Health inspection·August 22, 2019

F 0623 Level of Harm - Potential for minimal harm Residents Affected - Many 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** 3. Review of Resident #30's medical record revealed an admission date of 09/04/07 with diagnoses including anxiety, falls, anemia, Alzheimer's disease and dysphagia. Review of the quarterly MDS 3.0 assessment, dated 07/11/19 revealed Resident #30 was cognitively intact and was totally dependent on one staff for locomotion on the unit. Review of a nurse's note, dated 06/10/19 at 1:51 P.M. revealed Resident #30 was trying to walk to her room after lunch, lost her balance and fell backwards in the dining room. Resident #30's right lower extremity had been extended and sideways and the resident was complaining of pain; the family was notified. Resident #30 was admitted to the hospital for partial hip replacement due to hip fracture. Bed-hold information and discharge communication were communicated to the family. A nursing assessment dated [DATE] indicated Resident #30 returned to the facility for skilled care. Review of the facility ombudsman notification documentation, dated 07/01/19 revealed no evidence the Long-Term Care Ombudsman (LTCO) was notified of Resident #30's transfer to the hospital on [DATE]. Interview on 08/21/19 at 1:55 P.M. with the Director of Nursing (DON) and Social Service Designee (SSD) #202 verified the LTCO was not notified of Resident #30's hospitalization on 06/10/19. Based on record review and staff interview the facility failed to notify the Ombudsman's office of resident transfers from the facility. This affected three residents (#20, #30 and #46) of three residents reviewed for hospitalization and had the potential to affect all 42 residents residing in the facility. Findings include: 1. Record review revealed Resident # 46 was admitted to facility on 12/04/17 with diagnoses including encephalopathy, dementia, pneumonia, sepsis, and major depressive disorder. Her code status was full measures. Review of Resident #46's medical record revealed she had been discharged to the hospital on [DATE] for a urinary tract infection (UTI) and readmitted on [DATE]. She was also discharged on 06/27/19 for a respiratory infection and UTI and was readmitted on [DATE]. Review of the emails of resident discharges that was sent to the State Ombudsman revealed Resident #46 was not included on the list for May or June 2019. Interview on 08/21/19 at 1:55 P.M. with the Director of Nursing (DON) and Social Service Designee (SSD) #202 verified Resident #46 was not included on the discharged lists sent to the State Ombudsman. The DON stated Resident #46 was not actually discharged from the facility, as if she had run out of bed hold days, so she did not make it on the list. 2. Record review revealed Resident #20 was admitted to this facility on 07/17/18 with admitting diagnoses including malignant neoplasm of the brain, major depressive disorder, epilepsy, cerebral infarction and corticobasal degeneration. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366240 If continuation sheet Page 2 of 5 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 366240 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Western Reserve Masonic Comm 4931 Nettleton Road Medina, OH 44256 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 - Potential for minimal harm Residents Affected - Many Review of the Minimum Data Set Assessment (MDS) 3.0 assessment, dated 07/03/19 revealed the resident had severe cognitive impairment and was totally dependent on staff for transfers, locomotion on and off the unit, toilet use and personal hygiene. She required extensive assistance for bed mobility, dressing and eating. Review of the nursing progress notes from 03/10/19 to 03/15/19 revealed the resident had been running a high fever as high as 102.7. She was given an anti-pyretic (fever reducing medication) and the physician was notified. On 03/11/19 the physician ordered stat chest x-ray and a test to be administered for the flu. She was diagnosed with pneumonia and had a right lower lobe infiltrate. The physician also ordered antibiotics for her pneumonia. From 03/11/19 to 03/15/19 the resident continued to decline to the point where the staff were unable to get her to take her antibiotics or drink anything. Review of progress note dated 03/15/19 at 01:34 P.M. showed that the physician was contacted again regarding the resident's continued refusal to drink or take her medication. The physician ordered the resident to be sent to the emergency room for further evaluation. She left the faciity on [DATE] and was admitted to the hospital Review of the progress noted dated 03/20/19 at 11:07 P.M. revealed the resident was readmitted back to the facility at this time. Review of the facility Notification of Ombudsman documentation from the past six months revealed the facility did not notify the Ombudsman the resident was discharged to the hospital Interview with the DON on 08/21/19 at 1:55 P.M. verified the Ombudsman was not notified of the resident's discharge to the hospital. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366240 If continuation sheet Page 3 of 5 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 366240 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Western Reserve Masonic Comm 4931 Nettleton Road Medina, OH 44256 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 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 ensure resident oxygen tubing was dated to reflect when it had been changed and to ensure it was being routinely changed. This affected four residents (#7, #39, #43, and #45) of six residents reviewed for oxygen therapy. Residents Affected - Some Findings include: 1. Review of Resident #7's medical record revealed an admission date of 03/15/18 with diagnoses of congestive heart failure (CHF) and peripheral vascular disease (PVD). The quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #7 was cognitively intact. This assessment reflected Resident #7's use of oxygen. Observations of Resident #7 from 08/19/19 through 08/22/19 at various times revealed the resident had oxygen in place. The oxygen tubing was observed to be not dated. Interview on 08/22/19 at 9:49 A.M. with LPN #220, confirmed there was no date on the oxygen tubing, from nasal cannula to oxygen concentrator. LPN #220 stated she had only seen the attached bag the tubing was stored in have a date when changed. However, no date was on the bag either. Interview and observation on 08/22/19 from 11:10 A.M. to 11:25 A.M. with the Director of Nursing (DON) revealed Resident #7's oxygen tubing was not dated at this time. 2. Review of Resident #39's medical record revealed an admission date of 11/22/18 with diagnoses of malignant neoplasm of left lung, acute and chronic respiratory failure, chronic obstructive pulmonary disease (COPD), allergic bronchopulmonary aspergillosis (ABPA is a hypersensitivity to fungus aspergillus), emphysema, and asthma. The quarterly MDS 3.0 assessment dated [DATE] revealed Resident #39 was alert and oriented and cognitively intact. This assessment reflected Resident #39's use of oxygen. Interview and observation on 08/22/19 from 11:10 A.M. to 11:25 A.M. with the Director of Nursing (DON) revealed Resident #39's oxygen tubing was not dated at this time. 3. Review of Resident #43's medical record revealed an admission date of 07/18/18 with diagnoses of acute and chronic respiratory failure, CHF, COPD, and morbid obesity. The quarterly MDS 3.0 assessment, dated 07/24/19 revealed Resident #43 was cognitively intact. Oxygen was not in use at the time of this assessment. Interview and observation on 08/22/19 from 11:10 A.M. to 11:25 A.M. with the Director of Nursing (DON) revealed Resident #43 had oxygen in place and the oxygen tubing was not dated at this time. 4. Review of Resident #45's medical record revealed an admission date of 12/23/15 with diagnoses of Alzheimer's disease, dementia and a sleep disorder. The quarterly MDS 3.0 assessment dated [DATE] revealed Resident #45 was not cognitively intact. This assessment reflected Resident #45's use of oxygen. Interview and observation on 08/22/19 from 11:10 A.M. to 11:25 A.M. with the Director of Nursing (DON) revealed Resident #45's oxygen tubing was not dated at this time. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366240 If continuation sheet Page 4 of 5 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 366240 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Western Reserve Masonic Comm 4931 Nettleton Road Medina, OH 44256 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 0695 Level of Harm - Minimal harm or potential for actual harm On 08/22/19 at 10:57 A.M. a telephone interview with Vendor #214 from the respiratory supply company revealed he changes the oxygen tubing every Friday for residents who have oxygen who are not on Hospice and who use a concentrator. He revealed he placed a dated sticker on the tubing when he changed it, up near the connection with the concentrator. The only reason, he reported, there would not be a sticker was if other staff had changed the tubing and didn't date it. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366240 If continuation sheet Page 5 of 5