Inspection·September 15, 2022

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. 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 Resident #36 received the appropriate beneficiary notice when skilled services were discontinued. This affected one resident (#36) of three residents reviewed for beneficiary notices. Residents Affected - Few Findings include: Review of Resident #36's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder, major depressive disorder and Alzheimer's disease. Review of Resident #36's Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review form revealed the resident's Medicare Part A skilled services started on 06/16/22 and her last covered day was 07/07/22. Review of Resident #36's Notice of Medicare Non-Coverage (NOMNC) form indicated skilled services would end 07/07/22. The form was verbally signed 07/05/22. The resident remained in the facility after the services ended. On 09/14/22 at 10:46 A.M. interview with Licensed Social Worker (LSW) #808 confirmed Resident #36 and/or her family did not receive the Advance Beneficiary Notice of Non-Coverage (SNFABN) form as required. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365836 If continuation sheet Page 2 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365836 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village at St Edward Nrsg Care 3131 Smith Rd Fairlawn, OH 44333 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to provide written notifications to residents and residents' representatives before transfer to a hospital. This affected four residents (#20, #63, #65 and #274) of five residents reviewed for hospitalization. Findings include: 1. Review of Resident #20's medical record revealed diagnoses including dementia, hypertension, depression, anxiety disorder, seizures, chronic pain, and epilepsy. A nursing note, dated 08/13/22 at 10:15 A.M. revealed Resident #20 was unresponsive and her head and extremities were flaccid. The note indicated Resident #20's color was gray and her skin was diaphoretic (sweating profusely). Resident #20 was drooling and a blood pressure was unable to be obtained. After being assisted to bed, Resident #20 opened her eyes and was able to respond verbally. The physician was notified and Resident #20 was sent to the hospital. The note indicated Resident #20's daughter was updated. A nursing note, dated 08/13/22 at 5:25 P.M. indicated Resident #20 was admitted to the hospital with altered mental status. A nursing note dated 08/14/22 at 4:09 P.M. indicated the hospital reported Resident #20 was evaluated for seizures and would be started on the medication, Depakote (anti-convulsant). A nursing note dated 08/15/22 at 4:15 P.M. indicated Resident #20 returned to the facility. A nursing note, dated 08/16/22 at 4:55 A.M. indicated Resident #20 was observed lying on the floor with blood smeared from the bed to the back of the resident's head. Resident #20 stated she fell off the bed. Resident #20 had a large abrasion on the back of her head that was bleeding. Resident #20 reported she was having back pain. Emergency services was contacted to transport Resident #20 to the hospital. The physician and daughter were notified of the incident. A nursing note, dated 08/16/22 at 6:25 P.M. indicated Resident #20 was admitted to the hospital with a subdural hematoma ( condition due to bleeding under the membrane covering the brain). Resident #20 returned to the facility on [DATE]. Record review revealed no evidence of a written transfer notice being issued to the resident and/or resident's responsible party related to the hospital transfers. On 09/13/22 at 3:04 P.M. interview with Assistant Administrator #863 verified the facility did not provide written transfer notices when the resident was discharged to the hospital. 2. Review of Resident #63's medical record revealed diagnoses including cognitive communication deficit, convulsions, anemia, paroxysmal atrial fibrillation, hypertension, dementia, and history of transient ischemic attacks ( brief stroke-like attack wherein symptoms resolve within 24 hours) and strokes. A nursing note, dated 09/04/22 at 1:34 P.M. revealed Resident #63 would not eat lunch, was diaphoretic, and had a low blood pressure of 79/44. Resident #63's pulse was 130 and oxygen saturation was 87% on room air. The power of attorney was notified and agreed he wanted Resident #63 sent to the hospital. A nursing note, dated 09/04/22 at 10:53 P.M. indicated Resident #63 was admitted to the hospital with a diagnosis of sepsis (the body's overwhelming and life-threatening response to infection). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365836 If continuation sheet Page 3 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365836 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village at St Edward Nrsg Care 3131 Smith Rd Fairlawn, OH 44333 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 0623 Resident #63 returned to the facility on [DATE]. Level of Harm - Minimal harm or potential for actual harm Record review revealed no evidence of a written transfer notice being issued to the resident and/or resident's responsible party related to the hospital transfer. Residents Affected - Some On 09/13/22 at 3:04 P.M. interview with Assistant Administrator #863 verified the facility did not provide written transfer notices when the resident was discharged to the hospital. 3. Review of Resident #65's medical record revealed diagnoses including bipolar disorder, psychosis, affective mood disorder, anxiety disorder, and depression. A nursing note, dated 07/14/22 at 12:49 P.M. indicated Resident #65 was in the hallway after breakfast and started yelling at other residents, telling them to get out of there and leaning forward in her chair to intimidate them. Resident #65 started screaming over and over stating her dog was dead and she needed a cab. Attempts to redirect and provided one on one care were unsuccessful. Resident #65 kept yelling at any one that walked by. Several staff members tried to sit with her and redirect Resident #65 who was having random thoughts one after the other, going from angry to happy. The Assistant Director of Nursing was notified and reached out to the psychiatrist services. A social worker note, dated 07/14/22 at 2:15 P.M. indicated Resident #65 was discharged to a psychiatric hospital. Resident #65 returned to the facility on [DATE]. Record review revealed no evidence of a written transfer notice being issued to the resident and/or resident's responsible party related to the hospital transfers. On 09/13/22 at 3:04 P.M. interview with Assistant Administrator #863 verified the facility did not provide written transfer notices when the resident was discharged to the hospital. 4. Review of Resident #274's medical record revealed diagnoses including Alzheimer's disease, anxiety disorder, depression, left hip fracture and presence of left artificial hip joint. A nursing note, dated 08/24/22 at 10:45 A.M. indicated Resident #274 was found on the floor in the hallway on the left side. When Resident #274 was assisted back to the wheelchair she was moaning of pain to the left hip/femur region. The Certified Nurse Practitioner ordered a stat x-ray. A social service note dated 08/24/22 at 4:51 P.M. indicated Resident #274 was discharged to the hospital. Resident #274 returned to the facility on [DATE]. Record review revealed no evidence of a written transfer notice being issued to the resident and/or resident's responsible party related to the hospital transfers. On 09/13/22 at 3:04 P.M. interview with Assistant Administrator #863 verified the facility did not provide written transfer notices when the resident was discharged to the hospital. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365836 If continuation sheet Page 4 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365836 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village at St Edward Nrsg Care 3131 Smith Rd Fairlawn, OH 44333 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to provide timely written notifications to residents or residents' representatives related to the bed hold policy when residents were transferred to a hospital. This affected four residents (#20, #63, #65 and #274) of five residents reviewed for hospitalization. Findings include: 1. Review of Resident #20's medical record revealed diagnoses included dementia, hypertension, depression, anxiety disorder, seizures, chronic pain, and epilepsy. A nursing note dated 08/13/22 at 10:15 A.M. revealed Resident #20 was unresponsive and her head and extremities were flaccid. The note indicated Resident #20's color was gray and her skin was diaphoretic (sweating profusely). Resident #20 was drooling and a blood pressure was unable to be obtained. After being assisted to bed, Resident #20 opened her eyes and was able to respond verbally. The physician was notified and Resident #20 was sent to the hospital. The note indicated Resident #20's daughter was updated. A nursing note, dated 08/13/22 at 5:25 P.M. indicated Resident #20 was admitted to the hospital with altered mental status. A nursing note, dated 08/14/22 at 4:09 P.M. indicated the hospital reported Resident #20 was evaluated for seizures and would be started on the medication, Depakote (anti-convulsant). A nursing note, dated 08/15/22 at 4:15 P.M. indicated Resident #20 returned to the facility. A nursing note, dated 08/16/22 at 4:55 A.M. indicated Resident #20 was observed lying on the floor with blood smeared from the bed to the back of the resident's head. Resident #20 stated she fell off the bed. Resident #20 had a large abrasion on the back of her head that was bleeding. Resident #20 reported she was having back pain. Emergency services was contacted to transport Resident #20 to the hospital. The physician and daughter were notified of the incident. A nursing note dated 08/16/22 at 6:25 P.M. indicated Resident #20 was admitted to the hospital with a subdural hematoma (condition due to bleeding under the membrane covering the brain). Resident #20 returned to the facility on [DATE]. Review of the payor information revealed Resident #20 was paying privately for her stay prior to both hospitalizations. Review of bed hold notices, dated 08/16/22 and 08/18/22 revealed the notices were sent because Resident #20 was being admitted or was recently admitted to the hospital or would be out of the facility temporarily on therapeutic leave or vacation. The notice indicated private pay residents could choose to pay privately to hold a bed at the current room and board rates until the resident returned to the facility. The resident or responsible party was required to verify they wished to have the bed held within 24 hours of being admitted to the hospital or the bed would be relinquished. Verification of bed hold was required to be made prior to the start of vacation or therapeutic leave from the facility. Bed hold fees were payable prior to return to the facility. The notices indicated notification was made/verbal consent received from Resident #20's son on the days Resident #20 returned to the facility. On 09/14/22 at 9:25 A.M. interview with Assistant Administrator #863 verified the bed hold notice on 8/16/22 was dated after the resident returned from the hospital and the one dated 8/18/22 was on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365836 If continuation sheet Page 5 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365836 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village at St Edward Nrsg Care 3131 Smith Rd Fairlawn, OH 44333 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the day of return from the hospital. Assistant Administrator #863 verified it would be important for the resident/responsible party to know of the bed hold policy and cost to hold the bed in a more timely manner. 2. Review of Resident #63's medical record revealed diagnoses including cognitive communication deficit, convulsions, anemia, paroxysmal atrial fibrillation, hypertension, dementia, and history of transient ischemic attacks ( brief stroke-like attack wherein symptoms resolve within 24 hours) and strokes. A nursing note, dated 09/04/22 at 1:34 P.M. indicated Resident #63 would not eat lunch, was diaphoretic and had a low blood pressure of 79/44. Resident #63's pulse was 130 and oxygen saturation was 87% on room air. The power of attorney was notified and agreed he wanted Resident #63 sent to the hospital. A nursing note, dated 09/04/22 at 10:53 P.M. indicated Resident #63 was admitted to the hospital with a diagnosis of sepsis ( the body's overwhelming and life-threatening response to infection). Resident #63 returned to the facility on [DATE]. Review of the payor source information indicated Resident #63 was receiving Medicaid at the time of discharge to the hospital. Review of the bed hold notice revealed if a resident's stay was paid by Medicaid, the bed would be held at not cost for a maximum of 30 days in a calendar year (January - December). The notice informing Resident #63's representative of the number of days used during the year and of the bed hold policy revealed the notification was made with verbal consent to hold the bed the day (09/08/22) Resident #63 returned to the facility. On 09/14/22 at 9:25 A.M. interview with Assistant Administrator #863 verified the bed hold notice was dated the day the resident returned from the hospital and verified it would be important for the resident/responsible party to know of the bed hold policy in a more timely manner. 3. Review of Resident #65's medical record revealed diagnoses including bipolar disorder, psychosis, affective mood disorder, anxiety disorder, and depression. A nursing note, dated 07/14/22 at 12:49 P.M. indicated Resident #65 was in the hallway after breakfast and started yelling at other residents, telling them to get out of there and leaning forward in her chair to intimidate them. Resident #65 started screaming over and over stating her dog was dead and she needed a cab. Attempts to redirect and provided one on one care were unsuccessful. Resident #65 kept yelling at any one that walked by. Several staff members tried to sit with her and redirect Resident #65 who was having random thoughts one after the other, going from angry to happy. The Assistant Director of Nursing was notified and reached out to the psychiatrist services. A social worker note dated 07/14/22 at 2:15 P.M. indicated Resident #65 was discharged to a psychiatric hospital. Resident #65 returned to the facility on [DATE]. Review of payor source information revealed Resident #65's stay was paid for by Medicaid. Review of the bed hold notice revealed if a resident's stay was paid by Medicaid, the bed would be held at not cost for a maximum of 30 days in a calendar year (January - December). The notice informing Resident #65's representative of the number of days used during the year and of the bed hold policy revealed the notification was made with verbal consent to hold the bed 11 days after Resident #65 was discharged to the hospital. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365836 If continuation sheet Page 6 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365836 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village at St Edward Nrsg Care 3131 Smith Rd Fairlawn, OH 44333 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 0625 Level of Harm - Minimal harm or potential for actual harm On 09/14/22 at 9:25 A.M. interview with Assistant Administrator #863 verified the bed hold notice was provided 11 days after discharge and that it was important to provide timely notices. 4. Review of Resident #274's medical record revealed diagnoses including Alzheimer's disease, anxiety disorder, depression, left hip fracture and presence of left artificial hip joint. Residents Affected - Some A nursing note, dated 08/24/22 at 10:45 A.M. indicated Resident #274 was found on the floor in the hallway on the left side. When Resident #274 was assisted back to the wheelchair she was moaning of pain to the left hip/femur region. The Certified Nurse Practitioner ordered a stat x-ray. A social service note dated 08/24/22 at 4:51 P.M. indicated Resident #274 was discharged to the hospital. Resident #274 returned to the facility on [DATE]. Review of payor source information revealed Resident #274 paid privately. Review of the bed hold notice information Resident #274's responsible party revealed verbal consent was provided to hold the bed the day (08/29/22) Resident #274 returned to the facility (five days after discharge to the hospital). The notice indicated the responsible party or resident were required to verify if they wished to have the bed held within 24 hours of being admitted to the hospital or the bed would be relinquished. There was no evidence Resident #274's responsible party was notified of the bed hold rate at the time of discharge. On 09/14/22 at 9:25 A.M. interview with Assistant Administrator #863 verified the bed hold notice was dated the day Resident #274 returned from the hospital. Assistant Administrator #863 verified it would be important for a resident/responsible party to know of the bed hold policy and cost to hold the bed in a more timely manner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365836 If continuation sheet Page 7 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365836 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village at St Edward Nrsg Care 3131 Smith Rd Fairlawn, OH 44333 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to refer a resident with newly evident or possible serious mental disorder for a pre-admission screening and resident review (PASARR) Level II review. This affected one resident (#65) of two residents reviewed for PASARR. Findings include: Review of Resident #65's medical record revealed an original admission date of 04/20/22 with no psychiatric/mood diagnoses identified. A Hospital Exemption from Preadmission Screening Notification, dated 04/20/22 indicated prior to hospital admission Resident #65 resided at a residential care facility. There had been no adverse preadmission screen and record review (PASARR) determination within the past 60 days. Resident #65 had a diagnosis of depression. Resident #65 had no physical or mental disability, or related condition, that was not solely caused by mental illness and was manifested prior to the age of 22. The certification for hospital exemption indicated as the individual's attending physician, he certified the individual was being discharged to a nursing facility directly from a hospital after receiving acute patient care at the hospital, required nursing facility services for the condition for which she received care in the hospital and required fewer than 30 days of nursing facility services, no later than the date of discharge. The form indicated the nursing facility accepted responsibility for electronically initiating a resident review (if required) prior to the 30th day following admission from the hospital. On 04/21/22 an order was written for the antipsychotic medication, Seroquel 25 milligrams (mg) every 12 hours as needed for agitation for 14 days. Resident #65 was discharged [DATE] and returned 04/28/22. A diagnosis of anxiety disorder was added. Seroquel 25 mg every 12 hours as needed for 14 days for agitation was ordered. On 04/30/22 the resident's diagnosis list included a diagnosis of affective mood disorder and major depressive disorder. A PASARR dated 05/05/22 indicated Resident #65 had no diagnosis of dementia, no diagnosis of any of the mental disorders listed, no diagnosis of substance use related to a disorder, no psychiatric services used in last two years, no disruption of her usual living arrangement due to mental disorder, and in the past six months no functional limitations on continuing or intermittent basis due to mental disorder and no prescribed psychotropic medications. Review results indicated there were no indications of serious mental illness and/or developmental disability. The resident's diagnosis list was updated on 06/13/22 to include a diagnosis of bipolar disorder and psychosis. Between 06/28/22 and 07/13/22 orders were obtained for use of the use of the antipsychotic medication, Haldol on an as needed basis due to psychosis/agitation. A nursing note dated 07/14/22 at 12:49 P.M. indicated Resident #65 was in the hallway after breakfast and started yelling at other residents, telling them to get out of there and leaning forward in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365836 If continuation sheet Page 8 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365836 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village at St Edward Nrsg Care 3131 Smith Rd Fairlawn, OH 44333 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few her chair to intimidate them. Resident #65 started screaming over and over stating her dog was dead and she needed a cab. Attempts to redirect and provided one on one care were unsuccessful. Resident #65 kept yelling at any one that walked by. Several staff members tried to sit with her and redirect Resident #65 who was having random thoughts one after the other, going from angry to happy. The Assistant Director of Nursing was notified and reached out to the psychiatrist services. A social worker note, dated 07/14/22 at 2:15 P.M. indicated Resident #65 was discharged to a psychiatric hospital. Resident #65 returned to the facility on [DATE]. On 08/02/22 the resident's diagnosis list was updated to reflect diagnoses of dementia with behavioral disturbance and delusional disorders. Between 08/02/22 and 08/17/22 Resident #65 had orders for the antipsychotic medication, Zyprexa. A diagnosis of senile degeneration of the brain was added 08/31/22. On 09/13/22 at 3:04 P.M. interview with Assistant Administrator #863 verified a new PASARR was not completed after Resident #65 had a psychiatric hospitalization and new psychiatric diagnoses/psychiatric medications ordered. On 09/15/22 at 10:45 A.M. interview with Assistant Administrator #863 provided a PASARR dated 09/14/22 and indicated a new screen was completed. The new screen indicated Resident #65 was re-admitted from a psychiatric facility/unit with admission on [DATE]. It indicated although Resident #65 had no diagnosis of dementia she had a diagnosis of senile degeneration of the brain. Resident #65 also had mood disorder and panic or other severe anxiety. The screen indicated Resident #65 did not utilize psychiatric services more than once due to the mental disorder. It indicated the resident used ongoing case management from a mental health agency once in the past two years. The inpatient psychiatric hospitalization was not recorded in determining if Resident #65 had a serious mental illness. The screen indicated in the past six months Resident #65 experienced one or more of the following functional limitations on a continuing or intermittent basis due to the mental disorder: maintaining personal hygiene, dressing herself and verbalizing needs were checked. In the past six months Resident #65 was prescribed antipsychotics and anti-anxiety medications. The screen indicated Resident #65 had indications of serious mental illness. A referral was made for a Level II evaluation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365836 If continuation sheet Page 9 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365836 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village at St Edward Nrsg Care 3131 Smith Rd Fairlawn, OH 44333 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, record review and interview the facility failed to ensure Resident #59 was assisted with her breakfast meal in a timely manner. This affected one resident (#59) and had the potential to affect seven additional residents (#16, #26, #27, #29, #31, #47 and #53) who resided on the third floor and required staff assistance with meals. Residents Affected - Few Findings include: Review of Resident #59's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including unspecified dementia with behavioral disturbance, muscle weakness and expressive language disorder. Review of Resident #59's activities of daily living (ADL) care plan revealed an intervention dated 07/11/22 which reflected the resident was able to feed herself after set-up and needed maximum verbal cues at times to initiate and/or complete meals. Review of Resident #59's Minimum Data Set (MDS) 3.0 assessment, dated 08/11/22 revealed the resident exhibited a memory problem, required limited one person assist for meals and did not have significant weight loss. Review of Resident #59's physician's orders revealed an order, dated 09/02/22 for Hospice services and a regular diet, pureed texture with a thin liquid consistency. On 09/12/22 at 9:20 A.M. Resident #59's breakfast meal tray was observed sitting on her over bed tray table, pushed against the wall and away from the bed. The utensils were still wrapped and the food and fluids still had the lids on them. Resident #59 was not interviewable. On 09/12/22 at 9:41 A.M. State Tested Nursing Assistant (STNA) #900 was observed to enter Resident #59's room and picked up the breakfast meal tray located on the over bed table. A subsequent interview on 09/12/22 at 9:42 A.M. with STNA #900 revealed residents who required assistance with meals would normally not receive a tray until the staff were ready to assist them with the meal. The STNA revealed she would heat up Resident #59's breakfast tray because she had not had time previously to this to assist the resident with her breakfast. The STNA was unaware of how long the tray had been sitting on the over bed table and indicated she was not aware of any other staff assisting Resident #59 with the breakfast meal until this point. STNA #900 revealed Resident #59 had a decline in condition and currently required more assistance with meals. On 09/12/22 at 9:50 A.M. interview with STNA #942 revealed he had delivered Resident #59's breakfast meal tray at approximately 8:30 A.M. and set it on the over bed table for another staff member to assist the resident with the breakfast meal. STNA #942 revealed he was usually the only staff member who delivered the meal trays and he had to deliver them all. On 09/12/22 at 9:57 A.M. interview with Dining Services Supervisor #905 revealed the meal trays left the third floor servery (the floor where Resident #59 resided) at approximately 8:20 A.M. and once they were placed in the hall, the STNA staff were required to deliver the meal trays. On 09/12/22 at 11:15 A.M. during an interview with Assistant Administrator (AA) #863, the AA was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365836 If continuation sheet Page 10 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365836 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village at St Edward Nrsg Care 3131 Smith Rd Fairlawn, OH 44333 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 made aware Resident #59's breakfast meal tray was delivered and remained on her over bed table from the time it was delivered at approximately 8:30 A.M. until 9:41 A.M. when STNA #900 entered the room. During the interview, Assistant Administrator #863 confirmed there were eight residents, Resident #16, #26, #27, #29, #31, #47, #53 and #59 who resided on the third floor who required assistance with meals. Residents Affected - Few This deficiency substantiates Complaint Number OH00135272. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365836 If continuation sheet Page 11 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365836 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village at St Edward Nrsg Care 3131 Smith Rd Fairlawn, OH 44333 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, medical record review and interview the facility failed to ensure fall interventions were implemented as plan to decrease the risk of falls/injury for Resident #20 and Resident #274. This affected two residents (#20 and #274) of three residents reviewed for accidents. Findings include: 1. Review of Resident #20's medical record revealed diagnoses including dementia, chronic pain, epilepsy and chronic pain. The resident's current plan of care revealed Resident #20 was at risk for falls related to gait and balance problems, impaired mobility, potential chronic pain, impaired cognition, poor to no safety awareness, impulsiveness, believing she could walk by herself at times, self-transfer attempts, removing non-skid footwear/shoes at times and history of falls. An intervention noted was to place a Dycem (non-skid surface) above and below the pressure reducing cushion in the resident's wheelchair. A fall risk assessment, dated 08/18/22 revealed Resident #20 was at high risk for falls with risk factors including history of falls, co-morbidities, impaired gait and over-estimating or forgetting limits. A significant change Minimum Data Set (MDS) 3.0 assessment, dated 08/31/22 indicated Resident #20 was able to make herself understood and was able to understand others. The assessment revealed Resident #20 had short and long term memory problems, was dependent on staff for transfers and did not walk. On 09/13/22 at 2:49 P.M. Resident #20's wheelchair was observed with no Dycem on top of the cushion. On 09/13/22 at 2:56 P.M. interview with State Tested Nursing Assistant (STNA) #826 verified there was no Dycem in the wheelchair, stating the cushion in the chair was velcroed on the bottom so it did not slide. STNA #826 revealed she believed the Dycem was not needed on top of the cushion because Resident #20 no longer slid in the chair. On 09/13/22 at 3:26 P.M. interview with Licensed Practical Nurse (LPN) #937 revealed the Dycem was supposed to be placed on top of the resident's wheelchair cushion. On 09/13/22 at 4:00 P.M. interview with LPN #937 revealed she placed a Dycem on top of Resident #20's wheelchair cushion because there had been none there. 2. Review of Resident #274's medical record revealed diagnoses including Alzheimer's disease, anxiety disorder, presence of left artificial hip joint and peri-prosthetic fracture around the internal prosthetic left hip joint. A care plan initiated 07/14/22 revealed Resident #274 was at risk for falls related to deconditioning, impaired cognition, impaired mobility, incontinence, poor to no safety awareness, and attempts to transfer/ambulate unassisted at times. An intervention included to place Dycem above and below the pressure reducing cushion in the wheelchair. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365836 If continuation sheet Page 12 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365836 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village at St Edward Nrsg Care 3131 Smith Rd Fairlawn, OH 44333 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 0689 Level of Harm - Minimal harm or potential for actual harm A fall risk assessment, dated 08/29/22 revealed Resident #274 was at high risk for falling. Risk factors included history of falls, co-morbidities, impaired gait and overestimating or forgetting limits. A Medicare five day MDS 3.0 assessment, dated 09/02/22 revealed Resident #274 rarely/never understood others, had hallucinations, required extensive (staff) assistance for transfers and did not walk. Residents Affected - Few On 09/13/22 at 11:29 A.M. Resident #274 was observed in the hallway attempting to raise herself out of a specialized (Broda) chair. At 2:44 P.M. Resident #274 was observed sitting in the television lounge area occasionally leaning forward in the Broda chair. On 09/14/22 9:58 A.M. Resident #274 was observed sitting in a Broda chair in the hall by the nurse's station occasionally leaning forward then sitting back. At 11:43 A.M. STNA #826 and STNA #920 were observed transferring Resident #274 from the Broda chair to bed with a mechanical lift. There was no Dycem observed between Resident #274 and the cushion or between the cushion and the chair. At 11:57 A.M. interview with STNA #826 verified there was no Dycem on top of or below the cushion in the Broda chair. On 09/14/22 at 12:49 P.M. interview with LPN #937 revealed although Resident #274 now used a Broda chair instead of a wheelchair there should still be a Dycem above and below the cushion. LPN #937 revealed she had just reviewed that information (use of Dycem) with staff the afternoon of 09/13/22 and morning of 09/14/22. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365836 If continuation sheet Page 13 of 13