Health inspection·August 29, 2019

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 08/26/19 at 3:25 P.M. with Licensed Practical Nurse (LPN) #912 and #913 confirmed Resident #912 was lying in bed on top of two saturated incontinence pads and a wet fitted bed sheet with a dried dark brown border edge to the saturation. LPN #912 also verified a strong odor of urine. 3. Record review revealed Resident #29 was admitted to the facility on [DATE] with diagnoses of type 2 diabetes mellitus with diabetic neuropathy, heart failure, and chronic obstructive pulmonary disease. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed no cognitive impairment, was totally dependent on staff for toileting, personal hygiene, and bathing, and was always incontinent of bowel and bladder. Interview on 08/25/19 at 3:31 P.M. with Resident #29 revealed the aides were cleaning her bottom with paper towels instead of incontinence wipes because there was not enough supplies. Observation on 08/27/19 at 10:33 A.M. with STNA #803 searched the tub room and storage room and found no incontinence wipes to provide incontinence care. Interview with STNA #803 at the time of the observation revealed paper towels are used sometimes when incontinence wipes are not available. Interview on 08/28/19 at 7:06 A.M. with State Tested Nursing Assistant (STNA) #802 confirmed using paper towels to wipe residents off when incontinence wipes run out. Interview on 08/28/19 at 4:30 P.M. with Director of Nursing confirmed incontinence wipes were not in stock. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366058 If continuation sheet Page 2 of 17 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 366058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aristos Nursing and Rehabilitation 4650 Rocky River Dr Cleveland, OH 44135 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 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 #40, #300 and #303's advance directives were available in the paper chart and/or in the electronic charting system. This affected three of five residents reviewed for advance directives. Findings include: Review on 08/25/19 of the paper chart and the electronic charts for Residents #40, #300 and #303's medical records confirmed the advance directives were not listed. On 08/25/19 at 1:15 P.M. interview with Licensed Practical Nurse (LPN) #906 verified advance directives were not available in the paper chart or electronic records for Residents #40, #300 and #303. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366058 If continuation sheet Page 3 of 17 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 366058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aristos Nursing and Rehabilitation 4650 Rocky River Dr Cleveland, OH 44135 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to timely notify hospice of Resident #9's skin concerns. This finding affected one (Resident #9) of two residents observed for pressure ulcers. Findings include: Review of Resident #9's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including vascular dementia without behavioral disturbance, altered mental status and muscle weakness. Review of Resident #9's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited a memory problem. Review of Resident #9's physician order dated 08/27/19 to cleanse the right and left buttock with normal saline, apply zinc and cover with a border gauze dressing every shift and when soiled. Review of Resident #9's progress notes from 08/01/19 to 08/26/19 did not reveal evidence hospice was notified of the resident's skin breakdown. Observation on 08/27/19 at 9:14 A.M. with Hospice State Tested Nursing Assistant (STNA) #907 of Resident #9's incontinence care revealed the resident had skin breakdown on the right, left and center coccyx. Interview on 08/27/19 at 9:18 A.M. with Hospice State Tested Nursing Assistant (STNA) #907 confirmed Resident #9's buttocks were reddened during care on 08/23/19 and she informed Licensed Practical Nurse (LPN) #805. Interview on 08/27/19 at 10:50 A.M. with Hospice Registered Nurse (RN) #910 confirmed she was not informed of Resident #9's skin breakdown until 08/26/19 or 08/27/19 (she could not determine which). Interview on 08/29/19 at 9:33 A.M. with the Director of Nursing (DON) confirmed hospice was not notified timely of Resident #9's skin breakdown. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366058 If continuation sheet Page 4 of 17 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 366058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aristos Nursing and Rehabilitation 4650 Rocky River Dr Cleveland, OH 44135 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 0584 Level of Harm - Potential for minimal harm Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation and interview, the facility failed to provide an adequate supply of towels for resident care. This affected all 54 of 54 residents residing in the facility. Residents Affected - Many Findings include: On 08/25/19 at 3:54 P.M. ten towels were observed in the clean linen area. An interview with the Director of Nursing at the time of the observation verified it was the only towels available to provide resident care. Interview on 08/27/19 at 10:41 A.M. with State Tested Nursing Assistant (STNA) #908 who works as a Laundry Assistant verified there was 31 towels in stock for use in the building, and indicated there was an average of eight towels for use on the shelf with ten in dryer. Interview on 08/28/19 at 4:05 P.M. with Regional Director (RD) #909 verified there was only 31 towels available for resident care. RD #909 indicated the towels were not on the formulary, and did not get ordered last quarter. RD further verified the staff did not place an order for towels. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366058 If continuation sheet Page 5 of 17 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 366058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aristos Nursing and Rehabilitation 4650 Rocky River Dr Cleveland, OH 44135 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 0602 Protect each resident from the wrongful use of the resident's belongings or money. 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 Resident #31's narcotic medications were not misappropriated. This finding affected one (Resident #31) of three residents reviewed for misappropriation. Residents Affected - Few Findings include: Review of Resident #31's self-reported incident (SRI) investigation dated 07/30/19 indicated on 07/29/19 Registered Nurse (RN) #902 reported that a pharmacy card of 38 Percocet (pain medication) belonging to Resident #31 was removed from the narcotic drawer and the count sheet was removed from the narcotic binder. The discontinued narcotic medication had not been administered to Resident #31 since the end of May 2019. The facility was unable to locate Resident #31's Percocet pain tablets. Review of Resident #31's medical record revealed the resident was admitted to the facility on [DATE] and discharged on 08/12/19 with diagnoses including schizoaffective disorder, major depressive disorder and cocaine abuse. Review of Resident #31's Minimum Data Set (MDS) 3.0 assessment dated [DATE] confirmed the resident exhibited intact cognition. Review of Resident #31's physician order dated 05/24/19 and discontinued on 05/30/19 for oxycodone-acetaminophen (Percocet) 5-325 mg (milligrams) give one tablet by mouth three times a day for pain. Review of Resident #31's medication administration record (MAR) from 05/01/19 to 05/31/19 revealed the resident's last dose of Percocet pain medication administered was on 05/24/19. Interview on 08/27/19 at 3:50 P.M. with the Director of Nursing (DON) confirmed the facility could not locate Resident #31's Percocet pain tablets or the pink narcotic flow record and the 38 pain tablets were misappropriated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366058 If continuation sheet Page 6 of 17 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 366058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aristos Nursing and Rehabilitation 4650 Rocky River Dr Cleveland, OH 44135 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease with early onset, unspecified dementia without behavioral disturbance, anxiety disorder. Review of the quarterly MDS 3.0 dated 06/05/19 comprehensive assessment revealed Resident #5 exhibited severe cognitive impairment. Review of Resident #5's medication orders revealed physician's order dated 02/07/19 for aripiprozole 2 mg once a day for schizophrenia, bipolar disorder and depression and a physician's order dated 05/24/19 for Cymbalta capsule delayed release 60 mg once a day for depression. Review of Resident #5's assessments revealed AIMS assessments were not completed by the facility. Residents Affected - Few Interview on 08/29/19 at 8:55 A.M. with Assistant Director of Nursing (ADON) #911 who works as a MDS Coordinator confirmed Resident #5's medical record did not include AIMS assessment for the resident's psychotropic medication use as required. Based on interview and record review the facility failed to ensure assessments were completed for residents receiving psychotropic medications. This affected two (Residents #5 and #19) of five residents reviewed for unnecessary medications. Findings include: 1. Record review revealed Resident #19 was admitted to the facility on [DATE] with diagnoses including vascular dementia with behavioral disturbance, dysphagia following cerebral infarction and personal history of self-harm. Review of the quarterly Minimum Data Set (MDS) 3.0 dated 07/02/19 comprehensive assessment revealed Resident #19 exhibited moderate cognitive impairment and received psychotropic medications on a routine basis. Review of Resident #19's medication orders revealed an order dated 03/12/19 for Risperidone 0.5 milligrams (mg) twice daily for bipolar disorder. Review of Resident #19's assessments revealed an AIMS evaluation was not completed by the facility. Interview on 08/29/19 at 8:55 A.M. with Assistant Director of Nursing (ADON) #911 who works as a MDS Coordinator confirmed Resident #19's medical record did not include an AIMS evaluation as required. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366058 If continuation sheet Page 7 of 17 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 366058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aristos Nursing and Rehabilitation 4650 Rocky River Dr Cleveland, OH 44135 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 - Some 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 medical record review and staff interview the facility failed to initiate care plans with resident centered interventions in a timely manner after identifying resident concerns. This affected 10 residents (Resident #49, #29, #33, #251, #30, #38, #19, #32, #1, and #37) of 54 residents reviewed for care plans. Findings Include: 1. Record review revealed Resident #49 was admitted to the facility on [DATE] with diagnoses including alcohol dependence, nicotine dependence, chronic obstructive pulmonary disease (COPD), heart disease, bipolar disorder, and high blood pressure. The smoking care plan for Resident #49 was initiated on 08/23/19. 2. Record review revealed Resident #29 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder, diabetes, heart disease, major depression, nicotine dependence, COPD, substance dependence, and high blood pressure. Review of Resident #29's care plans revealed the smoking care plan was initiated on 08/06/19. A diabetes care plan was created on 08/23/19. 3. Record review revealed Resident #33 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder, nicotine dependence, and infective endocarditis (an infection around the outside of the heart). Review of Resident #33's care plans revealed a smoking care plan was not initiated for the resident. 4. Record review revealed Resident #251 was admitted to the facility on [DATE] with diagnoses including cocaine abuse, COPD, nicotine dependence, and schizophrenia. Review of Resident #251's care plans revealed a smoking care plan was initiated on 08/26/19. No care plan regarding substance abuse was found. 5. Record review revealed Resident #30 was admitted to the facility on [DATE] with diagnoses including chronic kidney disease, psychosis, major depression, anxiety, nicotine dependence, and arthritis. Review of Resident #30's care plans revealed a smoking care plan and a mood/depression care plan were not initiated until 02/25/19. No psychotropic medication care plan was found for the use of Xanax (an anti-anxiety medication) or Cymbalta (an anti-depressant medication). 6. Record review revealed Resident #38 was admitted to the facility on [DATE] with diagnoses including cocaine abuse, schizophrenia, bipolar disorder, epilepsy, nicotine dependence, and a traumatic brain injury. Review of the care plans for Resident #38 revealed a care plan for smoking was not initiated until 08/25/19 and opioid abuse until 08/25/19. No care plans were noted for epilepsy. 7. Record review revealed Resident #19 was admitted to the facility on [DATE] with diagnoses including dementia with behavioral disturbance, diabetes, major depression, a previous stroke, and post-traumatic stress disorder. Review of the care plans for Resident #19 revealed a mood care plan, and a diabetes care plan were not initiated until 02/25/19 and a smoking care plan was never initiated. 8. Record review revealed Resident #32 was admitted to the facility on [DATE] with diagnoses including a stroke, nicotine dependence, COPD, anxiety, alcohol abuse, and diabetes. Review of the care plans for Resident #32 revealed a care plan for mood/depression, diabetes, respiratory status were not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366058 If continuation sheet Page 8 of 17 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 366058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aristos Nursing and Rehabilitation 4650 Rocky River Dr Cleveland, OH 44135 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 developed until 05/13/19. No care plan related to smoking was noted. Level of Harm - Minimal harm or potential for actual harm 9. Record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including anxiety, high blood pressure, cirrhosis of the liver, COPD, nicotine dependence, and depression. Review of the care plans for Resident #1 revealed no care plan for respiratory status, mood, or smoking had been developed. Residents Affected - Some 10. Record review revealed Resident #37 was admitted to the facility on [DATE] with diagnoses including high blood pressure, diabetes, asthma, nicotine dependence, anxiety, schizophrenia, and cocaine abuse. Review of the care plans for Resident #37 revealed a care plan for smoking, diabetes, high blood pressure, asthma, and drug seeking behaviors were not initiated until 08/25/19. The resident's code status was not initiated until 07/01/19. On 08/29/19 at 9:00 A.M. interview with the Director of Nursing confirmed the facility had initiated the care plans for the above residents either late or not created at all. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366058 If continuation sheet Page 9 of 17 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 366058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aristos Nursing and Rehabilitation 4650 Rocky River Dr Cleveland, OH 44135 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop or revise care plans for Residents #29 for activities of daily living, Residents #5 and #19 for dementia care, Resident #43 for dialysis and positioning, and Resident #10 for edema. This finding affected one (Resident #29) of two residents reviewed for activities of daily living, two (Residents #5 and #19) of five residents reviewed for unnecessary medications, one (Resident #10) of one resident reviewed for edema, and one resident (Resident #43) of one resident reviewed for dialysis and positioning. Findings Include: 1. Record review revealed Resident #19 was admitted to the facility on [DATE] with diagnoses including vascular dementia with behavioral disturbance, dysphagia following cerebral infarction and personal history of self-harm. Review of the quarterly Minimum Data Set (MDS) 3.0 dated 07/02/19 comprehensive assessment revealed Resident #19 exhibited moderate cognitive impairment and received psychotropic medications on a routine basis. Review of Resident #19's medication orders revealed an order dated 03/12/19 for Risperidone 0.5 milligrams (mg) twice daily for bipolar disorder. Review of Resident #19's care plans failed to include a care plan with interventions for the resident's psychotropic medication use. Interview on 08/29/19 at 8:55 A.M. with the Director of Nursing (DON) confirmed Resident #19's medical record did not include a care plan with interventions for the resident's psychotropic medication use as required. 2. Record review revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease with early onset, unspecified dementia without behavioral disturbance, and anxiety disorder. Review of the quarterly MDS 3.0 dated 06/05/19 comprehensive assessment revealed Resident #5 exhibited severe cognitive impairment and wandered one to three days during the assessment period. Review of Resident #5's behavior flow record dated 07/30/19 through 08/26/19 revealed one episode of wandering on 08/25/19. Review of Resident #5's care plan dated 02/07/19 failed to include a care plan for monitoring behaviors including wandering. Review of Resident #5's medication orders revealed an order dated 02/07/19 for aripiprozole 2 mg once a day for schizophrenia, bipolar disorder and depression, and an order dated 05/24/19 for Cymbalta capsule delayed release 60 mg once a day for depression. Review of Resident #5's care plan dated 02/07/19 failed to include a care plan with interventions for Resident #5's psychotropic medication use. Interview on 08/29/19 at 8:36 A.M. with the Assistant Director of Nursing (ADON) #911 also working as MDS Coordinator confirmed Resident #5's medical record did not include a care plan for monitoring behaviors including wandering, and with interventions for Resident #5's psychotropic medication use as required. 3. Record review revealed Resident #10 was admitted to the facility on [DATE] with diagnoses including hemiplegia (partial or total paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction affecting right dominant side, morbid severe obesity due to excess calories and chronic atrial fibrillation. Review of the quarterly MDS 3.0 dated 06/28/19 comprehensive assessment revealed Resident #10 exhibited mild cognitive impairment. Review of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366058 If continuation sheet Page 10 of 17 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 366058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aristos Nursing and Rehabilitation 4650 Rocky River Dr Cleveland, OH 44135 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident #10's physicians orders included wrapping bilateral legs up to the knees with ace wrap twice a day for fluid retention. Review of Resident #10's care plan dated 12/18/18 failed to include a care plan with interventions for Resident #10's leg wraps order. Interview on 08/29/19 at 8:36 A.M. with the Assistant Director of Nursing (ADON) #911 also working as MDS Coordinator confirmed Resident #10's medical record did not include a care plan with interventions for Resident #10 to wear bilateral leg wraps as required. 4. Record review revealed Resident #29 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder, bipolar type, diabetes mellitus II, obesity and urinary tract infection. Review of the quarterly MDS 3.0 dated 07/10/19 comprehensive assessment revealed Resident #29 had no cognitive impairment, total dependence on staff for toileting, and was always incontinent of bowel and bladder. Review of Resident #29's care plan dated 04/16/19 included a focus and goal for urge stress bladder incontinence, but failed to include any interventions or address bowel incontinence. Interview on 08/29/19 at 8:36 A.M. with the Assistant Director of Nursing (ADON) #911 also working as MDS Coordinator confirmed Resident #29's medical record did not include interventions in the care plan for urge stress bladder incontinence and did not include a care plan with interventions addressing Resident #29's bowel incontinence as required. 5. Record review revealed Resident #43 was admitted to the facility on [DATE] with diagnoses including end stage renal disease, anemia in chronic kidney disease and essential primary hypertension. Review of the quarterly MDS 3.0 dated 08/13/19 comprehensive assessment revealed Resident #43 exhibited severe cognitive impairment and received dialysis. Review of the physician's orders dated 05/10/19 indicated dialysis treatment was ordered Monday, Wednesday and Friday. Review of the physician's orders dated 07/30/19 indicated a dialysis port for the right chest requiring daily dressing changes. Review of Resident #43's care plan dated 07/17/19 failed to be revised to include dialysis. Review of the physician's orders dated 08/13/19 revealed an order for Resident #43 was to wear a left resting hand roll splint and left elbow extension splint during the day for 12 hours. Review of the care plan dated 07/17/19 revealed it failed to be revised to include wearing a left resting hand roll splint and left elbow extension splint. Interview on 08/29/19 at 8:36 A.M. with the Assistant Director of Nursing (ADON) #911 also working as MDS Coordinator confirmed Resident #43's medical record did not include a dialysis care plan, and a care plan with interventions for Resident #43 wearing a left resting hand roll splint and left elbow extension splint as required. Review of policy entitled, Care Plan Policy and Procedure, dated 12/01/18, revealed the comprehensive care plan must be person centered and contain all necessary information to allow the resident to receive care while maintaining their highest practicable well-being, and the comprehensive care plan must be updated quarterly and as necessary to ensure accuracy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366058 If continuation sheet Page 11 of 17 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 366058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aristos Nursing and Rehabilitation 4650 Rocky River Dr Cleveland, OH 44135 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to provide care and services in the areas of dressing and personal hygiene for Resident #10, #15, and #29. This affected three residents (#10, #15 and #29) of three reviewed for care and services. The facility census was 54. Residents Affected - Few Findings include: 1. Record review revealed Resident #10 was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease, type 2 diabetes mellitus with diabetic neuropathy, and low back pain. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed mild cognitive impairment, and a requirement of extensive assistance with one person assistance for dressing, toileting, personal hygiene, and bathing. Observation on 08/25/19 at 12:43 P.M. of Resident #10 revealed resident sitting in a chair next to an unmade bed dressed in a hospital gown. An interview with Resident #10 at the time of the observation revealed Resident #10 was waiting for assistance to wash up and get dressed and have the bed made. Resident #10 indicated, I do not like being stuck in a hospital gown. Observation on 08/25/19 at 3:03 P.M. of Resident #10 revealed resident sitting in a chair next to an unmade bed dressed in a hospital gown. An interview with Resident #10 at the time of the observation revealed Resident #10 was still waiting for assistance to wash up and get dressed and have the bed made. An interview on 08/25/19 at 3:04 P.M. with State Tested Nursing Assistant (STNA) #802 confirmed Resident #10 was still sitting in the chair next to an unmade bed dressed in a hospital gown waiting for assistance to wash up and get dressed and to have the bed made. 2. Record review revealed Resident #15 was admitted to the facility on [DATE] with morbid severe obesity due to excess calories, type 2 diabetes with diabetic nephropathy (kidney disease), and schizophrenia. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed severe cognitive impairment, total dependence with bed mobility, dressing, toileting, and personal hygiene, and total incontinence of bowel and bladder. Resident #15's care plan dated 02/14/18 revealed a focus of incontinence and risk for impaired skin integrity. Observation on 08/26/19 at 3:22 P.M. revealed Resident #15 was lying in bed on top of two heavily yellow saturated incontinence pads which overflowed onto the fitted bed sheet underneath. The saturation border was dark drown and dried, and there was a strong odor of urine. Interview on 08/26/19 at 3:25 P.M. with Licensed Practical Nurse (LPN) #912 and #913 confirmed Resident #912 was lying in bed on top of two saturated incontinence pads and a wet fitted bed sheet with a dried dark brown border edge to the saturation. LPN #912 also verified a strong odor of urine. 3. Record review revealed Resident #29 was admitted to the facility on [DATE] with diagnoses of type 2 diabetes mellitus with diabetic neuropathy, heart failure, and chronic obstructive pulmonary disease. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed no cognitive impairment, was totally dependent on staff for toileting, personal hygiene, and bathing, and was always incontinent of bowel and bladder. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366058 If continuation sheet Page 12 of 17 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 366058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aristos Nursing and Rehabilitation 4650 Rocky River Dr Cleveland, OH 44135 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 08/25/19 at 3:31 P.M. with Resident #29 revealed the aides were cleaning her bottom with paper towels instead of incontinence wipes because there was not enough supplies. Observation on 08/27/19 at 10:33 A.M. with STNA #803 searched the tub room and storage room and found no incontinence wipes to provide incontinence care. Interview with STNA #803 at the time of the observation revealed paper towels are used sometimes when incontinence wipes are not available. Interview on 08/28/19 at 7:06 A.M. with State Tested Nursing Assistant (STNA) #802 confirmed using paper towels to wipe residents off when incontinence wipes run out. Interview on 08/28/19 at 4:30 P.M. with Director of Nursing confirmed incontinence wipes were not in stock. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366058 If continuation sheet Page 13 of 17 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 366058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aristos Nursing and Rehabilitation 4650 Rocky River Dr Cleveland, OH 44135 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure Resident #43 was assessed and monitored for complications before and after hemodialysis treatments. This affected one (Resident #43) of one resident reviewed for hemodialysis. Residents Affected - Few Findings include: Record review revealed Resident #43 was admitted to the facility on [DATE] with diagnoses of end stage renal disease, anemia in chronic kidney disease, essential primary hypertension, and type 2 diabetes mellitus without complications. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #43 was severely cognitively impaired, totally dependent on staff for activities of daily living, and receiving dialysis. Review of Resident #43's physician orders dated 05/10/19 indicated dialysis treatment was ordered for Monday, Wednesday, and Friday, and orders dated 07/30/19 indicated a port to the right chest required daily dressing changes. Review of Resident #43's medical record revealed no pre or post dialysis assessments were completed from 05/10/19 to 08/28/19 except for 08/12/19. Interview on 08/28/19 at 7:08 A.M. with Director of Nursing (DON) verified pre and post dialysis assessments were not completed for Resident #43 since 05/10/19 except for 08/12/19. Review of policy entitled Hemodialysis Policy and Procedure, dated 08/01/18, revealed facility will monitor dialysis access site as ordered by a physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366058 If continuation sheet Page 14 of 17 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 366058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aristos Nursing and Rehabilitation 4650 Rocky River Dr Cleveland, OH 44135 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 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. 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 faciliy failed to be administered in a manner which allowed each resident to maintain their highest level of physical, mental, and psychosocial well-being and to prevent the use of illegal substances/drugs on facility grounds. This had the potential to affect all 54 residents residing in the facility including Residents #49, #303, #29, #37, and #300. Residents Affected - Many Findings Include: 1. On 08/25/19 at 10:30 A.M. interview with Resident #49 revealed she had been a resident in the facility for a few months. During the interview, Resident #49 shared one resident in the facility, Resident #40, had repeatedly offered to supply drugs to the other residents while she had resided here. The resident stated she had told administration about this but no one had done anything to stop it. Resident #49 stated she had come to the facility to become healthy and the resident selling drugs was making it difficult. Interview on 08/26/19 at 5:55 A.M. with Registered Nurse (RN) #902 revealed she worked the 10:00 P.M. to 6:00 A.M. shift and was aware Resident #303 and Resident #29 reported they were offered drugs from Resident #40 during the last month. Review of an Incident Accident Investigation form, dated 08/03/19 at 8:30 P.M. revealed Resident #40 was suspected of drug activity. The investigation revealed Resident #40 stated, I gave him a torn up shirt to give my wife to fix. Other residents indicated they had observed a visitor put money through the door crack to give to Resident #40. As a result of the investigation, Resident #40 was encouraged to attend Individual Outpatient Program (IOP) and Alcoholic Anonymous (AA) meetings. The resident was re-educated on the substance abuse policy and a drug test was offered which the resident refused. 2. Review of Resident #37's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including cocaine abuse, schizophrenia and anxiety disorder. Review of Resident #37's progress note, dated 06/15/19 at 3:15 P.M. revealed the resident was observed in his room sitting in a wheelchair with his eyes open and in a frozen position. The resident was not responding to verbal commands or a sternal rub (also used to determine a person's responsiveness). Emergency services were notified. Review of an Incident Accident Investigation, dated 06/15/19 at 3:15 P.M. revealed Resident #37 was suspected of drug activity. Interventions following the incident revealed Resident #37 was encouraged to attend individual outpatient program meetings at a local drug treatment program associated with the facility. Review of Resident #37's MDS 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. 3. Review of Resident #300's progress note dated 08/18/19 at 1:01 A.M. revealed the nurse knocked on the resident's bathroom door and he was sitting backwards on the toilet. On the toilet tank he had a white substance, a spoon and a lighter. The nurse asked the resident what he was doing and he (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366058 If continuation sheet Page 15 of 17 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 366058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aristos Nursing and Rehabilitation 4650 Rocky River Dr Cleveland, OH 44135 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 0835 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many looked up and wiped his finger in the white substance and brushed it against his nose. Following the incident, Resident #300 left voluntarily with emergency services and the police. No documentation was available as to what occurred after the resident left with emergency services. On 08/26/19 at 10:58 A.M. interview with the Director of Nursing (DON) revealed the facility does admit residents into a drug rehab program which is associated with a local drug treatment center. All residents accepted into the program sign an agreement allowing the facility to obtain random urine drug screens as well as random room searches for those residents suspected of possible drug abuse. If the resident refuses to submit to either request an emergency discharge notice or a 30 day discharge notice can be given to the involved resident. The DON said she did not recall anyone being discharged for refusals as the majority of those residents in the program are homeless and there is nowhere they can safely discharge the resident to. Interview with Rehab Liaison (RL) #925 on 08/26/19 at 3:30 P.M. revealed she is the facility's contact person for those people participating in their IOP for substance abuse. RL #925 said the residents in the program attend the program three times per week for counseling. They are also seen by the program's physician who orders lab work, drug screens, and other medical tests as required. The facility's medical director is also part of the rehab center's staff so he is constantly updated on his residents conditions. The rehab center does weekly drug screening on those in the program which is more sensitive than the screens provided at the facility. If one of the facility's residents enrolled in their program were to be emergently discharged from the facility for a violation of the substance abuse agreement the rehab center would be able to refer the discharged resident to a safe location outside the facility. Interview with Corporate RN #926 and the Administrator on 08/26/19 at 3:50 P.M. revealed the facility would be making changes to their substance abuse program to provide a safer environment for their residents, staff, and visitors. RN #926 also said they were never able to obtain proof which resident was offering to sell drugs to other residents residing in the facility. At the time of the interview, RN #926 and the Administrator were not able to provide information on how they would protect the residents, staff, and visitors from residents offering to sell them drugs, to prevent future overdoses and other problems from occurring associated with illegal substance/drug use that was occurring in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366058 If continuation sheet Page 16 of 17 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 366058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aristos Nursing and Rehabilitation 4650 Rocky River Dr Cleveland, OH 44135 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility failed to ensure documentation was entered into resident records regarding the care provided by the facility. This affected two residents (Resident #49 and #37) of 34 residents reviewed for documentation. The facility census was 54. Findings Include: 1. Record review revealed Resident #49 was admitted to the facility on [DATE] with diagnoses including alcohol dependence, nicotine dependence, chronic obstructive pulmonary disease (COPD), heart disease, bipolar disorder, and high blood pressure. Review of the Minimum Data Set (MDS) 3.0 comprehensive quarterly assessment dated [DATE] revealed Resident #49 was cognitively intact, demonstrated no adverse behaviors, and was participating in therapy services. Review of the medical record revealed the resident was discharged from the facility but no documentation was noted as to why or where Resident #49 was transferred. Interview with the Director of Nursing (DON) on 08/28/19 at 11:00 A.M. revealed Resident #49 had been transferred to a local psychiatric unit for a mandatory in-patient stay due to aggressive behaviors toward other residents and visitors. The DON verified this was not documented in the resident record. 2. Record review revealed Resident #37 was admitted to the facility initially on 05/15/19 with diagnoses including cocaine abuse, schizophrenia and anxiety disorder. On 05/31/19 Resident #37 was readmitted to the facility but review of the medical record revealed no information as to why he was discharged or why he was readmitted . Review of Resident #37's progress note dated 06/15/19 at 3:15 P.M. indicated the resident was observed in his room sitting in a wheelchair with his eyes open and in a frozen position. The resident was not responding to verbal commands or a sternal rub (also used to determine a person's responsiveness). Emergency services were notified. No documentation was noted regarding what treatment the resident received or what occurred after Resident #37 left the facility with emergency services. The DON confirmed on 08/29/19 at 11:00 A.M. the medical record should have information regarding the care provided to the residents, how they responded to the care provided, and any follow up information regarding the incidents in both residents' medical records. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366058 If continuation sheet Page 17 of 17