Health inspection·July 29, 2024

F 0677 Level of Harm - Actual harm Tiny white worms were noted on top of the resident's tongue when mouth care was provided. The resident sneezed and more tiny white worms came out of her nostrils. The concern was reported to the administration and the physician. A call was placed to the hospice nurse who was asked to return to the facility to address. Residents Affected - Few Review of Resident #99's progress note dated 06/21/24 at 12:30 P.M. authored by LPN #821 indicated the hospice nurse returned to the facility to assess the resident. Review of Resident #99's progress note dated 06/21/24 at 2:00 P.M. authored by LPN #821 indicated the hospice nurse collected a tiny white worm specimen to send with the resident to the ER. A call was placed to 911 per hospice and the resident's son was notified via the phone by the hospice nurse and updated on the resident's condition. Review of Resident #99's progress note dated 06/21/24 at 5:17 P.M. authored by the Administrator indicated the hospice nurse informed him that she spoke with the resident's family, and they were aware of the reason for hospitalization and in agreement with the plan. The hospice nurse stated they were going to ensure a head CAT scan (CAT or CT which was a computed tomography scan or medical imaging technique that uses X-rays and computers to create detailed cross-sectional images of the inside of the body) and a chest X-ray were completed, and that the family had already asked about an in-patient hospice house. Review of Resident #99's progress note dated 06/21/24 at 11:27 P.M. authored by LPN #822 indicated a call was placed to the ER to obtain an update on the resident. The resident had been transported by a private ambulance to the hospice center. Review of Resident #99's hospital documentation dated 06/21/24 indicated the resident presented from the skilled nursing facility (SNF) for concerns of larvae in the resident's nose. Nursing was completing oral and mouth care and noted larvae in the nose. The resident had ALS and was nonverbal. She had a percutaneous endoscopic gastrostomy tube (PEG tube which was passed into a resident's stomach through the abdominal wall to provide a means of feeding when oral intake was not adequate). The resident was on hospice services, and they provided care as well. The hospice team was worried about the resident's airway and sent the resident in for an airway assessment. A CAT of the facial area was ordered to evaluate the extent of an intraoral involvement or airway involvement. The CAT of the facial without contrast was obtained per the request of hospice services and there was no evidence of an erosive abnormality noted in the facial region. A reassessment of the resident did not reveal evidence of intraoral larvae or maggots. The resident did have a dry tongue and received all nutrition through the PEG tube. The resident was moved to the hospice care center and would be discharged from the ED for hospice ongoing care. The larvae were sent for an analysis but were most likely consistent with a fly. Review of the Timeline of Events (facility investigative report) for Resident #99 dated 06/21/24 indicated at 9:30 A.M. the facility notified hospice of an intolerance to the current tube feeding regimen and the hospice nurse reported that a tiny white worm was found on the resident's chest when providing a bed bath. At 9:50 A.M., the facility nurse and two staff members completed a full body assessment and noted that white worms were on top of the resident's tongue during oral care. The resident sneezed and more came out of the nasal passages. The Administrator, physician and hospice were notified. At 11:30 A.M., the hospice nurse returned to the facility and obtained a specimen to send to the emergency room (ER). The family was notified at this time. At 2:37 P.M., the facility completed oral assessments on all residents to ensure no other residents were affected. No other concerns (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365731 If continuation sheet Page 2 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365731 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/29/2024 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 0677 Level of Harm - Actual harm Residents Affected - Few were identified. Housekeeping did an audit of rooms and the building, and no other flies were noted. Window screens were audited, and six screens were noted to have holes in them. Tape was applied to the holes until repairs could be made. Audits would be completed three times a week for oral care for five residents per the Director of Nursing (DON) and/or designee. The concern would be reviewed in the quality assurance perform improvement (QAPI) meeting. Information obtained from the resident's family as part of the complaint investigation revealed Resident #100 had been admitted to the facility since late April 2022 and had a diagnosis of ALS. The family revealed they had been contacted by a hospice nurse, (this nurse visited the resident weekly) on Friday 06/21/24 indicating she had some bad news. The family revealed what was reported to them left them horrified and speechless. The nurse informed the family that a nurse's aide found fly larvae in the resident's mouth. The family stated literal fly eggs that had hatched into larvae and were now feeding on my poor mother, while she laid in bed not being able to move or help herself. The resident was transferred to the hospital for a CT scan to determine how deep the bug infestation had made it into her sinuses and lungs. The family indicated the next 24 hours were very rough having to endure multiple bug larvae being extracted from her body. Interview on 07/29/24 at 8:15 A.M. with the Administrator indicated he was aware that the hospice nurse had observed a maggot on Resident #99's shirt/gown on 06/21/24. Interview on 07/29/24 at 8:23 A.M. with State Tested Nursing Assistant (STNA) #814 indicated she assisted STNA #817 with Resident #99's ADL care when the hospice nurse had discovered a maggot crawling across the resident's gown. STNA #814 confirmed she had looked in Resident #99's mouth during oral care and had observed five maggots in the resident's mouth. She stated she also did see a maggot drop out of the resident's left nostril during care. She stated the resident always had her mouth open and could not move independently from the neck down. She stated the resident was dependent on all care. Telephone interview on 07/29/24 at 8:48 A.M. with Licensed Social Worker (LSW) for hospice house #816 revealed Resident #99 was admitted to their facility on 06/21/24 and discharged home on [DATE]. She was aware of maggots in the resident's mouth and nose but unable to provide further details. Telephone interview on 07/29/24 at 9:22 A.M. with Hospice Registered Nurse (RN) #846 and Chief Quality Officer for Hospice #815 confirmed on 06/21/24, she had assessed Resident #99 in the morning and provided a bed bath with the hospice nurse. She stated at that time, a small fly larvae was discovered crawling across the resident's chest on top of the gown. Hospice RN #846 stated she did a body assessment and could not determine the cause of the fly larvae so she notified the shift nurse. She stated she was called by the facility later in the day and was informed by the facility that the resident had sneezed and found maggots in her nose. Hospice RN #846 confirmed she went back to the facility and assessed the resident and identified a maggot in her right nostril which she scooped out and placed in a plastic bag to be sent with the resident to the ER. Hospice RN #846 confirmed Resident #99 was discharged to the hospital and then to the hospice house before discharging home. Interview on 07/29/24 at 11:42 A.M. with the DON confirmed Resident #99's oral care should be completed every shift by the nursing staff and the facility had three shifts per day. The DON also confirmed the resident's oral care was not completed as required as evidenced by the documentation in the resident's medical record. A follow up interview on 07/29/24 at 1:40 P.M. with STNA #814 confirmed she had observed three or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365731 If continuation sheet Page 3 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365731 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/29/2024 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 0677 four flies flying around Resident #99's room on 06/21/24 when the maggots were discovered in the resident's nose and mouth. Level of Harm - Actual harm Residents Affected - Few Review of the facility ADL policy, reviewed 08/2021, revealed residents would be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out ADL care. Appropriate care and services would be provided for residents who were unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, grooming and oral care). The deficient practice was corrected on 06/26/24 when the facility implemented the following corrective actions: • Regional Support RN #551 completed staff inservices for ADLs and Oral Care Recommendations in person on 06/21/24 which included RN #810, LPNs #821, #902, #903, STNAs #805, #820, #825, #901. • Regional Support RN #551 and STNA Scheduler #808 completed additional staff inservices for ADLs and Oral Care Recommendations via the telephone for all other nursing staff from 06/21/24 at 3:55 P.M. to 06/23/24 at 12:40 P.M. which included 3 RNs, 10 LPNs and 19 STNAs. • LPN #821 completed Oral Cavity Assessment Audits of all residents on 06/21/24 with no negative findings. • Director of Housekeeping #552 completed an audit of resident rooms for flies on 06/21/24 with no negative findings. • Director of Housekeeping #552 completed an audit for intact window screens on 06/21/24. The facility identified six resident rooms with holes in the screen including rooms 104, 106,108, 111 and 115. Tape was placed over the holes in the screens. • A QAPI Meeting was held on 06/24/24 at 3:45 P.M. with the Administrator, DON via phone and Medical Director via phone. No other staff had signed the form including the Infection Preventionist, Dietitian/Dietary Representative, Pharmacy Representative, Lab Representative, Life Enrichment Representative, Life Enrichment Representative, Environmental Services, Rehabilitation/Restorative Representative, MDS Representative, Safety Representative, Medical Records Representative and Human Resources. • (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365731 If continuation sheet Page 4 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365731 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/29/2024 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 0677 The DON completed Oral Care Audits beginning 06/26/24 for three times a week for five weeks. Level of Harm - Actual harm • Residents Affected - Few Pest control services were provided for flies in the facility with fly baits on 06/17/24, 06/24/24, 07/15/24 and 07/17/24. The facility maintained the use of a contracted company for pest control. This deficiency represents non-compliance investigated under Complaint Number OH00155328. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365731 If continuation sheet Page 5 of 5