Health inspection·October 5, 2023

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on observation and interview the facility failed to maintain confidentiality of resident medical information and provide privacy during the delivery of wound care. This affected one resident (Resident #38) and had the potential to affect 20 residents who resided on the long term care hallway. The facility census was 48. Residents Affected - Some Findings include: Tour of the long term care hallway on 10/02/23 at 9:28 A.M. revealed a desk top computer monitor at the nurse station was visible from the public hallway and left open to a resident electronic medical Record (EMR). The nurses station and monitor was unattended by staff. Interview on 10/02/23 at 9:32 A.M. with Licensed Practical Nurse (LPN) #849 verified the computer was visible from the public hallway and identifying resident information was open and visible. LPN #849 stated she forgot to close out the medical record prior to leaving the area. Observation of Resident #38's wound care on 10/03/23 at 3:08 P.M. with LPN #849 and State Tested Nurse Assistant (STNA) #920 revealed LPN #849 completed wound care to Resident #38's right ankle wound without securing privacy. The completion of Resident #38's wound care was visible from the public hallway. Interview with LPN #849 on 10/03/23, directly following Resident #38's wound care, verified the door to Resident #38's room was open during treatment and resident privacy was not maintained. Observation on 10/04/23 at 2:28 P.M. of the long term care hallway nurse station revealed a desk top computer monitor was visible from the public hallway and left open to a resident EMR. The nurses station and monitor was unattended by staff. Interview on 10/04/23 at 2:28 P.M. with STNAs #920 and #928 revealed LPN #849 had been using the computer prior to leaving the nurses station. STNA #920 and #928 confirmed resident information was visible to the public hallway and verified the facility policy was to secure confidential medical information from the public. Interview with LPN #849 on 10/04/23 at 2:31 P.M. verified she had not secured the computer prior to leaving the nurse station. LPN #849 confirmed the EMR was open with resident medical information visible. LPN #849 further stated she did not feel it was necessary to maintain confidential information at the nurses station. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366272 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 366272 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 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 record review, interview, and policy review the facility failed to obtain weekly weights per physician orders and ensure the physician was notified of weight changes. This affected one (#52) of two residents reviewed for nutrition (#52 and #53). The facility census was 48. Residents Affected - Few Findings include: Review of the medical record for Resident #52 revealed an admission date of 09/06/23. Diagnoses included left femur fracture, repeated falls, Raynaud's disease, history of breast cancer, and feeding tube. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #52 had intact cognition, required extensive assistance for bed mobility and transfers. The MDS assessment also indicated Resident #52 required total dependence of one staff for eating, weight was 121 pounds, and Resident #52 received 51% or more of calories and 501 milliliters (ml) per day or more from feeding tube. Review of the physician orders for September 2023 revealed an order to monitor weight weekly for four weeks every Wednesday evening shift for health maintenance for four weeks until finished with a start date of 09/13/23. Review of the September 2023 treatment administration record (TAR) for September 2023 for the order to monitor weight weekly for four weeks every Wednesday evening shift for health maintenance for four weeks until finished, revealed blank spaces for 09/13/23 and 09/20/23. A weight of 99.6 pounds was documented for 09/27/23. Review of the weight summary for Resident #52 revealed on 09/06/23 the resident weighed 121 pounds. The next weight was on 09/27/23 and the resident weighed 99.6 pounds. The next weight was on 10/04/23 and the resident weighed 107.4 pounds. Review of the dietary note dated 09/28/23 timed 10:40 A.M. revealed Resident #52's current body weight (CBW) on 09/27/23 was 99.6 pounds which indicated a loss of 21.4 pounds within one month. The weight loss was significant and unplanned and a reweigh to verify would be requested. Resident #52 was receiving Jevity 1.5 via feeding tube at 50 ml per hour (ml/hr) from 6:00 P.M. to 6:00 AM. with 250 ml bolus twice daily and 135 ml of water flush every four hours. The tube feeding and water flush provided 1650 calories, 74 grams of protein, and 1646 ml of free fluids. The author of the note suggested increasing Jevity 1.5 to 65 ml/hr from 6:00 P.M. to 6:00 A.M. and to continue with current bolus and flushes. The note indicated the new orders would provide 1920 calories, 87 gram of protein, and 1782 ml of free fluids to help increase weight and Resident #52 had an order for a modified barium swallow (MBS) study. The author indicated monitoring would continue. Further review of Resident #52's medical record revealed no evidence the physician or nurse practitioner were notified of the resident's weight loss. Interviews on 10/02/23 at 10:58 A.M. and on 10/04/23 at 3:00 P.M. with Resident #52 revealed she had a recent history of weight loss. Resident #52 weighed 110 pounds prior to admission to the hospital for surgery for her femur fracture. Resident #52 was told she had a weight loss, but she could not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366272 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 366272 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 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 tell if she lost weight while in the facility. Resident #52 stated she was not weighed on admission at the facility. Resident #52 was recently weighed again either on 10/03/23 or the morning of 10/04/23 but she was not sure. Resident #52 stated she had been receiving her tube feeding as ordered and had no issues related to her tube feeding. Interview on 10/05/23 at 8:05 A.M. with Registered Dietitian (RD) #951 revealed the weights in Resident #52's medical record were the weights she received. In general nursing put out a list to obtain weights when needed and the aides obtained them. The aides reported the weights to the nurse and the nurse put the weights in the computer. RD #951 checked to ensure Resident #52 had received her tube feeding per order and stated there were concerns related to the resident's tube feeding and that they were meeting her nutritional needs. RD #951 was aware of Resident #52's weight and had requested a re-weigh . The reweigh was obtained on 10/04/23 and was 107.4 pounds. RD #951 liked to see the reweighs done within a day of the weight in question. When RD #951 spoke with Resident #52, she had reported she had weight loss prior to admission to the facility but did not mention weighing 110 pounds. RD #951 stated it was nursing responsibility to inform the physician or nurse practitioner of weight losses. Interview on 10/05/23 at 2:15 P.M. with the Director of Nursing (DON) revealed she was unable to find any additional weights or evidence the physician was notified of Resident #52's weight loss. Review of the facility policy titled Obtaining and Documenting Weights, revised June 2012 revealed weights were to be obtained upon admission, weekly for three more weeks, then monthly unless directed otherwise by the physician orders/RDLD (registered dietitian/licensed dietitian)/dietetic professional's recommendation. Unit Manager or designated nurse were responsible for overseeing that monthly weights were obtained and documented in the resident's vitals section of PCC, that they were accurate, and that proper follow through was done for their assigned residents. If a significant weight discrepancy was noted (plus or minus five percent (5%) in one month), the resident was to be reweighed under the direct supervision of a nurse. If the significant weight change (+/- 5% in one month) was confirmed, the nurse was to notify dietary/RDLD/dietetic professional (utilizing a dietary communication form), the Unit Manager/designated nurse (if not the observing nurse), the resident's attending physician, and the resident and/or the resident's legal representative or an interested family member. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366272 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 366272 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 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 observation, resident interview, staff interview, and policy review, the facility failed to ensure oxygen tubing was up-to-date and sterile water containers were changed and dated for use with oxygen concentrator. This affected one resident (#8) of one resident reviewed for oxygen. The facility identified four Residents (#1, #8 #33, #35) who utilized oxygen. The facility census was 48. Residents Affected - Few Findings include: Review of the medical record for Resident #8 revealed an admission date of 07/18/23 with diagnoses that included metabolic encephalopathy, anemia, pleural effusion, and chronic obstructive pulmonary disease (COPD). Review of the 5-Day, Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #8 had a Brief Interview for Mental Status (BIMS) score of 13 that indicated she was alert and oriented to person, place, and time. Review of the MDS assessment revealed Resident #8 was a one-person physical extensive assistance for activities of daily living (ADLs). Review of the care plan dated 09/28/23 revealed Resident #8 had an altered respiratory status, difficulty breathing, and shortness of breath related to COPD and chronic respiratory failure with hypoxia (low oxygen levels). Interventions included provide oxygen as ordered. Review of the physician orders dated 07/18/23 revealed an order for oxygen at two liters per minute via nasal cannula continuous. Review of the physician orders dated 07/23/23 revealed an order to change oxygen tubing weekly, every night shift every Sunday. Review of the MDS Nursing Documentation assessment dated [DATE] revealed Resident #8 had a cardiopulmonary status of shortness of breath and/or trouble breathing when sitting at rest, with exertion, and when lying flat. Resident #8 was to receive oxygen at two liters via nasal cannula. Observation on 10/02/23 at 10:18 A.M. revealed Resident #8 sitting in her wheelchair with her oxygen running via nasal cannula and tubing in place. The oxygen tubing lead from Resident #8 to the bathroom. The bathroom door was closed and the oxygen tubing went underneath the door. Upon opening the bathroom door, the oxygen concentrator was positioned underneath the bathroom sink and running. Observation of the oxygen concentrator revealed an empty 500 milliliter sterile water container which was undated, dry and without liquid residue and oxygen tubing dated 08/28/23 with initials written on a small white piece of tape affixed to the tubing. Interview on 10/02/23 at 10:18 A.M. with Resident #8 revealed she utilized oxygen every day and did not know when the last time her oxygen tubing or sterile water was changed. Resident #8 revealed she had shortness of breath and used a nebulizer and inhaler for breathing issues. Observation and Interview on 10/02/23 at 10:21 A.M. with Licensed Practical Nurse (LPN) #864 revealed Resident #8's oxygen tubing was to be changed weekly and the sterile water was to be checked as needed to ensure sufficiency. LPN #864 verified the oxygen tubing was outdated and the container of sterile water was empty. LPN #864 verified the initials with a date reading 08/28/23, approximately (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366272 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 366272 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 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 thirty-six days ago. LPN #864 was unable to verify who the initials belonged to. Level of Harm - Minimal harm or potential for actual harm Interview on 10/04/23 at 9:40 A.M. with State Tested Nurse Assistant (STNA) #875 revealed Resident #8 was on oxygen and it was to be given continuously. Residents Affected - Few Interview on 10/04/23 at 12:00 P.M. with Registered Nurse (RN) #950 revealed the initials on the oxygen tubing were the initials of agency LPN #986. Interview on 10/04/23 at 12:13 P.M. with Human Resources (HR) #848 revealed the initials on the oxygen tubing belonged to LPN #986 and she worked 08/27/23 through 08/28/23 on the overnight shift. Review of the facility document titled Oxygen Therapy dated January 2015, revealed oxygen would be applied and administered as ordered by physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366272 If continuation sheet Page 6 of 6