Health inspection·July 27, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few never asked if she wanted it replaced. Resident #84 shared nobody could replace her father's ring, it was a real diamond and the band was gold with black [NAME]. Resident #84 revealed the ring might have fallen off her finger then someone stole it. Resident #84 stated she told them she thought that someone may have stolen the ring. Interview on 07/25/23 at 8:50 A.M. with the DON revealed he did not know about Resident #84's missing ring. Interview on 07/25/23 at 9:10 A.M. with Licensed Social Worker (LSW) #106 revealed shortly after Resident #84 was admitted to the facility, she was missing her black ring. The ring had gold on the band with a stone. LSW #106 revealed there were inventory sheets that were to be filled out on admission by the staff and family, but they (the inventory sheets) don't always get done. LSW #106 revealed she did see a picture from the resident's admission with the ring on her finger, that's how she remembered what the ring looked like. LSW #106 was unsure what happened to the photo of the resident wearing the ring. Interview on 07/25/23 at 9:24 A.M. with LSW #101 revealed she reviewed the concern log for Resident #84's missing ring. LSW #101 revealed the inventory list was always an issue to remind staff and family to fill out. Resident #84's inventory list was not in her chart. LSW #101 revealed if a resident had a missing item, the facility would offer to replace it but the facility did not offer to replace Resident #84's ring. Interview on 07/25/23 at 9:29 A.M. with the Administrator confirmed the facility did not complete a self-reported incident (SRI) for Resident #84's missing ring. The Administrator revealed unless the resident reported an item stolen, an SRI would not be completed. The Administrator revealed Resident #84 did not use the word stolen, she reported it lost and that was different. The Administrator revealed she received the concern on 10/20/22 and personally looked in Resident #84's room and the laundry room for Resident #84's ring but it wasn't found. The Administrator revealed she was not sure what happened to the missing picture of Resident #84 wearing the ring, a former medical records person took the picture, and she was unsure what the former medical records person did with the picture, but it was unable to be found. The Administrator revealed Resident #84 never asked for the ring to be replaced so she never offered. Review of the facility undated policy titled, Missing Items revealed should items become missing, the facility would take reasonable efforts to attempt to locate the missing items. The procedure included the resident or responsible party should notify a staff member of the missing item and the staff member would notify their supervisor, the Administrator, DON, social work designee and complete the missing items report. This person would then coordinate all efforts to locate the missing items. In the event that misappropriation of a resident's property was suspected or known, the facility would follow the investigation and follow up sections of its policy on abuse, neglect, and misappropriation of residents funds or property. Review of the Abuse, Neglect, Exploitation and Misappropriation of Resident Property Policy revised 10/2020 revealed the facility will not tolerate Abuse, Neglect, and Exploitation of its residents or the Misappropriation of resident property. It is the facility's policy to investigate all alleged violations involving abuse, neglect, exploitation and mistreatment of a resident, or misappropriation of resident property, including injuries of unknown source, in accordance with this policy. Misappropriation is defined as the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent. The Administrator or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365926 If continuation sheet Page 2 of 6 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 07/27/2023 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 his/her designee will notify the state agency of all alleged violations involving Abuse, Neglect, exploitation, mistreatment of a resident, or misappropriation of resident property as soon as possible, but in no event later than 24 hours from the time of the incident/allegation was made known to the staff member. This deficiency represents non-compliance investigated under Complaint Number OH00144205. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365926 If continuation sheet Page 3 of 6 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 07/27/2023 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility policy, the facility failed to ensure a thorough investigation was completed regarding an allegation of misappropriation. This affected one resident (Resident #84) of three residents reviewed for missing items. The facility census was 133. Residents Affected - Few Findings include: Record review for Resident #84 revealed an admission date of 10/07/22. Diagnoses included Parkinson's Disease, chronic obstructive pulmonary disease, spinal stenosis, muscle weakness, abnormal posture, and need for assistance with personal care. Record review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #84 had a Brief Interview of Mental Status score of 12 (moderately impaired). Resident #84 required extensive assistants of two for bed mobility, total dependence for transfers, and toilet use, and extensive assistants of one for personal hygiene. Resident #84 was always incontinent of bowel and bladder. Record review of Resident #84's medical record revealed no documentation of a missing item. Record review of a Complaint/Concern form dated 10/20/22 completed by Administrator revealed Resident #84 described a large black ring with a diamond that looked like a man's ring, had gone missing. Resident #84 revealed she was wearing the ring on her middle finger at night, and it was gone in the morning. Resident #84 revealed the ring was loose on her finger and this happened a couple of days ago. The family was notified and the family does not have the ring. The concern was referred to nursing, laundry, Social Services and the Administrator. Resident #84's room and the laundry room was searched. The form included the Administrators signature and date of 10/20/22 next to the signature. The second page of the report had a typed notation reading, This writer completed a room search on 10/20/22 to look for resident's ring that she reported missing. This writer did not find the ring. Resident reported she did not think it was stolen but that it might have fallen off in her bed. This writer informed the resident that we would continue looking for the ring. The form was signed by the Administrator and dated 10/20/22. Interview on 07/25/23 at 8:22 A.M. with Resident #84 revealed she was missing a ring. The resident stated the ring was her father's ring that came up missing at the facility. Resident #84 revealed she reported the missing ring to the Director of Nursing (DON) a few months ago and nothing happened. Resident #84 shared she always wore the ring on her left middle finger, but it was loose on her finger. She went to sleep one night and when she woke up in the morning, it was gone. That's when she reported it to the DON. Resident #84 shared nobody came back to tell her they didn't find it and they never asked if she wanted it replaced. Resident #84 shared nobody could replace her father's ring, it was a real diamond and the band was gold with black [NAME]. Resident #84 revealed the ring might have fallen off her finger then someone stole it. Resident #84 stated she told them she thought that someone may have stolen the ring. Interview on 07/25/23 at 8:50 A.M. with the DON revealed he did not know about Resident #84's missing ring. Interview on 07/25/23 at 9:10 A.M. with Licensed Social Worker (LSW) #106 revealed shortly after Resident #84 was admitted to the facility, she was missing her black ring. The ring had gold on the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365926 If continuation sheet Page 4 of 6 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 07/27/2023 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few band with a stone. LSW #106 revealed there were inventory sheets that were to be filled out on admission by the staff and family, but they (the inventory sheets) don't always get done. LSW #106 revealed she did see a picture from the resident's admission with the ring on her finger, that's how she remembered what the ring looked like. LSW #106 was unsure what happened to the photo of the resident wearing the ring. Interview on 07/25/23 at 9:24 A.M. with LSW #101 revealed she reviewed the concern log for Resident #84's missing ring. LSW #101 revealed the inventory list was always an issue to remind staff and family to fill out. Resident #84's inventory list was not in her chart. LSW #101 revealed if a resident had a missing item, the facility would offer to replace it but the facility did not offer to replace Resident #84's ring. Interview on 07/25/23 at 9:29 A.M. with the Administrator confirmed the facility did not complete a self-reported incident (SRI) for Resident #84's missing ring. The Administrator revealed unless the resident reported an item stolen, an SRI would not be completed. The Administrator revealed Resident #84 did not use the word stolen, she reported it lost and that was different. The Administrator revealed she received the concern on 10/20/22 and personally looked in Resident #84's room and the laundry room for Resident #84's ring but it wasn't found. The Administrator also verified she did not interview the staff regarding the missing ring. Review of the facility undated policy titled, Missing Items revealed should items become missing, the facility would take reasonable efforts to attempt to locate the missing items. The procedure included the resident or responsible party should notify a staff member of the missing item and the staff member would notify their supervisor, the Administrator, DON, social work designee and complete the missing items report. This person would then coordinate all efforts to locate the missing items. In the event that misappropriation of a resident's property was suspected or known, the facility would follow the investigation and follow up sections of its policy on abuse, neglect, and misappropriation of residents funds or property. Review of the Abuse, Neglect, Exploitation and Misappropriation of Resident Property Policy revised 10/2020 revealed the facility will not tolerate Abuse, Neglect, and Exploitation of its residents or the Misappropriation of resident property. It is the facility's policy to investigate all alleged violations involving abuse, neglect, exploitation and mistreatment of a resident,, or misappropriation of resident property, including injuries of unknown source, in accordance with this policy. Misappropriation is defined as the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent. The person investigating the incident should take the following actions: Interview the resident, the accused and all witnesses. Witnesses generally include anyone who: witnessed or heard the incident; came in close contact with the resident the day of the incident (including other residents, family members): and employees who worked closely with the accused employee (s) and/or alleged victim the day of the incident. Obtain a statement from the resident, if possible, the accused, and each witness. Evidence of the investigation should be documented. After a completion of the investigation, all of the evidence should be analyzed, and the Administrator (or his/her designee) will make a determination regarding whether the allegation or suspicion is substantiated. This deficiency represents non-compliance investigated under Complaint Number OH00144205. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365926 If continuation sheet Page 5 of 6 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 07/27/2023 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 - Many 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 policy review, the facility failed to properly store medications. This had the potential to affect all 133 residents in the facility. Findings include: On 07/24/23 at 8:42 A.M. during preparation of medication administration observation, Registered Nurse (RN) #108 had unlocked the medication cart, exposing one five-ounce drinking cup approximately half full of white tablets. The cup was uncovered and written on the outside of the cup, with marker, was sodium bicarb 325 mg. Interview with the RN revealed she was unsure how many tablets were in the cup and she verified there was no expiration date listed for the medications. RN #108 revealed she was unsure how many days the cup with the white tablets had been stored in the cart. Further interview revealed sodium bicarb was an over the counter medication and there was only one cart that had a bottle of sodium bicarb 325 mg available for resident administration, so the medication was shared by pouring some of the tablets into a medication cup to store them in the medication cart for resident administration. Interview on 07/25/23 at 2:00 P.M. with the Director of Nursing (DON) verified medications were to be stored in the original packaging with the appropriate label and expiration date and never be stored outside of the original package with clear labeling. Review of the facility undated policy titled, Medication Storage revealed it was the facility policy to ensure all medications housed on the premises would be stored in the pharmacy and or medication rooms according to the manufacturer's recommendation and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. This deficiency represents non-compliance investigated under Complaint Number OH00144205. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365926 If continuation sheet Page 6 of 6