Health inspection·February 28, 2019

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete catheter drainage bag was not covered and that from the hallway urine could be seen inside the drainage bag. Review of the undated facility policy Urinary Drainage Bag/ Urinary leg Drainage bag Cleansing During Alternating Use revealed the continuous drainage bag should be placed inside the drainage privacy bag to maintain dignity for continued socialization and mobility. Event ID: Facility ID: 366103 If continuation sheet Page 2 of 8 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 366103 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Welsh Home The 22199 Center Ridge Rd Rocky River, OH 44116 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to notify the appropriate state agency (The Ohio Department of Mental Health) of a significant change in a resident's mental health condition as required. This affected one resident (Resident #47) of one resident reviewed for pre admission screening and resident review (PASRR). The facility census was 77. Findings Include: Medical record review revealed Resident #74 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), history of falling and difficulty walking. Review of the psychiatric consult note for Resident #74 dated 02/21/18 revealed Resident #74 was given a diagnosis of major depressive disorder and violent behavior. These diagnosis were reflected and dated as such throughout Resident #74's medical record. Review of both the electronic and hard charts revealed no evidence the appropriate state agency (The Ohio Department of Mental Health) was notified of the new diagnosis for PASRR review as required. Social Service Designee #500 verified the appropriate state agency was not notified of the new diagnosis/decline in an interview on 02/28/19 at 11:32 A.M. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366103 If continuation sheet Page 3 of 8 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 366103 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Welsh Home The 22199 Center Ridge Rd Rocky River, OH 44116 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 observation, interview and record review the facility failed to ensure nutritional interventions recommended per the dietitian were implemented after Resident #55 and Resident #227 had significant weight loss. This affected two residents (Resident #55 and Resident #227) of three residents reviewed for nutritional status. Residents Affected - Few Findings include: 1. Record review of Resident #55 revealed an admission date of 01/16/19 and diagnoses that included unspecified severe protein calorie malnutrition, subsequent encounter for fracture with routine healing contusion of lower back and pelvis, and dementia without behavioral disturbances. Review of Resident #55's weight record revealed an admission weight on 01/16/19 of 132.6 pounds. Review of the Nutritional assessment dated [DATE] revealed Resident #55 had a low body mass index and low albumin level (protein level). Dietitian #603 indicated Resident #55 needed additional calories and protein and recommended a Magic cup (nutritional supplement) with each meal. Review of physician order for Resident #55 dated 01/17/19 revealed Magic cup with meals for supplementation. Review of Resident #55's care plan dated 01/17/19 revealed Resident #55 had a nutritional problem related to textured altered diet, illness, and infection related to low body mass index. Intervention included provide and serve supplements as ordered. Resident #55's subsequent weights were noted as: 01/19/19 - 132 pounds. 01/22/19 - 105 pounds indicating a significant weight loss of 20.45 percent. 01/22/19 a re-weigh of 105.2 pounds. 01/26/19 - 104.2 pounds. 01/28/19 - 103.8 pounds. 02/04/19 - 105.2 pounds. 02/05/19 - 100 pounds. 02/14/19 - 103.8 pounds. 02/20/19 - 107.8 pounds. Review of a 30- day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #55 had impaired cognition and required supervision with set up help only with eating. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366103 If continuation sheet Page 4 of 8 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 366103 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Welsh Home The 22199 Center Ridge Rd Rocky River, OH 44116 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 Level of Harm - Minimal harm or potential for actual harm Observation on 02/26/19 at 11:57 A.M. revealed Resident #55 did not have a Magic cup on his lunch tray when served. Observation on 02/27/19 at 11:58 A.M. revealed Resident #55 did not have a Magic cup on his lunch tray. Interview with Resident #55 revealed that he had not received a Magic cup. Residents Affected - Few Interview on 02/27/19 at 12:00 P.M. with State Tested Nurse Aides (STNAs) #604 and #605 revealed they were currently assigned on the unit where Resident #55 resided and they gave Resident #55 his meal tray. They indicated Resident #55 did not receive a Magic cup with his meal. They also said Resident #55 had not received the Magic cup in awhile; they thought the Magic cup was discontinued when his thickened liquids were discontinued. Interview on 02/27/19 at 12:48 P.M. with Dietary Manager #606 revealed Resident #55 was on a Regular diet and was to receive a Magic cup with his meals. Phone interview on 02/27/19 at 12:58 P.M. with Dietitian #603 verified she recommended Resident #55 receive a Magic cup with his meals due to weight loss. She was not aware that he had not been receiving his supplement as ordered. 2. Record review of Resident #227 revealed an admission date of 01/14/19 and diagnoses that included trochanteric fracture of right femur, protein- calorie malnutrition, and sepsis. Review of Resident #227's weight record revealed an admission weight on 01/14/19 of 165 pounds. Review of Resident #227's care plan dated 01/15/19 revealed he had unplanned and unexpected weight loss related to acute illness, increased nutritional and calorie needs associated with fracture injury and decreased food intake. Interventions included giving supplements as ordered and alert dietitian if not consuming on a routine basis. Review of the Nutritional assessment dated [DATE] for Resident #227 revealed decreased appetite with significant weight loss prior to admission in the last two to six months. Dietitian #604 added a Boost supplement. Review of the dietitian progress note dated 01/22/19 at 5:43 P.M. revealed Resident #227 expressed concern with recent weight loss and stated that his usual weight was 190 pounds. Resident #227 reported poor appetite. Resident #227 agreed to increase his Boost supplement to four times daily and was agreeable to have a peanut butter and jelly sandwich on each lunch and dinner tray for benefit of added calories. Review of a nursing note dated 01/23/19 at 2:03 P.M. revealed the dietitian recommended Boost supplement four times a day and a peanut butter and jelly on wheat bread per resident request for lunch and dinner. Resident #227's subsequent weights were: 01/28/19 - 157.4 pounds. 02/02/19 - 158.2 pounds. 02/12/19 - 150 pounds. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366103 If continuation sheet Page 5 of 8 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 366103 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Welsh Home The 22199 Center Ridge Rd Rocky River, OH 44116 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 02/20/19 - 154.4 pounds. Level of Harm - Minimal harm or potential for actual harm 02/26/19 - 153.6 pounds. 02/26/19 - 152.6 pounds (significant weight loss of 7.52 percent). Residents Affected - Few Review of the 14- day Minimum Data Set (MDS) 3.0 assessment dated [DATE] for Resident #227 revealed he was cognitively impaired and required supervision with set up help only with eating. He had a height of 72 inches and a weight of 157 pounds with a weight loss noted that was not prescribed. Review of the Nutritional assessment dated [DATE] for Resident #227 revealed history of significant weight loss with recent hip and rib fracture from fall. Dietitian #603 indicated Resident #227 was agreeable to supplements and a peanut butter and jelly sandwich for added calories due to weight loss. Observation on 02/26/19 at 12:02 P.M. revealed Resident #227's lunch tray did not include a peanut butter and jelly sandwich. Interview on 02/26/19 at 4:34 P.M. with State Tested Nurse Aide (STNA) #607 revealed he worked on Resident #227's unit on second shift and Resident #227 did not receive a peanut butter jelly sandwich on his dinner trays unless he asked for it as an alternative to the main course. STNA #607 revealed that he was not aware Resident #227 was to receive a peanut butter jelly sandwich on his lunch and dinner trays. Observation on 02/27/19 at 11:54 P.M. revealed Resident #227 did not not receive a peanut butter and jelly sandwich on his lunch tray. Interview on 02/27/19 at 12:00 P.M. with STNAs #604 and #605 revealed they were currently assigned to the unit where Resident #227 resided. They stated Resident #227 did not get a peanut butter jelly sandwich with his lunch trays and they did not know that it was a dietitian recommendation to receive a peanut butter and jelly sandwich with his lunch and dinner trays. Interview on 02/27/19 at 12:48 P.M. with Dietary Manager #606 revealed she had recommendations from the Dietitian that Resident #227 was on a Regular diet with no added salt and was to receive a peanut butter and jelly sandwich at lunch and dinner. Phone interview on 02/27/19 at 12:58 P.M. with Dietician #603 verified Resident #227 had a significant weight loss and that her recommendation was that Resident #227 was to receive a peanut butter and jelly sandwich on his lunch and dinner tray. She verified she was not aware he was not receiving the sandwiches. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366103 If continuation sheet Page 6 of 8 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 366103 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Welsh Home The 22199 Center Ridge Rd Rocky River, OH 44116 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure Resident #56's indwelling urinary catheter drainage bag and tubing were not on the floor and maintained below Resident #56's bladder to prevent urine back up into the bladder. This affected one resident (Resident #56) of six residents with indwelling urinary catheters. The facility also failed to ensure staff wore gloves when administering insulin to Resident #8. This affected one of one resident observed for subcutaneous injections. Facility census was 77. Residents Affected - Few Findings include: 1. Record review for Resident #56 revealed an admission date of 05/15/18 and diagnoses that included paraplegia, urine retention, benign prostatic hyperplasia, and history of urinary tract infections. Review of a physician order dated 05/15/18 revealed Resident #56 had an indwelling urinary catheter to be maintained every shift due to chronic urinary retention related to benign prostatic hyperplasia. Review of Resident #56's care plan dated 09/25/18 revealed the potential for complications related to catheter use due to diagnoses of benign prostatic hyperplasia, urine retention and obstructive uropathy. Intervention included position catheter bag and tubing below the level of the bladder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #56 was cognitively intact. He required extensive assist of two person for toilet use, extensive assist of one person for locomotion on unit, and total dependence of two person assist with transfers. He had an indwelling urinary catheter. Observation on 02/26/19 at 9:17 A.M. revealed Resident #56 was sitting in his wheelchair with his indwelling catheter drainage bag and tubing touching the floor. Interview on 02/26/19 at 9:20 A.M. with Registered Nurse (RN) #600 verified Resident #56's indwelling urinary catheter bag and tubing was touching the floor. She indicated the wheelchair was low to the ground which caused the catheter bag and tubing to drag. Observation on 02/26/18 at 4:25 P.M. revealed Resident #56 sitting in his room in his wheelchair with his indwelling urinary catheter drainage bag on his lap. Resident #56 revealed staff unhooked his urinary catheter drainage bag and put the drainage bag on his lap. Resident #56 revealed that he had been waiting twenty minutes for staff to come back to lay him in bed. Interview on 02/26/18 at 4:28 P.M. with State Tested Nursing Assistant (STNA) #603 verified the indwelling urinary catheter drainage bag was placed on Resident #56's lap. STNA #603 indicated she did not know who placed the drainage bag on his lap but that it should not have been placed on the resident's lap. STNA #603 said Resident #56 had returned from dialysis about twenty minutes ago and was waiting for staff to transfer him to his bed. Interview on 02/28/19 at 1:42 P.M. with the Director of Nursing verified that indwelling urinary catheter drainage bags should be maintained below the resident's bladder and the drainage bag or tubing should not touch the floor to prevent the risk of bladder infections. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366103 If continuation sheet Page 7 of 8 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 366103 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Welsh Home The 22199 Center Ridge Rd Rocky River, OH 44116 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. Observation of a medication administration for Resident #8 by Licensed Practical Nurse (LPN) #201 on 02/27/19 at 11:22 A.M. revealed the nurse did not wear gloves while administering a subcutaneous injection of insulin to the resident. Interview with LPN #201 on 02/27/19 at 11:40 A.M. confirmed the above findings. LPN #201 confirmed she should have worn gloves when administering subcutaneous injections. Review of the facility infection control policy concerning glove-wearing dated 08/2009 revealed gloves were to be worn when it was likely the employee's hands would come in contact with body fluids or non-intact skin, as well as during all invasive procedures. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366103 If continuation sheet Page 8 of 8