Health inspection·December 5, 2023

F 0689 • Level of Harm - Immediate jeopardy to resident health or safety On 11/12/23, the DON (Director of Nursing) and LNHA (Administrator) investigated the incident as a possible elopement. By 11:00 P.M., after interviewing staff and collecting staff statements, the facility concluded Resident #84 had a Brief Interview for Mental Status (BIMS) of 14 out of 15, was alert and oriented times four, had a low risk elopement assessment, had displayed the desire to go home, initiated a call to family requesting to be picked up, when no one was willing to pick her up, resident decided to leave the facility and walk to her daughter's place of work. Residents Affected - Few • On 11/12/23, by 11:00 P.M., the DON and Unit Managers ensured all residents had current elopement assessments completed. Residents who were assessed to be high risk and had displayed exit seeking behavior, had wander guards in place and care plans had been updated. • On 11/12/23, by 11:00 P.M., the DON ensured all wander guards were in place and functioning for the residents that were assessed, care planned, and had orders. There were six residents that were assessed and had orders for wander guards. No issues were identified. • On 11/12/23, by 11:00 P.M. an elopement binder at the front desk was updated by the DON with residents assessed to be an elopement risk. There were six residents assessed to be high risk. • On 11/12/23, by 11:00 P.M. DON checked all doors to ensure they were functioning properly. All doors were functioning, and alarming if pressed to exit with a 15 second egress. The front door was open during the hours a receptionist was present and then locked like the other doors when receptionist leaves. If a door was seen to have an issue, the alarm company was called immediately to be addressed. Wind caused issues on 11/27/23 for two doors and Maintenance Director #264 called the alarm company. The alarm company came to the facility on [DATE] and replaced the transformers for mag locks due to high winds. • On 11/12/23, by 11:00 P.M. all facility staff were educated by DON on the elopement policy and AMA policy. Policies included education for investigating, exit seeking behavior, safety, and reporting to LNHA and DON so corrective measures and interventions could be put into place. Staff from every department were educated including four RN's, seven LPNs, and twenty STNAs. Staff that were not present were called, texted, and educated by the evening of 11/12/23. • On 11/12/23, by 11:00 P.M. nursing schedules were checked and verified by DON to ensure sufficient staffing was present for shift 7:00 A.M. to 7:30 P.M. There were four LPN's and six STNA's. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365845 If continuation sheet Page 2 of 19 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 365845 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rae Ann Suburban 29505 Detroit Rd Westlake, OH 44145 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 - Immediate jeopardy to resident health or safety On 11/12/23, by 11:00 P.M. the three facility receptionists were educated by LNHA (the Administrator) on notifying staff if they were on break so another staff member could cover the front desk. • Residents Affected - Few On 11/12/23, LNHA began auditing doors, elopement assessments to ensure completion and interventions were in place, nursing documentation for exit seeking behavior, three times a week for three weeks to ensure continued compliance. All results would be reviewed with the QAPI committee to ensure continued compliance. Although the Immediate Jeopardy was removed on 11/13/23, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was not in substantial compliance at the time of the current survey for the specific regulatory requirement(s), as referenced by the specific tag. Findings include: Review of Resident #84's ED (Emergency Department) Provider Note and History and Physical Exam dated 09/21/23 included Resident #84 was transported to the hospital Emergency Department via ambulance and was accompanied by her niece and daughter. Resident #84's niece stated Resident #84 was unable to care for herself, her house was unsanitary, unkept and she was being evicted. Resident #84's niece and daughter stated Resident #84 was not eating or drinking and was incontinent. Resident #84's niece and daughter requested a competency evaluation completed so Resident #84 could be placed in an assisted living or skilled nursing facility. Resident #84's niece and daughter did not feel Resident #84 could live safely on her own and were concerned Resident #84 was going to get hurt. Resident #84 was alert, agitated and her judgement was inappropriate (her main concern was care for her dogs when she was not taking care of herself). As Resident #84 was at risk for being discharged home and displayed failure to thrive and inability to care for self, the plan would be to admit Resident #84 to the hospital for further evaluations. Resident #84 had a history of delirium and neuro cognitive disorder (dementia). Review of Resident #84's After Visit Summary dated 09/21/23 through 09/26/23 included Resident #84 was seen in the Emergency Department for concerns of not managing home life. Resident #84 was admitted to the hospital due to failure to thrive. After admission to the hospital Resident #84 was evaluated by a geriatric team who felt Resident #84 was not able to make home-going decisions. Due to this, Adult Protective Services (APS) was involved and felt Resident #84 should be discharged to an extended care facility. Problems and diagnoses included failure to thrive in adult, major neurocognitive disorder (HCC), generalized weakness and encounter for assessment of decision-making capacity. Resident #84 had no resolved hospital problems. A new medication, Seroquel (Quetiapine) 12.5 milligrams daily at bedtime for three doses, and then 0.5 tablet by mouth every eight hours as needed for agitation up to three days was ordered. Review of Resident #84's Mental Capacity Note dated 09/25/23 stated Resident #84 had a primary diagnosis of delirium and psychoses and lacked sufficient decision-making ability to make informed decisions to leave the hospital. The note indicated Resident #84 should not be allowed to leave the hospital against medical advice. Resident #84 should be stabilized medically until a clinical point was reached where she could be reevaluated. An attempt would be made to identify an appropriate surrogate (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365845 If continuation sheet Page 3 of 19 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 365845 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rae Ann Suburban 29505 Detroit Rd Westlake, OH 44145 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 decision maker to be an active participant in the Resident #84's care. Level of Harm - Immediate jeopardy to resident health or safety Review of Resident #84's closed medical record revealed the resident was admitted to the skilled nursing facility on [DATE] with diagnoses including unspecified dementia, unspecified severity, with other behavioral disturbances, major depressive disorder, unsteadiness on feet, and adult failure to thrive. Resident #84 was discharged from the facility on 11/12/23. Residents Affected - Few Review of Resident #84's admission progress note dated 09/26/23 at 3:56 P.M. included Resident #84 was alert and oriented times two (person and place), was confused at times and made poor decisions. Resident #84 was anxious and had behaviors. Resident #84 was in the hospital for failure to thrive, lived by self and had dementia. APS was involved. Resident #84 was incontinent at times. Review of Resident #84's Fall Risk Evaluation dated 09/26/23 revealed Resident #84 was at high risk for falls. Resident #84 received antidepressants, antihypertensives, hypoglycemics, laxatives and narcotic analgesics. Resident #84 ambulated with staff assistance with no stability, gait impairment. Resident #84's elimination status was elimination with assistance. Review of Resident #84's progress notes dated 09/27/23 at 11:27 P.M. included Resident #84 was having erratic behavior, was unable to be redirected, was touching another resident's catheter, going in other resident rooms and was combative with staff. Review of Resident #84's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #84 was cognitively intact and used a walker. Resident #84 required partial to moderate assistance with personal hygiene and required supervision or touching assistance to walk ten feet in a room, corridor, or similar space. Resident #84 had non-Alzheimer's dementia. Review of Resident #84's Family, Resident Communication Note dated 10/05/23 at 2:46 P.M. included a family conference was held with the DON, Director of Rehab (DOR), the Administrator, Resident #84 and Resident #84's niece, Daughter #291 and son in-law. Discussed Mental Capacity Note completed while she was in the hospital by Certified Nurse Practitioner (CNP) #290. APS was involved when Resident #84 resided in the community. Daughter #291 was the resident's power of attorney (POA) for health and was working to get a guardianship in place. Resident #84 was notified by her family she would be staying at the facility, her house was foreclosed, and her animals were placed in foster homes. Resident #84 stated her pets were the most important thing to her. Review of Resident #84's progress note dated 10/05/23 at 4:44 P.M. included Resident #84 continued to be very agitated and difficult to redirect. Resident #84 stated she was leaving the facility. Discussed wander guard with Daughter #291 and other family members and all were in agreement with a wander guard being placed. Review of Resident #84's Elopement Evaluation dated 10/05/23 included Resident #84 had a Neurocognitive Disorder with Lewy Bodies (the Administrator stated Resident #84 had a Neurocognitive Disorder, but her diagnoses did not specify Lewy Bodies, and this diagnosis was an error), was alert, had poor safety, environment awareness and had one elopement in the past three months. A wander guard was placed to Resident #84's right ankle. Daughter #291 was one hundred percent agreeable to having Resident #84's wander guard placed. Resident #84 was non-compliant consistently and would be at a higher risk of removing the wander guard. Review of Resident #84's physician orders dated 10/05/23 revealed secure band to right ankle, check (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365845 If continuation sheet Page 4 of 19 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 365845 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rae Ann Suburban 29505 Detroit Rd Westlake, OH 44145 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 - Immediate jeopardy to resident health or safety Residents Affected - Few placement, skin, every shift for elopement risk related to Neurocognitive Disorder with Lewy Bodies (Resident #84 had a Neurocognitive Disorder but it did not specify Lewy Bodies). Further review revealed to discontinue physical therapy (PT) services. Resident #84 required supervision for transfers and ambulation with wheeled walker. Review of Resident #84's Physical Therapy Discharge Summary signed 10/05/23 at 12:00 P.M. included discharge recommendations were for 24-hour care, assistive device for safe functional mobility and functional mobility program (FMP), restorative nurse program (RNP). RNP, FMP to facilitate patient maintaining current level of performance and to prevent decline, development and instruction in the following RNPs was completed with the interdisciplinary team (IDT), ambulation and active range of motion (ROM). Review of Resident #84's progress notes dated 10/09/23 included Resident #84 had constant exit seeking behaviors but was easily redirected. Review of Resident #84's progress notes dated 10/13/23 at 1:03 P.M. included a call was placed to Daughter #291's with an update on Resident #84's wander guard and Resident #84's noncompliance. Daughter #291 agreed to leave Resident #84's wander guard off. Review of Resident #84's care plan dated 10/13/23 included Resident #84 exhibited behaviors related to dementia. Resident #84 would go into other residents' rooms and touch their belongings, she would touch other resident's catheter, and was combative with care at times. Resident #84 would exhibit behaviors one time a week. Interventions included staff to monitor Resident #84 closely, for example, sitting outside her room for a while. There were no further interventions documented after Resident #84's wander guard was discontinued on 10/13/23. There was no care plan for a wander guard or risk of elopement. Review of Resident #84's Social Services progress note dated 10/23/23 at 4:02 P.M. included Resident #84 was anxious, confused and upset. Resident #84 was throwing her belongings away in the garbage and stated she was going home. Social Services Designee (SSD) reminded Resident #84 her home was foreclosed, and the APS worker was in the process of establishing a guardian for her. Resident #84 was told a doctor completed an expert evaluation during her hospitalization prior to her admittance to the facility. Review of Resident #84's progress notes dated 10/23/23 at 10:18 P.M. included Resident #84 had balance problems and an unsteady gait. Resident #84 appeared upset after finding out her house was in foreclosure per Daughter #291. Review of Resident #84's Long Term Care Encounter note dated 11/01/23 written by Psychiatric Certified Nurse Practitioner (CNP) #296 included Resident #84 was seen in her room, resting in bed and watching television. Resident #84 was alert and oriented to self, location, time and date of birth . Resident #84 stated she was waiting to die, was stuck in the facility and did not have her house or stuff. Resident #84 voiced anger towards Daughter #291 because she gave away her cat and two dogs and sent her to the facility to die. Resident #84 endorsed depression and anxiety and stated she did not choose or prepare to be here. No delusions were noted. Staff reported Resident #84 was stable. Resident #84 refused to take showers, have laundry done, declined medication adjustments and would be referred for counseling. Resident #84's problems included adjustment disorder with mixed anxiety, depressed mood and unspecified dementia, unspecified severity with other behavioral disturbances. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365845 If continuation sheet Page 5 of 19 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 365845 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rae Ann Suburban 29505 Detroit Rd Westlake, OH 44145 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 - Immediate jeopardy to resident health or safety Review of Resident #84's Skilled Nursing Evaluation dated 11/07/23 included Resident #84 Resident #84 was alert and oriented to person, place, time, and situation and did not have neuromuscular disorder. Review of Resident #84's progress notes dated 11/12/23 from 12:00 P.M. through 5:00 P.M. revealed there was no documentation Resident #84 was agitated, upset, attempted to hit a nurse with her cane, and stated she wanted to go home. There was no evidence interventions were implemented. Residents Affected - Few Review of Resident #84's progress notes dated 11/12/23 at 6:56 P.M. revealed prior to Registered Nurse (RN) #292's lunch break Resident #84 was sitting on the side of the bed in her room. RN #292 informed Nurse #293 she was going to take a meal break. When she returned from lunch RN #292 was told Resident #84 tried to hit Nurse #293 with a cane. RN #292 went to Resident #84's room and was unable to locate her. When RN #292 returned to the nurse's station she was told by the Receptionist (Receptionist #272) that Resident #84's family member (Daughter #291) was on the phone and wanted to speak with her. Daughter #291 told RN #292 that Resident #84 was with her and had a wheelchair and her suitcase and she would call RN #292 back. RN #292 informed management and also notified CNP #294. A follow up call placed to Daughter #291 revealed Resident #84 was transported to the local hospital. Management was notified. Review of a witness statement dated 11/12/23 and written by Licensed Practical Nurse (LPN) #293 revealed Resident #84 was angry after lunch and stated she hated her food, and the barbecue sauce was nasty. Resident #84 became verbally abusive and combative with the staff and attempted to hit a staff member with a cane. Resident #84 stated she hated the facility, and her daughter (Daughter #291) would come and get her. Resident #84 was redirected and went calmly into her room. The statement indicated this was the last time LPN #293 saw Resident #84; however, the time LPN #293 last saw Resident #84 was not documented. Review of a witness statement dated 11/12/23 around 5:00 P.M. and written by State Tested Nursing Assistant (STNA) #229 revealed she saw Resident #84 walk into the sitting area and Resident #84 was highly upset. Resident #84 called her daughter and asked her daughter to pick her up, and State Tested Nursing Assistant (STNA) #229 assumed Resident #84's daughter said no because Resident #84 cursed the daughter out and afterwards she hung up the phone and walked out of the sitting area. STNA #229 stated she did not see Resident #84 go out the door. There was no documentation STNA #229 told the nurse assigned to Resident #84 what she overheard and observed. Review of Resident #84's undated Telephone Witness Statement with a time documented as 4:00 P.M. to 4:30 P.M. revealed STNA #220 last saw Resident #84 in the common area on the nursing unit she resided on. STNA #220 stated she saw a nurse (unidentified) talk to Resident #84 and then Resident #84 walked back to her room. Review of Resident #84's Telephone Witness Statement undated revealed STNA #297 last saw Resident #84 around 3:30 P.M. to 3:40 P.M. and she was in her room changing clothes. Review of a witness statement dated 11/12/23 revealed Receptionist #272 stated Resident #84 asked to use the phone, Receptionist #272 took her to the library and Resident #84 called Daughter #291. After Resident #84 called her daughter, Daughter #291 called the facility and told Receptionist #272 that Resident #84 was very irritated and threatening to leave the facility. Receptionist #272 stated Resident #84's nurse was on break and she immediately found LPN #293 who was covering for RN #292 while she was on break and told her Daughter #291 called the facility and was on hold and wanted to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365845 If continuation sheet Page 6 of 19 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 365845 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rae Ann Suburban 29505 Detroit Rd Westlake, OH 44145 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 - Immediate jeopardy to resident health or safety Residents Affected - Few speak to Resident #84's nurse. Receptionist #272 stated LPN #293 told her she would handle it. Receptionist #272 stated at around 5:00 P.M. Daughter #291 called to say Resident #84 was at her (the daughter's) workplace. Receptionist #272 stated she put Daughter #291 on hold and ran to find Resident #84's nurse (RN #292) so she could take the call. Receptionist #272 stated she did not see Resident #84 leave the facility. Review of a Call for Service Report dated 11/12/23 at 5:19 P.M. from the local police department included police officers were dispatched at 5:22 P.M. and arrived at 5:31 P.M. at a local business located in a shopping plaza. The Complainant (Niece #295) reported Resident #84 left the (nursing) facility on foot, unaccompanied and Niece #295 had no idea how Resident #84 was able to leave there safely. Niece #295 stated Resident #84 had Alzheimer's Disease and was unable to make decisions for herself. Niece #295's cousin (Resident #84's Daughter #291) worked at a local business at the shopping plaza and called Niece #295 to report Resident #84 showed up at her workplace and she was in the back room of the store. Niece #295 was en route to the store (Daughter #291's workplace) to escort Resident #84 back to the facility but was afraid Resident #84 would become defiant, combative. Resident #84 agreed to be transported to the local hospital by the police. Review of Resident #84's ED Provider Note dated 11/12/23 at 6:44 P.M. included Resident #84 walked out of the facility and walked to a local shopping plaza. Resident #84 presented to the ED for evaluation of behavior concern. Resident #84 stated she was not happy at the facility and convinced someone to open the door and let her out of the locked unit (locked door) after she told them she was trying to take her bags to the car. Resident #84 packed her bags and brought them with her. Resident #84 stated she walked approximately one mile to find her daughter and her daughter called the police to bring her to the Emergency Department. Resident #84 was escorted by police to the Emergency room. Resident #84 complained of mild nausea and stated she was not happy with the food at the facility, asked for an antacid, was not given the antacid, became upset and decided to leave the facility. Daughter #291 arrived to the bedside and stated during Resident #84's previous admission there were concerns that Resident #84 was not able to make her own medical decisions. Daughter #291 was Resident 84's Medical Power of Attorney and was working on a guardianship. A psychiatric evaluation was requested. Resident #84 complained of nausea, back pain after walking out of the facility. Resident #84 was cooperative but intermittently agitated, and a sitter was in place throughout Resident #84's ED stay. Resident #84 had a urinary tract infection, delirium and agitation. Resident #84 was admitted to the hospital. Review of Resident #84's hospital History and Physical dated 11/12/23 at 11:08 P.M. included Resident #84 had agitation and walked out of the facility and was transported to the hospital by the police. Resident #84 had a past medical history including Alzheimer's Disease and behavior agitation and paranoia, MDD (Major Depressive Disorder), anxiety and mood disorder. Resident #84 was brought to the hospital by police after she walked out of the facility to a shopping plaza. Resident #84 was agitated and had paranoia when Daughter #291 found her at the shopping plaza. Resident #84 refused to return to the facility and was brought to the hospital by police for evaluation. Per daughter Resident #84 had cognitive decline which became worse over time to the point where she ignored to care for herself at home with mood changing easily and Resident #84 would become agitated and had paranoia. Resident #84 was deemed not competent to make her own decisions and was sent to the facility. Since her admission to the facility Resident #84 had more mood changes, depression and was easily agitated and had paranoia. Today Resident #84 attempted to walk out of the facility, finally succeeded and walked to a shopping plaza. Police were called due to Resident #84 was agitated and uncooperative. In the ED Resident #84 was agitated, uncooperative and when an exam was attempted Resident #84 threatened to hit the ED provider and staff because they did not give her what she requested, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365845 If continuation sheet Page 7 of 19 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 365845 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rae Ann Suburban 29505 Detroit Rd Westlake, OH 44145 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 - Immediate jeopardy to resident health or safety Residents Affected - Few and she waited a long time. Resident #84 had mild confusion, agitation and paranoia. Resident #84's principal problems included moderate late onset Alzheimer's dementia with agitation, untreated depression, anxiety and mood disorder and acute infection. Interview on 11/21/23 at 5:58 P.M. with Daughter #291 revealed Resident #84 wore a wander guard while she resided in the facility because she was trying to elope, but she kept removing the wander guard, so the facility discontinued it. Daughter #291 stated she was concerned Resident #84 might leave the facility. Daughter #291 stated on 11/12/23 Resident #84 called her and said she was not feeling well, and she was threatening to leave the facility. Daughter #291 stated she called the facility and told the staff to send Resident #84 to the hospital if she was not feeling well and she also told the staff Resident #84 was threatening to leave the facility. Daughter #291 stated she talked to the Receptionist after Resident #84 left the facility and was told Resident #84 was agitated and waving her cane around before she left. Daughter #291 indicated Resident #84 tried to get out the door used by ambulance staff, was unsuccessful then put her bags on a wheelchair and walked out the front door. Daughter #291 stated Resident #84 walked about a half mile and crossed a busy intersection to get to Daughter #291's workplace. Daughter #291 stated the facility staff did not know Resident #84 was gone from the facility and were not able to pick her up and take her back to the facility. Daughter #291 indicated Resident #84 was agitated and was taken by the police to the local hospital. Daughter #291 stated while Resident #84 was in the hospital from [DATE] through 09/26/23 she had a Statement of Expert Evaluation, and it was determined she could not make her own decisions regarding living arrangements. Daughter #291 indicated APS was involved in Resident #84's care and her caseworker was working on a state guardianship. Daughter #291 stated the facility indicated they did not have the Mental Capacity Note initially during the conference and Resident #84's APS caseworker was contacted. Daughter #291 stated Resident #84's caseworker was going to email the Mental Capacity Note, however, before it was mailed, someone in the facility found it, brought it to the area where Resident #84's care conference was conducted, and the APS caseworker did not have to email the Mental Capacity Note to the Administrator. Daughter #291 stated she did not know the name of the staff member who found the Mental Capacity Note but felt the facility was aware or should have been aware of the content of the note during the resident's stay. Observation on 11/22/23 at 12:30 P.M. of the road and intersection Resident #84 crossed to walk to Daughter #291's workplace revealed the road leading to the intersection was a very busy road with many cars traveling in both directions on the road. Observation of the intersection Resident #84 traveled on foot revealed Resident #84 walked across six lanes of traffic in a high traffic area. Observation of the shopping plaza Resident #84 walked across to reach her daughter's workplace revealed the shopping plaza was large, with a large parking lot and many cars entering and exiting the shopping area. Interview on 11/22/23 at 12:48 P.M. with CNP #294 revealed CNP #294 took care of Resident #84 when she resided in the facility and was told by the facility Resident #84 left against medical advice (AMA), but he did not remember the date it happened. CNP #294 stated Resident #84 was confused, yelled out a lot and whenever he visited her and was often in her bed in her room yelling out. CNP #294 stated Resident #84 had behaviors. CNP #294 stated Resident #84 had cognitive deficits, it was not a good idea for Resident #84 to be outside by herself and it was unsafe for her to be walking by a main road. CNP #294 stated he was not aware Resident #84 had a wander guard ordered, thought she was going to stay in the facility long term, and did not know anything about a guardian for Resident #84. CNP #294 stated he did not know anything about Resident #84's Mental Capacity Note and psychiatry services would do the Mental Capacity Note. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365845 If continuation sheet Page 8 of 19 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 365845 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rae Ann Suburban 29505 Detroit Rd Westlake, OH 44145 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 - Immediate jeopardy to resident health or safety Residents Affected - Few Interview on 11/22/23 at 1:01 P.M. with Registered Nurse (RN) #292 revealed she took care of Resident #84 on 11/12/23 but she was on lunch break when the incident occurred. RN #292 stated Resident #84 was upset about the barbecue sauce served with her lunch meal and hours later she was still upset about it and was still nasty. RN #292 stated Resident #84 kept saying the facility should get better barbecue sauce and RN #292 tried to redirect her. Resident #84 told her she was going back to her room. RN #292 indicated she took her lunch break around 4:30 P.M., checked on Resident #84 before she took her break and Resident #84 was sitting on the side of her bed. Resident #84 was still upset and asked RN #292 what do you want. RN #292 stated she sat in the parking lot and ate her sandwich, came back around 4:50 P.M., and did not see Resident #84 outside the facility. RN #292 revealed while she was on break Resident #84 tried to hit another nurse with her cane. RN #292 stated she went to check on Resident #84 and Resident #84 was not in her room and her suitcases were gone. RN #292 stated when she walked out of Resident #84's room Receptionist #272 told her Daughter #291 was on the phone and wanted to speak with Resident #84's nurse. RN #292 indicated Daughter #291 told her Resident #84 was at her workplace and wanted Resident #84 picked up. RN #292 told Daughter #291 it was a liability issue, and she could not pick Resident #84 up in her car. RN #292 asked Daughter #291 to bring Resident #84 back to the facility, because her workplace was in a shopping plaza not far from the facility. Daughter #291 told RN #292 she would call her back. RN #292 stated she notified CNP #294 and told him Resident #84 left the facility. RN #292 stated she called Daughter #291 because she had not heard back from her and was told Resident #84 was transported to the local hospital. RN #292 stated STNA #229 heard Resident #84 call her daughter to come to the facility and pick her up and Resident #84 was upset and slammed the phone down after the call. RN #292 indicated STNA #229 did not tell her this happened until after Resident #84 left the facility, and she did not know if STNA #229 told LPN #293 about it. RN #292 revealed LPN #293 told her Resident #84 tried to hit her with a cane while she was on break. RN #292 stated Resident #84 should have been wearing a wander guard even though she was alert, and she had a wander guard on while she resided in the facility. RN #292 did not know why Resident #84's wander guard was discontinued. Interview on 11/22/23 at 1:23 P.M. with State Tested Nursing Assistant (STNA) #298 revealed she was working on 11/12/23 when Resident #84 left the facility, but she was not assigned to the nursing unit Resident #84 resided on and did not see her leave the facility. STNA #298 stated sometimes Resident #84 talked about leaving the facility. STNA #298 stated Resident #84 was supposed to use a walker and she did not think it was safe for Resident #84 to be outside by herself walking around. STNA #298 stated Resident #84 was confused at times, and she thought she had dementia. Interview on 11/22/23 at 1:46 P.M. with the DON revealed Resident #84 was admitted to the facility and did not want to be in the facility. The DON stated Resident[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365845 If continuation sheet Page 9 of 19 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 365845 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rae Ann Suburban 29505 Detroit Rd Westlake, OH 44145 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, review of facility policy, review of Centers for Disease Control and Prevention guidance, and review of the facility COVID-19 Line List, the facility failed to maintain and implement an effective infection prevention and control program to prevent the development and transmission of COVID-19, including measures to ensure the COVID-19 Line List was completed accurately, proper Personal Protective Equipment (PPE) was worn by staff when entering COVID-19 positive rooms, accurate COVID-19 isolation orders were in place for all COVID-19 positive residents, and responsible parties were notified when their roommates tested positive for COVID-19. This had the potential to affect all 83 residents residing in the facility. The census was 83. Residents Affected - Many Findings include: Review of the facility COVID-19 Line List from 11/16/23 through 11/30/23 revealed 30 residents (Resident's #2, #6, #10, #13, #15, #16, #18, #24, #25, #33, #34, #35, #37, #38, #40, #43, #44, #47, #51, #54, #60, #63, #64, #66, #68, #70, #71, #74, #81, #82) tested positive for COVID-19. 1a. Review of Resident #35's medical record revealed an admission date of 07/08/23 and diagnoses included paranoid schizophrenia, major depressive disorder and hypertension. Review of Resident #35's Quarterly Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #35 was cognitively intact. Review of the facility COVID-19 Line List dated 11/27/23 revealed Resident #35 tested positive for COVID-19. Review of Resident #35's physician orders dated 11/27/23 at 3:00 P.M. revealed Resident #35 remained in dual room isolation for COVID-19. Resident #35 would receive all treatment, therapies, meals, activities and medications in room three times daily, every shift for COVID-19 precautions for ten days. Review of Resident #35's progress notes revealed a late entry dated 11/30/23 stated on 11/27/23 at 3:26 P.M. Resident #35 was complaining of a headache and chills and requested a COVID-19 test and the results were positive. Isolation and PPE (Personal Protective Equipment) were in place. Review of Resident #35's medical record revealed she resided in room [ROOM NUMBER] bed one since admission on [DATE]. b. Review of Resident #79's medical record revealed an admission date of 06/14/23 and diagnoses included unspecified fracture of shaft of humerus, right arm, subsequent encounter for fracture with routine healing, congestive heart failure, and type two diabetes mellitus with diabetic neuropathy. Review of Resident #79's Quarterly MDS 3.0 assessment dated [DATE] revealed Resident #79's Brief Interview for Mental Status was not assessed. Review of Resident #79's physician orders dated 11/21/23 revealed to monitor for signs and symptoms of COVID-19 every shift and as necessary, every shift for monitoring and as needed for monitoring. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365845 If continuation sheet Page 10 of 19 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 365845 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rae Ann Suburban 29505 Detroit Rd Westlake, OH 44145 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Review of Resident #79's progress notes dated 11/14/23 through 11/29/23 did not reveal her roommate (Resident #35) tested positive for COVID-19 and there was no documentation Resident #79's Responsible Party was notified Resident #79 was residing in a room with Resident #35 who tested positive on 11/27/23 for COVID-19. Per the Director of Nursing Resident #79 tested negative on 11/21/23 for COVID-19. Review of Resident #79's medical record revealed she resided in room [ROOM NUMBER] bed two since her admission on [DATE]. Observation on 11/30/23 at 8:41 A.M. of Resident #35 and #79's room revealed PPE supplies hanging on the door and droplet precautions and contact precautions signs hanging on the door. The droplet precaution sign stated to make sure eyes, nose, and mouth were fully covered before room entry. The PPE supplies on the door did not included goggles or face shields. Observation on 11/30/23 at 8:41 A.M. of Licensed Practical Nurse (LPN) #300 revealed she entered Resident #35 and #79's room with a meal tray. LPN #300 did not don an eye shield or goggles and did not wear glasses, and LPN #300 did not cover her N95 respirator with a surgical mask before entering the room. After exiting Resident #35 and #79's room LPN #300 did not discard her N95 respirator and walked to the meal cart to continue assisting with passing meal trays for the residents. After questioned by the surveyor and stopped before she passed additional meal trays LPN #300 confirmed she did not don goggles or a face shield before entering Resident #35 and #79's room and she should have. LPN #300 confirmed she did not cover her N95 with a surgical mask before entering the room and did not discard the N95 respirator and don a new N95 after she left Resident #35 and #79's room. LPN #300 donned a new N95 before passing more resident meal trays. Interview on 12/04/23 at 1:52 P.M. of Daughter #302 revealed she was Resident #79's Responsible Party. Daughter #302 stated she was aware the facility had residents who tested positive for COVID-19 but she did not know Resident #79's roommate (Resident #35) was positive for COVID-19 on 11/27/23. Daughter #302 stated she was not contacted and did not receive a phone call informing her Resident #79's roommate was positive for COVID-19. 2a. Review of Resident #68's medical record revealed an admission date of 05/25/23 and diagnoses included disc degeneration lumbosacral region, delusional disorders and generalized anxiety disorder. Review of Resident #68's Quarterly MDS 3.0 assessment dated [DATE] revealed Resident #68's Brief Interview for Mental Status was unable to be assessed. Review of the facility Line List for COVID-19 revealed Resident #68 tested positive for COVID-19 on 11/22/23. Review of Resident #68's physician orders dated 11/22/23 revealed Resident #68 remained in single room isolation (Resident #68 had a roommate) for COVID-19. Resident #68 would receive all treatment, therapies, meals, activities and medications in room three times daily, every shift for precautions. Review of Resident #68's progress notes dated 11/21/23 through 11/29/23 revealed on 11/22/23 Resident #68 tested positive for COVID-19 with mild signs and symptoms. The notes stated monitoring to continue and isolation precautions in place. Review of Resident #68's medical record revealed she resided in room [ROOM NUMBER] bed two since (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365845 If continuation sheet Page 11 of 19 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 365845 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rae Ann Suburban 29505 Detroit Rd Westlake, OH 44145 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 her admission on [DATE]. Level of Harm - Minimal harm or potential for actual harm b. Review of Resident #64's medical record revealed an admission date of 06/08/23 and diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, schizoaffective disorder, bipolar type, and type two diabetes mellitus. Residents Affected - Many Review of Resident #64's physician orders dated 11/20/23 revealed monitor for signs and symptoms of COVID-19 every shift and as necessary, every shift for monitoring and as needed for monitoring. Review of Resident #64's progress notes from 11/04/23 through 11/29/23 did not reveal documentation Resident #64's family or Responsible Party was notified Resident #64's roommate (Resident #68) tested positive for COVID-19 on 11/22/23. Per the Director of Nursing, on 11/21/23 Resident #64 tested negative for COVID-19. Further review of Resident #64's progress notes revealed Resident #64 tested positive on 11/26/23 for COVID-19 (four days after her roommate tested positive). Review of the facility COVID-19 Line List revealed Resident #64 tested positive for COVID-19 on 11/26/23. Review of Resident #64's medical record revealed Resident #64 resided in room [ROOM NUMBER] bed one since 07/26/23. Interview on 12/04/23 at 1:45 P.M. of Son #303 revealed he was not aware Resident #64's roommate (Resident #68) tested positive for COVID-19 on 11/22/23. Son #303 stated he did not remember facility staff calling him or contacting him via text or email to let him know Resident #64's roommate was positive for COVID-19. Son #303 confirmed Resident #64 tested positive for COVID-19 on 11/26/23 (four days after her roommate, Resident #68, tested positive). 3a. Review of Resident #70's medical record revealed an admission date of 11/20/23 and diagnoses included chronic obstructive pulmonary disease, depression, and schizophrenia. Review of Resident #70's admission Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #70 had moderate cognitive impairment. Review of the facility COVID-19 Line List dated 11/25/23 revealed Resident #70 tested positive for COVID-19. Review of Resident #70's physician orders dated 11/26/23 revealed isolation maintained for ten days from 11/25/23 through 12/05/23, two times a day for isolation until 12/05/23. (The orders did not specify why Resident #70 was on isolation or the type of isolation) Review of Resident #70's progress notes dated 11/20/23 through 11/29/23 did not reveal documentation Resident #70 tested positive for COVID-19 on 11/25/23, and did not reveal any documentation related to COVID-19. b. Review of Resident #17's medical record revealed an admission date of 10/20/23 and diagnoses included chronic obstructive pulmonary disease (acute exacerbation), acute respiratory failure with hypoxia, and cerebral infarction due to unspecified occlusion or stenosis of left posterior cerebral artery. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365845 If continuation sheet Page 12 of 19 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 365845 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rae Ann Suburban 29505 Detroit Rd Westlake, OH 44145 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Review of Resident #17's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #17 had moderate cognitive impairment. Review of Resident #17's physician orders dated 11/21/23 revealed to monitor for signs and symptoms of COVID-19 every shift and as necessary, every shift for monitoring and as needed for monitoring. Residents Affected - Many Review of Resident #17's progress notes dated 11/14/23 through 11/29/23 did not reveal documentation that Resident #17's roommate (Resident #70) tested positive for COVID-19 on 11/25/23. Further review did not reveal documentation Resident #17's Responsible Party was notified his roommate tested positive for COVID-19. Per the Director of Nursing, Resident #17 tested negative for COVID-19 on 11/21/23. 4a. Review of Resident #74's medical record revealed an admission date of 12/29/14 and diagnoses included Alzheimer's Disease, major depressive disorder and hypertension. Review of Resident #74's progress notes dated 11/25/23 revealed Resident #74 had signs and symptoms of a cold and Resident #74 tested positive for COVID-19. Resident #74's son was notified. Review of the facility COVID-19 Line List revealed Resident #74 tested positive for COVID-19 on 11/25/23. Review of Resident #74's physician orders dated 11/26/23 revealed isolation maintained for ten days from 11/25/23 through 12/05/23. The orders did not specify why Resident #74 was in isolation and what type of isolation she was in. 4b. Review of Resident #61's medical record revealed an admission date of 01/06/22 and diagnoses included cerebral infarction, chronic kidney disease, and vascular dementia. Review of Resident #61's physician orders dated 11/20/23 revealed monitor for signs and symptoms of COVID-19 every shift and as necessary, every shift for monitoring and as needed for monitoring. Review of Resident #61's progress notes from 11/11/23 through 11/29/23 did not reveal documentation Resident #61's roommate tested positive for COVID-19 on 11/25/23 or Resident #61's Responsible party was notified her roommate (Resident #74) tested positive for COVID-19. Per the Director of Nursing, Resident #61 tested negative for COVID-19 on 11/21/23. 5a. Review of Resident #47's medical record revealed an admission date of 12/30/22 and diagnoses included sepsis due to escherichia coli, metabolic encephalopathy, chronic kidney disease, and type two diabetes mellitus. Review of Resident #47's Quarterly MDS 3.0 assessment dated [DATE] revealed Resident #47 was cognitively intact. Review of the facility COVID-19 Line List revealed Resident #47 tested positive for COVID-19 on 11/21/23. Review of Resident #47's physician orders dated 11/21/23 revealed Resident #47 remained in single room isolation (Resident #47 had a roommate) for COVID-19. Resident #47 would receive all treatment, therapies, meals, activities and medications in room three times daily, every shift for precautions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365845 If continuation sheet Page 13 of 19 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 365845 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rae Ann Suburban 29505 Detroit Rd Westlake, OH 44145 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Review of the facility census dated 11/21/23 revealed Resident #42 and #47 resided in the same room and were roommates. Review of Resident #47's progress notes from 11/01/23 through 11/29/23 did not reveal documentation Resident #47 tested positive for COVID-19 and did not reveal any documentation related to COVID-19. Residents Affected - Many 5b. Review of Resident #42's medical record revealed an admission date of 08/16/23 and diagnoses included heart failure, chronic obstructive pulmonary disease and type two diabetes mellitus. Review of Resident #42's physician orders dated 11/20/23 revealed monitor for signs and symptoms of COVID-19 every shift and as necessary, every shift for monitoring and as needed for monitoring. Review of Resident #42's progress notes from 11/09/23 through 11/29/23 did not reveal documentation Resident #42's roommate (Resident #47) tested positive for COVID-19 or his responsible party was notified Resident #47 tested positive for COVID-19. Per the Director of Nursing, Resident #42 tested negative for COVID-19 on 11/21/23. 6a. Review of Resident #51's medical record revealed an admission date of 08/22/23 and diagnoses included congestive heart failure, type two diabetes mellitus with unspecified complications and hypertension. Review of Resident #51's admission MDS 3.0 assessment dated [DATE] revealed Resident #51 had moderate cognitive impairment. Review of the facility COVID-19 Line List revealed Resident #51 tested positive for COVID-19 on 11/23/23. Review of Resident #51's physician orders dated 11/23/23 revealed Resident #51 remained in single room isolation (Resident #51 had a roommate) for COVID-19. Resident #51 would receive all treatment, therapies, meals, activities and medications in room three times daily, every shift for COVID-19 precautions. Review of the facility census dated 11/21/23 revealed Resident #51 and #72 resided in the same room and were roommates. Review of Resident #51's progress notes dated 11/16/23 through 11/29/23 revealed Resident #51 tested positive on 11/23/23 for COVID-19 and his brother was notified. 6b. Review of Resident #72's medical record revealed an admission date of 02/01/23 and diagnoses included acute respiratory failure with hypoxia, metabolic encephalopathy, and acute kidney failure. Review of Resident #72's physician orders dated 11/21/23 revealed monitor for signs and symptoms of COVID-19 every shift and as necessary, every shift for monitoring and as needed for monitoring. Review of Resident #72's progress notes dated 11/16/23 through 11/29/23 did not reveal documentation Resident #72's roommate (Resident #51) tested positive on 11/23/23 for COVID-19 or Resident #72's responsible party was notified Resident #72's roommate tested positive for COVID-19. Per the Director of Nursing, on 11/21/23 Resident #72 tested negative for COVID-19. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365845 If continuation sheet Page 14 of 19 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 365845 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rae Ann Suburban 29505 Detroit Rd Westlake, OH 44145 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 7a. Review of Resident #66's medical record revealed an admission date of 07/18/19 and diagnoses included hypertensive heart disease without heart failure, chronic obstructive pulmonary disease, and dementia. Review of the facility COVID-19 Line List dated 11/22/23 revealed Resident #66 tested positive for COVID-19. Review of Resident #66's physician orders dated 11/22/23 revealed Resident #66 remained in single room isolation (Resident #66 had a roommate) for COVID-19. Resident #66 would receive all treatment, therapies, meals, activities and medications in room three times daily, every shift for precautions. Review of the facility census dated 11/21/23 revealed Resident #66 and #46 resided in the same room and were roommates. Review of Resident #66's progress notes dated 11/16/23 through 11/29/23 revealed on 11/22/23 Resident #66 tested positive for COVID-19 and was placed on COVID-19 precautions. Resident #66's guardian was aware. 7b. Review of Resident #46's medical record revealed an admission date of 06/08/23 and a re-entry date 10/19/23 and diagnoses included conversion disorder with seizures or convulsions, unspecified psychosis, and schizophrenia. Review of Resident #46's admission MDS 3.0 assessment dated [DATE] revealed Resident #46 had moderate cognitive impairment. Review of Resident #46's physician orders dated 11/20/23 revealed monitor for signs and symptoms of COVID-19 every shift and as necessary, every shift for monitoring and as needed for monitoring. Review of Resident #46's progress notes dated 11/16/23 through 11/29/23 did not reveal documentation Resident #46's roommate (Resident #66) tested positive on 11/22/23 for COVID-19 or Resident #46's responsible party was notified Resident #46's roommate tested positive for COVID-19. Per the Director of Nursing, Resident #46 tested negative on 11/21/23 for COVID-19. 8. Review of the facility COVID-19 Line List dated 11/25/23 revealed Resident #60 tested positive for COVID-19. Review of the facility census dated 11/21/23 revealed Resident #10 and #60 resided in the same room and were roommates. Observation on 11/29/23 at 3:47 P.M. with the DON confirmed Resident #10 and #60 were roommates. Review of Resident #60 physician orders dated 11/26/23 revealed Resident #60 remained in single room isolation for COVID-19. Resident #60 would receive all treatment, therapies, meals, activities and medications in room three times daily, every shift until 12/05/23. Interview on 11/29/23 at 2:18 P.M. with the Director of Nursing (DON) revealed she was Infection Preventionist for the facility. The DON stated the facility had an outbreak of COVID-19 which started on 11/16/23. The DON stated all residents residing on the same hall of the nursing unit Resident #13 resided on were tested for COVID-19 and were negative. The DON stated over the next few days more (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365845 If continuation sheet Page 15 of 19 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 365845 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rae Ann Suburban 29505 Detroit Rd Westlake, OH 44145 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many residents had symptoms and tested positive for COVID-19. The DON stated on 11/21/23 all residents in the facility were tested. The DON indicated residents positive for COVID-19 were placed in isolation as best as we could, and the shared bathroom situation between two rooms had to be taken into consideration. The DON stated residents who tested positive for COVID-19 were kept in isolation for ten days, and some residents were very unhappy with the isolation and if they tested negative for COVID-19 on days five and seven they could be moved out of isolation. The DON stated the Unit Managers and floor nurses tested the residents for COVID-19. The DON stated the Unit Managers had the results of the COVID-19 testing. The DON stated after 11/21/23 residents were only tested for COVID-19 if they had symptoms or asked to be tested. Interview on 11/29/23 at 3:47 P.M. with the DON revealed if a resident tested positive for COVID-19 and had a roommate who tested negative for COVID-19 the responsible parties of the resident who tested negative were notified. The DON stated the COVID-19 positive and negative roommates were kept together and both were put on precautions. The DON stated it was too difficult to try to rearrange residents and the management team made the decision together to keep residents who were COVID-19 positive and negative together if they were roommates. The DON stated the Medical Director and his Nurse Practitioner were aware of the situation. The DON stated the facility had two sister facilities, there was talk of moving the residents but then COVID-19 seemed to stabilize so we did not move any residents to other facilities. The DON stated she was not aware CDC guidance recommended not to cohort residents who tested positive for COVID-19 with residents who tested negative. The DON confirmed Resident's #47, #57, #60 and #66 had roommates and their orders stated they were in single room isolation. The DON indicated it was a mistake and she would make sure it was corrected. Tour of the facility on 11/29/23 at 3:47 P.M. with the DON confirmed Resident's #35, #47, #51, #66, #70, #74 tested positive for COVID-19 and had roommates who tested negative (Resident's #17, #42, #46, #61, #72, #79) for COVID-19. The DON confirmed Resident #68 tested positive for COVID-19 and at the time her roommate (Resident #64) tested negative for COVID-19 and four days later Resident #64 tested positive for COVID-19. Interview on 11/29/23 at 4:02 P.M. with the Administrator revealed she spoke to Communicable Disease Investigator (CCI) #304 who was their liaison with the County Board of Health about a week ago, CCI #304 went through a series of things, and the Administrator let her know the facility did not have the capability of a separate COVID-19 unit. The Administrator said she told CCI #304 the facility cohorted residents who were COVID-19 positive and negative together, monitored signs and symptoms and tested residents who were symptomatic. The Administrator she did not remember CCI #304 saying anything about cohorting. The Administrator stated she did not discuss this with the Medical Director, but his Nurse Practitioner knew. The Administrator stated the County Health Department did not have additional recommendations. The Administrator stated responsible parties were notified if a resident who tested negative for COVID-19 had a roommate who tested positive, but she did not know if it was documented. Interview on 11/30/23 at 9:13 A.M. with CCI #304 revealed she spoke to the Administrator on 11/21/23 and completed a cluster intake form and asked a series of questions. CCI #304 stated after her conversation with the Administrator she felt like the facility was doing the best they could with what they had, however at the time she was under the impression the facility separated well residents from sick residents. CCI #304 stated she absolutely did not know residents who tested positive for COVID-19 were in the same room with residents who tested negative. CCI #304 stated she would have reported that immediately to her supervisor if she was aware. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365845 If continuation sheet Page 16 of 19 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 365845 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rae Ann Suburban 29505 Detroit Rd Westlake, OH 44145 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Observation on 11/30/23 at 10:24 A.M. with the Administrator and Field Manager (FM) #306 of the main entrance to the facility revealed there was no sign stating the facility had an outbreak of COVID-19 and to consider wearing a mask when visiting families and friends. Further observation revealed there were surgical masks available by the Receptionist desk, but there was no observation of N95 respirators or face shields. The Administrator stated the sign must have fallen down. The Administrator stated visitors were verbally instructed about the COVID-19 outbreak and offered N95's and face shields. FM #306 stated she was not verbally told about the COVID-19 outbreak or given instructions when she entered the facility. Interview on 11/30/23 at 2:23 P.M. with Epidemiologist #305 revealed the best practice would be to cohort resident positive for COVID-19 together. Epidemiologist #305 stated Resident's negative for COVID-19 should be cohorted together. Epidemiologist #305 stated best practice would be to cohort for residents who were exposed to COVID-19. Epidemiologist #305 stated as a last resort residents who tested positive for COVID-19 could be placed in a room with residents who tested negative. Epidemiologist #305 stated facilities should be 100 percent transparent to families and responsible parties if residents who were positive for COVID-19 were placed in rooms with residents negative for COVID-19. Epidemiologist #305 stated best practice for any outbreak would be to have some sort of notification to visitors stating the increased activity of whatever illness is going on in the facility at the time. Epidemiologist #305 stated best practice would be to have a sign on the facility door stating the facility had an increase in COVID-19 and to please consider wearing a mask when visiting families and friends. 9. Observation on 11/29/23 at 9:58 A.M. of Resident #81's room revealed Personal Protective Equipment (PPE) supplies were hanging on the door, and there was a sign for droplet precautions and contact precautions hanging on the door. The droplet precaution sign stated to make sure eyes, nose, and mouth were fully covered before room entry. The contact precaution sign stated to put on a gown before room entry. Observation on 11/29/23 at 9:58 A.M. of Registered Nurse (RN) #265 revealed Resident #81's call light was activated and RN #265 donned gloves, but did not don an isolation gown, goggles or a face shield before entering Resident #81's room and closing the door. RN #265 exited Resident #81's room a short time after she entered it, then turned around immediately and re-entered Resident #81's room and closed the door again. When RN #265 exited Resident #81's room a second time and was asked why she did not don an isolation gown, goggles or a face shield RN #265 stated she did not need PPE because the first time she entered the room she stood just inside the door, and the second time she walked back in the room and turned off the call light 10. Observation on 11/30/23 at 8:32 A.M. of Resident #43's room revealed Personal Protective Equipment (PPE) supplies were hanging on the door, and there was a sign for droplet precautions and contact precautions hanging on the door. The droplet precaution sign stated to make sure eyes, nose, and mouth were fully covered before room entry. The PPE supplies on the door did not include goggles or face shields. Observation on 11/30/23 at 8:32 A.M. of Registered Nurse/Unit Manager (RN/UM) #227 entering Resident #43's room revealed she had glasses on but no eye shield or goggles and RN/UM's #227 glasses did not have side shields. After exiting Resident #43's room RN/UM #227 confirmed she did not don an eye shield or goggles before entering Resident #43's room. RN/UM #227 stated she thought she did not have to don an eye shield or goggles if she wore glasses. RN/UM #227 confirmed Resident #43's PPE supplies hanging on the door did not contain goggles or face shields. RN/UM #227 stated she was going to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365845 If continuation sheet Page 17 of 19 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 365845 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rae Ann Suburban 29505 Detroit Rd Westlake, OH 44145 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 replenish the supplies. Level of Harm - Minimal harm or potential for actual harm 11. Observation on 11/30/23 at 8:41 A.M. of Resident #44 room revealed PPE supplies hanging on the door and droplet precautions and contact precautions signs hanging on the door. The droplet precaution sign stated to make sure eyes, nose, and mouth were fully covered before room entry. The PPE supplies on the door did not included goggles or face shields. Residents Affected - Many Further observation on 11/30/23 at 8:41 A.M. of State Tested Nursing Assistant (STNA) #247 revealed she entered Resident #44's room to provide care. STNA #247 did not wear glasses and did not don a face shield or goggles before entering Resident #44's room. After exiting Resident #44's room STNA #247 confirmed she did not don goggles or a face shield before entering the room, and stated there was no goggles or face shields included with the PPE supplies on the door. STNA #247 stated goggles and face shields were not readily available and staff would enter resident rooms with droplet precaution signs on the door often during the day without donning goggles and face shields. 12. Observation on 11/30/23 at 8:56 A.M. of Resident #40's room revealed PPE supplies hanging on the door and droplet precautions and contact precautions signs hanging on the door. The droplet precaution sign stated to make sure eyes, nose, and mouth were fully covered before room entry. Observation on 11/30/23 at 8:56 A.M. of LPN #301 revealed she was standing at the medication cart preparing medications for Resident #40. LPN #301 was wearing a surgical mask. LPN #301 did not don an N95 respirator or goggles or a face shield before entering Resident #40's room to administer medications. After exiting Resident #40's room LPN #301 confirmed she did not don an N95 respirator, eye shield or goggles before entering Resident #40's room. LPN #301 stated she did not know she needed to wear an N95 when entering a room of a resident on droplet precautions who was COVID-19 positive. Observation of LPN #301 revealed she did not discard her surgical mask and replace it with a new surgical mask after leaving Resident #40's room. LPN #301 walked to the medication cart, prepared medications for Resident #45 (did not have a droplet or contact precaution sign on the door), walked to Resident #45's room without changing her surgical mask and was stopped by the surveyor before she entered the room and was instructed to change her surgical mask before entering Resident #45's room. LPN #301 confirmed she did not change her surgical mask after entering Resident #40's room and was going to enter Resident #45's room without changing her mask. 13. Review on 11/30/23 of the facility COVID-19 Line List revealed Resident's #64 and #81 were not included. Resident's #64 tested positive for COVID-19 on 11/26/23 and Resident #81 tested positive for COVID on 11/20/23. Interview on 11/30/23 at 9:13 A.M. of CCI #304 revealed when she reviewed the facility COVID-19 Line List the residents' gender was not correct and she had to send it back to the facility for revisions. CCI #304 stated she knew female residents at the facility tested positive for COVID-19. Interview on 11/30/23 at 10:24 A.M. of the Administrator confirmed Resident's #64 and #81 tested positive for COVID-19 and were not listed on the COVID-19 Line List. Review of facility policy titled COVID-19 Prevention, Response and Reporting revised 05/2023 included it was the policy of the facility to ensure appropriate interventions were implemented to prevent the spread of COVID-19 and promptly respond to any suspected or confirmed COVID-19 infections. COVID-19 would be reported through the proper channels as per federal, state, and or local health authority. Residents with suspected or confirmed SARS-CoV-2 infection should be placed in a single-person (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365845 If continuation sheet Page 18 of 19 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 365845 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rae Ann Suburban 29505 Detroit Rd Westlake, OH 44145 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many room with the door kept closed, if safe to do so, and a dedicated bathroom if possible. If limited single-rooms were available, or if numerous residents were simultaneously identified to have know SARS-CoV-2 exposures or symptoms concerning for COVID-19, residents should remain in their current location. The facility might consider designating entire units within the facility, with dedicated HCP (health care personnel) to care for residents with SARS-Co-V-2 infection when the number of residents with SARS-Co-V-2 infection was high. Review of the Centers for Disease Control and Prevention (CDC) guidance titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic updated 05/08/23 included recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed SARS-CoV-2 Infection included the IPC recommendations also apply to patients of COVID-19 and asymptomatic patients who have met the criteria for empiric Transmission Based Precautions based on close contact with someone with SARS-CoV-2 infection. However these patients should NOT be cohorted with patients with confirmed SARS-Co-V-2 infection unless they were confirmed to have SARS-Co-V-2 through testing. HCP who enter the room of a patient with suspected or confirmed SARS-Co-V-2 infection should adhere to Standard Precautions and use a NIOSH (National Institute for Occupational Safety and Health) approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection such as goggles or a face shield that covers the front and sides of the face. This deficiency represents non-compliance investigated under Master Complaint Number OH00148610. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365845 If continuation sheet Page 19 of 19