Health inspection·July 11, 2019

F 0570 Assure the security of all personal funds of residents deposited with the facility. Level of Harm - Minimal harm or potential for actual harm Based on review of interview, review of personal needs accounts and surety bond, the facility failed to ensure the surety bond was enough to cover the amount of money in the resident accounts. This affected all 48 residents with personal needs accounts (#3, #4, #6, #7, #8, #10, #11, #12, #14, #15, #16, #17, #19, #20, #21 (x2), #22, #23, #24, #26, #27, #28, #31, #32, #34, #35 (x2), #36, #38, #40, #41, #45, #46, #47, #48, #50, #54, #55, #56, #57 (x2), #61, #63, #64, #65, #67, #71 and #371) with a total of $30,705.20 as of 07/08/19. Residents Affected - Some Findings include: Review of the trial balance report with Resident's #3, #4, #6, #7, #8, #10, #11, #12, #14, #15, #16, #17, #19, #20, #21 (x2), #22, #23, #24, #26, #27, #28, #31, #32, #34, #35 (x2), #36, #38, #40, #41, #45, #46, #47, #48, #50, #54, #55, #56, #57 (x2), #61, #63, #64, #65, #67, #71 and #371 current balances revealed the balance of the accounts was $30,705.20. Review of the surety bond dated 10/01/18 and good through 10/01/19 indicated the account was covered for $30,000.00. Interview with the Administrative Assistant, Accounts Payable and Business Office Manager #21 on 07/08/19 at at 3:29 P.M. indicated it was her first time being in this type of role. She said the surety bond was just mailed to her from corporate, and she had never seen it before. She verified the amount of the bond was less that the amount in the personal needs account. Interview with the Administrator on 07/08/19 at 3:39 P.M. also verified the surety bond was not enough to cover the amount in the personal needs account. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365753 If continuation sheet Page 2 of 13 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 365753 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Royal Oak Nursing & Rehab Ctr 6973 Pearl Rd Middleburg Heights, OH 44130 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 0637 Assess the resident when there is a significant change in condition Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon interview and record review the facility failed to initiate and complete a significant change assessment as required. This affected one (Resident #32) of two resident reviewed with significant changes. Residents Affected - Few Findings include: Review of the medical record for Resident #32 revealed an admission date of 07/06/15. Diagnoses included peripheral vascular disease, heart failure, diabetes, depression and anxiety. Review of the assessments titled Skin Grid Pressure revealed the first assessment was dated 05/24/19 and documented a stage II left buttock pressure area (partial-thickness skin loss with exposed dermis) measuring 1.4 centimeters by 1.3 centimeters by 0.2 centimeters with serosanguineous drainage. Review of the Skin Pressure Grid dated 06/13/19 revealed the resident continued to have an open pressure area on the buttock. Review of the weights revealed on 11/23/18 the resident weighed 157.4 pounds, and on 11/30/18 the resident weighed 154 pounds. On 05/24/19 the resident weighed 140 pounds, creating an alert in the electronic record noting the resident had a significant weight loss over the previous three months and over the previous six months. The resident continued to lose weight and created weight alerts again on 05/31/19, 06/13/19, 06/21/19 and 07/02/19. Review of the Minimum Data Set (MDS) 3.0 assessments revealed quarterly assessments were completed on 04/10/19 and 06/18/19. Review of the MDS dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate cognitive impairment, felt tired or had little energy two to six days during the prior two weeks, required extensive assistance for bed mobility or transfers, weighed 148 pounds, had no significant weight loss, and had no open areas. Review of the MDS 3.0 assessment dated [DATE] revealed the resident had a BIMS score of 5, indicating severe cognitive impairment, felt tired or had little energy on 12 to 14 days during the prior two weeks, was totally dependent for bed mobility and transfers, weighed 138 pounds and had significant weight loss. The MDS documented conflicting responses to questions indicating whether or not the resident had a pressure ulcer but indicated she had a stage two pressure ulcer which had not been present on the previous assessment. Interview on 07/10/19 at 3:54 P.M. with MDS Nurse #24 revealed the MDS had been incorrectly coded under M0100A and should have indicated the resident had a pressure area, she modified the 06/18/19 quarterly MDS to correct the response to M0100A. A subsequent interview on 07/11/19 at 10:46 A.M. with MDS Nurse #24 revealed she was uncertain of the the indications for completing a significant change assessment except for the addition of hospice services or a decline in activities of daily living and when asked if a significant weight loss and a new stage II pressure area were indications, she stated she did not know. Further interview with MDS Nurse #24 revealed the family of Resident #32 had been approached about considering hospice services. Interview on 07/11/19 at 1:30 P.M. with the Director of Nursing revealed the facility did not have any evidence that the facility had recognized the significant change for Resident #32, and the Interdisciplinary Team discussed the declines in cognition, mood, bed mobility, transfers, weight and the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365753 If continuation sheet Page 3 of 13 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 365753 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Royal Oak Nursing & Rehab Ctr 6973 Pearl Rd Middleburg Heights, OH 44130 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 0637 development of a pressure ulcer with relation to a significant change in the resident. Level of Harm - Minimal harm or potential for actual harm Review of the MDS 3.0 Resident Assessment Instrument manual revealed a significant change occurred when declines in two or more areas of the following occurred: the emergence of unplanned weight loss of five percent in 30 days or ten percent in 180 days, decline in physical function where total dependence is coded, an increase in frequency in mood symptoms, the presence of a stage II pressure ulcer, or an overall decline in condition. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365753 If continuation sheet Page 4 of 13 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 365753 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Royal Oak Nursing & Rehab Ctr 6973 Pearl Rd Middleburg Heights, OH 44130 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** 3. Review of the medical record for Resident #32 revealed an admission date of 07/06/15. Diagnoses included peripheral vascular disease, heart failure, diabetes, depression and anxiety. Residents Affected - Few Review of the assessments titled Skin Grid Pressure revealed the first assessment was dated 05/24/19 and documented a stage II left buttock pressure area (partial-thickness skin loss with exposed dermis) measuring 1.4 centimeters by 1.3 centimeters by 0.2 centimeters with serosanguineous drainage. Review of the Skin Pressure Grid dated 06/13/19 revealed the resident continued to have an open pressure area on the buttock. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed question M0100A had been answered no indicating the resident did hot have a pressure ulcer, injury, scar or non-removable dressing. Interview on 07/10/19 at 3:54 P.M. with MDS Nurse #24 revealed the MDS had been incorrectly coded under M0100A and should have indicated the resident had a pressure area. She modified the 06/18/19 quarterly MDS to correct the response to M0100A. Review of the MDS 3.0 Resident Assessment Instrument (RAI) manual indicated the items in Section M document the risk, presence and appearance of pressure ulcers. Based on interview and record review, the facility failed to accurately record the medical status of three residents (Resident #70, Resident #72 and Resident #32). This affected three of 28 records reviewed for accurate assessments. The facility census was 66. Findings include: 1. Review of the medical record for Resident #72 revealed he was admitted to the facility on [DATE]. His diagnoses included impulse disorder, unspecified open wound of the scrotum and testes and dementia with behavioral disturbance. Review of the admission Minimum Data Set (MDS) 3.0 assessment with an Assessment Reference Date (ARD) of 06/25/19, section M, indicated conflicting information. The assessment indicated Resident #72 did not have a surgical wound but was receiving surgical wound care. Registered Nurse (RN) #24 was interviewed on 07/10/19 at 2:26 P.M. and was asked if Resident #72 had a surgical wound. RN #24 verified on 07/10/19 at 3:52 P.M. that Resident #72 did have a surgical wound from a biopsy site, and that the MDS data on the admission assessment was incorrect. 2. Review of the medical record for Resident #70 revealed he was admitted to the facility on [DATE]. His diagnoses included alcohol dependence with withdrawal delirium, chronic Hepatitis C, dermatitis with Methyl-Resistant Staphylococcus Aureus (MRSA), a bacterial infection of the skin. Review of the admission MDS 3.0 assessment with an ARD of 07/02/19, section M, indicated Resident #70 had a pressure ulcer. RN #23 was interviewed on 07/09/19 at 2:43 P.M. and stated Resident #70 did not have a pressure ulcer. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365753 If continuation sheet Page 5 of 13 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 365753 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Royal Oak Nursing & Rehab Ctr 6973 Pearl Rd Middleburg Heights, OH 44130 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 Level of Harm - Minimal harm or potential for actual harm RN #24 was interviewed on 07/10/19 at 2:26 P.M. and was asked if Resident #70 had a pressure ulcer. RN #24 verified on 07/10/19 at 3:52 P.M. that Resident #70 did not have a pressure ulcer, and the MDS data on the admission assessment was incorrect. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365753 If continuation sheet Page 6 of 13 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 365753 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Royal Oak Nursing & Rehab Ctr 6973 Pearl Rd Middleburg Heights, OH 44130 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** Based on observation, interview, record review and policy review, the facility failed to implement pressure relieving measures and communicate, follow-up and implement podiatry recommendations of Resident #72's pressure ulcers. This affected one Resident (#67) of two residents reviewed for pressure ulcers. Residents Affected - Few Findings include: Review of the medical record revealed Resident #72 was admitted to the facility on [DATE] with diagnoses including impulse control disorder, atrial fibrillation, benign prostatic hypertrophy with lower urinary tract symptoms, hyperlipidemia, open wound of scrotum and testes and dementia with behavioral disturbance. Review of the comprehensive assessment (MDS 3.0) dated 06/25/19 indicated he was severely cognitively impaired and displayed physical abuse, verbal abuse and rejected care during the assessment period. He was identified to have an unstageable pressure ulcer with slough and/or eschar that was present on admission. He was also noted to have an open lesion on the foot. He was identified as moderate risk for the development of pressure sores per the Braden scale dated 06/18/19 despite having one. Review of the plan of care regarding the potential for skin alteration initiated on 06/19/19 revealed the interventions to include educate resident/family on skin breakdown risk factors and preventative measures, encourage to float heels while in bed, encourage to turn and position every two hours and as needed, pressure reducing cushion to chair, pressure reducing mattress, assist with hygiene including peri care as needed, record meal intake percentages, use barrier cream with showers and with incontinent episodes. Review of the physician order dated 06/18/19 indicated to cleanse the left heel with normal saline, pat dry, apply pad and protect dressing every other day, and cleanse the top of his left foot with normal saline, apply Calcium Alginate (Calcium Alginate is a highly absorbent, biodegradable alginate dressing derived from seaweed. Alginate dressings maintain a physiologically moist microenvironment that promotes healing and the formation of granulation tissue.), covered with an ABD (abdominal) pad and wrap with stretch gauze. Review of the podiatry note dated 06/21/19 indicated he was seen for a sore on the top of his left foot and also on his left heel that were present on admission. He relayed some pain on palpation. The left heel measured 5.5 centimeters (cm) by 4.5 cm unstageable with 100% eschar. The dorsal left foot measured 3.9 cm by 3.5 cm by 0.1 cm blister secondary to edema that was 100% granular. He had 2+ pitting edema. The plan identified a change in the treatment to the top of the foot. The podiatrist indicated to cleanse dorsal foot with saline, apply Xeroform (occlusive petrolatum gauze) to the dorsal foot covered with an ABD pad and stretch gauze, apply offloading heading to the left heel with an ABD pad and stretch gauze. Change the dressing three times a week. Continue to offload heels. Follow up in one week. There was no evidence the podiatrist note was reviewed and the order written for the recommended treatment and no evidence the facility added the intervention to offload the heels. Resident #72 was observed on 07/08/19 at 10:00 A.M. and 4:06 P.M. sitting in a Broda chair (comfort tension seating) had a bandage on the left heel with a regular sock over the bandage all day. The foot was resting on the foot rest of the chair. On 07/08/19 at 4:25 P.M., he was observed with the left foot directly on the foot rest. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365753 If continuation sheet Page 7 of 13 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 365753 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Royal Oak Nursing & Rehab Ctr 6973 Pearl Rd Middleburg Heights, OH 44130 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 Interview with Registered Nurse #23 on 07/08/19 at 4:25 P.M. verified his left foot was directly on the foot rest with no pressure prevention in place. Interview with the Assistant Director of Nursing on 07/10/19 at 09:06 A.M. verified the current treatment did not include the podiatrist recommendations. The Assistant Director of Nursing indicated offload meant the heel would not come in contact with a surface. She said this information was not communicated to the team. She said normally the podiatrist writes her own orders. She was unable to say who would review specialist documentation to see if orders or recommendations were imbedded in the documentation. Interview with the Director of Nursing on 07/11/19 at 9:00 A.M. said she contacted the podiatrist on 07/10/19 and confirmed an order was not written for the treatment identified in the note. She said the podiatrist decided to not change the treatment from the existing treatment since the resident was healing. The Director of Nursing stated the podiatrist was responsible for writing the order. She was asked who was responsible for reviewing the notes after a specialists visit and replied it was the podiatrist's responsibility to write the order. Review of the wound care policy and procedure, revised November 2018, indicated wounds were to be evaluated when they were noted and weekly until resolved. Wounds would be monitored for location, size (measure, length, width and depth) undermining, tunneling, exudates, necrotic tissue and the presence or absence of granulation tissue and epitheliazation. Only pressure ulcers need to be staged. Procedure: notify physician upon discovery of a new skin area or when a delay in healing was noted; obtain a treatment, notify the resident/representative of the skin area and treatment; notify the dietitian to complete a nutrition risk assessment, notify the wound nurse for routine evaluation of skin area until resolved, review/revise the care plan for skin treatment and prevention, document the assessment, care and treatments, the residents response to the care and treatment and document the notification of the physician, resident and representative. Review of the skin care policy and procedure, revised November 2018, indicated the skin would be observed upon admission and routinely throughout the resident's stay, a Braden Score would be completed upon admission, routinely and as needed with change in condition, preventative care plans would be developed and implemented for each resident, residents identified would be encouraged/assisted to turn and reposition, nutrition risk assessments would be completed on admission, routinely and as needed with a change in condition and notify the wound nurse, physician and resident representative upon observation of new skin area. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365753 If continuation sheet Page 8 of 13 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 365753 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Royal Oak Nursing & Rehab Ctr 6973 Pearl Rd Middleburg Heights, OH 44130 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. Based upon observation, interview and record review, the facility failed to ensure solution used for tuberculin testing was stored according to manufacturer's recommendations. This affected three residents (Residents #70, #71 and #72) admitted to the facility between 06/11/19 and 07/11/19. Findings include: Observation on 07/11/19 at 10:10 A.M. of the medication room on the [NAME] wing with Licensed Practical Nurse (LPN) #26 revealed an open, partially used vial of purified protein derivative solution for tuberculin testing which was undated when opened. The label indicated the pharmacy had dispensed the vial on 01/23/19. Interview on 07/11/19 at 10:11 A.M. with LPN #26 confirmed the vial of tuberculin was undated and she did not know when it had been opened. Review of the Medication Storage policy, dated 06/21/17, revealed the facility was to discard outdated, contaminated, deteriorated medications were to be removed from stock. Review of the manufacturer's package insert for tuberculin purified protein derivative revealed a vial that had been entered and in use for 30 days was to be discarded. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365753 If continuation sheet Page 9 of 13 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 365753 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Royal Oak Nursing & Rehab Ctr 6973 Pearl Rd Middleburg Heights, OH 44130 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 0880 Provide and implement an infection prevention and control program. 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 #72 was admitted to the facility on [DATE] with diagnoses including impulse control disorder, atrial fibrillation, benign prostatic hypertrophy with lower urinary tract symptoms, hyperlipidemia, open wound of scrotum and testes and dementia with behavioral disturbance. Residents Affected - Few Review of the comprehensive assessment (MDS 3.0) dated 06/25/19 indicated he was severely cognitively impaired and displayed physical abuse, verbal abuse and rejected care during the assessment period. He was identified to have an unstageable pressure ulcer with slough and/or eschar that was present on admission. He was also noted to have an open lesion on the foot. He was identified as moderate risk for the development of pressure sores per the Braden scale dated 06/18/19, despite having one. Review of the plan of care regarding the potential for skin alteration initiated on 06/19/19 revealed the interventions to include educate resident/family on skin breakdown risk factors and preventative measures, encourage to float heels while in bed, encourage to turn and position every two hours and as needed, pressure reducing cushion to chair, mattress, assist with hygiene including peri care as needed, record meal intake percentages, use barrier cream with showers and with incontinent episodes. Review of the physician order dated 06/18/19 indicated to cleanse the left heel with normal saline, pat dry, apply pad and protect dressing every other day, and cleanse the top of his left foot with normal saline, apply Calcium Alginate (Calcium Alginate is a highly absorbent, biodegradable alginate dressing derived from seaweed. Alginate dressings maintain a physiologically moist microenvironment that promotes healing and the formation of granulation tissue.), covered with an ABD (abdominal) pad and wrap with stretch gauze. Review of the podiatry note dated 06/21/19 indicated he was seen for a sore on the top of his left foot and also on his left heel that were present on admission. He relayed some pain on palpation. The left heel measured 5.5 centimeters (cm) by 4.5 cm unstageable with 100% eschar. The dorsal left foot measured 3.9 cm by 3.5 cm by 0.1 cm blister secondary to edema that was 100% granular. He had 2+ pitting edema. The plan identified a change in the treatment to the top of the foot. The podiatrist indicated to cleanse dorsal foot with saline, apply Xeroform (occlusive petrolatum gauze) to the dorsal foot covered with an ABD pad and stretch gauze, apply offloading heading to the left heel with an ABD pad and stretch gauze. Change the dressing three times a week. Continue to offload heels. Follow-up in one week. There was no evidence the podiatrist note was reviewed and the order written for the recommended treatment and no evidence the facility added the intervention to offload the heels. Resident #72 was observed on 07/08/19 at 10:00 A.M. and 4:06 P.M. sitting in a Broda chair (comfort tension seating) had a bandage on the left heel with a regular sock over the bandage all day. The foot was resting on the foot rest of the chair. On 07/08/19 at 4:25 P.M., he was observed with the left foot directly on the foot rest. On 07/11/19 at 8:30 A.M., RN #25 and the Assistant Director of Nursing (ADON) were observed to do the treatment change. The ADON washed her hands and donned gloves to remove his non-skid sock and boot. She elevated his leg on the wheelchair with the rest on the back of his calf. The dressing was dated 07/10/19 at 3:00 A.M., RN #25 washed her hands but turned off the faucet with her wet hands then dried them with a paper towel. She placed a clean blanket on the floor under his foot. She cleansed the scissors with an alcohol pad. She donned gloves and cut off the existing dressing. She said (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365753 If continuation sheet Page 10 of 13 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 365753 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Royal Oak Nursing & Rehab Ctr 6973 Pearl Rd Middleburg Heights, OH 44130 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few there was no drainage and no odor. She washed her hands but turned off the faucet with her wet hands then dried them with a paper towel. She donned gloves and measured the wound on the top of his foot. She said it was 2.5 cm long by 2.0 cm wide with no depth. She removed her gloves and rinsed her hands with water at the sink but did not wash them with soap. She turned off the faucet with her wet hands then dried them. She went out to the treatment cart to obtain additional supplies. She washed her hands but turned off the faucet with her wet hands then dried them. She described the left heel as having dried, slough and scab. She donned gloves to measure the heel ulcer. She said there were two areas measuring 1.2 cm by 2.5 cm and 0.5 cm by 2.5 cm of peeling necrotic tissue. She washed her hands and turned off the faucet with her wet hands. She squeezed normal saline onto a small stack of gauze. She cleansed the ulcer on the top of his foot with saline soaked gauze then used another piece to cleanse the skin surrounding the area. She removed her gloves and cleansed her scissors. She washed her hands but turned off the faucet with her wet hands. She donned gloves and cleansed the heel ulcer in the same fashion as described above. She washed her hands but turned off the faucet with her wet hands. She opened packages of ABD pads and stretch gauze laying them inside the packaging. She donned gloves and placed a pre-cut piece of Calcium Alginate (a dressing to maintain a physiologically moist microenvironment that promotes healing and the formation of granulation tissue) in the ulcer on the top of his foot and covered it with an ABD pad. She then placed an ABD pad over the heel and wrapped the entire foot with stretch gauze. She removed her gloves and used pre-dated tape to secure the dressing. She washed her hands and turned the faucet off with paper towels. Interview with RN on 07/11/19 at 8:58 A.M. verified she should have used a paper towel to turn off the faucet to not contaminate her hands after cleansing. Interview with RN #23 on 07/08/19 at 4:25 P.M. verified his left foot was directly on the foot rest with no pressure prevention in place. Interview with the Assistant Director of Nursing on 07/10/19 at 9:06 A.M. verified the current treatment did not include the podiatrist recommendations. The Assistant Director of Nursing indicated offload meant the heel would not come in contact with a surface. She said this information was not communicated to the team. She said normally the podiatrist writes her own orders. She was unable to say who would review specialist documentation to see if orders or recommendations were imbedded in the documentation. Interview with the Director of Nursing on 07/11/19 at 9:00 A.M. said she contacted the podiatrist on 07/10/19 and confirmed an order was not written for the treatment identified in the note. She said the podiatrist decided to not change the treatment from the existing treatment since the resident was healing. The director of nursing stated the podiatrist was responsible for writing the order. She was asked who was responsible for reviewing the notes after a specialists visit and replied it was the podiatrist's responsibility to write the order. Interview with the Director of Nursing on 07/11/19 at 9:00 A.M. said she contacted the podiatrist on 07/10/19 and confirmed an order was not written for the treatment identified in the note. She said the podiatrist decided to not change the treatment from the existing treatment since the resident was healing. The director of nursing stated the podiatrist was responsible for writing the order. She was asked who was responsible for reviewing the notes after a specialists visit and replied it was the podiatrist's responsibility to write the order. Review of the hand washing guidelines, revised January 2019, indicated hands should be washed with soap and water or antiseptic agent after removing gloves. When a procedure called for changing gloves (such as during wound care) hands should be washed after removing the dirty gloves and before putting on the clean gloves. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365753 If continuation sheet Page 11 of 13 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 365753 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Royal Oak Nursing & Rehab Ctr 6973 Pearl Rd Middleburg Heights, OH 44130 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the hand washing/hand hygiene policy, revised August 2015, indicated after washing the hands dry them thoroughly with paper towels and then turn off the faucets with a clean, dry paper towel. Based on observation, interview and record review, the facility failed to maintain proper infection control for two residents (Resident #70 and Resident #72). This affected one of one resident on isolation precautions and one of one resident observed for wound dressing changes. The facility census was 66. Findings include: 1. Review of the medical record for Resident #70 revealed he was admitted to the facility on [DATE]. His diagnoses included alcohol dependence with withdrawal delirium, chronic Hepatitis C, dermatitis with Methyl-Resistant Staphylococcus Aureus (MRSA), a bacterial infection. Further review of the medical record for Resident #70 revealed a physician order dated 06/25/19. The order stated the resident was to be on contact isolation (contact precautions). Observation on 07/09/19 at 2:40 P.M., revealed an isolation cart in the hallway near Resident #70's door and a sign on the door with instructions to see nurse before entering the room. During an observation on 07/10/19 at 9:55 A.M., Registered Nurse (RN) #25 was observed administering intravenous (IV) antibiotics to Resident #70. RN #25 removed supplies from the medication cart at the nurse's station. The supplies included the antibiotic, alcohol wipes and a syringe of normal saline to flush the IV line. At the nursing cart, RN #25 sanitized her hands, donned gloves and walked down the hall to Resident #70's room. RN #25 knocked on the door and entered the room, without donning an isolation gown. RN #25 then set the supplies on the bedside table without placing a barrier on the table. RN #25 proceeded to flush the IV line with 10 milliliters of normal saline and connected the antibiotic. After completing the connection, RN #25 removed the glove of one hand and placed the wadded removed glove in the same hand holding the empty flush syringe. RN #25 then removed the final glove, pulling it over the syringe and the soiled glove from the other hand, encapsulating both. RN #25 then walked from the room to discard the syringe in the puncture proof container located on the medication cart at the nurse's station. RN #25 did not wash her hands as she left the room. RN #25 was interviewed immediately following the procedure and confirmed she did not don a gown and did not wash her hands prior to leaving the room. RN #25 stated she always threw syringes and needles away in puncture proof containers. RN #25 further verified there was no needle or medication in the syringe and that it could have been discarded in the hazardous waste trash in Resident #70's room. RN #25 further stated at that time that she did not put on a gown unless she was planning to touch Resident #70. Review of the facility policy titled Isolation Precautions, revised February 2019, stated transmission-based precautions, which included contact precautions, were based on specific clinical symptoms and conditions that pose a risk to others. Review of the facility Infection Prevention and Control Program, revised February 2019, revealed standard and transmission-based precautions will be implemented and followed to prevent spread of infections. The policy further stated, the facility will maintain hand hygiene procedures to be followed by staff involved in direct resident contact. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365753 If continuation sheet Page 12 of 13 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 365753 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Royal Oak Nursing & Rehab Ctr 6973 Pearl Rd Middleburg Heights, OH 44130 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 0880 Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled Handwashing/Hand Hygiene, revised August 2015, stated all personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. The policy further stated use of an alcohol-based hand rub or soap and water should be used before and after direct contact with residents, before and after handling IV access sites, after removing gloves, and before and after entering isolation precaution settings. Residents Affected - Few Review of the facility policy titled Hand Washing Guidelines, revised 01/2019, specified hands should be washed when leaving a resident's room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365753 If continuation sheet Page 13 of 13