Inspection·August 15, 2024

F 0582 corrective actions: Level of Harm - Potential for minimal harm • Residents Affected - Some On 05/17/24, the Administrator identified NOMNC and SNF ABN notices were not being provided to residents as required. • Between 05/17/24 and 06/10/24, the Administrator and regional support staff added social services job duties to their Quality Assurance (QA) monitoring and conducted audits. • On 06/10/24, the former SSD was educated on job responsibilities and timeliness of completing NOMNC and SNF ABN notices. • On 06/14/24, the former SSD turned in a notice of immediate resignation. • On 06/17/24, SSD #509 was hired as the new SSD. • Review of the NOMNCs and SNF ABNs provided by SSD #509 between 07/02/24 and 08/09/24 were provided in a timely manner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366011 If continuation sheet Page 2 of 5 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 366011 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Concord Ridge Health and Rehabilitation 9901 Johnnycake Ridge Rd Mentor, OH 44060 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. 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 facility policy review the facility failed to ensure pre and post dialysis assessments were completed as ordered for Resident #3. This affected one resident (#3) of one resident review for dialysis services. The facility census was 77. Residents Affected - Few Findings include: Review of the medical record for Resident #3 revealed an admission date of 02/03/24. Diagnosis included heart failure, diabetes, end stage renal disease, obesity, anemia, and insomnia. Review of the physician's orders for August 2024 revealed an order for dialysis Monday, Wednesday, and Friday. A dialysis communication form was to be sent with Resident #3 for each visit. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 was cognitively intact. She required supervision or touch assistance for eating and oral hygiene and substantial or maximum assistance for toileting, showering, and personal hygiene. Resident #3 received dialysis. Review of the care plan dated 07/29/24 revealed Resident #3 received dialysis on Mondays, Wednesdays, and Fridays. Interventions included checking for new orders upon return from dialysis, monitoring labs, and maintaining communication with the dialysis physician. Further review of the medical record revealed Resident #3 revealed no pre or post dialysis assessments had been completed since 06/07/24. There was no documented evidence the resident had missed any scheduled dialysis days since that time. Interview on 08/15/24 at 3:12 P.M. with the Administrator confirmed there was no documented evidence pre and post dialysis assessments were completed for Resident #3 since 06/07/24. Review of the undated facility policy titled Hemodialysis revealed the facility would provide necessary care and treatment for the provision of dialysis to following physician's orders and monitoring for complications before and after dialysis treatments. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366011 If continuation sheet Page 3 of 5 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 366011 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Concord Ridge Health and Rehabilitation 9901 Johnnycake Ridge Rd Mentor, OH 44060 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and facility policy review the facility failed to ensure clear instruction was in place for the use of opioid pain medication and did not ensure nonpharmacological interventions were attempted prior to the administration of pain medication for Resident #33. This affected one resident (#33) of five residents reviewed for unnecessary medications and had the potential to affect all residents. The facility census was 77. Residents Affected - Few Findings include: Review of the medical record for Resident #33 revealed an admission date of 06/21/24 with diagnoses including heart failure, respiratory failure, asthma, and diabetes. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #33 was cognitively intact. She required set up or clean up help for eating, supervision or touch assistance for oral hygiene, substantial or maximum assistance for personal hygiene and was dependent for toileting and showering. Review of the physician's orders for August 2024 revealed an order for Acetaminophen 325 milligrams (mg) every six hours as needed (prn) pain and Tramadol (an opioid pain medication) 50 mg every six hours prn for pain. Review of the medication administration record (MAR) for June 2024 revealed Resident #33 received one dose of Tramadol on 06/22/24 for a pain level of 7, one dose on 06/25/24 for a pain level six, one dose on 06/26/24 for a pain level of three, one dose on 06/26/24 for a pain level of five, one dose on 06/28/24 for a pain level of three, one dose on 06/28/24 for a pain level of five, one dose on 06/29/24 for a pain level of six, and one dose on 06/30/24 for a pain level of seven. Review of the MAR for July 2024 revealed resident #33 received one dose of Tramadol on 07/01/24 for a pain level of eight, one dose on 07/03/24 for a pain level of six, one dose on 07/03/24 for a pain level of seven, one dose on 07/05/24 for a pain level of seven, one dose on 07/09/24 for a pain level of six, one dose on 07/09/24 for a pain level of five, one dose on 07/12/24 for a pain level of nine, one dose on 07/13/24 for a pain level of five, one dose on 07/14/24 for a pain level of five, one dose on 07/15/24 for a pain level of three, one dose on 07/16/24 for a pain level of four, one dose on 07/16/24 for a pain level of five, one dose on 07/18/24 for a pain level of eight one dose on 07/18/24 for a pain level of five, two doses on 07/19/24 for a pain level of six, one dose on 07/20/24 for a pain level of five, one dose on 07/22/24 for a pain level of eight, one dose on 07/23/24 for a pain level of 10, one dose on 07/25/24 for a pain level of eight, one dose on 07/26/24 for a pain level of six, two doses on 07/30/24 for a pain level of five, and one dose on 07/31/24 for a pain level of nine. Resident #33 received one dose of Acetaminophen on 07/08/24 for a pain level of five, one dose on 07/09/24 for a pain level of four, one dose on 07/20/24 for a pain level of five, and one dose on 07/31/24 for a pain level of seven. Review of the MAR for August 2024 revealed Resident #3 received one dose of Tramadol on 08/03/24 for a pain level of four, one dose on 8/04/24 for a pain level of five, one dose on 8/05/24 for a pain level of three, and one dose on 8/13/24 for a pain level of six. Resident #3 received one dose of Acetaminophen on 08/02/24 for a pain level of four. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366011 If continuation sheet Page 4 of 5 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 366011 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Concord Ridge Health and Rehabilitation 9901 Johnnycake Ridge Rd Mentor, OH 44060 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 0757 Level of Harm - Minimal harm or potential for actual harm Review of the progress notes dated 06/01/24 through 08/15/24 revealed nonpharmacological interventions were attempted prior to the administration of pain medications on 06/01/24, 06/04/24, 06/05/24, 06/06/24, 06/10/24, 06/11/24, 06/12/24, 06/15/24, 06/16/24, 06/18/24, 06/22/24, 06/25/24, 07/05/24, 07/09/24, 07/22/24, and 08/01/24. There was no other documented evidence of nonpharmacological interventions were attempted prior to the use of the above pain medications. Residents Affected - Few Interview on 08/15/24 at 11:46 A.M. with the Director of Nursing (DON) confirmed nonpharmacological interventions should be attempted prior to the administration of pain medications and could provide no further evidence attempts were made for the above-mentioned pain medications. The DON also confirmed Tramadol is usually given for a pain level of five to six on a pain scale of one to ten, with ten being the worst. Acetaminophen should be administered for a pain level of one to four. Review of the facility policy titled Pain Assessment and Management, dated 03/31/16, revealed the facility would use a one to ten scale, with ten being the worst, to determine the intensity of pain. In addition, the facility would attempt non-pharmacological pain reduction techniques prior to administering pain medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366011 If continuation sheet Page 5 of 5