Inspection·October 10, 2023

F 0600 Level of Harm - Minimal harm or potential for actual harm Review of the sanitation company statement for July 2023 revealed the facility owed the company $488.80 with a past due balance of $488.80 and a 60-day balance due of $47.21. The due date was 07/21/23. Review of the sanitation company statement for August 2023 revealed the facility owed the company $489.59 with a past due balance of $488.80. The due date was 08/18/23. Residents Affected - Many c. Review of the gas company statement dated 06/27/23 revealed the current billing was for $409.77 with a total due of $808.48. There was a shut off notice attached indicating the disconnect amount due by 08/14/23 was $398.71. Review of the gas company statement dated 07/27/23 revealed the current billing was for $388.61 with a total due of $1197.09. There was a shut off notice attached indicating the disconnect amount due immediately was $398.71 and a disconnect amount due by 08/14/23 was $409.77. Review of the gas company statement dated 08/25/23 revealed the current billing was for $468.56 with a total due of $1665.65. There was a shut off notice attached indicating the disconnect amount due immediately was $808.48 and a disconnect amount due by 09/13/23 was $388.61. On 10/03/23 at 12:00 P.M. an interview with Maintenance Director #105 revealed the facility had issues two times where the trash bill had not been paid. He stated in the last week of August the trash company had not picked up the trash all week (they picked up on Mondays and Thursdays) so he called them and he was told their service was on hold for nonpayment due to unpaid invoices for June and July. He stated he emailed the corporation to find out what was going on. He stated they paid June's invoice but not July invoice. He stated then the next week, which was the first week of September, the trash was not picked up again so he called the trash company and he was told again they were put on hold because they owed for July and August. He stated he called the corporation and told them they had two full dumpsters and piles of trash on the ground and they needed to pay the bills so the trash would be picked up. He stated he received an email that the invoices were paid in full and the trash resumed pick up. He stated they have not had any issues since then. On 10/03/23 at 2:38 P.M. an interview with the Administrator revealed the housekeeping company's contract was ending at the end of July 2023 and the facility did not continue their services. She stated they hired their own housekeepers. She verified there had been no payment to the Electric/water/sewage company for June, July, and August 2023. She verified they had made one payment of $47.21 on 07/13/23 to the sanitation company however there was no documentation of a payments in May, June, or August. She stated they made three payments on 09/12/23 of $491.17, $492.54, and $491.75 leaving a $0 balance so trash service could resume. On 10/04/23 at 11:20 A.M. an interview with Company Controller #100 revealed the facility did not have a third-party payer source for facility. Their procedure was for the facility's Business Office Manager (BOM) or Administrator to send the bills to cooperate and then corporate would pay them. He stated a delay in payment was usually due to new staff being hired or not being trained properly. He stated they have a list of vendors the facility used and every month they would make sure they received those bills, if they did not, they would reach out to the facility and tell them they did not receive a certain bill and have them send it over. He stated the corporate office realized there was an issue when they had not received any bills from the facility. He stated he believed it was due to the facility having a new BOM and he had also had a new employee at the corporate level covering the facility. He stated they never let anything get to the point of being shut off. He stated when (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365874 If continuation sheet Page 2 of 4 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 365874 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hudson Elms Nursing Center 563 W Streetsboro Road Hudson, OH 44236 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many they found out about the trash bills, they paid all three months. He stated regarding the past-due amount of $426.80 and shut of notice from the gas company, he was going to have his corporate bookkeeper contact the gas company concerning the past due amount because he believed there was a check they had not received. He stated they paid the most recent bill and they do not immediately reach out to the company if there was an outstanding balance because there may be a lag time between when they get the statement and payment was sent. He stated he told the person taking care of the facility to reach out to the gas company prior to him going on vacation to find out what was going on but he was not sure what was said and he was on vacation so he could not ask him. He stated he does not know what happened or why the sanitation company was not paid. He stated the bills for the city electric/water/sewage were missing and that was why they stopped payment on the one check they sent out because the city stated they never received that check so the canceled and they just did a payment over the phone with them. He stated they never let it reach the point of being shut off. He verified he had not been receiving statement from the facility for June, July, and August. He stated they just went out payment for June, July, and August statements in September when they realized they all had outstanding balances. On 10/04/23 at 12:19 P.M. an interview with the Administrator revealed she followed the same process for sending bills to the main office since she has been here. She would get the statement/bills, sign them off and give them to the facility BOM and they would send them to the main office to be paid. She stated both the old BOM prior to July and the new BOM add her to all the emails so she was aware of when the bills were sent . She stated there has never been a lapse in them sending bills to the main office. Review of an email from Housekeeping Company Owner #101 dated 10/04/23 at 9:13 P.M. revealed the facility had finally paid them but it was a battle to get paid. She indicated they constantly were paid late and they would have to practically beg for their money and multiply time they had to stop services until payments were caught up. She stated on 07/12/23 her staff went to the facility and worked that day and then sent them an email as soon as they left, they would not be coming back until they were paid. She stated they were paid the next day, however the Administrator stated she no longer wanted their serviced because she was hiring her own housekeeping staff. On 10/05/23 at 2:25 P.M. a telephone call conducted by the Administrator to the City electric/water/sewage company with the State Surveyor #102 , Field Manager #103 , and Corporate [NAME] President of Operations #104 present revealed the electronic system stated the facility owed $5940.38. The Administrator verified at this time the amount as the same amount as the shutoff notice they had received. On 10/05/23 at 2:30 P.M. a telephone call conducted by the Administrator to the gas company with the State Surveyor #102, Field Manager #103, and Corporate [NAME] President of Operations #104 revealed the customer service representative stated the facility owed $501.01. She stated the last payments were on 05/19/23, 09/07/23 and 09/14/23 to bring their account current. The Corporate [NAME] President of operations #104 stated she was not sure why there was no payment in June July and August. On 10/05/23 at 3:40 P.M. an interview with Corporate [NAME] President of Operations #104 revealed the corporate controller started am Excel spreadsheet to track when all the bills were due for each facility they owned as soon as the corporate controller realized there was an issue at the facility. She stated the corporate controlled stated he could not remember if it was started in July or August. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365874 If continuation sheet Page 3 of 4 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 365874 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hudson Elms Nursing Center 563 W Streetsboro Road Hudson, OH 44236 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Minimal harm or potential for actual harm On 10/05/23 at 4:21 P.M. an interview with the Administrator revealed the facility's old BOM last day was 06/02/3 and the new BOM was hired on 06/16/23 but did not start until 06/26/23. She stated at the corporate office the former BOM last day was 06/05/23 and the new one was hired on 06/06/23 but needed software training so he did not technically start in his position until the first week of July. Residents Affected - Many This deficiency represents non-compliance investigated under Complaint Number OH00146514. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365874 If continuation sheet Page 4 of 4