Inspection·October 3, 2019

F 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview with the Director of Nursing (DON) on 10/02/19 at 4:50 P.M. confirmed resident privacy should be respected, and LPN #824 should have shut the door while administering medications to Resident #80. An interview with Resident #80 on 10/03/19 at 2:30 P.M. confirmed the door had not been shut during the medication pass. He stated the visitor was a friend of his, and indicated he wasn't sure if he cared that she observed the procedure. The facility did not provide a specific policy regarding resident privacy but did provide a copy of the rights of residents, undated, which indicated residents should have the right to privacy during medical examination or treatment and in the care of personal or bodily needs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365746 If continuation sheet Page 2 of 27 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 365746 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brentwood Health Care Center 907 Aurora Rd Sagamore Hills, OH 44067 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on record review or interview, the facility failed to ensure the Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property policy reflected all staff were to be checked against the Ohio Nurse Aide Registry as required in the current regulatory language. This finding had the potential to affect all residents residing in the facility. The facility census was 86. Residents Affected - Many Findings include: Review of personnel files revealed from 08/31/18 to 10/03/19 revealed nine nurses including Registered Nurse (RN) #870, hired 09/16/19; Licensed Practical Nurse (LPN) #827, hired 09/13/19; LPN #834, hired 08/14/19; LPN #822, hired 07/15/19; LPN #817, hired 09/16/19; LPN #830, hired 08/14/19; RN #872, hired 06/19/19; LPN #821, hired 06/22/19; and LPN #816, hired 09/24/19 were not screened using the State of Ohio Nurse Aide Registry to identify any negative findings. Interview on 09/30/19 at 4:47 P.M. with Business Office Manager (BOM) #889 verified the facility did not check all new hires, including nurses, against the State of Ohio Nurse Aide Registry. BOM #889 confirmed she checked the unlicensed staff and the nurse aides but not the nurses against the State of Ohio Nurse Aide Registry. Review of the Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, revised 2017, indicated the facility would check with the Ohio Nurse Assistant Registry and any other registries for unlicensed persons that the facility had reason to believe contain information on an individual, prior to the use of that individual. The facility would check with all applicable licensing and certification authorities to ensure that employees hold the requisite license and/or certification status to perform their job functions and do not have a disciplinary action in effect against his or her professional license by a state licensure agency as a result of a finding of abuse, neglect, exploitation or misappropriation of resident property. Interview on 10/03/19 at 2:45 P.M. with the Administrator confirmed the abuse policy and procedure did not reflect the current regulatory language to check all new hires against the Ohio Nurse Aide Registry as required by the current regulatory language. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365746 If continuation sheet Page 3 of 27 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 365746 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brentwood Health Care Center 907 Aurora Rd Sagamore Hills, OH 44067 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** Based on observation, interview and record review, the facility failed to develop individualized care plans for Resident's #30, #34, #59, #66, #76 and #80. This affected six residents of 41 Residents (#3, #5, #6, #7, #8, #9, #10, #12, #13, #15, #17, #19, #23, #24, #26, #27, #29, #30, #34, #38, #49, #51, #54, #55, #56, #57, #59, #63, #64, #65, #66, #75, #76, #78, #79, #80, #82, #83, #84, #282 and #283) records reviewed for individualized plans of care. The facility census was 86. Findings include: 1. Review of the medical record revealed Resident #80 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including congestive heart failure, acute kidney failure, psychosis, chronic respiratory failure, chronic kidney disease Stage 4, diabetes with diabetic polyneuropathy, hypertensive heart and chronic kidney disease with heart failure, cardiomegaly, anemia, anxiety, dementia with behavioral disturbance, automatic cardiac defibrillator, aortocoronary bypass graft, chronic ischemic heart disease, chronic gout, edema, hypertension, low back pain, chronic obstructive pulmonary disease, dependence on supplemental oxygen, reflux and major depressive disorder. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated she was cognitively impaired, displayed no behaviors and had the conditions as listed above. Review of the annual MDS 3.0 care area assessment (CAA) dated 11/10/18 indicated to proceed to care planning in the areas of cognition, activities of daily living, incontinence, falls, nutrition, pressure ulcers, psychotropic medication and pain. Review of the electronic plan of care revealed it was not complete. The following areas were identified but had no interventions developed: diabetes, shortness of breath, pain, cognition, anemia and activities of daily living. There was no care plan developed for psychotropic medication, incontinence or pressure ulcers. Interview and observation of Resident #80 on 09/30/19 at 10:19 A.M. said she was supposed to use her oxygen at all times. She verified her oxygen tubing was observed on the floor by her. Interview with the care plan nurse, Licensed Practical Nurse (LPN) #818, on 10/02/19 at 3:50 P.M. verified the care plans were not developed. 2. Review of the medical record revealed Resident #59 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting right dominant side, osteoarthritis, low back pain, osteoporosis and anxiety disorder. Review of the physician order dated 12/27/18 indicated there was a hand treatment: soak right hand in warm water, apply hydrogen peroxide with a Q-tip to each digit and palm of hand twice daily. Please medicate for pain before treatment. She was also ordered a right palm protector on 10/31/18 to be applied during waking hours and removed at night and/or at resident tolerance for positioning and hygiene. Review of the MDS 3.0 dated 07/16/19 indicated she had short and long-term memory impairment and moderate cognitive impairment. No behaviors were identified. She required the extensive assistance of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365746 If continuation sheet Page 4 of 27 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 365746 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brentwood Health Care Center 907 Aurora Rd Sagamore Hills, OH 44067 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 one staff for personal hygiene. Her functional limitation in range of motion identified that she was impaired on one side of upper and lower extremities. Review of the annual MDS 3.0 CAA dated 04/13/19 indicated to proceed to care planning for pain, activities of daily living and behaviors. Review of the plan of care identified right side hemiplegia with interventions including use of the right hand protector and general pain interventions but was not individualized to include her resistance to all care to the right hand and the need for the family to be present to provide care to the contracted right hand. There was no evidence alternative interventions had been explored. Review of the specialist note dated 02/19/19 indicated he provided Botox therapy with some improvement in range of motion at the elbow but no improvement in the fingers. He noted she continued to have pain in the right hand, and the family was hoping something could be done to open her hand so that it could be cleaned. He indicated the diagnoses was focal dystonia, and the plan was for daily stretching of the right upper and lower extremities. Resident #59 was observed on 09/30/19 at 10:54 A.M., 10/01/19 and 10/02/19 at various times to hold her right hand tight. There was no roll or splint in place. Interview with Registered Nurse (RN) #876 on 10/03/19 at 7:47 A.M. verified no device had been placed in her right hand. He said anytime you went near the hand she screamed bloody murder. She refused treatment to the hand. He said they tried a carrot, wash cloth, gauze and she pulled them out. She was also followed by therapy but resisted any treatment. He said she had Botox treatments, and they were not effective. He said a surgical procedure had been recommended to the family to release the tendons, but the family refused for her to have surgery. He said she received Hospice services and had an as needed order for Morphine (opioid pain medication) and used to have an order for Tramadol (opioid pain medication), but it was discontinued by the nurse practitioner. He said the only time the hand got clean was when they cut her nails. He said the daughter had to be present and assist because it was a real struggle. Interview with RN Supervisor #874 and State Tested Nurse Aide (STNA) #839 on 10/03/19 at 8:33 A.M. said the family discontinued the Botox therapy because it was not helping. They verified it was a struggle to provide care to the hand because she screamed. They indicated the family had to be present for the cutting of her nails because it was so bad. The idea was to let therapy loosen her up but she refused. Interview with LPN #818 on 10/03/19 at 1:33 P.M. verified the current care plan was not individualized to include interventions for the contracted right hand, pain and refusal of care. 5. Review of the medical record of Resident #66 revealed he was admitted to the facility on [DATE] with diagnoses including aphasia, seizure disorder and hypertension. The record also indicated a diagnoses of calculus of the kidney (kidney stones). Review of his quarterly MDS 3.0 assessment dated [DATE] revealed he was severely cognitively impaired. Review of a nursing note dated 06/04/19 at 12:41 P.M. revealed the resident was transferred to the hospital at the request of the family for increased confusion and a note on 06/04/19 at 10:15 P.M. revealed he was admitted for kidney stones. He returned to the facility on [DATE]. Review of the record revealed a nursing note dated 06/22/19 at 11:54 P.M. which indicted the resident was stable with no concerns. The next note dated 06/24/19 at 12:57 P.M. revealed the resident had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365746 If continuation sheet Page 5 of 27 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 365746 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brentwood Health Care Center 907 Aurora Rd Sagamore Hills, OH 44067 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 been discharged to the hospital on [DATE]. The next note in the record dated 06/25/19 at 3:22 P.M. revealed the resident returned from the hospital after a stay for a kidney stone and urinary retention. Review of the record did not reveal any assessment or further information on the resident's medical status, change in condition or symptoms that led to his transfer to the hospital. Further review of the record revealed the care plans did not contain any plans or interventions related to kidney stones or interventions to prevent or treat symptoms of pain related to the condition. An interview with LPN #818 on 10/03/19 at 2:00 P.M. confirmed she was the nurse who completed care plans for residents. She verified the resident had at least two hospitalizations for kidney stones, and the record did not contain care plans related to nursing interventions to prevent, identify or treat symptoms of the condition. 6. Review of the medical record of Resident #30 revealed she was admitted to the facility on [DATE] with diagnosis including a fracture of the left ankle. She also had an immobilizer brace to her left leg. Her admission MDS 3.0 assessment dated [DATE] revealed she was cognitively impaired and required the extensive assistance of one to two staff members for her activities of daily living. Review of her care plans dated 07/15/19 revealed she had the potential for pressure ulcer development related to decreased mobility and need for extensive assistance with mobility. Review of the nursing note dated 09/13/19 at 2:56 P.M. revealed the resident was observed with an open area to left outer ankle, from the brace the resident wears daily. The note indicated a treatment was put in place to cleanse the area with normal saline, cover with an antibiotic ointment and cover with coversite (a dressing). The note also indicated a note was left with the wound nurse so the resident could be seen by the wound NP (Nurse Practioner). There was no assessment of the area noted in the record, including appearance or size of the open area. Review of the record did not reveal further narrative documentation regarding the impaired skin area. Review of a note written by the consulting wound nurse practioner, Registered Nurse (RN) #700 dated 09/17/19 revealed she assessed the wound as a pressure area and applied a new dressing of Santyl (debriding agent), Calcium Alginate (absorbent dressing) covered with adherent foam to be applied daily and as needed. The next note by RN #700 on 09/24/19 indicated the dressing order should be continued as previously. The note indicated the only change to the assessment was the periwound was macerated. Review of skin grids provided by the facility revealed the areas was measured on 09/17/19 as 2.0 centimeters (cm) by 1.0 cm by 0.1 cm deep. It was a stage three (an area that extends into the tissue, forming a small crater) and had a moderate amount of sero-sanguineous drainage. The skin grid indicated the skin area measured 1.4 cm by 1.0 cm by 0.1 cm with edges macerated. The skin grid entry for 09/24/19 indicated the order for the Santyl and Calcium Alginate. Review of the treatment administration record (TAR) for September 2019 did not reveal any evidence of the dressing application of the antibiotic ointment. The TAR did not show the dressing of the Santyl and Calcium Alginate ordered by the wound nurse practioner on 09/17/19 until 09/25/19. The pressure area was not measured again until 10/01/19 when an entry indicated it measured 1.1 cm (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365746 If continuation sheet Page 6 of 27 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 365746 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brentwood Health Care Center 907 Aurora Rd Sagamore Hills, OH 44067 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 by 1.0 cm by 0.1 cm. No changes were made to the treatment. Level of Harm - Minimal harm or potential for actual harm LPN #821 verified on 10/03/19 at 12:57 P.M. the record did not contain an assessment of the pressure area discovered on 09/13/19 until 09/17/19 and that the record did not show evidence of the ordered treatment in place or the change in treatment as ordered until 09/25/19. Residents Affected - Some An interview with LPN #818 on 10/03/19 at 2:00 P.M. confirmed she was the nurse who completed care plans for residents. She verified Resident #30 had developed a pressure area from her immobilizer brace and the record did not contain a care plan related to the actual skin impairment and interventions to treat the impairment. 3. Review of Resident #34's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including chronic kidney disease, secondary malignant neoplasm of the bone and malignant neoplasm of the prostate. Review of Resident #34's MDS 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #34's wound grids confirmed on 09/23/19 the resident had a stage two (superficial with a pale pink wound bed and serous drainage and may present itself as an abrasion, blister or shallow crater) on the right buttock and the coccyx. The right buttock was first identified 08/06/19 and the coccyx was first identified on 09/23/19 and both pressure wounds were facility acquired. Review of Resident #34's physician orders dated 09/25/19 revealed an order for a foam dressing to the right buttock and change the dressing every Monday, Wednesday and Friday and as needed and an order for Mepilex dressing (absorbent wound dressing) to the coccyx to be changed every three days and as needed. Review of Resident #34's medical record did not reveal evidence a care plan for pressure wounds was developed with measurable goals and interventions. Interview on 10/02/19 at 4:15 P.M. with LPN #818 confirmed Resident #34's medical record did not have a care plan with goals and interventions individualized for Resident #34's pressure wounds. 4. Review of Resident #76's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including lack of coordination, malaise and dementia without behavioral disturbance. Review of Resident #76's MDS 3.0 assessment dated [DATE] indicated the resident exhibited severe cognitive impairment and was on hospice services. Review of Resident #76's physician order dated 01/16/18 indicated the resident was admitted to hospice with a diagnosis of congestive heart failure (CHF). Review of Resident #76's medical record did not reveal evidence the resident had a care plan for hospice which included measurable goals and interventions to meet the resident's needs. Interview on 10/02/19 at 4:15 P.M. with LPN #818 confirmed Resident #76's medical record did not include a care plan for hospice care with measurable goals and interventions to meet the resident's needs and provide coordination of care for hospice services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365746 If continuation sheet Page 7 of 27 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 365746 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brentwood Health Care Center 907 Aurora Rd Sagamore Hills, OH 44067 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 - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure Resident #54 was monitored for a reddened rash under the resident's bilateral breasts and failed to ensure coordination of Resident #76's code status. This finding affected one (Resident #54) of two residents reviewed for general skin conditions and one (Resident #76) of three residents reviewed for hospice. The facility census was 86. Residents Affected - Few Findings include: Review of Resident #54's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including type two diabetes, muscle weakness and difficulty in walking. Review of Resident #54's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment. Review of Resident #54's physician orders revealed an order dated 06/12/19 for Nystatin cream (antifungal cream) apply to under both breasts topically two times a day for a rash and may discontinue when healed. Review of Resident #54's progress notes from 08/17/19 to 10/03/19 revealed no evidence the resident had a rash under her bilateral breasts. Review of Resident #54's medication administration records (MAR) and treatment administration records (TAR) from 09/01/19 to 10/02/19 revealed the anti-fungal cream was applied at 9:00 A.M. and 5:00 P.M. every day. Interview on 09/30/19 at 9:41 A.M. with Resident #54 revealed the staff did not put the cream underneath her breasts during the previous nightshift. Observation on 09/30/19 at 10:55 A.M. revealed Resident #54's bilateral breasts had a large reddened rash underneath both breasts which was bright red and shiny. There was no evidence any type of antifungal cream was applied underneath the bilateral breasts as documented in the medical record. Interview on 10/03/19 at 9:33 A.M. with Registered Nurse (RN) #873 indicated she was made aware at some point last week of the rash underneath Resident #54's bilateral breasts. Interview on 10/03/19 at 11:00 A.M. with Licensed Practical Nurse (LPN) #819 indicated the staff did not inform her of Resident #54's bilateral breasts rash, did not assess or monitor the resident's rash underneath her breasts and did not ensure documentation was in the resident's medical record related to the resident's bilateral breasts rash. 2. Review of Resident #76's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including lack of coordination, malaise and dementia without behavioral disturbance. Review of Resident #76's MDS 3.0 assessment dated [DATE] indicated the resident exhibited severe cognitive impairment and was on hospice services. Review of Resident #76's Ohio DNR (do not resuscitate) form dated 11/2/12 indicated the resident's code status was DNRCC-Arrest. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365746 If continuation sheet Page 8 of 27 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 365746 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brentwood Health Care Center 907 Aurora Rd Sagamore Hills, OH 44067 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 - Minimal harm or potential for actual harm Review of Resident #76's physician order dated 01/16/18 indicated the resident was admitted to hospice with a diagnosis of congestive heart failure (CHF). Review of Resident #76's hospice declaration page dated 01/16/18 indicated the resident's code status was DNR. Residents Affected - Few Review of Resident #76's hospice code status paperwork dated 01/19/18 revealed the resident's code status was DNRCC. Interview on 10/02/19 at 5:49 P.M. with Hospice RN #900 confirmed Resident #76's code status was supposed to be DNRCC, and the code status at the facility in the resident's medical record was DNRCCA. Hospice RN #900 confirmed she missed identifying the facility did not have an accurate code status for Resident #76 and coordination of care was not completed to ensure the resident's code status was updated and accurate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365746 If continuation sheet Page 9 of 27 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 365746 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brentwood Health Care Center 907 Aurora Rd Sagamore Hills, OH 44067 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record revealed Resident #29 was admitted to the facility on [DATE] with diagnoses including dementia with Lewy bodies, severe protein-calorie malnutrition, generalized osteoarthritis, Alzheimer's disease, contracture of left hip, left knee and right lower leg, dementia with behavioral disturbance, disorder of bone density and structure, cerebrospinal fluid drainage device, hypertension, normal pressure hydrocephalus, insomnia, anxiety disorder, major depressive disorder and macular degeneration with blindness. Residents Affected - Few Review of the physician orders indicated an initial treatment to the left hip was ordered on 06/19/19. Subsequently, the treatment for the left hip had been altered to aid in the healing process. The latest treatment order was 09/06/19. Review of the admission comprehensive MDS 3.0 assessment dated [DATE] indicated she was severely cognitively impaired and displayed verbal behavioral symptoms directed towards others on one to three days of the assessment period. She required the extensive assistance of one person for bed mobility, eating, toileting and personal hygiene and the extensive assistance of two plus persons for transfer. She was identified as being always incontinent of bowel and bladder. She weighed 67 pounds. She was identified at risk for the development of pressure ulcers but did not have pressure sores at the time of the assessment. Review of the pressure ulcer plan of care indicated to assess/record/monitor wound healing per facility protocol/physicians orders. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the physician. Review of the Braden scale for predicting pressure ulcer risk dated 06/05/19 indicated she was high risk for the development of pressure ulcers. Review of the admission assessment dated [DATE] indicated she was bed bound, her skin was intact and she needed to be fed because she was blind. There was no documented evidence of the left hip ulcer description, characteristics, measurements or location at the onset nor was there documented evidence of monitoring of the left hip ulcer until 09/20/19. The first facility documentation of the left hip ulcer other than the physician's order was by the dietary staff on 06/30/19 at 12:49 P.M. who noted the resident had a deep tissue injury (purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear) of the left hip. Review of the weekly nurse note authored by LPN #871 dated 09/02/19 by at 10:07 P.M. noted a pressure ulcer was present and a pressure reducing mattress was in place. There no descriptors of this pressure ulcer. Review of the wound/skin care management documentation: The left hip ulcer was noted on 08/13/19. It was not present on admission. There was no documented evidence of the description or measurement of the area until 09/10/19 where it was identified as unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar) measuring 5.5 cm x 2.5 cm with 100% slough. Review of the bi-monthly nursing comprehensive assessment dated [DATE] indicated movement caused (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365746 If continuation sheet Page 10 of 27 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 365746 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brentwood Health Care Center 907 Aurora Rd Sagamore Hills, OH 44067 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few severe pain. She had Stage I (intact skin with non-blanchable redness) pressure ulcers on the side of her feet and a left hip protuberance. The note indicated her left heel touched her buttocks. Review of the conference meeting summary, care plan and comprehensive assessment updated dated 06/26/19 indicated on 06/14/19 she had a Stage I to II (a stage II pressure ulcer is described as partial thickness skin loss of dermis presently as a shallow open ulcer with a red pink wound bed, without slough) on the left hip, two Stage I's and a Stage II on the right foot, red knees, a Stage I on the sacrum 06/25/19 and a Stage II on the left great toe. On 07/24/19 it was noted her contractures were worsening causing her briefs to fit incorrectly. She had redness on the bony prominence's and had breakdown on her feet and left hip. On 08/21/19 she was noted to have a worsening left hip wound with necrosis (death of most or all of the cells in an organ or tissue due to disease, injury, or failure of the blood supply). Interview with the resident representative on 09/30/19 at 10:55 A.M. indicated there was an issue because Resident #29 developed a pressure ulcer in the facility. Interview with the family member on 09/30/19 at 12:03 P.M. indicated Resident #29 developed a pressure ulcer in the facility and it was huge, covering the entire hip and buttock area. Interview with the wound nurse, LPN #819, on 10/02/19 at 11:37 A.M. verified that Hospice identified the wound on 09/06/19 and ordered a treatment for the area. She said she was not aware of the pressure ulcer until 09/10/19 and said it was 100% slough. She admitted she did not document about pressure ulcer until 09/23/19. She said the wound nurse practitioner was involved and did a partial debridement one week and last week did the rest of the debridement. LPN #819 said last week there were three more pressure ulcers identified. LPN #819 verified the facility had awareness of the pressure ulcers since 06/14/19 and failed to document the assessments to monitor the progression/regression of the area. Review of the pressure sore policy and procedure, dated March 2014, indicated the purpose was to assess all residents at risk for developing pressure areas and to assess/maintain the healing process of pressure areas. All residents would be assessed for the risk of developing pressure areas on admission, quarterly and daily during care by the charge nurse and nursing assistant. The charge nurse would assess and monitor each pressure area daily during treatment administration and document any changes in the condition in the nurse's notes. The treatment nurse would assess, monitor and document on the pressure areas every week. The charge nurse/treatment nurse to report any changes in condition of pressure areas and any lack of progress with the current treatment plan. The supervisor would notify the physician and responsible party of changes in condition and implement interventions as ordered by physician. Documentation/assessment of the ulcer should include the date, location, type and stage of the ulcer, measurements, characteristics, monitor dressings and treatments, monitor the healing progress and/or potential complications and assess, treat and monitor for pain. Review of the concern log indicated on 09/13/19 the family wanted a second opinion on her wound. The action was the resident was sent to the emergency room per the family request and returned with no new orders. This deficiency was an incidental finding to Complaint Number OH001007050. Based on observation, interview and record review, the facility failed to ensure impaired skin areas were identified, assessed and treatments were put in place as ordered for Residents #29 and 30. This affected two of three residents (Resident #29, #30 and #34) reviewed for pressure ulcers. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365746 If continuation sheet Page 11 of 27 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 365746 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brentwood Health Care Center 907 Aurora Rd Sagamore Hills, OH 44067 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 facility census was 86. Level of Harm - Minimal harm or potential for actual harm Findings include: Residents Affected - Few 1. Review of the medical record of Resident #30 revealed she was admitted to the facility on [DATE] with diagnosis including a fracture of the left ankle. She also had an immobilizer brace to her left leg. Her admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she was cognitively impaired and required the extensive assistance of one to two staff members for her activities of daily living. Review of her nursing note dated 09/13/19 at 2:56 P.M. revealed the resident was observed with an open area to left outer ankle, from the brace the resident wears daily. The note indicated a treatment was put in place to cleanse the area with normal saline, cover with an antibiotic ointment and cover with Coversite (a dressing). The note also indicated a note was left with the wound nurse so the resident could be seen by the wound NP (Nurse Practioner). There was no assessment of the area noted in the record, including appearance or size of the open area. Review of the record did not reveal further narrative documentation regarding the impaired skin area. Review of a note written by the consulting wound nurse practioner, Registered Nurse (RN) #700 dated 09/17/19 revealed she assessed the wound as a pressure area and applied a new dressing of Santyl (debriding agent), calcium alginate (absorbent dressing) covered with adherent foam to be applied daily and as needed. The next note by RN #700 on 09/24/19 indicated the dressing order should be continued as previously. The note indicated the only change to the assessment was the periwound was macerated. Review of skin grids provided by the facility revealed the areas was measured on 09/17/19 as 2.0 centimeters (cm) by 1.0 cm by 0.1 cm deep. It was a stage three (an area that extends into the tissue, forming a small crater) and had a moderate amount of sero-sanguineous drainage. The skin grid indicated the skin area measured 1.4 cm by 1.0 cm by 0.1 cm with edges macerated. The skin grid entry for 09/24/19 indicated the order for the Santyl and Calcium Alginate. Review of the treatment administration record (TAR) for September 2019 did not reveal any evidence of the dressing application of the antibiotic ointment. The TAR did not show the dressing of the Santyl and Calcium Alginate ordered by the wound nurse practioner on 09/17/19 until 09/25/19. The pressure area was not measured again until 10/01/19 when an entry indicated it measured 1.1 cm by 1.0 cm by 0.1 cm. No changes were made to the treatment. An interview with the facility wound nurse, Licensed Practical Nurse (LPN) #819 on 10/02/19 at 11:54 A.M. revealed she was made aware of the open area on 09/16/19. She stated a nurse found the area on 09/13/19 and received and order for the antibiotic ointment. She stated she looked at the area on 09/16/19 because the wound nurse practioner came to the facility on Tuesday's (09/17/19), and she wanted to see if the wound should be followed by the nurse practioner. She stated she looked at the wound but did not measure it or complete an assessment. She said a dressing was in place when she looked at the area and she completed a dressing change, but did not mark the dressing change off as completed on the TAR. She stated she did not notice there was not an order in the record or TAR for staff to sign off the treatment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365746 If continuation sheet Page 12 of 27 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 365746 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brentwood Health Care Center 907 Aurora Rd Sagamore Hills, OH 44067 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few LPN #819 stated when the wound nurse visited on 09/17/19, she recorded the measurements obtained by the wound nurse on the skin grid. She stated she noted the wound nurse had applied the new dressing but somehow the new order for the dressing change did not get ordered or transposed to the TAR on 09/17/19. She stated she made sure the order was put on the treatment record after the wound nurse visit on 09/24/19 and it was started on 09/25/19, since the wound nurse had completed the dressing change on 09/24/19. An observation of the area and dressing change observation was made on 10/02/19 at 2:30 P.M. with LPN #821. LPN #821 completed the dressing change to the impaired skin area, which was toward the back of the resident's left leg, slightly above and lateral to the ankle. Another scabbed area measuring approximately 1.0 cm round was noted on the front of the resident's left leg, open to air. LPN #821 indicated there was no dressing to that area. She stated she had seen it before but did not know where it had come from or if the facility wound nurse was aware of its existence. An interview with LPN #821 on 10/02/19 at 3:30 P.M. revealed she was unaware of any other impaired skin area for Resident #30. She was informed of the observation of the scabbed area to the left leg and stated she would go look at it. An interview with the consulting wound nurse practioner, RN # 700, on 10/03/19 at 12:15 P.M. by phone revealed she remembered the resident. She stated she had ordered the Santyl to debride the area and the Calcium Alginate helped to absorb the moisture. She verified the wound had gotten smaller but that her note indicated the edges of the wound were macerated. She stated the description just meant the area was moist. She denied the area had declined, based off the measurements, but did not remember if she noted the correct dressing in place when she visited the resident on 09/24/19 or if she discussed with staff any concerns related to the order not carried out as ordered on 09/17/19. An interview with LPN #821 on 10/03/19 at 12:30 P.M. revealed she had not yet checked the scabbed skin area observed during the dressing change on 10/02/19. On 10/03/19 at 12:57 P.M., LPN #821 verified a scab was present on the front shin area of Resident #30's left leg, which measured 1.5 cm by 1.0 cm. She stated she was unaware of the skin area and had not seen the area when she checked the pressure area on 10/01/19. She verified impaired skin areas should be reported and investigated to determine the cause and any possible treatments that should be put in place. LPN #821 further verified the record did not contain an assessment of the pressure area discovered on 09/13/19 until 09/17/19 and that the record did not show evidence of the ordered treatment in place or the change in treatment as ordered until 09/25/19. Review of the facility policy for skin assessment documentation and prevention of pressure ulcers, dated March 2014, revealed changes in skin condition would be reported to the charge nurse and wound nurse. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365746 If continuation sheet Page 13 of 27 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 365746 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brentwood Health Care Center 907 Aurora Rd Sagamore Hills, OH 44067 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and policy review, the facility failed to ensure medications were administered properly through a naso-gastric tube. This affected Resident #80, one of four residents (Residents #34, #36, #80 and #86) observed for medication administration, with a facility census of 86. Findings include: Medication administration for Resident #80 was observed on 10/02/19 at 3:55 P.M. with Licensed Practical Nurse (LPN) #824. LPN #824 stated Resident #80 had an NG (naso-gastric) tube (feeding tube through his nose into his stomach) and received his medications through the tube. She stated she did not check for placement of the NG tube because it has a weight at the bottom in his stomach, which keeps it in place. LPN #824 prepared the medication for administration into the resident's NG tube which included four tablets. She crushed the tablets and added some warm water, stirring each with a spoon in their separate medication cups to dissolve the medications. She entered the room and disconnected the resident's tube feed solution, which was running through a pump. She used a large syringe to pull up 30 cubic centimeters (cc) of water using the plunger in the syringe. She attached the syringe with plunger to the tube and slowly pushed the water through the tube. She disconnected the syringe, removed the plunger and reconnected the syringe. Holding the syringe up with the tube connected, she poured the contents of each of the four medication cups into the syringe, flushing with water after each by pour a small amount of water into the syringe. The medications and water flowed freely through the syringe without any noted impairment. After completing the four medications, she removed the syringe, reattached the plunger and pulled up another 30 cc of water, which she pushed slowly through the tube after reconnecting it to the tube. LPN #824 then reconnected the tube feeding solution, started the tube feeding pump and indicated she was finished at 4:10 P.M. An observation of the cups that had contained the medications revealed two of the four cups had a significant amount of medication still in the cup. LPN #824 verified she had not rinsed the cups and full doses of the medications had not been delivered. She indicated the medications did not dissolve well in water and said she should have added more water to the cups to ensure the full doses could be administered. LPN #824 added a small amount of water to one of the cups, and, using the tip of the syringe with the plunger in it, stirred the medication around until it was dissolved and then pulled the medication/water mixture into the syringe. She disconnected the feeding tube and, without flushing with more water, pushed the medication with the plunger through the tube. She repeated the process with the second cup that contained residual medication, pulling the medication water mixture into the syringe after stirring it and pushing the medication through the tube with the plunger. She then pulled up 30 cc of water into the syringe and flushed the tube again. When she had finished, she again reconnected the feeding tube to the pump with the tube feed fluid and started the machine. After the medication pass, LPN #824 again verified she did not check the placement of the NG because of the weight at the bottom of the tube. She verified she had used the plunger to push water and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365746 If continuation sheet Page 14 of 27 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 365746 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brentwood Health Care Center 907 Aurora Rd Sagamore Hills, OH 44067 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few medications through the tube. She stated she did that sometimes because it ran slowly. She verified she had not attempted to flush the tube by using gravity and that the medication/water mixtures had gone through the tube using just gravity with no problems. Review of the record revealed Resident #80 was admitted to the facility on [DATE] with diagnoses including malnutrition, ulcerative colitis and dysphasia. An interview with the Director of Nursing on 10/02/19 at 4:50 P.M. confirmed the placement of an NG tube should be confirmed prior to medication administration and that medications and flushes should run by gravity if possible during medication administration by NG tube. Review of the facility policy on Medication Administration through Enteral Tubes, dated October 2007, revealed tube placement should be verified by inserting a small amount of air into the tube with the syringe and listen to the stomach with a stethoscope for gurgling sounds and by aspirating stomach contents with a syringe to check for residual. The policy also indicated the plunger should be removed from the syringe before inserting into the tubing to flush the tube initially, and that medication should be allowed to flow down the tube via gravity, using gentle boost with the plunger only if the medication would not flow by gravity. The policy indicated medications should not be pushed down the tube. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365746 If continuation sheet Page 15 of 27 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 365746 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brentwood Health Care Center 907 Aurora Rd Sagamore Hills, OH 44067 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 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation, record review and interview, the facility failed to ensure the nurse staffing information accurately reflected the correct date and staffing ratios. This finding had the potential to affect all 86 residents residing in the facility. Residents Affected - Many Findings include: Observation on 09/30/19 at 8:00 A.M. revealed the posted nurse staffing information located on the front desk reflected a date of 09/27/19 and did not reflect the current staffing for the day. Interview on 09/30/19 at 8:15 A.M. with Secretary #887 confirmed the posted nurse staffing information did not accurately reflect the correct date or staffing information. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365746 If continuation sheet Page 16 of 27 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 365746 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brentwood Health Care Center 907 Aurora Rd Sagamore Hills, OH 44067 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility did not ensure the physician acted upon pharmacist recommendation timely for Residents #29 and #80. This affected two of six Residents (#17, #29, #49, #56, #66 and #80) reviewed for unnecessary medications. The facility census was 86. Findings include: 1. Review of the medical record revealed Resident #29 was admitted to the facility on [DATE] with diagnoses including dementia with Lewy bodies, severe protein-calorie malnutrition, generalized osteoarthritis, Alzheimer's disease, contracture of left hip, left knee and right lower leg, dementia with behavioral disturbance, disorder of bone density and structure, cerebrospinal fluid drainage device, hypertension, normal pressure hydrocephalus, insomnia, anxiety disorder, major depressive disorder and macular degeneration with blindness. Review of the admission comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated she was severely cognitively impaired and displayed verbal behavioral symptoms directed towards others on one to three days of the assessment period. Review of the physician order dated 06/05/19 indicated she was ordered Ativan, an antianxiety medication, 0.5 milligrams (mg) every four hours for anxiety and restlessness. Review of the pharmacy recommendation made on 06/30/19 indicated anxiolytics (Ativan) could only be used for 14 days and would need to be re-evaluated. Review of the medical record revealed the physician responded on 08/21/19 to the pharmacy recommendation dated 06/30/19 that he disagreed because she was on Hospice. There was a physician note dated 07/03/19 but did not address the Ativan. Interview with the pharmacist on 10/03/19 at 09:23 AM said he made a recommendation to review the as needed Ativan for Resident #29 on 06/30/19. He did not know what happened to the recommendation after that. 2. Review of the medical record revealed Resident #80 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including congestive heart failure, unspecified psychosis, chronic respiratory failure, anxiety, dementia with behavioral disturbance, dependence on supplemental oxygen and major depressive disorder. The physician ordered Ativan 0.5 mg every 12 hours as needed on 01/17/19 for anxiety. Review of the MDS 3.0 dated 08/13/19 indicated she had no behaviors and had used an antianxiety medication twice during the assessment period. Review of the pharmacy recommendation dated 06/30/19 indicated anxiolytics (Ativan) could only be used for 14 days and would need to be re-evaluated. The physician did not respond until 08/13/19 to extend the medication for 180 days then he would re-evaluate. The nurse practitioner then discontinued the medication on 08/13/19. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365746 If continuation sheet Page 17 of 27 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 365746 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brentwood Health Care Center 907 Aurora Rd Sagamore Hills, OH 44067 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 Interview with the Director of Nursing on 10/02/19 at 4:00 P.M. said the physician was to respond to pharmacy recommendations within 30 days. 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: 365746 If continuation sheet Page 18 of 27 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 365746 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brentwood Health Care Center 907 Aurora Rd Sagamore Hills, OH 44067 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure medications were held as ordered based vital sign parameters for Resident #66. This affected one of six residents (Resident #17, #29, #49, #56, #66 and #80) reviewed for unnecessary medications. The facility census was 86. Residents Affected - Few Findings include: Review of the medical record of Resident #66 revealed he was admitted to the facility on [DATE] with diagnoses including aphasia, seizure disorder and hypertension. Review of his quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he was severely cognitively impaired. Review of the September 2019 Medication Administration Record (MAR) revealed the resident was ordered Lisinopril, a blood pressure medication, 10 milligrams once a day at 9:00 A.M., after a visit to his internal medication physician on 09/17/19. The order indicated the resident's blood pressure and pulse should be checked prior to the administration of the medication and if the resident's BP (blood pressure) was less than 110 (milligrams of mercury) or the HR (heart rate) was less than 70, the medication should be held. Review of the MAR revealed the resident's pulse was less than 70 on 09/25/19 (68 beats a minute) and on 10/01/19 (60 beats a minute), however the resident received the medication. An interview with Licensed Practical Nurse (LPN) #830 on 10/02/19 at 10:00 A.M. confirmed she was the nurse who had given the medication on 10/01/19. She stated she was aware of the parameters, but just had forgotten to hold the medication. The nurse who administered the dose on 09/25/19 was not identified. An interview with the Director of Nursing on 10/02/19 at 3:00 P.M. confirmed the medication was administered when it should have been held related to the pulse reading. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365746 If continuation sheet Page 19 of 27 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 365746 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brentwood Health Care Center 907 Aurora Rd Sagamore Hills, OH 44067 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the medication error rate was less than 5%. The error rate was 10.7% with three errors in 28 opportunities, affecting Residents #34 and #80. This affected two of four residents (Residents #34, #36, #80 and #86) observed for medication administration, with a facility census of 86. Residents Affected - Few Findings include: 1. Medication administration for Resident #34 was observed on 10/02/19 at 9:07 A.M. with Licensed Practical Nurse (LPN) #817. LPN #817 prepared all medications for the resident, which initially included an inhaler, an insulin injection and nine tablets or capsules. She confirmed the number of medications, including the nine pills, which were in two separate cups, one containing six pills and the other with three pills. LPN #817 administered the medications to the resident, who requested a pain pill, which she obtained and administered, completing the medication pass at 9:35 A.M. The surveyor also observed as she administered another medication to the resident on 10/02/19 at 10:16 A.M. as it was originally unavailable. Review of the residents record revealed he was admitted to the facility on [DATE] and had pressure ulcer. The resident was ordered a multivitamin on 01/25/19 to be given daily at 9:00 A.M. as a supplement, but LPN #817 had not administered the multivitamin during the medication administration. An interview with LPN #817 on 10/02/19 at 11:30 A.M. confirmed the count of the medications observed by the surveyor and that she had not administered the multivitamin. 2. Medication administration for Resident #80 was observed on 10/02/19 at 3:55 P.M. with LPN #824. LPN #824 stated Resident #80 had an NG (naso-gastric) tube (feeding tube through his nose into his stomach) and received his medications through the tube. LPN #824 administered an eye drop to Resident #80, then returned to her medication cart, prepared the medication for administration into the resident's NG tube which included four tablets. She crushed the tablets and added some warm water, stirring each with a spoon in their separate medication cups to dissolve the medications. She entered the room and disconnected the resident's tube feed solution, which was running through a pump. She administered all four medications into the NG tube individually, flushing after each. After a final flush, LPN #824 reconnected the tube feeding solution and indicated she was finished at 4:10 P.M. An observation of the cups that had contained the medications revealed two of the four cups had a significant amount of medication still in the cup. LPN #824 identified the first cup, which had a white tablet residue left in the cup, as the residents Magnesium Oxide, a supplement. A second cup contained an orange colored tablet, which LPN #824 identified as the resident's dose of Sulfasalazine, a medication to treat ulcerative colitis. There was a large amount of medication residue left in the cup. She verified she had not rinsed the cups and full doses of the medications had not been delivered. She indicated the medications did not dissolve well in water and verified she should have added more water to the cups to ensure the full doses could be administered. Review of the record revealed Resident #80 was admitted to the facility on [DATE] with diagnoses including malnutrition, ulcerative colitis and dysphasia. The Magnesium Oxide was ordered on 08/27/19, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365746 If continuation sheet Page 20 of 27 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 365746 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brentwood Health Care Center 907 Aurora Rd Sagamore Hills, OH 44067 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 0759 and the Sulfasalazine was ordered on 09/09/19. Level of Harm - Minimal harm or potential for actual harm An interview with the Director of Nursing on 10/02/19 at 4:50 P.M. confirmed the full amount of a medication should be administered. Residents Affected - Few Review of the facility policy on Medication Administration through Enteral Tubes, dated October 2007, revealed the medication cup was to be rinsed with water to ensure the entire dose of medication had been administered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365746 If continuation sheet Page 21 of 27 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 365746 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brentwood Health Care Center 907 Aurora Rd Sagamore Hills, OH 44067 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 observation, interview and policy review, the facility failed to maintain a clean and sanitary kitchen. This affected all residents who take food by mouth. The facility identified two residents (Resident's #52 and #80) that did not receive food by mouth. The facility census was 86. Findings include: The initial tour of the kitchen was conducted by the Executive Chef (EC) #930 on 09/30/19 beginning at 8:51 A.M. and the follow was observed: • The ice machine was observed to have a black substance scattered across the bottom of the white plastic chute where the ice passes into the storage bin below. Interview with EC #930 at that time verified the black substance on the white plastic chute, and reported the ice machine was cleaned weekly by maintenance. • The reach in cooler had a clear plastic container with three shelled hard-boiled eggs inside. There was debris on the inside of the container and directly on the eggs. The EC #930 verified there was debris inside the container and on the eggs and removed them from the cooler to be disposed. • The perimeter of the kitchen floor around and under appliances was heavily soiled with dirt, grease and food debris. The appliances also had a moderate amount of dried drips, food debris and grease on the sides and front of the appliances. • Two male Dietary Staff #900 and #912 wore hair nets over the tops of their head but did not contain the long braids and/or dread locks with a hair restraint. The following was observed on 10/01/19 beginning at 11:15 A.M.: • During tray line, the cook was observed to use china plates that were chipped. Interview with EC #930 at 11:23 A.M. indicated china plates with chips should have been pulled out of service. He went through the stacks of china and pulled 15 plates out of service that were chipped. • During tray line Dietary Staff #900 and #912 were observed again to wear hair nets over the tops of their head but did not contain the long braids and/or dread locks with a hair restraint. State Tested Nurse Aides (STNA) #841 came in and out of the kitchen a few times without wearing a hair net. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365746 If continuation sheet Page 22 of 27 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 365746 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brentwood Health Care Center 907 Aurora Rd Sagamore Hills, OH 44067 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 STNA #847 was observed to wear a hair net over the top of her head but had multiple long braids that were draped over her left shoulder and hung down her chest. Interview with the EC #930 at 11:30 A.M. confirmed all of the hair needed to be covered. Review of the weekly cleaning tasks policy and procedure, dated April 2019, indicated the staff would maintain the sanitation of the kitchen through compliance with a written weekly cleaning schedule. Review of the weekly cleaning schedule from July through September 2019 indicated every Monday detail the soup kettle and scrub down all shelving, every Tuesday stove top to the dish tank and change the foil on stove drip pan, every Wednesday scrub down stainless steel walls behind equipment and detail the steamer, every Thursday clean the ice machine and deep clean coolers on line and every Friday detail tilt skillet an detail the mixer. There was no indication of when the floor was to be cleaned. There were markings to indicate the above items were completed, but there was no indication who completed the cleanings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365746 If continuation sheet Page 23 of 27 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 365746 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brentwood Health Care Center 907 Aurora Rd Sagamore Hills, OH 44067 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 0814 Dispose of garbage and refuse properly. Level of Harm - Potential for minimal harm Based on observation, interview and policy review, the facility failed to ensure garbage was disposed of/stored in sanitary conditions to prevent the harborage of pests. This had the potential to affect all 86 residents in the facility. Residents Affected - Many Findings include: On 09/30/19 at 9:13 A.M. two dumpsters were observed outside of the facility. One dumpster was overflowing with garbage piled high enough that it raised the lid several feet above the top. A moderate amount of debris was on the ground surrounding the dumpsters including trash in bags, trash directly on the ground and broken furniture. Interview with the Executive Chef #930 on 09/30/19 at 9:13 A.M. verified the overflowing garbage and indicated garbage pick-up was due today. Review of the waste disposal policy and procedure, dated January 2019, indicated all garbage would be disposed of daily. Trash would be deposited into sealed containers outside the premises. Review of the dumpster pickup policy, dated September 2018, indicated scheduled pick-ups were Monday, Tuesday, Wednesday, Thursday, Friday and Saturday. If the dumpster was full, the trash removal company would be notified and an additional pickup would take place. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365746 If continuation sheet Page 24 of 27 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 365746 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brentwood Health Care Center 907 Aurora Rd Sagamore Hills, OH 44067 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure an accurate assessment in the record of Resident #66 regarding a transfer to the hospital. This affected one of three residents (Residents #27, #66 and #84) reviewed for hospitalization. The facility census was 86. Findings include: Review of the record of Resident #66 revealed he was admitted to the facility on [DATE] with diagnoses including aphasia (loss of ability to understand or express language), seizure disorder and hypertension (high blood pressure). Review of his quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he was severely cognitively impaired. Review of the record revealed a nursing note dated 06/22/19 at 11:54 P.M. which indicted the resident was stable with no concerns. The next note dated 06/24/19 at 12:57 P.M. revealed the resident had been discharged to the hospital on [DATE]. The next note in the record dated 06/25/19 at 3:22 P.M. revealed the resident returned from the hospital after a stay for a kidney stone and urinary retention. Review of the record did not reveal any assessment or further information on the resident's medical status, change in condition or symptoms that led to his transfer to the hospital. Review of the hospital discharge paperwork dated 06/25/19 revealed the resident was admitted with abdominal pain and found to have a kidney stone that passed. An interview with the Director of Nursing on 10/02/19 at 3:30 P.M. confirmed the record did not contain an assessment of the resident's condition prior to transfer to the hospital on [DATE]. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365746 If continuation sheet Page 25 of 27 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 365746 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brentwood Health Care Center 907 Aurora Rd Sagamore Hills, OH 44067 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 - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure Residents #65 and #79's room and bedding was clean and sanitary. This finding affected two (Residents #65 and #79) of twenty-seven residents residing on the 100 hall. Findings include: Review of Resident #65's medical record revealed the resident was re-admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, anxiety disorder and major depressive disorder. Review of Resident #65's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment and required extensive two person assist for bed mobility, dressing and personal hygiene. Review of Resident #79's medical record revealed the resident was readmitted to the facility on [DATE] with diagnoses including Alzheimer's disease with early onset, alcohol-induced persisting dementia and dysphasia. Review of Resident #79's MDS 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment and required extensive one person assist for bed mobility, transfers, dressing, eating, toilet use and personal hygiene. Observation on 09/30/19 at 9:54 A.M. revealed Residents #65 and #79's room smelled like urine, and the floor was sticky and tacky. Observation on 10/01/19 at 10:30 A.M. revealed Resident #79's bed was made up with brown soiling on the top cover. Resident #65 was in bed at the time of the observation, and Resident #79 was in the common lounge in a wheelchair. The resident room smelled like urine, and the floor was sticky and tacky. Interview on 10/01/19 at 1:08 P.M. with Housekeeping #810 indicated she mops the rooms on the 100 hall every day, and had just cleaned and mopped Residents #65 and #79's room. Housekeeping #810 indicated Resident #79 urinates on the floor. Interview on 10/01/19 at 1:53 PM. with Registered Nurse (RN) Supervisor #874 confirmed Residents #65 and #79's room smelled like urine, and Resident #79's bedsheets were soiled. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365746 If continuation sheet Page 26 of 27 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 365746 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brentwood Health Care Center 907 Aurora Rd Sagamore Hills, OH 44067 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility did not ensure three residents were free from flying pests. This finding affected three (Residents #33, #65 and #79) of twenty-seven residents residing on the 100 hall. Residents Affected - Few Findings include: Review of Resident #65's medical record revealed the resident was re-admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, anxiety disorder and major depressive disorder. Review of Resident #65's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment and required extensive two person assist for bed mobility, dressing and personal hygiene. Review of Resident #79's medical record revealed the resident was readmitted to the facility on [DATE] with diagnoses including Alzheimer's disease with early onset, alcohol-induced persisting dementia and dysphasia. Review of Resident #79's MDS 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment and required extensive one person assist for bed mobility, transfers, dressing, eating, toilet use and personal hygiene. Review of Resident #33's medical record revealed the resident was readmitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis, major depressive disorder and muscle weakness. Review of Resident #33's MDS 3.0 assessment dated [DATE] indicated the resident exhibited moderate cognitive impairment and required extensive two person assist for transfers as well as extensive one person assist for bed mobility, dressing, toilet use and personal hygiene. Observation on 09/30/19 at 9:56 A.M. revealed Residents #65 and #79 were both in bed. Three flies were observed on Resident #79's bed cover, overbed table and the resident's leg, and two flies were observed on Resident #65's bed covers. Observation and subsequent interview on 09/30/19 at 10:17 A.M. with Resident #33 revealed three flies were observed on the resident's overbed table, covers and on the resident. Interview on 09/30/19 at 10:20 A.M. with Housekeeping #804 confirmed three flies were observed flying around Residents #65 and #79's room. Interview on 09/30/19 at 10:29 A.M. with Housekeeping Supervisor #814 confirmed Resident #33's room had several flies, and the facility staff swatted the flies with a fly swatter. Interview on 09/30/19 at 10:55 A.M. Resident #29's representative informed State Tested Nursing Assistant (STNA) #932 that a fly landed on the resident's eye and it was bothering her, and the representative requested a fly swatter. STNA #932 indicated she had killed a fly several days prior with the fly swatter and did not know where the fly swatter went. Observation on 10/01/19 at 1:29 P.M. revealed several flies were on Resident #33's over bed table. Interview on 10/01/19 at 1:53 P.M. with Registered Nurse (RN) Supervisor #874 confirmed flies were observed flying around in Residents #65 and #79's room and the 100 hall. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365746 If continuation sheet Page 27 of 27