Health inspection·October 28, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #20 revealed an admission date of 02/27/21 with diagnoses including cerebral infraction, a stroke affecting the right dominant side, dementia, aphasia, contracture of the right hand, atrial fibrillation, and legionnaires disease. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #20 had impaired cognition and required substantial to maximum assistance with showers and dressing. Review of the plan of care dated 09/24/24 revealed Resident #20 was recovering from legionnaires disease. Interventions included notifying the guardian and physician. In addition to assessing the resident's respiratory status. Review of the progress note dated 08/23/24 at 4:15 P.M. revealed Resident #20 was sent out to the hospital by emergency medical services (911) per physician order. Note dated 08/31/24 at 6:30 P.M. stated Resident #20 arrived by stretcher to the facility. The resident was alert and oriented and on two liters of oxygen. The resident presented with no distress or pain. There was no documented evidence that Resident #20's guardian was notified he was back from the hospital. Interview on 10/22/24 at 11:56 A.M. with Resident #20's guardian stated he did not know Resident #20 was back from the hospital. Interview on 10/28/24 at 2:33 P.M. with the Administrator verified there was no documented evidence that Resident #20's guardian was notified the resident returned to the facility. Review of the policy titled Change in a Resident's Condition' reviewed on 8/2023, revealed the facility shall notify the resident, his or her Attending Physician and representative (sponsor) of changes in the resident's medical/mental condition. This deficiency represents non-compliance investigated under Complaint Number OH00158492. Based on record review, interview, and facility policy review, the facility failed to timely notify emergency contacts/guardians of a change of condition in a timely manner for Residents #205 and #20. This affected two residents (#205, #20) of two residents reviewed for change of condition. The facility census was 50. Findings include: 1. Review of the medical record for Resident #205 revealed an admission date of 10/04/24 and a discharge date of 10/22/24 with diagnoses of vascular dementia with behavioral disturbance, atrial fibrillation, hypotension, hyperlipidemia, alcohol abuse, anxiety, major depressive disorder, and insomnia. Review of the care plan dated 10/19/24 revealed Resident #205 was at fall risk related to impaired balance, hypotension, dementia, impaired judgement, incontinence, and use of psychotropic medications. Interventions included re-education of use of call light for assistance with transfers/ambulation, notify therapy for evaluation if applicable, monitor for latent signs/symptoms of pain/injury, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365731 If continuation sheet Page 2 of 33 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 10/28/2024 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 0580 notify family/power of attorney (POA) of incident and intervention, and notify the physician of incident. Level of Harm - Minimal harm or potential for actual harm Review of a late entry nurse progress note dated 10/18/24 revealed Resident #205's roommate let staff know that the resident was on the floor. Resident #205 did have some confusion when located at his bedside. The resident was evaluated for injuries and vital signs were obtained. Resident #205 was assisted back to bed by the certified nurse aide (CNA). Resident #205 was able to perform range of motion (ROM) and had no complaints of pain or discomfort at this time. No visible injuries were noted. Residents Affected - Few Review of the nurse progress note dated 10/21/24 at 2:00 P.M. revealed the CNA reported Resident #205 lying on his left side on the floor in his room. He stated he was getting clothes out of his closet, lost his balance, and fell on his left elbow. ROM was within normal limits (WNL). Tylenol was administered. An order was obtained for a STAT (immediate) left elbow x-ray. Resident #205 had confusion at times and was ambulatory without assistance. Resident #205 was to have a room change to be closer to the nurse's station. Vital signs 99/56, pulse 90, respirations 20, temperature 97.8 degrees Fahrenheit and oxygen saturation per pulse oximetry at 97 percent on room air. The certified nurse practitioner (CNP) was updated. Review of the nurse progress note for Resident #205 dated 10/21/24 at 3:22 P.M. revealed an order for STAT x-ray of the left elbow was submitted to the radiology provider. Review of the nurse progress note for Resident #205 dated 10/22/24 at 8:46 A.M. revealed the CNP returned the call and said it was okay to send the resident to the emergency room (ER) for treatment and evaluation of the left elbow due to the STAT x-ray results. Review of the hospital ER documentation dated 10/22/24 revealed Resident #205 arrived at the ER at approximately 9:00 A.M. with a left elbow fracture as well as a left pelvic fracture. Review of the nurse progress note dated 10/22/24 at 9:53 A.M. revealed that a call was placed to Resident #205's daughter and a message left on the home phone to return call to facility. Review of the nurse progress note dated 10/22/2024 at 10:02 A.M. revealed Resident #205's daughter returned the call and was updated on the x-ray results of the left elbow fracture from the fall. Interview on 10/23/24 at 12:27 P.M. with Resident #205's daughter confirmed that facility informed her that her father was hospitalized after a fall and fractured elbow. She indicated that the resident was found to also have a fracture of hip while in the ER. Resident #205 was transferred to another hospital due to trauma for surgery. The facility stated that the resident was in good spirits. The daughter stated his mental state was okay and had good days and bad days, but due to his fluctuating mental status the surgeon wanted her okay for surgery. She also stated the resident had a diagnosis of low blood pressure and needed to stay hydrated. Resident #205's daughter said she was notified of the hospitalization the morning of 10/22/24. She was told that he had mobility in the elbow, and it was not swollen or bruised immediately after the fall. She stated she was not notified of the residents' fall at 2:00 P.M. the prior afternoon. The daughter also stated she was not notified of the resident's previous fall on 10/18/24. Interview on 10/24/24 at 3:03 P.M. with the Director of Nursing (DON) and Assistant Director of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365731 If continuation sheet Page 3 of 33 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 10/28/2024 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Nursing (ADON) confirmed that there was no documented evidence to support that Resident #205's emergency contact/daughter, was notified of the residents falls on 10/18/24 and 10/21/24 nor his elbow fracture confirmed by x-ray, until 10:02 A.M. on 10/22/24. Review of the policy titled Change in a Resident's Condition, reviewed on 8/2023, revealed the facility shall notify the resident, his or her Attending Physician and representative (sponsor) of changes in the resident's medical/mental condition. Event ID: Facility ID: 365731 If continuation sheet Page 4 of 33 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 10/28/2024 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on record review and interview the facility failed to ensure grievances during resident council meetings related to evening snacks not being distributed were responded to timely and appropriately. This affected eight residents (#10, #11, #21, #22, #32 #37, #44 and #52) who attended the resident council group meeting, and one resident (#36) reviewed for food. The facility census was 50. Findings include: Interview on 10/21/24 at 11:54 A.M. with Resident #36 revealed snacks in the evening were not being passed. Review of the resident council meeting minutes dated 07/22/24, 08/21/24, and 09/18/24 revealed either snacks were not being distributed or brought to all the rooms in the evening. Completion of the resident council group meeting portion of the annual survey on 10/24/24 between 11:00 A.M. and 12:00 P.M. with Residents #10, #11, #21, #22, #32, #37, #44 and #52 revealed significant concerns related to snacks being unavailable before and after resident meals. Multiple residents commented that staff eat the majority and often times eat all of the snacks that are left at the nurse's station. The group also noted that snack availability was an ongoing issue and that any concerns brought up in the resident council meetings were ignored. Interview on 10/28/24 10:34 A.M. with Dietary Manager (DM) #368 verified there were resident complaints about snacks not being distributed in the evening in the last few resident council meetings. DM #368 stated she told the Director of Nursing (DON) and talked with Staff Coordinator (SC) #304 to remind the staff to pass the snacks in the evening. DM #368 stated there were three residents she knew that complained, and she started making their own bags of snacks to keep in their rooms. DM #368 stated last week she started making snack bags for Resident #32 and was about to start one for Resident #22. DM #368 stated she had been making snack bags for Resident #36 for months now. Interview on 10/28/24 at 10:53 A.M. with SC #304 stated she was informed that snacks were not being distributed in the evening and she spoke with the aides and nurses on evenings to ensure snacks were being distributed. SC #304 stated she didn't have anything documented but came in early to talk with them before they left after their shift. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365731 If continuation sheet Page 5 of 33 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 10/28/2024 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 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #204 revealed an admission date of 09/30/24 with diagnoses including polyneuropathy, subluxation of C3/C4 cervical vertebrae, mid-cervical region cervical disc disorder with myelopathy, cervical spine fusion, adult failure to thrive, bradycardia, generalized anxiety, history of alcohol abuse, and chronic post-traumatic stress disorder. Review of the comprehensive care plan for Resident #204 initiated on 10/01/24 revealed no care plan was initiated for the resident's risk of pain due to his diagnosis of polyneuropathy and spinal issues. Review of the MDS assessment dated [DATE] revealed Resident #204 was cognitively intact, used a wheelchair for mobility, and required minimal staff assistance for all activities of daily living (ADL). Review of the physician's orders for Resident #204 dated 9/30/24 revealed an order to monitor pain every shift. Review of the physician's orders for Resident #204 dated 09/30/24 revealed orders for acetaminophen 500 milligrams (mg) (pain reliever) give two tablets by mouth every six hours as needed for pain and pregabalin (Lyrica) (medication to treat nerve pain) oral capsule 150 mg one capsule by mouth two times a day for pain for 30 days. Review of the medical record for Resident #204 revealed no pain risk evaluation was conducted upon admission. Review of the medication administration record (MAR) for October 2024 revealed pain levels marked as zero out of ten for each shift from the date of admission to the date of the survey. During interview with Resident #204 on 10/21/24 at 12:10 P.M. revealed the resident complained of constant pain in his hands making it difficult for him to maintain his grip on things. He stated he told the nursing staff on multiple occasions, and they say they will contact the physician. During follow up interview on 10/24/24 at 10:27 A.M. with Resident #204, he indicated continued pain at a seven on a pain scale of zero to ten, ten being the worst. He stated the pain goes up his arms almost to his elbows and although he gets Lyrica, it is not sufficient to help decrease the pain. Resident #204 stated that the nurses say that they will call the physician, but no changes were ever made. Resident #204 stated he contacted the physician at the hospital but was told the nurse at the facility had to contact the physician to advise about medications. Resident #204 stated he continued to report pain to the nurses. Interview on 10/23/24 at 4:41 PM with MDS Coordinator Licensed Practical Nurse (LPN) #336 confirmed that the care plans had not been initiated for Resident #204 due to a prolonged power outage which caused a delay in developing appropriate care plans for residents in the facility. MDS Coordinator LPN #336 indicated care plans were currently in progress for all that had been delayed. Based on record review, interview, and facility policy review the facility failed to ensure (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365731 If continuation sheet Page 6 of 33 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 10/28/2024 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 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few comprehensive assessments were implemented and completed for Residents #7 and #204. This affected two residents (#7 and #204) of 17 sample residents reviewed for assessments. The facility census was 50. Findings include: 1. Review of the medical record for Resident #7 revealed an admission date of 09/01/20 with diagnoses including psychotic disorder, delusions, insomnia, and seizures. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 had intact cognition and required partial to moderate assistance with rolling left and right. Review of the plan of care dated 09/24/24 revealed Resident #7 had a mobility deficit related to seizures, chronic obstructive pulmonary disease (COPD), asthma, and spinal stenosis. Interventions for bed mobility included supervision from one staff to turn and reposition in bed and bilateral grab bars to each side of the bed to assist with turning and repositioning. Review of the physician's orders dated October 2024 revealed Resident #7 had an order for bilateral grab bars to the bed to increase independence with bed mobility. Review of the assessments revealed the last bedrail assessment was completed on 09/22/21. There was no documented evidence of a current assessment. Interview on 10/23/24 at 3:09 P.M. with the Director of Nursing (DON) verified there was no current bed rail assessment completed. Review of the facility policy titled Assistive Devices and Equipment, revised July 2017, stated side rails, grab bars, specialized chairs, specialized mattress, specialized room arrangement will be assessed upon initiation, quarterly, and as needed for appropriateness. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365731 If continuation sheet Page 7 of 33 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 10/28/2024 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 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and facility policy review, the facility failed to complete a required Minimum Data Set (MDS) 3.0 assessment upon Resident #30's discharge from the facility. This affected one resident (#30) of two residents reviewed for discharge. The facility census was 50. Residents Affected - Few Findings include: Resident #102 was admitted to the facility on [DATE] with diagnoses including Hepatitis C, cocaine abuse, chest pain, and kidney failure. Review of the census records and nursing progress notes, Resident #102 was discharged from the facility on 07/03/24. Review of the MDS records for Resident #102 revealed an initial MDS assessment was completed on 05/29/24. No other MDS assessments were completed for Resident #102 during his stay at the facility, including a required discharge assessment upon Resident #102 returning home from the facility. MDS Nurse #336 verified Resident #102's required discharge MDS assessment was not completed as required during an interview on 10/23/24 at 8:00 A.M. Review of the facility policy titled MDS Completion and Submission Timeframes, dated 07/01/17, revealed the facility would conduct and submit resident assessments in accordance with current federal and state submission time frames. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365731 If continuation sheet Page 8 of 33 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 10/28/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the record for Resident #19 revealed an admission date of 09/09/24 with diagnoses including recurrent E. Coli, striatonigral degeneration, obstructive and reflux uropathy, type two diabetes, chronic obstructive pulmonary disease, hypothyroidism, atherosclerotic heart disease, occlusion and stenosis of carotid artery, aortic ectasia, generalized anxiety disorder, major depressive disorder, and panic disorder. Upon admission, Resident #19 presented with an indwelling urinary catheter related to the diagnoses of obstructive and reflux uropathy, a wound to her right lower extremity, and blanching in the perineal area. Review of the physician's order dated 09/10/24 indicated once daily wound care instructions for the right lower extremity wound and the open area at the intergluteal cleft. Review of the physician's orders dated 09/16/24 indicated Foley (indwelling urinary catheter) to continuous drainage for urinary retention along with orders for Foley care. Review of the comprehensive care plan for Resident #19 initiated on 09/01/24 revealed no care plan was initiated for the resident's indwelling urinary catheter or the existing wounds. Interview on 10/23/24 at 4:41 PM with MDS Coordinator Licensed Practical Nurse (LPN) #336 revealed that care plans for pressure wounds and Foley catheter were delayed due to weather/tornado and power outage in August 2024. The MDS Coordinator LPN #336 verified that the care plans were overdue and were currently in progress and would be placed in the resident's electronic medical record. 3. Review of the medical record for Resident #20 revealed an admission date of 02/27/21 with diagnoses including cerebral infarction, a stroke affecting the right dominant side, dementia, aphasia, contracture of the right hand, atrial fibrillation, and legionnaires disease. Review of the comprehensive MDS assessment, dated 09/13/24, revealed Resident #20 had impaired cognition and needed substantial to maximum assistance with showers and dressing. Review of the care plan dated 09/24/24 revealed Resident #20 had a self-care deficit related to hemiplegia, impaired balance, limited range of motion, and stroke. Interventions for showering/bathing included the resident required assistance from one staff member, avoid scrubbing, and pat dry sensitive skin. In addition, check and trim nails and report any changes to the nurse. The documentation did not reveal the resident refused showers. Review of the shower documentation from 09/01/24 through 10/21/24 revealed there was no documented evidence of shower/bed bath for the month of September 2024. The October documentation revealed that Resident refused shower/bed bath on 10/01/24, 10/04/24, 10/08/24, and 10/15/24. Resident #20 received one bed bath on 10/11/24. Observation on 10/21/24 at 11:21 A.M. revealed the Resident #20 looked disheveled and had not been shaven. Further observation on 10/23/24 at 10:00 A.M. revealed he was disheveled and unshaven. Interview on 10/24/24 at 5:33 P.M. with the DON verified the resident refused showers and verified (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365731 If continuation sheet Page 9 of 33 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 10/28/2024 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 0656 the care plan did not reflect refusals of care. Level of Harm - Minimal harm or potential for actual harm Based on record review, staff interview, and facility policy review, the facility failed to develop and implement resident centered care plans for Residents #4, #19, #20, #40 and #51. This affected five residents (#4, #19, #20, #40 and #51) of seventeen sampled residents. The facility census was 50. Residents Affected - Some Findings include: 1. Resident #4 was admitted to the facility on [DATE] with diagnoses including dementia, syncope and collapse, and seizures. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #4 was severely cognitively impaired and required extensive assistance of two staff persons for completing her activities of daily living (ADL). Review of the physician's orders for October 2024 revealed an order dated 04/10/23 stating admit resident to (contracted hospice agency) with a diagnosis of dementia. Review of the care plan dated 04/24/24 revealed a care plan was developed for Resident #4's hospice care. Interventions included hospice aide visits, hospice nurse visits, hospice Chaplin visits, and hospice social worker visits. No specific number of visits were noted on each intervention and each intervention was noted to read specify frequency and did not contain any specific visit frequency information. Review of Article V Hospice Plan of Care subsection F of the hospice contract for services, dated 12/09/19, revealed Each Facility providing Hospice care under a written agreement must ensure that each resident's written plan of care includes both the most recent Hospice Plan of Care and a description of the services furnished by the Facility to attain maintain the resident's highest practicable physical, mental and psychosocial well-being as required by 42 C.F.R. 483.25. Interview with the Director of Nursing (DON) on 10/22/24 at 3:00 P.M. verified the facilities care plan did not reflect the frequency of visits and other specific information related to care and services provided by the contracted hospice to Resident #4. Review of the policy entitled Hospice Program, dated 07/01/17, revealed Coordinated care plans for residents receiving hospice services will include the most recent hospice plan of care as well as the care and services provided by our facility (including the responsible provider and discipline assigned to specific tasks) in order to maintain the resident's highest practicable physical, mental and psychosocial well-being. 4. Review of the medical record for Resident #40 revealed an admission date of 09/27/24. Diagnoses included right femur fracture, muscle weakness, and cognitive communication deficit. Review of the smoking and safety assessment dated [DATE] revealed Resident #40 was a smoker and did not require any devices for smoking safety. Review of the admission MDS assessment dated [DATE] revealed Resident #40 had intact cognition and used tobacco. Review of the plan of care for Resident # 40 revealed there was no care plan for smoking. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365731 If continuation sheet Page 10 of 33 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 10/28/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 10/23/24 at 4:28 P.M. with MDS Coordinator #336 revealed she does most of the care plans and verified there was no smoking care plan created for Resident #40. 5. Review of the medical record for Resident #51 revealed an admission date of 09/24/24. Diagnoses included sepsis, morbid (severe) obesity due to excess calories, cellulitis of abdominal wall and type two diabetes without complications. Review of the admission minimum data set (MDS) assessment dated [DATE] revealed Resident #51 had intact cognition, required substantial/maximum staff assistance for toileting, hygiene and shower/bathing. The MDS indicated Resident #51 had three unhealed stage three pressure ulcers. Review of the progress note dated 10/03/24 at 10:37 A.M. revealed the interdisciplinary team (IDT) discussed skin alteration from 10/02/24, found on wound rounds. Resident #51 was observed with new pressure area to center midline sacro-coccyx during wound rounds. The area was cleansed and treatment order provided by Wound Nurse Practitioner (WNP) #800. Resident #51 was educated on the importance of getting out of bed and hygiene to decrease the risk of skin breakdown. Resident #51 verbalized understanding. Will be followed by wound WNP weekly. Resident #51's care plan was reviewed and interventions in place. A new intervention was added to educate Resident #51 on the importance of getting out of bed and hygiene to decrease the risk of skin breakdown. Review of Resident #51's care plan revealed no care plan goals or interventions related to wounds or skin impairments. Interview on 10/23/24 at 4:28 P.M. with MDS Coordinator #336 stated she does the majority of the care plans. MDS Coordinator #336 verified Resident #51 did not have a care plan related to wounds or skin impairments but she was working on her care plan today. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365731 If continuation sheet Page 11 of 33 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 10/28/2024 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 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observation, resident interview, medical record review, staff interview and review of facility policy, the facility failed to ensure residents who required staff assistance with baths/showers received needed care. This affected two (#22 and #51) of five residents reviewed for activities of daily living (ADLs). The facility census was 50. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #22 revealed an admission date of 04/23/24. Diagnoses included left femur fracture, difficulty in walking, repeated falls, congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD). Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/11/24, revealed Resident #22 had impaired cognition, had no behaviors and required partial/moderate assistance from staff for showers and bathing. Interview on 10/21/24 at 3:47 P.M. with Resident #22 revealed he has not had a shower or bath in the last two weeks and the water in the bathroom was cold. Concurrent observation revealed a strong odor in the resident's room. Observation on 10/22/24 at 3:44 P.M. of Resident #22 revealed the resident sitting on the side of his bed in the same clothing as the day prior. Interview on 10/24/24 at 8:57 A.M. with Resident #22 revealed staff occasionally offered showers and his scheduled days were on Wednesday and Sunday. Resident #22 stated staff came up with excuses or the aides did not show up. Resident #22 stated there was one aide who provided him a bed bath about one time per week but he would like one to two showers weekly. Review of the weekly shower schedule, updated 10/11/24, revealed Resident #22 scheduled shower days were Sundays and Wednesdays on the 3:00 P.M. to 11:00 P.M. shift. Review of the shower/bath sheets for the past two months revealed three sheets revealed on 08/14/24 and 08/21/24, Resident #22 refused a shower. A third shower sheet indicated the resident received a shower on 08/28/24. There was no shower documentation for September and October 2024. Interview on 10/24/24 at 9:56 A.M. with the Administrator revealed the Director of Nursing (DON) was unable to locate any additional documentation of showers for Resident #22 for the past two months. 2. Review of the medical record for Resident #51 revealed an admission date of 09/24/24. Diagnoses included sepsis, morbid (severe) obesity due to excess calories, cellulitis of abdominal wall and type two diabetes without complications. Review of the admission MDS assessment, dated 10/01/24, revealed Resident #51 had intact cognition and required substantial/maximum assistance from staff for shower/bathing. Review of the plan of care for Resident #51 revealed no care plans related to the resident refusing or resisting showers/baths. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365731 If continuation sheet Page 12 of 33 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 10/28/2024 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 Further review of Resident #51's medical record revealed no documented refusals of showers/baths. Level of Harm - Minimal harm or potential for actual harm Interview on 10/21/24 at 3:26 P.M. with Resident #51 revealed she had not had a shower since her admission to the facility but would like one. Concurrent observation of Resident #51 revealed she was dressed in a black, floral dress and had hair on her chin. Resident #51 stated sometimes she would ask the staff to shave her, but no one had offered a shower. Residents Affected - Few Observations on 10/22/24 at 3:40 P.M., 10/23/24 at 8:24 A.M. and on 10/23/24 at 3:27 P.M. of Resident #51 revealed the resident was wearing the same black, floral dress she was wearing on 10/21/24. Review of the weekly shower schedule, updated 10/11/24, revealed Resident #51's scheduled shower days were Mondays and Fridays on the 3:00 P.M. to 11:00 P.M. shift. Interview on 10/24/24 at 9:42 A.M. with the DON revealed she was unable to locate evidence of bath/showers for Resident #51. Observation on 10/24/24 at 10:50 A.M. of Resident #51 revealed she was in a pink and black flower dress. The resident had hair on her chin. Resident #51's room was odorous. Concurrent interview with Licensed Practical Nurse (LPN) #333 verified Resident #51's room was odorous. A telephone interview on 10/24/24 at 5:58 P.M. with Certified Nursing Assistant (CNA) #364 revealed she worked on Monday, 10/21/24, and was assigned to provide care for the resident until 7:00 P.M. CNA #364 stated she was unaware Monday was Resident #51's shower day and verified the resident was not offered or provided a shower. Review of the facility policy titled Activities of Daily Living (ADLs), Supporting, revised March 2018, revealed residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out ADLs. Appropriate care and services will be provided for residents who are 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). This deficiency represents noncompliance investigated under Complaint Number OH00158492. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365731 If continuation sheet Page 13 of 33 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 10/28/2024 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, hospital record review, facility policy review and interviews, the facility failed to ensure timely evaluation, physician notification and treatment following a fall with fracture for Resident #205. Residents Affected - Few Actual Harm occurred for Resident #205 on 10/21/24 at 7:19 P.M. when the facility received results of a STAT (immediate) x-ray indicating the resident had a left elbow fracture but failed to seek medical intervention or treatment for the resident. The nurse practitioner (NP) was notified of the results on 10/22/24 at 8:42 A.M. at which time an order was obtained to transfer the resident to the hospital. The delay in treatment and lack of timely medical intervention resulted in Resident #205 experiencing increased pain and resulted in a delay in the facility identification of additional injuries (the hospital identified the resident also had a left acetabulum fracture, left iliac fossa (bone that is part of the hip) fracture and left retroperitoneal hemorrhage (bleeding in the space located behind the abdominal cavity). Resident #205 was transferred to a level 2 trauma hospital for further treatment. This affected one resident (#205) of one resident reviewed for change in condition. The facility census was 50. Findings include: Review of Resident #205's medical record revealed an admission date of 10/04/24 with diagnoses including vascular dementia with behavioral disturbance, atrial fibrillation, hypotension, hyperlipidemia, alcohol abuse, anxiety, major depressive disorder and insomnia. Resident #205 was transferred to the hospital on [DATE]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #205 was minimally cognitively impaired, was able to ambulate with a wheeled walker and required minimal (staff) assistance for eating and oral hygiene, partial/moderate (staff) assistance for toileting and dressing and maximal (staff) assistance all other activities of daily living (ADLs.) Review of the care plan dated 10/19/24 revealed Resident #205 was at risk for falls related to impaired balance, hypotension, dementia, impaired judgement, incontinence and use of psychotropic medications. Interventions included to re-educate on the use of the call light for assistance with transfers/ambulation, notify therapy for evaluation if applicable, monitor for latent signs/symptoms of pain/injury, notify family/Power of Attorney (POA) of incidents and interventions and notify the physician of incidents. Review of the nursing progress note dated 10/21/24 at 2:00 P.M. revealed the State Tested Nursing Assistant (STNA) reported Resident #205 was lying on his left side on the floor in his room. The resident stated he was getting clothes out of his closet, lost his balance and fell on his left elbow. Range of motion was within normal limits. Tylenol was given. STAT x-ray of the left elbow was ordered. The note revealed the resident was confused at times and ambulatory without assistance. Following the incident, the resident had a room change to be closer to the nurses' station. Vital signs were taken and were as follows: blood pressure 99/56, pulse 90, respirations 20, temperature 97.8 degrees Fahrenheit (F) and oxygen saturation per pulse oximetry at 97 percent on room air. The note documented NP updated. Review of a physician order dated 10/21/24 revealed an order for a STAT x-ray of the left elbow and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365731 If continuation sheet Page 14 of 33 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 10/28/2024 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 0684 acetaminophen 325 milligrams (mg), two tablets by mouth every six hours as needed for pain. Level of Harm - Actual harm Review of Medication Administration Record (MAR) for October 2024 revealed acetaminophen 650 mg was administered to Resident #205 by LPN #333 on 10/21/24 at 4:30 P.M. Residents Affected - Few Review of the nursing progress note dated 10/21/24 at 3:22 P.M. revealed an order for a STAT x-ray of the left elbow was submitted to the radiology provider. Review of the pain assessment records revealed Resident #205 had consistent pain levels of 0 out of 10 (on a scale from 0-10) from admission on [DATE] until the date of injury on 10/21/24. Following the fall, Resident #205's pain levels increased to 5 out of 10. Observation on 10/22/24 at 8:19 A.M., during medication administration with Licensed Practical Nurse (LPN) #333, revealed Resident #205 was lying in bed with his left arm resting on his chest and bent at a 90-degree angle. The resident's left elbow was red and swollen. Concurrent interview with Resident #205 revealed his elbow hurt. Coinciding interview with LPN #333 revealed Resident #205 had a fractured elbow due to a fall the previous day. LPN #333 stated she was waiting for the NP to call back with an order to send the resident to the emergency room (ER) for further evaluation. LPN #333 stated the facility did not like to send residents to the ER unless there was an order from the NP. Review of the nursing progress note dated 10/22/24 at 8:46 A.M. revealed a return call was received from the NP and order given to send the resident to the ER for evaluation and treatment of the left elbow per STAT x-ray results. Review of the hospital ER Physician Report dated 10/22/24 at 11:14 A.M. revealed Resident #205 presented to the ER following a fall. The resident had an x-ray that showed an intra-articular fracture of the left ulna. Resident #205 could not provide the physician with specifics and denied pain but had pain when his left elbow was touched or moved and in the left hip with movement. Additional radiological imaging was completed and confirmed Resident #205 had a left olecranon (bony part of the elbow, allows the elbow to move) fracture. Furthermore, imaging indicated Resident #205 also had a left acetabular (socket part of the hip joint where the thigh bone sits) fracture and acute fracture of the posterior right 11th rib. Pre-operative diagnoses included left olecranon fracture, left acetabulum fracture, left iliac fossa (bone that is part of the hip) fracture and left retroperitoneal hemorrhage (bleeding in the space located behind the abdominal cavity). Resident #205 was transferred to a level 2 trauma hospital for further treatment. Interview on 10/24/24 at 4:50 P.M. with LPN #333 revealed she was notified of Resident #205's fall by Staffing Coordinator (SC) #304 after the resident's roommate heard the resident fall and called out for staff assistance. LPN #333 stated Resident #205 was assessed and complained of elbow pain, but no other pain at that time. LPN #333 stated Resident #205 had full range of motion and once he was back in bed, he was able to demonstrate full body mobility buy doing bicycles with his legs. LPN #333 stated the resident told her he tried to break his fall with his left elbow. LPN #333 stated she notified the NP, and an order was received for a STAT x-ray of the left elbow and acetaminophen for pain, which was administered to the resident. The radiology provider was contacted immediately for the x-ray. LPN #333 denied Resident #205 had any swelling at that time. LPN #333 stated she gave report to Registered Nurse (RN) #310, informing her of Resident #205's fall and pending x-ray results. When she arrived for her shift on 10/22/24 at 7:00 A.M., she found the x-ray results, which were faxed to the facility on [DATE] at 7:19 P.M., laying on the nurses' station desk. LPN #333 stated she immediately checked on Resident #205 and received report from RN #310, who indicated the resident's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365731 If continuation sheet Page 15 of 33 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 10/28/2024 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 0684 Level of Harm - Actual harm left elbow was swollen and discolored and had ballooned from the previous afternoon. RN #310 did not indicate whether or not he had contacted anyone regarding the x-ray results. LPN #333 stated she administered Tylenol to the resident, elevated his elbow on a pillow and stated that he needs to go (to the hospital). Residents Affected - Few Review of the timeline provided by the Director of Nursing (DON) revealed the STAT left elbow x-ray was completed 10/21/24 at 6:38 P.M. and the results were faxed to the facility on [DATE] at 7:19 P.M. On 10/22/24 at 7:05 A.M., LPN #333 sent a message and the x-ray results to the NP. After receiving no response, LPN #333 called the NP at 7:44 A.M. (left a message) and again at 8:42 A.M. The NP responded with an order to send Resident #205 to the ER. The timeline provided no indication RN #310 notified the NP on 10/21/24 when the results were received. Interview 10/24/24 at 3:03 P.M. with the DON and Assistant Director of Nursing (ADON) #367 revealed Resident #205 was transferred to the ER via 911 emergency squad after receiving the order from the NP on 10/22/24 at 8:42 A.M. The DON indicated she left a message for RN #310 regarding physician notification when the x-ray results were received on 10/21/24 but she had not received a response. The DON verified the NP should have been notified of the x-ray results indicating a fracture immediately for further orders. Additionally, the DON confirmed Resident #205 was in pain and his injuries went untreated from the time of the fall on 10/21/24 at 2:00 P.M. until he was transferred to the ER at approximately 8:45 A.M. on 10/22/24. This deficiency represents noncompliance investigated under Complaint Number OH00158492. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365731 If continuation sheet Page 16 of 33 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 10/28/2024 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, review of hospital documents, staff documents and review of facility policy, the facility failed to ensure an accurate weight was obtained to monitor nutritional status for a resident at risk for significant weight loss. This affected one (#201) of two residents reviewed for nutrition. The facility census was 50. Residents Affected - Few Findings include: Review of the medical record for Resident #201 revealed an admission date of 10/08/24 with diagnoses including dementia with behavioral disturbance, Meniere's disease, hypertension, osteoarthritis, anemia, rheumatoid arthritis and major depressive disorder, severe, with psychotic features. Review of the care plan dated 10/15/24 revealed Resident #201 had a nutritional problem related to diagnoses, psychotropic medications, weight loss, underweight related to body mass index (BMI) and mechanically altered diet. Interventions included the following: weight per facility protocol; monitor, record and report to the physician signs/symptoms of malnutrition; and monitor, document and report to the physician signs/symptoms of dysphagia. Review of physician's order dated 10/11/24 revealed weekly weights times four weeks upon admission, then monthly. If gain or loss greater than three pounds (lbs.), reweigh and notify the physician. Review of hospital records revealed Resident #201 had a hospital weight of 95.7 lbs. and a BMI of 14.2 and stated the resident was severely underweight for advanced age. Further review of the medical record revealed there was no documented facility admission weight. Review of nutritional assessment note dated 10/15/24 revealed a review of Resident #201's hospital records indicated weight loss prior to admission to the hospital. Resident #201 was at risk for weight loss related to acute infection and recent hospitalization and at risk for malnutrition related to a BMI less than 18.5, mechanically altered diet and chronic disease. The recommendations included: house supplement eight ounces two times daily, obtain admission weight, weigh weekly for four weeks and to monitor weight, meal intakes, skin and labs. Interview on 10/23/24 at 3:37 PM with Nutrition Consultant Diet Tech (NCDT) #381 revealed she liked to see an admission weight due to hospital weights being estimated. NCDT #381 stated due to Resident #201 being severely underweight, any weight loss would be significant so an accurate baseline weight was needed. Review of a weight obtained for Resident #201 on 10/17/24 revealed a weight of 83.6 lbs. Based on the hospital's estimated weight of 95.7 during her hospital admission from 9/26/24 to 10/08/24, Resident #201 experienced a 12.1 lbs. significant weight loss. Interview on 10/24/24 at 3:03 PM with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) #367 verified an admission weight was not obtained for Resident #201 until 10/17/24, which was nine days after admission and two days after the nutritional assessment was completed, resulting in no current weight to compare the resident's nutritional status and needs to. Review of the the facility policy titled Weight Policy & Procedure, dated August 2024, revealed weights will be reviewed routinely by nursing and dietary services to identify those residents who are (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365731 If continuation sheet Page 17 of 33 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 10/28/2024 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 0692 experiencing weight changes. 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 18 of 33 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 10/28/2024 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on resident and staff interview, medical record review and review of facility policy, the facility failed to accurately document and effectively manage resident's pain. This affected one (#204) of two residents reviewed for pain management. The facility census was 50. Residents Affected - Few Findings include: Review of the record for Resident #204 revealed an admission date of 09/30/24 with diagnoses including polyneuropathy, subluxation of C3/C4 cervical vertebrae, mid-cervical region cervical disc disorder with myelopathy, cervical spine fusion, adult failure to thrive, bradycardia, generalized anxiety, history of alcohol abuse and chronic post-traumatic stress disorder. Review of the Minimum Data Set (MDS) assessment, dated 10/07/24, revealed Resident #204 was cognitively intact, used a wheelchair for mobility and required minimal staff assistance for all activities of daily living (ADLs.) Review of the comprehensive care plan initiated, 10/01/24, revealed no care plan was initiated for Resident #204's risk for pain due to his diagnosis of polyneuropathy and spinal issues. Review of Resident #204's current physician's orders revealed to monitor for pain every shift. Additionally, Resident #204 had orders for acetaminophen 500 milligrams (mg), two tablets by mouth every six hours as needed for pain and pregabalin (Lyrica) oral capsule 150 mg, one capsule by mouth two times a day for pain for 30 days. Review of Medication Administration Record (MAR) for October 2024 revealed Resident #204's pain levels were marked as 0 out of 10 (on a scale of one to 10) for each shift from the date of admission. Further review of Resident #204's medical record revealed no pain risk assessment was completed upon admission. Interview on 10/21/24 at 12:10 P.M. with Resident #204 revealed he had constant pain in his hands, making it difficult for him to maintain his grip on things. Resident #204 stated he has told the nursing staff on multiple occasions about his pain and they say they will contact the physician. A follow-up interview on 10/24/24 at 10:27 A.M. with Resident #204 revealed he continued to have pain at a 7 out of 10. Resident #204 stated the pain went up his arms, almost to his elbows, and although he gets Lyrica, it is not sufficient to help decrease the pain. Resident #204 stated the nurses say that they will call the physician but no changes are ever made. Resident #204 stated he contacted the physician at the hospital but was told the facility nurse had to contact the physician to advise about medications. Resident #204 stated he continued to report pain to the nurses. Interview on 10/24/24 at 3:30 P.M. with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) #367 confirmed they were unaware of Resident #204's ineffective pain management and would follow up with the physician. A follow-up interview on 10/24/24 at 4:00 PM. with the DON revealed she spoke with the physician and, due to Resident #204's history of alcohol abuse, they were hesitant to administer more pain medication. The DON stated the physician would arrange for a pain management evaluation for Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365731 If continuation sheet Page 19 of 33 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 10/28/2024 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 0697 #204. Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled Assessment, Intervention and Management of Pain, dated October 2020, revealed to contact the physician if the current pain management regimen, including nonpharmacological and pharmalogical intervention, is ineffective at managing resident pain at a satisfactory level. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365731 If continuation sheet Page 20 of 33 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 10/28/2024 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on medical record review, review of pharmacy recommendations, staff interview and review of facility policy, the facility failed to ensure pharmacy recommendations were addressed in a timely manner. This affected one (#14) of five residents reviewed for unnecessary medications. The facility census was 50. Findings include: Review of the medical record for Resident #14 revealed an admission date of 01/03/24. Diagnoses included dementia, schizoaffective disorder, suicidal ideation and major depressive disorder. Review of the October 2024 physician orders revealed active orders for: • Breo Ellipta Inhalation Aerosol Powder Breath Activated 100-25 microgram/actuation (mcg/act) one inhalation, inhale orally one time a day related to chronic obstructive pulmonary disease with a start date of 01/27/24. • Tiotropium Bromide Monohydrate Inhalation Aerosol Solution 2.5 mcg/act, two puff inhale orally one time a day related to chronic obstructive pulmonary disease with a start date of 01/27/24. • Seroquel oral tablet 50 milligrams (mg), give one tablet by mouth every eight hours as needed (PRN) for Schizophrenia with a start date of 08/20/24 with no end date. • Ativan (Lorazepam) oral tablet one mg, give one tablet by mouth every six hours PRN for anxiety with a start date of 03/18/24 with no end date. Review of the recommendations from the pharmacist dated 01/30/24 and 02/29/24 revealed the resident received therapy with an inhaled corticosteroid. To reduce the risk of developing thrush, please advise the resident to rinse their mouth out with water after each dose. Review of the recommendation from the pharmacist dated 03/28/24 revealed the resident had a PRN order for the psychotropic, Lorazepam, one mg every six hours PRN for anxiety. Per the Centers for Medicare and Medicaid Services (CMS), PRN psychotropic medications are limited to 14 days. If used beyond 14 days, the rationale and estimated duration of use must be documented. Further review revealed on 04/29/24, a stop date of 12/29/24 was indicated and signed by the physician. Review of the recommendation from the pharmacist dated 08/28/24 revealed the resident had a PRN order for the antipsychotic, Seroquel, which is limited to 14 day use per CMS regulations. Schizophrenia is not a symptom and is not really an indicator. Please define the guidelines for nursing to give (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365731 If continuation sheet Page 21 of 33 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 10/28/2024 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few this medication and add a stop date. The disagree box was checked and a handwritten note to cont. scheduled, signed by the physician and dated 09/24/24. Review of the recommendation from the pharmacist dated 08/28/24 revealed the resident had a PRN order for Lorazepam tablet one mg, which had been in place for greater than 14 days without a stop date. CMS requires that PRN orders for psychotropics drugs be limited to 14 days unless the prescriber documents all of the following: the specific condition being treated, the rationale for the extended time period and the specific duration for the PRN order. The disagree box was checked and the recommendation was signed by the physician and dated 09/24/24. Interview on 10/23/24 at 3:03 P.M. with the Director of Nursing (DON) verified the recommendations dated 01/30/24 and 02/29/24 were not addressed until today. While the physician timely addressed the recommendation dated 03/28/24, the order was not updated to reflect an end date. The DON stated the physician did not want to add a stop dated for the PRN Seroquel and Ativan and decided to discontinue both orders today. Review of the facility policy titled Pharmacy Recommendations, revised January 2020, revealed the DON or the Assistant Director of Nursing (ADON) will review the recommendations with the physician and Medical Director as soon as practical but no later than 30 days. The DON will track recommendations and ensure any changes are implemented into the medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365731 If continuation sheet Page 22 of 33 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 10/28/2024 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on medical record review, staff interview and review of the facility policy, the facility failed to ensure as needed (PRN) psychotropic medication orders had an end date. This affected one (#14) of five residents reviewed for unnecessary medications. The facility census was 50. Findings include: Review of the medical record for Resident #14 revealed an admission date of 01/03/24. Diagnoses included dementia, schizoaffective disorder, suicidal ideation and major depressive disorder. Review of the October 2024 physician orders revealed active orders for: Seroquel oral tablet 50 milligrams (mg), give one tablet by mouth every eight hours PRN for Schizophrenia with a start date of 08/20/24. The order had no end date. Ativan oral tablet one mg, give one tablet by mouth every six hours PRN for anxiety with a start date of 03/18/24. The order had no end date. Review of the Medication Administration Record (MAR) from April 2024 through October 2024 revealed Resident #14 received the PRN Ativan 27 times in April, six times in May, four times in June and no administration of the medication in August, September or October 2024. Further review revealed Resident #14 received zero doses of the PRN Seroquel, ordered on 08/20/24, in August, September or October 2024. Interview on 10/23/24 at 3:03 P.M. with the Director of Nursing (DON) verified there were no end dates for the PRN Ativan and Seroquel and stated the physician did not want to add one. The DON stated the physician decided to discontinue both orders today. Review of facility policy titled Psychotropic Medication Use, dated August 2021, revealed PRN orders for psychotropic drugs are limited to 14 days. If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration of the PRN order. PRN orders for psychotropic medications will not be renewed beyond 14 days unless the healthcare practitioner has evaluated the resident for the appropriateness of that medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365731 If continuation sheet Page 23 of 33 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 10/28/2024 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on observation, medical record review, staff interview, review of manufacturer's instructions and review of facility policy, the facility failed to ensure residents were free from significant medication errors during insulin administration. This affected one (#2) of five residents reviewed for medication administration. The facility census was 50. Residents Affected - Few Findings include: Review of the medical record for Resident #2 revealed an admission date of 03/31/23 with diagnoses including aphasia, type II diabetes, traumatic brain injury, cerebral infraction (stroke) and anxiety. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 08/06/24, revealed the resident had impaired cognition and received insulin by injection. Review of the plan of care dated 10/04/24 revealed Resident #2 had diabetes mellitus. Intervention included to administer medication as ordered by the physician. Review of the physician's orders dated October 2024 revealed the resident had an order for Lispro (fast acting insulin) to be injected subcutaneous (into layer of skin) by pen prior to meals and before bedtime. The resident had a sliding scale for glucose results of 51-200 give four units, 201- 250 give eight units, 301-350 give 16 units and 352-400 give 20 units. Observation on 10/23/24 at 4:59 P.M. revealed Licensed Practical Nurse (LPN) #306 prepared Resident #2's dinner time insulin for a glucose level 163. LPN #306 attached the needle to the insulin pen, dialed up four units and administered the insulin to Resident #2. The pen was not primed prior to injection to ensure no air bubbles and proper functioning. Interview on 10/23/24 at 5:10 P.M. with LPN #306 verified she did not prime the insulin pen prior to injection. LPN #306 was unaware the pen needed to be primed. Review of the insulin manufacture's instructions revealed to prime the pen prior to injection. Priming the pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. Review of the facility policy titled Insulin administration, revised September 2014, revealed the nursing staff will have access to specific instructions from the manufacturer on all forms of insulin delivery system prior to use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365731 If continuation sheet Page 24 of 33 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 10/28/2024 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 0790 Provide routine and 24-hour emergency dental care for each resident. Level of Harm - Minimal harm or potential for actual harm Based on observation, interviews, record review and review of the facility policy, the facility failed to ensure Resident #30 received timely and adequate dental services. This affected one resident (Resident #30) out of three residents reviewed for dental services. The facility census was 51. Residents Affected - Few Findings include: Review of Resident #30's medical record revealed an admission date of 01/19/23 and diagnoses included syncope and collapse, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, heart failure, and hemiplegia (paralysis) affecting the left nondominant side. Review of Resident #30's care plan revised 04/22/24 included Resident #30 received hospice care from a local hospice agency. Diagnosis of dementia with prognosis of less than six months. Resident #30 would receive integrated care from the facility and hospice agency that would meet her physical, social, intellectual, emotional and spiritual needs. Interventions included hospice agency and facility staff to maintain open lines of communication to fulfill the plan of care. Review of Resident #30's medical record revealed the resident had a history of a tooth abscess that was treated with a course of antibiotics, completed on 10/10/24. Review of Resident #30's Quarterly Minimum Data Set (MDS) 3.0 assessment 10/17/24 revealed Resident #30 had severe cognitive impairment. Resident #30 was dependent for dressing and required substantial to maximal assistance for toileting and person hygiene, eating and bathing. Resident #30 was dependent for rolling right and left and sit to lying. Resident #30 had upper extremity impairment on one side and lower extremity impairment on both sides. Resident #30 was always incontinent of urine and bowel. Review of Resident #30's care plan dated 10/29/24 through 11/24/24 did not reveal a care plan for Resident #30's history of a tooth infection or follow-up related to the tooth abscess. Review of Resident #30's medical record from 10/29/24 through 11/25/24 included there was no evidence Resident #30 was evaluated by a facility physician, nurse practitioner or a dentist in follow-up to dental care or a tooth abscess. There was no evidence the facility monitored the resident's dental status after being treated for a tooth abscess. Observation on 11/21/24 at 4:12 P.M. of Resident #30 revealed she was lying in bed, eyes closed, the head of the bed was elevated, Resident #30 was holding her left arm and hand close to her chest and a splint could be seen on her left hand. Resident #30's husband and Hospice Aide (HA) #410 were standing by her bed. Interview on 11/21/24 at 4:12 P.M. with FM #408 revealed he was Resident #30's husband and Resident #30 had resided in the facility for about two years. FM #408 revealed Resident #30 received hospice services and one of the biggest problems he had with the facility was Resident #30 had a tooth abscess which started back in 09/2024 and she still had a tooth abscess. HA #410 stated she was not aware of Resident #30's tooth abscess until today, but her understanding was the facility physician should evaluate the tooth abscess and treat it if needed because the hospice physician was more for end of life concerns. FM #408 stated Resident #30's abscess was bleeding really bad about a month ago (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365731 If continuation sheet Page 25 of 33 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 10/28/2024 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 0790 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few when her brushed her teeth and he told the nurse about it. FM #408 indicated both the facility and the hospice nurse told him the other one should take care of the tooth abscess, but the hospice nurse finally got a prescription for an antibiotic to treat Resident #30's tooth abscess. FM #408 stated Resident #30's mouth was still sore and Former Social Services Director (FSSD) #411 asked him if he wanted Resident #30 to see a dentist and FM #408 told her yes and signed a paper so the dentist could see Resident #30. FM #408 stated FSSD #411 no longer worked at the facility, Resident #30 had not seen a dentist, the dentist was not coming until the second week of December and he did not understand why Resident #30 had to wait a month and a half to see the dentist. FM #408 indicated the facility had multiple Director of Nursing (DON)'s, there were so many and when he talked to them the DON would say they were going to handle his concerns, but they did not handle the concerns. Review of Resident #30's physician orders dated 11/22/24 revealed observe resident for any signs and symptoms of dental infection, facial swelling, redness, drainage, odor every shift and notify physician of any concerns, every day and evening shift for monitoring Interview on 11/25/24 at 10:43 A.M. with Interim Director of Nursing (IDON) #412 revealed Resident #30 received hospice services and her experience was all concerns went through hospice first. IDON #412 stated HN #409 was Resident #30's hospice nurse and she said concerns not related to end of life should go through the facility first, and anything end of life related should go through hospice. IDON #412 stated she would still tell the nurses to call HN #409 first. IDON #412 indicated Resident #30's abscess was part of the tug of war with hospice, hospice ordered antibiotics and Resident #30 completed the course of antibiotics. IDON #412 revealed HN #409 initially said Resident #30's tooth abscess should be handled by the facility, but hospice ordered antibiotics and when the antibiotics were finished HN #409 stated the facility should handle any further tooth or abscess issues. Interview on 11/25/24 at 10:58 A.M. with Social Services Director (SSD) #389 revealed she started working at the facility on 10/28/24. SSD #389 stated she was not sure if Resident #30 was evaluated by a dentist recently, the facility dental services provider had just changed and the new provider was coming for the first time on 12/03/24. Interview on 11/25/24 at 1:39 P.M. with Hospice Supervisor (HS) #415 revealed Resident #30's hospice primary diagnosis was senile degeneration of the brain and hospice covered anything related to the primary hospice diagnosis including anything with the skin, skin breakdown, dysphagia. HS #415 revealed hospice handled Resident #30's tooth abscess treatment in the past and the resident had something else going on with her dental needs but was not sure of the details. Interview on 11/26/24 at 8:55 A.M. with IDON #412 revealed the Administrator told her the dental provider changed on 10/01/24, but was delayed because the new dental provider was bought by another provider and the dentist was not available to see Resident #30 until 12/03/24. Interview on 11/26/24 at 11:00 A.M. with FM #408 revealed he told FSSD #411, the previous DON, the nurse on the nursing unit, and the Administrator he wanted Resident #30 to see a dentist. FM #408 stated he was very upset because he told anyone he could think of at the facility that Resident #30 needed a dentist and it did not happen and still had not happened. FM #408 stated the facility told him hospice needed to take care of the tooth abscess and hospice told him the facility needed to take care of the tooth abscess, and it just went back and forth between the two. FM #408 stated hospice ordered an antibiotic for the tooth abscess and after the antibiotic was finished nothing else happened, it was just done. FM #408 stated he even asked if he could bring his own dentist, but the Administrator said he could not do that. FM #408 indicated he signed a consent form stating he wanted (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365731 If continuation sheet Page 26 of 33 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 10/28/2024 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 0790 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #30 to see a dentist. FM #408 stated when he provided mouth care Resident #30 turned her head away like her tooth was still hurting. Interview on 11/26/24 at 11:27 A.M. with the Administrator confirmed FM #408 spoke to him and requested a dentist for Resident #30, but the dental provider changed on 10/01/24 and the new provider was purchased by a different provider and it delayed the dentist coming to the facility until 12/03/24. Interview on 11/26/24 at 12:15 P.M. with IDON #412 and RDCO #413 revealed FM #408 did not tell either of them Resident #30 needed a dentist and the facility would have had a dentist come emergently if the infection had not cleared. Interview on 11/26/24 at 12:30 P.M. of SSD #389 revealed she could find no appointments scheduled with the dentist for Resident #30's tooth abscess and she could not find a consent form signed by FM #408. SSD #389 stated FSSD #411 resigned before she started working at the facility and she did not have an orientation from FSSD #411. Review of the policy titled Resident Rights included the rights of resident representatives included if the resident's wishes were not known, the guardian, next of kin, reciprocal beneficiary or health care agent should make decisions in accordance with the resident's best interests and in accordance with accepted medical practices. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365731 If continuation sheet Page 27 of 33 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 10/28/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, staff interview and review of facility policy, the facility failed to maintain a clean and sanitary kitchen and further failed to ensure male staff with beards wore hair restraints while in the kitchen. This had the potential to affect all 50 residents. Findings include: 1. Observations on 10/21/24 from 8:36 A.M. to 8:56 A.M., during the initial kitchen tour with Dietary Manager (DM) #368, revealed various food splatter and stains on the outside of the steamer table and on the shelf underneath. The preparation (prep) table had three large, open bags of dried pasta stored on the shelf with clean pots and pans. Both shelves of the prep table were dirty with various dried food and debris. The stove and the flat grill were covered in black, dried, burnt-on grease and dust covered grease was observed under the flat grill area. The back wall and floor between the steamer and stove had various dried food splatters and debris, with dried food crumbs and debris on the pipe affixed to this wall. On the floor underneath the dish machine was a dark colored dried substance and a tan colored dried substance. Continued observation revealed a build-up of a tan colored substance on the dish machine. Lastly, the reach-in cooler near the dish machine, which stored milk and juice, had a dried white splatter along the inside walls and the bottom. Concurrent interview with DM #368 verified the findings. 2. Observation on 10/21/24 at 12:57 P.M. of meal service revealed two male dietary staff in the kitchen. Both male dietary staff had uncovered and unrestrained beards during the meal service. Interview on 10/21/24 at 1:10 P.M. with DM #368 verified the two male dietary staff were not wearing hair restraints over their beards. DM #368 stated she meant to have them put them on when they came in for their shift at 11:00 A.M. Review of the facility policy titled Sanitation, revised October 2008, revealed the food service area shall be maintained in a clean and sanitary manner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365731 If continuation sheet Page 28 of 33 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 10/28/2024 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 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, review of the hospital discharge documents and staff interview, the facility failed to ensure effective communication between attending physicians and administration to ensure adequate and appropriate resident care. This affected one (#20) of one resident reviewed for coordination of care. The facility census was 50. Residents Affected - Few Findings include: Review of the medical record for Resident #20 revealed an admission date of 02/27/21 with diagnoses including cerebral infraction (stroke) affecting the right dominant side, dementia, aphasia, contracture of the right hand, atrial fibrillation and Legionnaires disease. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 09/13/24, revealed the resident had impaired cognition and needed substantial to maximum assistance with showers and dressing. Review of the plan of care dated 09/24/24 revealed Resident #20 was recovering from Legionnaires disease. Interventions included to notify the guardian and physician and to assess respiratory status. Review of the progress note dated 08/23/24 revealed Resident #20 was sent out to the hospital per physician order. Review of a progress note dated 08/31/24 revealed Resident #20 arrived by stretcher to the facility. The resident was alert and oriented and on two liters of oxygen. The resident presented with no distress or pain. Review of the hospital documents, printed 08/31/24 at 3:04 P.M., revealed an assessment completed by Physician #382 on 08/30/24 at 8:53 A.M. indicated the resident admitted to the hospital with sepsis, Legionella pneumonia, history of stroke, hypertension and acute renal failure. Further review of Resident #20's medical record revealed Physician #382, who treated the resident in the hospital, was also the resident's attending physician at the facility. Interview on 10/22/24 at 4:30 P.M. with the Administrator revealed Resident #20 was diagnosed with Legionella at the hospital; however, he came back to the facility and the discharge summary did not reveal he had Legionella. The Administrator stated he was notified on 09/11/24 by the local health department of the Legionella diagnosis. Interview on 10/24/24 at 3:00 P.M. with the Director of Nursing (DON) revealed Physician #382 did not relay any information regarding Resident #20's Legionella diagnosis to the facility. Interview on 10/28/24 at 11:55 A.M. with the Medical Director (MD) revealed he was notified of Resident #20's Legionella diagnosis on 09/11/24 by the DON. The MD confirmed Physician #382 was one of two additional physicians working at the facility. The MD stated it was the responsibility of the admitting physician to communicate any crucial information to administration so that the facility could investigate the concern. The MD stated he would have expected Physician #382 to relay the diagnosis of Legionella to the facility. Interview on 10/28/24 at 12:45 P.M. with Registered Nurse (RN) #300 revealed she spoke with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365731 If continuation sheet Page 29 of 33 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 10/28/2024 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 0835 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Physician #382 on Resident #20's readmission to verify the discharge orders. RN #20 stated Physician #382 did not disclose the resident had Legionella. RN #300 stated she reviewed the hospital discharge summary and did not see the diagnosis of Legionella. Interview on 10/28/24 at 5:02 P.M. with Physician #382 confirmed she treated Resident #20 in the hospital and at the facility. Physician #382 verified she did not speak to the DON or communicate any information on the follow-up visit regarding Resident #20's Legionella diagnosis in the hospital. Event ID: Facility ID: 365731 If continuation sheet Page 30 of 33 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 10/28/2024 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 0838 Level of Harm - Potential for minimal harm Residents Affected - Many Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility assessment and staff interview, the facility failed to ensure the facility assessment contained all required information. This had the potential to affect all 50 residents residing in the facility. The facility census was 50. Findings include: Review the facility assessment dated [DATE] revealed the assessment did not contain the following required information: - Evidence of direct input into the assessment from direct care staff, including but not limited to, Registered Nurses (RNs), Licensed Practical Nurses (LPNs), Certified Nursing Assistants (CNAs) and other representatives of the direct care staff. - Consideration of specific staffing needs for each shift (day, evening and night) or plans to adjust, as necessary, based on any changes to its resident population. - Consideration of specific staffing needs for each resident unit in the facility and plans to adjust, as necessary, based on changes to its resident population. Interview on 10/21/24 at 2:15 P.M. with the Administrator verified the lack of required information in the facility assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365731 If continuation sheet Page 31 of 33 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 10/28/2024 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, staff interview and resident interview, the facility failed to maintain a clean, sanitary and safe environment. This had the potential to affected all 50 residents residing in the facility. The facility census 50. Findings include: 1. Observation on 10/22/24 at 3:50 P.M. of the west hall shower room with Certified Nursing Assistant (CNA) #374 revealed a spa tub that appeared to be nonfunctional. The bottom side of the tub had a cover that was pulled off exposing a pipe and wires. Coinciding interview with CNA # 374 verified the finding and stated the chair portion to the tub broke about a month ago and the facility was waiting on a new part. 2. Observation on 10/23/24 between 2:00 P.M. and 2:32 P.M., during an environmental tour with Housekeeping Supervisor (HSKP) #369 and Maintenance Director (MD) #321, revealed the following: - The ceiling fans that were in the dinning area were noted to be unclean and the blades full of dust. - One of the ceiling fans in the dinning room had no chain and was unable to be turned off. - The dinning room tables and chair were significantly dirty with numerous areas of chipped paint and other debris through out the tables and chairs. - The wooden doors to resident rooms and bathrooms throughout the facility had levels of significant chipping, scratching, scuffing and other damage. - The hallways of the facility revealed numerous water stained ceiling tiles. - The cover of the air conditioning unit in Resident #21 and Resident #38's room was completely off and exposed the coils of the unit, which were observed to be covered in a significant thick layer of dust. - The metal baseboard in the room occupied by Resident #20 and Resident #34 was on the floor. - The walls in the room occupied by Resident #10, Resident #22, Resident #41 and Resident #53 and had numerous areas of paint peeling off the wall. - The base of the tube feed poles utilized by Resident #1 and Resident #19 were coated in residual tube feed formula. -The plastic base of the west hall hoyer lift was cracked. The lift was also observed to be extremely dirty and full of visible dirt and debris. The north hall Hoyer lift was also noted to be extremely dirty. - The carpeting in the rooms occupied by Resident #8, Resident #25, Resident #32, Resident #33 and Resident #40 had areas of significant staining. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365731 If continuation sheet Page 32 of 33 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 10/28/2024 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 0921 Level of Harm - Minimal harm or potential for actual harm -The rooms occupied by Resident #22, Resident #31, Resident #51 and Resident #53 had numerous water stained ceiling tiles. - The west unit shower room area had a significant area of an unknown red substance along with a mold-like substance around the drain. Residents Affected - Many Interview with HSKP #369 and MD #321, at the time of the environmental tour, verified the above findings. Interviews on 10/24/24 at 11:00 A.M. with Residents #10, #11, #21, #22, #32, #37, #44 and #52, during Resident Council, revealed the residents expressed concerns related to the facility being unclean, dirty and not well maintained. The residents stated the facility had been in this state for a significant period of time. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365731 If continuation sheet Page 33 of 33