Health inspection·February 12, 2024

F 0582 Level of Harm - Minimal harm or potential for actual harm for $500.00 per month were removed for the months Resident #97 did not receive a bill. BOM #275 revealed Resident #97 told the Ombudsman the facility gave her a 30-day notice, so the Ombudsman suggested they gave Resident #97 a letter rescinding the notice. BOM #275 confirmed Resident #97 did not receive a bill from the facility during the six-month period until discussing her bill and 30-day notice with her. Residents Affected - Few Review with BOM #275 of requested billing statements for Resident #97's previous six months billing revealed a billing statement dated 10/01/23 which had a due date of 10/05/23 and a billing statement of 01/01/24 with a due date of 01/05/24. BOM #275 revealed those were the only two statements available. BOM #275 confirmed Resident #97 did not receive any bill from the facility for the previous six months including the billing statement dated 10/05/23 because it had been misplaced. Phone interview on 02/07/24 at 8:30 A.M., with Ombudsman #401 revealed she had concerns which included the Business Office Manager (BOM) not giving residents their bank statements or billing statements. Ombudsman #401 revealed she spoke with three residents who verified this but only one (#97) gave permission to release their name. Ombudsman #97 revealed she did not tell anyone at the facility to give a retraction of a 30-day notice to any resident and revealed she had many concerns with the BOM at the facility. Interview on 02/07/24 at 10:11 A.M., with Administrator revealed she had been on leave, recently returning and an Interim Administrator assisted while she was gone. Administrator revealed there was confusion in the business office and some residents were not getting billed for several months. This deficiency represents non-compliance investigated under Complaint Number OH00150244. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365926 If continuation sheet Page 2 of 12 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 02/12/2024 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 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review, resident interview, Ombudsman interview, and staff interviews, the facility failed to deliver all of residents mail to them and or their authorized representative. The facility also failed to provide residents mail to them unopened. This affected five (#10, #36, #97, #122, and #123) of five reviewed for mail and had the potential to affect all residents. The facility census was 117. Residents Affected - Many Findings include: 1. Review for Resident #97's medical record revealed an admission date of 05/05/23. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #97 revealed Resident #97 was cognitively intact. Interview on 02/06/24 at 3:04 P.M., with Resident #97 revealed she received her mail the previous day delivered by an Activities Assistant #262. Resident #97 revealed she received four envelopes of mail and one of the envelopes was opened prior to her receiving it. Resident #97 grabbed the four envelopes. One of the four envelopes were opened. The envelope opened had Resident #97's full name on the top line of the envelope. Under her name was the facility name then the facility address. The sender was a bank. Resident #97 removed the paper inside the envelope which was a non-negotiable check with Resident #97's name on it. Resident #97 revealed this was very upsetting, the facility should not be opening her mail. Interview on 02/06/24 at 3:38 P.M., with Activities Director #262 revealed the receptionist separates the mail. The resident's business mail goes to the business office and the resident's personal letters goes to the activities department to be delivered. Activities Director #262 revealed she had seen resident's mail opened prior to giving it to the residents. Interview on 02/06/24 at 3:47 P.M., with Business Office Manger (BOM) #275 revealed she received all resident's business mail. If the mail had anything from the payment distribution center, she opened it because a lot of families members would pay the resident's bill with a check. If anything was from Medicaid she opened it to verify the check list verification mailed to the resident. If it was from a bank and looked like a check she opened it to see what was inside or if it just looked like a bank statement, she usually would just filed it in the file cabinet. BOM #275 revealed she use to give residents the bank statements in the past but usually they just said file them, so now she just filed them all without asking the resident. BOM #275 revealed she did open Resident #97's mail because it was from a bank and had a payment distribution on it. BOM #275 stated if any mail to any resident had the facility name on the envelope anywhere, even under the resident name, that was considered distribution, so she had the right to open it. BOM #275 revealed that was what she was told by the Regional BOM, she said if it looks like a check, open it. BOM #275 revealed she had been in the position of BOM for over a month and had been opening resident's mail the whole time. Interview on 02/06/24 at 3:57 P.M., with Director of Social Services #304 revealed the resident has the right to receive mail unopened. Director of Social Services #304 revealed she had not received concerns from residents receiving unopened mail until this day. Interview on 02/06/24 at 4:10 P.M., with Administrator revealed the resident has the right to receive all of their mail and mail unopened. Administrator verified all residents received mail at the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365926 If continuation sheet Page 3 of 12 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 02/12/2024 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 0583 Level of Harm - Minimal harm or potential for actual harm Phone interview on 02/07/24 at 8:30 A.M., with Ombudsman #401 revealed she had concerns which included the Business Office Manager (BOM) not giving resident's their bank statements or billing statements. Ombudsman #401 revealed she spoke with three residents who verified this but only one, Resident #97 gave permission to release their name. Ombudsman #401 revealed she had many concerns with the BOM at the facility. Residents Affected - Many Interview and record review on 02/07/24 at 10:38 A.M., with BOM #275 revealed a large filing cabinet in the office. BOM #275 opened the top drawer and revealed this was where she placed all resident's mail opened or unopened that was not going to be delivered. Observation revealed multiple files with resident's names in alphabetic order. BOM #275 removed four random files, Resident #10 had an unopened letter from an unknown source with his name on the top line of the letter, Former Resident #122 had multiple envelopes with some from Care Source/Centers for Medicaid and Medicare unopened. Resident #36 had a statement from Care Source unopened. Former Resident #123 had an unopened envelope from personal insurance company. BOM #275 revealed all residents residing in the memory care unit has all their mail automatically filed, none was to be delivered. BOM #275 revealed Activities will make one attempt to deliver mail to all other residents, if the resident is not there, the mail is returned to her and she filed it. There was no second attempt or notification made to the resident regarding their mail. Interview on 02/07/24 at 10:45 A.M., with Resident #10 revealed he wanted all his mail, he was never told he was not receiving any mail, the post office delivered mail no matter what, so he was not worried. Interview on 02/07/24 at 2:13 P.M., with Regional Business Office Manager (BOM) #402 revealed if the facility's name is on any letter, anywhere on the envelope, that gives the facility permission to open the mail. Regional BOM revealed it was not a policy, it is just something she was told. Review of the policy titled, Resident Rights dated 04/04/22, revealed the resident has the right to send and receive mail, and to receive letters, packages and other materials delivered to the facility for the resident through a means other than postal service, including the right to privacy of such communications consistent with this section. This deficiency represents an incidental finding investigated under Master Complaint Number OH00150460, and Complaint Numbers OH00150319, OH00150244, and OH00149914. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365926 If continuation sheet Page 4 of 12 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 02/12/2024 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, family interview, staff interview, and policy review, the failed to update to care plans to included fall interventions. This affected three (#2, #88, and #120) of three resident reviewed for care plans. The facility census was 117. Findings included: 1. Review of Resident #120's medical record revealed an admission date of 12/19/22, a re-admission date of 12/08/23 and a discharge date of 12/15/23. Diagnosis included unspecified dementia, chronic atrial fibrillation, difficulty in walking, muscle weakness, need for assistants with personal care, and cognitive communication deficit. Record review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #120 was severely cognitively impaired. Review of the Morse Fall Scale completed on 12/19/22, 01/02/23, 01/13/23, 04/18/23, and 07/19/23 revealed Resident #120 was at high risk for falls. Review of the Morse Fall Scale completed on 10/21/23 revealed Resident #120 was a moderate risk for falls and review of the Morse Fall Scale completed on 12/05/23 and 12/08/23 revealed Resident #120 was at high risk for falls. Review of the care plan dated 12/20/22 and revised 12/18/23 for Resident #120 revealed Resident #120 was at risk for falls related to confusion, reconditioning, gait/balance problems, unaware of safety needs, history of falls and cognitive impairment. Interventions included reminder sign, dycem in front of recliner, anticipate and meet the resident needs, assist with ambulation, transfer, and toileting, call light in reach and non-skid socks as ordered. Review of the care plan revealed there was no intervention in place for Resident #120 to have the bed in lowest position while in bed. Review of the All Staff Inservice dated 11/17/23 included to be sure Resident #120's bed was in the lowest position after you are done providing care. The All Staff Inservice was signed by four LPN's and ten State Tested Nursing Assistants (STNA). Interview on 02/06/24 at 3:34 P.M., with Resident #120's son revealed he visited his mother, daily over the past year while she resided at the facility. Resident #120's son revealed Resident #120 was confused and had already had two falls at the facility when he met with the Administrator, DON, and the Unit Manager to request her bed be placed in the lowest position while she was in bed. He feared if she fell out of bed at a routine bed height, she could be seriously injured. Resident #120's son revealed Administrator, DON, and the Unit Manager assured him the bed would be placed in the lowest position while she was in bed. On multiple visits he would find Resident #120's bed was not in the lowest position while she was in bed. Resident #102's son revealed he continued to meet with the Administrator, DON, and the Unit Manager on multiple occasions who consistently assured him the bed would be placed in the lowest position while she was in bed. Resident #120's son revealed facility staff who found Resident #120 on the floor on 12/05/23 confirmed her bed was not lowered when she was left unattended and fell out of bed resulting in multiple fractures. Interview on 02/07/24 between 2:45 P.M. and 4:40 P.M., with DON, Administrator, and Unit Manager confirmed Resident #120's son had spoken with each of them on a few different occasions regarding his (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365926 If continuation sheet Page 5 of 12 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 02/12/2024 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few concerns of her bed being placed too high with concerns of her falling out of bed. DON confirmed the facility used electric beds, the beds were able to raise and lower by using a remote control. During care, staff would raise the bed but were to lower it when care was complete. DON revealed Resident #120's bed was to be in a low position while she was in bed unattended. DON revealed staff were in-service to keep Resident #120's bed in a low position. DON confirmed the low bed intervention was not placed in Resident #120's care plan and revealed he had met with the Interdisciplinary Team on several occasions, discussed the concern of staff not keeping her bed in the low position in morning meetings several different times and the MDS nurse who was present during those meetings was supposed to put the intervention in the care plan but never did. DON stated if the resident was at risk for falls then the beds should always be in the lowest position when unattended by staff. DON confirmed the MDS nurse at that time was no longer employed at the facility. DON confirmed he was also able to add interventions to the care plans. Interview on 02/08/24 at 10:14 P.M., with RN #258 confirmed she was the charge nurse on 12/05/23 when Resident #120 fell out of bed. Housekeeping notified her of the fall. RN #258 revealed she remembered seeing Resident #120 lying on her back next to her bed. Resident #120 said she was in a lot of pain. RN #258 revealed Resident #120's bed was not in the low position; it was standard position a resident would use if they transferred themselves in an out of bed. RN #258 revealed she was not aware Resident #120's bed was supposed to be in a low position and revealed, It was not in her care plan. Interview on 02/08/24 at 10:55 A.M., with LPN Unit Manager (UM) #361 confirmed Resident #120's son spoke with her a couple times about Resident #120's bed needing to be in low position. LPN UM #361 revealed she in serviced staff several times about it. LPN UM #361 confirmed the All Staff Inservice was not signed by RN #258. LPN UM #361 confirmed not all the staff were in service and the intervention was not placed in the care plan. 2. Review of Resident #88's medical record revealed an admission date of 09/20/19. Diagnosis included Alzheimer's disease with early onset, abnormal posture, and transient cerebral ischemic attack. Review of the quarterly MDS dated [DATE] revealed Resident #88 was severely cognitively impaired. Resident #88 required substantial to maximum assistants with care. Resident #88 had a history of falls. Review of the care plan for Resident #88 revealed Resident #88 was at risk for falls related to diabetes mellitus, hypertension, psychoactive drug use, and needs staff assist for transfers. Interventions included bolstering to exit side of bed. Review of the care plan revealed no interventions were in place to have the bed in low position while in bed. Interview on 02/07/24 at 5:07 P.M., with DON stated Resident #88 should have had the intervention in her care plan to have the bed in low position while in bed because she was at risk for falls. DON stated Resident #88 did not have the intervention for a low bed in her care plan. 3. Review for Resident #2's medical record revealed an admission date of 08/29/23. Diagnosis included anxiety disorder, difficulty in walking, muscle weakness, lack of coordination, repeated falls, unspecified fall subsequent encounter subluxation of cervical four and five vertebrae, sequela. Record review of the Quarterly MDS dated [DATE] revealed Resident #2 was severely cognitively impaired. Resident #2 required substantial maximum assist for sitting to stand, transfers, and ambulation. Review of the care plan on 02/07/24 for Resident #2 dated 08/30/23 revealed Resident was at risk (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365926 If continuation sheet Page 6 of 12 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 02/12/2024 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few for falls related to confusion, deconditioning, gait balance problems and a history of falls. Interventions included assessing the resident for fall risk upon admission, quarterly and as needed. Assist with ambulation, transfer, toileting as needed, and to be sure the residents call light was within reach and encourage the resident to use it for assistants as needed. Review of the care plan on 02/07/24 revealed there was no intervention in the care plan to have the bed in the low position well in bed. Review of the care plan revealed interventions were added to included bed in lowest position while occupied added 02/09/23. Interview on 02/07/24 at 5:07 P.M., with DON stated Resident #2 should have had the intervention in her care plan to have the bed in low position while in bed because she was at risk for falls. DON confirmed Resident #2 did not have the intervention for a low bed in her care plan. Review of the policy titled, Fall Prevention and Management Policy, dated 04/01/22, revealed each resident will be assessed for fall risk on admission, quarterly, after any fall and as needed. If risks are identified, preventive measures will be put in place and added to the resident's care plan. All falls will be reviewed and investigated. This deficiency represents non-compliance investigated under Complaint Number OH00150460 and OH00149914. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365926 If continuation sheet Page 7 of 12 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 02/12/2024 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 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record reviews, observations, family interview, staff interviews, and policy review the facility failed to ensure adequate fall interventions were in place to promote resident safety and prevent falls. Actual harm occurred on 12/05/23 when Resident #120, who was severely cognitively impaired and assessed at risk for falls, sustained an unwitnessed fall from a bed that was not in low position resulting in increased pain and hospitalization for traumatic sacral fractures with presacral edema and lumbar one and four compression fractures. The resident was not a candidate for invasive procedures and returned to the facility with hospice consultation orders. This affected three residents (#2, #88 and #120) of three residents reviewed for falls. The facility census was 117. Findings include: 1. Review of Resident #120's medical record revealed an admission date of 12/19/22, a re-admission date of 12/08/23 and a discharge date of 12/15/23. Diagnosis included unspecified dementia, chronic atrial fibrillation, difficulty in walking, muscle weakness, need for assistants with personal care, and cognitive communication deficit. Review of the Morse Fall Scale completed on 12/19/22 revealed Resident #120 was at high risk for falls. Review of the care plan dated initiated 12/20/22 revealed Resident #120 was at risk for falls related to confusion, reconditioning, gait/balance problems, unaware of safety needs, history of falls and cognitive impairment. Interventions included reminder sign, Dycem in front of recliner, anticipate and meet the resident needs, assist with ambulation, transfer, and toileting, call light in reach and non-skid socks as ordered. Review of the care plan revealed there was no intervention in place for Resident #120 to have the bed in lowest position while in bed. Review of an incident note dated 01/02/23 at 5:54 P.M., completed by Registered Nurse (RN) #273 revealed this nurse was alerted by the aide that the resident was on the floor. The resident was observed sitting on her buttocks with back up against the recliner. Following the incident, a Dycem was applied to the recliner as a fall/safety intervention. Review of a progress note for Resident #120 dated 01/13/23 at 6:42 A.M., completed by Licensed Practical Nurse (LPN) #257 revealed this nurse was alerted by resident calling out that she needed help and that she was on the floor. Upon entry into the room, the resident observed sitting straight up on the side of the bed, back towards nightstand, knees bent, when asked what happened, she stated she was trying to go to the bathroom and forgot to utilize call button. Following the incident, the interdisciplinary team (IDT) met and identified the resident stated she was trying to go to the bathroom and forgot to use the call light. A reminder sign was placed for the resident to ensure use of call system for help. Review of the Morse Fall Scale completed on 01/13/23, 04/18/23, and 07/19/23 revealed Resident #120 was at high risk for falls. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #120 was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365926 If continuation sheet Page 8 of 12 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 02/12/2024 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 0689 severely cognitively impaired. Level of Harm - Actual harm Review of the All Staff Inservice dated 11/17/23 included staff were educated to be sure Resident #120's bed was in the lowest position after you are done providing care. The All Staff Inservice was signed by four LPN's and ten State Tested Nursing Assistants (STNA). Record review revealed no evidence the resident's plan of care was updated following this inservice to reflect the bed position as an intervention for falls/safety for the resident. Residents Affected - Few Review of a progress note dated 12/05/23 at 2:48 P.M., for Resident #120 completed by Registered Nurse (RN) #258 revealed Resident #120 was found lying on her back on the floor between her bed and her nightstand. Housekeeper #346 informed RN #258, Housekeeper #346 stated she had heard a Slap sound and then heard someone calling out. Resident #120 was crying at the moment and expressing she was in pain. An x-ray was ordered. On 12/05/23 at 3:49 P.M., Resident #120 had a change in mental status with more confusion post fall. The Certified Nurse Practitioner (CNP) was notified, and Resident #120 was sent to the emergency room (ER). Review of the hospital record for Resident #120 dated 12/06/23 at 10:06 A.M. revealed the status post fall, traumatic sacral fractures with presacral edema, lumbar one and four compression fractures, and a suspected type two myocardial infarction. Resident #120 was not a candidate for any invasive procedure and was referred to Hospice. Review of the progress note dated 12/08/23 at 12:00 P.M., completed by LPN #354 revealed Resident #120 returned to the facility. Hospice was in to evaluate patient. Review of the physician orders for Resident #120 dated 12/08/23 revealed Morphine Sulfate 0.25 milligrams (mg) to five mg every two hours as needed for pain. On 12/09/23, Resident #120 received additional orders for Tramadol 50 mg every six hours as needed for pain. Review of the Medication Administration Record for December 2023 revealed prior to Resident #120's fall on 12/05/23, Resident #120's only pain medication order was for Tylenol 325 mg as needed for pain which was not used prior to the fall on 12/05/23. After returning from the hospital on [DATE] Resident #120 required 20 doses of narcotic pain medication rating her pain a two to a nine level (on a scale of one to 10 with 10 being the most severe pain) prior to passing away on 12/15/23. Review of the progress note dated 12/15/23 at 2:00 P.M., revealed the son came and got nurse and stated that his mom had passed. Two nurses verified resident absence of vital signs. Interview on 02/06/24 at 3:34 P.M., with Resident #120's son revealed he visited his mother, daily over the past year while she resided at the facility. Resident #120's son revealed Resident #120 was confused and had already had two falls at the facility when he met with the Administrator, DON, and the Unit Manager to request her bed be placed in the lowest position while she was in bed. He feared if she fell out of bed at a routine bed height, she could be seriously injured. Resident #120's son revealed the Administrator, DON, and the Unit Manager assured him the bed would be placed in the lowest position while she was in bed. On multiple visits he stated he would find Resident #120's bed was not in the lowest position while she was in bed. Resident #120's son revealed he continued to meet with the Administrator, DON, and the Unit Manager on multiple occasions who consistently assured him the bed would be placed in the lowest position while she was in bed. Resident #120's son revealed facility staff who found Resident #120 on the floor on 12/05/23 confirmed her bed was not lowered when she was left unattended and fell out of bed resulting in multiple fractures. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365926 If continuation sheet Page 9 of 12 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 02/12/2024 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 0689 Level of Harm - Actual harm Residents Affected - Few Interview on 02/07/24 between 2:45 P.M. and 4:40 P.M., with the DON, Administrator, and Unit Manager confirmed Resident #120's son had spoken with each of them on a few different occasions regarding his concerns of her bed being placed too high with concerns of her falling out of bed. The DON confirmed the facility used electric beds, the beds were able to raise and lower by using a remote control. During care, staff would raise the bed but were to lower it when care was complete. The DON revealed Resident #120's bed was to be in a low position while she was in bed unattended. The DON revealed staff were in-service to keep Resident #120's bed in a low position. The DON confirmed the low bed intervention was not placed in Resident #120's care plan and revealed he had met with the Interdisciplinary Team on several occasions, discussed the concern of staff not keeping her bed in the low position in morning meetings several different times and the MDS nurse who was present during those meetings was supposed to put the intervention in the care plan but never did. The DON stated if the resident was at risk for falls then the beds should always be in the lowest position when unattended by staff. The DON confirmed the MDS nurse at that time was no longer employed at the facility. The DON confirmed he was also able to add interventions to the care plans. Interview on 02/07/24 at 3:54 P.M., with Housekeeper #346 revealed she was the first one in the room after Resident #120 fell out of bed on 12/05/23. Housekeeper #346 revealed she heard Resident #120 screaming as she was talking to Housekeeping Supervisor #243 in the hall. They both started walking and went into Resident #120's room. Resident #120 was on the floor between the bed and nightstand. Housekeeper #346 revealed Resident #120's bed was not in any low position when she found her on the floor. Interview on 02/07/24 at 3:57 P.M., with Housekeeping Supervisor # 243 revealed she was with Housekeeper #346 when they heard someone screaming. They went into Resident #120's room and could see she had fallen; she was lying on the floor between the bed and nightstand, no one else was there. Housekeeping Supervisor #243 revealed Resident #120's bed was at regular height, not in the low position. Interview on 02/08/24 at 10:14 P.M., with RN #258 confirmed she was the charge nurse on 12/05/23 when Resident #120 fell out of bed. Housekeeping notified her of the fall. RN #258 revealed she remembered seeing Resident #120 lying on her back next to her bed. Resident #120 said she was in a lot of pain. RN #258 revealed Resident #120's bed was not in the low position; it was standard position a resident would use if they transferred themselves in an out of bed. RN #258 revealed she was not aware Resident #120's bed was supposed to be in a low position and revealed, It was not in her care plan. Interview on 02/08/24 at 10:55 A.M., with LPN Unit Manager (UM) #361 confirmed Resident #120's son spoke with her a couple times about Resident #120's bed needing to be in low position. LPN UM #361 revealed she in serviced staff several times about it. LPN UM #361 confirmed the All Staff Inservice in November 2023 was not signed by RN #258. LPN UM #361 confirmed not all the staff were in serviced and the intervention was not placed on the resident's care plan. 2. Review of Resident #88's medical record revealed an admission date of 09/20/19. Diagnosis included Alzheimer's disease with early onset, abnormal posture, and transient cerebral ischemic attack. Review of the quarterly MDS dated [DATE] revealed Resident #88 was severely cognitively impaired. Resident #88 required substantial to maximum assistants with care. Resident #88 had a history of falls. Review of the care plan for Resident #88 revealed Resident #88 was at risk for falls related to diabetes mellitus, hypertension, psychoactive drug use, and needs staff assist for transfers. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365926 If continuation sheet Page 10 of 12 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 02/12/2024 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 0689 Interventions included bolstering to exit side of bed. Review of the care plan revealed no interventions were in place to have the bed in low position while in bed. Level of Harm - Actual harm Residents Affected - Few Record review of the physician orders for Resident #88 revealed an order dated 04/16/21 for bolster to exit side of bed. Observation on 02/06/24 at 2:55 P.M., revealed Resident #88 was lying in bed. Observation revealed Resident #88's bed was not in a low position. Resident #88 did not have a bolster in place to the exit side of the bed. LPN #354 verified Resident #88's bed was not in a low position and revealed Resident #88 was at risk for falls and the bed should be in the lowest position while she was in bed. Interview on 02/07/24 at 5:07 P.M., with DON stated Resident #88 should have had the intervention in her care plan to have the bed in low position while in bed because she was at risk for falls. DON stated Resident #88 did not have the intervention for a low bed in her care plan. Observation on 02/08/24 at 2:37 P.M., revealed Resident #88 was lying in bed. Observation revealed the bed was not in low position and there was no bolster on the bed Resident #88 was lying in. Interview and observation on 02/08/24 between 2:38 P.M. and 2:40 P.M., with RN #379 and LPN #277 confirmed Resident #88's bed was not in low position but should be because she was at risk for falls and confirmed Resident #88 did not have a bolster to the exit side of the bed and should have had one at all times while in bed to assist in preventing falls. 3. Review for Resident #2's medical record revealed an admission date of 08/29/23. Diagnosis included anxiety disorder, difficulty in walking, muscle weakness, lack of coordination, repeated falls, unspecified fall subsequent encounter subluxation of cervical four and five vertebrae, sequela. Record review of the Quarterly MDS dated [DATE] revealed Resident #2 was severely cognitively impaired. Resident #2 required substantial maximum assist for sitting to stand, transfers, and ambulation. Review of the care plan on 02/07/24 for Resident #2 dated 08/30/23 revealed Resident was at risk for falls related to confusion, deconditioning, gait balance problems and a history of falls. Interventions included assessing the resident for fall risk upon admission, quarterly and as needed. Assist with ambulation, transfer, toileting as needed, and to be sure the residents call light was within reach and encourage the resident to use it for assistants as needed. Review of the care plan on 02/07/24 revealed there was no intervention in the care plan to have the bed in the low position well in bed. Review of the care plan revealed interventions were added to included bed in lowest position while occupied added 02/09/23. Review of the progress note for Resident #2 dated 12/24/23 at 3:36 A.M., completed by LPN #403 revealed a State Tested Nurse Aides (STNA) informed this nurse (Resident #2) was found lying the left side of her bed on the floor, this nurse entered resident, noted floor clear from clutter, bed placed in lowest position, approached the resident, this nurse noted resident positioned on her right side on the side of her bed, this nurse asked Resident #2 what happened, resident stated she rolled out of bed. Intervention for resident rolling out of bed would be placing a floor mat on each side of the bed. Review of the progress note for Resident #2 dated 01/07/24 at 1:17 P.M., completed by Registered Nurse (RN) #336 revealed a fall occurred in the resident's room. The reason for the fall was not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365926 If continuation sheet Page 11 of 12 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 02/12/2024 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 0689 evident. The resident was up in wheelchair for breakfast, she did not want to stay up in wheelchair and attempted to transfer to bed unassisted. Level of Harm - Actual harm Residents Affected - Few Review of the progress note for Resident #2 dated 01/12/24 at 1:36 P.M., completed by Unit Manager #361 revealed the IDT team reviewed the resident's fall. Resident #2 has had an increase of restlessness in the past couple weeks. Resident was found on floor in room, wheelchair located behind resident. Immediate intervention was resident was assessed for injury, pain and neuro checks initiated. When asked by the staff what she was doing resident stated that she was trying to get back into bed. At the time of fall, the resident is currently being seen by therapy for Part B services. With resident's gradual decline there is an order for a hospice consult. Due to resident's decline, there will be a move room closer to nursing station. Staff educated on ensuring that resident's wheelchair brakes are locked before leaving room. Review of the progress note for Resident #2 dated 01/16/24 at 1:43 P.M., completed by Unit Manager #361 revealed the IDT team reviewed resident's fall. The resident was found on the floor in a room. The resident was unable to clearly state what she was doing. She stated that they moved my room, and they did not come back to make my bed. Immediate intervention for fall was assessed for injury, pain, neuro checks initiated. No apparent injury noted at time of fall no complaints of pain noted. Immediate intervention was provided new intervention for this fall is bolster overlay mattress. Observation on 02/06/23 at 1:57 P.M., revealed Resident #2 was in bed eating her lunch. The bed was not in a low position and a bed bolster was observed. Unit Manager #361 verified the bed was not in a low position and stated it should have been. Interview on 02/07/24 at 5:07 P.M., with DON stated Resident #2 should have had the intervention in her care plan to have the bed in low position while in bed because she was at risk for falls. DON confirmed Resident #2 did not have the intervention for a low bed in her care plan. Observation on 02/12/24 at 3:00 P.M. revealed Resident #2 was lying in bed. Resident #2's bed was not in the lowest position, but the bed bolster mattress was in place. Observation and interview on 02/12/24 at 3:01 P.M., with RN #258 confirmed Resident #2's bed was not in the lowest position and confirmed bed should be in the lowest position if resident at risk for fall. Review of the policy titled, Fall Prevention and Management Policy, dated 04/01/22, revealed each resident will be assessed for fall risk on admission, quarterly, after any fall and as needed. If risks are identified, preventive measures will be put in place and added to the resident's care plan. All falls will be reviewed and investigated. This deficiency represents non-compliance investigated under Complaint Number OH00150460 and OH00149914. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365926 If continuation sheet Page 12 of 12