Health inspection·April 10, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #10's late entry SBAR Summary for Providers dated 03/18/25 at 2:27 P.M. included on 03/18/25 at 1:49 A.M. Resident #10 had a change in condition and the CIC (change in condition) evaluation was functional decline (worsening function and, or mobility). Outcomes of a physical assessment included Resident #10 had weakness or hemiparesis, decreased mobility. Review of Resident #10's medical record including progress notes did not reveal evidence Resident #10's responsible party was notified he was sent to the hospital with a change in condition. Review of Resident #10's hospital records dated 03/18/25 through 03/21/25 included his admission diagnosis was cerebrovascular accident due to intracerebral hemorrhage, ischemic stroke. Resident #10 presented to the ED on 03/18/25 with complaints of right-sided weakness. Resident #10 stated his weakness began approximately four days ago, and he described his right-sided weakness as a heaviness to his upper and lower extremities. Resident #10 stated his weakness had not improved since the initial onset. Resident #10 reported that he suffered a fall yesterday because his leg gave out and he had no injuries from the fall. Resident #10 was not anticoagulated. Resident #10 was chronically ill-appearing and in no obvious distress. Resident #10 had obvious drift to the right upper and lower extremities. Resident #10 had an unequal weak grip strength to the right hand in comparison to the contralateral side. Resident #10 had noticeable unilateral weakness to the right upper and lower extremities. Resident #10 stated his symptoms began on 03/15/25 and his symptoms have not improved. Resident #10 was out of the window for significant intervention and a stroke alert was not called. Observation on 04/09/25 at 8:31 A.M. of Resident #10 revealed he was sitting in a wheelchair in his room. Resident #10 stated the facility needed improvement. Resident #10 indicated if he needed to go to the hospital the nurse had to call the physician and he had to wait for the physician to call back. Resident #10 stated he had a stroke, he told the nurse he needed to go to the hospital, and three hours later he finally went because he insisted. Resident #10 stated he was having a hard time walking, knew something was not right and told the nurse he had to go to the hospital, but he had to really insist because she did not want to send him. Resident #10 stated on 03/14/25 or 03/15/25 he was walking fine, the next day something did not feel right, then he had trouble walking. Resident #10 stated he told the nurse he needed to go to the hospital and she said your vitals are fine. Resident #10 revealed he experienced a fall and his roommate screamed for the nurse. Resident #17 nodded his head yes when Resident #10 stated this, but did not say anything. The nurses came to the room and the nurse told me she would call for transportation to the hospital, but the wait would be four hours and it was non-emergency transportation. Resident #10 could not remember the name of the nurse. Resident #10 stated the facility did not call the physician for three hours. Interview on 04/09/25 at 2:45 P.M. with Licensed Practical Nurse (LPN) #438 revealed she was assigned to care for Resident #10 the night he was transported to the hospital. LPN #438 stated what she knew was Resident #10 said he was not feeling well, and kept saying he did not feel well, and wanted sent out to the hospital. LPN #438 stated she took Resident #10's vital signs and they were fine. LPN #438 indicated she was new to the facility and in orientation and let the nurse manager know Resident #10 wanted sent to the hospital. LPN #438 indicated she asked Resident #10 questions to get more information about how he was feeling, he just came in from smoking and she thought he smoked more than one cigarette and the smoking was what made him not feel well. LPN #438 indicated she asked Resident #10 if he was having pain, and he said he felt numbness, and he was able to squeeze her hand. LPN #438 stated Resident #10 did not experience a fall, and when he came out of the bathroom he was kind of leaning and said his leg felt numb, he needed help (she could not remember which side) and he was assisted back to bed. LPN #438 indicated she called a physician, but she did not remember who she called or when and told the physician Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365828 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 365828 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harvard Gardens Rehabilitation & Care Center 18810 Harvard Ave Cleveland, OH 44122 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few #10 was having numbness and was told to send him out to the hospital. Resident #10 was sent to the hospital via non-emergency transportation. Interview on 04/10/25 at 11:18 A.M. with the Director of Nursing (DON) revealed LPN #438 called Unit Manager (UM) #442 because Resident #10 said he was not feeling well, had numbness in his right arm, and never told her he had a fall. The DON stated UM #442 said Resident #10 did not know how to describe how he was feeling, said he wanted to smoke a cigarette and wanted to go to the hospital. UM #442 did not think it was serious. UM #442 instructed LPN #438 to call the physician and have Resident #10 sent to the hospital because it was Resident #10's right to go to the hospital if he wanted to. The DON confirmed Resident #10's medical record including progress notes did not have evidence Resident #10's numbness and weakness were evaluated thoroughly while he was at the facility, and confirmed there was no evidence Physician #600 was contacted and Physician #600 did not write a progress note regarding the call. The DON confirmed there was no evidence Resident #10's responsible party was contacted when he was transported to the hospital. Review of the facility policy titled Change in a Residents Condition or Status dated 08/2024 included the facility should promptly notify the resident, physician and representative of changes in a residents medical, mental condition or status. The nurse would notify the resident's physician when there was a significant change in the resident's physical, emotional, mental condition. Unless otherwise instructed by the resident the nurse would notify the residents representative when there was a significant change in a resident's physical, mental or psychosocial status. This deficiency represents non-compliance investigated under Complaint Number OH00163886. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365828 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 365828 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harvard Gardens Rehabilitation & Care Center 18810 Harvard Ave Cleveland, OH 44122 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Based on medical record review, review of personnel files, review of witness statements, interviews, and review of facility policy, the facility failed to prevent staff to resident verbal abuse. This affected one resident (#28) of three reviewed for respect and dignity. The facility census was 87. Findings include: Review of the medical record for Resident #28 revealed an admission date of 06/20/23 with diagnoses including hypertension, alcohol induced persisting dementia, dementia with agitation, violent behavior, anxiety disorder, anterograde amnesia, insomnia, and heartburn. Review of the behavior care plan, revised 08/29/24, indicated Resident #28 did not conform to the boundaries of socially acceptable behaviors because he would take bowel movements and place them in drawers and cabinets, go in and out of rooms and turn the water on and off, and have episodes of refusing personal and incontinence care. Interventions included discuss with resident in a straight-forward yet kind manner that his behavior was unacceptable, evaluate if behavior was a result of cognitive impairment, refer to psychiatric services for evaluation if behaviors continued, and remind the resident of the need to respect rights of other residents. Review of the care plan, revised 01/16/25, indicated Resident #28 was non-compliant with care or treatment as ordered by the physician, refused personal care, refused showers, refused medications, was noted to spit out medications, refused labs, and refused to allow staff to obtain weights. Interventions included attempting to refocus behavior, stop care as appropriate if resident is upset and try again later, administer medications as ordered, approach resident calmly and speak in a calm voice, educate resident on negative consequences of not following physician's orders, and observe and document mood and behavior changes in the nurses notes. Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/18/25, indicated Resident #28 had moderately impaired cognitive skills for daily decision making. The assessment also indicated Resident #28 had physical and verbal behaviors directed toward others for one to three days within the previous seven day lookback period. Review of Resident #28's progress notes for February 2025 revealed there was no note documented for the alleged incident that occurred between Resident #28 and Certified Nursing Assistant (CNA) #549 on 02/26/25. Review of the list of Self Reported Incidents (SRIs) submitted by facility revealed there was no SRI related to the incident that took place on 02/26/25 between Resident #28 and CNA #549. Review of the personnel file for CNA #549 revealed a hire date of 09/12/24 and a disciplinary action form (dated 02/28/25) indicating CNA #549 was terminated for telling a resident that she would punch him in the face. Review of the accompanying written witness statements (all dated 02/26/25) revealed CNA #482 reported witnessing CNA #549 in Resident #28's room telling Resident #28 she was going to knock him the [expletive] out. In addition, Registered Nurse (RN) #502's witness statement indicated CNA #549 was asked if she told Resident #28 she would [expletive] him up and CNA #549 responded yes I did, he pulled my [expletive] hair. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365828 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 365828 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harvard Gardens Rehabilitation & Care Center 18810 Harvard Ave Cleveland, OH 44122 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 04/09/25 at 10:26 A.M., an interview with Resident #28 stated sometimes the aides had an attitude with him. He did not elaborate further. On 04/09/25 at 11:51 A.M., an interview with the Director of Nursing (DON) confirmed there was an alleged incident between CNA #549 and Resident #28, and she stated there were too many conflicting stories to determine if anything actually happened. The DON verified the content of the written statements from CNA #482 and RN #502. On 04/09/25 at 3:19 P.M., an interview with CNA #482 stated she heard CNA #549 yelling from down the hallway. CNA #482 said she witnessed CNA #549 standing outside Resident #28's room yelling [expletive] these residents and Resident #28 was definitely within earshot because she had heard CNA #549 from all the way down the hall. She denied witnessing CNA #549 say anything directly to Resident #28 despite her written statement regarding the incident. On 04/10/25 at 9:27 A.M., an interview with RN #502 stated she heard yelling and cussing from the nurses station and heard Resident #28 yelling that CNA #549 was going to hit him. On 04/10/25 at 3:08 P.M., an interview with CNA #549 confirmed she told Resident #28 that she was going to knock him the [expletive] out because he grabbed her by the hair and kicked her. On 04/10/25 at 3:39 P.M., an interview with CNA #534 stated she witnessed Resident #28 cussing and punching at CNA #549. She said CNA #549 was cussing as she left the room. Review of the facility's policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, revised 03/2024, indicated residents had the right to be free from abuse, neglect, exploitation, and misappropriation of resident property. The definition of abuse included intimidation and verbal abuse. This deficiency represents non-compliance investigated under Complaint Number OH00162969. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365828 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 365828 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harvard Gardens Rehabilitation & Care Center 18810 Harvard Ave Cleveland, OH 44122 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, review of personnel files, review of witness statements, interviews, review of the facility's self-reported incidents (SRIs), and review of facility policy, the facility failed to effectively implement their policy on abuse in regard to the timely reporting of an allegation of abuse and conducting a thorough investigation of an allegation of abuse. This affected one resident (#28) of one reviewed for abuse. The facility census was 87. Residents Affected - Few Findings include: Review of the medical record for Resident #28 revealed an admission date of 06/20/23 with diagnoses including hypertension, alcohol induced persisting dementia, dementia with agitation, violent behavior, anxiety disorder, anterograde amnesia, insomnia, and heartburn. Review of the behavior care plan, revised 08/29/24, indicated Resident #28 did not conform to the boundaries of socially acceptable behaviors because he would take bowel movements and place them in drawers and cabinets, go in and out of rooms and turn the water on and off, and have episodes of refusing personal and incontinence care. Interventions included discuss with resident in a straight-forward yet kind manner that his behavior was unacceptable, evaluate if behavior was a result of cognitive impairment, refer to psychiatric services for evaluation if behaviors continued, and remind the resident of the need to respect rights of other residents. Review of the behavior care plan, revised 01/16/25, indicated Resident #28 was non-compliant with care or treatment as ordered by the physician, refused personal care, refused showers, refused medications, was noted to spit out medications, refused labs, and refused to allow staff to obtain weights. Interventions included attempting to refocus behavior, stop care as appropriate if resident is upset and try again later, administer medications as ordered, approach resident calmly and speak in a calm voice, educate resident on negative consequences of not following physician's orders, and observe and document mood and behavior changes in the nurses notes. Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/18/25, indicated Resident #28 had moderately impaired cognitive skills for daily decision making. The assessment also indicated Resident #28 had physical and verbal behaviors directed toward others for one to three days within the previous seven day lookback period. Review of the progress notes for February 2025 revealed there was no note documented for the alleged incident that occurred between Resident #28 and Certified Nursing Assistant (CNA) #549 on 02/26/25. Review of the list of Self Reported Incidents (SRIs) submitted by facility revealed there was no SRI related to the incident that took place on 02/26/25 between Resident #28 and CNA #549. Review of the personnel file for CNA #549 revealed a hire date of 09/12/24 and a disciplinary action form (dated 02/28/25) indicating CNA #549 was terminated for telling a resident that she would punch him in the face. Review of the accompanying written witness statements (all dated 02/26/25) revealed CNA #482 reported witnessing CNA #549 in Resident #28's room telling Resident #28 she was going to knock him the [expletive] out. In addition, Registered Nurse (RN) #502's witness statement indicated CNA #549 was asked if she told Resident #28 she would [expletive] him up and CNA #549 responded yes I did, he pulled my [expletive] hair. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365828 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 365828 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harvard Gardens Rehabilitation & Care Center 18810 Harvard Ave Cleveland, OH 44122 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 04/09/25 at 10:26 A.M., an interview with Resident #28 stated sometimes the aides had an attitude with him. He did not elaborate further. On 04/09/25 at 11:51 A.M., an interview with the Director of Nursing (DON) confirmed there was an alleged incident between CNA #549 and Resident #28, and she stated there were too many conflicting stories to determine if anything actually happened. The DON verified the content of the written statements from CNA #482 and RN #502 and continued to insist they could not determine if anything actually happened. The DON verified no SRI was submitted related to this alleged incident and the actions of CNA #549 were not reported to the nurse aide registry. On 04/09/25 at 3:19 P.M., an interview with CNA #482 stated she heard CNA #549 yelling from down the hallway. CNA #482 said she witnessed CNA #549 standing outside Resident #28's room yelling [expletive] these residents and Resident #28 was definitely within earshot because she had heard CNA #549 from all the way down the hall. She denied witnessing CNA #549 say anything directly to Resident #28 despite her written statement regarding the incident. On 04/10/25 at 9:27 A.M., an interview with RN #502 stated she heard yelling and cussing from the nurses station and heard Resident #28 yelling that CNA #549 was going to hit him. On 04/10/25 at 3:08 P.M., an interview with CNA #549 confirmed she told Resident #28 that she was going to knock him the [expletive] out because he grabbed her by the hair and kicked her. On 04/10/25 at 3:39 P.M., an interview with CNA #534 stated she witnessed Resident #28 cussing and punching at CNA #549. She said CNA #549 was cussing as she left the room. The facility did not provide any other information or documentation related to the incident between Resident #28 and CNA #549. Review of the facility's policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, revised 03/2024, indicated facility staff should immediately report all allegations of abuse to the Administrator and the Administrator or designee should report the allegation to the Ohio Department of Health (ODH) immediately or not later than two hours after the allegation was made. If a staff member was accused or suspected of abusing a resident, the following should occur: the resident involved or suspected to be involved should be assessed for injury, the resident's physician should be notified of the incident, the resident should be sent to the hospital for evaluation if necessary, the alleged staff member should be immediately removed from the facility and taken off the schedule pending the results of the investigation, social services should be notified of the incident, the resident's representative should be notified of the incident, and the incident should be documented in the resident's medical record. The Enhanced Information Dissemination and Collection (EIDC) system should be used to submit a Self-Reported Incident (SRI) form to ODH unless there is an internet outage, in which case the notification could be made by phone and the online form submitted once internet service was restored. The investigation should be completed within five working days and should include the following: interview with the involved residents, interviews with witnesses, interviews with pertinent staff, review of all relevant medical records, review of employment record if staff member involved, and the facility's investigation should be documented according to quality assurance protocols. The results of the investigation should be submitted to ODH utilizing the EIDC system within five working days after the discovery of the incident. In addition, the facility would report the results of the investigation of staff to resident abuse to the licensing agencies and registries, as appropriate. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365828 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 365828 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harvard Gardens Rehabilitation & Care Center 18810 Harvard Ave Cleveland, OH 44122 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0607 This deficiency represents non-compliance investigated under Complaint Number OH00162969. 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: 365828 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 365828 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harvard Gardens Rehabilitation & Care Center 18810 Harvard Ave Cleveland, OH 44122 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. Based on medical record review, review of personnel files, review of witness statements, interviews, review of the facility's self-reported incidents (SRIs), and review of facility policy, the facility failed to report an allegation of staff to resident verbal abuse to the proper authorities. This affected one resident (#28) of one reviewed for abuse. The facility census was 87. Findings include: Review of the medical record for Resident #28 revealed an admission date of 06/20/23 with diagnoses including hypertension, alcohol induced persisting dementia, dementia with agitation, violent behavior, anxiety disorder, anterograde amnesia, insomnia, and heartburn. Review of the behavior care plan, revised 08/29/24, indicated Resident #28 did not conform to the boundaries of socially acceptable behaviors because he would take bowel movements and place them in drawers and cabinets, go in and out of rooms and turn the water on and off, and have episodes of refusing personal and incontinence care. Interventions included discuss with resident in a straight-forward yet kind manner that his behavior was unacceptable, evaluate if behavior was a result of cognitive impairment, refer to psychiatric services for evaluation if behaviors continued, and remind the resident of the need to respect rights of other residents. Review of the behavior care plan, revised 01/16/25, indicated Resident #28 was non-compliant with care or treatment as ordered by the physician, refused personal care, refused showers, refused medications, was noted to spit out medications, refused labs, and refused to allow staff to obtain weights. Interventions included attempting to refocus behavior, stop care as appropriate if resident is upset and try again later, administer medications as ordered, approach resident calmly and speak in a calm voice, educate resident on negative consequences of not following physician's orders, and observe and document mood and behavior changes in the nurses notes. Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/18/25, indicated Resident #28 had moderately impaired cognitive skills for daily decision making. The assessment also indicated Resident #28 had physical and verbal behaviors directed toward others for one to three days within the previous seven day lookback period. Review of the progress notes for February 2025 revealed there was no note documented for the alleged incident that occurred between Resident #28 and Certified Nursing Assistant (CNA) #549 on 02/26/25. Review of the list of Self Reported Incidents (SRIs) submitted by facility revealed there was no SRI related to the incident that took place on 02/26/25 between Resident #28 and CNA #549. Review of the personnel file for CNA #549 revealed a hire date of 09/12/24 and a disciplinary action form (dated 02/28/25) indicating CNA #549 was terminated for telling a resident that she would punch him in the face. Review of the accompanying written witness statements (all dated 02/26/25) revealed CNA #482 reported witnessing CNA #549 in Resident #28's room telling Resident #28 she was going to knock him the [expletive] out. In addition, Registered Nurse (RN) #502's witness statement indicated CNA #549 was asked if she told Resident #28 she would [expletive] him up and CNA #549 responded yes I did, he pulled my [expletive] hair. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365828 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 365828 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harvard Gardens Rehabilitation & Care Center 18810 Harvard Ave Cleveland, OH 44122 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 On 04/09/25 at 10:26 A.M., an interview with Resident #28 stated sometimes the aides had an attitude with him. He did not elaborate further. On 04/09/25 at 11:51 A.M., an interview with the Director of Nursing (DON) confirmed there was an alleged incident between CNA #549 and Resident #28, and she stated there were too many conflicting stories to determine if anything actually happened. The DON verified the content of the written statements from CNA #482 and RN #502 and continued to insist they could not determine if anything actually happened. The DON verified no SRI was submitted related to this alleged incident and the actions of CNA #549 were not reported to the nurse aide registry. On 04/09/25 at 3:19 P.M., an interview with CNA #482 stated she heard CNA #549 yelling from down the hallway. CNA #482 said she witnessed CNA #549 standing outside Resident #28's room yelling [expletive] these residents and Resident #28 was definitely within earshot because she had heard CNA #549 from all the way down the hall. She denied witnessing CNA #549 say anything directly to Resident #28 despite her written statement regarding the incident. On 04/10/25 at 9:27 A.M., an interview with RN #502 stated she heard yelling and cussing from the nurses station and heard Resident #28 yelling that CNA #549 was going to hit him. On 04/10/25 at 3:08 P.M., an interview with CNA #549 confirmed she told Resident #28 that she was going to knock him the [expletive] out because he grabbed her by the hair and kicked her. On 04/10/25 at 3:39 P.M., an interview with CNA #534 stated she witnessed Resident #28 cussing and punching at CNA #549. She said CNA #549 was cussing as she left the room. The facility did not provide any other information or documentation related to the incident between Resident #28 and CNA #549. Review of the facility's policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, revised 03/2024, indicated facility staff should immediately report all allegations of abuse to the Administrator and the Administrator or designee should report the allegation to the Ohio Department of Health (ODH) immediately or not later than two hours after the allegation was made. The Enhanced Information Dissemination and Collection (EIDC) system should be used to submit a Self-Reported Incident (SRI) form to ODH unless there is an internet outage, in which case the notification could be made by phone and the online form submitted once internet service was restored. The investigation should be completed within five working days and should include the following: interview with the involved residents, interviews with witnesses, interviews with pertinent staff, review of all relevant medical records, review of employment record if staff member involved, and the facility's investigation should be documented according to quality assurance protocols. The results of the investigation should be submitted to ODH utilizing the EIDC system within five working days after the discovery of the incident. In addition, the facility would report the results of the investigation of staff to resident abuse to the licensing agencies and registries, as appropriate. This deficiency represents non-compliance investigated under Complaint Number OH00162969. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365828 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 365828 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harvard Gardens Rehabilitation & Care Center 18810 Harvard Ave Cleveland, OH 44122 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, review of personnel files, review of witness statements, interviews, review of the facility's self-reported incidents (SRIs), and review of facility policy, the facility failed to conduct a thorough investigation of an allegation of staff to resident verbal abuse. This affected one resident (#28) of one reviewed for abuse. The facility census was 87. Residents Affected - Few Findings include: Review of the medical record for Resident #28 revealed an admission date of 06/20/23 with diagnoses including hypertension, alcohol induced persisting dementia, dementia with agitation, violent behavior, anxiety disorder, anterograde amnesia, insomnia, and heartburn. Review of the behavior care plan, revised 08/29/24, indicated Resident #28 did not conform to the boundaries of socially acceptable behaviors because he would take bowel movements and place them in drawers and cabinets, go in and out of rooms and turn the water on and off, and have episodes of refusing personal and incontinence care. Interventions included discuss with resident in a straight-forward yet kind manner that his behavior was unacceptable, evaluate if behavior was a result of cognitive impairment, refer to psychiatric services for evaluation if behaviors continued, and remind the resident of the need to respect rights of other residents. Review of the behavior care plan, revised 01/16/25, indicated Resident #28 was non-compliant with care or treatment as ordered by the physician, refused personal care, refused showers, refused medications, was noted to spit out medications, refused labs, and refused to allow staff to obtain weights. Interventions included attempting to refocus behavior, stop care as appropriate if resident is upset and try again later, administer medications as ordered, approach resident calmly and speak in a calm voice, educate resident on negative consequences of not following physician's orders, and observe and document mood and behavior changes in the nurses notes. Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/18/25, indicated Resident #28 had moderately impaired cognitive skills for daily decision making. The assessment also indicated Resident #28 had physical and verbal behaviors directed toward others for one to three days within the previous seven day lookback period. Review of the progress notes for February 2025 revealed there was no note documented for the alleged incident that occurred between Resident #28 and Certified Nursing Assistant (CNA) #549 on 02/26/25. Review of the list of Self Reported Incidents (SRIs) submitted by facility revealed there was no SRI related to the incident that took place on 02/26/25 between Resident #28 and CNA #549. Review of the personnel file for CNA #549 revealed a hire date of 09/12/24 and a disciplinary action form (dated 02/28/25) indicating CNA #549 was terminated for telling a resident that she would punch him in the face. Review of the accompanying written witness statements (all dated 02/26/25) revealed CNA #482 reported witnessing CNA #549 in Resident #28's room telling Resident #28 she was going to knock him the [expletive] out. In addition, Registered Nurse (RN) #502's witness statement indicated CNA #549 was asked if she told Resident #28 she would [expletive] him up and CNA #549 responded yes I did, he pulled my [expletive] hair. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365828 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 365828 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harvard Gardens Rehabilitation & Care Center 18810 Harvard Ave Cleveland, OH 44122 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the facility's investigation into the incident revealed the facility was unable to provide any evidence of additional investigation activities. There was no evidence of an interview with or written statement from the alleged perpetrator (CNA #549), there was no evidence of an interview with or written statement from CNA #534 (who was also present in the resident's room at the time of the alleged incident), and the facility was unable to provide the additional statement that CNA #482 said she wrote after she wrote her initial statement. On 04/09/25 at 10:26 A.M., an interview with Resident #28 stated sometimes the aides had an attitude with him. He did not elaborate further. On 04/09/25 at 11:51 A.M., an interview with the Director of Nursing (DON) confirmed there was an alleged incident between CNA #549 and Resident #28, and she stated there were too many conflicting stories to determine if anything actually happened. The DON verified the content of the written statements from CNA #482 and RN #502 and continued to insist they could not determine if anything actually happened. On 04/09/25 at 3:19 P.M., an interview with CNA #482 stated she heard CNA #549 yelling from down the hallway. CNA #482 said she witnessed CNA #549 standing outside Resident #28's room yelling [expletive] these residents and Resident #28 was definitely within earshot because she had heard CNA #549 from all the way down the hall. She denied witnessing CNA #549 say anything directly to Resident #28 despite her written statement regarding the incident. On 04/10/25 at 9:27 A.M., an interview with RN #502 stated she heard yelling and cussing from the nurses station and heard Resident #28 yelling that CNA #549 was going to hit him. On 04/10/25 at 3:08 P.M., an interview with CNA #549 confirmed she told Resident #28 that she was going to knock him the [expletive] out because he grabbed her by the hair and kicked her. On 04/10/25 at 3:39 P.M., an interview with CNA #534 stated she witnessed Resident #28 cussing and punching at CNA #549. She said CNA #549 was cussing as she left the room. The facility did not provide any other information or documentation related to the incident between Resident #28 and CNA #549. Review of the facility's policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, revised 03/2024, indicated facility staff should immediately report all allegations of abuse to the Administrator and the Administrator or designee should report the allegation to the Ohio Department of Health (ODH) immediately or not later than two hours after the allegation was made. If a staff member was accused or suspected of abusing a resident, the following should occur: the resident involved or suspected to be involved should be assessed for injury, the resident's physician should be notified of the incident, the resident should be sent to the hospital for evaluation if necessary, the alleged staff member should be immediately removed from the facility and taken off the schedule pending the results of the investigation, social services should be notified of the incident, the resident's representative should be notified of the incident, and the incident should be documented in the resident's medical record. This deficiency represents non-compliance investigated under Complaint Number OH00162969. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365828 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 365828 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harvard Gardens Rehabilitation & Care Center 18810 Harvard Ave Cleveland, OH 44122 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 review of the facility policy the facility failed to ensure Resident #31's incontinence care was provided timely. This affected one resident (Resident #31) out of three residents reviewed for incontinence care. The facility census was 87. Residents Affected - Few Findings include: Review of Resident #31's medical record revealed an admission date of 08/01/14 and diagnoses included Alzheimer's Disease, anxiety disorder and type two diabetes mellitus. Review of Resident #31's care plan revised 02/11/25 included Resident #31 was incontinent of bowel and, or bladder. Resident #31 refused care at times and was not a candidate for a toileting program. Resident #31 would be free of skin breakdown related to incontinence. Interventions included to change Resident #31 every two hours and as needed; provide incontinence care and apply barrier cream after each incontinent episode. Review of Resident #31's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 did not have a Brief Interview for Mental Status completed due to he was unable to complete the interview. Resident #31 required substantial to maximal assistance for toileting hygiene, bathing and upper and lower body dressing. Resident #31 was always incontinent of urine and frequently incontinent of bowel. Review of Resident #31's progress notes dated 04/09/25 from 7:00 A.M. through 2:26 P.M. did not reveal evidence Resident #31 refused to have his incontinence brief changed. Review of Resident #31's aide charting dated 04/09/25 from 7:00 A.M. through 2:26 P.M. did not reveal evidence Resident #31's incontinence brief was changed. Observation on 04/09/25 at 2:26 P.M. of Certified Nursing Assistant (CNA) #454 providing Resident #31's incontinence care revealed Resident #31's incontinence brief was saturated with urine and he had a moderate size, formed bowel movement. Resident #31's draw sheet was saturated with urine, and his sheet under the draw sheet had a large amount of urine observed on it with dried yellow urine observed around the outer aspect of the urine on the sheet. Resident #31's draw sheet was a folded blanket. CNA #454 stated blankets were not used for draw sheets, and someone probably could not find a reusable draw sheet and substituted a blanket. CNA #454 confirmed it did not look like Resident #31 was changed for quite a long time and stated, it sure doesn't. CNA #454 stated she just took over this assignment including Resident #31 and did not know the last time Resident #31 had his incontinence brief changed. CNA #454 removed Resident #31's bed linens including the sheet and draw sheet saturated with urine and threw them on the floor next to the plastic bag she had prepared to place them in. CNA #454 finished providing Resident #31's incontinence care, did not apply barrier cream before putting his new brief on, picked up the soiled bed linens from the floor, placed them in the plastic bag and left the room to take the soiled linens to the utility room. CNA #454 confirmed she threw the soiled bed linens on the floor and not in the plastic bag, and did not apply barrier cream. Interview on 04/09/25 at 4:00 P.M. of the Director of Nursing (DON) revealed it was not okay to throw soiled linens directly on the floor when providing Resident #31's incontinence care and Resident #31's incontinence brief should have been changed timely. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365828 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 365828 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harvard Gardens Rehabilitation & Care Center 18810 Harvard Ave Cleveland, OH 44122 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 0677 Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled Incontinence Care dated 01/2022 included the purpose of the procedure was to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. This deficiency represents non-compliance investigated under Complaint Number OH00162969. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365828 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 365828 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harvard Gardens Rehabilitation & Care Center 18810 Harvard Ave Cleveland, OH 44122 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 - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of the facility policy the facility failed to ensure Resident #10 received timely medical intervention for an acute change in condition. Residents Affected - Few Actual Harm occurred on 03/18/25 at 1:49 A.M. when Resident #10 complained of numbness of the right side of the body and requested to go to the hospital. However, the resident was not transferred to the hosptial until 03/18/25 at 4:08 A.M. Hospital documentation revealed the resident was admitted for a cerebrovascular accident due to intracerebral hemorrhage, ischemic stroke. The resident reported he had complaints of right-sided weakness approximately four days ago which he described as a heaviness to his upper and lower extremities. Resident #10 stated his weakness had not improved since the initial onset. The resident reported he suffered a fall yesterday because his leg gave out. The resident had obvious drift to the right upper and lower extremities and an unequal weak grip strength to the right hand in comparison to the contralateral side. Resident #10 had noticeable unilateral weakness to the right upper and lower extremities. Resident #10 stated his symptoms began on 03/15/25 and his symptoms had not improved. At the time the resident arrived to the hospital, Resident #10 was out of the window for significant intervention and a stroke alert was not called. Following the hospitalization, the resident's ability to ambulate had deteriorated and the resident required the use of a wheelchair for mobility. This affected one resident (Resident #10) of three residents reviewed for change of condition. The facility census was 87. Findings include: Review of Resident #10's medical record revealed an admission date of 11/03/23 and a re-entry date of 03/21/25. Resident #10's diagnoses included malignant neoplasm of the pancreas, drug-induced polyneuropathy, and hemiplegia (paralysis) and hemiparesis (weakness) following cerebral infarction affecting the right dominant side. Review of Resident #10's care plan revised 12/11/24 included Resident #10 needed assistance for ADL's related to cancer, bronchitis, asthma and other diagnoses. Resident #10 was able to ambulate on and off the unit, was alert and oriented times three (time, place, person), was able to voice needs and was able to perform ADL's independently and might require assistance during times of fatigue. Resident #10 would be well groomed and free of odors at all times and would participate as able in ADL self-care. Interventions included to observe for changes in ADL ability and adjust assistance as needed; an intervention initiated on 03/24/25 revealed utilized walker. Review of Resident #10's Quarterly Minimum Data Set (MDS) assessment dated [DATE] included Resident #10 was cognitively intact. Resident #10 had no impairment of the upper or lower extremities. Resident #10 did not use a cane, crutch, walker or wheelchair. Resident #10 was independent for toileting hygiene, bathing, upper and lower body dressing, personal hygiene and walking 50 feet. Review of Resident #10's medical record including progress notes dated 03/15/25 through 03/17/25 did not reveal evidence Resident #10 was experiencing numbness or weakness. Review of Resident #10's skilled nursing progress notes dated 03/16/25 at 11:26 A.M. included Resident #10's vital signs were within normal limits. Resident #10 was alert and oriented to time, place (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365828 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 365828 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harvard Gardens Rehabilitation & Care Center 18810 Harvard Ave Cleveland, OH 44122 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 - Actual harm Residents Affected - Few and situation. Resident #10 was weight bearing as tolerated, and had a steady gait. Weakness was not noted, able to move all extremities, and had full sensation. The note included Resident #10 did not have changes in ADL capability and did not require assistance with bed mobility. Review of Resident #10's skilled nursing progress notes dated 03/17/25 did not reveal a skilled nursing progress note was completed. Review of Resident #10's progress notes dated 03/18/25 at 1:49 A.M. revealed Resident #10 complained of numbness of the right side of the body, Resident #10 requested to go to the hospital, Resident #10 was alert and oriented times three. Vital signs were blood pressure 117/33, pulse 84, respirations 18 per minute, oxygen saturation was 98 percent on room air. The non-emergency transportation company was contacted and Resident #10 would be picked up on 03/18/25 at 8:00 A.M. Review of Resident #10's progress notes dated 03/18/25 at 1:53 A.M. revealed Resident #10 complained of numbness to the right side of his body. Review of Resident #10's medical record including progress notes dated 03/18/25 at 1:49 A.M. through 03/18/25 at 4:08 A.M. did not reveal evidence Resident #10's weakness and numbness were thoroughly evaluated. Review of Resident #10's progress notes dated 03/18/25 at 4:08 A.M. revealed Resident #10 left the facility via stretcher with two paramedics. Resident #10 was being transported to the local hospital Emergency Department. Review of Resident #10's late entry SBAR Summary for Providers dated 03/18/25 at 2:27 P.M. included on 03/18/25 at 1:49 A.M. Resident #10 had a change in condition and the CIC (change in condition) evaluation was functional decline (worsening function and, or mobility). Outcomes of a physical assessment included Resident #10 had weakness or hemiparesis, decreased mobility. Review of Resident #10's medical record including progress notes dated 03/18/25 through 03/21/25 did not reveal evidence Resident #10's physician was notified Resident #10 was having numbness and weakness and what his recommendations were. Review of Resident #10's physician orders dated 03/18/25 through 03/21/25 did not reveal a physician order to transport Resident #10 to the hospital. Review of Resident #10's medical record including progress notes did not reveal evidence Resident #10's responsible party was notified he was sent to the hospital. Review of Resident #10's hospital records dated 03/18/25 through 03/21/25 included his admission diagnosis was cerebrovascular accident due to intracerebral hemorrhage, ischemic stroke. Resident #10 presented to the ED on 03/18/25 with complaints of right-sided weakness. Resident #10 stated his weakness began approximately four days ago, and he described his right-sided weakness as a heaviness to his upper and lower extremities. Resident #10 stated his weakness had not improved since the initial onset. Resident #10 reported that he suffered a fall yesterday because his leg gave out and he had no injuries from the fall. Resident #10 was not anticoagulated. Resident #10 was chronically ill-appearing and in no obvious distress. Resident #10 had obvious drift to the right upper and lower extremities. Resident #10 had an unequal weak grip strength to the right hand in comparison to the contralateral side. Resident #10 had noticeable unilateral weakness to the right upper and lower (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365828 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 365828 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harvard Gardens Rehabilitation & Care Center 18810 Harvard Ave Cleveland, OH 44122 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 extremities. Resident #10 stated his symptoms began on 03/15/25 and his symptoms have not improved. Resident #10 was out of the window for significant intervention and a stroke alert was not called. Level of Harm - Actual harm Residents Affected - Few Review of Resident #10's After Hours Telehealth Consult progress notes dated 03/21/25 at 1:00 A.M. included Resident #10 was readmitted to the facility this evening after a hospitalization for acute CVA (cerebrovascular accident). Review of Resident #10's progress notes dated 03/21/25 at 6:48 P.M. revealed Resident #10 arrived to the facility via a stretcher accompanied by two EMT (Emergency Medical Technician)'s. Review of Resident #10's progress notes dated 03/21/25 at 5:59 P.M. included Resident #10 had right sided weakness due to CVA. Resident #10 was alert and oriented times three. Review of Resident #10's Significant Change in Status assessment dated [DATE] included Resident #10 used a cane, crutch and a wheelchair. Resident #10 did not use a walker. Resident #10 was independent for toileting hygiene, needed setup or clean-up assistance for bathing, and putting on and taking off footwear. Resident #10 required partial to moderate assistance for the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed, and bed mobility. Resident #10 required supervision or touching assistance for toilet transfers, to walk 10 feet and to walk 50 feet. Observation on 04/09/25 at 8:31 A.M. of Resident #10 revealed he was sitting in a wheelchair in his room. Resident #10 stated the facility needed improvement. Resident #10 indicated if he needed to go to the hospital the nurse had to call the physician and he had to wait for the physician to call back. Resident #10 stated he had a stroke, he told the nurse he needed to go to the hospital, and three hours later he finally went because he insisted. Resident #10 stated he was having a hard time walking, knew something was not right and told the nurse he had to go to the hospital, but he had to really insist because she did not want to send him. Resident #10 stated on 03/14/25 or 03/15/25 he was walking fine, the next day something did not feel right, then he had trouble walking. Resident #10 stated he told the nurse he needed to go to the hospital and she said your vitals are fine. Resident #10 revealed he experienced a fall and his roommate screamed for the nurse. Resident #17 nodded his head yes when Resident #10 stated this, but did not say anything. The nurses came to the room and the nurse told me she would call for transportation to the hospital, but the wait would be four hours and it was non-emergency transportation. Resident #10 could not remember the name of the nurse. Resident #10 stated the facility did not call the physician for three hours. Interview on 04/09/25 at 2:45 P.M. with Licensed Practical Nurse (LPN) #438 revealed she was assigned to care for Resident #10 the night he was transported to the hospital. LPN #438 stated what she knew was Resident #10 said he was not feeling well, and kept saying he did not feel well, and wanted sent out to the hospital. LPN #438 stated she took Resident #10's vital signs and they were fine. LPN #438 indicated she was new to the facility and in orientation and let the nurse manager know Resident #10 wanted sent to the hospital. LPN #438 indicated she asked Resident #10 questions to get more information about how he was feeling, he just came in from smoking and she thought he smoked more than one cigarette and the smoking was what made him not feel well. LPN #438 indicated she asked Resident #10 if he was having pain, and he said he felt numbness, and he was able to squeeze her hand. LPN #438 stated Resident #10 did not experience a fall, and when he came out of the bathroom he was kind of leaning and said his leg felt numb, he needed help (she could not remember which side) and he was assisted back to bed. LPN #438 indicated she called a physician, but she did not remember who she called or when and told the physician Resident #10 was having numbness and was told to send him (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365828 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 365828 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harvard Gardens Rehabilitation & Care Center 18810 Harvard Ave Cleveland, OH 44122 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 out to the hospital. Resident #10 was sent to the hospital via non-emergency transportation. Level of Harm - Actual harm Interview on 04/09/25 at 4:06 P.M. wit LPN #417 revealed she was working when Resident #10 was sent to the hospital. LPN #417 stated she arrived to the facility on [DATE] around 1:00 A.M. and LPN #438 already had received orders to send Resident #10 to the hospital via non-emergency transportation. LPN #417 indicated she did not know when the transportation company was due to arrive. LPN #417 stated Resident #10 was fine when she saw him, and she told him transportation was on the way. LPN #417 stated Resident #10 did not experience a fall before he left the facility. Residents Affected - Few Interview on 04/10/25 at 9:32 A.M. with Physician #600 revealed he remembered something about a call regarding Resident #10, but he took care of Resident #10 while he was in the hospital and he could not remember if the calls were before or after Resident #10 was admitted to the hospital. Physician #600 stated he did not always put a physician note in the resident record when he was called. Physician #600 stated if Resident #10 was experiencing weakness and numbness on one side of the body and it was sudden onset like within an hour or so he would definitely order him to be sent out via 911. Interview on 04/10/25 at 10:18 A.M. with Certified Nursing Assistant (CNA) #524 revealed Resident #10 could walk before he went to the hospital and now he was in a wheelchair. CNA #524 stated she thought Resident #10 had a stroke, and he told her he would be able to walk in time. CNA #524 stated Resident #10 told her he fell before he went to the hospital but he did not give details. Interview on 04/10/25 at 11:18 A.M. with the Director of Nursing (DON) revealed LPN #438 called Unit Manager (UM) #442 because Resident #10 said he was not feeling well, had numbness in his right arm, and never told her he had a fall. The DON stated UM #442 said Resident #10 did not know how to describe how he was feeling, said he wanted to smoke a cigarette and wanted to go to the hospital. UM #442 did not think it was serious. UM #442 instructed LPN #438 to call the physician and have Resident #10 sent to the hospital because it was Resident #10's right to go to the hospital if he wanted to. The DON confirmed Resident #10's medical record including progress notes did not have evidence Resident #10's numbness and weakness were evaluated thoroughly while he was at the facility, and confirmed there was no evidence Physician #600 was contacted and Physician #600 did not write a progress note regarding the call. The DON confirmed there was no evidence Resident #10's responsible party was contacted when he was transported to the hospital. Review of the facility policy titled Change in a Residents Condition or Status dated 08/2024 included the facility should promptly notify the resident, physician and representative of changes in a residents medical, mental condition or status. The nurse would notify the resident's physician when there was a significant change in the resident's physical, emotional, mental condition. Unless otherwise instructed by the resident the nurse would notify the residents representative when there was a significant change in a resident's physical, mental or psychosocial status. This deficiency represents non-compliance investigated under Complaint Number OH00163886. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365828 If continuation sheet Page 18 of 18