Inspection·September 14, 2021

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation, staff interview and policy review, the facility failed to ensure privacy curtains were cleaned and in sanitary condition. This affected one resident (Resident #70) observed for soiled privacy curtains. The facility census was 89. Findings include: Observation on 09/07/21 at 3:31 P.M. of Resident #70's privacy curtain revealed a soiled and stained privacy curtain with brown spots located near the bottom. Interview on 09/07/21 at 3:31 P.M. with Assistant Director of Nursing (ADON) #106 confirmed the privacy curtain for Resident #70 was soiled and stained. ADON #106 revealed all staff were responsible to check resident rooms and report any necessary upkeep to housekeeping or the maintenance department. Review of the facility document titled Complete Room Cleaning, dated 01/01/00, revealed the facility had a policy in place to check and report any soil or damage to cubicle curtains. This deficiency substantiates Complaint Number OH00111707. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365811 If continuation sheet Page 2 of 11 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 365811 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northwestern Healthcare Center 570 North Rocky River Drive Berea, OH 44017 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 ensure residents care plans were updated and revised to the meet the individual needs of its residents. This affected two residents (Resident #9, and Resident #62) of 44 residents whose care plans were reviewed. The facility census was 87. Findings include: 1. Review of the medical record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses including schizophrenia, morbid obesity, dementia, Alzheimer's disease, and sensorineural hearing loss. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact. She primarily spoke the Spanish language. Functionally, she was independent for bed mobility, transfers, and dressing. For eating, toileting, and personal hygiene she required supervision and set-up only. Attempts to interview the resident on 09/09/21 were unsuccessful due to the resident was hard of hearing. Per the Director of Nursing (DON) on 09/09/21, she is hard of hearing and she tries to read lips. She would be able to understand some words while lip reading if they were in Spanish. Interview with Resident #30 who stated he is an advocate for all residents in this facility on 09/06/21 at 11:40 A.M. revealed he had a concern regarding Resident #9 getting hearing aids replaced. He further stated the facility lost Resident #9's hearing aids while rearranging rooms due to the COVID outbreak, and they have never replaced them. Resident #30 further stated it has been over a year since the hearing aids were lost. Per the Administrator on 09/13/21, the lost hearing aids were in the process of being replaced by the facility. Review of this resident's plan of care initiated on 03/17/21 revealed Resident #9 had the potential risk for communication problems related to sensorineural hearing loss, Spanish speaking symbolic dysfunction. Review of the interventions revealed no documented evidence interventions were put into place regarding the resident's lost hearing aids and/or what interventions were put into place to maintain communication between the resident and staff. Interview with MDS Nurse #102 on 09/13/21 at 2:00 P.M. revealed the resident did have a care plan for her hearing aids, but no interventions were noted in that plan to address her loss of hearing due to the hearing aids being lost. 2. Record review was conducted for Resident #62 who was admitted to the facility on [DATE] with diagnoses including prostate cancer and heart failure. A physician's order dated 07/28/21 stated he was to have pain monitoring every shift. On 07/28/21 a physician's order was written for docusate sodium (stool softener) 200 milligrams (mg) by mouth twice a day for constipation. On 08/06/21 that order was changed to 200 mg daily as needed for constipation. A physician's order dated 09/01/21 stated the resident was to ambulate with staff to promote digestive health. On 09/09/21 a physician's order was written to give docusate sodium 100 mg every morning and bedtime for constipation. Record review of the Progress Notes from 09/01/2021 to 09/11/2021 revealed Resident #62 was being (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365811 If continuation sheet Page 3 of 11 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 365811 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northwestern Healthcare Center 570 North Rocky River Drive Berea, OH 44017 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 treated for a mild ileus, constipation, and increased pain. He had recurrent complaints of increased back pain beginning on 09/01/2021 and Tramadol (pain medication) one half 50 mg tablet by mouth as needed for pain every six hours was ordered. Review of the Medication Administration Record (MAR) dated September 2021 revealed he was being medicated for pain every one to two days. Review of the Plan of Care initiated on 08/09/21 revealed there was no initial care plan to address constipation nor revision made to the plan of care to address the ongoing constipation and ordered interventions to treat the constipation. There was also no initial care plan to address pain nor revision made to the plan of care to address the ongoing pain. Observation and interview were conducted with Resident #62 on 09/13/21 at 11:59 A.M. The resident was a tall, thin man of advanced age who was alert and oriented to person, place, time, and conversation. He presented as calm and well spoken. He revealed he developed back pain due to issues with constipation but had chronic pain in his knees for many, many years. He expressed his pain was constant, but he did get some relief with the Tramadol. He said he had been quite constipated which had also resolved. Interview was conducted on 09/13/21 at 3:54 P.M. with Registered Nurse (RN) #215 who verified he had no care plan to address pain management nor constipation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365811 If continuation sheet Page 4 of 11 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 365811 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northwestern Healthcare Center 570 North Rocky River Drive Berea, OH 44017 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 0661 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to provide a complete discharge summary to Resident #91 prior to her discharge. This affected one of two residents reviewed for discharge. The facility census was 89. Findings include: Record review was conducted for Resident #91 who was admitted to the facility on [DATE] and discharged home on [DATE]. She was her own responsible party and her diagnoses included femur fracture. She was at the facility for skilled therapy. Review of the document titled Discharge Summary Recapitulation of Stay OH V6 dated 07/02/21 revealed the form was signed by the resident on 07/02/21 and by the physician on 07/02/21. The form was incomplete and lacked any homegoing information from social services, facility staff contact information, dietary services, and the activity director. Review of the Progress Notes dated 06/30/21 by Social Service Designee (SSD) #180 revealed she was going to find out which home health care company she wanted to use and identified which pharmacy the resident preferred. This information was not included on the discharge summary for the resident. Review of additional progress notes from 06/30/21 to 07/02/21 showed no recapitulation of stay information from dietary services or the activity department. Review of a second Discharge Summary Recapitulation of Stay OH V6 opened in the electronic medical record on 07/02/21 and completed on 07/05/21 by Registered Nurse (RN) #119 revealed the parts previously left blank on the resident copy sent home with her were filled out on 07/05/21. Record review and interview were conducted on 09/09/21 at 1:17 P.M. with the Director of Nursing who verified the resident was sent home with an incomplete discharge summary and RN #119 had gone into the medical record on 07/05/21 three days after the resident went home and completed the parts that had been left blank on the discharge summary. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365811 If continuation sheet Page 5 of 11 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 365811 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northwestern Healthcare Center 570 North Rocky River Drive Berea, OH 44017 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 record review and interview, the facility failed to ensure a resident's lost hearing aid was replaced in a timely manner. This affected one (Resident #9) of two (Resident's #18 and #61) with hearing aids. The facility census was 89. Residents Affected - Few Findings include: Review of the medical record for Resident #9 revealed she was admitted to the facility on [DATE] with diagnoses including schizophrenia, morbid obesity, dementia, Alzheimer's disease, and sensorineural hearing loss. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact. She primarily spoke the Spanish language. Functionally, she was independent for bed mobility, transfers, and dressing. She required supervision and set-up only for eating, toileting, and personal hygiene. Review of the facility concern form dated 03/15/21 revealed Resident #9 lost her hearing aids on 03/15/21. The concern form stated the facility searched and if the hearing aids were not found, the facility would replace the hearing aids. Attempts to interview the resident on 09/09/21 were unsuccessful due to the resident was hard of hearing. Per the Director of Nursing (DON) on 09/09/21, she was hard of hearing and she tried to read lips. She could understand some words while lip reading if they were in Spanish. Interview with Resident #30 who stated he is an advocate for all residents in this facility on 09/06/21 at 11:40 A.M. revealed he had a concern regarding Resident #9 getting hearing aids replaced. He further stated the facility lost Resident #9's hearing aids while rearranging rooms due to the COVID outbreak, and they have never replaced them. Interview with the Administrator on 09/13/21 at 8:04 A.M. revealed Resident #9 did lose her hearing aids during the rearranging of rooms. She further stated she did not know who was responsible for the lost hearing aids. The Administrator then stated the facility was replacing them. On 04/08/21 Mobile Care Group came to assess the resident and gave the facility an invoice with the cost of the replacement hearing aids. Review of the form titled internal check request revealed this form was completed by the Administrator on 08/11/21. Review of the copy of the check cut to pay for the hearing aids revealed it was issued until 09/08/21. Interview with the Administrator on 09/13/21 at 12:30 P.M. verified she did not request a check for the payment of the hearing aids until 08/11/21. She also verified they did find out about the missing hearing aids in March, but nothing further was done to get the replacement hearing aids for this resident until August of 2021. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365811 If continuation sheet Page 6 of 11 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 365811 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northwestern Healthcare Center 570 North Rocky River Drive Berea, OH 44017 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 As of 09/13/21, the resident was still waiting on her replacement hearing aids. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365811 If continuation sheet Page 7 of 11 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 365811 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northwestern Healthcare Center 570 North Rocky River Drive Berea, OH 44017 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, record review and policy review, the facility failed to ensure a medication error rate of less than 5 percent (%). Two errors were observed in 32 opportunities resulting in a 6.25 % medication error rate. This affected one (Resident #21) of eight residents observed for medication administration. The facility census was 89. Residents Affected - Some Findings include: Review of the medical record for the Resident #21 revealed an admission date of 06/28/21 with diagnoses including acute respiratory failure, acute kidney failure, and iron deficiency. Review of the resident's September 2021 physician's orders revealed orders for levofloxacin 500 milligrams (mg) (an antibiotic), ferrous sulfate 325 mg (an iron supplement), and aspirin enteric coated 81 mg delayed release tablet. Observation of medication administration on 09/09/21 at 8:18 A.M. revealed Licensed Practical Nurse (LPN) #114 passing medications to Resident #21. She prepared multiple medications for the resident, including a levofloxacin, iron, and aspirin. LPN #114 walked into the room and handed the medications to Resident #21. LPN #114 was asked to stop the administration and review the order for instructions for levofloxacin. The levofloxacin obtained from the card stated not to take iron two hours before or after the medication. The aspirin tablet obtained from the bottle stated it was 81 mg and chewable. Interview with LPN #114 on 09/09/21 at 8:45 A.M. verified she did not see the instructions printed on the card not to give with iron and did not realize the aspirin she administered was not enteric coated. Interview with the Director of Nursing (DON) on 09/09/21 at 9:38 A.M. verified the above findings. Review of the facility policy on Medication Administration, revised 12/14/17, revealed to read the label three times and administer mediations in accordance with manufacture guidelines. This deficiency substantiates Master Complaint Number OH00125207. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365811 If continuation sheet Page 8 of 11 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 365811 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northwestern Healthcare Center 570 North Rocky River Drive Berea, OH 44017 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** Based on observation, interview, record review and policy review, the facility failed to maintain infection control during medication administration and ensure transmission-based precautions (TBP) were maintained for new admissions and readmissions. This affected two of two residents reviewed for TBP (Resident's #51 and #291) and one (Resident #50) of one resident observed for medication administration through a percutaneous endoscopic gastrostomy (PEG) tube. The facility census was 89. Residents Affected - Some Finding include: 1. Review of the medical record for Resident #50 revealed an admission date of 07/20/18 with diagnoses including dysphagia, dementia, and chronic duodenal (small intestine) ulcer. The annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had a PEG tube. Review of the resident's September 2021 physician's orders revealed the resident was order Reglan 10 milligram (mg) (a medication used to relieve heartburn), a diet order for nothing by mouth (NPO), an order for Jevity 1.5 (nutritional supplement) by PEG tube at 50 milliliter (ml) an hour for 20 hours a day. Observation of medication administration on 09/07/21 at 12:40 P.M. with Licensed Practical Nurse (LPN) #118 revealed she prepared and crushed the Reglan to administer through the PEG tube. LPN #118 placed water for the flushes on the nightstand next to the bed. She turned off and disconnected the feeding tube and wrapped the tubing around the tube feeding pump that was place behind her. LPN #118 backed up to the tube feeding pole touching the uncapped insertion tip of the feeding tube. LPN #118 continued administering the medication and then reconnected the feed tube. Interview on 09/07/21 at 12:45 P.M. with LPN #118 stated usually there is a cap to cover the insertion tip, but it was missing. Interview on 09/07/21 at 12:58 PM. with the Director of Nursing (DON) verified the above findings. Review of the facility policy titled Medication Administration by Enteral Tube, revised 05/28/19, revealed to plug the devise or clamp the tube between medications to prevent contamination. 2. Review of the medical record for Resident #51 revealed the resident was discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. Diagnoses included hemiplegia and hemiparesis following cerebral infarction. The resident was unvaccinated for COVID-19. Review of the nurse's note by Assistant Director of Nursing (ADON) #106 on 08/27/21 at 10:39 P.M. revealed Resident #51 was readmitted from the hospital at 10:00 P.M. The resident was up in a wheelchair self-propelling throughout the facility. Observation on 09/07/21 at 10:30 A.M. of Resident #51's room revealed a cart with Personal Protective Equipment (PPE) outside the room. There was a Droplet Precaution sign on the door that revealed the resident was only to leave the room for essential transport and wear a mask when out of the room. Observation on 09/07/21 at 10:32 A.M. of Resident #51 revealed the resident was wheeling around the hallway in his wheelchair with his mask under his chin. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365811 If continuation sheet Page 9 of 11 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 365811 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northwestern Healthcare Center 570 North Rocky River Drive Berea, OH 44017 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 - Some Observation on 09/07/21 at 11:12 A.M. revealed Resident #51 wheeling around hallway with his mask under his chin. Interview on 09/13/21 at 9:12 A.M. with the DON revealed when a resident returned from the hospital, they are placed on droplet precautions for 14 days. The resident was not supposed to come out of their room, however some residents needed to. If they needed to leave their room, they were to wear mask. Staff were to help direct them back to their room, as well as remind them to put mask on and keep it pulled up. Interview on 09/13/21 11:50 A.M. with State Tested Nurse Aide (STNA) #156 revealed staff asked Resident #51 to try to stay in his room. When he couldn't, he was asked to use a mask. Review of the COVID Tracking and Cohorting policy, updated 06/22/21, revealed all new admissions or readmissions who are not fully vaccinated are placed on droplet precautions. 3. Record review was conducted for Resident #291 who was admitted to the facility on [DATE] with diagnoses including left side hemiplegia and pulmonary embolism. He was transferred to the hospital on [DATE], readmitted to the facility on [DATE] and had a transfer to the emergency room of a local hospital then back to the facility on [DATE]. The MDS 3.0 assessment dated [DATE] was in progress during the annual survey. A physician's order dated 09/01/21 indicated he would be monitored for signs and symptoms of COVID-19 and placed in droplet precautions for 14 days for COVID-19 precautions. Review of a progress note dated 09/01/21 and authored by Registered Nurse (RN) #121 revealed he was admitted on [DATE] at 3:27 P.M., had not received a COVID-19 vaccination, tested positive for COVID-19 in the last 90 days and would be placed into isolation. Observation was conducted on 09/07/21 at 6:23 A.M. outside the room of Resident #291 who had signs posted outside of his door for Droplet Precautions. The sign listed instructions to stop, put on PPE including washing or gelling hands, a gown, mask, eye cover and gloves before entering the room. The sign listed instructions to discard gown, gloves, mask, eye cover and wash or gel hands prior to leaving the room. There was a container of PPE just below the sign. During the observation, Certified Nursing Assistant (CNA) #171 came walking towards the surveyor wearing a N95 mask with a surgical mask underneath and eye protection. She walked directly into the room of Resident #291 without washing or using gel sanitizer on her hands and without putting on any additional PPE. She stood approximately two feet from him and spoke with him for a minute before she exited the room in the same N95 mask, surgical mask, and eye protection. She did not wash her hands, did not sanitize her hands nor change or wipe down her eye protection or masks. Interview was conducted with CNA #171 when she exited the room. The surveyor asked why the resident had signs posted for droplet isolation and what did that mean to her as a CNA. She replied she was not sure why he was in droplet isolation but thought it was either because he was a new admission or had not been tested for COVID-19 yet. She said before entering his room she should have put on a gown but did not and was to wear a mask and eye shield at all times while in the room. She verified she did not change her mask or eye protection and did not wash and/or sanitize her hands before exiting the room. Review of the facility policy titled Standard Precautions and Transmission Based Precautions, date revised 06/25/21. The review revealed for residents on droplet precautions staff will utilize the proper PPE before entering the room such as gown, gloves, eye protection before coming into contact (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365811 If continuation sheet Page 10 of 11 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 365811 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northwestern Healthcare Center 570 North Rocky River Drive Berea, OH 44017 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 with the resident or the environment and will discard the PPE before leaving the room. Staff are to also perform hand hygiene before leaving the room. Interview was conducted on 09/13/21 at 9:12 A.M. with the DON who verified when a resident was newly admitted and/or returned from a hospital visit, they were placed on droplet precautions for 14 days. Residents Affected - Some This deficiency substantiates Complaint Number OH00111428. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365811 If continuation sheet Page 11 of 11