/maximal assistance with rolling left and right in bed. Resident #62 resided in private room [ROOM NUMBER] during her entire stay. Review of the pest control invoice dated 01/27/24 revealed Treated room [ROOM NUMBER] for bed bugs. No new activity found while treating (they found two). Review of the pest control invoice dated 02/09/24 revealed follow up treatment for room [ROOM NUMBER] with one live and one dead found on recliner. Nothing on bed. Interview on 03/12/24 at 10:50 A.M. with the Administrator verified there were active bed bugs in room [ROOM NUMBER] when Resident #62 resided in the room and the pest control company sprayed pesticides in the room then Resident #62 discharged on 02/04/24. The Administrator also verified that Resident #60 admitted to room [ROOM NUMBER] on 02/06/24 before the pest control company returned to inspect and/or retreat the room then when the pest control company returned on 02/09/23, the pest control company found room [ROOM NUMBER] to have continued active bed bugs. Review of the Centers for Disease Control (CDC) Bed Bugs Frequently Asked Questions website (www.CDC.gov) dated 09/16/20 revealed bed bugs were experts at hiding. Their slim flat bodies allowed them to fit into the smallest of spaces and stay there for long periods of time, even without a blood meal. Everyone was at risk for getting bed bugs when visiting an infected area. However, anyone who traveled frequently and shared living and sleeping quarters where other people have previously slept had a high risk of being bitten and spreading a bed bud infestation. The best way to prevent bed bugs was regular inspection for signs of an infestation. Review of the facility's undated General Pest Control policy revealed the community would be inspected/sprayed by a certified pest control provider on a semi-monthly schedule for the purpose of the prevention/elimination of general pests. If a pest problem should develop, the Maintenance Director or designee would contact the approved pest control vendor. The pest control vendor would report any problems or changes to the Maintenance Director. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365731 If continuation sheet Page 10 of 11 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 365731 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE East Park Care Center 8 East Park Circle Brook Park, OH 44142 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 0925 This deficiency represents non-compliance investigated under Complaint Number OH00151533, OH00151451 and OH00150574. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365731 If continuation sheet Page 11 of 11