Inspection·August 10, 2023

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many shield before entering Resident #16's room. STNA #108 stated if they are just passing trays to residents with Covid-19, they do not need to wear goggles or a face shield. Further interview with STNA #108 confirmed she was not assigned to Resident #16 or any residents on that hall but she assisted with tray delivery/pass on all halls during meals. Interview on 08/09/23 at 6:01 P.M. with the Director of Nursing revealed staff were to wear face shields, an N-95 mask, gown, and gloves before entering any room where a resident resides with Covid-19 including while passing meal trays. 2. Record review for Resident #37 revealed an admission date of 05/12/23. Diagnosis included hypertensive heart disease. Review of the admission MDS dated [DATE] revealed the resident was cognitively intact and required extensive assistants of one with bed mobility, transfers, locomotion, and was independent with eating. Review of the physician orders dated 08/08/23 revealed droplet and contact precautions for Covid-19, PPE per guidelines every shift for Covid-19 for 10 Days. Review of the Nursing Progress notes dated 08/08/23 at 10:27 A.M. revealed Resident (#37) with complaints of not feeling, exhibits signs and symptoms of nasal congestion and fatigue. Resident tested for Covid and results positive. Review of the actual infection of Covid-19 care plan dated 08/10/23 revealed interventions including isolation per protocol. Observation on 08/10/23 at 10:56 A.M. revealed LPN #146 entered Resident #37's room wearing a surgical mask, gown and gloves. LPN #146 did not donn an N-95 mask before entering the room. At 11:00 A.M. LPN #146 was observed to exit Resident #37's room. LPN #146 confirmed she did not place an N-95 mask on before entering Resident #37's room. The deficiency represents non-compliance investigated under Complaint number OH00144111. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366057 If continuation sheet Page 2 of 4 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 366057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Middleburg Heights Health & Rehabilitation Center 19530 Bagley Road Middleburg Heights, OH 44130 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, interview, record review, and review of the facility policy, the facility failed to ensure sharps containers were emptied prior to overfilling on two of the four nursing medication carts (Medication Cart for 200 hall and 400 hall) and one resident bathrooms Resident #48. This had the potential to affect 32 residents, Resident #9, #54, #37, #47, #33, #58, #28, #16, #19, #40, #39, #11, #27, #45, #42, #36, #22, #25, #53, #23, #51, #43, #2, #1, #13, #30, #48, #41, #15, #52, #7, and #10 who were independent with mobility. The facility census was 52. Findings include: 1. Record review for Resident #48 revealed an admission date of 05/25/23. Diagnosis included type two diabetes mellitus (DM). Record review of the five-day Minimum Data Set (MDS) Assessment 3.0 dated 06/01/23 revealed Resident #48 was cognitively intact. Resident #48 required supervision with bed mobility, transfers, locomotion, and toilet use. Resident #48 was always continent of bowel and bladder and received injections seven out of seven days. Record review of the physician orders revealed Resident #48 had physician orders to include insulin glargine 100 units per milliliter (ml) solution pen-injector, inject 42 unit subcutaneously at bedtime for diabetes mellitus (DM) dated 08/07/23 and insulin lispro subcutaneous solution pen-injector 200 units per ml (Insulin Lispro) Inject 18 units subcutaneously with meals for DM, Hold for blood sugar (less than) 80, dated 08/07/23. Observation on 08/09/23 at 4:23 P.M. of a fingerstick blood sugar assessment completed by Registered Nurse (RN) #152 for Resident #48 revealed after the blood sugar assessment was completed using a lancet (contained a small needle used to poke the finger to release blood for the assessment), RN#152 entered Resident #48's bathroom where there was a sharps container (a container made of rigid puncture-resistant plastic with leak-resistant sides and bottom and a tight fitting, puncture resistant lid with an opening to accommodate depositing used medical devices that could cut or stick a resident, visit or healthcare provider such as a needle or lancet but not large enough for a hand to enter) located directly above the toilet. RN #152 disposed of the used lancet into the sharps container. Observation revealed the sharps container had a line near the top with the words FULL. Observation revealed the sharps in the sharps container was past the full line nearing the opening of the container. RN #152 verified the container should have been replaced before the sharp items went past the full line and confirmed the sharp items were past the full line nearing the opening. Observation on 08/10/23 at 11:10 A.M. with RN #152 confirmed the sharps container in Resident #48's bathroom was not changed and continued to be full past the full line on the container and the sharps objects were near the opening of the container. RN #152 revealed the nurses were supposed to change out the sharps containers when they get to the full line, but she forgot to. RN #152 confirmed all residents had a bathroom in their rooms and all bathrooms had sharps containers located above the toilets. 2. Observed on 08/10/23 at 11:16 A.M. with LPN #138 confirmed the sharps container on the 200-hall medication cart (located in the residential area in front of the nurses station) was full past the full line. LPN #138 revealed she did not know where the key was to replace the sharps container. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366057 If continuation sheet Page 3 of 4 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 366057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Middleburg Heights Health & Rehabilitation Center 19530 Bagley Road Middleburg Heights, OH 44130 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 3. Observation on 08/10/23 at 11:24 A.M. with RN #129 confirmed the sharps container on the 400-hall medication cart located in the residential area had needles and lancets above the full line. RN #129 confirmed there were a total of four medication carts that provide medications to residents. Record review of the Nursing and Rehab Daily Bedboard highlighting independently mobile residents provided by Regional Nurse Consultant #156 revealed there were 32 residents residing in the facility who were independently mobile. Regional Nurse Consultant #156 confirmed the highlighted residents were the independently mobile residents. Record review of the facility policy titled, Sharps Disposal revised January 2012 included designated individuals will be responsible for sealing and replacing containers when they are 75% to 80 % full. The deficiency represents non-compliance investigated under Complaint number OH00144111. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366057 If continuation sheet Page 4 of 4