Inspection·September 7, 2023

F 0558 Level of Harm - Minimal harm or potential for actual harm Review of the care plan dated 08/04/23 revealed Resident #31 had a self-care deficit related to cognitive deficits, dementia, and weakness and was at risk for falls with interventions including call light within reach. Observation on 09/06/23 at 8:14 A.M. revealed Resident #31 call light was on side table and not within reach. Residents Affected - Few Interview and observation on 09/06/23 at 9:06 A.M. with STNA #944 verified Resident #31's call light was on the side table and out of reach. STNA #944 revealed Resident #31 needed to have his call light on the right side of the bed. Review of the facility document titled Answering the Call Light revised September 2022, revealed the facility had a policy in place to ensure timely responses to the resident's request and needs. Further review of the policy revealed the facility staff would ensure the call light was accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366266 If continuation sheet Page 2 of 15 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 366266 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Enniscourt Nursing Care 13315 Detroit Ave Lakewood, OH 44107 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 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on record review, observation and interview, the facility did not ensure private and confidential handling of resident medical information for Residents #14, #15, #19, #20, #29 and #31. This affected six residents ( #14, #25, #19, #20, #29 and #31) of six residents reviewed for weights and had the potential to affect all residents living in the facility. The facility census was 42. Residents Affected - Many Findings include: Record review of weight documentation and physician orders for weights revealed Residents #14, #15, #19, #20, #29, and #31 each had an order to be weighed at least once a month and each had multiple weights missing from the medical record of weights. Interview on 09/06/23 at 8:50 A.M. with the Director of Nursing (DON) revealed the system in place for recording resident weights consisted of weights obtained by State Tested Nursing Assistant (STNA) #944 who recorded the weights in a paper logbook and those weights were then transposed into the electronic medical record (EMR) by the DON. Interview on 09/06/23 at 2:18 P.M. with STNA #944 revealed he was the staff person who was responsible for weighting the residents and he kept a paper copy of the resident weights which would then be given to the DON to enter into the EMR. Observation and interview on 09/06/23 at 4:22 P.M. with STNA #944 revealed STNA #944 voluntarily entered an unlocked employee break room and returned to the hallway a few minutes later holding loose papers that were folded in quarters and piled together in a stack. STNA #944 verified the papers were the monthly weight logs dated from 01/2023 to 08/2023 and each page contained resident names, room numbers, dates and body weights of all the residents he had to weigh each month. STNA #944 verified the information was not secure, as other employees also used the breakroom where he was keeping the weight logs. Review of the United States Department of Health and Human Services Office for Civil Rights Health Insurance Portability and Accountability Act (HIPAA) indicated residents to be provided with assurances their sensitive health data will remain confidential, sets rules and places limits on who can look at and receive health information. The Privacy Rule applies to all forms of an individuals' protected health information, whether electronic, written, or oral. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366266 If continuation sheet Page 3 of 15 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 366266 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Enniscourt Nursing Care 13315 Detroit Ave Lakewood, OH 44107 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 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** 2. Review of Resident #43's medical record identified admission to the facility occurred on 01/17/22 with medical diagnoses including stroke, dementia, alzheimer's, skin cancer, and depression. The record identified Resident #43 discharged to the hospital on [DATE] and did not re-enter the facility. Review of both the electronic medical record and hard chart revealed no evidence Resident #43 and/or representative received notification in writing for transfer to the hospital dated 07/12/23. Interview on 09/07/23 at 9:30 A.M. with Registered Nurse (RN) #964 revealed he was responsible for notifying the ombudsman of discharges and transfers to the hospital and did so via email. RN #964 said he was also responsible to give bed hold notices to residents/resident respresentativees when discharging or transferring to the hospital, but was not doing this because instead all residents were provided the policy on bed holds, discharges and transfers during the admission process and no follow-up information was provided to them. RN #964 verified no evidence the Ombudsman was notified of Resident #40's transfer to the hospital on [DATE] and 07/17/23 or Resident #40 and/or representative receiving notification in writing for transfers to the hospital dated 06/25/23, 07/04/23, and 07/17/23. RN #964 also verified he had no evidence Resident #43 and/or representative received notification in writing for transfer to the hospital dated 07/12/23. Based on record review and staff interview the facility failed to ensure the state ombudsman and resident/representatives were notified in writing of all resident transfers to the hospital. This affected two (Resident #40 and #43) of two residents reviewed for hospitalization and had the potential to affect all residents living in the facility. The facility census was 42. Findings include: 1. Review of Resident #40's medical record identified admission to the facility occurred on 06/06/23 with medical diagnoses including sepsis, dementia, and dysphagia. The record identified Resident #40 discharged to the hospital on [DATE] returning on 06/28/23, discharged on 07/04/23 and returned on 07/11/23, and discharged on 07/17/23 and returned on 07/20/23. Review of both the electronic record and hard charts revealed no evidence the state ombudsman was notified of Resident #40's transfer to the hospital on [DATE] and 07/17/23. Further review revealed Resident #40 and/or representative did not receive notification in writing for transfers to the hospital dated 06/25/23, 07/04/23, and 07/17/23. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366266 If continuation sheet Page 4 of 15 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 366266 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Enniscourt Nursing Care 13315 Detroit Ave Lakewood, OH 44107 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 0625 Level of Harm - Potential for minimal harm Residents Affected - Many Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility bed hold policy and staff interviews, the facility failed to ensure Resident #40 and #43 were provided bed hold notices. This affected two residents (#40 and #43) of two residents reviewed for hospitalization and had the potential to affect all residents living in the facility. The facility census was 42. Findings include: 1. Review of Resident #40's medical record identified admission to the facility occurred on 06/06/23, with medical diagnoses that included sepsis, dementia, and dysphagia. The record identified Resident #40 required hospitalization on 06/25/23, 07/04/23, and 07/17/23. Review of both the electronic and hard charts revealed no evidence Resident #40 or her family/representative were given information regarding bed hold days remaining and other related procedures for her return to the facility upon each discharge to the hospital. 2. Review of Resident #43's medical record identified admission to the facility occurred on 01/17/22, with medical diagnoses that included stroke, dementia, Alzheimer's, skin cancer, and depression. The record identified Resident #43 discharged to the hospital on [DATE] and did not re-enter the facility. Review of both the electronic medical record and hard chart revealed no evidence Resident #43 and/or representative received information regarding bed hold days. Interview with Registered Nurse (RN) #964, occurred on 09/07/23 at 9:30 A.M., verified the lack of bed hold notice given to Resident #40, Resident #43 or their family/representative. RN #964 indicated he was responsible for the bed hold notices but had not been giving them to the residents or their representatives as required when they discharged to the hospital. Review of the facility document titled Bed-Holds and Returns revised October 2022, revealed the facility had a policy in place that residents and/or representatives would be informed (in writing) of the facility and state (if applicable) bed-hold policies. Review of the document revealed the facility did not implement the policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366266 If continuation sheet Page 5 of 15 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 366266 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Enniscourt Nursing Care 13315 Detroit Ave Lakewood, OH 44107 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure the pre admission screen and resident review status was coded correctly on the Minimum data set (MDS) assessment. This affected two (Residents #1 and #2) of two residents with a level two mental illness currently residing at the facility. The facility census was 42. Residents Affected - Some Findings Include: 1. Record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder, type two diabetes and hypothyroidism. Review of the pre-admission screen and resident review (PASRR) level two evaluation from the state department of mental health dated 11/06/97 revealed Resident #8 had level two mental illness. Review of section A of the most recent comprehensive MDS 3.0 assessment dated [DATE] revealed the facility answered no to the question of Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability (mental retardation in federal regulation) or a related condition? 2. Record review revealed Resident #2 was admitted to the facility on [DATE] with diagnoses that included bipolar disorder, major depressive disorder and severe anxiety disorder . Review of the pre-admission screen and resident review (PASRR) level two evaluation from the state department of mental health dated 07/23/15 revealed Resident #13 had level two mental illness. Review of section A of the most recent comprehensive MDS 3.0 assessment dated [DATE] revealed the facility answered no to the question of Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability (mental retardation in federal regulation) or a related condition? MDS Coordinator #949 verified that Resident #1 and #2's PASRR status was coded incorrectly on the MDS in an interview on 09/06/23 at 1:45 P.M. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366266 If continuation sheet Page 6 of 15 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 366266 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Enniscourt Nursing Care 13315 Detroit Ave Lakewood, OH 44107 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 record review, observation and interview, the facility failed to ensure adequate and sufficient documentation of residents' weights in the medical record for the monitoring of residents at nutrition risk and identification and assessment of significant weight changes. This affected six residents (#14, #15, #19, #20, #29, and #31) of six reviewed for nutrition. The facility census was 42. Residents Affected - Some Findings include: 1. Review of the medical record for Resident #14 revealed an admission date of 12/04/22. Diagnoses included feeding tube, muscle weakness, hypothyroidism, lupus, dementia, and history of cancer of the uterus. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed the resident had impaired cognition, required supervision with set up help for eating, weight was 124 pounds, with no weight changes, received mechanically altered diet, and received 26%-50% of calories and 501 ml or more per day of fluids from a feeding tube. Review of Resident #14 weight history revealed on 12/04/22 the resident weighed 124 pounds (lbs.), next weight documented was dated 06/21/23 and the resident weighed 111.4 lbs. Weight on 07/28/23 was 113.4 lbs., and on 08/31/23 was 110.8 lbs. Review of the nutrition assessment dated [DATE] revealed Resident #14 received a mechanically soft diet with honey thickened liquids and 250 milliliters (ml) of Isosource 1.5 with 100 ml of water when 50% of meals were consumed. The assessment also indicated under weight history, current body weight was 124 pounds on 12/04/22 and N/A was noted for 30 day weight and 90 day weight. Also noted on the assessment under recommendations was to monitor monthly weights. Interview on 09/06/23 at 2:18 P.M., State Tested Nurse Aide (STNA) #944 stated over the past 10 years he had obtained the residents' weights monthly and weights other than monthly weights when asked by the nurse. STNA #944 verified the missing weights for Resident #14 for January 2023 through May 2023. STNA #944 stated at one time they had two scales; one was a chair scale and the other was a walk-up scale. STNA #944 stated because Resident #14 could not bend her legs well, he had a hard time weighing her on the chair scale and she could not stand to use the walk-up scale. STNA #944 stated once they received the Hoyer lift with the scale, he was then able to weigh Resident #14. STNA #944 stated he was not sure when they had received the Hoyer lift with the scale. Review of monthly weight sheets provided by STNA #944 from the weight sheets in his locker revealed weights were obtained for Resident #14 dated between January 2023 to May 2023. The weights obtained indicated Resident #14's weight was consistent between 110 lbs. to 113 lbs. during those months. STNA #944 verified he had kept the weights in his locker. Review of the delivery ticket for the Hoyer lift with scale revealed it was delivered on 01/30/23. Interview on 09/06/23 at 3:17 P.M. with the Director of Nursing (DON) revealed when STNA #944 obtained the resident weights she would put them in the resident's electronic medical record. DON stated STNA #944 did not always give her the weights to enter in the electronic medical record and that he kept the log of residents' weights in his locker. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366266 If continuation sheet Page 7 of 15 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 366266 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Enniscourt Nursing Care 13315 Detroit Ave Lakewood, OH 44107 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 - Some Interview on 09/07/23 at 11:57 A.M. with Registered Dietitian (RD) #850 revealed she looked at residents' weight as part of her assessments. RD #850 stated the facility had one person that obtained residents' weights and the DON entered the weights into the resident's electronic medical record. RD #850 stated she used the last weight available in the electronic medical record with the date of when the weight was obtained in her assessments. RD #850 verified there were no weights available for her to review for Resident #14 between January 2023 through May 2023, and on her assessment dated [DATE] for the 30 day and 90 day weight history she put N/A. RD #850 stated when they finally got a weight in June 2023, Resident #14's body mass index (BMI) was at the low end of normal but the interventions in placed were acceptable and no changes were needed. RD #850 stated she looked at the resident's intakes, received feedback from nursing, and the interventions during that time frame included tube feeding bolus when Resident #14's meal intakes were less than 50%. 4. Review of the medical record for Resident #15 revealed an admission date of 07/15/23 with diagnoses including fracture of right femur, mood disorder, and dysphagia. Review of the physician orders for Resident #15 revealed she was to be weighed twice a week and then monthly starting 07/15/23. Further review of the medical record revealed two weights recorded, a weight of 128 pounds on 07/15/23 and 119.4 pounds on 07/18/23 resulting in a 6.72 percent loss. Review of the medical record revealed no other documented weights as of 09/06/23. Review of the admission MDS assessment, dated 07/21/23, revealed Resident #15 had a Brief Interview for Mental Status (BIMS) score of eight indicating she had long-term and short-term cognition impairment. Further review of the MDS assessment revealed Resident #15 was a two-person extensive assist for ADLs and was on a therapeutic diet. Review of the care plan dated 07/18/23 revealed Resident #15 was at risk for alteration in nutrition status, required a therapeutic diet, had a poor appetite, and had potential weight loss with interventions that included monitor weight per policy. Review of the physician orders dated 07/18/23 revealed Resident #15 had an order to provide an additional 120 milliliters of clear liquid at medication pass by mouth three times a day. Review of the physician orders dated 07/19/23 revealed Resident #15 had an order for six ounces fortified juice by mouth every breakfast meal one time a day and four ounces ice cream every lunch meal one time a day. Review of the physician orders dated 08/22/23 revealed Resident #15 had an order to utilize built-up utensils for all meals for increased independence in self-feeding. Review of the physician orders dated 09/02/23 revealed Resident #15 had an order for a health shake one time a day for supplement and Hi-cal shake provided by dietary three times a day for supplement and poor appetite. Review of the admission Medical Nutrition Therapy Assessment, dated 07/18/23, revealed Resident #15 was fed by staff at all meals, had poor appetite, and potential for weight loss. Review of the progress note dated 07/25/23 at 12:59 P.M. revealed Resident #15 had a weight change warning indicating a weight loss of 6.7 percent over the past three days. Review of the logged paper weights provided by STNA #944 and the DON revealed on 08/31/23 Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366266 If continuation sheet Page 8 of 15 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 366266 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Enniscourt Nursing Care 13315 Detroit Ave Lakewood, OH 44107 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 #15 had a recorded weight of 107 pounds. Level of Harm - Minimal harm or potential for actual harm Interview on 09/06/23 at 7:50 A.M. with Registered Nurse (RN) #972 revealed Resident #15 was supervised for feeding but most days requested only oatmeal for breakfast, had a poor appetite, and had orders for a lot of supplements. RN #972 revealed Resident #15 needed her weights monitored. Residents Affected - Some Interview on 09/06/23 at 8:50 A.M. with the Director of Nursing (DON) revealed weights were documented in the electronic medical record and if weights were missing STNA #944 kept them in his logbook. Interview on 09/06/23 at 2:18 P.M. with STNA #944 revealed he weighed residents monthly and turned the logs over to the nursing staff. STNA #944 revealed nursing staff kept the records of resident weights. STNA #944 revealed if nursing staff informed him of residents with special cases, he would weigh them accordingly. STNA #944 revealed Resident #15 utilized a sitting chair scale and was weighed monthly. STNA #944 revealed he sometimes did not get a chance to weigh residents as ordered due to being busy with another task. Interview on 09/07/23 at 11:57 A.M. with RD #850 revealed when completing assessments she utilized residents diet orders, height and weight, labs, change in medications and change in condition. RD #850 revealed there was one staff member, STNA #944, responsible for resident weights and the DON was responsible for entering weights into the electronic medical record. RD #850 revealed she received all her weights from the electronic medical record and base interventions on the last documented weight. RD #850 revealed Resident #15 was at risk for weight loss and had multiple interventions in place. RD #850 verified Resident #15 had only two documented weights located in the electronic medical record so had not assessed any other weights obtained for the resident. 5. Review of the medical record for Resident #29 revealed an admission date of 02/02/23 with diagnoses including heart failure, chronic kidney disease, and dysphagia. Review of the physician orders dated 02/02/23 revealed an order for weekly weights, twice a week, then monthly. Further review of the medical record revealed a weight of 185 pounds on 02/13/23 and 181.2 pounds on 08/31/23. Review of the medical record revealed no other documented weights as of 09/06/23. Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/11/23, revealed Resident #29 had a BIMS score of 12 indicating he was alert and oriented to person, place, and time. Further review of the MDS assessment revealed Resident #29 was a two-person extensive assist to total dependence for ADLs and was on a therapeutic diet. Review of the care plan dated 08/11/23 revealed Resident #29 was at risk for alteration in nutrition status, required a therapeutic diet, monitor for need for mechanically altered diet, and had potential for weight fluctuations with interventions that included monitor weight per policy. Review of the quarterly Medical Nutrition Therapy Assessment, dated 08/23/23 revealed Resident #29 required staff supervision for meals, required 88 percent consumption for weight maintenance with potential for weight fluctuations and history of fluid volume overload. Review of the logged paper weights provided by STNA #944, and the DON revealed Resident #29 had monthly documented weights from 03/13/23 to 05/27/23. Interview on 09/06/23 at 8:50 A.M. with the DON revealed weights were documented in the electronic (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366266 If continuation sheet Page 9 of 15 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 366266 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Enniscourt Nursing Care 13315 Detroit Ave Lakewood, OH 44107 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 - Some medical record and if weights were missing, State Tested Nursing Assistant (STNA) #944 kept them in his logbook. Interview on 09/06/23 at 2:18 P.M. with STNA #944 revealed he weighed residents monthly and turned the logs over to the nursing staff. STNA #944 revealed nursing staff kept the records of resident weights. STNA #944 revealed if nursing staff informed him of residents with special cases, he would weigh them accordingly. STNA #944 revealed Resident #29 utilized a Hoyer scale and was weighed monthly. STNA #944 revealed he sometimes did not get a chance to weigh residents as ordered due to being busy with another task. Interview on 09/07/23 at 11:57 A.M. with RD #850 revealed when completing assessments she utilized residents diet orders, height and weight, labs, change in medications and change in condition. RD #850 revealed there was one staff member, STNA #944, responsible for resident weights and the DON was responsible for entering weights into the electronic medical record. RD #850 revealed she received all her weights from the electronic medical record and base interventions on the last documented weight. RD #850 revealed Resident #29 was at risk for weight fluctuations and had a history of fluid overload. RD #850 verified Resident #29 had only two documented weights located in the electronic medical record. 6. Review of the medical record for Resident #20 revealed an admission date of 02/06/16 with diagnoses that included dementia, muscle weakness, and dysphagia. Review of the physician orders for Resident #20 revealed she was to be weighed monthly by the 10th of each month starting 04/10/17. Further review of the medical record revealed a weight of 105.6 pounds documented on 02/07/23, on 06/21/23 a weight of 95.6 pounds and no other weights entered until 08/31/23 of 93.4 pounds. Review of the quarterly MDS assessment, dated 08/09/23, revealed Resident #20 had a short-term and long-term memory problem and was severely impaired for task of daily living. Further review of the MDS assessment revealed Resident #20 was a two-person extensive assist to total dependence for activities of daily living ADLs and was on a therapeutic diet that included a mechanically altered diet for textures of food and liquids. Review of the care plan dated 08/09/23 revealed Resident #20 had a history of weight loss requiring a therapeutic diet that was mechanically altered with interventions that included maintain current body weight plus and/or minus five pounds and monitor weight per policy. Review of the physician orders dated 06/03/22 revealed an order to provide additional 180 cubic centimeters of clear liquid with medication pass two times a day. Review of the physician orders dated 03/01/21 revealed an order for health shake two times a day as a supplement. Review of the physician orders dated 04/18/23 revealed an order for no added salt diet, pureed texture, thin liquids with regular solids at breakfast and mechanical soft solids at lunch and dinner. Review of the quarterly, Medical Nutrition Therapy Assessment, dated 08/14/23 revealed Resident #20 had a loss of 12.3 percent body weight over 172-day period. Resident #20 had varying appetite intake averaging 51 to 100 percent consumptions of most meals. Review of the assessment revealed Resident #20 diet and supplements remained adequate and appropriate to meet nutrition needs with interventions to monitor as appropriate. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366266 If continuation sheet Page 10 of 15 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 366266 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Enniscourt Nursing Care 13315 Detroit Ave Lakewood, OH 44107 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 - Some Interview on 09/06/23 at 8:50 A.M. with the Director of Nursing (DON) revealed weights were documented in the electronic medical record and if weights were missing, State Tested Nursing Assistant (STNA) #944 kept them in his logbook. Interview on 09/06/23 at 2:18 P.M. with STNA #944 revealed he weighed residents monthly and turned the logs over to the nursing staff. STNA #944 revealed nursing staff kept the records of resident weights. STNA #944 revealed if nursing staff informed him of residents with special cases, he would weigh them accordingly. STNA #944 revealed Resident #20 utilized seated scale and was weighed monthly. STNA #944 revealed he sometimes did not get a chance to weigh residents as ordered due to being busy with another task. Interview on 09/07/23 at 11:57 A.M. with RD #850 revealed when completing assessments she utilized residents diet orders, height and weight, labs, change in medications and change in condition. RD #850 revealed there was one staff member, STNA #944, responsible for resident weights and the DON was responsible for entering weights into the electronic medical record. RD #850 revealed she received all her weights from the electronic medical record and base interventions on the last documented weight. RD #850 verified Resident #20 was at risk for weight loss and had multiple missing weights not documented in the electronic medical record. Review of the facility document titled Nutrition (Impaired) Unplanned Weight Loss revised September 2017, revealed the facility had a policy in place to monitor and document the weight and dietary intake of residents in a format in which permits comparisons over time, identify individuals with weight loss and/or gain and significant risk for impaired nutrition. Review of the document revealed the facility did not implement the policy. 2. Review of the medical record for Resident #19 revealed an admission date of 02/21/2022. Diagnosis included morbid obesity due to excess calories. The record revealed multiple monthly weights were missing from the medical record. Review of the plan of care dated 07/28/23 for Resident #19 revealed an alteration in nutrition status secondary to diagnosis of DMII (diabetes mellitus type two) with long term insulin use, requires a therapeutic diet. Diagnosis of GERD (Gastroesophageal reflux disease), potential for gastrointestinal (GI) distress. History of weight refusals, last available weight (LAW) is indicative of obesity III (morbid) per BMI (body mass index). Interventions included to report significant weight gain or loss of five % or more to MD (physician) and/or Registered Dietician; weigh per policy. Review of the admission MDS assessment, dated 08/21/23, revealed Resident #19 was cognitively impaired and required extensive assist of one to two staff for activities of daily living (ADL's). Review of the physician order dated 08/12/22 revealed Resident #19 was ordered weekly weights for two weeks and then monthly. Review of the monthly weight logs provided by STNA #944 who kept the logs in his locker revealed monthly weights were obtained for Resident #19 but STNA #944 had not made those weights available to the other health care staff to enter into the medical records. Interview on 09/06/23 at 2:18 P.M., State Tested Nurse Aide (STNA) #944 verified the above findings. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366266 If continuation sheet Page 11 of 15 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 366266 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Enniscourt Nursing Care 13315 Detroit Ave Lakewood, OH 44107 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 - Some Interview on 09/07/23 at 11:57 A.M. with RD #850 revealed when completing assessments she utilized residents diet orders, height and weight, labs, change in medications and change in condition. RD #850 revealed there was one staff member, STNA #944, responsible for resident weights and the DON was responsible for entering weights into the electronic medical record. RD #850 revealed she received all her weights from the electronic medical record and based interventions on the last documented weight. The RD #850 confirmed missing weights for Resident #19. 3. Review of the medical record for Resident #31 revealed an admission date of 07/01/2022. Diagnosis included Alzheimer's disease. Review of the physician order dated 07/28/22 revealed Resident #31 had order for weekly weights times two weeks and then monthly. Review of the admission MDS assessment, dated 08/04/23, revealed Resident #31 was cognitively impaired and required extensive assist of one to two staff for ADL's. Review of the plan of care dated 08/04/23 revealed Resident #31 had an alteration in nutrition secondary to diagnosis of: CKD (chronic kidney disease) and hypertension, requires a therapeutic diet. Diagnosis of GERD, potential for GI distress. Interventions included to report significant weight gain or loss of five % or more to MD (physician) and/or Registered Dietician; weigh per policy. Review of the electronic medical chart (EMR) for Resident #31 revealed the following weights: 09/22/22 140.6 lbs, 11/10/22 146.4 lbs, 06/08/23 - 155.8 lbs, 06/21/23 - 155.0 lbs and 08/31/23 - 160.4 lbs. Review of the weight log kept by STNA #944 and provided by the Director of Nursing (DON), revealed Resident #31 had weights obtained in December 2022, January through May 2023 ranging between 154.0 lbs and 158.2 lbs which had not been recorded in Resident #31's resident records. Interview on 09/06/23 at 8:50 A.M. with the Director of Nursing (DON) revealed weights were documented in the electronic medical record and if weights were missing, State Tested Nursing Assistant (STNA) #944 kept them in his logbook. Interview on 09/06/23 at 2:18 P.M. with STNA #944 revealed he weighed residents monthly and turned the logs over to the nursing staff. Interview on 09/06/23 at 3:17 P.M., the DON stated STNA #944 kept the weight logs in his personal locker. The DON confirmed the monthly weight log had not been received from STNA #944 and therefore, resident weights were not entered into the EMR. Interview on 09/06/23 at 4:22 P.M., the STNA #944 confirmed the residents monthly weights were located in his personal locker. The STNA #944 confirmed the monthly weight logs had not been turned in to the DON and the resident weights had not been entered in the EMR. Observation on 09/06/23 at time of interview, STNA #944 voluntarily entered the unlocked employee break room and returned to the hallway with a stack of loose papers folded in quarters. The STNA #944 provided the weight logs dated from 01/2023 to 08/2023. Each monthly weight log contained the resident name, room number, date, and body weight. Interview on 09/07/23 at 11:57 A.M. with RD #850 revealed when completing assessments she utilized residents diet orders, height and weight, labs, change in medications and change in condition. RD (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366266 If continuation sheet Page 12 of 15 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 366266 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Enniscourt Nursing Care 13315 Detroit Ave Lakewood, OH 44107 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 #850 revealed there was one staff member, STNA #944, responsible for resident weights and the DON was responsible for entering weights into the electronic medical record. RD #850 revealed she received all her weights from the electronic medical record and based interventions on the last documented weight. RD #850 confirmed missing weights for Resident #31. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366266 If continuation sheet Page 13 of 15 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 366266 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Enniscourt Nursing Care 13315 Detroit Ave Lakewood, OH 44107 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 record review and interview, the facility failed to ensure a physician order was written for dialysis treatments, a dialysis contract was in place between the facility and the dialysis center, and also failed to ensure assessments before and after dialysis treatments were completed for Resident #145. This affected one resident (#145) of one resident reviewed for dialysis services. The facility census was 42. Residents Affected - Few Findings include: Review of the medical record for Resident #145 revealed an admission date of [DATE]. Diagnoses included end stage renal disease (ESRD), dependence on renal dialysis, and congestive heart failure. Review of the 48 hour care plan dated [DATE] revealed the resident received dialysis on Tuesdays, Thursdays, and Saturday. Review of the care plan dated [DATE] revealed the resident was on dialysis and received treatments two to three times per week. At risk for infection, diagnosis of ESRD. Resident had a history of choosing not to go to dialysis as scheduled. Review of the [DATE] physician orders revealed no orders for dialysis. Further review of Resident #145's medical record revealed no evidence of communication forms between the facility and the dialysis center or evidence of before and after dialysis assessments. Interview on [DATE] at 2:58 P.M., the Minimum Data Set (MDS) Nurse #949 verified there was no order for dialysis and stated they knew she was on dialysis when she was admitted . MDS Nurse #949 stated they dropped the ball, but they were putting in the order at this time. Interview on [DATE] at 3:39 P.M., Registered Nurse (RN) #964 stated they were in the process of negotiating a new contract because he believed the old one expired. RN #964 stated he would try to get a copy of the old contract. RN #964 stated they normally don't have anyone on dialysis. Interview on [DATE] at 4:23 P.M., Licensed Practical Nurse (LPN) #976 stated the dialysis center would call with changes and stated they called a couple weeks ago to inform him that Resident #145 was tired and nauseous. LPN #976 stated Resident #145 was skilled care, vitals were taken daily in the morning, and they checked for the presence of bruit and thrills each shift. LPN #976 stated there were no communication forms between the facility and the dialysis center. Interview on [DATE] at 4:57 P.M., the Director of Nursing (DON) stated she had called the dialysis center and was told they emailed the dialysis contract to her when Resident #145 was admitted . DON stated she was waiting for the dialysis center to re-send it. DON stated she never got the original contract when Resident #145 was admitted and was not sure who they sent it to. DON stated after a while she didn't think anything else about it. DON stated Resident #145 was already established at that dialysis center. DON stated they had communication forms at the facility for dialysis, but they did not send them with Resident #145. DON stated the dialysis center also did not ask for them. DON stated the dialysis center did not call the facility except for one time to inform them that the resident had refused, and they were sending her back to the facility. DON stated resident #145 was skilled and they charted on her daily. DON stated vitals were done daily regardless and on dayshift either (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366266 If continuation sheet Page 14 of 15 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 366266 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Enniscourt Nursing Care 13315 Detroit Ave Lakewood, OH 44107 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 before or after she returned from dialysis but this did not get communicated in writing to the dialysis center. Level of Harm - Minimal harm or potential for actual harm Follow up interview on [DATE] at 9:50 A.M., the RN #964 stated they were still in process of getting the dialysis contract. RN #964 stated they had one that was still active and there were no changes. RN #964 stated the dialysis center was looking for it and was not able to locate it. RN #964 stated the facility was unable to locate it. Residents Affected - Few Interview on [DATE] at 11:57 A.M., the Registered Dietitian (RD) #850 stated when residents were admitted , she would make a call to the dialysis center and request monthly labs so that they could coordinator with dialysis. RD #850 state she was at the facility once weekly but had not gotten anything on her from the dialysis center. RD #850 stated the dialysis center normally sends them through the fax and nursing gets it. RD #850 stated the nurse would then put it in her mailbox. On [DATE] at 1:36 P.M. the facility still had not provided the dialysis contract to the surveyor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366266 If continuation sheet Page 15 of 15