Health inspection·July 13, 2021

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 record review, observation, interview and policy review, the facility failed to ensure Resident #364's call light was answered in a timely manner. This affected one of one resident reviewed for call light response time. The facility census was 60. Residents Affected - Few Findings include: Review of the medical record reviewed Resident #364 was admitted to the facility on [DATE] with diagnoses including fibromyalgia, type two diabetes, and major depressive disorder. Review of the most recent Minimum Data Set (MDS) 3.0 assessment revealed Resident #364 required extensive assistance for toileting and was incontinent of her bowels. Observation of Resident #364's room on 07/08/21 at 1:33 P.M. revealed Resident #364's call light was turned on. Observation of the hallway of Resident #364's room on 07/08/21 at 1:37 P.M. revealed Maintenance Director #127 was within visual eye sight (about 30 feet) of Resident #364's call light and did not answer the call light. Observation of the hallway of Resident #364's room on 07/08/21 at 1:41 P.M. revealed Physical Therapist #566 went to obtain personal protective equipment (PPE) from a table located directly across the hall and approximately three feet from Resident #364's room and did not answer the call light. Observation of the hallway of Resident #364's room on 07/08/21 at 1:44 P.M. revealed Admissions Director #569 left the room directly diagonal (approximately seven to ten feet) from Resident #364's room after completing admission paperwork with another resident and did not answer the call light. Observation of the hallway of Resident #364's room on 07/08/21 at 1:47 P.M. revealed State Tested Nursing Assistant (STNA) #105 walked down the hallway conversed with residents in the three rooms surrounding both sides of Resident #364's room and walked back up the hallway and did not answer Resident #364's call light. Observation of the hallway of Resident #364's room on 07/08/21 at 1:49 P.M. revealed Licensed Practical Nurse (LPN) #947 came down the hallway to get PPE and stood approximately five feet from Resident #364's room and began conversing with STNA #105. LPN #947 proceeded to go in the two rooms adjacent to Resident #364 and did not answer Resident #364's call light. Observation of the hallway of Resident #364's room on 07/08/21 at 1:51 P.M. revealed STNA #207 answered Resident #364's call light for a total wait time of 24 minutes. Interview with Resident #364 on 07/08/21 at 1:59 P.M. verified she had her call light on for 24 minutes and even longer prior to surveyor observation. Resident #364 stated she had to use the restroom and almost had an accident. Interview with Corporate Nurse #600 revealed it is the facilities expectation that all staff, regardless of role at the facility, answer call lights as soon as possible. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366272 If continuation sheet Page 2 of 8 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 366272 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE O'Neill Healthcare North Olmsted 4800 Clague Road North Olmsted, OH 44070 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 Level of Harm - Minimal harm or potential for actual harm Review of the policy titled Responding to Resident Call Lights and Alarms, dated 10/01/11, revealed It is the responsibility of all staff to answer call lights and alarms. If the staff member is unable to meet the residents need, they should then alert a staff member that can address their safety or request for assistance, and follow-up with the resident to reassure them that someone will be responding. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366272 If continuation sheet Page 3 of 8 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 366272 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE O'Neill Healthcare North Olmsted 4800 Clague Road North Olmsted, OH 44070 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 interview, record review and policy review, the facility failed to obtain Resident #48's weight daily per physician's order. This affected one (Resident #48) of three residents (Resident's #48, #37, and #256) reviewed for nutrition. The facility census was 60. Residents Affected - Few Findings include: Review of the medical record for Resident #48 revealed an admission date of 12/21/20 with diagnoses including cerebral infarction, congestive heart failure, atrial fibrillation, and hypothyroidism. Review of the Medication Administration Record (MAR) and weight record for June 2021 revealed there was no documented evidence Resident #48's daily weight was completed on 06/11/21, 06/12/21, 06/13/21, 06/18/21, 06/23/21, 06/28/21, 06/29/21, and 06/30/21. The MAR revealed Resident #48 was sleeping, and there was no documented evidence of further attempts to obtain her weight on 06/10/21, 06/17/21, 06/24/21, and 06/26/21. Review of the care plan last revised 06/02/21 revealed Resident #48 was at risk for altered nutrition and hydration related to weight loss, laxative use, low albumin, and skin impairment. Interventions included supplements as ordered, monitor weight per protocol, monitor labs as ordered, and monitor oral intake. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #48 had impaired cognition. She required supervision and set-up assistance for bed mobility and extensive assist of one staff with transfers and ambulation. She was independent with set-up help only with eating. She had a weight loss that was not prescribed. Review of the Nutritional assessment dated [DATE] and completed by Dietitian Technician #601 revealed Resident #48 fed herself with set-up only, and her intakes were fair at meals. Her weight was 142 pounds which was stable this month, but she had a weight loss of greater than ten percent in the last three months. She revealed Resident #48's weight loss was most likely related to fluid and diuresis. She revealed Resident #48 was to remain on daily weights due to her congestive heart failure. Review of the MAR and weight record for July 2021 revealed there was no daily weight documented for Resident #48 on 07/01/21, 07/03/21, 07/04/21, 07/05/21 and it was documented on 07/06/21 Resident #48 was sleeping, and there was no documented evidence of further attempts to obtain her weight on 07/06/21. Review of the current physician's orders dated July 2021 revealed Resident #48 had an order dated 04/28/21 to obtain her weight daily in the morning after Resident #48 voided and to notify the physician if there was a three or more pound increase in one day due to her congestive heart failure protocol. Review of the care plan dated 07/02/21 revealed Resident #48 was at risk for decreased cardiac output related to congestive heart failure, intermittent bilateral lower extremity edema, and diuretic use. Interventions included elevate legs as tolerated, monitor for signs of heart failure such as shortness of breath and increased edema, and monitor weight daily in morning after she voided, and notify the physician if weight increase of three or more pounds. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366272 If continuation sheet Page 4 of 8 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 366272 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE O'Neill Healthcare North Olmsted 4800 Clague Road North Olmsted, OH 44070 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 Interview on 07/07/21 at 2:20 P.M. with Dietitian Technician #601 verified Resident #48 was to have a daily weight, and she verified there was no documented evidence a weight was obtained on 06/11/21, 06/12/21, 06/13/21, 06/18/21, 06/23/21, 06/28/21, 06/29/21, 06/30/21, 07/01/21, 07/03/21, 07/04/21 and 07/05/21. She verified on the MAR there was no documented evidence a weight was obtained instead it was only documented Resident #48 was sleeping but she verified there was no documented evidence of further attempts to obtain a weight on 06/10/21, 06/17/21, 06/24/21, 06/26/21 and 07/06/21. Interview on 07/08/21 at 10:23 A.M. with the Director of Nursing (DON) verified Resident #48's weights were not completed daily as ordered and verified the facility did not document if Resident #48 refused or if additional attempts were made to obtain a weight after they documented she was sleeping. Review of facility policy titled Protocol to Address Unexpected Weight Loss in Residents, dated 2012, revealed the purpose was to establish guidelines for staff to follow if a resident was noted to have an unexpected weight loss. The policy revealed to obtain weights as ordered and if there was a difference of three pounds from the previous recorded weight noted then the facility was to obtain a reweigh to ensure accuracy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366272 If continuation sheet Page 5 of 8 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 366272 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE O'Neill Healthcare North Olmsted 4800 Clague Road North Olmsted, OH 44070 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 interview, observation, record review and policy review, the facility failed to ensure Resident #35's respiratory equipment was dated and/or documented when it was changed last. This affected one (Resident #35) of one resident reviewed for respiratory care. This had the potential to affect 12 residents (Resident's #358, #361, #157, #23, #43, #158, #159, #33, #39, #359, #35 and #360) with respiratory equipment. The facility census was 60. Residents Affected - Few Findings include: Review of the medical record for Resident #35 revealed an admission date of 12/23/20 with diagnoses including congestive heart failure, chronic obstructive pulmonary disease, obstructive sleep apnea, and morbid obesity. Review of the care plan dated 04/12/21 revealed Resident #35 had an ineffective breathing pattern as evidenced by shortness of breath, chronic obstructive pulmonary disorder, and congestive heart failure. Interventions included adjust head of bed and body positioning to assist with ease of respirations, administer oxygen per physician order, and encourage resident to turn every two hours as tolerated. Review of the significant change Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #35 had intact cognition and required extensive assist of two staff with bed mobility and was totally dependent of two staff with transfers. She was unable to ambulate and required oxygen. Review of the current physician's orders for July 2021 revealed Resident #35 had an order dated 03/24/21 for oxygen at two liters per minute via nasal cannula continuous every shift. There was no order to change Resident #35's oxygen tubing weekly prior to 07/08/21. Interview and observation on 07/07/21 at 10:55 A.M. and on 07/08/21 at 8:21 A.M. revealed Resident #35 was receiving oxygen at two liters per minute by nasal cannula continuous, and the nasal cannula was not dated as to when it was changed last. Resident #35 was not aware when her oxygen tubing had been changed last. Interview on 07/08/21 at 9:52 A.M. with Agency Licensed Practical Nurse (LPN) #608 verified Resident #35's oxygen nasal cannula was not dated when it was changed last or she revealed she did not have any documentation in Resident #35 per her Medication Administration Record (MAR) when the oxygen tubing was to be changed or when it was changed last. Agency LPN #608 revealed since she was from agency, she was unsure how often or who changed the respiratory equipment including oxygen nasal cannulas at the facility. Interview on 07/08/21 at 9:57 A.M. with the Director of Nursing revealed she was relatively new to the facility and was unsure of the system the facility had in place of who changed the respiratory equipment, how often the respiratory equipment was changed, and where it was documented that the respiratory equipment was changed. Interview on 07/08/21 at 10:23 A.M. with the Director of Nursing revealed any resident that had respiratory equipment was to have an order to change the respiratory equipment weekly, and the nurse was to sign off in the MAR that they changed the respiratory equipment. The Director of Nursing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366272 If continuation sheet Page 6 of 8 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 366272 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE O'Neill Healthcare North Olmsted 4800 Clague Road North Olmsted, OH 44070 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 Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete verified Resident #35 did not have an order to change her oxygen nasal cannula weekly stating it must have been missed. The Director of Nursing verified she was unsure when Resident #35's nasal cannula was changed last. Review of undated facility policy titled Oxygen Administration revealed the purpose of the procedure was to provide guidelines for oxygen administration as the following information should be documented in the resident's medical record: the date and time the procedure was performed. The policy did not include any information regarding dating and labeling the oxygen tubing after changing and the frequency of changing the respiratory equipment. Event ID: Facility ID: 366272 If continuation sheet Page 7 of 8 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 366272 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE O'Neill Healthcare North Olmsted 4800 Clague Road North Olmsted, OH 44070 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed to ensure proper infection control practices were maintained for residents in isolation. This affected one resident (Resident #39)of one resident reviewed for transmission based precautions. The facility census was 60. Residents Affected - Many Findings include: Review of the medical record revealed Resident #39 was admitted to the facility on [DATE] with diagnoses including rectal cancer, liver cancer, and anxiety disorder. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had mild cognitive impairment and required two staff assistance for activities of daily living. Interview with the Director of Nursing on 07/08/21 at 10:55 A.M. revealed Resident #39 was residing on the facilities New admission Monitoring Unit and was on isolation precautions for 30 days per facility policy due to Resident #39 not being vaccinated against COVID-19. Observation of the sign outside of Resident #39's room on 07/08/21 at 10:57 A.M. revealed a sign titled droplet precautions with a stop sign and the following instructions Perform hand hygiene, wear your N95 mask before entering room, gown before entering room, gloves before entering room, face shield before entering room. Observation of Licensed Practical Nurse (LPN) #947 on 07/08/21 between 11:00 A.M. and 11:15 A.M. revealed LPN #947 entered Resident #39's room without performing hand hygiene and had an isolation gown draped over his right arm, no gloves and no face shield while entering the room. LPN #947 put the gown through his arms when he was approximately two feet away from the resident but did not tie or secure his gown to his clothing. LPN #947 verified proper infection control practices were not followed in an interview on 07/08/21 at 11:19 A.M. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366272 If continuation sheet Page 8 of 8