Inspection·August 29, 2019

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 record review and interview, the facility failed to ensure residents were provided with written notice of transfer. This affected one resident (Resident #41) of one resident reviewed for hospitalization. The facility census was 49 residents. Findings include: Review of Resident #41's medical record revealed an admission date of 05/14/12 and diagnoses including failure to thrive, multiple sclerosis, diabetes, cocaine abuse, dysphagia and hypertension. Review of a discharge minimum data set (MDS) assessment dated [DATE] revealed Resident #41 was cognitively intact and required extensive assistance for transfers and dressing. Review of a nurses' note dated 07/18/19 revealed Resident #41 was lethargic, drowsy, drooling and cold and clammy to touch. Registered Nurse (RN) #103 took his blood sugar which measured 46 millimoles/liter (mmol/L) and administered orange juice, oral glucose (sugar) and a glucagon injection (injectable sugar solution used to raise blood sugar levels). RN #103 took Resident #41's blood sugar again and it was 58 mmol/L; Resident #41 was not verbally responding appropriately to RN #103 and a sternal rub was needed to keep the resident from falling asleep. The nurse practitioner was notified and Resident #41 was sent to the emergency room (ER). Resident #41 was told he was going to the ER and an attempt was made to contact Resident #41's family. Review of a hospital transfer form dated 07/18/19 revealed Resident #41 had hypoglycemia (low blood sugar) with a blood sugar reading of 52 and was not responsive. Report was called into the hospital and no one was notified as the resident was his own representative. Interview on 08/28/19 at 12:41 P.M. with the Director of Nursing (DON) confirmed the facility did not provide a written notice of transfer to residents but told them verbally and put a nurses' note in the medical record if they refused. Interview on 08/28/19 at 1:54 P.M. with Licensed Practical Nurse (LPN) #104 verified for emergent transfers, no other documents were provided to the resident. Review of the facility transfer discharge policy revised April 2019 revealed for emergent transfers to acute care, transfers were considered facility-initiated and the administrator was to ensure compliance with 483.15 of the Centers for Medicare and Medicaid (CMS) regulations before discharge is commenced. This reference to regulations included written notice of transfer being provided to the resident by the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365875 If continuation sheet Page 2 of 15 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 365875 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crestmont North Nursing Home 13330 Detroit Ave Lakewood, OH 44107 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 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. 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 submit a resident discharge assessment for a resident who was discharged to the hospital and did not return to the facility. This affected one resident (Resident #1) of one residents reviewed for resident discharge assessments. The facility census was 49. Residents Affected - Few Findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses including dementia, chronic obstructive pulmonary disease, senile degeneration of brain, hypertension and depression. Review of the medical record for Resident #1 revealed nurses' notes indicating the resident was discharged to the hospital on [DATE]. The medical record did not reveal a completed or transmitted resident MDS (minimum data set) discharge assessment. An interview with the Assistant Director of Nursing (ADON)/MDS Nurse on 08/29/18 at 3:00 P.M., confirmed that Resident #1 was transferred to the hospital on [DATE] and then transferred to another facility. The ADON/MDS Nurse indicated the family did not inform the facility of the Resident being discharged to another facility and not returning. The ADON/MDS confirmed that no Discharge Assessment had been completed for Resident #1. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365875 If continuation sheet Page 3 of 15 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 365875 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crestmont North Nursing Home 13330 Detroit Ave Lakewood, OH 44107 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 record review and interview, the facility failed to coordinate care regarding resident pre-admission screen and resident review (PASRR). This affected one resident (Resident #19) of three residents reviewed who had a level two mental illness or intellectual disability. The facility census was 49. Findings include: Resident #19 was admitted to the facility on [DATE] with diagnoses including bipolar disorder, muscle weakness, generalized anxiety disorder, dementia with behavioral disturbance and paranoid schizophrenia. Review of the pre-admission screen and resident review (PASRR) determination dated [DATE] revealed Resident #19 had a history of serious mental illness and was approved for nursing facility services for a specified period of 90 days to allow sufficient time to prepare for a safe and orderly transition from the nursing facility to the community. Resident #19 was to return to the community when the determination expired on [DATE]. Review of Resident #19's electronic and paper medical records revealed no follow up assessment or further information regarding the resident's return to the community. An interview was conducted on [DATE] at 8:44 A.M. with Licensed Social Worker (LSW) #101. LSW #101 stated she had been employed by the facility since [DATE] and verified there was no further follow-up regarding Resident #19's PASRR or return to the community. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365875 If continuation sheet Page 4 of 15 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 365875 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crestmont North Nursing Home 13330 Detroit Ave Lakewood, OH 44107 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure care plans were revised as needed. This affected one (Resident #51) of 23 residents reviewed for care plans. The facility census was 49 residents. Findings include: Review of Resident #51's medical record revealed an admission date of 02/27/19 with diagnoses including hypertension (high blood pressure), type two diabetes, anemia and osteoarthritis, Review of a quarterly comprehensive assessment dated [DATE] revealed Resident #51 was cognitively intact, required supervision for eating and extensive assistance of one staff for toileting, hygiene and dressing. Review of a smoking assessment dated [DATE] revealed Resident #51 required assistance to get to the outside patio and his cigarettes and lighter were to be kept in a secured area. Review of an undated care plan for smoking revealed Resident #51's cigarettes were to be kept at the nurses's station and the resident could smoke unsupervised. An additional intervention listed revealed a smoking assessment would be completed on admission and quarterly. Observation on 08/26/19 at 10:06 A.M. revealed Resident #51 laying in bed with cigarettes and a lighter located on the bedside table to his right. Interview on 08/26/19 at 10:06 A.M. with Resident #51 revealed he was able to smoke unsupervised and was able to hold on to his smoking materials at the facility. Interview on 08/26/19 at 11:12 A.M. with State Tested Nurse Aide (STNA) #102 revealed all residents on the front unit, including Resident #51 were alert and oriented and could keep their smoking materials in their possession. Interview and observation on 08/26/19 at 11:25 A.M. with Registered Nurse (RN) #103 revealed the unit bin for smoking materials was empty and denied concerns with Resident #51 keeping his smoking materials. Interview and observation on 08/26/19 at 11:31 A.M. with Licensed Practical Nurse (LPN) #104 revealed Resident #51 was identified on the facility smoking list as an independent smoker. LPN #104 stated earlier in his admission Resident #51 required more assistance with smoking. When shown Resident #51's smoking assessment dated [DATE] and the resident's undated care plan, LPN #104 verified Resident #51's assessment and care plan should have been revised as he improved with therapy. Review of the facility document, Current Smokers revised 07/29/19 identified Resident #51 as an independent smoker. Review of the facility document, Current Smoking Policy, revised 07/14/16 revealed when the smoking area would be closed. The document did not detail where or how smoking materials were to be stored for smoking residents that required supervision. The document did not address in any capacity how (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365875 If continuation sheet Page 5 of 15 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 365875 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crestmont North Nursing Home 13330 Detroit Ave Lakewood, OH 44107 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 0657 Level of Harm - Minimal harm or potential for actual harm the facility managed residents who were identified as independent with smoking. The document also did not address smoking safety for residents who chose to smoke and how non-smoking residents were protected from smoking. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365875 If continuation sheet Page 6 of 15 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 365875 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crestmont North Nursing Home 13330 Detroit Ave Lakewood, OH 44107 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure Resident #48 received treatment and care in accordance with the comprehensive person-centered care plan. This affected one, Resident #48, of three residents (#21, #35 and #48) reviewed for non-pressure skin impairment. The facility census was 49 residents. Residents Affected - Few Findings include: Review of the medical record revealed Resident #48 was admitted to the facility on [DATE] with diagnoses including altered mental status, symbolic dysfunctions, dementia without behavioral disturbance and weakness. Review of the physician's order dated 07/26/19 indicated she was to wear Tubigrips or Geri sleeves (protective sleeves) to all extremities. Review of the comprehensive assessment (MDS 3.0) dated 08/06/19 indicated she was severely cognitively impaired, displayed no behavioral symptoms, had skin tears and non surgical dressings. Review of the potential for skin tears related to thin skin plan of care developed on 07/26/19 indicated to keep her nails short, monitor and document the location, size and treatment of the skin tear. Protective sleeves to the arms daily when out of bed. Resident #48 was observed on 08/26/19 at 9:30 A.M., 11:01 A.M. and on 08/27/19 at 11:00 A.M. and 2:55 P.M. wearing short sleeve shirts. Her arms were marked with bruises, scars and skin tears with dried blood around them. On 08/28/19 at 11:17 A.M. Resident #48 was observed to be wearing protective sleeves. Interview with Resident #48 on 08/26/19 at 11:01 A.M. revealed she was not able to say how she obtained the skin tears nor was she able to say if they were painful. Interview with Licensed Practical Nurse (LPN) #104 on 08/26/19 at 11:05 A.M. said Resident #48 had a behavior of scratching herself. Her nails were observed to be short, smooth but with some dried blood underneath. Further interview with LPN #104 on 08/28/19 at 1:43 P.M. indicated the protective sleeves were supposed to be worn every day. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365875 If continuation sheet Page 7 of 15 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 365875 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crestmont North Nursing Home 13330 Detroit Ave Lakewood, OH 44107 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents receive appropriate and assessed restorative services. This affected three residents (#9, #27 and #43) of four residents (#9, #27, #31 and #43) reviewed for range of motion out of 45 residents #2, #4, #5, #6, #7, #8, #9, #10, #12, #14, #15, #16, #17, #18, #19, #20, #21, #23, #25, #26, #27, #28, #29, #31, #32, #33, #34, #35, #36, #38, #39, #40, #41, #42, #43, #44, #45, #46, #47, #49, #50, #51, #52, #53 and #204) identified as receiving one or more restorative services. The facility census was 49 residents. Findings include: 1. Review of the medical record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses including moyamoya disease, altered mental status, restlessness an agitation, hemiplegia and hemiparesis affecting left non dominant side, convulsions, brief psychotic disorder, encephalopathy, cortical blindness, left watershed and right stroke. Review of the restorative mobility assessment on 03/08/19 indicated her left elbow was moderately contracted but had no limitation in wrists or fingers. Review of the comprehensive assessment (MDS 3.0) dated 06/14/19 indicated she was severely cognitively impaired, displayed no behaviors, had functional limitation in range of motion to one side of upper and one side of lower extremity. She was provided seven days of passive range of motion and six days of splint or brace application. Review of the restorative plan of care initiated 06/26/18 indicated to apply the left elbow splint at night as tolerated and remove in the morning. Range of motion to be provided six to seven days per week. Resident #9 was observed on 08/26/19 at 11:00 A.M., 08/27/19 at 8:48 A.M., at 12:12 P.M. and 2:54 P.M. and on 08/28/19 at 9:18 A.M. and 11:17 A.M. without the restorative devices in place. Interview with occupational therapist #107 on 08/27/19 at 12:43 P.M. said she had been in therapy services but was so floppy with her movements that it was not effective. She was unaware of any device but indicated the facility usually put some device even a rolled-up wash cloth into tight hands/joints. Interview with Licensed Practical Nurse (LPN) #104 on 08/28/19 at 9:18 A.M. verified Resident #9's left elbow was contracted as was here left thumb. She verified no device was in place. Interview with LPN #104 on 08/28/19 at 1:45 P.M. verified two elbow splints were on the over bed table. She said the resident must not have tolerated them. Review of the restorative data indicated she was provided a passive range of motion and left upper splint application in the morning. Review of the last 14 days of documentation revealed she refused it twice in the last 14 days and not applicable was documented on 11 shifts. 2. Review of the medical record revealed Resident #27 was admitted to the facility on [DATE] with diagnoses including hypertension, joint contracture, anxiety disorder, major depressive disorder, dementia without behavioral disturbance and tremor. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365875 If continuation sheet Page 8 of 15 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 365875 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crestmont North Nursing Home 13330 Detroit Ave Lakewood, OH 44107 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 0688 Level of Harm - Minimal harm or potential for actual harm Review of the comprehensive assessment (MDS 3.0) dated 07/05/19 indicated he was moderately cognitively impaired and displayed no behavioral symptoms. He had functional limitation in range of motion on one side of an upper extremity. He had restorative active range of motion, dining and ambulation services six times in the assessment period. Residents Affected - Some Review of the physician orders lacked any orders for restorative services or splint application. Review of the restorative plan of care initiated on 05/05/17 indicated he would be provided a range of motion program six to seven days a week, on 08/25/17 he would be provided restorative dining program six to seven days per week and an ambulation program six to seven days per week. Review of the restorative documentation indicated he received active range of motion and ambulation programs. Review of the restorative services documentation revealed he was on a restorative dining program indicating verbal/physical cues to encourage self-feeding of the resident. It was documented that this service was provided at two meals daily. Review of the restorative dining program delivery record for the last 30 days revealed staff documented they spent 5-45 minutes with Resident #27 at 33 meals. Review of the restorative ambulation program delivery record for the last 30 days revealed the program was delivered 31 times. Resident #27 was observed on 08/26/19 at 12:45 P.M. feeding himself in his room. His right hand was in a tight fist. On 08/27/19 at 8:23 A.M. and 12:16 P.M. his right hand was in a tight fist. Interview with LPN #108 on 08/27/19 at 12:45 P.M. indicated a soft palm protector was to be in hand at night per his preference. She said sometimes he will refuse. Interview with LPN #104 on 08/28/19 at 9:08 A.M. was not sure if therapy got him a brace or not. She reported he came in with the contracted right hand. She verified there was no palm protector found in his room. On 08/28/19 at 11:18 A.M. and 12:46 A.M. he was observed in his room wearing a palm protector. On 08/28/19 at 12:46 P.M. he was feeding himself in his room alone. 3. Review of the medical record revealed Resident #43 was admitted to the facility on [DATE] with diagnoses including acute kidney failure, contracture of left thigh muscle, cerebral infarction, diabetes with neuropathy, gastrointestinal hemorrhage, hypertension, anemia, gastro-esophageal reflux disease and acute and chronic respiratory failure with hypoxia. Review of the comprehensive assessment (MDS 3.0) dated 08/01/19 indicated she had moderate cognitive impairment, she displayed no psychosis or behavioral symptoms. She functional limitation on one side of the upper and lower extremity. Review of the restorative mobility assessment dated [DATE] indicated she was a mechanical lift for all transfers, full range of motion to both wrist and fingers and moderate elbow flexion to right elbow. Review of the restorative plan of care indicated she would be provided active and passive range of motion six to seven days per week a dining program indicating she would eat each meal with assistance to bring food to her mouth using hand over hand guidance. The restorative dining program would be run six to seven days per week for 15 minutes. Interview with LPN #104 on 08/28/19 at 8:58 A.M. verified the resident had a contracted hand and leg. She said the nurse who did the assessments and ran the restorative program was no longer employed by the facility. She said the resident has a palm (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365875 If continuation sheet Page 9 of 15 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 365875 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crestmont North Nursing Home 13330 Detroit Ave Lakewood, OH 44107 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some protector that was applied after breakfast each morning. She verified the resident was not on a restorative dining program and fed herself independently in her room. Review of the restorative service delivery records revealed she was provided an active range of motion, a passive range of motion program and a restorative dining program providing verbal/physical cues to encourage self-feeding of the resident. The documentation indicated the program was provided at two meals per day. Resident #43 was observed on 08/26/19 at 9:30 A.M., 10:29 A.M., 08/27/19 at 12:13 P.M. sitting in a wheelchair in her room. Her left hand was held tightly in a fist. She was not able to open it when asked. No splints were observed on her leg or in the room. She was observed on 08/28/19 at 11:17 A.M. with a palm protector in place but no leg splint. Resident #43 was observed feeding herself lunch on 08/26/19 at 12:45 P.M., feeding herself lunch on 08/28/19 at 12:43 P.M. Interview with occupational therapist #107 on 08/27/19 at 12:45 P.M. said she should have a soft palm protector in her hand. Interview with Resident #43's son on 08/28/19 at 11:39 A.M. said when he came in to visit (weekly) she did not have any splints in place to her hand or her leg. Interview with the assistant director of nursing and LPN #104 on 08/28/19 at 2:38 P.M. said they just reviewed the list of who was to receive restorative services and said it was impossible for 45 of 49 residents to be receiving one or more programs. They said many of the programs were not necessary for the residents. They reported they will reassess everyone in the facility and develop necessary programs only. No staff were designated to provide restorative services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365875 If continuation sheet Page 10 of 15 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 365875 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crestmont North Nursing Home 13330 Detroit Ave Lakewood, OH 44107 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and policy review, the facility failed to ensure the humidifier had enough water to bubble and failed to ensure oxygen equipment was kept clean. The affected six residents (#6, #35, #38, #41, #43 and #55) of eight residents (#6, #18, #35, #38, #41, #43, #49, and #55) whose oxygen concentrators were not maintained. The facility census was 49. Residents Affected - Some Findings include: On 08/26/19 at 9:30 A.M. Resident #43 was observed in room using oxygen via nasal canula at 2 liters per minute. The oxygen concentrator was observed to be moderately soiled with loose and dried debris. The bottle of water was dated 08/02/19 and was empty. On 08/26/19 at 4:28 P.M. Licensed Practical Nurse (LPN) #104 verified the condition of the oxygen concentrator, the date on the bottle and that the bottle was empty. Interview with LPN #104 on 08/26/19 at 4:28 P.M. indicated every shift the nurse was to check the oxygen for each resident. She said the equipment should be changed weekly including the humidifier. She confirmed the bottle was dated 08/02/19 and should have been changed a couple of times since then. Oxygen concentrators for Resident #6, #35, #38, #41, #43, #49 and #55 were observed on 08/28/19 at 12:53 P.M. with the assistant director of nursing. She verified the condition of Resident's #6, #35, #38, #41, #43 and #55 oxygen concentrators as soiled with debris and food/liquid spills. She verified Resident #35's humidifying jar had a little amount of water and bubbled when she moved it around. Review of the oxygen administration and cleaning and disinfection of oxygen items and equipment policy (undated) indicated step 12 in the procedure indicated to check the humidifying jar and make sure there was water in the humidifying jar and the water was high enough that the water bubbles as oxygen flows through. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365875 If continuation sheet Page 11 of 15 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 365875 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crestmont North Nursing Home 13330 Detroit Ave Lakewood, OH 44107 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 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on record review and staff interview the facility failed to ensure daily posted nursing staff information was updated timely. This had the potential to affect all 49 residents residing in the facility. Residents Affected - Many Findings include: Observation of the posted nursing staff information on 08/27/19 12:57 P.M. revealed the posted nursing staff information was dated from Sunday 08/25/19 into Monday 08/26/19. The Director of Nursing (DON) verified the information was not up to date in an interview on 08/27/19 at 12:57 P.M. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365875 If continuation sheet Page 12 of 15 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 365875 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crestmont North Nursing Home 13330 Detroit Ave Lakewood, OH 44107 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation of trayline, review of a test tray, interview, record review and policy review the facility failed to ensure meals were served at palatable temperatures. This had the potential to affect all 49 residents residing in the facility. Residents Affected - Many Findings include: Observation of lunch trayline on 08/27/19 starting at 12:03 P.M. revealed a meal consisting of bruchetta chicken (breaded chicken breast with tomatoes and cheese), buttered bowtie pasta, Italian green beans, a bread stick and an ice cream cup. Temperatures were taken at the start of trayline by [NAME] #106 with the facility's self-calibrating digital thermometer and were as follows: pureed noodles 166 degrees Fahrenheit (F), pureed green beans 178 degrees F, mashed potatoes 197 degrees F, pureed chicken bruchetta 158 degrees F, ground chicken bruchetta 149 degrees F, noodles 143 degrees F, green beans 209 degrees F, chicken 182 degrees F and milk 33 degrees F. Trayline started on 08/27/19 at 12:10 P.M. and a test tray was requested for the back (secured) unit. The back unit meals were started at 12:21 P.M., the test tray was assembled at 12:27 P.M., the cart left the kitchen at 12:35 P.M., the cart arrived on the back unit at 12:37 P.M. and staff began to pass trays at 12:37 P.M. until 12:46 P.M. The test tray was assessed with Dietary Manager (DM) #100 on 08/27/19 at 12:47 P.M. Temperatures were taken by DM #100 with the facility's self-calibrating digital thermometer and were as follows: bowtie pasta 110 degrees F, chicken bruchetta 136 degrees F, milk 40.8 degrees F and green beans 119.9 degrees F. The meal was appetizing in appearance but all three hot foods tested tasted lukewarm. Interview on 08/27/19 at 12:49 P.M. with DM #100 revealed point-of-service hot temperature had to be 120 degrees F or above. DM #100 described previous concerns with hot food temperatures, so staff would put plates in the oven to heat them up prior to trayline. DM #100 denied the facility having a pellet system (heated component that fit under plates to keep them warm) or a plate-warmer but mentioned the plate bottom and lid would securely close around the plate to help maintain food temperatures. DM #100 agreed the beans and pasta could have been warmer. Interview on 08/27/19 at 2:26 P.M. with Dining Service Director (DSD) #105 revealed the facility conducted test trays routinely and used 120 degrees F as the minimum hot temperature required. DSD #105 confirmed the green bean temperature of 119.9 degrees F and the bowtie pasta temperature of 110 degrees F were not acceptable for service. Review of facility test tray audits dated 07/03/19, 07/09/19, 07/19/19, 08/08/19, 08/16/19 and 08/23/19 revealed large temperatures losses from the kitchen to the nursing units. Hot foods lost 20 to 68 degrees in temperature on these audits. An attached in-service dated 08/08/19 revealed cooks were to put plates in the oven for increased temperatures for all meals. Review of the facility food preparation and service policy (no date) revealed hot food is served hot as discerned by the resident and customary practice. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365875 If continuation sheet Page 13 of 15 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 365875 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crestmont North Nursing Home 13330 Detroit Ave Lakewood, OH 44107 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and policy review, the facility failed to ensure clean and sanitary nourishment areas. This affected all 49 residents receiving food from the kitchen. The facility census was 49. Findings include: Observation of the back unit nourishment refrigerator with Dietary Manager (DM) #100 on 08/26/19 at 9:20 A.M. revealed three sandwiches not labeled or dated, three takeout containers not labeled or dated and a half gallon of chocolate milk dated 08/19/19. The back unit refrigerator's shelves were noted to have spilled juice on them. Observation of the front unit nourishment refrigerator with DM #100 on 08/26/19 at 9:25 A.M. revealed two sandwiches and one chef's salad not labeled or dated and three containers of whitefish spread not dated. Interview with DM #100 at the time of the above observations verified resident food items were to be labeled, dated and stored in a clean and sanitary environment. Review of an undated sign posted on both the back and front unit refrigerators revealed third shift nurses were responsible for filling out temperature logs nightly on all refrigerators; all resident personal food items were to be labeled with a resident room number and date placed in the refrigerator; State Tested Nurse Aides (STNAs) were to check the fridge nightly and throw away outdated (three days) foods; and STNAs were to thoroughly clean the fridge every Thursday. Review of the facility policy, Guidelines for Food Brought in For Individual Residents, dated 06/13/18 revealed food brought to the facility requiring refrigeration could be stored in the refrigerators on the nursing unit, was to be labeled with the resident's name and date the food was brought in and was to be discarded after three days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365875 If continuation sheet Page 14 of 15 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 365875 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crestmont North Nursing Home 13330 Detroit Ave Lakewood, OH 44107 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 0926 Have policies on smoking. Level of Harm - Potential for minimal harm Based on observations and interviews the facility failed to ensure smoking areas were maintained in a clean manner, and cigarette butts were disposed of in approved containers. This had the potential to affect the 12 Residents who smoke. The facility census was 49. Residents Affected - Many Findings include Observations of the enclosed smoking area with the assistant maintenance director #6 on 08/26/19 at 10:59 A.M., revealed Residents utilized an enclosed smoking area located off the main dining room. There was a red container with a lid, the red container had cigarette butts, paper and plastic items. There was a large trash receptacle, three quarters filled with items and dried leaves. There were over 15 cigarette butts in the leaves. The assistant maintenance staff #6 verified the findings at the time of the observations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365875 If continuation sheet Page 15 of 15