Health inspection·August 2, 2018

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure residents advanced directives were placed in the resident's electronic health record. This affected two (#74 and #244) of two residents reviewed for advanced directives. The facility census was 97. Findings include: 1. Medical record review revealed Resident #74 admitted to the facility on [DATE]. Diagnoses included pelvic fracture, difficulty walking, and Parkinson's disease. Review of the resident's physician's orders, dated [DATE], revealed the advanced directives for Resident #74 was to be a do not resuscitate, comfort care (DNRCC), which meant he/she wished for comfort care measures only with no cardiopulmonary resuscitation (CPR) performed. Review of the resident's electronic health record revealed no advanced directive for Resident #74. 2. Medical record review revealed Resident #244 admitted to the facility on [DATE]. Diagnoses included deep vein thrombosis (blood clot), pneumonia, heart failure, and major depressive disorder. Review of the resident's physician's orders, dated [DATE], revealed the advanced directives for Resident #244 was to be a do not resuscitate, comfort care arrest (DNR CCA), he/she wished to have all medically necessary services provided, until a point of pulmonary, or cardiac arrest. Review of the resident's electronic health record revealed no advanced directive for Resident #244. Interview on [DATE], at 3:44 P.M., the Director of Nursing (DON) revealed all resident's advanced directive whishes were to be placed in both the residents paper chart, as well as the electronic health record on admission. The DON verified Resident #244 and Resident #74 did not have an advanced directive in their electronic health record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366176 If continuation sheet Page 2 of 6 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 366176 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/02/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Elyria 1212 South Abbe Road Elyria, OH 44035 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of facility policy, the facility failed to provide written notification of transfer/discharge to the resident and state Ombudsman. The facility also failed to provide a reason for the resident's transfer to the hospital. This affected one (#91) of one resident reviewed for hospitalization. The facility census was 97. Findings include: Medical record review revealed Resident #91 was admitted to the facility on [DATE]. Diagnoses included non-traumatic intra-cerebral hemorrhage, deep vein thrombosis, cerebral stroke, and dysphasia. Review of the nursing progress note dated 06/06/18, revealed Resident #91 was transferred to the hospital. There was no documented reason as to why the resident was transferred to the hospital. There was no evidence the facility provided written notification to the resident, or to state Ombudsman of the transfer. Interview on 07/31/18 at 9:51 A.M., with Director of Nursing (DON) confirmed the facility did not provide written notification to Resident #91, or the state Ombudsman regarding the resident's transfer/discharge to the hospital. The DON further confirmed there was no documentation of the reason the resident was sent to the hospital. Review of facility policy titled Transfer and Discharges, dated 09/01/17, revealed transfers and discharges will be handled appropriately to ensure proper notification and assistance to residents and families, in accordance with federal and state specific regulations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366176 If continuation sheet Page 3 of 6 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 366176 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/02/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Elyria 1212 South Abbe Road Elyria, OH 44035 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to follow physician orders when they failed to monitor resident's weight as ordered. This affected one (#87) of one resident reviewed for nutrition. The facility census was 97. Residents Affected - Few Findings include: Medical record review revealed Resident #87 was admitted to the facility on [DATE]. Diagnoses included congestive heart failure (CHF), pleural effusion, diabetes, and end stage renal disease with dependence on hemodialysis. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 07/10/18, revealed the resident was cognitively intact. Review of a physician order, dated 07/05/18, revealed the facility was to weigh Resident #87 daily. Review of Resident #87's weight documentation from 07/05/18 through 07/30/18 revealed no evidence the resident was weighed from 07/05/18 through 07/10/18, from 07/12/18 through 07/16/18, on 07/20/18, from 07/22/18 through 07/24/18, and from 07/26/18 through 07/30/18. Interview on 08/02/18, at 9:18 A.M., with the Director of Nursing (DON) verified the resident was ordered daily weights. The DON further verified there was no documentation the resident was weighed on the above mentioned dates. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366176 If continuation sheet Page 4 of 6 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 366176 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/02/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Elyria 1212 South Abbe Road Elyria, OH 44035 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 medical record review, review of an outpatient dialysis agreement, and staff interview, the facility failed to ensure ongoing communications occurred between the facility and dialysis. This affected one (#87) of one resident reviewed for dialysis. The facility census was 97. Residents Affected - Few Findings include: Medical record review revealed Resident #87 admitted to the facility on [DATE]. Diagnoses included congestive heart failure (CHF), pleural effusion, diabetes, and end stage renal disease, with dependence on hemodialysis. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 07/10/18, revealed the resident was cognitively intact. Review of the dialysis communication form used by the facility revealed the facility was to document the resident's condition pre, and post dialysis, including vital signs, medication administered that day, and any other significant pertinent information related to the resident. The dialysis center was to document the resident's condition during dialysis including pre and post weights, medication given, and any concerns, or new orders. Resident #87 attended dialysis 13 times since admission. Review of the dialysis communication forms for Resident #87 revealed the facility communicated with dialysis, regarding the resident's condition, six times out of 13 visits. The facility was unable to provide any further documentation of the communication. Interview on 07/25/18, at 8:17 A.M., the Director of Nursing (DON) revealed the facility was to document on the dialysis communication form prior to dialysis of the resident's condition. The DON revealed the form was then sent with the resident to the dialysis center where the dialysis center was to document on the resident's condition during dialysis, and sent the form back with the resident. The facility was then to document, post dialysis, the resident's condition, and file the communication form in the resident's chart. The DON further revealed staff were to call the dialysis center and request the information, if the communication form was not returned, or not filled out by the dialysis center. The DON verified Resident #87 attended dialysis 13 times since admission. The DON further verified there were only six dialysis communication forms completed for Resident #87. Review of an outpatient dialysis service agreement, dated 03/15/2016, between the dialysis center and the facility revealed the facility was to ensure all appropriate medical and administrative information accompanied each resident at the time of transfer. This was to include, but not limited to, any treatment being provided to the resident including the resident's medications, history of the resident's illness, any laboratory or diagnostic testing results, and the resident's advanced directive. Further review revealed the dialysis center would conform to all local, state, and federal regulations as well all applicable laws. The dialysis center was to provide the nursing facility information on all aspects of the resident's care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366176 If continuation sheet Page 5 of 6 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 366176 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/02/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Elyria 1212 South Abbe Road Elyria, OH 44035 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of facility policy, the facility failed to have an adequate indication of use regarding the use of an anti-depressant medication. This affected one (#53) of five residents reviewed for unnecessary medications. The facility census was 97. Findings include: Review of Resident #53's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses includes type II diabetes, hypertension, peripheral vascular disease, and dementia, without behaviors disturbances. Review of Resident #53's physician orders dated 06/26/18 revealed, an order for Remeron 15 milligrams (mg), tablet, every night for dementia. Interview on 08/01/18 at 3:08 P.M., with Director of Nursing (DON), verified Resident #53 was receiving Remeron without an adequate indication of use. Review of facility policy titled Drug Utilization Program, dated 08/16/06, revealed an accurate determination of each resident's diagnosis, and problems upon admission is a critical starting point in the overall management of the nursing home resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366176 If continuation sheet Page 6 of 6