Health inspection·April 22, 2021

F 0609 Level of Harm - Minimal harm or potential for actual harm Review of facility self- reported incidents (SRI's) revealed there was no self-reported incidents filed regarding Resident #37's incident that had occurred on 03/23/21. After the above was brought to the Administrator's attention during the survey, the Administrator filed a self-reported incident on 04/21/21 with a tracking number #205182 for Resident #37 regarding her allegation of physical and sexual abuse made on 03/23/21. Residents Affected - Few Review of social service note dated 03/23/21 at 4:20 P.M. and authored by Licensed Social Worker (LSW) #115 revealed Resident #37's son was made aware of Resident #37's behaviors of increased paranoia and delusions that she had the night of 03/23/21. Resident #37 was scheduled to see Psychiatrist #600 on 03/24/21. Resident #37's son agreed to have Psychiatrist #600 see Resident #37 and if he had any ideas for treatment. LSW #115 discussed the option of a specialized mental health facility but Resident #37's son would like that to be the last resort as he loved the current facility Resident #37 was residing in. Review of Psychiatrist #600's progress note dated 03/24/21 revealed Resident #37 reported to the nurse she was sexually assaulted. He evaluated Resident #37 and made medication adjustments and ordered lab work. There was no mention of any details Resident #37 provided to Psychiatrist #600 regarding the allegation in the progress note. Phone Interview on 04/20/21 at 12:06 P.M. with the Director of Nursing (DON) verified she was not contacted immediately after Resident #37 made the allegation of physical and sexual abuse by LPN #40. She revealed she believed she was notified when she came in that morning but was not for sure when she was notified. She revealed the facility did not file a self-reported incident (SRI) regarding the incident on 03/23/21. She revealed she did investigate into the allegation but did not have any written documentation such as witness statements, or a formal investigation. Interview on 04/21/21 at 9:02 A.M. with the Administrator revealed Resident #37 had long standing psychiatric issues including making allegations of sexual abuse. She verified Resident #37 made an allegation of physical and sexual abuse on 03/23/21 and LPN #40 did not immediately notify her or any other designee of the allegation of abuse as directed in the abuse policy. She revealed she was notified when she came into the facility the morning of 03/23/21. She verified the facility should have notified her, notified the physician immediately, and the facility should have completed a self-reported incident to the State Survey Agency per the facility policy. She verified the facility did not complete a formal investigation including interviews or witness statements regarding Resident #37's alleged abuse allegation. Interview on 04/21/21 at 2:38 P.M. with Psychiatrist #600 revealed he was made aware Resident #37 had stated she was sexually assaulted. He revealed Resident #37 had a history of false allegation, paranoia, and delusions and he did evaluate Resident #37 after her allegation on 03/24/21. She had no recollection of the events that she had reported, and he gave him no details of the alleged allegation. He revealed he increased her anti-psychotic medication and since she had less delusions; he felt she was doing better. Interview on 04/22/21 at 2:02 P.M. with LPN #40 revealed Resident #37 came to the nursing station and asked to speak with her in her room. LPN #40 stated she went to Resident #37's room and Resident #37's had stated a man had physically and sexually assaulted her by smashing her boob down. Resident #37 stated it was flat and the man had touched her private area with his fingers. LPN #40 revealed she did assess her breast area, but she did not note any abnormalities on assessment. LPN #40 revealed she did not assess any other areas including Resident #37's private area. LPN #40 revealed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366103 If continuation sheet Page 2 of 7 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 04/22/2021 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #37 was crying and was upset regarding the incident. LPN #40 revealed she did not report the allegation of abuse to the administrator, physician, or responsible party as per the abuse policy. LPN #40 revealed there was no excuse as to why she did not report, and she should have notified the administrator immediately of Resident #37's allegation of abuse. LPN #40 revealed Resident #37 made false allegations previously, so she revealed she just assumed it was another false allegation. LPN #40 revealed she did not report the allegation until change of shift on 03/23/21 at approximately 7:00 A.M. when she reported the incident either to the oncoming nurse or the Unit Manager/ Wound Nurse #24 but could not remember exactly who she reported the allegation to. LPN #40 verified she did not conduct any interviews or obtain any witness statements from other residents in the area, from other staff members, or that she initiated any investigation after Resident #37 made the allegation of abuse. Review of undated facility policy labeled, Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Resident Property revealed the facility failed to implement their policy as the policy revealed the facility would investigate all alleged violations involving abuse, neglect, exploitation, and mistreatment. The facility staff would immediately report all such allegations to the administrator and to the Ohio Department of Health. The facility in cases where a crime was suspected staff would report the allegation to the local law enforcement. The policy defines sexual abuse as non-consensual sexual contact of any type with a resident and physical abuse included but not limited to hitting, slapping, punching, biting, and kicking. The policy revealed if abuse or serious bodily injury was alleged the allegation would be reported to the Ohio Department of Health immediately but no later than two hours after the allegation was made and all other allegations involving abuse, neglect, exploitation mistreatment would be reported to the Ohio department of Health no later than 24 hours from the time the incident/ allegation was made. The policy revealed once the Administrator and the Ohio Department of Health were notified an investigation of the alleged violation would be consulted. The policy revealed the investigation would be completed within five working days. The investigation would include an interview with the resident, accused, and all witnesses by obtaining a statement from the resident if possible, the accused and each witness, and evidence of the investigation should be documented. The policy revealed the results of the investigation would be reported to the Administrator and the final report would be submitted to the Ohio Department of Health no later than five working days after discovery of the incident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366103 If continuation sheet Page 3 of 7 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 04/22/2021 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on interview, review of facility abuse policy and record review the facility failed to thoroughly investigate when Resident #37 alleged she was physically and sexually abused on 03/23/21. This affected one resident (Resident #37) out of one resident reviewed for abuse. This had the potential to affect all 64 residents residing in the facility. Residents Affected - Few Findings included: Review of medical record for Resident #37 revealed an admission date of 10/21/20 and diagnoses included Alzheimer's Disease, delusional disorder, dementia with behavioral disturbances, and anxiety disorder. Review of care plan for Resident #37 dated 03/01/21 revealed she had the potential to demonstrate verbally inappropriate behaviors related to mental and emotional illness. She had a history of false accusations towards caregivers. Interventions included analyze key times, places, circumstances, triggers, and what escalated her behaviors and document, and psychological consult as indicated. Review of Medicare five-day Minimum Data Set (MDS) 3.0 dated 03/03/21 revealed Resident #37 had impaired cognition and she had delusions. Review of nursing note dated 03/23/21 at 12:40 A.M. and authored per Licensed Practical Nurse (LPN) #40 revealed Resident #37 came to the nursing desk and stated, I need to talk to you in my room please. LPN #40 revealed she went into Resident #37's room and Resident #37 started to cry and whimper and pulled up her shirt showing LPN #40 her right breast. Resident #37 stated A man came in here and smashed my boob down and now its flat and hanging down low, and he also fingered my down there (vagina) as she whispered the word vagina. LPN #40 revealed there was no noticeable change to her breast. LPN #40 revealed Resident #37 began to whimper and cry and stated, What have I done so wrong, I tell you when I find the man that has done this to me and he won't have any balls left, he better leave his hands off of me, because I'm not the one to be messed with, I'm completely happy with my husband. LPN #40 revealed she listened to the resident and expressed to her that staff would make frequent checks and that it was safe at the facility. The nursing note revealed staff was monitoring her room and she was currently resting quietly with eyes closed and call light in reach. The nursing note revealed no further assessments that LPN #40 completed on Resident #37 for signs of abuse except for the breast exam. The nursing note revealed no notification to the Administrator or designee, physician, or responsible party regarding the allegation of abuse or no details regarding an initiation of an investigation regarding the allegation of abuse. Review of facility self- reported incidents (SRI's) revealed there was no self-reported incidents filed regarding Resident #37's incident that had occurred on 03/23/21. After the above was brought to the Administrator's attention during the survey, the Administrator filed a self-reported incident on 04/21/21 with a tracking number #205182 for Resident #37 regarding her allegation of physical and sexual abuse made on 03/23/21. Review of social service note dated 03/23/21 at 4:20 P.M. and authored by Licensed Social Worker (LSW) #115 revealed Resident #37's son was made aware of Resident #37's behaviors of increased paranoia and delusions that she had the night of 03/23/21. Resident #37 was scheduled to see Psychiatrist #600 on 03/24/21. Resident #37's son agreed to have Psychiatrist #600 see Resident #37 and if he had any ideas for treatment. LSW #115 discussed the option of a specialized mental health facility but (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366103 If continuation sheet Page 4 of 7 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 04/22/2021 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #37's son would like that to be the last resort as he loved the current facility Resident #37 was residing in. Review of Psychiatrist #600's progress note dated 03/24/21 revealed Resident #37 reported to the nurse she was sexually assaulted. He evaluated Resident #37 and made medication adjustments and ordered lab work. There was no mention of any details Resident #37 provided to Psychiatrist #600 regarding the allegation in the progress note. Phone Interview on 04/20/21 at 12:06 P.M. with the Director of Nursing (DON) verified she was not contacted immediately after Resident #37 made the allegation of physical and sexual abuse by LPN #40. She revealed she believed she was notified when she came in that morning but was not for sure when she was notified. She revealed the facility did not file a self-reported incident (SRI) regarding the incident on 03/23/21. She revealed she did investigate into the allegation but did not have any written documentation such as witness statements, or a formal investigation. Interview on 04/21/21 at 9:02 A.M. with the Administrator revealed Resident #37 had long standing psychiatric issues including making allegations of sexual abuse. She verified Resident #37 made an allegation of physical and sexual abuse on 03/23/21 and LPN #40 did not immediately notify her or any other designee of the allegation of abuse as directed in the abuse policy. She revealed she was notified when she came into the facility the morning of 03/23/21. She verified the facility should have notified her, notified the physician immediately, and the facility should have completed a self-reported incident to the State Survey Agency per the facility policy. She verified the facility did not complete a formal investigation including interviews or witness statements regarding Resident #37's alleged abuse allegation. Interview on 04/21/21 at 2:38 P.M. with Psychiatrist #600 revealed he was made aware Resident #37 had stated she was sexually assaulted. He revealed Resident #37 had a history of false allegation, paranoia, and delusions and he did evaluate Resident #37 after her allegation on 03/24/21. She had no recollection of the events that she had reported, and he gave him no details of the alleged allegation. He revealed he increased her anti-psychotic medication and since she had less delusions; he felt she was doing better. Interview on 04/22/21 at 2:02 P.M. with LPN #40 revealed Resident #37 came to the nursing station and asked to speak with her in her room. LPN #40 stated she went to Resident #37's room and Resident #37's had stated a man had physically and sexually assaulted her by smashing her boob down. Resident #37 stated it was flat and the man had touched her private area with his fingers. LPN #40 revealed she did assess her breast area, but she did not note any abnormalities on assessment. LPN #40 revealed she did not assess any other areas including Resident #37's private area. LPN #40 revealed Resident #37 was crying and was upset regarding the incident. LPN #40 revealed she did not report the allegation of abuse to the administrator, physician, or responsible party as per the abuse policy. LPN #40 revealed there was no excuse as to why she did not report, and she should have notified the administrator immediately of Resident #37's allegation of abuse. LPN #40 revealed Resident #37 made false allegations previously, so she revealed she just assumed it was another false allegation. LPN #40 revealed she did not report the allegation until change of shift on 03/23/21 at approximately 7:00 A.M. when she reported the incident either to the oncoming nurse or the Unit Manager/ Wound Nurse #24 but could not remember exactly who she reported the allegation to. LPN #40 verified she did not conduct any interviews or obtain any witness statements from other residents in the area, from other staff members, or that she initiated any investigation after Resident #37 made the allegation of abuse. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366103 If continuation sheet Page 5 of 7 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 04/22/2021 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Review of undated facility policy labeled, Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Resident Property revealed the facility failed to implement their policy as the policy revealed the facility would investigate all alleged violations involving abuse, neglect, exploitation, and mistreatment. The facility staff would immediately report all such allegations to the administrator and to the Ohio Department of Health. The facility in cases where a crime was suspected staff would report the allegation to the local law enforcement. The policy defines sexual abuse as non-consensual sexual contact of any type with a resident and physical abuse included but not limited to hitting, slapping, punching, biting, and kicking. The policy revealed if abuse or serious bodily injury was alleged the allegation would be reported to the Ohio Department of Health immediately but no later than two hours after the allegation was made and all other allegations involving abuse, neglect, exploitation mistreatment would be reported to the Ohio department of Health no later than 24 hours from the time the incident/ allegation was made. The policy revealed once the Administrator and the Ohio Department of Health were notified an investigation of the alleged violation would be consulted. The policy revealed the investigation would be completed within five working days. The investigation would include an interview with the resident, accused, and all witnesses by obtaining a statement from the resident if possible, the accused and each witness, and evidence of the investigation should be documented. The policy revealed the results of the investigation would be reported to the Administrator and the final report would be submitted to the Ohio Department of Health no later than five working days after discovery of the incident. Event ID: Facility ID: 366103 If continuation sheet Page 6 of 7 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 04/22/2021 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on record review and interview the facility failed to develop a Hospice Care Plan for Hospice for Resident #44. This affected one of two residents reviewed for hospice (Resident #16 and Resident #44). This had the potential to affect all seven hospice residents in the facility (#16, #30, #36, #44, #45, #55, and #62). The facility census was 64. Findings Include: Medical record for Resident #44 revealed an admission date of 01/11/17. Diagnoses included malignant neoplasm of left lung and Alzheimer's disease. Review of the Significant Change Minimum Data Set (MDS) assessment, dated 03/15/21, revealed the resident had severely impaired cognition. The resident required the extensive assistance for bed mobility, locomotion, dressing, toilet use and personal hygiene. Limited assistance was needed for eating. The resident was totally dependence for transfers. Review of physician orders for 04/21 identified an order for admission to hospice for malignant neoplasm of the left lung was initiated on 03/04/21. Record review revealed no hospice care plan had been developed. Interview on 04/22/21 at 11:41 with Assistant Director of Nursing (ADON) #70 verified there was no hospice care plan in the medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366103 If continuation sheet Page 7 of 7