Inspection·May 7, 2024

F 0805 Level of Harm - Immediate jeopardy to resident health or safety On 04/23/24 by 7:00 P.M., LPN/Unit Manager #2 interviewed all residents with Dysphagia Advanced diet orders about their meal consistency for the dinner meal on 04/23/24 with no additional concerns identified. • On 04/23/2024 at 7:00 P.M., the DON and LPN/Unit Manager #2 initiated a house audit to identify any Residents Affected - Some residents on Dysphagia Advanced diet. In addition, Regional Director of Operations Registered Dietitian (RDORD) #13 and RN #1 audited validation diet orders in the electronic medical record to ensure the meal tickets matched. • On 04/23/24, the DON began conducting interviews and obtained witness statements from nursing staff working the time of the event involving Resident #91. All the interviews/witness statements were completed on 04/24/24 at 4:30 P.M. • On 04/23/24, the DON initiated education with facility staff on Dysphagia Advanced diet, the difference between diets/food textures/thickened liquids/obstructed airway care and meal service policy. Education included dietary staff to serve food consistencies as ordered and nursing staff to validate meal being served to resident matches meal ticket prior to serving to residents. The education was completed on 04/24/24 at 4:30 P.M. • On 4/24/2024 at 7:30 A.M., the DON audited the breakfast meal to ensure Dysphagia Advanced diets were prepared appropriately with no concerns identified. • On 04/24/2024 at 12:30 P.M., the Administrator and DON reviewed all notes from Speech Language Pathologist (SLP) #15 and interviewed SLP #15 with no concerns identified. • On 04/24/2024 at 1:00 P.M., RDORD #13 reviewed Resident #91's meal ticket and dietary profile. • On 04/24/2024 at 1:30 P.M., RDORD #13 audited all diets in the electronic medical record and from the dietary meal tracker master list. Three (Residents #31, #20 and #12) residents' diet orders were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365811 If continuation sheet Page 2 of 7 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 05/07/2024 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 0805 fixed due to duplicate orders in the electronic medical record. Level of Harm - Immediate jeopardy to resident health or safety • On 04/24/24 at 2:00 P.M., the Administrator gave a verbal warning and suspended [NAME] #5 pending investigation in an effort to investigate the event prior to [NAME] #5 returning to work. Residents Affected - Some • On 04/24/24 at 2:00 P.M., the DON requested the EMS run report from the City Fire Department. • On 04/24/2024 at 5:30 P.M., RN #18 educated all residents/responsible parties with Dysphagia Advanced diets that refused to eat in dining room for potential risks of unsupervised dining. Education record assessment completed, and care plans were updated. • On 04/28/24 at 11:00 A.M., Dietary Manager (DM) #4 educated [NAME] #5 on preparing a Dysphagia Advanced diet with a return demonstration completed successfully. • On 05/06/24 at 11:50 A.M., the DON conducted an audit of all residents in house to identify residents ordered Dysphagia Advanced diet. The DON assessed all residents ordered a Dysphagia Advanced diet with no concerns identified. • On 05/06/24 at 2:48 P.M., RDORD #19 in collaboration with Regional Speech Therapy Director #20 updated the Dysphagia Advanced diet policy/manual to define the appropriate size of chopped vegetables to be approximately 0.5 inches. There were no food exclusions outside what was listed on the Dysphagia Advanced policy as long as the food items met the size requirement. • On 05/06/24 at 3:08 P.M., the DON conducted education with facility staff related to the updated Dysphagia Advanced policy/manual with the adjusted size of chopped vegetables to be approximately 0.5 inches via electronic communication to be completed on 05/07/24 by 12:00 P.M. Any staff not able to be educated by that time would be educated prior to the start of their next scheduled shift. • On 05/06/24, DM #4 initiated education with all Cooks related to preparing Dysphagia Advanced diet, including a return demonstration. All additional Cooks would be trained prior to the start of their next scheduled shift. • (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365811 If continuation sheet Page 3 of 7 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 05/07/2024 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 0805 Level of Harm - Immediate jeopardy to resident health or safety Beginning on 05/06/24, the Administrator/DON/Designee with support of interdisciplinary team bean audits which will be scheduled to be conducted on meal trays at different mealtimes to ensure correct meal consistencies were being served as ordered. Auditing would occur five times a week for two weeks, then three times a week for two weeks. Results of the audits will be reviewed with the Quality Assurance Performance Improvement (QAPI) committee with additional recommendations as warranted. Residents Affected - Some • Beginning on 05/06/24, Director of Therapy #21 conducted an audit of residents ordered a Dysphagia Advanced diet to identify date of last therapy screen. For any resident not screened in the last 90 days or that have not received speech therapy in the last 90 days, a screen would be completed by 05/07/24. Although the Immediate Jeopardy was removed on 05/06/24, the deficiency remained at Severity Level II (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action and monitoring for effectiveness and on-going compliance. Findings include: Review of the closed medical record for Resident #91 revealed an admission date of 10/13/22 and discharge date of 04/23/24. Resident #91 had diagnoses including memory deficit following cerebral infarction, diabetes, peripheral vascular disease, hypertensive heart disease, hepatitis C, and hyperlipidemia. Review of the oral/dental care plan dated 10/19/22 revealed Resident #91 had oral/dental problems related to (being) edentulous (lacking teeth) and did not wear dentures with an intervention that included provide a mechanically altered diet. Review of the Speech Therapy (ST) evaluation dated 06/14/23 revealed Resident #91 was referred to ST due to exacerbation of decreased safety awareness during oral intake, increased signs and symptoms of dysphagia (difficulty swallowing) and risk for aspiration (when food or liquid enters the airway and eventually the lungs by accident). Review of the ST Discharge summary dated [DATE] revealed Resident #91 had met short- and long-term goals and reached maximum potential with skilled services. Resident #91 was safely consuming the least restrictive diet consistency without overt signs and symptoms of difficulty/aspiration. Resident #91's recommended discharge diet order was mechanical soft textures (Dysphagia Advanced). Review of the MDS 3.0 quarterly assessment dated [DATE] revealed Resident #91 was severely cognitively impaired and was independent with eating. Review of the nutritional assessment dated [DATE] revealed Resident #91 was ordered a Dysphagia Advanced texture diet with good appetite and oral intake. Review of the April 2024 physician orders revealed Resident #91 was ordered a Dysphagia Advanced texture diet and could have regular ground beef (hamburger on bun, patty, meatballs, meatloaf and regular fish). The order had been in place since 02/22/23. Review of the nurse's note dated 04/23/24 timed 6:39 P.M. revealed Resident #91 was noted to be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365811 If continuation sheet Page 4 of 7 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 05/07/2024 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 0805 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some without vital signs, CPR started and 911 (EMS) and Power of Attorney (POA) notified. Continued CPR until EMS arrived and took over care of resident. EMS notified hospital emergency department and physician called time of death 6:19 P.M. Review of the Prehospital Care Report Summary (EMS run report) dated 04/23/24 revealed dispatch requested a squad for [AGE] year-old male not breathing at [address and name of facility]. Staff performing CPR and respirations on pulseless and apneic (not breathing) patient. Staff stated patient was last known well at 5:45 P.M. while eating dinner. Patient found unresponsive at approximately 5:52 P.M. at which time a Code was called by nurse supervisor. EMS crew took over manual CPR. Attempted intubation - no success. During resuscitation attempt, a piece of broccoli was removed from patient's airway with [NAME] forceps. Patient remained in asystole (without heartbeat) during code. Resuscitation attempt terminated per [name of physician]. Time of death was 6:19 P.M. Presumed cardiac arrest etiology: possible obstructed airway (broccoli removed). Review of a facility witness statement dated 04/24/24 authored by RN #9 revealed, I was passing dinner trays on [Front North]. I went into [Resident #91's room] and announced that I was bringing in dinner. [Resident #100] (Resident #91's wife/roommate) was sitting on her bed. [Resident #91] was lying down .[Resident #91] sat up and was sitting on the side of his bed like he always does to eat. He was acting his norm. I served [Resident #91] his tray. His tray was consistent with his diet order. Review of a facility witness statement dated 04/23/24 authored by State Tested Nurse Aide (STNA) #15 revealed, I started collecting trays and when I got to [Resident #91's] room, found [Resident #91] slumped over his tray. I yelled for the nurse and the nursing staff came when it was called Code Blue. Review of a facility witness statement dated 04/23/24 authored by STNA #14 revealed, At approximately 5:50 P.M., I other aides and I went down the hall to collect trays. Upon entering the room, we found resident faced down in his food tray. At that point, we all screamed for help down the nurses station. Review of a facility witness statement dated 04/23/24 authored by LPN #10 revealed, I was at the nurses' cart charting, when aide called, and I ran down to patients room. Patient was face down in dinner tray. This nurse pushed and assisted patient back on bed to obtain vitals and start CPR . Review of the Diet Guide Sheet for Dinner Day 3, Week 1 on Tuesday revealed ½ cup of broccoli salad, chop for resident's ordered a Dysphagia Advanced diet. Review of the recipe for Broccoli (floret) Salad revealed steam or boil broccoli, cook until tender, drain off excess liquid and chop or slice into pieces. For Dysphagia Advanced: chop to small, appropriate small. Review of the facility's 2019 Diet and Nutrition Care Manual for Dysphagia Advanced diets revealed this diet was used for individuals with mild oral and/or pharyngeal phase dysphagia. Foods that were difficult to chew were chopped, ground, shredded, cooked, or altered to make them easier to chew and swallow. Foods to avoid included cooked rubbery or non-tender cooked vegetables. There was no definition of what the measurement was for small, appropriate size. Review of the Employee Corrective Action Form dated 04/24/24 revealed [NAME] #5 was given a verbal warning and suspended pending investigation due to incident that occurred on 04/23/24. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365811 If continuation sheet Page 5 of 7 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 05/07/2024 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 0805 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Review of the Teachable Moment form dated 04/24/24 revealed RN #9 was educated related to diet consistency and texture types and validating that meal matched diet type prior to serving residents. Interview on 04/29/24 at 8:05 A.M. with Dietary Manager (DM) #4 revealed broccoli salad was on the menu for dinner on 04/23/24 and the salad was served cold. DM #4 had observed [NAME] #5 steam and chop the broccoli; however, DM #4 was not at the facility when dinner was served. DM #4 was told that Resident #91 had received a piece or a couple of pieces of broccoli that were not properly chopped, the resident choked and passed away. Interview on 04/29/24 at 10:50 A.M. with RN #9 revealed she served Resident #91 his dinner on 04/23/24 while the resident was sitting on the edge of his bed. RN #9 placed a fork into the broccoli salad and the broccoli was chopped and soft. RN #9 felt the dinner served was consistent with his diet order. RN #9 stated after CPR was completed and EMS called Resident #91's time of death, a paramedic told RN #9 that, we did pull a piece of broccoli out of his airway. Interview on 04/29/24 at 11:40 A.M. with [NAME] #5 revealed for dinner on 04/23/24, he cooked the broccoli in the steamer for approximately 25 minutes, ran the broccoli under cool water to cool it off, then cut up the broccoli in to bite size pieces using a chef's knife. [NAME] #5 stated if the broccoli salad was served to residents on a Dysphagia Advanced diet, he would have had to chop the broccoli into finer/smaller pieces rather than bite size pieces. During the interview, [NAME] #5 could not recall if he made a separate broccoli salad for residents on a Dysphagia Advanced diet. [NAME] #5 did not respond when asked if he referenced the broccoli recipe while preparing the broccoli salad. Observation of the lunch tray line on 04/29/24 at 12:00 P.M. revealed [NAME] #6 was serving lunch which included Capri Vegetable Blend which contained cooked, diced carrots. [NAME] #6 served the Carpi Vegetable Blend to the meal tray intended for Residents #31 and #21 who were ordered a Dysphagia Advanced diet. The diced carrots were approximately the size of a half dollar-sized coin. Interview, during the observation, with DM #4 revealed she trained the cooks to chop food items into ½ inch pieces for a Dysphagia Advanced diet. Review of the recipe for Capri Vegetable Blend revealed Capri Blend included 35% Julienne cut carrots strips, 27% bias cut green beans, 23% half round yellow squash, and 15% crinkle cut zucchini. Steam or boil vegetables until tender, toss lightly with margarine. For Dysphagia Advanced: chop to small, approximate size. Interview on 04/29/24 at 1:45 P.M. with DM #4, (Dietary District Manager (DDM) #11 and the Administrator were present) verified the Capri Vegetable Blend recipe called for Julienne cut carrots rather than diced carrots and verified the diced carrots in the Capri Vegetable Blend were larger than ½ inch. Interview on 04/29/24 at 2:20 P.M. with RDORD #13 verified there was no definition for small, appropriate size in the diet manual for a Dysphagia Advanced diet. Interview on 04/29/24 at 3:05 P.M. with STNA #15 revealed Resident #91 was a good eater and normally cleaned his plate. On 04/23/24, STNA #15 was assisting STNA #14 with collecting meal trays and STNA #15 began collecting trays from the back of the hallway. STNA #15 arrived at Residents #100 and #91's room, and STNA #15 began to collect Resident #100's tray (Resident #100 was not in the room) when STNA #15 looked up and observed Resident #91 slumped over his overbed table with his face down on his plate. STNA #15 rubbed Resident #91's head stating Resident #91's name. STNA #15 began yelling (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365811 If continuation sheet Page 6 of 7 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 05/07/2024 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 0805 for LPN #10. Level of Harm - Immediate jeopardy to resident health or safety Interview on 04/29/24 at 4:00 P.M. with the Administrator revealed the facility conducted an investigation after Resident #91 expired and the investigation concluded that Resident #91 had choked. Residents Affected - Some Interview on 04/29/24 at 4:25 P.M. with Speech Language Pathologist (SLP) #16 revealed she worked with Resident #91 in June/July 2023 to determine his diet order. Resident #91 was edentulous. SLP #15 would expect that broccoli be served in ½ inch chopped, soft pieces and soft enough to mash with a fork for resident's ordered a Dysphagia Advanced diet. SLP #15 revealed broccoli stems were not able to be mashed. Interview on 04/30/24 at 10:15 A.M. with LPN #10 revealed she was Resident #91's nurse on 04/23/24. That evening, LPN #10 was passing medications while three STNAs and one nurse passed meal trays to the residents on the hall. At approximately 5:20 P.M. or 5:30 P.M., LPN #10 administered medications to Resident #100 (Resident #91's roommate) in the hallway. At that time, LPN #10 observed Resident #91 sitting on the edge of his bed feeding himself without any concerns. LPN #10 returned to the nursing station and was standing at the medication cart when STNAs alerted the nurses to come to Resident #91's room. LPN #10 ran down the hallway into Resident #91's room and the resident's face was in his tray. A follow-up interview on 05/06/24 at 2:25 P.M. with SLP #16 revealed she had not screened Resident #91 for swallowing since October 2023 and a therapy screening list including Resident #91 should have been provided to the therapy department in March 2024 but that did not occur. The facility identified 15 additional residents, Resident #3, #16, #19, #20, #21, #22, #24, #27, #31, #37, #38, #56, #57, #59 and #61 who required a Dysphagia Advanced diet ordered by their physician or other delegated provider. The facility's failure to ensure food items were properly prepared and/or served at an appropriate size during the dinner meal on 04//23/24 and lunch meal on 04/29/24 placed these additional residents at risk for choking and/or adverse outcomes. Review of the facility's Meal Distribution policy revised September 2017 revealed all meals would be assembled in accordance with the individualized diet order, plan of care and preferences. The nursing staff would be responsible for verifying meal accuracy and timely delivery of meals to residents/patients. For point-of-service dining, the Dining Services department staff, under the supervision of the licensed nurse, would assemble the meal in accordance with the individual meal card and present it to the resident/patient or care staff for delivery to the resident/patient. This deficiency represents non-compliance investigated under Complaint Number OH00153286 and OH00153283. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365811 If continuation sheet Page 7 of 7