Health inspection·April 15, 2022

F 0569 Level of Harm - Minimal harm or potential for actual harm Interview on [DATE] at 4:41 P.M. with Director of Social Services (DOSS) #577 indicated she also did not provide residents and/or their representatives with spend-down letters. The above findings were also verified with the Administrator and Assistant Administrator (AA) #547 during an interview on [DATE] at 4:45 P.M. Residents Affected - Few No policy regarding resident funds was available during the survey. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365926 If continuation sheet Page 2 of 22 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 365926 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Normandy Manor of Rocky River 22709 Lake Rd Rocky River, OH 44116 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility policy review, the facility failed to prevent resident to resident sexual abuse. This affected affected four residents (Resident #35, Resident #39, #47, and #95) of four residents reviewed for abuse. The facility census was 88. Findings include: Review of the medical record for Resident #35 revealed an admission date of 06/27/14, with diagnoses including unspecified diastolic congestive heart failure, osteoporosis, history of falling, glaucoma, type 2 diabetes, Parkinson's disease, obsessive-compulsive disorder, unspecified dementia, anxiety disorder, major depressive disorder, and delusional disorder. Review of the progress notes dated 11/18/21 at 1:15 P.M. revealed a state tested nursing assistant (STNA) observed Resident #35 with his hand on the breast of a female resident. The residents were immediately separated, and Resident #35 was wheeled back to his room and placed in bed at his request. Review of the progress notes dated 01/16/22 at 11:55 A.M. revealed Resident #35 was observed with hands inside a disoriented female resident's shirt, on her breasts (Resident #39). The residents were separated, and Resident #35 was talked to about his behavior. After being separated, Resident #35 again approached the same resident (Resident #39) and started rubbing her legs. The female resident (Resident #39) was heard saying please don't do that and the residents were again separated. Staff would continue to monitor closely. Further review of Resident #35's progress notes revealed no further evidence of alleged sexual abuse incidents. Review of the quarterly minimum data set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact with a brief interview for mental status (BIMS) of 13. He exhibited no behaviors and required supervision for locomotion in a wheelchair throughout the facility. Review of the care plan dated 04/03/22 revealed Resident #35 had a history of exhibiting affection that may be distressing to other residents, and resident's friends, and/or family members. Interventions included considering other options or resident's tactile pleasure or social intimacy, educating staff and family regarding normalcy of affectionate behaviors and discuss clear plans to divert and discourage displays, and subtly try to divert resident's attention at the earliest signs of growing affection. Further review of the care plan revealed the resident had exhibited episodes of being sexually inappropriate towards other residents. Interventions included redirecting the resident when being sexually inappropriate and explain why the behavior was not appropriate, as well as monitoring and documenting signs and symptoms of resident posing danger to self and others and behaviors observed. 1. Review of the medical record for Resident #47 revealed an admission date of 03/04/21 with diagnoses including cerebral palsy, intestinal obstruction, delirium due to unknown physiological condition, dementia, and epilepsy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365926 If continuation sheet Page 3 of 22 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 365926 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Normandy Manor of Rocky River 22709 Lake Rd Rocky River, OH 44116 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the quarterly MDS 3.0 assessment dated [DATE] revealed the resident was severely cognitively impaired with a BIMS of 00. She exhibited physical and verbal behaviors, received routine antipsychotics, and required supervision for locomotion throughout the facility. Review of the care plan dated 03/03/22 revealed Resident #47 had impaired cognitive function and impaired thought process related to being developmentally delayed, having dementia with behavioral disturbances, and a potential for delusions related to dementia. Interventions included to reorient and supervise resident as needed. Review of the progress notes dated 11/18/21 at 1:20 P.M., revealed an STNA observed a male resident with his hand on her breast while she was sitting in her wheelchair in the doorway of her room. Review of the self-reported incident (SRI) #21441 dated 11/18/21 revealed STNA #615 observed Resident #35 in a wheelchair sitting outside of Resident #47's room touching her breast. The conclusion of the investigation by the Director of Nursing (DON) was that the interaction between Resident #35 and Resident #47 was not sexual or physical abuse as STNA #615 assumed the placement of Resident #35's hand on Resident #47 was inappropriate, but she could not clearly see the interaction related to the touching. Staff would closely monitor the two residents and keep them separated. 2. Review of the medical record for Resident #39 revealed an admission date of 09/14/19. Diagnoses included Alzheimer's disease, unspecified dementia, essential hypertension, type 2 diabetes, and muscle weakness. Review of he quarterly MDS 3.0 assessment dated [DATE] revealed the resident had severe cognitive impairment with a BIMS of 3, exhibited no behaviors, and was supervision for locomotion in wheelchair throughout the facility. Review of the care plan dated 03/27/22 revealed the resident was an elopement risk as resident was disoriented and wandered. Interventions included placing a wander guard monitor to the left ankle and reporting changes in decision making ability, memory, understanding others, and general awareness. Review of the progress notes for Resident #39 lacked documentation regarding the incident that occurred on 01/16/22 involving Resident #35. Resident #39 resided in the 300 hall during the time of the incident on 01/16/22 as her room on the 800 hall was being renovated. The 300 hall was adjacent to the 400 hall, where resident #35 resided, and the halls shared common areas. Review of SRI #216841 dated 01/19/22 revealed housekeeper #608 reported to Registered Nurse (RN) #609 on 01/16/22 at 11:55 A.M. that Resident #35 was observed behind resident #39 with his arms around her and touching her breast. RN #609 intervened and observed Resident #35 with his hands inside Resident #39's shirt on her breasts. The conclusion of the investigation revealed the DON believed that Resident #35 thought Resident #39 was his girlfriend. Since Resident #39 had been coming to the common area of Resident #35 and spending time with him, it was unclear to the DON if the interaction observed on 01/16/22 was consensual. Interview on 04/13/22 at 2:15 P.M. with the Administrator and the DON revealed the SRI #216841 was unsubstantiated because it could not be determined if the actions during the incident were consensual as Resident #39 had been witnessed kissing Resident #35 after she approached him and both residents wanted intimacy. The facility was not allowing Resident #35 to have a girlfriend and they feel the situation had been resolved. The DON stated it was a fine line between abuse and consensual (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365926 If continuation sheet Page 4 of 22 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 365926 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Normandy Manor of Rocky River 22709 Lake Rd Rocky River, OH 44116 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 interactions of intimacy. Level of Harm - Minimal harm or potential for actual harm Interview on 04/13/22 at 4:50 P.M. with Clinical Manager (CM) #585 revealed Resident #39 seeks out Resident #35 even though they had been separated and live on opposite ends of the building. Resident #39 wheeled herself to the 400 hall where Resident #35 resided on several occasions. Staff would take her back to her unit on the 800 hallway. For about three months the two residents would watch television together in the library and hold hands. This was no longer occurring since they were separated. Residents Affected - Few Interview on 04/13/22 at 5:05 P.M. with Licensed Practical Nurse (LPN) #630 revealed Resident #39 was not cognitively intact to provide consent for intimacy or sexual actions. 3. Review of the medical record for Resident #95 revealed an admission date of 02/15/22 and a discharge date of 03/04/22. Diagnoses included displaced fracture of right femur, unspecified dementia, altered mental status, urinary tract infection, chronic kidney disease, and type 2 diabetes. Review of the discharge MDS 3.0 assessment dated [DATE] revealed the resident had a BIMS of 4 and exhibited wandering behaviors. Review of the care plan dated 02/16/22 revealed Resident #95 had impaired cognitive function/impaired thought process related to dementia and altered mental status. Interventions included cueing, re-orienting, and supervising as needed using consistent simple directives. Review of the progress notes lacked documentation regarding the alleged incident that occurred on 03/03/22. Review of SRI #218597 dated 03/03/22 revealed Resident #95 reported to Speech Therapist (ST) #631 on 03/03/22 at 3:25 P.M. that a male resident had touched her breast the previous day (03/02/22). Resident #95 told ST #631 she thought the man was lonely to do something like that. No male resident was observed in the vicinity during the time the incident was reported to ST #631. DON interviewed Resident #95 on 03/03/22 at 3:45 P.M. verified the man touched her breast, but a name or identity was not provided. Resident #95 was seen earlier in the day approaching Resident #35 and offering him a snack. Resident #35 denied he touched Resident #95's breast. Staff had separated Resident #95 and Resident #35 during previous interactions as they were aware of Resident #35 having a history of seeking female companionship. The conclusion of the SRI by the DON revealed it was uncertain if Resident #35 touched the breast of Resident #95 as she could not provide clear details of the occurrence. Resident #95 discharged from the facility on 03/04/22. Review of the facility policy titled, Abuse, Neglect, Misappropriation, Mistreatment Policy and Procedure, dated 05/14/21, revealed instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It included physical, mental, or sexual abuse. Sexual abuse was any non-consensual sexual act of any type with a resident, including resident to resident contact. Residents would not be subjected to abuse by anyone, including other residents. The goal of the facility was to protect residents from abuse, including sexual abuse, through the development of Operational policies and procedures. The facility recognized its' obligation to keep its' residents safe and to protect them from any harm to whatever extent possible and within acceptable standards of practice by following the abuse protocol. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365926 If continuation sheet Page 5 of 22 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 365926 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Normandy Manor of Rocky River 22709 Lake Rd Rocky River, OH 44116 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on interview, medical record review, and facility policy review, the facility failed to report allegations of abuse in a timely manner as required. This affected one resident (Resident #39) of three residents reviewed for reporting allegations of abuse. The facility census was 88. Findings include: Review of the facility Self-Reported Incident (SRI) #216841 dated 01/19/22 revealed the incident was reported on 01/19/22 but occurred on 01/16/22 at 11:55 A.M. Review of the progress notes for Resident #35 revealed a behavior progress note dated 01/16/22 at 11:55 A.M. stating Resident #35 was observed with hands inside a disoriented female resident's shirt, on her breasts (Resident #39). The residents were separated, and Resident #35 was talked to about his behavior. After being separated, Resident #35 again approached the same resident (Resident #39) and started rubbing her legs. The female resident (Resident #39) was heard saying please don't do that and the residents were again separated. Staff would continue to monitor closely. The progress notes lacked documentation of reporting the incident to Director of Nursing (DON) or the Administrator. Interview on 04/13/22 at 11:43 A.M. with DON verified the incident involving sexual abuse occurred on 01/16/22 and was not reported until 01/19/22. Review of the facility policy titled, Abuse, Neglect, Misappropriation, Mistreatment Policy and Procedure dated 05/14/21, revealed facility staff would immediately report any allegations of abuse, including sexual abuse, to the Administrator. If the Administrator was not in the facility, the individual reporting the alleged violation of mistreatment, neglect, or abuse to the DON. The Administrator must be contacted immediately, regardless of day or time. All allegations and known events of mistreatment, neglect, abuse, injuries of unknown origin, or misappropriation of property were to be reported to the Ohio Department of Health immediately, but no later than four hours after forming a suspicion. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365926 If continuation sheet Page 6 of 22 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 365926 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Normandy Manor of Rocky River 22709 Lake Rd Rocky River, OH 44116 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 ensure Minimum Data Set (MDS) assessments were completed following the death of a resident. This affected one resident (Resident #1) of two reviewed MDS assessments. Residents Affected - Few Findings include: Review of closed medical record for Resident #1 revealed an admission date of 09/26/21 and a date of death of [DATE] with diagnoses of unspecified protein-calorie malnutrition, delirium due to physiological condition, anorexia, anemia, hypertension, dementia without behavioral disturbance. No MDS was found to be completed following the death of the Resident #1 on 12/16/21. Interview on 04/14/22 at 12:20 P.M. with Clinical Manager #585 confirmed no MDS was completed following death at the facility for Resident #1. Review of November 2019 revised facility policy titled, MDS Assessment Coordinator, revealed a Registered Nurse (RN) will conduct and coordinate the completion of the MDS. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365926 If continuation sheet Page 7 of 22 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 365926 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Normandy Manor of Rocky River 22709 Lake Rd Rocky River, OH 44116 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 record review and staff interview, the facility failed to ensure a resident with a level two mental illness was screened by the appropriate state agency (The Ohio Department of Mental Health) for services and placement in the nursing facility. This affected one resident (Resident #90) of two residents reviewed for Pre-admission Screen and Resident Review (PASRR) status Residents Affected - Few Findings Include: Review of the medical record revealed Resident #90 was initially admitted from the hospital on [DATE] and readmitted on [DATE] with diagnoses including dementia with behavior, unspecified psychosis, and major depressive disorder. Review of the hospital exemption PASRR screening form dated 11/07/17 for Resident #90 did not reveal a level of mental illness and/or developmental disability. Interview on 04/12/22 at 10:00 A.M. with Social Worker (SW) #567 revealed PASRR for Resident #90 was unable to be located. Interview on 04/13/22 at 12:56 P.M. with SW #577 revealed she was unable to locate a completed PASRR for Resident #90 since admission on [DATE] or readmission on [DATE] and stated a PASRR was completed for Resident #90 on 04/12/22 and therefore the facility had not notified the appropriate state agency (The Ohio Department of Mental Health.) timely following admission on [DATE] or readmission on [DATE]. Review of undated facility policy titled, Coordination-Pre-admission Screening and Resident Review (PASRR) program, revealed all residents admitted to the facility should receive a PASRR in accordance with State and Federal Regulations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365926 If continuation sheet Page 8 of 22 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 365926 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Normandy Manor of Rocky River 22709 Lake Rd Rocky River, OH 44116 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of facility policy, the facility failed to provide appropriate care and services and ensure physician orders were followed for one Resident #444 to prevent pressure ulcers from developing on the buttocks, thighs, and sacral area. This affected one resident (Resident #444) out of three residents reviewed for wounds. Residents Affected - Few Findings include: Review of Resident #444's medical record revealed an admission date of 03/23/22 and diagnoses included osteomyelitis, hemangioma of intracranial structures, and paraplegia. Resident #444 was discharged from the facility on 04/11/22. Review of Resident #444's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed Resident #444 was cognitively intact and required extensive assistance of two staff members for bed mobility and transfers. Resident #444 required total dependence of one person for toilet use. Resident #444 did not have a pressure ulcer, had an indwelling catheter and was frequently incontinent of bowel. Review of Resident #444's Braden Scale for Predicting Pressure Sore Risk dated, 03/23/22 revealed Resident #444 was at moderate risk for developing a pressure ulcer or injury. Review of Resident #444's care plan dated 03/23/22, did not reveal a care plan for skin integrity and the potential for developing a pressure ulcer or injury. Review of Resident #444's physician orders on 03/24/22 revealed strict repositioning every two hours every shift for skin integrity. Review of Resident #444's Occupational Therapy Progress Note on 03/30/22 did not reveal documentation of redness, bleeding to his thighs and buttocks. Review of Resident #444's Skin Observation Tool on 03/30/22 at 4:24 P.M. revealed Resident #444 had a left buttock skin tear, wound nurse aware. There was no documentation of the left buttock wound measurement or characteristics including wound bed and drainage. Review of Resident #444's progress notes on 03/31/22 at 3:47 P.M. revealed Resident #444 had a circular redness to the buttocks and upper thighs. Scattered open areas and a blister at the base of the spine were noted. Resident #444 was questioned, and stated he could not feel, and had fallen asleep on the bedpan two nights ago. Review of Resident #444's physician orders on 03/31/22 revealed buttocks and upper thighs, cleanse red, open areas with normal saline and pat dry. Apply Calmasyn ointment (skin protectant) to open areas and cover area with large sacral foam and foams as needed to cover area. Review of Resident #444's Investigation of Skin Alteration dated 03/31/22 included State Tested Nursing Assistant Supervisor (STNAS) #631 wrote she was notified by Nursing Supervisor/Wound Nurse #585 of a pressure area for Resident #444 due to being on a bedpan for an extended period of time. STNAS #631 immediately followed up with nurses and STNAs to inform them of the pressure area for Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365926 If continuation sheet Page 9 of 22 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 365926 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Normandy Manor of Rocky River 22709 Lake Rd Rocky River, OH 44116 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few #444 and the importance of turning and repositioning him every two hours. STNAS #631 made rounds periodically to check on Resident #444 and mad sure he was turned and repositioned. Review of Resident #444's Treatment Administration Record (TAR) on 03/29/22, 03/30/22 and 03/31/22 revealed although Resident #444 was left on a bedpan many hours one of those days, the documentation stated he was turned and repositioned every two hours. Review of Resident #444's progress notes from 03/27/22 through 04/04/22 did not reveal documentation Resident #444 refused to be turned and repositioned. Review of Resident #444's medical record from 03/28/22 through 04/04/22 did not reveal documentation of size, measurements, drainage, or description of wound bed for Resident #444's pressure ulcers on his buttocks, sacrum, and upper thighs. Interview on 04/11/22 at 9:34 A.M. with Resident #444 revealed a couple nights ago he needed to use the bedpan, a staff member put him on a large bedpan around 1:00 A.M. and he was left on the bedpan until the next morning. Resident #444 stated he was not taken off the bedpan until 11:00 A.M. Resident #444 revealed he did not know the name of the staff member who put him on the bedpan. Resident #444 revealed he developed large blisters on his butt from the bedpan, he was a paraplegic and could not feel anything in that area, and did not know anything was wrong until two days later when blood, blisters and open areas on his bottom were observed by facility staff. Resident #444 verified the sores went all the way down to his thighs. Resident #444 stated the staff did not turn and reposition him every two hours, and rarely turned and repositioned him at all. Observation on 4/11/22 at 10:09 A.M. of Resident #444's wounds with Nursing Supervisor/Wound Nurse #585 revealed the buttocks, sacral area and upper thighs had a reddened circular ring extending in a circle. Multiple scabs were noted in the circular ring, and multiple open areas with dressings covering the area with a moderate amount of pinkish yellow noted on the dressings. When the dressings were removed, multiple open areas approximately two to three inches long and one inch wide with pink wound beds were noted. Nursing Supervisor/Wound Nurse #585 applied calmoseptine ointment (skin protectant) and foam border dressings to the area. Interview on 04/13/22 at 1:40 P.M. of Nursing Supervisor/Wound Nurse (NS/WN) #585 confirmed the wounds on Resident #444's buttocks and thighs were caused by laying on a bedpan many hours. NS/WN #585 indicated she was called to Resident #444's room on 03/31/22 by Occupational Therapist (OT) #630. OT #630 rolled Resident #444 onto his side, and RN/WN #585 observed a reddened ring area with open wounds surrounding Resident #444's buttocks. RN/WN #585 stated the red ring surrounded Resident #444's entire buttock area including the upper thighs, and there were open bleeding areas on both sides of the buttocks, and a blister in the sacral area . RN/WN #585 stated Resident #444 told her two nights prior his wife visited the facility, they argued and he forgot he was on the bedpan. RN/WN #585 revealed State Tested Nursing Assistant (STNA) #623 was assigned to care for Resident #444 the night the bedpan was not removed, and STNA #623 told her she heard the resident and his wife fighting and did not go in the room during the night. RN/WN #585 revealed it was unclear who placed Resident #444 on the bedpan. RN/WN #585 stated she educated STNA #623 and all the staff on the need to enter Resident #444's room to check on him and provide care. When asked about the documentation on the Skin Observation Tool on 03/30/22 at 4:24 P.M. regarding a left buttock skin tear and a note stating the wound nurse was notified NS/WN #585 indicated she did not recall receiving a wound alert, had left for the day and did not remember seeing it on 03/31/22. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365926 If continuation sheet Page 10 of 22 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 365926 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Normandy Manor of Rocky River 22709 Lake Rd Rocky River, OH 44116 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 04/13/22 at 3:30 P.M. with Occupational Therapist (OT) #630 revealed she entered Resident #444's room around 11:00 A.M. to work with him, and when he was rolled onto his side to put the bedpan under him she saw redness, bright pink areas and bleeding all around the buttocks and thighs. Resident #444 stated he slept with the bedpan under him two nights ago, could not remember who put the bedpan under him. OT #630 stated she told Registered Nurse (RN) #609 immediately about the reddened, bleeding areas on Resident #444's buttocks and thighs. OT #630 stated she worked with Resident #444 on 03/30/22 but didn't see his bottom because he was already dressed with his pants on. Interview on 04/14/22 at 11:55 A.M. with State Tested Nursing Assistant (STNA) #592 revealed STNA #592 stated she usually worked day shift on the nursing unit Resident #444 resided on. STNA #592 indicated she entered Resident #444's room on 03/31/22 between 10:00 A.M. and 12:00 P.M. with Occupational Therapy Assistant (OTA) #630 to provide care for Resident #444. STNA #592 stated when Resident #444 was turned on his side she could see small and large blisters, black and blue areas, bleeding, and a bed pan ring on his buttocks, thighs and sacral area. STNA #592 stated Resident #444 told her he was left on the bedpan all night by a short, black girl with glasses a couple nights ago. STNA #592 stated Resident #444 needed assistance and could not put himself on the bedpan. STNA #592 stated she did not turn and reposition Resident #444 before 10:00 A.M. because he was usually drowsy in the morning. STNA #592 stated Resident #444 did not refuse care and would allow care to be provided. Review of the facility policy titled, Wound Care, undated, included review the resident's care plan to assess for any special needs of the resident. The policy included all assessment data, for example, wound bed color, size, drainage obtained when inspecting the wound. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365926 If continuation sheet Page 11 of 22 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 365926 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Normandy Manor of Rocky River 22709 Lake Rd Rocky River, OH 44116 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 - Few 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 Resident #78 wore a hand splint per physician order. This affected one resident (#78) out of two residents reviewed for positioning and range of motion (ROM). Findings include: Review of Resident #78's medical record revealed an admission date of 09/25/17 with diagnosis including dementia with behaviors disturbance and contracture of the left hand. Review of the quarterly admission Minimum Data Set (MDS) dated [DATE] revealed the resident was severely cognitively impaired. Review of the physicians orders from April 2022 revealed an order on 03/07/22 for a left hand splint to remain on at all times except during hygiene care. Observation on 04/12/22 at 8:45 A.M. revealed Resident #78 was in the common room not wearing a hand splint. Observation on 04/13/22 at 4:46 P.M. revealed Resident #78 was in the common room not wearing a hand splint. Interview on 04/13/22 at 4:52 P.M. with Licensed Practical Nurse (LPN) #528 revealed the LPN didn't know about an order for a hand splint for Resident #78. LPN #528 verified Resident #78 was not wearing a splint. Interview on 04/13/22 at 4:55 P.M. with LPN #574 revealed she knew resident's hand was contracted and he was supposed to wear a splint, but was resistant to it. The LPN verified Resident #78 was not wearing the splint. Interview on 04/13/22 at 5:15 P.M. with Director of Nursing verified there was an order for a hand splint but it was not showing up on the Treatment Administration Record (TAR) to be signed off on when applied. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365926 If continuation sheet Page 12 of 22 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 365926 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Normandy Manor of Rocky River 22709 Lake Rd Rocky River, OH 44116 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, record review and review of facility policy, the facility failed to ensure oxygen for one resident (Resident #93) was administered per physician orders. This affected one resident (Resident #93) out of three residents reviewed for oxygen administration. Residents Affected - Few Findings include: Review of Resident #93's medical record revealed an admission date of 03/18/22 and diagnoses included chronic atrial fibrillation, biventricular heart failure, and chronic venous hypertension with ulcer and inflammation of the right lower extremity. Review of Resident 93's admission Minimum Data Set (MDS) 3.0 assessment dated , 03/26/22 revealed Resident #93 required the extensive assistance of one staff member for bed mobility, was total dependence of two staff members for transfers, and total dependence of one staff member for toilet use. Resident #93 used oxygen. Review of Resident #93's care plan dated, 03/21/22 included Resident #93 had altered respiratory status, difficulty breathing related to risk for COVID-19. Resident #93 would maintain normal breathing pattern as evidenced by normal respirations, normal skin color, and regular respiratory rate pattern through the review date. Interventions did not include oxygen use or parameters for administration of oxygen. Review of Resident #93's physician orders from 03/18/22 through 04/11/22 did not reveal orders for administration of oxygen. Review of Resident #93's medical record from 03/19/22 through 04/11/22 revealed documentation of oxygen saturation levels for oxygen via nasal cannula on 03/26/22, 03/27/22, 03/28/22, 03/30/22, 03/31/22, 04/01/22, 04/03/22, 04/05/22, 04/09/22, 04/10/22, and 04/11/22. Observation on 04/11/22 at 12:40 P.M. of Resident #93 revealed she was sitting in a wheelchair, wearing a nasal cannula, there was an oxygen concentrator next to the wheelchair, and the oxygen tubing had popped off the concentrator and was laying on the floor. Observation of the oxygen concentrator revealed it was set to administer oxygen at three liters per minute. Further observation of the concentrator revealed the sterile water bottle used for humidification was empty and no water bubbles were observed. Interview on 04/11/22 at 12:44 P.M. with Director of Nursing (DON) confirmed Resident #93's oxygen tubing popped off the oxygen concentrator and was lying on the floor. DON confirmed the oxygen was set to administer 3 liters per nasal cannula per minute. Interview on 04/11/22 at 12:50 P.M. with Registered Nurse (RN) #602 confirmed Resident #93's oxygen tubing was lying on the floor, and sterile water bottle empty. RN #602 stated there was a tiny bit of water left in the sterile water bottle. Interview on 04/11/22 at 01:03 P.M. with RN #602 confirmed Resident #93 did not have physician orders for administration of oxygen or orders to change oxygen tubing and water for humidification. Review of the facility policy titled, Oxygen Administration, undated, included the purpose of this (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365926 If continuation sheet Page 13 of 22 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 365926 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Normandy Manor of Rocky River 22709 Lake Rd Rocky River, OH 44116 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 Level of Harm - Minimal harm or potential for actual harm procedure was to provide guidelines for safe oxygen administration. Verify there was a physician order for this procedure. Review the resident's care plan to assess for any special needs of the resident. Check the mask, tank, humidifying jar, etcetera to be sure they were in good working order and were securely fastened. Be sure there was water in the humidifying jar and the water level is high enough that the water bubbles as oxygen flows through. Periodically re-check the water level in the humidifying jar. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365926 If continuation sheet Page 14 of 22 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 365926 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Normandy Manor of Rocky River 22709 Lake Rd Rocky River, OH 44116 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 - Some 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. Based on observation, interview, and facility policy review, the facility failed to ensure medication stored in the medication carts were not expired and insulin vials were labeled with the date opened. This affected nine residents (Resident #21, #24, #35, #39, #54, #64, #86, #87, and #245) and had the potential to affect all 88 residents residing in the facility. Findings include: Observation on 04/12/22 at 3:03 P.M. of the medication cart in the 800 hall revealed the following: 1. Humalog insulin Kwik pen labeled only with room number for Resident #24 and an open date of 03/22/21 2. Lantus Solostar insulin 100 units per milliliter (u/ml) for Resident #64 was opened with an unreadable date on bottle 3. Vial of Humalog insulin 100 u/ml for Resident #54 was not labeled with date opened. A date of 03/27/22 was only on the opened box without a lid 4. Vial of Humalog insulin 100 u/ml for Resident #39 was not labeled with date opened. A date of 03/20/22 was only on the opened box without a lid 5. Vial of Lantus insulin 100 u/ml for Resident #39 was not labeled with date opened. A date of 04/02/22 was only on the opened box without a lid 6. Vial of Lantus insulin 100 u/ml for Resident #87 was not labeled with date opened. A date of 03/30/22 was only on the opened box without a lid 7. Vial of Lantus insulin 100 u/ml for Resident #21 was not labeled with date opened. A date of 03/30/22 was only on opened box without a lid 8. Bottle of Nitroglycerin 0.4 milligrams (mg) sublingual (SL) tablets for Resident #21 with expiration date of 02/2021 9. A second bottle of Nitroglycerin 0.4 mg SL tablets for Resident #21 was in a bag with an expiration date of 03/23/22, but the bottle was dated 06/2023 10. Bottle of Saline nasal spray for Resident #87 with an expiration date of 12/2021 Interview with Licensed Practical Nurse (LPN) #539 during medication storage observation for the 800 hall on 04/13/22 at 3:23 P.M. verified the above medications were expired or not labeled properly. Observation on 04/12/22 at 3:30 P.M. of medication refrigerator on the 400 hall revealed the following: 11. Bottle of 100 mg Nystatin Swish and Swallow for Resident #86 with an expiration date of 03/31/22 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365926 If continuation sheet Page 15 of 22 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 365926 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Normandy Manor of Rocky River 22709 Lake Rd Rocky River, OH 44116 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 12. Vial of Novolog insulin 100 u/ml for Resident #35 was not labeled with date opened. A date of 03/01/22 was only on the box and was after the 28-day use of opened insulin vials. 13. Vial of Tuberculin solution 0.1 ml was opened and was not labeled on the vial, nor the box with the date opened. Residents Affected - Some Interview on 04/12/22 at 3:30 P.M. with Registered Nurse (RN) #602 during the observation of medication storage for the 400 hall verified the above medications were expired or not labeled properly. Observation on 04/12/22 at 4:05 P.M. of the medication cart for the memory care unit revealed the following: 14. Bottle of Aspirin 81 mg stock medication with an expiration date of 10/2021 15. Bottle of Sodium Bicarbonate 325 mg with an expiration date of 04/2022 Interview on 04/12/22 at 4:05 P.M. with LPN #630 during observation of medication storage for the memory care unit verified the above medications were expired. Review of the facility policy titled, Storage of Medications, revised November 2020, revealed drug containers with missing, incomplete, improper, or incorrect labels would be returned to the pharmacy for proper labeling before storing. Discontinued, outdated , or deteriorating drugs or biologicals would be returned to the dispensing pharmacy or destroyed. 16. Observation on 04/11/22 from 9:00 A.M. to 9:09 A.M. during tour of nourishment refrigerators with Dietary Manager (DM) #546 revealed on the memory care unit there was a box of tuberculin solution inside the door of the nourishment refrigerator. The tuberculin solution was labeled 04/2022; no specific date of first use was further identified on the label. Interview with DM #546 at the time of observation verified medication was not to be stored in the nourishment refrigerator. Interview on 04/11/22 at 9:09 A.M. with Licensed Practical Nurse (LPN) #617 revealed she was unaware of the tuberculin solution in the nourishment refrigerator. LPN #617 denied any malfunctions of the medication refrigerator on the memory care unit. Interview on 04/11/22 at 9:11 A.M. with Director of Nursing (DON) verified the tuberculin solution was not to be stored in the nourishment refrigerator. DON denied any malfunctions of the medication refrigerator on the memory care unit. Follow-up interviews on 04/11/22 at 10:42 A.M. and 3:00 P.M. with DON verified no date of first use was specified on the opened package of tuberculin solution and should have been. DON identified one resident received tuberculin solution from this package, Resident #245. Review of the facility policy, Storage of Medications, revised November 2020 revealed medications requiring refrigeration were stored in a refrigerator located in the drug room at the nurses' station or other secured location. Medications are stored separately from food and are labeled accordingly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365926 If continuation sheet Page 16 of 22 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 365926 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Normandy Manor of Rocky River 22709 Lake Rd Rocky River, OH 44116 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of the facility's menu spreadsheet the facility failed to serve portions as specified on the menu spreadsheet. This affected 27 residents including 19 residents on a mechanical soft diet (Residents #9, #13, #15, #18, #22, #33, #49, #55, #59, #65, #68, #73, #77, #78, #85, #88, #91, #246 and #445) and eight residents on a pureed diet (Residents #27, #34, #37, #44, #47, #56, #72 and #74). The facility census was 88 residents. Findings include: Review of the menu spreadsheet for 04/12/22 for the lunch meal revealed a meal consisting of chicken, potatoes au gratin, California blend vegetables, and mint chocolate chip ice cream with alternates listed as pork roast, gravy, sweet potatoes, and Prince [NAME] vegetable mix. Portions for the chicken included three ounces for regular consistency diets, a #10-scoop for mechanical soft chicken, and a #10-scoop for pureed chicken. Observation of tray line on 04/12/22 starting at 11:27 A.M. revealed a lunch meal consisting of chicken, potatoes au gratin, mixed vegetables, mechanically altered chicken, pureed chicken, pureed vegetables, gravy, mashed potatoes, and soup as well as pork and alternate vegetable items. The pureed chicken was served with a green #12-scoop, and the mechanically altered chicken was served with a green #12-scoop. Tray-service began at 11:39 A.M. and both pureed chicken and the mechanically altered chicken were served with a green #12-scoop. Interview on 04/12/22 at 12:08 P.M. with Dietary Manager (DM) #546 verified the mechanically altered chicken and the pureed chicken both were served with a green #12-scoop. DM #546 was made aware during the interview the facility did not follow the menu spreadsheet that showed a larger, #10-scoop should have been used to serve these items during the meal. Review of a diet list as of 04/12/22 revealed 19 residents were on a mechanical soft diet (Resident's #9, #13, #15, #18, #22, #33, #49, #55, #59, #65, #68, #73, #77, #78, #85, #88, #91, #246 and #445), eight residents were on a pureed diet (Resident's #27, #34, #37, #44, #47, #56, #72 and #74) and Resident #345 was ordered nothing-by-mouth (NPO). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365926 If continuation sheet Page 17 of 22 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 365926 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Normandy Manor of Rocky River 22709 Lake Rd Rocky River, OH 44116 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 record review the facility failed to ensure the high temperature dish machine reached the minimum rinse temperature required to ensure appropriate sanitation of dishes and utensils. This had the potential to affect 87 residents receiving meals from the kitchen (Resident #345 was ordered nothing-by-mouth). The facility census was 88. Findings include: Observation on 04/11/22 at 8:57 A.M. of the facility's dish machine with Dietary Manager (DM) #546 revealed the machine was in use. There were two indicator gauges for the wash and rinse cycle water temperatures, and both read 90 degrees Fahrenheit (F). Dish machine temperature logs were posted to the left of the dish machine. Review of the April 2022 dish machine temperature logs revealed temperatures were taken at breakfast, lunch, and dinner meals. Data through 04/11/22 at the breakfast meal revealed final rinse temperatures were as follows: • 04/01/22 150 degrees Fahrenheit (F), breakfast; 149 degrees F, lunch; 150 degrees F, dinner • 04/02/22 155 degrees F, breakfast; 155 degrees F, lunch; 150 degrees F, dinner • 04/03/22 150 degrees F, breakfast; 154 degrees F, lunch; 147 degrees F, dinner • 04/04/22 155 degrees F, breakfast; 155 degrees F, lunch; 147 degrees F, dinner • 04/05/22 145 degrees F, breakfast; 150 degrees F, lunch; 150 degrees F, dinner • 04/06/22 140 degrees F, breakfast; 180 degrees F, lunch; 150 degrees F, dinner • 04/07/22 147 degrees F, breakfast; 150 degrees F, lunch; 150 degrees F, dinner • (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365926 If continuation sheet Page 18 of 22 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 365926 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Normandy Manor of Rocky River 22709 Lake Rd Rocky River, OH 44116 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 04/08/22 160 degrees F, breakfast; 155 degrees F, lunch; 152 degrees F, dinner Level of Harm - Minimal harm or potential for actual harm • 04/09/22 160 degrees F, breakfast; 155 degrees F, lunch; 154 degrees F, dinner Residents Affected - Many • 04/10/22 155 degrees F, breakfast; 160 degrees F, lunch; 157 degrees F, dinner Interview with DM #546 on 04/11/22 at 8:47 A.M. revealed the dish machine was a high temperature dish machine. DM #546 was made aware during the interview that 90 degrees F was not a sufficient temperature to ensure adequate sanitizing of dishes and utensils and that the minimum temperature for heat sanitization through the rinse cycle on a high temperature dish machine was 180 degrees F. Interview on 04/11/22 at 3:35 P.M. with Assistant Administrator (AA) #547, DM #546 and Maintenance Director #521 revealed the two front temperature gauges of the dish machine were incorrect. DM #546 stated a temperature strip had been run through the dish machine around lunch and rinse temperatures had been in the 150 degrees F range. DM #546 confirmed this did not meet the minimum rinse temperature of 180 degrees F. Review of dish machine operating instructions dated 08/22/19 revealed the high temperature dish machine would have a final rinse temperature of 180 degrees F to 195 degrees F. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365926 If continuation sheet Page 19 of 22 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 365926 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Normandy Manor of Rocky River 22709 Lake Rd Rocky River, OH 44116 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on observation, interview, medical record review, and facility policy review, the facility failed to ensure accurate documentation was contained in the medical record. This affected one (Resident #67) of four residents reviewed for documentation of medication administration. The facility census was 88. Findings include: Review of the medical record for Resident #67 revealed an admission date of 02/16/21 and a readmission date of 11/30/21. Diagnoses included wedge compression fracture of lumbar vertebrae, cyst of kidney, dysphagia, hypertension, pneumonia, and elevation of levels of liver enzymes (transaminase). Observation of medication administration on 04/12/22 at 8:15 A.M. by Licensed Practical Nurse (LPN) #580 for Resident #67 revealed the resident was administered Miralax (laxative) 17 grams (gm) powder mixed in four ounces of water, Preservation Areds (eye vitamin), Senna-S (laxative) 8.6-50 milligrams (mg), Vitamin D3 5000 units, and Atenolol (medication for high blood pressure or chest pain) 25 mg. There were 4 pills verified with LPN #580 prior to administration. The Senna-S and Atenolol were crushed and the Preservation Areds and Vitamin D3 were whole. All 4 pills were then mixed in applesauce and administered per resident preference. The Miralax was administered separately with no concerns. Review of the medication administration record (MAR) for Resident #67 revealed the observed medications were signed as administered. Further review of the MAR identified a digital signature for the administration of Lactobacillus (probiotic) tablet during the medication administration on 04/12/22 at 8:15 A.M. by LPN #580. Review of the physician orders for April 2022 identified orders for Senna-Docusate Sodium tablet 8.6-50 mg tablet two times a day for constipation, Miralax powder 17 gm by mouth daily for constipation, Vitamin D3 tablet 5000 units by mouth one time a day for supplement, Preservation Areds 2 plus multivitamin capsule two times a day for supplement, Atenolol 25 mg one time a day for hypertension, and Lactobacillus tablet one tablet by mouth two times a day for prophylaxis. Further review of the orders revealed the Lactobacillus was discontinued on 04/12/22 at 9:58 A.M. after the observation of medication administration for Resident #67 performed on 04/12/22 at 8:15 A.M. Interview on 04/12/22 at 9:00 A.M. with LPN #580 verified she signed for the administration of the Lactobacillus tablet as given during the observation of medication administration for Resident #67 and verified the medication was not administered. Review of facility policy titled Charting and Documentation, revised July 2017, revealed documentation in the medical record would be objective, complete, and accurate. Documentations of procedures and treatments would include care-specific details, including the name and date of the procedure or treatment provided, and the name, title, and date, and time the procedure or treatment was provided. Review of the undated facility policy titled Administering Medications revealed medications would be administered in a safe and timely manner, and as prescribed. The individual administering the medication would initial the resident's MAR on the appropriate line after giving each medication and before administering the next ones. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365926 If continuation sheet Page 20 of 22 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 365926 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Normandy Manor of Rocky River 22709 Lake Rd Rocky River, OH 44116 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, facility policy review, and review of the Centers for Disease Control (CDC) Considerations for Preventing Spread of Covid-19, the facility failed to maintain proper infection control procedures to prevent the spread of infection. This had the potential to affect all residents residing in the facility. In addition, the facility failed to properly clean a shared glucometer between residents. This affected two (Resident's #79 and #64) of two residents reviewed for blood glucose monitoring. The facility census was 88. Residents Affected - Many Findings include: 1. Review of Resident #248's medical records revealed an admission date of 04/11/22 with diagnoses including stroke, kidney failure, and sickle cell. Review of Resident #248's immunizations revealed no evidence of a Covid-19 vaccination. Review of the physician orders dated 04/11/22 revealed Resident #248 was ordered to be placed on isolation precautions for ten days upon admission. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed an incomplete assessment. Review of the care plan dated 04/11/22 revealed Resident #248 was at risk for contracting the Covid-19 virus related to unvaccinated status. Observation on 04/13/22 at 7:53 A.M. revealed Resident #248 was on isolation precautions, and signage was posted outside of the resident's room that indicated a gown, gloves, N95 and face shield were to be worn prior to entering the room. Further observation revealed Clinical Manager (CM) #585 entered the resident's room to deliver her breakfast tray and assist with setting the residents tray up. Further observation revealed CM #585 did not wear a N95 or a face shield prior to entering the resident's room. Interview at 7:58 A.M. with CM #585 confirmed Resident #248 was on isolation precautions; however, CM #585 stated she was not aware she was required to wear a face shield or N95 into the resident's room. CM #585 confirmed the posted signage indicated a face shield and N95 were required prior to entering the resident's room. Interview on 04/13/22 at 8:03 A.M. with the Director of Nursing (DON) confirmed staff was required to wear a gown, gloves, face shield, and N95 prior to entering Resident #248's room. The DON further confirmed she had placed the required Personal Protective Equipment (PPE) requirements outside of the resident's room. Review of the CDC guidance updated 09/10/21 titled Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes revealed older adults living in congregate settings are at high risk of being affected by respiratory and other pathogens, such as SARS-CoV-2. A strong infection prevention and control (IPC) program is critical to protect both residents and healthcare personnel (HCP). Even as nursing homes resume normal practices, they must sustain core IPC practices and remain vigilant for SARS-CoV-2 infection among residents and HCP to prevent spread and protect residents and HCP from severe infections, hospitalizations, and death. In general, healthcare (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365926 If continuation sheet Page 21 of 22 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 365926 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Normandy Manor of Rocky River 22709 Lake Rd Rocky River, OH 44116 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many facilities should continue to follow the IPC recommendations for unvaccinated individuals (e.g., use of Transmission-Based Precautions for those that have had close contact to someone with SARS-CoV-2 infection) when caring for fully vaccinated individuals with moderate to severe immunocompromise due to a medical condition or receipt of immunosuppressive medications or treatments. Manage residents with suspected or confirmed SARS-CoV-2 infection HCP caring for residents with suspected or confirmed SARS-CoV-2 infection should use full PPE (gowns, gloves, eye protection, and a NIOSH-approved N95 or equivalent or higher-level respirator). Source control and physical distancing (when physical distancing is feasible and will not interfere with provision of care) are recommended for everyone in a healthcare setting. 2. Review of the medical record for Resident #79 revealed an admission date of 03/09/22. Diagnoses included chronic obstructive pulmonary disease (COPD), anxiety disorder, and type two diabetes with diabetic neuropathy. Review of the physician orders dated 03/15/22 identified an order to check fasting blood glucose each morning and document results. Observation on 04/12/22 at 7:30 A.M. of blood glucose testing by Accucheck glucometer used for multiple residents, by Registered Nurse (RN) #563 for Resident #79 revealed after the blood glucose was checked, RN #563 placed the glucometer in her pocket and did not sanitize it. Observation on 04/12/22 at 7:57 A.M. of RN #563 revealed she removed the glucometer from her pocket and placed it on top of the medication cart. There was no observation of RN #563 disinfecting he glucometer before placing it on the mediation cart. Interview on 04/12/22 at 7:57 A.M. with RN #563 verified she did not disinfect the glucometer and she was going home. 3. Review of the medical record for Resident #64 revealed an admission date of 10/22/21 and a readmission date of 04/06/22. Diagnoses included type one diabetes with ketoacidosis without coma, other specified diabetes mellitus with hypoglycemia without coma, and type one diabetes mellitus with hyperglycemia. Review of the physician orders dated 04/11/22 identified an order for blood glucose testing by Accucheck glucometer at 7:00 A.M. and at bedtime (8:00 P.M.) and notify physician if blood glucose is less than 80 or greater than 350. Observation on 04/12/22 at 12:18 P.M. of blood glucose testing by Accucheck glucometer for Resident #12 by Licensed Practical Nurse (LPN) #539 revealed she proceeded to use the glucometer for glucose testing on Resident #64 without disinfecting or sanitizing the glucometer between residents. Interview on 04/12/22 at 12:19 P.M. verified she did not disinfect the glucometer between residents. Review of the undated facility policy titled Glucometer Cleaning revealed all glucometers would be cleaned and disinfected using Clorox Germicidal wipes, or equivalent. All glucometers that would be shared by multiple patients would be thoroughly wiped with disinfectant and allowed to air dry after every use and between every patient. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365926 If continuation sheet Page 22 of 22