Inspection·December 22, 2022

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was aware Resident #275 had bruising to her neck. LPN #542 revealed she normally did not work with Resident #275 and was unsure how the bruising occurred. Interview on 12/19/22 at 12:24 P.M. with Resident #275's daughter confirmed she was also Resident #275 Power of Attorney (POA)/Responsible Party. Resident #275's daughter revealed she last visited Resident #275 on 12/15/22 when she was admitted to the facility. Resident #275's daughter revealed she had not been contacted of any changes in condition by the facility regarding Resident #275 and was unaware of any bruising to Resident #275's left side of her neck. Interview and observation on 12/20/22 at 1:36 P.M. with Registered Nurse (RN) #524 confirmed he was Resident #275's charge nurse. Observation of Resident #275's bruising to the left side of her neck with RN #524 confirmed Resident #275 had a large dark blue/ purple bruise covering the entire left side of her neck including a portion of the upper left chest. RN #524 revealed he was unaware Resident #524 had bruising to her neck area. Interview and observation on 12/20/22 at 1:45 P.M. with Wound Care Nurse Licensed Practical Nurse (LPN) #532 revealed she completed a skin assessment for Resident #275 on 12/16/22 (date after admission) during the day shift. Wound Care Nurse LPN #532 revealed Resident #275 did not have any bruising to her neck when she assessed her on 12/16/22. Record review of the progress note for Resident #275 dated 12/20/22 at 3:26 P.M. completed by RN #524 revealed Resident #275 had a dark purple in color with light purple bruise from the mid breast to the left ear lobe which measured 26 centimeters (cm) in length by 11 cm in width. Resident #275 also had a dark purple bruise to the left upper arm that measured 13 cm by 12 cm. Interview on 12/20/22 at 3:21 P.M. with Director of Nursing confirmed the physician nor certified nurse practitioner (CNP) had been made aware of Resident #275's bruise to the left side of the neck. Interview on 12/20/22 at 3:38 P.M. with LPN #535 revealed she worked with Resident #275 on 12/16/22 during the evening shift, 3:00 P.M. to 11:00 P.M. LPN #535 confirmed Resident #275 had the large bruise to her left neck area at that time. LPN #375 confirmed she did not report the bruise to anyone and revealed she assumed the bruise to Resident #275's neck was present on admission. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365746 If continuation sheet Page 2 of 18 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 12/22/2022 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to timely report and investigate an injury of unknown origin for Resident #275. This affected one resident (Resident #275) of two residents reviewed for injuries of unknown origin. Findings include: Record review for Resident #275 revealed an admission date of 12/15/22. Diagnosis included history of congestive heart failure and paroxysmal atrial fibrillation. Record review of the admission Baseline Care Plan dated 12/15/22 completed by Licensed Practical Nurse (LPN) #582 revealed Resident #275 was alert to person and confused. Resident #275 had an unsteady gait and weakness. Resident #275 was dependent for toileting, required extensive assistance for bed mobility and total dependence for transfers of two person physical assistants. Record review of the admission Skin assessment dated [DATE] initiated by LPN #544 revealed Resident #275 had bruising to the chest and on both arms. Record review of the physician orders for December 2022 for Resident #275 revealed Resident #275 had orders for coumadin five milligrams (mg) by mouth at bed time for atrial fibrillation. Orders included to monitor for signs and symptoms of bleeding every shift due to anticoagulants. Record review of Resident #275's medical record revealed no documentation of bruising to Resident #275's left side of her neck. Observation on 12/19/22 at 10:03 A.M. revealed Resident #275 was sitting up in a wheelchair in her room. The door to her room had been closed. Resident #275 was sitting in the chair with no shirt on and just a bra. Resident #275 had a large dark blue/ purple bruise covering the entire left side of her neck including a portion of the upper left chest. The bilateral arms had multiple small bruises. Resident #275 rambled and was unable to explain how the large bruise to her neck occurred. Interview on 12/19/22 at 10:08 A.M. with State Tested Nursing Assistant (STNA) #559 revealed she assisted Resident #275 with A.M. care and was unsure how the bruising occurred to Resident #275's neck. Interview on 12/19/22 at 10:15 A.M. with Licensed Practical Nurse (LPN) #542 revealed she was Resident #275's charge nurse and was aware Resident #275 had bruising to her neck. LPN #542 revealed she normally did not work with Resident #275 and was unsure how the bruising occurred. Interview and observation on 12/20/22 at 1:36 P.M. with Registered Nurse (RN) #524 confirmed he was Resident #275's charge nurse. Observation of Resident #275's bruising to the left side of her neck with RN #524 confirmed Resident #275 had a large dark blue/ purple bruise covering the entire left side of her neck including a portion of the upper left chest. RN #524 revealed he was unaware Resident #524 had bruising to her neck area. Interview and observation on 12/20/22 at 1:45 P.M. with Wound Care Nurse Licensed Practical Nurse (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365746 If continuation sheet Page 3 of 18 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 12/22/2022 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (LPN) #532 revealed she completed a skin assessment for Resident #275 (initiated by LPN #544) on 12/16/22 during the day shift. Wound Care Nurse LPN #532 revealed Resident #275 did not have any bruising to her neck when she assessed her on 12/16/22. Interview on 12/20/22 at 1:53 P. M with Director of Nursing (DON) and Administrator revealed the DON was not made aware of the bruising at the time it occurred on Resident #275's neck. DON confirmed this was bruising that occurred after admission and she should have been updated when it occurred so she could investigate the cause of the injury. Record review of the progress note for Resident #275 dated 12/20/22 at 3:26 P.M. completed by RN #524 revealed Resident #275 had a dark purple in color with light purple bruise from the mid breast to the left ear lobe which measured 26 centimeters (cm) in length by 11 cm in width. Resident #275 also had a dark purple bruise to the left upper arm that measured 13 cm by 12 cm. Interview on 12/20/22 at 3:38 P.M. with LPN #535 revealed she worked with Resident #275 on 12/16/22 during the evening shift, 3:00 P.M. to 11:00 P.M. LPN #535 confirmed Resident #275 had the large bruise to her left neck area at that time. LPN #375 confirmed she did not report the bruise to anyone and revealed she assumed the bruise to Resident #275's neck was present on admission. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365746 If continuation sheet Page 4 of 18 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 12/22/2022 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of medical record for Resident #30 revealed an admission date of 05/27/22. Diagnoses included major depressive disorder, anxiety disorder, acute kidney failure and Barrette's esophagus. Residents Affected - Few Review of the quarterly Minimum Data Set (MDS) assessment, dated 12/02/22, revealed the resident had intact cognition. The MDS dated [DATE], 12/03/22 and current MDS assessment dated for 03/05/23 indicated Resident #30 was ordered a mechanical soft diet and a prescribed weight loss regimen. Interview on 12/20/22 at 315 P.M. with Diet Manager (DM) #501 stated Resident #30 was not on a weight loss program, the manager stated resident received a boost nutritional supplement daily. The manager stated she personally takes the menus down to resident for the resident to choose her meals because she was so picky with meals. Interview on 12/20/22 at 3:20 P.M. with Dietitian #619 stated Resident #30 was not on a weight loss program and the dietitian verified the error in documentation on the MDS. Interview on 12/20/22 at 3:38 P.M. with LPN #534 stated Resident #30 was not on a weight loss program, and verified the error in documentation on the MDS. Based on record review and interview, the facility failed to maintain accurate Minimum Data Set (MDS) assessments for Resident #30 and Resident #66. This affected two residents (Resident #30 and Resident #60) of seven residents reviewed for accuracy of assessments. Findings include: 1. Review of the medical record for Resident #66 revealed an admission date of 08/18/22. Diagnoses included dementia without behavioral disturbance, fibromyalgia, muscle weakness, difficulty walking, and depression. Review of physician order dated 08/18/22 revealed Resident #66 had order for 325 milligram (mg) tablet of Tramadol twice daily for pain. Review of the discharge Minimum Data Set (MDS) assessment, dated 10/21/22, revealed Resident #66 had impaired cognition. The assessment indicated Resident #66 had no falls with injury. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/24/22, revealed Resident #66 had impaired cognition. The assessment indicated Resident #66 had one fall with no injuries and Resident #66 received as needed pain medications. Review of progress Notes from August 2022 to December 2022 revealed Resident #66 had falls on 09/22/22, 09/23/22, and 11/24/22. Resident #66 was reported to sustain skin tear to right elbow from the 09/22/22 fall, skin tear on bilateral arms and left thigh on 09/23/22, and skin tears to right elbow, right wrist, and right forearm at 11/24/22 fall. Interview on 12/21/22 at 3:00 P.M. with Licensed Practical Nurse (LPN) #534 confirmed she miscoded falls with injury on 09/22/22 and 09/23/22 for 10/21/22 MDS assessment and fall with injury on 11/24/22 for the 11/24/22 MDS assessment. LPN #534 confirmed she miscoded the regimented pain medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365746 If continuation sheet Page 5 of 18 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 12/22/2022 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Based on observation, interview and record review, the facility failed to complete a comprehensive baseline care plan for Resident #275 to include care for bruising and anticoagulant therapy. This affected one resident (Resident #275) of three residents reviewed for baseline care plans. Findings include: Record review for Resident #275 revealed an admission date of 12/15/22. Diagnosis included history of congestive heart failure and paroxysmal atrial fibrillation. Record review of the admission Baseline Care Plan dated 12/15/22 completed by Licensed Practical Nurse (LPN) #582 revealed Resident #275 was alert to person and confused. Resident #275 had an unsteady gait and weakness. Resident #275 was dependent for toileting, required extensive assistance for bed mobility and total dependence for transfers of two person physical assistants. Record review of the admission Skin Assessment initiated by Licensed Practical Nurse #544 dated 12/16/22 revealed Resident #275 had bruising to the chest and on both arms. Record review of the physician orders for December 2022 for Resident #275 revealed Resident #275 had orders for Coumadin (anticoagulant medication) five milligrams (mg) by mouth at bed time for atrial fibrillation. Orders included to monitor for signs and symptoms of bleeding every shift due to anticoagulants. Review of the admission Baseline Care Plan revealed it was silent of a plan to manage the resident's anticoagulant therapy, bruising or skin impairments. Observation on 12/19/22 at 10:03 A.M. revealed Resident #275 was sitting up in a wheelchair in her room. The door to her room had been closed. Resident #275 was sitting in the chair with no shirt on and just a bra. Resident #275's shirt was lying on the floor next to her. Resident #275 had a large dark blue/ purple bruise covering the entire left side of her neck including a portion of the upper left chest. The bilateral arms had multiple small bruises. Resident #275 rambled and was unable to explain how the large bruise to her neck occurred. Record review of Resident #275's medical record revealed no documentation of the bruising to Resident #275's left side of her neck. Interview and observation on 12/20/22 at 1:36 P.M. with Registered Nurse (RN) #524 confirmed he was Resident #275's charge nurse. Observation of Resident #275's bruising to the left side of her neck with RN #524 confirmed Resident #275 had a large dark blue/ purple bruise covering the entire left side of her neck including a portion of the upper left chest. RN #524 revealed he was unaware Resident #524 had bruising to her neck area. Interview and observation on 12/20/22 at 1:45 P.M. with Wound Care Nurse Licensed Practical Nurse (LPN) #532 revealed she completed a skin assessment for Resident #275 on 12/16/22 (date after admission) during the day shift. Wound Care Nurse LPN #532 revealed Resident #275 did not have any bruising to her neck when she assessed her on 12/16/22. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365746 If continuation sheet Page 6 of 18 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 12/22/2022 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Interview on 12/20/22 at 3:21 P.M. with Director of Nursing (DON) confirmed the baseline care plan did not include the location of Resident #275's bruising on admission, the use of Coumadin and need for continued monitoring for additional bruising. DON confirmed these items should have been added to the baseline care plan. Interview on 12/20/22 at 3:59 P.M. with Certified Nurse Practitioner (CNP) #618 confirmed he was not made aware of the additional bruising which included the bruising to Resident #275's left side of her neck and the new bruise located on Resident #275's left upper arm. CNP #618 revealed due to the additional bruising, his concern for Resident #275 was bleeding. CNP #618 revealed he would hold Resident #275's coumadin and obtain additional lab values. Event ID: Facility ID: 365746 If continuation sheet Page 7 of 18 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 12/22/2022 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 - Few 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. Record review for Resident #67 revealed an admission date of 10/08/22. Diagnosis included hypertensive heart and chronic kidney disease with heart failure. Record review of the admission Medicare five day Minimum Data Set, dated [DATE] revealed Resident #67 was cognitively intact. Resident #67 received routine pain medication rated a five on the pain scale of one to 10. Record review of the physician orders dated 10/09/22 revealed Resident #67 had an order Chlorhexidine Gluconate solution 0.12% 30 milliliters (ml) mucous membrane two times a day for mouth pain. Record review of the current care plan for 12/22/22 revealed Resident #67 had no care plan to address pain. Interview on 12/22/22 at 10:34 A.M. with LPN #531 confirmed there was pain care plan in the current comprehensive care plan for Resident #67. Based on record review and interview, the facility failed to develop and implement comprehensive care plans for Resident #67's pain and Resident #66's pain and infection. This affected one resident (Resident #66) of three residents reviewed for infections and two residents (Resident #66 and #67) of five reviewed for pain. Findings include: 1. Review of the medical record for Resident #66 revealed an admission date of 08/18/22. Diagnoses included dementia without behavioral disturbance, fibromyalgia, muscle weakness, difficulty walking, and depression. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/24/22, revealed Resident #66 had impaired cognition. The assessment indicated Resident #66 had one fall with no injuries and Resident #66 received as needed pain medications. Review of physician order dated 08/18/22 revealed Resident #66 had order for 325 milligram (mg) tablet of Tramadol twice daily for pain, 1 drop of Gentamicin Sulfate in left eye four times per day for infection, and 250 mg Keflex once daily for infection prophylactic. Review of current care plan for 12/22/22 revealed no care plan to address Resident #66's pain or infections. Interview on 12/22/22 at 10:14 A.M. with Licensed Practical Nurse (LPN) #534 confirmed there was no care plans for pain or infection control in the current care plan for Resident #66. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365746 If continuation sheet Page 8 of 18 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 12/22/2022 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to update the care plan for Resident #274 to include her missing eye glasses. This affected one resident (Resident #274) of five residents reviewed for comprehensive care plans. Findings include: Record review for Resident #274 revealed an admission date of 01/12/15. Diagnosis included Parkinson's disease and combined forms of age related cataract, bilateral. Record review of the activity assessment dated [DATE] revealed Resident #274 enjoyed spending most of her time reading the bible, sitting in silence, and visiting with friends. Record review of the quarterly Minimum Data Set, dated [DATE] revealed resident was able to make herself understood, usually understands others, vision was impaired and wore corrective lenses. Resident #274 required supervision with activities of daily living. Record review of the care plan dated 09/29/22 revealed Resident #274 had a potential for communication problem related to severely impaired cognition, unclear speech and impaired hearing. Resident #274 spoke German so she required a longer period to understand and be understood. Interventions included to face Resident #274 and make eye contact, use alternative communication tools as needed such as the communication book/board. Resident #274 had impaired vision related to cataracts. Interventions included to arrange consultation with eye care practitioner as required and Resident #274 required the following visual aids, glasses. Record review of the progress note for Resident #274 dated 11/21/22 (untimed) completed by Optometrist #619 revealed the examination was completed for a follow up six months for cataracts and dry eyes. Spectacle exam included flat top bifocal which resident was noted to have. Observation on 12/19/22 at 11:00 A.M. of Resident #274 revealed Resident #274 was sitting up in her wheelchair in her room. Resident #274 was not wearing eye glasses. Resident #274 spoke a different language and the surveyor was unable to communicate with Resident #274. On the nightstand near Resident #274 was a a bible (German) and watch magazines. Interview on 12/19/22 at 11:54 A.M. with Resident #274's daughter revealed Resident #274's eye glasses were missing at facility for over six months. Resident #274 wore her glasses daily due to poor vision. Resident #274 enjoyed reading which was difficult for her without the glasses. Resident #274's daughter revealed the staff told her the eye doctor was coming months ago to replace the glasses. Resident #274's daughter revealed she requested the facility let her know when the eye doctor was coming so she could be there due to Resident #274 spoke German and the doctor would not be able to understand her during the assessment. Resident #274's daughter revealed the facility did not let her know when the appointment was so when the eye doctor visited, he was unable to understand her and Resident #274 still had not received her new glasses. Interview on 12/21/22 at 10:16 A.M. with Licensed Social Worker (LSW) #594 revealed Resident #274 and her daughter had a care conference on 08/05/22 at 11:41 A.M. LSW #594 revealed this was the first (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365746 If continuation sheet Page 9 of 18 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 12/22/2022 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few time she became aware Resident #274 was missing her eye glasses. LSW #594 confirmed she forgot to communicate with Optometrist #619 prior to his visit and also when he visited Resident #274 in November 2022 that Resident #274 needed her eye glasses replaced. LSW #594 confirmed Optometrist #274 was unaware Resident #274's eye glasses were missing at the time of the visit and the eyeglasses have not been reordered. LSW revealed the optometrist visited the facility quarterly to see residents and would also make emergency visits if needed. Interview on 12/21/22 at 2:08 P.M. with State Tested Nursing Assistant (STNA) #559 revealed Resident #274's glasses had been missing for a while. STNA #559 revealed prior to Resident #274's glasses missing, Resident #274 would put her glasses on and take them off herself. STNA #559 revealed Resident #274 enjoyed watching television (German channels when available) and reading the bible with her daughter. Interview on 12/21/22 at 2:44 P.M. with Licensed Practical Nurse (LPN)/Care Plan Nurse #531 confirmed Resident #274's care plan was not updated for vision and not having her glasses available. LPN/Care Plan Nurse #531 revealed the care plan should have been updated with the quarterly MDS. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365746 If continuation sheet Page 10 of 18 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 12/22/2022 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 Based on observation, interview and record review, the facility failed to monitor Resident #275's change in condition related to bruising. This affected one resident (Resident #275) of three residents reviewed for quality of care. Residents Affected - Few Findings include: Record review for Resident #275 revealed an admission date of 12/15/22. Diagnosis included history of congestive heart failure and paroxysmal atrial fibrillation. Record review of the admission Baseline Care Plan dated 12/15/22 completed by Licensed Practical Nurse (LPN) #582 revealed Resident #275 was alert to person and confused. Resident #275 had an unsteady gait and weakness. Resident #275 was dependent for toileting, required extensive assistance for bed mobility and total dependence for transfers of two person physical assistants. Record review of the admission Skin Assessment initiated by Licensed Practical Nurse #544 dated 12/16/22 revealed Resident #275 had bruising to the chest and on both arms. Record review of the physician orders for December 2022 for Resident #275 revealed Resident #275 had orders for Coumadin five milligrams (mg) by mouth at bed time for atrial fibrillation. Orders included to monitor for signs and symptoms of bleeding every shift due to anticoagulants. Record review of Resident #275's medical record revealed no documentation of bruising to Resident #275's left side of her neck. Observation on 12/19/22 at 10:03 A.M. revealed Resident #275 was sitting up in a wheelchair in her room. The door to her room had been closed. Resident #275 was sitting in the chair with no shirt on and just a bra. Resident #275's shirt was lying on the floor next to her. Resident #275 had a large dark blue/ purple bruise covering the entire left side of her neck including a portion of the upper left chest. The bilateral arms had multiple small bruises. Resident #275 rambled and was unable to explain how the large bruise to her neck occurred. Interview on 12/19/22 at 10:08 A.M. with State Tested Nursing Assistant (STNA) #559 revealed she assisted Resident #275 with A.M. care and was unsure how the bruising occurred to Resident #275's neck. STNA #559 revealed Resident #275 often removed her own clothing. Interview on 12/19/22 at 10:15 A.M. with Licensed Practical Nurse (LPN) #542 revealed she was Resident #275's charge nurse and was aware Resident #275 had bruising to her neck. LPN #542 revealed she normally did not work with Resident #275 and was unsure how the bruising occurred. Interview and observation on 12/20/22 at 1:36 P.M. with Registered Nurse (RN) #524 confirmed he was Resident #275's charge nurse. Observation of Resident #275's bruising to the left side of her neck with RN #524 confirmed Resident #275 had a large dark blue/ purple bruise covering the entire left side of her neck including a portion of the upper left chest. RN #524 revealed he was unaware Resident #524 had bruising to her neck area. Interview and observation on 12/20/22 at 1:45 P.M. with Wound Care Nurse LPN #532 revealed she completed a skin assessment for Resident #275 on 12/16/22 (date after admission) during the day shift. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365746 If continuation sheet Page 11 of 18 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 12/22/2022 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 Residents Affected - Few Wound Care Nurse LPN #532 revealed Resident #275 did not have any bruising to her neck when she assessed her on 12/16/22. Record review of the progress note for Resident #275 dated 12/20/22 at 3:26 P.M. completed by RN #524 revealed Resident #275 had a dark purple in color with light purple bruise from the mid breast to the left ear lobe which measured 26 centimeters (cm) in length by 11 cm in width. Resident #275 also had a dark purple bruise to the left upper arm that measured 13 cm by 12 cm. Interview on 12/20/22 at 3:21 P.M. with Director of Nursing confirmed the physician nor Certified Nurse Practitioner (CNP) #618 had been made aware of Resident #275's bruise to the left side of the neck. Interview on 12/20/22 at 3:38 P.M. with LPN #535 revealed she worked with Resident #275 on 12/16/22 during the evening shift, 3:00 P.M. to 11:00 P.M. LPN #535 confirmed Resident #275 had the large bruise to her left neck area at that time. LPN #375 confirmed she did not report the bruise to anyone and revealed she assumed the bruise to Resident #275's neck was present on admission. Interview on 12/20/22 at 3:59 P.M. with CNP #618 confirmed he was not made aware of the additional bruising which included the bruising to Resident #275's left side of her neck and the new bruise located on Resident #275's left upper arm. CNP #618 revealed due to the additional bruising, his concern for Resident #275 was bleeding. CNP #618 revealed he would hold Resident #275's coumadin and obtain additional lab values. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365746 If continuation sheet Page 12 of 18 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 12/22/2022 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 0685 Assist a resident in gaining access to vision and hearing services. 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 assist Resident #274 in replacing lost eye glasses to help maintain vision. This affected one resident (Resident #274) of one resident reviewed for vision. Residents Affected - Few Findings include: Record review for Resident #274 revealed an admission date of 01/12/15. Diagnosis included Parkinson's disease and combined forms of age related cataract, bilateral. Record review of the activity assessment dated [DATE] revealed Resident #274 enjoyed spending most of her time reading the bible, sitting in silence, and visiting with friends. Record review of the quarterly Minimum Data Set, dated [DATE] revealed resident was able to make herself understood, usually understands others, vision was impaired and wore corrective lenses. Resident required supervision with activities of daily living. Record review of the care plan dated 09/29/22 revealed Resident #274 had a potential for communication problem related to severely impaired cognition, unclear speech and impaired hearing. Resident #274 spoke German so she required a longer period to understand and be understood. Interventions included to face Resident #274 and make eye contact, use alternative communication tools as needed such as the communication book/board. Resident #274 had impaired vision related to cataracts. Interventions included to arrange consultation with eye care practitioner as required and Resident #274 required the following visual aids, glasses. Record review of the progress note for Resident #274 dated 11/21/22 (untimed) completed by Optometrist #619 revealed the examination was completed for a follow up six months for cataracts and dry eyes. Spectacle exam included flat top bifocal which resident was noted to have. Observation on 12/19/22 at 11:00 A.M. of Resident #274 revealed Resident #274 was sitting up in her wheelchair in her room. Resident #274 was not wearing eye glasses. Resident #274 spoke a different language and the surveyor was unable to communicate with Resident #274. On the nightstand near Resident #274 was a a bible (German) and watch magazines. Interview on 12/19/22 at 11:54 A.M. with Resident #274's daughter revealed Resident #274's eye glasses were missing at facility for over six months. Resident #274 wore her glasses daily due to poor vision. Resident #274 enjoyed reading which was difficult for her without the glasses. Resident #274's daughter revealed the staff told her the eye doctor was coming months ago to replace the glasses. Resident #274's daughter revealed she requested the facility let her know when the eye doctor was coming so she could be there due to Resident #274 spoke German and the doctor would not be able to understand her during the assessment. Resident #274's daughter revealed the facility did not let her know when the appointment was so when the eye doctor visited, he was unable to understand her and Resident #274 still had not received her new glasses. Interview on 12/21/22 at 10:16 A.M. with Licensed Social Worker (LSW) #594 revealed Resident #274 and her daughter had a care conference on 08/05/22 at 11:41 A.M. LSW #594 revealed this was the first time she became aware Resident #274 was missing her eye glasses. LSW #594 confirmed she forgot to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365746 If continuation sheet Page 13 of 18 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 12/22/2022 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 0685 Level of Harm - Minimal harm or potential for actual harm communicate with Optometrist #619 prior to his visit and also when he visited Resident #274 in November 2022 that Resident #274 needed her eye glasses replaced. LSW #594 confirmed Optometrist #274 was unaware Resident #274's eye glasses were missing at the time of the visit and the eyeglasses have not been reordered. LSW #594 revealed the optometrist visited the facility quarterly to see residents and would also make emergency visits if needed. Residents Affected - Few Interview on 12/21/22 at 2:08 P.M. with State Tested Nursing Assistant (STNA) #559 revealed Resident #274's glasses had been missing for a while. STNA #559 revealed prior to Resident #274's glasses missing, Resident #274 would put her glasses on and take them off herself. STNA #559 revealed Resident #274 enjoyed watching television (German channels when available) and reading the bible with her daughter. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365746 If continuation sheet Page 14 of 18 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 12/22/2022 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 0697 Provide safe, appropriate pain management for a resident who requires such services. 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 Resident #42's chronic pain was addressed in a timely manner. This affected one resident (Resident #42) of five residents reviewed for medications. Residents Affected - Few Findings include: Review of the medical record for Resident #42 revealed admission date of 03/17/22. Diagnoses included generalized osteoarthritis, fibromyalgia, age related osteoporosis, anxiety disorder, spinal stenosis, history of clavicle and thoracic spinal vertebra #7 fracture, presence of left artificial hip joint, and pain of unspecified joint. Review of Care Plan dated 07/21/22 revealed Resident #42 had alteration in comfort related to fibromyalgia, osteoporosis, spinal stenosis, and history of fractures. Interventions included administer medications as ordered, monitor for side effects and effectiveness, report abnormal findings to physician, monitor and report signs and symptoms of non-verbal pain, report requests of pain treatment, and notify physician of breakthrough pain. Review of Psych Solutions progress note dated 09/27/22 revealed staff reported Resident #42 was seeking medications at times and was noted to watch clock for pain medications. Resident #42 had worsening anxiety and chronic somatic complaints. Psych Nurse Practitioner recommended pain management consult. Review of nursing progress note dated 09/29/22 revealed physician rounded and new order to increase Gabapentin to 200 milligrams (mg) three times per day. Review of quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 received scheduled and as needed (PRN) pain medication. Resident #42 reported frequent pain in last five days. Resident #42 reported seven out of 10 pain which made it hard to sleep and limited day to day activities. Review of the current physician's orders for December 2022 revealed Resident #42 had standing orders for 200 mg Gabapentin three times per day for pain, 1 percent (%) Voltaren gel applied to right hip twice daily for pain, and 4% Lidocaine patch applied to right knee once daily for pain. Resident #42 had as needed orders for 650 mg Acetaminophen every eight hours for pain and 325 mg Percocet every four hours as needed for moderate pain. Resident #42 had order to monitor pain level every shift. Review of medication administration record (MAR) for November 2022 revealed Resident #42 used as needed (PRN) Acetaminophen on 11/27/22 for pain with effective results. Resident #42 received PRN Percocet, six doses on 11/29/22, five doses on 11/04/22, 11/06/22, 11/11/22, 11/15/22, 11/17/22, 11/19/22, 11/23/22, 11/25/22, and 11/27/22, and three doses on 11/05/22, 11/07/22, 11/08/22, 11/10/22, 11/13/22, 11/16/22, 11/20/22, 11/24/22, 11/28/22, and 11/30/22 with complaints of four to 10 out of 10 pains. Resident #42 also received scheduled medications as ordered for pain including Gabapentin, Voltaren gel, and Lidocaine patch. Review of Physician's Progress Note dated 11/14/22 revealed Resident #42 was reviewed for general medical care follow up and had medications reviewed. There was no indication of review of frequent (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365746 If continuation sheet Page 15 of 18 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 12/22/2022 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 0697 reports of moderate to severe pain. Level of Harm - Minimal harm or potential for actual harm Review of MAR for December 2022 revealed Resident #42 used PRN Acetaminophen on 12/11/22 for pain with effective results. Resident #42 received PRN Percocet, six doses on 12/01/22, five doses on 12/02/22, 12/04/22, 12/09/22, and 12/15/22, and four doses on 12/05/22, 12/06/22, 12/07/22, 12/08/22, 12/10/22, 12/11/22/, 12/12/22, 12/13/22, 12/16/22, 12/17/22, 12/18/22. Resident #42 used two doses of PRN Percocet on 12/03/22. Resident #42 was complaining of pain ranging from two to eight out of 10. Resident #42 also received scheduled medications as ordered for pain including Gabapentin, Voltaren gel, and Lidocaine patch. Residents Affected - Few Interview on 12/19/22 at 11:18 A.M. with Resident #42 revealed she had been having a lot more pain in legs, hands, and feet. Resident #42 described the pain was throbbing. Resident #42 indicated she had reported pain to facility staff. During interview Resident #42 was observed to be laying back in bed with legs pulled up. Resident #42 was noted to be restless and squirming in bed with eyes closed throughout most of the interview. Resident #42's legs appeared to be tensed. Resident #42 indicated the facility provided her with a gel for pain however it did not help. Review of phone physician's order form dated 12/21/22 revealed physician placed order for pain management consult for fibromyalgia. Interview on 12/21/22 at 2:01 P.M. with Licensed Practical Nurse (LPN) #542 revealed Resident #42 had been declining. Resident #42 was noted to ask for her PRN Percocet every four hours. LPN #542 noted Resident #42 would count pills in cup and ask for Percocet even if not due. LPN #542 indicated she won't report the pain but watches the clock. Interview on 12/21/22 at 2:06 P.M. with State Tested Nursing Assistant (STNA) #562 revealed Resident #42 does most of her care on her own. STNA #562 noted Resident #42 always just wants her pain medications. Interview on 12/21/22 at 3:07 P.M. with Director of Nursing (DON) and Registered Nurse (RN) Supervisor #522 revealed the social worker usually gets the psych notes and files them right away. The psych team usually does not make many recommendations so we must have missed the recommendation for pain management consult. DON indicated Resident #42 was declining in October 2022 and we recommended hospice services however the family was not agreeable. RN Supervisor #522 indicated Resident #42 has good and bad days with pain. DON reported when she works the floor and passes medications Resident #42 knows to the minute when she can get PRN Percocet. DON and RN Supervisor #522 confirmed pain management recommendation was not addressed until 12/21/22. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365746 If continuation sheet Page 16 of 18 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 12/22/2022 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to properly store and secure medications for Resident #30 and Resident #67. This affected two residents (Resident #30 and #67) of two residents reviewed for medication storage. Findings include: 1. Record review for Resident #30 revealed an admission date of 11/08/21. Diagnosis included hypertensive heart disease, paroxysmal atrial fibrillation, Barrette's esophagus without dysplasia, gastro-esophageal reflux disease (GERD), gout, and need for assistance with personal care. Record review of the Modification of Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #30 was cognitively intact. Resident #30 required supervision with activities of daily living. Record review of the care plan dated 12/04/22 revealed Resident #30 had an alteration in the digestive system related to hiatal hernia, Barret's esophagus, and GERD. Interventions included to administer medication per the physician orders. Record review of the physician orders for 12/19/22 for Resident #30 revealed orders for Metoprolol Succinate extended release (ER) tablet 25 milligrams (mg) by mouth two times a day for hypertension, hold for heart rate below 60 or systolic blood pressure below 110, Omeprazole tablet delayed release 20 mg two times a day for GERD, and Zyloprim tablet 300 mg (Allopurinol) give one tablet by mouth one time a day for gout. Observation on 12/19/22 at 9:38 A.M. revealed Resident #30 was resting quietly in bed with her eyes closed. A medication cup was sitting on the bedside table with three pills in the cup, one white, one brown and one orange. Interview on 12/19/22 at 9:40 A.M. with Licensed Practical Nurse (LPN) #542 verified the medications Allopurinol, Omeprazole, and Metoprolol were left at Resident #30's bedside. Interview on 12/19/22 at 1:23 P.M. with Resident #30 revealed staff always left her medications for her to take when she got up. Interview on 12/22/22 at 10:38 A.M. with Director of Nursing (DON) confirmed Resident #30 did not have orders to self administer medications. DON revealed she would expect the nurse to stay with the residents until the resident either took the medication or refused the medication. 2. Record review for Resident #67 revealed an admission date of 10/08/22. Diagnosis included hypertensive heart and chronic kidney disease with heart failure. Record review of the admission Medicare five day Minimum Data Set, dated [DATE] revealed Resident #67 was cognitively intact. Resident #67 required extensive assistance of two for bed mobility, transfers, dressing and one person physical assist and supervision with eating. Resident #67 received routine pain medication rated a five on the pain scale of one to 10. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365746 If continuation sheet Page 17 of 18 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 12/22/2022 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of the physician orders dated 10/09/22 revealed Resident #67 had an order Chlorhexidine Gluconate solution 0.12% 30 milliliters (ml) mucous membrane two times a day for mouth pain. Medication scheduled to be administered at 9:00 A.M. and 5:00 P.M. Record review of the care plan dated 10/10/22 revealed Resident #67 had an activity of daily living self care performance deficit due to musculoskeletal impairment, decreased mobility. Interventions included to allow time for completion of any task, do not rush, praise/encourage all efforts. Observation on 12/19/22 at 10:14 A.M. revealed Resident #67 was up in his wheelchair and exiting his room. Observation revealed Resident #67 had a liquid medication in a medication cup sitting on his bedside table. Resident #67 revealed he had forgotten to take his medication. Interview on 12/19/22 at 10:15 A.M. with LPN #542 revealed the medication left on Resident #67's bedside table was Chlorhexidine Gluconate solution. LPN #542 revealed if residents were alert and oriented, she would tell them what medications they had then leave it for them and come back later to check on them. Interview on 12/22/22 at 10:38 A.M. with Director of Nursing (DON) confirmed Resident #67 did not have orders to self administer medications. DON revealed she would expect the nurse to stay with the residents until the resident either took the medication or refused the medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365746 If continuation sheet Page 18 of 18