Health inspection·October 24, 2023

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few television area (common lounge) of the SNF. He said that while he was talking with them, Resident #24 reached out and touched his penis on the outside of his shorts. He thought it was interesting and he asked her to do it again. He said that she began to reach for his penis again and he reached out his hand and placed it on hers and guided it to his penis. Interview on 10/23/23 at 9:50 A.M. with Administrator #2 confirmed sexual abuse had occurred and the staff were educated on abuse following the incident. Administrator #2 also confirmed Resident #7 was not allowed back into the SNF and was required to visit his wife in the ALF and Resident #7 was placed on thirty-minute safety checks while the investigation was conducted to ensure Resident #24's safety. Administrator #2 stated interviews with other residents on the SNF were not completed during the abuse investigation to determine if other residents had concerns regarding sexual abuse including residents who might have been in the common lounge area when the incident occurred. Interview on 10/23/23 at 10:32 A.M. with STNA #810 indicated she was providing care to another resident when she walked by the common area and noticed Resident #7 with his penis out and he held Resident #24's hands around his penis. STNA #810 indicated Resident #7 was gyrating back and forth while he held Resident #24's hands around his penis and Resident #24 was watching television. STNA #810 stated Resident #24 was not alert and oriented and other residents were in the common area watching television with Resident #24 when the incident occurred. She could not remember exactly who was in the common lounge. Interview on 10/24/23 at 11:51 A.M. with the Administrator confirmed the sexual incident between Residents #7 and #24 was reported to the police, skin sweeps were completed for all residents to ensure abuse did not occur, staff education was completed and Physician #827 assessed Residents #7 and #24 for any negative findings related to the sexual abuse incident. Review of the Freedom from Abuse, Neglect, and Exploitation policy revised 10/03/22 indicated the facility must take steps to ensure that the resident was protected from abuse. These steps should include evaluating whether the resident had the capacity to consent to sexual activity. The deficient practice was corrected on 10/12/22 when the facility implemented the following corrective actions: • On 10/03/22, the facility contacted the police to report inappropriate sexual contact between Resident #24 and Resident #7. Charges were not filed. • On 10/03/22, Resident #7 was restricted from the skilled facility and was required to visit his wife (who resides on the skilled side of the facility) in his apartment on the assisted living side of the facility. • On 10/03/22, staff were educated to ensure Resident #7 was restricted to the assisted living side of the facility and the resident was not allowed in the skilled side of the facility. (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 10/24/2023 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 0600 • Level of Harm - Minimal harm or potential for actual harm From 10/04/22 to 10/06/22, the facility conducted skin sweeps on all 28 residents residing in the facility including Residents #4, #5, #8, #9, #10, #12, #13, #17, #24, #25, #26, #28, #31, #36, #37, #38, #39, #40, 41, #42, #43, #44, #45, #46, #47, #48, #49, and #50. No negative findings were identified regarding abuse. Residents Affected - Few • Physician #827 assessed Residents #7 on 10/06/23 and Paxil was added to his medication regimen. Resident #24 was assessed on 10/06/23 by psychiatry and on 10/11/22 by Physician #827 for concerns related to the sexual abuse incident. No additional concerns were identified. • On 10/12/22, the facility conducted an in-service on all staff for abuse education and the abuse policy. This deficiency represents non-compliance investigated under Complaint Number OH00147645. 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 10/24/2023 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy review and interview, the facility failed to develop and implement a comprehensive pressure ulcer program to ensure ongoing assessment/monitoring of skin integrity was completed and to ensure treatments were implemented as ordered for Resident #23. This affected one resident (#23) of three residents reviewed for pressure ulcers. Residents Affected - Few Findings include: Review of Resident #23's assisted living (AL) Wound Provider Consultation form dated 09/27/23 revealed the resident had a right gluteal in-house pressure ulcer measuring 4.0 cm (centimeters) by 3.5 cm by no cm depth and moisture associated skin damage (MASD). Review of Resident #23's medical record revealed the resident was re-admitted from the assisted living memory care unit and status post hospitalization from a fall on 10/02/23 with diagnoses including right hip pain, non-surgical right pelvic fracture, essential hypertension and unspecified dementia. Review of Resident #23's facility admission Skin Observation Tool dated 10/02/23 indicated the resident's right and left buttocks were excoriated and the resident had pressure ulcers to the bilateral heels. No staging or sizes were identified on the form. Review of Resident #23's physician orders revealed an order dated 10/02/23 for Betamethasone Dipropionate (reduces swelling, itching and redness and was considered a corticosteriod) external cream 0.05% (percent) apply topically to affected area two times a day for preventative care and an order dated 10/19/23 to cleanse the left and right buttock wound with soap and water, pat dry and apply Triad daily every evening shift. Review of Resident #23's medication administration records (MARS) and treatment administration records (TARS) from 10/02/23 to 10/19/23 revealed no evidence the Betamethasone Dipropionate external cream was applied as ordered from 10/02/23 to 10/10/23. In addition, there was no evidence of bilateral heel pressure ulcer care, monitoring and assessments completed on 10/02/23, 10/04/23 and 10/06/23. Review of Resident #23's nursing progress note dated 10/07/23 at 10:24 P.M. authored by Registered Nurse (RN) #826 indicated the resident had skin impairments to the bilateral heels which measured 3.0 cm (centimeters) length by 2.5 cm width with less than 0.1 cm. The wound bed was reddened and open and the peri wound looked like normal healthy skin tissue. The area was cleansed and a foam dressing was applied. The family and physician were notified. Review of Resident #23's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment and had two Stage III (full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present) ulcers that were present upon admission/entry or reentry as well as one deep tissue injury (DTI) that was present upon admission/entry or reentry. Review of Resident #23's physician's orders revealed an order dated 10/09/23 (discontinued 10/11/23) to cleanse bilateral heels with normal saline (NS), pat dry, apply bordered foam dressing every evening shift on Monday, Wednesday and Friday for wound care; an order dated 10/13/23 (discontinued (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 10/24/2023 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 10/18/23) to cleanse the heels with normal saline, pat dry, apply Medi honey sheet (antibacterial dressing) and cover with a foam dressing every Monday, Wednesday and Friday for wound care; an order dated 10/19/23 to cleanse the left heel with normal saline, pat dry, apply a Medi honey sheet and cover with an abdominal dressing and wrap with gauze daily every day shift for wound treatment; and an order dated 10/21/23 to cleanse the right heel with normal saline, pat dry, apply skin prep and a foam dressing three times per week and as needed every Monday, Wednesday and Friday for wound care. Review of Resident #23's Wound Provider Consultation form dated 10/11/23 revealed the resident had a right gluteal suspected deep tissue injury (DTI), a Stage III pressure ulcer to the left heel measuring 2.2 cm length by 2.0 cm width with 0.2 cm depth with moderate serous exudate and a Stage III right heel pressure ulcer measuring 2.5 cm by 2.2 cm by 0.2 cm with moderate serous exudate. Observation on 10/23/23 at 1:05 P.M. with RN #809 of Resident #23's bilateral heels revealed a Kerlix wrap was on the left foot and a foam dressing was on the right heel. Both dressings were dated 10/23/23. Interview with the Director of Nursing (DON) on 10/23/23 at 3:08 p.m. confirmed Resident #23's wound care to her coccyx, which included the Betamethasone cream, was not completed from 10/02/23 to 10/10/23 and then the wound nurse practitioner (NP) came in on 10/11/23 and changed the treatment to barrier cream as needed. She also confirmed Resident #23's bilateral heel pressure wounds were not assessed and monitored effectively including wound care on 10/02/23, 10/04/23 and 10/06/23. Review of the Skin Care Management policy revised 04/20/23 revealed a resident who enters the facility without a pressure ulcer does not develop a pressure ulcer unless the clinical condition demonstrates that the pressure ulcer was unavoidable and a resident have pressure ulcers receives's necessary treatment and services to promote healing, prevent infection and prevent new pressure ulcers from developing. This deficiency represents non-compliance investigated under Complaint Numbers OH00147645 and OH00146845. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366240 If continuation sheet Page 5 of 5