Health inspection·May 16, 2022

F 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure accurate and complete transmission of Minimum Data Set (MDS) assessments. This affected two residents (Resident #2 and Resident #3) out of three residents reviewed for resident assessment. The facility census was 162 residents. Residents Affected - Few Findings include: 1. Review of Resident #2's medical record revealed an admission date of 09/10/21 and diagnoses including generalized anxiety disorder, dementia with behavioral disturbance, pneumonia and acute and chronic respiratory failure. Review of the MDS assessment lookup tab indicated Resident #2 discharged on 04/26/22 but no date of submission or acceptance was listed. Interview on 05/12/22 at 8:12 A.M. with MDS Licensed Practical Nurse (LPN) #605 verified Resident #2's discharge MDS assessment had not been submitted. Further review of the discharge MDS assessment during the interview indicated sections A, J and O were also incomplete. MDS LPN #605 verified questions A0310, A1200, J0200, J1100, J1550 and O0400 on the MDS assessment were not completed and should have been. MDS LPN #605 indicated the facility did not have a scrubber or other system to check for MDS errors. 2. Review of Resident #3's record revealed an admission date of 08/25/21 and diagnoses including COVID-19, hypothyroidism, Alzheimer's disease with late onset and muscle weakness. Review of the MDS assessment lookup tab indicated Resident #3 had a quarterly assessment dated [DATE] but no date of submission or acceptance was listed. Interview on 05/12/22 at 8:12 A.M. with MDS LPN #605 verified Resident #3's quarterly MDS assessment was not completed, submitted or accepted even though it was signed. MDS LPN #605 verified question M1040 on the MDS assessment was not completed and should have been. MDS LPN #605 indicated the facility did not have a scrubber or other system to check for MDS errors. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366045 If continuation sheet Page 2 of 9 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 366045 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jennings Hall 10204 Granger Road Garfield Heights, OH 44125 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observations, interview and record review, the facility failed to complete nail care for residents who could not provide self-care. This affected two (Resident #101 and Resident #155) of 10 residents reviewed for nail care. The facility census was 162 residents. Residents Affected - Few Findings include: 1. Review of medical record for Resident #101 revealed an admission date of 07/04/20. Diagnoses included vascular dementia and major depression. Review of the quarterly Minimum Data Set (MDS) assessment, dated 03/05/22, revealed Resident #101 had impaired cognition and required extensive assistance for bed mobility, toilet use and personal hygiene. Observation on 05/09/22 at 9:40 A.M. revealed Resident #101's fingernails were long and jagged with brown material located under the nails. Interview with Resident #101 at the time of the observation revealed he would like to have his nails trimmed because they were long. Interview on 05/09/22 at 2:40 P.M. with State Tested Nurse Assistant (STNA) #602 revealed Resident #101 was not resistant to nail care and the activity staff trimmed resident nails. Interview on 05/09/22 at 2:45 P.M. with Licensed Practical Nurse (LPN) #603 revealed nursing staff were responsible for trimming resident fingernails. LPN #603 stated she observed Resident #101's nails and they were horrific and LPN #603 trimmed the nails. LPN #603 stated Resident #101 played with his feces at times. 2. Review of Resident #155's record revealed an admission date of 04/08/22 with diagnoses including hypertension, urinary incontinence, falls and spinal stenosis. Review of Resident #155's admission Minimum Data Set (MDS) assessment revealed Resident #155 was moderately cognitively impaired and required the extensive assistance of one staff for hygiene care. Nurses' notes did not indicate that Resident #155 refused nail care. Observation on 05/09/22 at 12:03 P.M. of Resident #155 revealed his nails were long, jagged and dirty. Interview with Resident #155 at the time of observation revealed his nails were last cut about a month ago and it was annoying because his nails would chip and then be jagged. Observation on 05/10/22 at 3:53 P.M. of Resident #155 revealed his nails were still long and dirty and he was seated in his wheelchair watching television. Observations on 05/11/22 at 8:52 A.M., 11:51 A.M. and 2:40 P.M. revealed Resident #155's nails remained long, dirty and jagged as he was seated in his wheelchair in his room. Interview on 05/11/22 at 4:06 P.M. with Licensed Practical Nurse (LPN) #607 indicated Resident #155 did not refuse care. LPN #607 accompanied the surveyor to observe Resident #155's nails during the interview and verified his nails should not be long, dirty and jagged. Interview on 05/11/22 at 4:10 P.M. with State Tested Nursing Assistant (STNA) #608 indicated Resident #155 did not refuse care. STNA #608 stated nail care was to be provided on shower days or upon request. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366045 If continuation sheet Page 3 of 9 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 366045 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jennings Hall 10204 Granger Road Garfield Heights, OH 44125 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 0677 Interview on 05/11/22 at 5:07 P.M. with Registered Nurse (RN) #609 verified nail care was to be provided on shower days and was unaware of any residents with nail care not being provided in a timely manner. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366045 If continuation sheet Page 4 of 9 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 366045 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jennings Hall 10204 Granger Road Garfield Heights, OH 44125 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, record review and policy review the facility failed to ensure oxygen tubing was dated to ensure timely replacement. This affected six residents (Residents #1, #2, #65, #164, #266 and #270) of seven residents reviewed for respiratory care. The facility census was 162 residents. Residents Affected - Some Findings include: 1. Review of Resident #1's medical record revealed an order dated 04/14/22 for keeping nasal cannula oxygen at three liters with goal of 88% [oxygen saturation] and an order dated 05/07/22 for two to four liters of oxygen via nasal cannula continuously. Observation on 05/12/22 starting at 4:43 P.M. with the Interim Director of Nursing (IDON) verified Resident #1's oxygen tubing was not dated. Interview with the IDON during the observation revealed nasal cannulas and oxygen tubing were to be changed weekly and dated at that time. 2. Review of Resident #2's medical record revealed an order dated 05/11/22 indicating do not go above two liters of oxygen due to increased cannula, call physician if pulse oxygenation is less than 88; continuous for oxygen. Observation on 05/12/22 starting at 4:43 P.M. with the IDON verified Resident #2's oxygen tubing was not dated. Interview with the IDON during the observation revealed nasal cannulas and oxygen tubing were to be changed weekly and dated at that time. 3. Review of Resident #65's medical record revealed an order dated 05/05/22 for oxygen via nasal cannula three liters continuously. Observation on 05/12/22 starting at 4:43 P.M. with the IDON verified Resident #65's oxygen tubing and humidifier bottle were not dated. Interview with the IDON during the observation revealed nasal cannulas and oxygen tubing were to be changed weekly and dated at that time. 4. Review of Resident #164's medical record revealed an order dated 05/10/22 for oxygen via nasal cannula two liters continuously. Observation on 05/12/22 starting at 4:43 P.M. with the IDON verified Resident #164's oxygen tubing was not dated. Interview with the IDON during the observation revealed nasal cannulas and oxygen tubing were to be changed weekly and dated at that time. 5. Review of Resident #266's medical record revealed an order dated 04/30/22 for oxygen via nasal cannula three liters continuously. Observation on 05/12/22 starting at 4:43 P.M. with the IDON verified Resident #266's oxygen tubing was not dated. Interview with the IDON during the observation revealed nasal cannulas and oxygen tubing were to be changed weekly and dated at that time. 6. Review of Resident #270's medical record revealed an order dated 04/30/22 for oxygen two liters via nasal cannula continuously. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366045 If continuation sheet Page 5 of 9 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 366045 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jennings Hall 10204 Granger Road Garfield Heights, OH 44125 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation on 05/12/22 starting at 4:43 P.M. with the IDON verified Resident #270's oxygen tubing was not dated. Interview with the IDON during the observation revealed nasal cannulas and oxygen tubing were to be changed weekly and dated at that time. Review of the facility policy, Oxygen, dated 09/26/05 revealed the concentrator filter, prefilled humidifier bottle, tubing and plastic bags were changed weekly by the service tech from the oxygen service company and the humidifier bottles and tubing would be labeled with the date, resident's name and room number. This deficiency substantiates Complaint Number OH00132637. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366045 If continuation sheet Page 6 of 9 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 366045 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jennings Hall 10204 Granger Road Garfield Heights, OH 44125 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and review of manufacturer instructions, the facility failed to date insulin vials when opened and remove expired insulin vials from the medication cart. This affected three (Resident #27, Resident #36, and an unidentified resident) of 15 residents who received insulin. The facility census was 162 residents. Findings include: Observations of medication cart on the main level on [DATE] at 10:36 A.M. revealed an opened vial of Lantus insulin which was not dated for Resident #27, an opened Humalog insulin vial dated [DATE] for Resident #36 and a used Toujeo Solostar (glargine) insulin pen with no name or date. Interview with Licensed Practical Nurse (LPN) #500, at the time of the observation, verified the Lantus insulin was not dated as to when it was opened, the opened vial of Humalog insulin was expired, and the insulin pen did not have a name or date. Review of the manufacturer instructions dated [DATE] revealed open (in use) Lantus insulin vials should be thrown away 28 days after the first use even if it still had insulin in it. Review of the manufacturer instructions dated [DATE] revealed in use (opened) Taujeo SoloStar single-patient use prefilled pens stored at room should be discarded after 56 days. Review of the manufacturer instructions dated [DATE] revealed for open (in use) Humalog insulin the vial should be thrown away 28 days after the first use even if it still had insulin in it. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366045 If continuation sheet Page 7 of 9 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 366045 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jennings Hall 10204 Granger Road Garfield Heights, OH 44125 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 0888 Ensure staff are vaccinated for COVID-19 Level of Harm - Minimal harm or potential for actual harm Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated 03/13/20, review of Centers for Medicare and Medicaid Services (CMS) memorandum QSO-22-09-ALL , review of the staff COVID-19 vaccination list, review of the respiratory surveillance line list, review of the facility policy, observation, and interview, the facility failed to ensure that all staff specified were fully vaccinated for COVID-19, except for those staff who have been granted exemption to the vaccination requirement, or staff for whom COVID-19 vaccination must be temporally delayed, as recommended by the CDC. This affected all 162 residents who resided in the facility. The census was 162. Residents Affected - Few Findings include: Review of the undated facility staff COVID-19 vaccination list revealed the facility had a total of 316 employees. There were 304 employees fully vaccinated for COVID-19, 11 employees had granted exemptions and one staff had a pending medical exemption. The current staff completed vaccination rate was 99.7 percent (%). This included Physician #301, who had a pending medical exemption. Review of the medical exemption for Physician #301 revealed an email dated 05/11/22 timed 11:34 A.M. from Physician #301's employer indicating the initial medical exemption request for the COVID-mandate vaccination was submitted. The exemption was pending due additional medical information requested. Interview 05/11/22 at 4:40 P.M. with Licensed Nursing Home Administrator (LNHA) #300 revealed Physician #301 provided services for residents on Monday, Tuesday, Wednesday, and Friday's. The medical exemption from Physician #301's hospital system needed more information before granting the medical exemption. Physician #301's hospital system was behind in granting the medical exemptions and Physician's #301's exemption should be granted within the month. Observation and interview on 05/16/22 at 12:00 P.M. with Physician #301 revealed she was sitting in the secured unit at the nurses' station documenting on the computer. Physician #301 was wearing eye protection and a N95 respirator. Interview at this time with Physician #301 revealed a medical exemption was filed with the hospital system in which she was employed and she was told additional information was needed before granting the medical exemption. Physician #301 needed to meet with infectious disease and complete other requirements. Physician #301 stated she complied with the facility's requirements and wore eye protection and a N95. Review of the facility's undated respiratory surveillance line list revealed three residents (Resident #90, #121, #154) were diagnosed with COVID-19 in the past four weeks. Interview on 05/18/22 at 10:39 A.M. with LNHA #300 revealed Resident #90 and Resident #154 were sent to hospital for non-COVID reasons and contacted COVID-19 during their stay. Resident #121 tested positive for COVID-19 when outbreak testing was completed on 05/08/22. Resident #108 tested positive for COVID-19 on 05/09/22 and was transferred to the hospital and subsequently admitted related to COVID-19 symptoms. Review of the Verification of National Health Care Safety Network (NHSN) data dated 04/12/22 revealed the facility had 96.4% percentage rate of staff who are fully vaccinated. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366045 If continuation sheet Page 8 of 9 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 366045 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jennings Hall 10204 Granger Road Garfield Heights, OH 44125 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 0888 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the Center for Medicare and Medicaid Services (CMS) data tracker for county transmission rates dated from 05/03/22 through 05/07/22 revealed the county had a high transmission rate. Review of the facility policy titled COVID-19 Staff Vaccine Mandate dated 11/16/21 revealed the facility required in its credentialing policies for credentialed physicians and other practitioners that all such individuals who qualified as staff were vaccinated in compliance with the vaccine mandate and provide evidence of vaccination or exemption upon request. Review of Centers for Medicare & Medicaid Services (CMS) memorandum, QSO-22-09-ALL regarding COVID-19 health care staff vaccination, dated 01/14/22, revealed CMS expected all providers' and suppliers' staff to have received the appropriate number of doses by the time frames specified in the QSO-22-07 unless exempted as required by law, or delayed as recommended by the Centers for Disease Control (CDC). Facility staff vaccination rates under 100% constitute non-compliance under this rule. Within 90 days and thereafter following issuance of this memorandum, facilities failing to maintain compliance with the 100% standard may be subject to enforcement action. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366045 If continuation sheet Page 9 of 9