Health inspection·May 2, 2022

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Based on record review and interview the facility failed to ensure residents' signed advance directive forms were contained in their medical record. This affected two (Residents #189 and #191) of two residents reviewed for advance directives. The facility census was 42. Findings include: 1. Review of the medical record for Resident #191 revealed an admission date of 04/19/22. Diagnoses included COVID-19, prostate cancer, spinal stenosis, and chronic cough. Review of the physician orders for April 2022 revealed orders for a Do Not Resuscitate Comfort Care-Arrest (DNRCC-Arrest) dated 04/19/22 for code status. Review of Resident #191's medical record revealed no signed and dated DNR Comfort Care form. 2. Review of the medical record for Resident #189 revealed an admission date of 04/21/22. Diagnoses included chronic obstructive pulmonary disease (COPD), lung cancer, and major depressive disorder. Review of the physician orders for April 2022 revealed orders for a Do Not Resuscitate Comfort Care-Arrest (DNRCC-Arrest) dated 04/22/22 for code status. Review of Resident #189's medical record revealed no signed and dated DNR Comfort Care form. Interview on 04/26/22 at 9:55 A.M. with Licensed Practical Nurse (LPN) #616 verified Residents #191 and #189 both had orders for DNRCC- Arrest and neither had the signed and dated DNR forms in their medical records. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366021 If continuation sheet Page 2 of 21 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shaker Gardens Nursing and Rehabilitation Center 3550 Northfield Road Shaker Heights, OH 44122 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 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. Based on record review, staff interview, and policy review the facility failed to identify a reason for an immediate discharge. This affected one (Resident #38) of three residents (#38, #40, and #192) reviewed for discharges. The facility census was 42. Findings include: Review of the closed medical record for Resident #38 revealed an admission date of 03/25/22 and a discharge date of 04/18/22. Diagnoses included cocaine abuse, chronic obstructive pulmonary disease (COPD), post-traumatic stress disorder (PTSD), lung cancer, and dementia with behavioral disturbance. Review of the discharge care plan dated 03/29/22 revealed the resident would state he was leaving Against Medical Advice (AMA) to the community but then chooses not to leave. Interventions included social services to assist with discharge planning. Review of the admission Minimum Data Set (MDS) assessment, dated 04/03/22, revealed the resident had impaired cognition. The resident required supervision and assistance of one staff for bed mobility and transfers, and required supervision and set up help only for ambulation. Review of a late entry progress note dated 04/04/22 at 12:12 P.M. revealed Social Worker (SW) #572 spoke with Resident #38 regarding concerns that he wanted to leave the facility. He stated he was not looking to leave but wanted to know where he was. He stated he was still interested in moving to an assisted living. He was calm and pleasant while interacting with this worker and presented no psychosocial issues at this time. SW #572 will update as needed. Review of the social service note revealed a late entry note dated 04/07/22 at 12:17 P.M. for a care conference held with the resident's daughter, SW #572, the DON, and the therapy director. The daughter stated she felt the resident needed long-term care due to his declining cognition and increase in behaviors. The daughter was informed of the facility concerns regarding exit seeking behavior from the resident and asked the daughter if she agreed with him having a leave of absence (LOA) order. The daughter did not want resident to leave the facility. She stated the resident had been aggressive toward her at home, had issues with substance abuse, was non-compliant with medication, and felt that some family members had misappropriated the his funds in the past. The daughter was educated that this facility was not a locked dementia unit. It was suggested that due to resident's physical abilities, an alternative placement more appropriate to meet his needs should be explored. The daughter expressed interest in moving him to an assisted living facility. The daughter was informed the resident would be allowed to come and go from the facility's assisted living as it was considered the community. The daughter stated she did not want to hinder his freedom but felt he would be at risk if he was permitted to leave the facility at will. The daughter stated she would explore alternative settings and asked staff to send the residents information to a specific assisted living and other facilities the facility identified that were more appropriate to meet his needs and safety. The resident was also seen by psychiatry outside the facility. The daughter also stated she planned to pursue guardianship of the resident. SW #572 will update as needed. Review of the late entry social services note dated 04/08/22 at 12:49 P.M. revealed Resident #38's daughter was notified the assisted living facility she requested would not accept him due to his needs. Will update as needed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366021 If continuation sheet Page 3 of 21 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shaker Gardens Nursing and Rehabilitation Center 3550 Northfield Road Shaker Heights, OH 44122 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 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the late entry social services note dated 04/8/22 at 12:52 P.M. revealed the DON faxed Resident #38's information to skilled nursing facilities (SNF) #1, SNF #2, and SNF #3. SNF #2 and #3 declined due to the resident's needs. SNF #1's Administrator contacted the DON and stated they would accept resident to their locked dementia unit. Transportation to be arranged by receiving facility. Will update as needed. Review of the progress note dated 04/18/22 at 2:26 P.M. revealed Resident #38 was discharged to SNF #1 with his belongings and medications. Interview on 04/27/22 at 10:04 A.M. with Licensed Practical Nurse (LPN) #616 revealed Resident #38 was a nice guy. LPN #616 stated the resident was put on a watch. LPN #616 stated one time he was down by the window looking out and they thought he was trying leave, but he was not. LPN #616 stated there was some type of family dynamics between resident and his daughter. LPN #616 stated she was not working the day Resident #38 discharged but knew he went to another facility. LPN #616 stated the plan was for the resident to go to an assisted living. LPN #616 stated she did not know how the resident's discharge came about but knew someone from the other facility had come to visit the resident. Interview on 04/27/22 at 6:11 P.M. with Resident #38's daughter revealed she was the Power of Attorney (POA) for Resident #38, and they had discharged him without her knowledge or consent. Resident #38's daughter stated the resident had called her from his cell phone the day the facility had discharged him, and he was in distress. She said she heard someone telling him he had to leave, and the phone hung up so she got into her car and headed to the facility. When she arrived at the facility the resident was in the transportation car with his belongings and the transportation lady told her she did not know what was going on and that the nurse had gone back into the facility to get oxygen for the resident. The daughter stated the resident was having trouble breathing and they did not have him on oxygen. The daughter stated the resident was already in the car and had rolled down the window and said to her they told him he had to leave. The daughter stated when they had the care conference, eight to 10 days before they discharged him, she had informed them she wanted Resident #38 to discharge to an assisted living facility and that she wanted to tour the facilities first. The daughter stated when she went into the facility on the day he was discharged , she had also asked for the discharge paperwork and had not received it. She went into the facility and spoke with two female staff members who told her they ' d called her, she did not remember their names, but no one had called her. The daughter stated the facility did not follow necessary procedures and felt they just kicked him out. She stated the resident was not able to make his own decisions and she was recently awarded guardianship at the hearing on 04/26/22. Interview on 04/28/22 at 10:40 A.M. with State Tested Nurse Aide (STNA) #603 revealed she packed Resident #38's belongings. STNA #603 stated he had told her he was not going anywhere and had planned to be discharged home the following Tuesday. STNA #603 stated Resident #38 had called his sister on his cell phone, and she did not know what was going on. STNA #603 stated the resident would not get dressed or allow her to pack his things and she had to inform the nurse. STNA #603 stated the nurse had to call the DON multiple times because the resident was not allowing her to pack his items. STNA # 603 stated she learned that day Resident #38 was being discharged and was told by the nurse. STNA #603 stated Resident #38 was alert and oriented, slept most of time, and was independent. STNA #603 stated he toileted himself and all they provided were towels for bathing. STNA #603 stated the resident finally allowed her to pack his items. STNA #603 stated she and a housekeeper took the resident and his items downstairs where transportation was waiting outside, and the DON was down there as well. STNA #603 stated the resident was a little upset but not yelling. STNA #603 stated she was not sure if Resident #38 was told ahead of time that he was discharging. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366021 If continuation sheet Page 4 of 21 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shaker Gardens Nursing and Rehabilitation Center 3550 Northfield Road Shaker Heights, OH 44122 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 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 04/28/22 at 11:10 A.M. with SW #572 stated she had been out and returned to work on 04/25/22 and Resident #38 was already gone. SW #572 stated when she returned, she had a stack of papers on her desk and verified she had entered those late entry progress notes on 04/26/22. SW #572 stated she'd met with Resident #38 when she was notified that the nurse indicated he was exit seeking. SW #572 stated when she met with Resident #38, he was own responsible party, he was alert and oriented, and pleasant. SW #572 stated when she did his brief interview mental status (BIMS) his score was 10 (indicating moderate cognitive impairment). SW #572 stated she did the BIMS for admission but liked to wait about two weeks later for a more accurate BIMS when the resident was more settled in, but he was gone before she could do that. SW #572 stated when she spoke with Resident #38, he said to her why would he try to leave when she was helping him find a place. SW #572 stated Resident #38 came from the hospital but was living home with his daughter prior to that. SW #572 stated there were issues between the resident and his daughter. SW #572 stated they had a care conference that included herself, the DON, the resident's daughter, and therapy, although the resident was not receiving skilled services. SW #572 stated the resident was not included due to his daughter's request as she did not want to upset him. SW #572 stated they discussed in the care conference pursuing future placement because the resident was not able to return home with the daughter. SW #572 stated Resident #38's daughter wanted her to send a referral to a specific assisted living, but it allowed the resident to come and go. SW #572 stated the daughter wanted the resident to be private and secured and did not want the resident to just come and go. SW #572 stated it she thought it was related to the resident's drug history and to keep his siblings from taking his money. SW #572 stated it was to protect the resident from them not so much himself. SW #572 stated she only sent the one referral the resident's daughter had requested and informed her of the denial and that was extent of her involvement with Resident #38's discharge. SW #572 stated when she returned to work, she went through the referrals and things that had been done and by who that she documented into the electronic health record on 04/26/22. Interview on 04/28/22 at 11:41 A.M. with the DON revealed while SW #572 was out she managed the discharge by sending referrals to SNF #1, #2, and #3. the DON stated she did not send any referrals to assisted living facilities because she was not aware of any that took waivers and had secured units. the DON stated it was not her area. The DON stated Resident #38 was noted to be exit seeking and had to be put on one on one supervision. The DON stated she was hearing from the nurses and had a brief conversation with the resident where he inquired about Leave of Absences (LOAs). The DON stated she did not have a conversation with the resident regarding exit seeking. The DON stated his cognition was okay. The DON stated based on his history of drug use and family dynamics it was only a matter of time before he tried to leave the facility and she was uncomfortable with the potential risk. The DON stated the resident's daughter wanted him on a secured unit, wanted to restrict his visitors and for him to be in a secure place with freedom and the facility was not a lock down unit. The DON stated Resident #38 had dementia, PTSD, and the daughter was in the process of getting guardianship. The DON stated it was a gray area when it came to the resident's daughter as his POA. The DON stated when SNF #1's administrator came out to visit the resident she did not recall the administrator saying one way or the other whether the resident agreed to transfer to that facility. The DON stated she was not sure who informed the resident of the discharge, she had not but believed SW #572 left a voicemail message for the daughter. The DON stated the day Resident #38's discharge was hectic and eventually she had made it upstairs and staff were packing his items. The DON stated the resident was ready to go and walked downstairs with his walker. The DON stated Resident #38 had not mentioned to her that he did not want to leave and did not seem to be upset. The DON stated she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366021 If continuation sheet Page 5 of 21 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shaker Gardens Nursing and Rehabilitation Center 3550 Northfield Road Shaker Heights, OH 44122 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 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few believed he wanted to delay his discharge. The DON stated after the resident left, the daughter had come into the facility and stated she did not know about the discharge. The DON stated Resident #38's sister had called the facility and stated she was going to call the police but could not give her any information and told her to call the resident's daughter. Review of facility policy titled Resident Transfer and Discharge Policy and Procedure, undated, revealed the facility shall not transfer or discharge a resident while an appeal is pending if the resident exercises his or her right to appeal a transfer or discharge notice from the facility, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility. The facility shall document the danger that failure to transfer, or discharge would pose. All transfers or discharges must be documented in the medical record and appropriate information is communicated to the receiving health care institution or provider. Documentation in the resident's medical record must include: the basis for the transfer, the specific resident need(s) that cannot be met, and the facility attempts to meet the resident needs, and the service available at the receiving facility to meet the need(s). The resident's physician must make the documentation when transfer or discharge is necessary; and when transfer or discharge is necessary. This deficiency substantiates Complaint Number OH00132084. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366021 If continuation sheet Page 6 of 21 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shaker Gardens Nursing and Rehabilitation Center 3550 Northfield Road Shaker Heights, OH 44122 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Based on record review, staff interview, and policy review the facility failed to notify the resident and the resident's representative of a discharge. This affected one (Resident #38) of three residents (#38, #40, and #192) reviewed for discharges. The facility census was 42. Findings include: 1. Review of the closed medical record for Resident #38 revealed an admission date of 03/25/22 and a discharge date of 04/18/22. Diagnoses included cocaine abuse, chronic obstructive pulmonary disease (COPD), post-traumatic stress disorder (PTSD), lung cancer, and dementia with behavioral disturbance. Review of the admission Minimum Data Set (MDS) assessment, dated 04/03/22, revealed the resident had impaired cognition. The resident required supervision and assistance of one staff for bed mobility, transfers, and required supervision and set up help only for ambulation. Review of the social service note revealed a late entry note dated 04/07/22 at 12:17 P.M. for a care conference held with the resident's daughter, SW #572, the Director of Nursing (DON), and therapy director. The daughter stated she felt the resident needed long-term care due to his declining cognition and increase in behaviors. The daughter was informed of the facility concerns regarding exit seeking behavior from the resident and asked if she agreed with him having a leave of absence (LOA) order. She did not. The daughter was educated that this facility was not a locked dementia unit. It was suggested that alternative placement more appropriate to meet the resident's needs should be explored. The daughter expressed interest in moving him to an assisted living. She was informed he would be allowed to come and go from the facility's assisted living. She stated she did not want to hinder his freedom but felt he would be at risk if he was permitted to leave the facility at will. She stated she would explore alternative settings and asked staff to send his information to a specific assisted living and other facilities that were more appropriate to meet his needs and safety. SW #572 will update as needed. Review of the late entry social services note dated 04/08/22 at 12:49 P.M. revealed Resident #38's daughter was notified that specified assisted living will not accept him due to his needs. Will update as needed. Review of the late entry social services note dated 04/08/22 at 12:52 P.M. revealed the DON faxed Resident #38's information to skilled nursing facilities (SNF) #1, SNF #2, and SNF #3. SNF #2 and #3 declined due to the resident's needs. SNF #1's Administrator contacted the DON and stated they would accept resident to their locked dementia unit. Transportation to be arranged by receiving facility. Will update as needed. Review of the progress note dated 04/18/22 at 2:26 P.M. revealed Resident #38 and his belongings and medications were discharged to SNF #1. Interview on 04/27/22 at 6:11 P.M. with Resident #38's daughter revealed she was the Power of Attorney (POA) for Resident #38, and they had discharged him without her knowledge or consent. Resident #38's daughter stated the resident had called her from his cell phone the day the facility had discharged him, and he was in distress. She stated she heard someone telling him he had to leave, and the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366021 If continuation sheet Page 7 of 21 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shaker Gardens Nursing and Rehabilitation Center 3550 Northfield Road Shaker Heights, OH 44122 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few phone hung up so she got into her car and headed to the facility. When she arrived he was in the transportation car with his belongings. The daughter stated the transportation lady told her she did not know what was going on. The resident rolled down the window and said to her they told him he had to leave. The daughter stated when they had the care conference, eight to 10 days before they discharged him, she had informed them she wanted him discharged to an assisted living and that she wanted to tour the facilities first. When she went into the facility on the day he was discharged , she had also asked for the discharge paperwork and had not received it. She went into the facility and spoke with two female staff members who told her they had called her, she did not remember their names, but no one had called her. She said the facility did not follow necessary procedures and felt they just kicked him out. She stated the resident was not able to make his own decisions and she was recently awarded guardianship at the hearing on 04/26/22. Interview on 04/28/22 at 10:40 A.M. with State Tested Nurse Aide (STNA) #603 stated she packed Resident #38's belongings. STNA #603 stated he had told her he was not going anywhere and had planned to be discharged home the following Tuesday. The resident would not get dressed or allow her to pack his things and she had to inform the nurse. The nurse called the DON multiple times because the resident was not allowing her to pack his items. STNA #603 stated she learned that day Resident #38 was being discharged and was told by the nurse. The resident finally allowed her to pack his items and she and a housekeeper took him and his items downstairs where transportation was waiting outside, the DON was down there as well. He was a little upset but not yelling. STNA #603 stated she was not sure if Resident #38 was told ahead of time that he was discharging. Interview on 04/28/22 at 11:10 A.M. with SW #572 stated she had been out and returned on 04/25/22 and Resident #38 was already gone. SW #572 stated they had a care conference that included herself, DON, the resident's daughter, and therapy. SW #572 stated the resident was not included due to his daughter's request did not want to upset him. SW #572 stated they discussed in the care conference pursuing future placement because the resident was not able to return home with the daughter. SW #572 stated Resident #38's daughter wanted her to send a referral to a specific assisted living, but it allowed the resident to come and go. SW #572 stated the daughter wanted the resident to be private and secured and did not want the resident to just come and go. SW #572 stated she only sent the one referral the resident's daughter had requested and informed her of the denial and that was extent of her involvement with Resident #38's discharge. SW #572 stated when she returned to work, she went through the were referrals and things that had been done and by who that she documented into the electronic health record on 04/26/22. Interview on 04/28/22 at 11:41 A.M. with the DON reveled while SW #572 was out she managed the discharge by sending referrals to SNF #1, #2, and #3. The DON stated she did not send any referrals to assisted livings because she was not aware of any that took waivers and had secured units. The DON stated Resident #38 was noted to be exit seeking and had to be put on one on one supervision. She did not have a conversation with the resident regarding exit seeking and his cognition was okay. She stated based on his history of drug use and family dynamics it was only a matter of time before he tried to leave the facility and the potential risk made her pretty uncomfortable. The resident's daughter wanted him on a secured unit, wanted to restrict his visitors and wanted him to be in a secure place with freedom, not a lock down unit. The DON stated Resident #38 had dementia, PTSD, and the daughter was in the process of getting guardianship. She DON stated it was a gray area when it came to if the resident's daughter was his POA. the DON stated when SNF #1's administrator came out to visit the resident she did not recall the administrator saying one way or the other whether the resident agreed to transfer to that facility. The DON stated she was not sure who informed the resident of the discharge and believed SW #572 left a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366021 If continuation sheet Page 8 of 21 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shaker Gardens Nursing and Rehabilitation Center 3550 Northfield Road Shaker Heights, OH 44122 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few voicemail message for the resident's daughter. The DON stated it was not her. The DON stated after the resident left, the daughter had come into the facility and stated she did not know about the discharge. Review of facility policy titled Resident Transfer and Discharge Policy and Procedure, undated, revealed before the facility transfers or discharges a resident, the facility shall, in a written notice notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. This deficiency substantiates Complaint Number OH00132084. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366021 If continuation sheet Page 9 of 21 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shaker Gardens Nursing and Rehabilitation Center 3550 Northfield Road Shaker Heights, OH 44122 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 0624 Prepare residents for a safe transfer or discharge from the nursing home. Level of Harm - Minimal harm or potential for actual harm Based on record review, staff interview, and policy review the facility failed to ensure a resident was oriented and prepared for discharge from the facility. This affected one (Resident #38) of three residents (#38, #40, and #192) reviewed for discharges. The facility census was 42. Residents Affected - Few Findings include: Review of the closed medical record for Resident #38 revealed an admission date of 03/25/22 and a discharge date of 04/18/22. Diagnoses included cocaine abuse, chronic obstructive pulmonary disease (COPD), post-traumatic stress disorder (PTSD), lung cancer, and dementia with behavioral disturbance. Review of the admission Minimum Data Set (MDS) assessment, dated 04/03/22, revealed the resident had impaired cognition. The resident required supervision and assistance of one staff for bed mobility and transfers, and required supervision and set up help only for ambulation. Review of a late entry progress note dated 04/04/22 at 12:12 P.M. revealed Social Worker (SW) #572 spoke with the resident regarding concerns that he wanted to leave the facility. Resident stated he was not looking to leave but wanted to know where he was. He stated he was still interested in moving to an assisted living. He was calm and pleasant while interacting with this worker and presented no psychosocial issues at this time. SW #572 will update as needed. Review of a late entry social service note dated 04/07/22 at 12:17 P.M. revealed a care conference was held with resident's daughter, SW #572, the Director of Nursing (DON), and therapy director. The daughter stated she felt the resident needed long-term care due to his declining cognition and increase in behaviors. The daughter was informed of facility concerns regarding exit seeking behavior from the resident and asked if she agreed with him having a leave of absence (LOA) order. She did not. She was educated that this facility was not a locked dementia unit and it was suggested that alternative placement more appropriate to meet the resident's needs should be explored. She expressed interest in moving the resident to an assisted living. The daughter was informed that the resident would be allowed to come and go from the facility's assisted living. The daughter did not want to hinder the resident's freedom but felt he would be at risk if he was permitted to leave the facility at will. She stated she would explore alternative settings and asked staff to send his information to a specific assisted living and other facilities more appropriate to meet his needs and safety. SW #572 will update as needed. Review of the late entry social services note dated 04/08/22 at 12:49 P.M. revealed Resident #38's daughter was notified that specified assisted living will not accept due to resident's needs. Will update as needed. Review of the late entry social services note dated 04/08/22 at 12:52 P.M. revealed the DON faxed Resident #38's information to skilled nursing facilities (SNF) #1, SNF #2, and SNF #3. SNF #2 and #3 declined due to the resident's needs. SNF #1's Administrator contacted the DON and stated they would accept resident to their locked dementia unit. Transportation to be arranged by receiving facility. Will update as needed. Review of the progress note dated 04/18/22 at 2:26 P.M. revealed Resident #38 and belongings and medications were discharged to SNF #1. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366021 If continuation sheet Page 10 of 21 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shaker Gardens Nursing and Rehabilitation Center 3550 Northfield Road Shaker Heights, OH 44122 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 0624 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 04/27/22 at 10:04 A.M. with Licensed Practical Nurse (LPN) #616 revealed Resident #38 was a nice guy. LPN #616 stated the resident was put on watch. LPN #616 stated one time he was down by the window looking out and they thought he was trying leave, but he was not. LPN #616 stated there was some type of family dynamics between resident and his daughter. LPN #616 stated she was not working the day Resident #38 discharged but knew he went to another facility. LPN #616 stated the plan was for the resident to go to an assisted living. LPN #616 stated she did not know how the resident's discharge came about but knew someone from the other facility had come to visit the resident. Interview on 04/27/22 at 6:11 P.M. with Resident #38's daughter revealed she was Power of Attorney (POA) him, and they had discharged him without her knowledge or consent. The daughter stated the resident called her from his cell phone the day the facility discharged him, and he was in distress. She heard someone telling him he had to leave, and the phone hung up so she got into her car and headed to the facility. When she arrived he was in the transportation car with his belongings. The transportation lady told her she did not know what was going on and that the nurse had gone back into the facility to get oxygen for the resident. The daughter stated the resident was having trouble breathing and they did not have him on oxygen. The resident was already in the car, he rolled down the window and said to her they told him he had to leave. The daughter stated when they had the care conference, eight to 10 days before they discharge him, she had informed them she wanted Resident #38 to discharge to an assisted living and that she wanted to tour the facilities first. The daughter stated she did not want him confined, she wanted him in an assisted living with his own apartment but with memory care. The daughter stated when she went into the facility on the day he was discharged , she had also asked for the discharge paperwork and had not received it. She went into the facility and spoke with two female staff members who said they had called her, she did not remember their names, but no one had called her. The daughter stated the facility did not follow necessary procedures and felt they just kicked him out. She said the resident was not able to make his own decisions and she was recently awarded guardianship at the hearing on 04/26/22. Interview on 04/28/22 at 10:40 A.M. with State Tested Nurse Aide (STNA) #603 stated she packed Resident #38's belongings. STNA #603 stated he had told her he was not going anywhere and had planned to be discharged home the following Tuesday. STNA #603 stated Resident #38 had called his sister on his cell phone, and she did not know what was going on. STNA #603 stated the resident would not get dressed or allow her to pack his things and she had to inform the nurse. The nurse called the DON multiple times because the resident was not allowing her to pack his items. STNA # 603 stated she learned that day Resident #38 was being discharged and was told by the nurse. STNA #603 stated Resident #38 was alert and oriented, slept most of time, and was independent. He finally allowed her to pack his items then she and a housekeeper took him downstairs where transportation was waiting outside. The DON was down there as well. STNA #603 stated the resident was a little upset but not yelling. STNA #603 stated she was not sure if Resident #38 was told ahead of time that he was discharging. Interview on 04/28/22 at 11:10 A.M. with SW #572 revealed been out and returned on 04/25/22 and Resident #38 was already gone. SW #572 stated she had met with Resident #38 when she was notified that the nurse indicated, he was exit seeking. SW #572 stated when she met with Resident #38, he was own responsible party, he was alert and oriented, and pleasant. SW #572 stated when she did his brief interview mental status (BIMS) it was a 10 (indicating moderate cognitive impairment). SW #572 stated she did the BIMS for admission but liked to wait about two weeks later for a more accurate BIMS when the resident was more settled in, but he was gone before she could do that. SW #572 stated when she spoke with Resident #38, he said to her why would he try to leave when she was helping him find a place. SW #572 stated Resident #38 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366021 If continuation sheet Page 11 of 21 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shaker Gardens Nursing and Rehabilitation Center 3550 Northfield Road Shaker Heights, OH 44122 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 0624 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few came from the hospital but was living home with his daughter prior to that. SW #572 stated there were issues between the resident and his daughter. SW #572 stated they had a care conference that included herself, DON, the resident's daughter, and therapy. SW #572 stated the resident was not included due to his daughter's as she did not want to upset him. SW #572 stated they discussed in the care conference pursuing future placement because the resident was not able to return home with the daughter. SW #572 stated Resident #38's daughter wanted her to send a referral to a specific assisted living, but it allowed the resident to come and go. SW #572 stated the daughter wanted the resident to be private and secured and did not want the resident to just come and go. SW #572 stated it she thought it was related to the resident's drug history and to keep his siblings from taking his money. SW #572 stated it was to protect the resident from them not so much himself. SW #572 stated she only sent the one referral the resident's daughter had requested and informed her of the denial and that was extent of her involvement with Resident #38's discharge. SW #572 stated when she returned to work, she went through the referrals and things that had been done and by who that she documented into the electronic health record on 04/26/22. Interview on 04/28/22 at 11:41 A.M. with the DON revealed while SW #572 was out she managed the discharge by sending referrals to SNF #1, #2, and #3. The DON stated she did not send any referrals to assisted livings because she was not aware of any that took waivers and had secured units. The DON stated Resident #38 was noted to be exit seeking and had to be put on one on one supervision. The DON stated she was hearing from the nurses and had a brief conversation with the resident where he inquired about LOAs. The DON stated she did not have a conversation with the resident regarding exit seeking. She stated his cognition was okay and based on his history of drug use and family dynamics it was only a matter of time before he tried to leave the facility and the potential risk made her pretty uncomfortable. The DON stated the resident's daughter wanted him on a secured unit, wanted to restrict his visitors and wanted him in a secure place with freedom and the facility was not a lock down unit. The DON stated Resident #38 had dementia, PTSD, and the daughter was in the process of getting guardianship. The DON stated it was a gray area when it came to if the resident's daughter was his POA. The DON stated when SNF #1's administrator came out to visit the resident she did not recall the administrator saying one way or the other whether the resident agreed to transfer to that facility. The DON stated she was not sure who informed the resident of the discharge and believed SW #572 left a voicemail message for the resident's daughter of the discharge. the DON stated it was not her. The DON stated the day Resident #38's discharge was hectic and eventually she had made it upstairs and staff were packing the his items. The DON stated he was ready to go and walked downstairs with his walker. Resident #38 had not mentioned to her that he did not want to leave and did not seem to be upset. The DON stated she believed he wanted to delay his discharge. the DON stated after the resident left, the daughter had come into the facility and stated she did not know about the discharge. The DON stated Resident #38's sister had called the facility and stated she was going to call the police but could not give her any information and told her to call the resident's daughter. Review of facility policy titled Resident Transfer and Discharge Policy and Procedure, undated, revealed orientation for transfer or discharge, the facility shall provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the Facility. This orientation must be provided in a form and manner that the resident can understand. This deficiency substantiates Complaint Number OH00132084. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366021 If continuation sheet Page 12 of 21 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shaker Gardens Nursing and Rehabilitation Center 3550 Northfield Road Shaker Heights, OH 44122 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop an individualized care plan for Resident #7's risk for skin breakdown or develop an individualized care plan for Resident #9's refusal of assessed contracture prevention devices and nail care. This affected two (Residents #7 and #9) of 20 residents whose care plans were reviewed (#2, #11, #15, #16, #22, #24, #25, #26, #29, #30, #31, #32, #38, #40, #139, #189, #191 and #192). The facility census was 42. Findings include: 1. Review of the medical record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses including quadriplegia, anoxic brain damage, dysphagia, abnormal posture, hypertension, muscle spasms, aphasia, disorders of bone density and structure, osteoarthritis, cardiomegaly, seasonal allergic rhinitis, anxiety disorder, major depressive disorder moderate recurrent, gastrostomy, glaucoma, anemia, mixed hyperlipidemia, and abnormal involuntary movements. Review of the orders dated 08/26/20 revealed bilateral ankle foot orthotics and a hip abductor orthosis were to be worn for up to eight hours daily. Review of the annual comprehensive assessment Minimum Data Set (MDS 3.0) dated 04/11/22 indicated he was moderately cognitively impaired, and no refusal of care or treatment was indicated. He was totally dependent on two plus staff for activities of daily living. He had functional limitations in range of motion on both upper and lower extremities. He did not receive splint or brace assistance or range of motion. Review of the plan of care lacked development of planned interventions related to his ordered orthotics. There was also no plan of care related to nail care. Interview with and observation of Resident #9 on 04/25/22 at 8:59 P.M. revealed him to be seated in an electric wheelchair. His left hand appeared tight, his nails were excessively long, and some were jagged. Both feet were positioned with the toes pointed. Resident #9 indicated he did not prefer his nails to be long and desired for them to be trimmed. His hand, nails and feet appeared to be in the same condition upon each observation between 04/25/22 and 04/26/22. On 04/27/22 at 8:08 A.M. observation with Licensed Practical Nurse (LPN) #620 present revealed his ankle foot orthotics and the hip abductor were present in the room but not on the resident. LPN #620 asked Resident #9 why he was not wearing the ankle foot orthotics and he responded he refused because they hurt. He did say they apply the hip abductors in the daytime. LPN #620 verified the excessive length of his fingernails. He reported the resident was previously treated for a nail fungus with a paint on treatment. He indicated to LPN #620 he preferred them to be trimmed. LPN #620 asked LPN #616 about the refusal of orthotics. LPN #616 reported Resident #9 consistently refused to use the orthotics, but the physician refused to remove the order. LPN #616 indicated she was one of the few nurses that was able to cut his nails because they were long with skin growing underneath the nails. She feared cutting then for him. LPN #620 suggested getting them professionally trimmed and treated for a nail fungus. Interview with the assessment nurse LPN #635 on 04/27/22 at 12:11 P.M. indicated she was not aware (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366021 If continuation sheet Page 13 of 21 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shaker Gardens Nursing and Rehabilitation Center 3550 Northfield Road Shaker Heights, OH 44122 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few of his refusal of care or staff difficulty in trimming his nails for fear of injuring him and verified those areas were not captured in the care plan. 2. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnoses including COVID 19, wedge compression fracture of the third lumbar vertebra, spinal stenosis cervical region, moderate protein-calorie malnutrition, chronic kidney disease stage three, hypertension, hyperlipidemia, anemia, depression, dementia, osteoarthritis, muscle weakness and history of falls. Review of the history and physical dated 01/25/22 lacked indication of skin impairment. Review of the skin risk assessment (Braden scale) dated 02/01/22 indicated she was at moderate risk for the development of pressure sores. Review of the admission comprehensive assessment MDS 3.0 dated 02/03/22 indicated she was severely cognitively impaired. She required the extensive assistance of one person for activities of daily living and the limited assistance of one staff for eating. She weighed 126 pounds and was 60 inches tall. Resident #7 was identified at risk for the development of a pressure ulcer but had none currently. She was not receiving Hospice services. A significant change MDS 3.0 was in progress with the date of 04/28/22. Review of the aide documentation of skin observation since 03/30/22 indicated on 04/05/22 an open area was present. On 04/18/22 a skin tear was noted. Open areas were noted on 04/17/22, 04/21/22, 04/22/22 and 04/26/22. On 04/21/22 an area was noted as new. Review of the progress notes since admission revealed on 04/14/22 at 3:07 P.M. staff made the nurse aware Resident #7 had an area on the sacrum and left heel. The area was cleaned and measured 0.4 centimeters (cm) x 0.4 cm. Barrier cream was applied. The resident yelled out in pain and pain medication was provided. The nurse practitioner and granddaughter were notified. On 04/14/22 at 3:09 P.M. the heel measured 0.7 cm x 0.7 cm. No depth or description was noted. Review of the pressure ulcer skin grid dated 04/20/22 at 1:17 P.M. indicated Resident #7 sustained a pressure ulcer on 04/15/22 to the left heel. The area measured 2.2 cm x 1.8 cm x UTD Unstageable. This was an unstageable wound of left heel. The wound base was composed of 50% granulation tissue and 50% slough. The wound bed was pink and partially slough. The surrounding skin was dry with moderate serous drainage. Review of the plan of care revealed a skin risk plan was not initiated until 04/25/22 after the development of the pressure ulcers. The plan indicated she had an alteration in skin integrity to the left and right heels and sacrum. Interventions included an air mattress, initiate wound treatment, monitor weekly, refer to dietitian for intervention, turn and reposition with routine rounds and as needed. Interview with the assessment nurse LPN #635 on 04/27/22 at 12:35 P.M. verified the plan of care was not developed for Resident #7 when she was identified at risk for pressure ulcers. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366021 If continuation sheet Page 14 of 21 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shaker Gardens Nursing and Rehabilitation Center 3550 Northfield Road Shaker Heights, OH 44122 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and policy review the facility failed to obtain weights as ordered by the physician to ensure accurate assessment and treatment by the dietitian for a resident identified at nutritional risk. This affected one (Resident #24) out of three residents reviewed for nutritional related concerns. The facility census was 42. Residents Affected - Few Findings include: Review of the medical record for Resident #24 revealed an admission date of 05/22/19. The resident was discharged to the hospital on [DATE] and returned to the facility with a percutaneous endoscopic gastrostomy (PEG) tube on 02/12/22. Diagnoses included malnutrition, muscle weakness, type II diabetes mellitus, and hypertension. Review of a physician order dated 02/12/22 revealed an order for weekly weights for four weeks, once per day every Monday. Review of the electronic weight records for Resident #24 revealed on 02/12/22 the resident weighed 140.14 pounds. No weights were documented for 02/14/22, 02/21/22, 02/28/22, or 03/07/22 as ordered. The resident was documented to weigh 111.4 pounds on 03/09/22. Review of additional weight records documented on paper, revealed the resident weighed 139 pounds on 03/01/22, and 109.8 pounds on 03/08/22. Review of the most recent quarterly Minimum Data Set (MDS) assessment, dated 03/16/22, revealed the resident had impaired cognition. The assessment also noted Resident #24 sustained weight loss greater than 5% in the past month or 10% in the past six months. Interview on 04/27/22 at 3:02 P.M. with Dietitian #635 verified Resident #24's weight was not obtained or documented per physician orders for 02/14/22, 02/21/22, 02/28/22, or 03/07/22. Dietitian #635 reported having access to weights for 02/12/22 and 03/09/22 as documented in the electronic medical record. Dietitian #635 was unaware of any other weights being obtained for Resident #24 within the required time period. Dietitian #635 verified having access to additional weights would have impacted Resident #24's care and treatment. Interview on 04/28/22 at 9:40 A.M. with the Director of Nursing (DON) revealed the DON would begin asking nursing staff to submit resident weights so the DON could ensure weights were being documented in resident medical records. Review of facility policy titled Weight Policy, not dated, revealed weights would be obtained in a timely and accurate manner, documented and responded to in an appropriate manner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366021 If continuation sheet Page 15 of 21 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shaker Gardens Nursing and Rehabilitation Center 3550 Northfield Road Shaker Heights, OH 44122 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. Based on observation, record review, staff interview, and policy review the facility failed to ensure serving sizes for vegetables were provided according to the menu. This had the potential to affect all residents except Residents #21, #24, #25, #139, and #190, who received nothing by mouth. The facility also failed to ensure serving sizes for the mechanical soft beef was served according to the menu. This had the potential to affect nine residents (#7, #10, #12, #18, #22, #29, #34, #189, and #239) who received a mechanical soft or ground diet. The facility census was 42. Findings include: Review of the menu for lunch on 04/27/22 revealed a one ½ cup (four ounces) serving of zucchini and for the residents on mechanical soft diet ground Salisbury steak using a number eight (#8) scoop which provided a four ounce serving. Observations on 04/27/22 between 11:23 A.M. and 11:29 A.M. of tray line revealed Dietary [NAME] (DC) #513 was observed give one serving each of the zucchini using a three-ounce serving spoon. Then observed DC #513 serve one serving each of the mechanical soft beef using a two-ounce spoon. Interview and review of the menu at this time with DC #513 verified the observations. Review of the facility policy titled Portion Control undated revealed individuals will receive the appropriate portions of food as planned on the menu. Control at the point of service is necessary to assure that accurate portion sizes are served. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366021 If continuation sheet Page 16 of 21 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shaker Gardens Nursing and Rehabilitation Center 3550 Northfield Road Shaker Heights, OH 44122 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 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation and staff interview, the facility failed to ensure the dumpsters and surrounding areas were maintained and free from trash and debris. This had the potential to affect all 42 residents currently residing in the facility. Residents Affected - Many Finding include: Observation on 04/26/22 at 10:42 A.M. of the outside dumpsters revealed two dumpsters, both with the lids open with a moderate to a large amount of debris and trash on ground around the dumpsters. Interview on 04/26/22 at 10:42 A.M. with Dietary Manager (DM) #536 verified the observation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366021 If continuation sheet Page 17 of 21 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shaker Gardens Nursing and Rehabilitation Center 3550 Northfield Road Shaker Heights, OH 44122 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 Based on observations, staff interview, record review, review of facility infection control policies and the Centers for Disease Control and Prevention (CDC) website the facility failed to implement infection control procedures for Personal Protective Equipment (PPE). This had the potential to affect all 42 residents currently residing in the facility. The facility also failed to ensure tuberculosis (TB) testing was completed as required. This affected two (Residents #30 and #38) of five residents reviewed for TB testing. Residents Affected - Many Findings include: 1. Observation on 04/25/22 at 7:13 P.M. revealed on the third floor, Licensed Practical Nurse (LPN) #631 with her facemask pulled down exposing her mouth and nose. LPN #631 was standing at the medication cart that was in front of the nurses' station. Interview at this time with LPN #631 verified the observation and stated she sometimes has to pull it down. LPN #631 then pulled up her facemask to cover her mouth and nose. 2. Review of the medical record for Resident #189 revealed an admission date of 04/21/22. Diagnoses included chronic obstructive pulmonary disease (COPD), lung cancer, and major depressive disorder. Review of the physician orders for April 2022 revealed orders for contact and droplet isolation precautions times 10 days due to not up to date with COVID Booster with a start date of 04/21/22. Observation on 04/27/22 at 9:56 A.M. revealed State Test Nurse Aide (STNA) #597 exiting Resident #189's room without disinfecting her face shield or changing her facemask. Interview on 04/27/22 at 9:58 A.M. with STNA #597 verified the observation and then stated they used a spray disinfectant that was kept at the nurses' station to disinfect the face shield. Observed STNA #597 look for the disinfectant at the nurses' station but she was unable to locate it. Interview on 04/27/22 at 10:42 A.M. with Infection Control Preventionist (ICP) #620 stated staff were to use the disinfectant spray that was kept at nurses' station to disinfectant their face shields when they exited the droplet isolation precaution rooms. ICP #620 stated staff were to let him, the nurse or housekeeping know if they ran out. ICP #620 stated staff should always wear their facemask and face shields when not within six feet away of someone. 3. Observation of the breakfast meal on 04/26/22 beginning at 7:42 A.M. on the second floor revealed STNA #597 was observed wearing a white bonnet, face shield and a mask. STNA #597 obtained a meal tray, brought it to the nurses station and set it down. She donned a gown and gloves then delivered the meal tray to Resident #89 who was in droplet isolation according to the posted sign. Prior to leaving the room, STNA #597 removed her gloves, gown and bonnet and used alcohol based hand rub to cleanse her hands. STNA #597 obtained a meal tray, brought it to the nurses station and set it down. STNA #597 donned a bonnet, gown and gloves and delivered the meal tray to Resident #90 who was in droplet isolation according to the posted sign. Prior to leaving the room, STNA #597 removed her gloves, gown and bonnet and used alcohol based hand rub to cleanse her hands. At no time did STNA #597 sanitize her face shield or change her mask. Review of the facility's policies titled Droplet Precautions and Infection Control-Transmission Precautions both dated March 2020 revealed no instructions related to sanitizing or changing facemask (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366021 If continuation sheet Page 18 of 21 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shaker Gardens Nursing and Rehabilitation Center 3550 Northfield Road Shaker Heights, OH 44122 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 after exiting a droplet isolation precaution room. Level of Harm - Minimal harm or potential for actual harm Review of the Centers for Disease Control and Prevention (CDC) website titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic dated 02/02/22 revealed when used solely for source control, any of the options listed above (a NIOSH- approved N95 or equivalent or higher level respirator, or a respirator approved under standards used in other countries that are similar to NIOSH-approved N95 filtering face piece respirators (Note: These should not be used instead of a NIOSH-approved respirator when respiratory protection is indicated), or a well-fitting facemask) could be used for an entire shift unless they become soiled, damaged, or hard to breathe through. If they are used during the care of patient for which a NIOSH-approved respirator or facemask is indicated for personal protective equipment (PPE) (e.g., NIOSH-approved N95 or equivalent or higher-level respirator) during the care of a patient with SARS-CoV-2 infection, facemask during a surgical procedure or during care of a patient on Droplet Precautions, they should be removed and discarded after the patient care encounter and a new one should be donned. Also noted healthcare personnel should wear source control when they are in areas of the healthcare facility where they could encounter patients (e.g., common halls/corridors) Residents Affected - Many 4. Review of the open medical record for Resident #30 revealed an admission date of 02/18/22. Diagnoses included congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and gastroesophageal reflux disease (GERD). Review of Resident #30's February 2022 Medication Administration Record (MAR) revealed the resident received step one of the two step Mantoux test for tuberculosis testing on 02/20/22. Review of Resident #30's March 2022 MAR revealed no evidence of the resident receiving step two of the Mantoux test. 5. Review of the closed medical record of Resident #38 revealed an admission date of 03/25/22 and a discharge date of 04/18/22. Diagnoses included cocaine abuse, chronic obstructive pulmonary disease (COPD), post-traumatic stress disorder (PTSD), lung cancer, and dementia with behavioral disturbance. Review of Resident #38's March 2022 Medication Administration Record (MAR) revealed the resident received step one of the two step Mantoux test for tuberculosis testing on 03/25/22. Review of Resident #38's April 2022 MAR revealed no evidence of the resident receiving step two of the Mantoux test. Interview on 04/27/22 at 5:32 P.M. with ICP #620 revealed residents were required to receive the two step Mantoux text on admission. ICP #620 stated he knew that Resident #30 had received the first step of the Mantoux but not step two. ICP #620 stated Resident #38 also received the first step but not the second. ICP #620 stated there were no concerns related to TB with Resident #30 or #38. Review of the facility policy titled Tuberculosis Infection Control Program dated January 2012 revealed the facility's TB infection control program includes the early identification, isolation, and transfer of persons with active tuberculosis. The program incorporates the following components which included screening and surveillance of residents and employees for latent tuberculosis infection (LTBI) and active TB as appropriate for the current TB risk class. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366021 If continuation sheet Page 19 of 21 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shaker Gardens Nursing and Rehabilitation Center 3550 Northfield Road Shaker Heights, OH 44122 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 This deficiency substantiates Complaint Number OH00132084. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366021 If continuation sheet Page 20 of 21 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shaker Gardens Nursing and Rehabilitation Center 3550 Northfield Road Shaker Heights, OH 44122 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm Based on record review and staff interview, the facility failed to ensure influenza and pneumonia vaccinations were completed as required. This affected four (Residents #30, #40, #191, and #192) of five residents (#30, #38, #40, #191, and #192) reviewed for influenza and pneumonia immunizations. The facility census was 42. Residents Affected - Some Findings include: 1. Review of the open medical record for Resident #30 revealed an admission date of 02/18/22. Diagnoses included congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and gastroesophageal reflux disease (GERD). There was no noted evidence of influenza or pneumonia immunizations. 2. Review of the closed medical record of Resident #40 revealed an admission date of 12/08/21 and a discharge date of 02/25/22. Diagnoses included first lumbar vertebra fracture, alcohol abuse, history of falling, and chronic obstructive pulmonary disease (COPD). There was no noted evidence of influenza or pneumonia immunizations. 3. Review of the open medical record of Resident #191 revealed an admission date of 04/19/22. Diagnoses included prostate cancer, COVID-19, and chronic cough. There was no noted evidence of influenza or pneumonia immunizations. 4. Review of the closed medical record of Resident #192 revealed an admission date of 01/19/22 and a discharged date of 03/15/22. Diagnoses included chronic obstructive pulmonary disease (COPD), multiple sclerosis, and pressure ulcers of the right hip and sacrum. There was no noted evidence of influenza or pneumonia immunizations. Interview on 04/27/22 at 5:32 P.M. with Infection Control Preventionist (ICP) #620 stated he could not find evidence of Residents #30, #40, #191, or #192 consenting to and/or receiving or declining of influenza or pneumonia immunizations. ICP #620 stated they had established today moving forward how the influenza and pneumonia immunizations would be tracked. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366021 If continuation sheet Page 21 of 21