Inspection·August 25, 2022

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Potential for minimal harm Based on review of Medicare Beneficiary Notices and interview, the facility failed to provide complete Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) forms for two residents (#35 and #45) and provided the Medicare Notice of Non-Coverage and the SNFABN to Resident #56 when these forms were not appropriate for a voluntary end of coverage. This affected three of three residents reviewed for SNFABN. Residents Affected - Many Findings include: Review of Resident #35's SNFABN revealed no indication of when non-coverage would begin, the estimated cost to remain in the facility and choosing one of three options. Resident #35 signed the notice on 03/12/22. Review of Resident #45's SNFABN revealed no indication of when non-coverage would begin, the estimated cost to remain in the facility and choosing one of three options. Resident #45 signed the notice on 06/14/22. Review of Resident #56's Notice of Medicare Non-Coverage for CMS10123 indicated his last covered day was 07/30/22. The facility indicated this was a voluntary end to the Medicare services. No notice was required however he was provided the CMS10123 and the SNFABN notices. Interview with the Administrator on 08/23/22 at 11:58 A.M. indicated social service completed this task. He verified the forms provided were incomplete or should not have been provided. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365875 If continuation sheet Page 2 of 21 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 08/25/2022 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure reasonable care was taken for the protection of resident property from loss or theft. This affected two residents (Resident#14, and #34) out of three residents (Resident #14, #32, and #34) reviewed for misappropriation of personal property. The facility census was 58. Findings include: 1. Review of medical record for Resident #34 revealed an admission date of 09/09/21. Resident #34 was admitted to the hospital on [DATE]. Diagnoses included multiple sclerosis, hypertension, morbid obesity, bipolar disorder, mood disorder, and major depression. The medical record did not include a personal inventory of her belongings. Review of the care plan dated 10/28/21 revealed Resident #34 had an activities of daily living self-care deficit related to multiple sclerosis, neurogenic bladder, lymphedema, and obesity. The care plan indicated Resident #34 was totally dependent of staff with bed mobility, and transfers. There was nothing per her care plan regarding locomotion. Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #34 had intact cognition, required total dependence of two people with bed mobility and transfer, was unable to ambulate, and required supervision with set up help with locomotion on and off the unit. Phone interview on 08/23/22 at 12:22 P.M. with Resident #34 revealed when she was admitted she brought her own personal electric wheelchair with charger. During her stay they moved her wheelchair out into the hallway and then her electric charger came up missing. Resident #34 did not know the date or time frame when this had occurred but stated she had reported the missing wheelchair charger to the Administrator and Director of Nursing (DON) who had at first stated they would replace the charger but then later came back and told her they were not replacing the charger because they had no documentation that she had came into the facility with the charger to her wheelchair. Interview on 08/24/22 at 10:42 A.M. with the DON revealed Resident #34 had two wheelchairs at the facility. Resident #34 used one wheelchair that had an electric wheelchair charger. Resident #34 also had another personnel electric wheelchair that was too small for her to use; Resident #34 reported she was missing a charger to that wheelchair. The DON revealed she did not have any documentation regarding a date of when Resident #34 had stated her personal electric wheelchair charger was missing, no investigation or documentation regarding the missing wheelchair charger. The DON said there was no record Resident #34 came into the facility with a charger to her personnel wheelchair. The DON said the admitting nurse was to complete the personal inventory form on admission. Interview with the Administrator on 08/25/22 at 9:16 A.M. revealed Resident #34 had told him she was missing her personal wheelchair charger. The Administrator observed surveillance footage from cameras and had concluded that Resident #34 did not come to the facility with her own personal wheelchair charger. The Administrator had no investigation or documentation regarding the allegation of the missing wheelchair charger. The Administrator verified the facility did not have record that a personnel inventory was completed on admission for Resident #34 and had no record of what items Resident #34 had at the facility. The Administrator verified nursing was responsible to complete inventories (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365875 If continuation sheet Page 3 of 21 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 08/25/2022 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 0584 upon admission and this had not been completed for Resident #34. Level of Harm - Minimal harm or potential for actual harm 2. Review of medical record for Resident #14 revealed an admission date of 01/25/18 and diagnoses included major depression with severe psychotic features, heart failure, hypertension, and peripheral vascular disease. The medical record did not include a personal inventory of her belongings. Residents Affected - Few Review of quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #14 had intact cognition. Review of police event report #2022-060-070 dated 03/01/22 at 3:09 P.M. revealed Resident #14 contacted the police department regarding missing items and Police Officer #902 responded to the facility. The report revealed Resident #14 had bedbugs in her room and the facility took all her belongings to disinfect. The report revealed the facility director reported that all items had been returned to her but Resident #14 stated she was missing a book and a computer hard drive. Resident #14 had stated she did not feel the items were stolen but that they were misplaced. Review of undated and unsigned facility investigation labeled; Bed Bugs Incident revealed Resident #14's room was infested with bed bugs brought in per Resident #14's husband that visited March 2021. The investigation revealed housekeeping followed the guidance of the exterminator and bagged and removed personal items from her room while the exterminator treated the infestation. The investigation revealed Resident #14 was advised that seriously infected items that were not salvageable was disposed of for the safety of the other residents and staff in the facility. The investigation revealed personal items that were salvageable were treated and returned to the resident. The investigation had no documentation of what items were disposed of and not salvageable. Interview on 08/22/22 at 9:20 A.M. with Resident #14 revealed she was missing a first edition book, Tel Basta that was printed in 1979 and an external computer hard drive. Resident #14 felt the book was worth over five hundred dollars. Resident #14 said her room had bedbugs March of 2021 and Director of Housekeeping #647 bagged up all her items and took them to the basement. Director of Housekeeping #647 brought her items back but only small amounts at a time and Resident #14 continued to request the book and the computer external hard drive to be returned. Resident #14 revealed she was never notified they threw away any of her items and that she would have never consented to those two items to be discarded as they were not replaceable especially her computer hard drive had personal information on it. Resident #14 contacted the police department to file a report. Police Officer #902 came to the facility and provided her with the report number as 2022-060-07. Resident #14 had not been provided with any further information since filing the report and would like to know what happened to her items. Interview on 08/24/22 at 8:47 A.M. with Director of Housekeeping #647 revealed in March 2021 Resident #14's room did have a bad infestation of bed bugs and they had bagged all Resident #14's items and took the items to the basement for pest control to treat the room. Director of Housekeeping #647 revealed there was a green notebook that was infested with bedbugs and she threw that way after approval from the Director of Nursing. No other items were discarded and all other items had been given back Resident #14 after treatment. Director of Housekeeping #647 said Resident #14 reported to her that she was missing an external computer hard drive and a first edition book. The Administrator was aware and stated if Resident #14 did not have any receipts for the items that he was not reimbursing. Director of Housekeeping #647 verified she only threw away a green notebook of Resident #14's but no other items. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365875 If continuation sheet Page 4 of 21 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 08/25/2022 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 08/25/22 at 9:16 A.M. with the Administrator revealed Resident #14 had told him she was missing a book and computer external hard drive. Resident #14 had stated her book was a first edition and was worth hundreds of dollars. The Administrator revealed he had a brief investigation and the police report regarding Resident #14 and believed the items were thrown away due to her room having a bed bug infestation. The Administrator verified he did not have any record regarding what items were disposed of and the facility did not have a record that a personnel inventory was completed on admission for Resident #14 and no record of what items Resident #14 had at the facility. The Administrator verified nursing was responsible to complete inventories upon admission and this was not completed for Resident #14. Review of undated facility policy labeled, Abuse, Neglect, Misappropriation of Resident Property, Exploitation and Mistreatment Policy revealed misappropriation of resident property was the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident belongings. The policy revealed once the administrator was notified an investigation of the allegation or suspicion would be conducted and the investigation should be documented using the quality assurance forms adopted by the facility and have suitable evidence that all alleged violations were thoroughly investigated. Review of facility policy labeled, Personal Property dated September 2012 revealed a resident's personal belongings and clothing would be inventoried and documented upon admission and as such items were replenished. The policy revealed the facility would promptly investigate any complaints of misappropriation or mistreatment of resident property. Review of blank form labeled, Inventory of Personal Effects dated 12/28/12 revealed each resident was to have a personal inventory upon admission and identified personal belongings on the form. The form revealed when listing items to be as specific as possible and instruct the resident or reasonable party when additional items were brought in and when removed to inform the nurse. The form revealed a section for wheelchair. The form included an area for signature of resident and facility representative. This deficiency substantiates Complaint Number OH00134936. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365875 If continuation sheet Page 5 of 21 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 08/25/2022 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Based on record review and interview, the facility failed to ensure a representative of the Office of the State Long-Term Care Ombudsman was notified of facility initiated discharges. This affected 18 residents (Residents #18, #51, #206, #207, #208, #209, #210, #211, #212, #213, #214, #215, #216, #217, #218, #219, #220 and #221.) The census was 58. Findings include: Interview on 08/24/22 at 11:45 A.M. with Social Services (SS) #608 revealed the facility had not been notifying the State Long-Term Care Ombudsman of facility-initiated discharges. SS #608 verified the last notification to the Ombudsman was on 02/02/21 for January 2021 facility discharges. Review of a facsimile transmittal report, dated 02/02/21, addressed to Ombudsman from the facility regarding discharge notification revealed a list of discharges from the facility during January 2021. Review of the facility admission/discharge report, dated 08/24/22, for residents discharged from 02/01/21 to 08/24/22 revealed the following residents received a facility-initiated discharge to an acute care hospital: - Resident #206 was discharged on 02/04/21 and again on 02/21/21 - Resident #51 was discharged on 02/19/21, on 05/05/21 and again on 05/13/21 - Resident #207 was discharged on 03/11/21 - Resident #208 was discharged on 03/16/21 - Resident #209 was discharged on 04/17/21 and again on 11/04/21 - Resident #210 was discharged on 04/29/21 - Resident #18 was discharged on 04/29/21 - Resident #211 was discharged on 05/01/21 - Resident #212 was discharged on 06/26/21 - Resident #213 was discharged on 07/29/21 and again on 08/06/21 - Resident #214 was discharged on 08/01/21 - Resident #215 was discharged on 08/24/21 - Resident #216 was discharged on 08/27/21 - Resident #217 was discharged on 11/05/21 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365875 If continuation sheet Page 6 of 21 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 08/25/2022 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 0623 - Resident #218 was discharged on 12/15/21 Level of Harm - Minimal harm or potential for actual harm - Resident #219 was discharged on 02/17/22 - Resident #220 was discharged on 02/24/22 Residents Affected - Some - Resident #221 was discharged on 03/31/22 FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365875 If continuation sheet Page 7 of 21 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 08/25/2022 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a Patient Assessment and Resident Review (PASRR) was completed as required for two residents (Resident #34 and Resident #37) out of two residents (Resident #34 and #37) reviewed for PASRR. The facility census was 58. Residents Affected - Few Findings include: 1. Review of medical record for Resident #34 revealed an admission date of 09/09/21. The record revealed Resident #34 was admitted to the hospital on [DATE] and discharged to another facility on 08/22/22. Diagnoses included multiple sclerosis, bipolar disorder, mood disorder, and major depression. There was no PASRR, or hospital exemption noted in her medical record. Review of the care plan dated 10/28/21 revealed Resident #34 had behavioral symptoms related to psychiatric diagnoses. Resident #34 had verbal aggression as she yelled at staff when immediate gratification could not be met, argumentative when redirected per caregivers, demanding, accusatory and manipulative behaviors as she threatened to contact the Ombudsman. Resident #34 tried to make her own regimen of medical management, and was noncompliant with physician orders. Interventions included approach resident to provide care in a calm manner, allow resident to make own choices to feel in control, monitor and report any changes in mood and behaviors. Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #34 had intact cognition and had verbal behaviors that had occurred one to three days during the assessment period. Interview on 08/23/22 at 2:45 P.M. with Licensed Social Worker (LSW) #608 revealed Resident #34 did not have a PASSR or a hospital exemption completed. Review of the undated facility policy labeled, PASRR Completion Policy revealed the facility would make sure that all admissions had an appropriate PASRR completed. The policy revealed if a resident referral indicated anything that might constitute a mental illness or an intellectual disability a PASSR must be completed prior to admission and if the resident was deemed hospital exempted it must be clearly documented in the transfer documents prior to admission. 2. Record review revealed Resident #37 was admitted to the facility on [DATE]. Diagnoses included recurrent severe depressive disorder without psychotic features, schizoaffective disorder, unspecified psychosis not due to a substance or known psychological condition, and unspecified personality disorder. Review of the hospital exemption from preadmission screening form from the Stage agency revealed Resident #37 was expected to be admitted to the facility on [DATE], and the facility was responsible for requesting a pre-admission screening and resident review (PASRR) prior to the thirtieth day following admission from the hospital. Review of the medical record revealed no evidence a new PASRR was submitted for approval to the State agency prior to the thirtieth day following admission on [DATE]. Interview on 08/22/22 at 4:36 P.M. with Social Worker #608 verified a new PASRR was not completed for Resident #37 prior to the thirtieth day following admission, and no valid PASRR was currently in place for Resident #37's continued stay at the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365875 If continuation sheet Page 8 of 21 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 08/25/2022 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 0645 Level of Harm - Minimal harm or potential for actual harm Review of the medical record revealed a new PASRR for Resident #37 was submitted for approval to the state agency on 08/22/22. Review of undated facility policy titled PASRR Completion Policy, revealed either the Admissions Director or Social Worker was responsible for making sure the PASRR and/or level of care was done. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365875 If continuation sheet Page 9 of 21 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 08/25/2022 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and policy review, the facility failed to develop individualized care plans for Residents #14, #35, #37, #42 and #48 related to smoking, wounds, and pain. This affected five of 24 resident care plans reviewed. Findings include: 1. Review of the medical record revealed Resident #35 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, anxiety disorder, cerebral ischemia, adult failure to thrive, surgical amputation of left big toe, major depressive disorder, chronic pain, insomnia, lumbago and sciatica, syncope and collapse. Review of the smoking assessment dated [DATE] indicated Resident #35 was a daily smoker and did not need the facility to store his lighter or cigarettes. On 08/22/22 at 11:29 A.M. Resident #35 was observed wheeling down the hallway with an unlit cigarette hanging out of his mouth. Resident #35 was also observed smoking independently on 08/23/22 at 10:29 A.M. and 12:17 P.M. Review of Resident #35's care plan revealed no indication he was a smoker or what, if any interventions were needed. Interview with the Director of Nursing on 08/23/22 at 2:00 P.M. verified no care plan was developed related to Resident #35's smoking safety. Interview with the assessment nurse, Registered Nurse (RN) #668 on 08/25/22 at 7:45 A.M. indicated she was new to the position. RN #668 indicated she signed the attestation portion of the MDS assessments but did not monitor that plan of cares were developed as indicated on the Care Area Assessments. 2. Review of the medical record revealed Resident #42 was admitted to the facility on [DATE] with diagnoses including pneumonia, vascular dementia with behavioral disturbance, hyperlipidemia, hypertension, hypothyroidism, psychosis, COVID 19, cerebral infarction. Review of the current physician orders revealed Resident #42 was ordered ibuprofen (a non-opioid analgesic) 500 milligrams as needed for pain and oxycodone (an opioid analgesic) for pain. There were no parameters as to when to administer the non-opioid or opioid analgesic. Review of the pain evaluation dated 06/15/22 indicated Resident #42 had general pain, occasionally, made it hard to sleep at night, limited her day to day activities, movement increased her pain, pain meds only help. Description was aching. Pain management indicated she received a scheduled pain medication regimen related to sleepiness. Review of Resident #42's care plan revealed it lacked a plan related to pain management. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365875 If continuation sheet Page 10 of 21 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 08/25/2022 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 0656 Interview with RN #668 on 08/25/22 at 7:45 A.M. verified no care plan was developed related to pain. Level of Harm - Minimal harm or potential for actual harm 3. Review of medical record for Resident #14 revealed an admission date of 01/25/18 and diagnoses that included hypertension, heart failure, peripheral vascular disease, and lymphedema. Residents Affected - Some Review of the comprehensive care plan that was last revised 10/04/21 revealed Resident #14 did not have a care plan for wound management including for venous ulcers. Review of Wound Nurse Practitioner (NP) #901's progress note dated 05/04/22 revealed Resident #14 had a long history of lymphedema and peripheral vascular disease with chronic ulcerations. Wound NP #901 evaluated and noted dermatitis to Resident #14's bilateral lower extremities and venous stasis ulcers that were unmeasurable and scattered. Wound NP #901 documented the sites were weeping and ordered to continue Unna boots (a compression bandage that is applied to treat slow healing lower leg wounds and ulcers) for the open sites, leg elevation, and low sodium intake. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #14 had intact cognition, was independent with bed mobility, transfers, dressing, and toileting, had two venous and/or atrial ulcers and had applications of a wound dressing applied to her feet. Review of Resident #14's August 2022 physician orders revealed apply Unna boots to bilateral lower extremities and cover with ace wraps one time a week and as needed, pressure redistribution cushion to wheelchair, pressure redistribution mattress to bed, and weekly skin assessments on shower days. Review of Wound NP #901's progress note dated 07/22/22 revealed Resident #14 continued to have chronic venous stasis ulcers and dermatitis. Resident #14 had some scattered open blisters to her bilateral lower legs that were still weeping. Wound NP #901 recommended to continue Unna boots, wrap with Kerlix (gauze wrap), ace wraps and change weekly, decrease sodium intake, and elevate legs. Observation and interview on 08/23/22 at 10:27 A.M. revealed Resident #14 sitting up in the wheelchair with ace wraps on her bilateral lower legs. Resident #14 stated she had venous ulcers to her legs for several years related to lymphedema and poor circulation. Resident #14 revealed she refused the Unna boots to be applied this week and she was going to talk with Wound NP #901 to see if she could take a break from wearing them and instead just wear the acre wraps. Interview on 08/24/22 at 3:44 P.M. with the Director of Nursing (DON) verified Resident #14 had a long history of lymphedema, peripheral vascular disease, and chronic venous ulcers to her bilateral lower extremities. The DON revealed Resident #14 was seen weekly per Wound NP #901 for the ulcers. The DON verified Resident #14 did not have a comprehensive care plan that included wound management of Resident #14's chronic venous ulcers and/ or the management of her lymphedema to prevent skin impairment. 4. Review of the medical record for Resident #48 revealed an admission date of 03/15/22 and diagnoses of severe protein-calorie malnutrition, diabetes mellitus type 2 without complications, quadriplegia, and essential primary hypertension. Review of the significant change Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #48 had impaired cognition. Resident #48 was dependent on two staff assistance for bed mobility, transfers, and toileting. The assessment indicated Resident #48 was always incontinent of urine and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365875 If continuation sheet Page 11 of 21 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 08/25/2022 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 0656 bowel and had unhealed pressure ulcers, one which was present upon admission. Level of Harm - Minimal harm or potential for actual harm Review of wound physician progress notes, dated 03/15/22, revealed an unstageable (full-thickness tissue loss covered by necrotic (dead) tissue or eschar) pressure wound to the sacrum and bilateral buttocks which measured 10.1 centimeters (cm) length, 14.8 cm width and unknown depth. There was an abrasion related wound located on the mid back which measured 3.0 cm length, 1.1 cm width and unknown depth. There was a wound to the left third toe which measured 0.5 cm length, 0.8 cm width and had protruding depth. Residents Affected - Some Review of Resident #48's physician orders effective March 2022 revealed an order to cleanse the mid back abrasions with normal saline and apply [NAME] oxide cream daily; to cleanse left third toe with normal saline, cover with abdominal pad and wrap with Kerlix (gauze wrap) twice daily; to cleanse sacral wound with normal saline, pat dry and pack with alginate silver (wound dressing for moist wound beds), cover with foam dressing and apply zinc oxide cream to peri-wound twice daily; alternating air mattress every shift; apply house lotion to bilateral heels every shift; heel protectors to be worn while in bed every shift; pressure reduction mattress every shift; and repositioning for calming and comfort. Review of Resident #48's care plan, dated 03/15/22, revealed no focus area, goals, and interventions for the prevention of skin breakdown or impaired skin integrity. Interview on 08/24/22 at 8:53 A.M. with MDS Nurse #668 verified Resident #48's comprehensive care plan did not include a focus, goals, and interventions for the prevention of skin breakdown or treatment of impaired skin integrity. 5. Review of the medical record for Resident #37 revealed an admission date of 01/16/21 and diagnoses of chronic obstructive pulmonary disease, diabetes, hypertension, hyperlipidemia, severe obesity, schizoaffective disorder, and severe depressive disorder. Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #37 had intact cognition. Resident #37 was independent, after set up, for locomotion and required supervision of one staff member for dressing, limited assistance of one staff member for transfers and toileting, extensive assistance of one staff member for personal bathing, and total assistance of one staff member for bathing. Interview on 08/22/22 at 11:55 A.M. with Resident #37 revealed she smoked out in the facility smoking area, and she kept her cigarettes on her. Interviews on 08/24/22 at 9:56 A.M. with Activities #633 and on 08/24/22 at 1:21 P.M. with Licensed Practical Nurse (LPN) #646 confirmed Resident #37 smoked in the facility outdoor smoking area. Review of medical record for Resident #37 revealed a smoking assessment was completed on 07/09/21 which indicated Resident #37 smoked daily, had no cognitive loss, visual deficit, or dexterity problems, was safe to smoke outside, and did not require the facility to store her cigarettes or lighter. Review of medical record for Resident #37 revealed a smoking assessment was completed on 07/09/21 and indicated Resident #37 smoked daily, had no cognitive loss, visual deficit, or dexterity problems, was safe to smoke outside, and did not require the facility to store her cigarettes or lighter. Review of Resident #37's comprehensive care plan revealed the plan did not include a focus, goals, or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365875 If continuation sheet Page 12 of 21 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 08/25/2022 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 0656 interventions for smoking, until it was created on 08/23/22. Level of Harm - Minimal harm or potential for actual harm Interview on 08/24/22 at 1:21 P.M. with the Director of Nursing confirmed there was no care plan area related to smoking prior to 08/23/22. Residents Affected - Some Review of facility policy titled Care Plans, Comprehensive Person-Centered, with a revision date of December 2016, revealed the care plan would incorporate identified problem areas. Assessments of residents were ongoing and care plans were revised as information about the residents and the residents' condition changed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365875 If continuation sheet Page 13 of 21 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 08/25/2022 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review the facility failed to ensure the designated smoking area was maintained in a safe manner affecting all 23 residents (Residents #1, #2, #3, #8, #10, #11, #12, #14, #16, #20, #21, #23, #27, #31, #35, #37, #44, #45, #48, #51, #54, #156, #207) that smoked at the facility. The facility also failed to ensure Resident #31 was properly supervised and smoking materials were maintained by nursing as identified in her care plan and/or smoking assessment affecting one resident (Resident #31) out of three residents (Residents #31, #35, and #37) reviewed for smoking. The facility census was 58. Findings include: 1. Observation on 08/22/22 at 11:44 A.M. revealed a plastic garbage container without a cover was in the outside designated smoking area that was approximately three- fourths full of plastic and Styrofoam cups and paper debris. The garbage container also contained approximately 15 cigarette butts laying on top of the cups and paper debris, and cigarette ashes were observed inside the garbage container. There were seven cigarette butts and a pile of ashes on the ground surrounding the garbage container. A red metal fireproof receptacle was observed sitting next to the garbage container. Interview on 08/22/22 at 11:47 A.M. with the Director of Nursing verified the above findings and revealed no cigarette butts, or ashes should be in the garbage can or laying on the ground as they should be placed in the red fireproof container located next to the garbage can. Observation on 08/23/22 at 1:39 P.M. revealed the plastic garbage container was approximately half full of garbage that contained Styrofoam cups and paper debris. Observation revealed on top of the cups and debris was multiple cigarette butts. Interview on 08/23/22 at 1:39 P.M. with the Director of Nursing verified the above findings and revealed maintenance was supposed to have removed the plastic garbage container from the designated smoking area so that residents used only the fire proof containers in the area. The facility identified Residents #1, #2, #3, #8, #10, #11, #12, #14, #16, #20, #21, #23, #27, #31, #35, #37, #44, #45, #48, #51, #54, #156, #207 as residents who smoked at the facility. 2. Review of medical record for Resident #31 revealed an admission date of 03/09/20 and diagnoses including paranoid schizophrenia, major depression with severe psychotic features, asthma, mood disorder, and seizures. Review of Smoking Assessment 4.0-V2 dated 01/03/21 and completed by Registered Nurse (RN) #900 revealed Resident #31 used tobacco products. Resident #31's cognition was not included on the assessment, the area was blank. The assessment revealed Resident #31 was unable to independently access the outside smoking area, required supervision with smoking, and the facility needed to store Resident #31's lighter and cigarettes. Review of the care plan last revised 04/29/22 revealed Resident #31 had the potential for injury when smoking due to cognition related to major depression and paranoid schizophrenia. Interventions included cigarettes, matches and/ or lighters were to be kept at the nursing station, and staff were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365875 If continuation sheet Page 14 of 21 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 08/25/2022 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 0689 to educate resident and family on smoking policies. Level of Harm - Minimal harm or potential for actual harm Review of annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #31 had moderately impaired cognition as her brief interview cognitive status (BIMS) score was ten. Resident #31 required extensive assist of two people with bed mobility and transfer. Residents Affected - Some Observation on 08/23/22 at 4:43 P.M. revealed Resident #31 was outside smoking independently in the designated smoking area without staff in the area. Resident #31 had two cigarettes with her. Interview on 08/23/22 at 4:43 P.M. with Resident #31 revealed she went out to smoke anytime and did not require supervision. Resident #31 revealed she obtained her cigarettes from the nursing station and did not have a lighter, she had Resident #3 light her cigarettes. Interview on 08/23/22 at 4:45 P.M. with Licensed Practical Nurse (LPN) #623 revealed Resident #31 went outside and smoked independently and did not require supervision. LPN #623 revealed nursing maintained Resident #31's cigarettes at the nursing station but that there were no lighters maintained at the nursing station. LPN #623 was unsure how Resident #31 lit her cigarettes. Observation on 08/24/22 at 9:08 A.M. revealed Resident #31 propelling back to her room with a lighter in her left hand. Interview on 08/24/22 at 9:09 A.M. with RN #636 and State Tested Nursing Assistant (STNA) #618 verified Resident #31 had a lighter in her left hand. They revealed that Resident #31 was independent with smoking and maintained her lighter in her room. Observation on 08/24/22 at 10:00 A.M. with STNA #618 verified Resident #31 had a half previous lit cigarette and lighter in the top drawer of her nightstand in her room. Interview on 024/22 at 10:00 A.M. with STNA #618 verified, after review of Resident #31's care plan and assessment, that Resident #31 was to be supervised when she smoked, and she was to keep her cigarettes and lighters at the nursing station. Interview on 08/24/22 at 11:02 A.M. with the Director of Nursing verified Resident #31's care plan and smoking assessment identified Resident #31 was to be supervised when smoking and was to have her lighter and cigarettes maintained at the nursing station. Review of facility policy labeled, Resident Smoking last revised 09/20/21 revealed the facility would establish and maintain safe resident smoking practices. The policy revealed metal containers with self-closing cover devices were available in the smoking area and that ashtrays were only to be emptied into designated receptacles. The policy revealed a resident's ability to smoke safely would be evaluated upon admission, in the event of significant change, and/ or if the resident was observed by staff to require a new assessment. The policy revealed any smoking privileges, restrictions and concerns would be noted on the care plan and all personnel caring for the resident shall be alerted to these issues. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365875 If continuation sheet Page 15 of 21 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 08/25/2022 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the physician acted upon the recommendations by the pharmacist for Resident #42. This affected one of five residents reviewed for unnecessary medications. Findings include: Review of the medical record revealed Resident #42 revealed the resident was admitted to the facility on [DATE] with diagnoses including pneumonia, vascular dementia with behavioral disturbance, hyperlipidemia, hypertension, hypothyroidism, psychosis, COVID 19, cerebral infarction. Review of the current physician orders revealed Resident #42 was ordered ibuprofen (a non-opioid analgesic) 500 milligrams as needed for pain and oxycodone (an opioid analgesic) for pain. There were no parameters as to when to administer the non-opioid or opioid analgesic. Review of the pain evaluation dated 06/15/22 indicated Resident #42 had general pain, occasionally, made it hard to sleep at night, limited her day to day activities, movement increased her pain, pain meds only help. Description was aching. Pain management indicated she received a scheduled pain medication regimen related to sleepiness. Review of Resident #42's care plan revealed there was no plan related to pain management. Review of the medication regimen review by the pharmacist on 07/06/22 indicated the use of oxycodone as needed was inappropriate. There was no evidence the physician reviewed the recommendation. Interview with the Assistant Director of Nursing Registered Nurse (RN) #653 on 08/25/22 at 7:30 A.M. indicated parameters for the use of both analgesic medications should have been specified, care planned and the physician should have reviewed and acted upon the pharmacy recommendations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365875 If continuation sheet Page 16 of 21 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 08/25/2022 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review the facility failed to ensure a bottle of Dakin's (diluted bleach solution) was secured in Resident #30 and Resident #48's room located on the secured unit. This affected two (Residents #30 and #48) out of seven Residents (#8, #15, #28, #29, #30, #48, and #256) reviewed for unsecured medications and/ or treatment supplies in their rooms. This had the potential to affect 18 residents (Resident #11, #12, #13, #16, #20, #24, #25, #27, #30, #32, #40, #48, #49, #50, #51, #52, #54, #156, #256) on the secured unit that were independent with ambulation and/or locomotion or unsecured medication was located in their room. Findings include: 1. Review of the medical record for Resident #48 revealed an admission date of 03/15/22 and diagnoses included chronic obstructive pulmonary disease, diabetes, quadriplegia, alcohol abuse, and borderline personality disorder. Review of the care plan dated 04/03/22 revealed Resident #48 required the secured behavioral unit as he had disruptive behaviors related to his borderline personality disorder that included biting, kicking, spitting, cussing, and refusing care. Interventions included attempt to ascertain events proceeding exacerbation and escalation of behaviors. Review of significant change Minimum data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #48 was rarely or never understood. He required total dependence of two people with bed mobility and transfer and was unable to ambulate. Review of physician orders for August 2022 revealed Resident #48 had the following orders: cleanse right heel wound area with normal saline, pat dry, apply Dakin's wet to dry dressing and cover with foam pad every night shift, and cleanse sacral wound area with normal saline, pat dry, apply Dakin's wet to dry dressing and cover with foam dressing every night shift. Observation on 08/22/22 at 10:03 A.M. revealed Resident #48 was laying in his bed and on his night stand next to his bed was a bottle of Dakin's solution that was one fourth full. Interview on 08/22/22 at 10:04 A.M. with Licensed Practical Nurse (LPN) #646 verified the above findings and revealed that there were several cognitively and mentally impaired residents residing on the secured unit including Resident #30 who resided in the same room as Resident #48. She revealed Resident #48's wound dressings were completed on night shift and the nurse must have left the bottle in the room unsecured. 2. Review of medical record for Resident #30 revealed an admission date of 02/23/22 and diagnoses included schizophrenia, and dementia. Review of census revealed Resident #30 was Resident #48's roommate. Review of the care plan dated 03/09/22 revealed Resident #30 was at risk for impairment of speech and altered cognition related to dementia. He had a lack of awareness of thinking, behavioral changes, lack of judgement and loss of thought process. Interventions included cue and supervised decision (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365875 If continuation sheet Page 17 of 21 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 08/25/2022 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 0761 making, speak slowly to resident and notify physician and family of condition changes. Level of Harm - Minimal harm or potential for actual harm Review of quarterly MDS 3.0 assessment dated [DATE] revealed Resident #30 had a brief mental status (BIMS) score of a 14 (suggests cognition is intact). Resident #30 required supervision with ambulation. Residents Affected - Few Observation on 08/22/22 at 10:03 A.M. revealed Resident #30 was sitting on the side of his bed and on his roommates, Resident #48's nightstand was a bottle of Dakin's solution that was one fourth full. Review of facility policy labeled, Storage of Medications dated April 2007 revealed the facility shall store all drugs and biological's in a safe secure and orderly manner. The policy revealed nursing staff was responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. The policy revealed antiseptics, disinfectants and germicides used in any aspect of resident care must be stored separately from regular medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365875 If continuation sheet Page 18 of 21 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 08/25/2022 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, staff interview and policy review, the facility failed to maintain the kitchen area in a clean and sanitary condition. This had the potential to affect 57 of 58 residents who resided in the facility. The facility identified one resident (#30) who did not receive food from the kitchen. Findings include: Observation during the tour of the kitchen with Assistant Dietary Manager #624 on 08/22/22 at 8:30 A.M. revealed the following: - An accumulation of dust on the evaporator fans hanging from the ceilings of both the walk in freezer and walk in refrigerator. There was so much dust on them you could see strings of dust blowing from the fans. Food items were stored in both of these areas. - Four sealed boxes (one each of broccoli, Brussel sprouts, oriental blend, and carrots) sitting on the floor of the walk-in freezer. - One undated and resealed bag of three breaded chicken patties; one undated and resealed bag of ten lasagna rolls; one undated and resealed half full bag of diced chicken; and one undated and resealed bag of eight country fried steak patties sitting on the walk-in freezer shelving. - One square plastic storage container of tuna salad in the reach-in refrigerator dated 08/15/22 on the lid. - Four loaves of wheat bread on the bread rack in the dry storage room with a use by date of 08/13/22 printed on the bread bag. - [NAME] splash marks on the base and underside of the stand mixer. - One white plastic scoop stored in the plastic bulk sugar container. Interview at the time of the observation with Assistant Dietary Manager #624 verified the above findings. Observation of the kitchen on 08/23/22 at 9:10 A.M. revealed visible dust in the filters above the stove. Interview at the time of the observation with Assistant Dietary Manager #624 confirmed the filters were dusty. Review of facility policy titled Dry Storage, with a revised date of 12/01/15, indicated scoops are stored, covered and outside of dry bulk containers, open packages are stored in closed containers, tightly secured with ties or in food quality storage bags and included the use by date. Review of facility policy titled Refrigerated/Frozen Storage, with a review date of 10/01/15, indicated food is dated with a use by date when opened. If removed from original container, foods are completely covered and labeled with the name of the product and use by date. Freezers and refrigerators are to be kept clean and organized. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365875 If continuation sheet Page 19 of 21 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 08/25/2022 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 0921 Level of Harm - Minimal harm or potential for actual harm Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, interview and policy review, the facility failed to maintain a clean and sanitary environment for residents, employees and visitors. This affected all 58 residents in the facility. Residents Affected - Many Findings include: General observations made on 08/22/22 at 9:15 A.M. revealed the carpeted hallways were significantly stained and worn. Observation of the smoking area on 08/22/22, 08/23/22 and 08/24/22 revealed two long wrought iron couches. One couch had no cushions. The other wrought iron couch had three discolored cushions. The cushions were lumpy and not flat. The smokers from the secured unit were observed being led to the designated smoking area. There were nine residents identified as smokers who resided on the secured unit (#11, #20, #27, #44, #48, #51, #54, #156 and #207). Four Residents (#20, #27, #54 and #156) were identified as ambulatory and would need a seat during smoking. Interview with Resident #26 on 08/22/22 at 12:08 P.M. reported his wheelchair was not cleaned. Observation of Resident #26's wheelchair at the time of the interview revealed the rungs under the seat were thick with dust and debris. Interview with Resident #45 on 08/22/22 at 2:24 P.M. reported his air conditioner vent and fans were thick with dust. He and his roommate were oxygen dependent and felt this was not good for them. Observations at the time of the interview revealed Resident #45's air conditioner was located near the ceiling. The louvers were thick with gray dust and debris and the fan was also thick with dust and debris. Interview with Environmental Services Director (ESD) #647 on 08/24/22 at 7:15 A.M. reported a few residents sat in the dining room and watched television until late at night and there were spills and other food stuffs. There was no third shift housekeeper so it would be the responsibility of the aides to clean up spills after hours. ESD #647 reported she cleaned air conditioner vents and personal fans as needed. Personal fans would be brought to the basement, the cages removed and they would be thoroughly cleaned. The aides were responsible for the cleaning of wheelchairs. Interview with Resident #1 on 08/25/22 at 11:00 A.M. reported there was no place for all the residents from the secured unit to smoke. She pointed out they all have to smoke at designated times and there was no where for them to sit. Observations with ESD #647 on 08/24/22 at 7:36 A.M. verified the air conditioning vent and fan were heavily soiled in Resident #45's room. On 08/25/22 at 8:09 A.M. the administrator verified the severely stained and worn carpet of black, brown and red. The centers of the hall carpet were much darker than the perimeter. The small hall from the dining room to the nurses station was severely worn and black in the middle. The administrator reported he had reported the concern related to the condition of the carpet to the owner. Further observation and interview revealed the smoking area had two ashtray stacks. There were three residents smoking, Resident #45, Resident #3, and Resident #35. Resident #35 said there was not enough ashtrays for all who smoked. There were two wrought iron couches and one chair. One of the couches had no cushions and the seat of the chair was broken and sharp. The residents reported they couldn't have (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365875 If continuation sheet Page 20 of 21 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 08/25/2022 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many cushions because people were burning holes in them. Resident #3 said his butt hurt from sitting directly on the wrought iron. Review of the housekeeping and pest control policy revised in March 2004 indicated the procedure was to provide guidelines for cleaning and disinfecting the environment in order to reduce the potential or spread of nosocomial infections due to environmental contamination and vector borne spread. Room cleaning, clean personal use items (lights, phone, call bells, beds rails) with disinfectant at least twice weekly. Clean curtains, blinds and walls when visibly soiled or dusty. Review of the resident smoking policy revised 09/20/21 indicated the facility would establish and maintain safe resident smoking practices. Prior to, or upon admission, residents would be informed of the facility smoking policy, including designated smoking areas and the extent to which the facility could accommodate their smoking or nonsmoking preferences. Metal containers, with self-closing cover devices were available in the smoking areas. Ashtrays were emptied only into designated receptacles. Any smoking-related privileges, restrictions and concerns should be noted on the care plan and all personnel caring for the resident should be alerted to these issues. This deficiency substantiates Complaint Number OH00131592. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365875 If continuation sheet Page 21 of 21