Inspection·April 20, 2023

F 0646 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to timely notify the appropriate state mental health authority when a resident with a level II mental illness had a significant change in condition. This affected one (#51) of four residents reviewed for Preadmission Screening and Resident Review (PASARR). The census was 92. Findings include: Review of Resident #51's medical record revealed an admission to the facility on [DATE] with diagnoses including major depressive disorder, anxiety disorder, impulse disorder, vascular dementia with agitation and mood disturbance, Moyamoya disease, and psychosis. Review of the Medicare Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #51 had moderate cognitive impairment. The assessment indicated Resident #51 had physical and verbal behaviors directed towards others and rejected care. Review of social services progress note dated 01/15/23 revealed Resident #51 was sent to the hospital for evaluation. Review of nursing progress note dated 01/17/23 revealed Resident #51 was transferred for a geriatric psychiatric evaluation. Review of a case management progress note dated 02/10/23 revealed Resident #51 was readmitted to facility on 02/09/23 after a lengthy hospital stay including an inpatient psychiatric stay for increased agitation and behavioral disturbance. Review of the PASARR identification screen dated 02/27/23 revealed Resident #51 had a level II mental illness and a readmission from the psychiatric facility. Review of the PASARR outcome explanation dated 03/25/23 revealed the needed information for PASARR determination was not provided to complete the assessment and the case was closed. Review of the electronic medical record (EMR) for Resident #51 revealed he returned to the facility on [DATE] with no evidence the facility notified the appropriate state mental health authority of his admission to the psychiatric hospital in a timely manner as indicated. Further review of the EMR for Resident #51 revealed no level II PASARR results were provided, which indicated an evaluation was not thoroughly completed. Interview on 04/20/23 at 11:03 A.M., with Case Manager #512 confirmed Resident #51 had inpatient psychiatric hospital stay. Case Manager #512 confirmed the PASARR screening was not completed until 02/27/23. Case Manager #512 indicated when she realized the hospital had not completed the PASARR screening she completed it and submitted it to The Ohio Department of Mental Health. 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 04/20/2023 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 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure residents had ophthalmologist recommendations followed up in a timely manner. This affected one (#54) of two reviewed for ancillary services. The census was 92. Residents Affected - Few Findings include: Review of the medical record for Resident #54 revealed an admission date of 06/16/22 and diagnoses including chronic kidney disease, congestive heart failure, dementia, and polyneuropathy. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #54 had intact cognition and had adequate vision with corrective lenses. Review of progress note dated 01/17/23 revealed Resident #54 had a vision appointment. Review of an eye care provider note dated 01/17/23 revealed Resident #54 complained of blurry vision. The assessment indicated Resident #54 was provided a prescription for new glasses and would be ordered pending insurance or payer approval. Review of a progress note dated 02/27/23 revealed Resident #54's daughter requested information on the glasses. The facility's vision service was contacted about the glasses and provided with a Medicaid number. The progress note further revealed the eye care provider would send a technician to visit Resident #54 to measure for the glasses. Review of a progress note dated 03/03/23 revealed a eye care provider technician visited Resident #54 to measure Resident #54's face for new pair of glasses. Review of a progress note dated 03/16/23 revealed Resident #54's daughter again requested information on glasses. Review of a progress note dated 03/20/23 revealed Resident #54's new glasses arrived to facility and the daughter was notified. Interview on 04/18/23 at 1:12 P.M. with Resident #54 revealed she received new glasses, and indicated the ancillary services were slow at the facility. Interview on 04/19/23 at 11:15 A.M. with Social Services Director confirmed Resident #54 was seen by the facility eye care provider on 01/17/23 and had an order for new glasses. Social Services Director indicated she usually sent the Medicaid number to the eye care provider for billing. Social Services Director indicated she was unsure why there was a delay from 01/17/23 to 02/27/23 to get Resident #54's new glasses ordered, and confirmed there was a delay in ordering Resident #54's new glasses. 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 04/20/2023 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 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 medical record review, staff interview, and review of a facility policy, the facility failed to provide timely nutritional supplements as ordered. This affected one (#305) of two resident reviewed for nutrition. The census was 92. Residents Affected - Few Findings include: Review of the medical record for Resident #305 revealed an admission date of 04/04/23. Diagnoses included chronic kidney disease, moderate protein calorie malnutrition, psychosis, dementia, depression, bradycardia, anxiety disorder, and hypotension. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #305 was cognitively intact, required supervision for eating, and had an active diagnosis of malnutrition. Review of the comprehensive care plan dated 04/10/23 revealed Resident #305 had nutritional problems of moderate malnutrition and a revision to the care plan on 04/19/23 revealed Resident #305 had weight loss. Goals identified within the care plan revealed Resident #305 would maintain adequate nutritional status as evidenced by maintaining weight within five percent of the resident's admission weight of 145.2 pounds. Interventions included medications to be administered as ordered, obtain food preferences and honor requests within limits of the diet ordered, provide and serve diet as ordered, provide and serve supplements as ordered, weekly weights for four weeks and then monthly if stable, and for the registered dietician to evaluate and make diet change recommendations as needed. Review of a nutritional assessment completed on 04/10/23 revealed Resident #305 had no known food allergies, was on a regular diet, and had a weight of 145.2 pounds which was below the ideal body weight identified as 178 pounds. Resident #305 had a diagnosis of moderate malnutrition. Interventions recommended included a house shake (supplement) twice a day. Review of a written paper physician order dated 04/10/23 revealed a diet change to mechanically altered and a house shake 120 milliliters (ml) twice a day. Review of current physician orders for Resident #305 revealed an order written on 04/04/23 for weekly weights and an order dated 04/17/23 at 4:30 P.M. for a house supplement 120 ml twice a day. Review of the medication administration record from 04/04/23 to 04/20/23 revealed the house supplement was first administered on 04/17/23 at 4:30 P.M., on 04/18/23 at 7:30 A.M. and 4:30 P.M., on 04/19/23 at 7:30 A.M. and 4:30 P.M. and on 04/20/23 at 7:30 A.M. with one hundred percent of the house supplement consumed by Resident #305 at each administration. Review of the the weekly weights for Resident #305 revealed an admission weight of 145.2 pounds on 04/04/23, a weight of 140 pounds on 04/11/23, and a weight of 135.1 pounds on 04/18/23. A weight of 139.7 pounds was obtained on 04/20/23. Interview with the Director of Nursing (DON) on 04/20/23 at 10:52 A.M. verified the order for dated 04/10/23 for Resident #305 to receive the house shake 120 ml twice a day for moderate malnutrition was not entered or implemented until 04/17/23. (continued on next page) 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 04/20/2023 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Review of the facility policy titled, Physician Diet Orders and Diet Changes, dated 04/27/22, revealed each resident is prescribed a diet by the physician that provides adequate nutrition and hydration consistent with the resident's nutritional needs. Residents are offered sufficient fluid intake to maintain proper hydration and health and when there is a nutritional problem, the health care provider orders the therapeutic diet and nutritional care needed and ensures nutritional care is provided in accordance with the resident's assessment and plan of care. The policy also revealed the nurse is responsible for dining service and information pertinent to the identified nutritional concerns. 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 04/20/2023 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 0699 Provide care or services that was trauma informed and/or culturally competent. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interview, and policy review the facility failed to ensure residents who were survivors of trauma were assessed and care planned appropriately to address such trauma to maintain the residents highest practical well being. This affected one (#4) of one resident reviewed for trauma informed care. The census was 92. Residents Affected - Few Findings include: Review of Resident #4's medical record revealed and admission dare of 08/06/17 with diagnoses that included multiple sclerosis, bipolar disorder, and posttraumatic stress disorder (PTSD). Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 was cognitively intact and required extensive assistance of two staff persons for completing her activities of daily living. Review of the psychiatric progress note dated 02/08/23 revealed Resident #4 was abused sexually by her cousin, babysitter, and her step father's father. The progress note also revealed Resident #4 was hospitalized in a psychiatric setting three times for suicidal ideation and attempted suicide one time by slicing her wrists. Interview with Resident #4 on 04/18/23 at 3:45 P.M. stated she was abused constantly as a child and it messed her up for life. Observation of Resident #4 during the interview revealed she was emotional during the interview while speaking of the past abuse and trauma. Review of assessments for Resident #4 revealed she was not assessed for needs related to her trauma until 04/19/23. Review of the care plan goal related to managing and assisting Resident #4's PTSD was noted as the resident will identify ways of increasing meaningful relationships by the review date. The only interventions noted were to allow the resident time to answer questions and to verbalize feelings, perceptions, and fears, and encourage participation from the resident who depends on others to make own decisions. Interview on 04/19/23 at 4:45 P.M., with Social Worker #638 verified Resident #4's care plan had no specific goals or interventions related to Resident #4's trauma history, and Resident #4 was not assessed for her care needs related to her trauma until 04/19/23. Review of the policy titled, Trauma-Informed Care, dated 10/04/22, revealed the faciliy will use a multi-pronged approach to identifying a resident with PTSD or history of trauma. This approach would included assessing the resident for indicators of trauma upon admission/readmission and with change in condition. This assessment will include asking the resident about triggers that may be stressors or may prompt recall of of a previous traumatic events. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366176 If continuation sheet Page 6 of 6