Health inspection·April 9, 2025

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few #161 had a tilt-in-space wheelchair in his room and when he was receiving skilled services approximately one week ago. CNA #853 stated he was assisted out of bed while on the skilled unit for short periods of time. CNA #853 stated she had not assisted Resident #161 out of bed and was unsure when he was last assisted been out of bed. An interview with Physical Therapy Director (PTD) #896 on 04/02/25 at 10:45 A.M. revealed he had completed the physical therapy evaluation for Resident #161 on 03/3/25. PTD #896 stated Resident #161 was dependent for all his activity of daily living needs and needed the assistance of two staff members with the use of a mechanical lift for transfers. PTD #896 stated there was no reason that the staff should not allow Resident #161 to get out of bed. An interview with Certified Nurse Practitioner (CNP) #897 on 04/02/25 at 11:23 A.M. stated there was no reason from a medical standpoint that the staff should not allow Resident #161 to get out of bed. An interview with Licensed Practical Nurse #839 on 04/03/25 at 9:15 A.M. verified Resident #161 had not been assisted out of bed while she was working on 04/02/25 and 04/03/25. LPN #839 verified Resident #161's plan of care indicated the staff should encourage Resident #161 to get out of bed. The facility policy and procedure titled ADL's (Activities of Daily Living) Protocol dated 10/2023 indicated the policy was to ensure that licensed or certified staff would provide assistance to residents for care that they can no longer perform on their own. Self-care will be encouraged for all residents, to the extent possible, and assistance will be provided for the task's resident is unable to perform. Residents will be provided assistance in the following areas, as requested, needed or as indicated by their plan of care: 1. Eating 2. Bathing. 3. Toileting or Incontinence Care as indicated. 4. Dressing. 5. Grooming. 6. General Hygiene to include trimming and cleaning of fingernails and shaving as desired. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366272 If continuation sheet Page 2 of 23 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 04/09/2025 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 0677 7. Level of Harm - Minimal harm or potential for actual harm Oral care and denture care as indicated. 8. Residents Affected - Few Transfers. 9. Ambulation. 10. Toenail care will be provided by the podiatrist, facility staff will not trim toenails. The policy further stated the level of assistance and self-care is resident specific. Residents that are unable to communicate their needs will be assisted with care as indicated by the need of each individual. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366272 If continuation sheet Page 3 of 23 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 04/09/2025 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 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure follow-up eye appointments were provided as indicated. This affected one (Resident #14) resident out of one reviewed for vision appointments. The facility census was 57. Residents Affected - Few Findings include: Review of Resident #14 medical record revealed an admission date of 01/18/22 with diagnoses including acute kidney injury, type two diabetes mellitus, major depressive disorder, anxiety, insomnia, muscle weakness, and cervicalgia. Review of medical record revealed Resident #14 was seen by the ophthalmologist on 02/05/25. The ophthalmologist indicated Resident #14 should have a cataract evaluation with ophthalmologist of facility choice. Review of Resident #14's physical medical chart revealed an optometry order form dated 02/05/25 for referral to ophthalmologist for cataract surgery for both eyes. There was no evidence in the resident's medical chart that a referral had been sent to or scheduled as recommended. Interview on 03/31/25 09:45 A.M. with Resident #14 revealed she needed cataract surgery, and it had not been scheduled. Interview with Unit Manager #832 on 04/01/25 at 01:14 P.M. revealed the appointment for Resident #14 was not scheduled, and the facility was aware in February of the referral for possible surgical removal of the resident's cataracts. Unit Manager #832 stated she was unsure why it took so long for the surgery to be scheduled and confirmed it had not been scheduled in a timely manner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366272 If continuation sheet Page 4 of 23 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 04/09/2025 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 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 observation, medical record review, staff interview, and facility policy, the facility failed to ensure pressure ulcer dressings were completed as ordered. This affected one resident (#33) of three residents reviewed for wounds. The facility census was 57. Residents Affected - Few Findings include: Review of Resident #33's medical record revealed an admission date of 10/29/21. Medical diagnoses included fracture of the lower end of the left radius (arm fracture), generalized idiopathic epilepsy, aphasia (difficulty speaking), history of falls, obesity, and history of transient ischemic attacks. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed Resident #33 had a Brief Interview for Mental Status (BIMS) score of 09 which indicated moderately impaired cognition. Resident #33 was recorded to use a walker, required supervision to walk ten feet, and required moderate assistance for toileting. The assessment did not indicate Resident #33 had any behaviors or areas of skin impairment. Review of Resident #33's Braden scale assessment (a nursing tool used to assess an individual's risk for developing pressure ulcers) revealed the resident scored a 16, indicating low risk for pressure ulcer development. The assessment noted Resident #33 was indicated as having slightly limited sensory perception, occasional skin moisture, and that Resident #33 was noted to walk occasionally, but spent most of each shift in bed or a chair. The assessment noted complete lifting (of Resident #33) without sliding against the sheets was impossible. Resident #33 was additionally noted to slide down in bed or chair and required frequent repositioning with maximum assistance. Review of a physician order dated 03/03/25 revealed Resident #33 was noted to have a sacral/coccyx split, and a treatment was ordered to cleanse the open area and apply triad ointment (a zinc oxide-based wound ointment) daily and after each episode of incontinence and as needed. Review of a shower sheet dated 03/04/25 revealed a bed bath was given to Resident #33. During the bed bath, an open wound was recorded on the resident's buttock. Review of a wound physician progress note dated 03/05/25 revealed a sacral split was observed and described as an unmeasured, superficial linear skin tear. The sacral split was classified as a moisture-associated skin damage (MASD) wound. During the observation, a second wound to Resident #33's left buttock was identified. The left buttock wound was classified as a pressure ulcer (injury) and classified as a deep tissue injury (DTI). The wound physician ordered triad ointment to be applied twice daily and as needed, recommended a low-air loss mattress for wound healing, turning every two hours, and the head of the bed to be less than 30 degrees to reduce the force on the wound. The prognosis for wound healing was listed as fair. Review of a physician order dated 03/05/25 revealed Resident #33's wound order included to cleanse bilateral buttocks with normal saline, pat dry, and apply triad ointment twice daily and as needed. The order was discontinued on 03/26/25. Review of Resident #33's care plan revised on 03/06/25 revealed Resident #33 had an alteration in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366272 If continuation sheet Page 5 of 23 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 04/09/2025 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few skin integrity as evidenced by a wound to bilateral buttocks and sacral split. Listed wound care interventions included to administer treatments as ordered and monitor for effectiveness, monitor dressing every shift to ensure it is intact and adhering, report loose dressings to nurse, and monitor for pain prior to dressing changes. Review of Resident #33's Treatment Administration Record (TAR) for March 2025 revealed on the night shift of 03/12/25, 03/17/25, and 03/22/25, the resident's treatment was blank and not recorded as having been applied. Observation on 04/02/25 at 8:44 A.M. with Resident #33 revealed he was awake and sitting upright in bed. Resident #33 was not interviewable. Observation and interview on 04/02/25 at 9:50 A.M. with Wound Nurse Practitioner (WNP) #950, Licensed Practical Nurse (LPN) #951, and Unit Manager (UM) #832 of Resident #33's left buttock wound revealed the DTI on the left buttock was first identified on 03/05/25 when WNP #950 was asked to look at Resident #33's sacral split area. When the resident turned onto his side, the DTI was found to Resident #33's left buttock. WNP #950 stated the left buttock wound was definitely a pressure injury. She further described Resident #33 as having limited mobility and stated he was unable to turn himself. During the observation of wound care, Resident #33 was assisted by LPN #951 to turn onto his right side. WNP #950 assessed the injury, measured the area, and cleansed the wound with a wound cleanser, applied triad ointment, and was positioned for comfort. Interview on 04/02/25 at 11:26 A.M. with UM #832 confirmed Resident #33's treatments were not applied as ordered on 03/12/25, 03/17/25, and 03/22/25. Review of the policy Pressure Ulcer Prevention and Treatment Protocol dated 01/2014 revealed that all residents will have a skin risk assessment (Braden scale) completed on admission and at least quarterly thereafter. Preventative measures will be put into place to address each resident's individual needs. These may include but are not limited to the following: turn and reposition every two hours when in bed, use pillows, wedges or other positioning devices to maintain pressure relieving positions as needed, and encourage residents to reposition every one to two hours when in the chair. In the event a resident develops a pressure ulcer, interventions for wound care will be implemented per the physician's orders. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366272 If continuation sheet Page 6 of 23 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 04/09/2025 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 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #36's medical record revealed an admission date of 02/19/24 with diagnoses including hemiplegia (paralysis) and hemiparesis (weakness) following cerebral infarction affecting the left non-dominant side, type two diabetes mellitus with other diabetic kidney complication, and mild cognitive impairment of uncertain or unknown etiology. Review of the facility incident log dated 03/01/24 through 03/01/25 included Resident #36 experienced falls on 05/12/24, 06/25/24, 08/06/24, 08/28/24, 11/03/24, 11/25/24, 11/28/24, 12/09/24, 12/11/24, 12/13/24, 01/13/25, and 02/04/25. Review of Resident #36's fall investigations dated 03/01/24 through 03/01/25 did not reveal evidence that witness statements were completed. Review of Resident #36's care plan dated 03/08/24 and revised 03/31/25 included Resident #36 was a fall risk characterized by a history of falls, injury. Resident #36 had multiple risk factors related to impaired mobility, history of falls. The goal was Resident #36 would have no fall related injuries. Prevent, minimize fall related injures through the review date. An intervention initiated on 03/08/24 was an anti-roll back device to the wheelchair (this intervention was initiated again on 11/04/24). An intervention initiated on 03/08/24 was to have commonly used articles within easy reach, especially on the table (this intervention was initiated again on 11/25/24). An intervention initiated 03/08/24 was to wear non-slip footwear (a new intervention to wear non-skid socks at all times when out of bed was found on Resident #36's Fall Review UDA dated 11/28/24, but the intervention was not updated on the care plan). Review of Resident #36's Fall Risk Calculations dated 05/20/24, 06/25/24, 08/06/24, 08/27/25, 11/03/24, 11/25/24, 12/06/24, 01/13/25 and 02/04/25 revealed Resident #36 was at high risk for falls. Review of Resident #36's Fall UDA (user-defined assessment, used to document clinical findings) dated 06/25/24 at 3:00 P.M. included Resident #36 had an unwitnessed fall, and Resident #36's roommate told staff he had fallen. Resident #36 stated, I made a couple steps out of bed, and I fell on my butt. An immediate intervention initiated was to place a reminder sign to use the walker, wheelchair in the room (not added to care plan until 09/12/24). Review of Resident #36's Fall Review UDAs dated 06/25/24 through 07/14/24 did not reveal evidence A Fall Review UDA was completed for Resident #36's fall on 06/25/24. Review of Resident #36's Fall UDA dated 08/06/24 at 5:30 A.M. included Resident #36 was heard yelling; staff found Resident #36 sitting on his buttocks in front of his wheelchair. Resident #36 stated, I don't know what happened. An immediate intervention initiated was to ensure the bed was in the lowest position (not added to care plan until 09/12/24). Review of Resident #36's Fall Review UDAs dated 08/06/24 through 08/20/24 did not reveal evidence A Fall Review UDA was completed for Resident #36's fall on 08/06/24. Review of Resident #36's Fall Review UDA dated 08/29/24 included Resident #36 experienced a fall on 08/28/24. Resident #36 attempted to get up on his own to go to the bathroom and lost his balance (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366272 If continuation sheet Page 7 of 23 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 04/09/2025 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 0689 and fell on his buttocks. An intervention initiated was to hang a Call Don't Fall' sign as a reminder to use the call light. Level of Harm - Actual harm Residents Affected - Few Review of Resident #36's care plan dated 08/28/24 through 04/03/25 did not reveal evidence a Call Don't Fall sign was added as an intervention. Review of Resident #36's care plan dated 09/12/24 revealed an intervention was initiated to use a visual reminder sign to remind the resident to use walker, wheelchair for mobility. There was no evidence this intervention was added to Resident #36's care plan on 06/25/24. Further review of the care plan on 09/12/24 revealed an intervention was initiated for a low bed, verify during each round. There was no evidence this intervention was added to Resident #36's care plan on 08/06/24. Review of Resident #36's Fall UDA dated 11/03/24 at 5:50 P.M. revealed Resident #36 was found on the floor in front of the toilet. Resident #36 forgot to lock his wheelchair when going to sit down after using the bathroom. An intervention initiated on 11/03/24 was anti-roll backs (this intervention was first initiated on 03/08/24, and there was no evidence the anti-roll back intervention was in place on 11/03/24 when Resident #36 experienced a fall). Review of Resident #36's Fall Review UDA dated 11/26/25 included Resident #36 experienced a fall on 11/25/24. Staff were called into Resident #36's room and found him lying on the floor next to his bed. When asked, Resident #36 stated he was reaching for something on his nightstand and fell out of bed. An intervention was initiated to keep all personal items within reach. This intervention was first initiated on 03/08/24. Review of Resident #36's Fall Review UDA dated 11/28/24 included Resident #36 experienced a fall on 11/28/24 at 2:14 P.M. Resident #36 had an unwitnessed fall, and the nurse heard Resident #36 talking to himself and found him sitting on the floor on his buttocks between his bed and the wheelchair. Resident #36 said he was trying to get up, and his feet just kept sliding. An immediate intervention initiated was to have Resident #36 wear non-skid socks at all times when out of bed (an intervention for non-slip footwear was initiated on 03/08/24). Review of Resident #36's Fall Review UDA dated 12/10/24 included Resident #36 experienced a fall on 12/09/24. Resident #36 was found on the floor by the Social Worker while walking past room. Resident #36 stated he slid out of his wheelchair. Resident #36 was assisted back into his wheelchair. An intervention initiated was dycem to the wheelchair. Review of Resident #36's care plan dated 12/09/24 through 04/03/24 did not reveal dycem to the wheelchair was added as an intervention. Review of Resident #36's Annual MDS assessment dated [DATE] included Resident #36 had severe cognitive impairment. Resident #36 required substantial to maximal assistance for bathing, toileting hygiene, and personal hygiene. Resident #36 required partial to moderate assistance for lower body dressing and supervision or touching assistance for toilet transfers and to walk 10 feet. Resident #36 was frequently incontinent of urine and occasionally incontinent of bowel. Observation on 04/01/25 at 2:57 P.M. with CNA #853 revealed Resident #36 was in bed, lying on his left side on a perimeter mattress and was sleeping. CNA #853 stated Resident #36 was receiving hospice services and needed a mechanical lift for transfers. CNA #853 indicated the mechanical lift for transfers was new in the last month or two. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366272 If continuation sheet Page 8 of 23 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 04/09/2025 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 0689 Level of Harm - Actual harm Residents Affected - Few Interview on 04/01/25 at 3:56 P.M. of RDCS #894 revealed he reviewed Resident #36's fall investigations and confirmed there were no witness statements. RDCS #894 stated the current DON had only been in the facility for a couple months, and he called the prior DON to ask about the fall investigations. RDCS #894 stated falls were investigated in the morning and aides were verbally asked what happened so an intervention could be initiated. RDCS #894 indicated the current DON addressed fall investigations recently in a nurse meeting. RDCS #894 stated the facility identified fall investigations as an area that needed worked on. A Fall Review UDA was completed by the IDT after a fall, and the floor nurse completed a Fall UDA at the time of the fall. RDCS #894 indicated a pain assessment should be completed at the time of the fall, and he thought there was an area in the Fall UDA or the Fall Review UDA to document pain. Review on 04/01/25 at 4:00 P.M. of the facility Fall UDA and Fall Review UDA revealed there was no evidence of an area to document a resident's pain level after a fall. Interview on 04/02/25 at 9:18 A.M. of CNA #870 revealed Resident #36 had not fallen since the facility started using a mechanical lift for transfers. CNA #870 stated Resident #36 had declined in the past month or two. Interview on 04/03/25 at 8:21 A.M. with the DON revealed there was an IDT meeting every morning to talk about falls, and all department heads were in attendance. At the time of the IDT meeting a new fall intervention was identified and implemented. The DON stated she was implementing a new fall protocol and was providing fall investigation in-services to the nurses. Interview on 04/07/25 at 10:58 A.M. with the DON revealed on 12/09/24 Resident #36 experienced a fall, and the fall intervention for dycem to the wheelchair was not added to his care plan. The DON confirmed Resident #36 experienced a fall on 06/25/24 and the intervention for a reminder sign to use the walker, wheelchair was not added to his care plan until 09/12/24. The DON confirmed Resident #36 experienced a fall on 08/06/24 and the intervention to ensure bed was in the lowest position was not added to his care plan until 09/12/24. The DON stated the fall intervention for Resident #36's fall on 11/28/24 was to use non-skid socks at all times when out of bed. The DON stated the fall interventions dated 03/08/24 were implemented to help prevent falls before Resident #36 experienced a fall at the facility. After Resident #36 experienced a fall, the interventions could be used as an intervention because he now had a fall. 3. Review of the medical record for Resident #8 revealed an admission date of 11/09/19. Diagnoses included sepsis, heart failure and atrial fibrillation. Resident #8 was cognitively impaired. Review of Resident #8's MDS quarterly assessment dated [DATE] revealed the resident had a severe cognitive impairment. Resident #8 was identified to need partial/moderate assistance for rolling left to right in bed and for chair/bed-to-chair and toileting transfers. Review of Resident #8's undated care plan revealed the resident was a fall risk, characterized by multiple risk factors including intermittent confusion, unsteady gait/balance, the presence of a Foley (indwelling urinary) catheter, bowel incontinence, and multiple medical co-morbidities. Listed interventions included signage in room stating call don't fall, keep call light in reach, ensure environment is free of clutter, non-slip footwear, and need to reinforce the need to call for assistance. Review of the post-fall assessment dated [DATE] at 7:40 P.M. revealed Resident #8 had an unwitnessed fall. Resident #8 was found on his floor with blood coming from his head. The immediate (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366272 If continuation sheet Page 9 of 23 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 04/09/2025 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 0689 intervention was ice to head and then he was sent to the emergency room. There was no identified root cause identified for Resident #8's fall. Level of Harm - Actual harm Residents Affected - Few Review of a progress dated 03/04/25 at 9:37 P.M. revealed Resident #8 was found on his floor with head bleeding by activity staff. The physician and responsible party were notified. He was sent to the hospital for treatment. Interview on 04/01/25 at 4:00 P.M. with RDCS #894 provided the fall assessment as the investigation. RDCS #894 confirmed there were no witness statements and stated that ideally, the facility would get witness statements even when unwitnessed falls occur. RDCS #894 stated there should have been a statement from the staff member who found Resident #8 on the floor. Review of the facility policy titled ONHC Fall Prevention and Management Policy and Procedure, revised 01/2024, included it was the policy of the facility to identify residents at risk for falls and plan appropriate care and interventions to maintain resident's safety to the extent possible. A Fall Risk Calculation would be completed upon admission, readmission, and, or quarterly or with any significant change of the resident. Those identified as HIGH RISK would have safety interventions implemented in an attempt to prevent falls or minimize the occurrence of injury because of a fall. Interventions would be individualized based on residents' needs. The plan of care would be evaluated at appropriate regular intervals, or when falls occur, to ensure interventions remain appropriate and were effective. If a fall occurred the resident would be assessed for injuries and the presence, absence of pain. Based on the investigation, the nurse and staff involved would re-evaluate the residents' specific care plan in place and implement new interventions as appropriate. The falls information and new interventions would be reviewed the next business day by the IDT. IDT members would determine if the interventions were appropriate. Based on medical record review, staff interview and facility policy review, the facility failed to ensure individualized care plan interventions were developed, updated, and initiated following falls for Resident #33 and Resident #36. The facility also failed to conduct thorough post-fall investigations with root cause analysis to ensure a comprehensive fall management program was in place for Resident #8, Resident #33 and Resident #36. This affected three residents (#8, #33, and #36) of three residents reviewed for accidents. The facility census was 57. Actual Harm occurred on 01/29/25 when Resident #33, who was identified as high risk for falls, had moderate cognitive impairment and required supervision or touching assistance with ambulation and partial to moderate assistance with toileting hygiene, was left unattended in the bathroom resulting in a fall with a left wrist fracture. Prior to this fall with injury, Resident #33 had a history of falls (03/24/24, 09/11/24, 10/20/24, and 12/05/24) without thorough investigations for root cause analysis, new fall prevention interventions being implemented, and/or the resident's plan of care being updated to prevent falls. Findings include: 1. Review of the medical record for Resident #33 revealed an admission date of 10/29/21 with current diagnoses including unspecified fracture of the lower end of the left radius (wrist), generalized idiopathic epilepsy and epileptic syndromes, aphasia, history of falling, unspecified convulsions, obesity and history of transient ischemic attacks. Review of Resident #33's fall care plan initiated on 12/03/21 (last revised on 01/18/24) revealed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366272 If continuation sheet Page 10 of 23 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 04/09/2025 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 0689 Level of Harm - Actual harm Residents Affected - Few the resident had fall risk characterized by repeated falls/history of falls/injury, multiple risk factors related to impaired balance, impaired mobility, epilepsy, incontinence, unsteady gait, and use of psychotropic medications. The plan of care included Resident #33 was noted to be non-compliant with fall interventions. Interventions included to be sure the call light was within reach and encourage use for assistance as needed, gait belt for all transfers, have commonly used articles within easy reach, non-slip footwear, and a chair alarm to the resident's recliner to alert staff of unassisted transfers/ambulation, check functioning status every shift (the chair alarm was discontinued on 11/24/23), ensure environment was free of clutter, dycem (non-slip material) to recliner chair at all times, monitor the resident's gait and report changes as needed (implemented on 01/05/22), non-skid strips to the floor outside of the restroom (initiated 01/18/23), ensure a reacher (adaptive equipment device that extends a user's reach, allowing them to pick up objects from the floor or difficult to access areas) was within reach of the resident at all times (initiated 04/14/22), reinforce need to call for assistance (initiated 02/08/22), therapy to screen fort self-transfers (initiated 06/02/23), routine toileting after dinner (initiated 08/07/23), and a night light in the resident's room (initiated 10/27/23). Record review revealed the resident sustained falls on 03/24/24, 09/11/24, 10/20/24 and 12/05/24. However, there were no revisions or new fall interventions added to the resident's plan of care following these falls to decrease the resident's risk of falls including falls with injury. Review of the facility incident log for the from 03/2024 to 03/2025 revealed Resident #33 had a fall on 03/24/24 at 6:09 P.M. with no noted injuries, on 09/11/24 at 7:00 P.M. with no noted injuries, a fall on 10/20/24 at 4:49 A.M. which resulted in a right distal radius fracture, a fall on 12/05/24 at 2:50 A.M. with no noted injuries, and a fall on 01/29/25 which resulted in a left wrist fracture. Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #33 had a Brief Interview for Mental Status (BIMS) score of 12, indicating the resident had intact cognition. The assessment revealed Resident #33 required (staff) supervision to touching assistance with toileting transfers and ambulation ten to 50 feet and partial to moderate assistance with toileting hygiene. The assessment also noted the resident had a history of falls. Review of the nursing progress note dated 10/20/24 at 4:15 A.M. revealed Resident #33 was found sitting on the floor in the bathroom with his walker in front of him. He was assessed with no obvious signs of trauma but was found to have pain in his right flank, wrist and forearm. Review of the nursing fall assessment dated [DATE] for Resident #33 revealed at 4:15 A.M., Resident #33 was attempting to stand up and go into the bathroom, lost his balance and fell landing on his right side. Neurological checks were initiated. Resident #33 was taken to the bathroom, toileted, changed and placed back in recliner. No witness statements were provided. Review of the 10/20/24 handwritten physician order for Resident #33 revealed an order for a three-view x-ray to right wrist and forearm and neurological checks to be initiated. Review of the 10/20/24 x-ray results for Resident #33 revealed an acute fracture of the right distal radius. Review of the nursing progress note dated 10/20/24 timed at 1:06 P.M. revealed x-ray results of a right distal radius fracture following fall. Resident #33 was to be sent out to the emergency room (ER) for treatment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366272 If continuation sheet Page 11 of 23 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 04/09/2025 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 0689 Level of Harm - Actual harm Review of the 10/20/24 fall risk calculation assessment for Resident #33 revealed he was evaluated as a score of 12 which indicated moderate risk for falls. Resident #33 was noted to have fallen, had gait disturbance, balance disorder, and required an assistive device for mobility. Resident #33 was continent with assistance to the toilet and required assistance with ambulation. Residents Affected - Few Review of the 10/21/24 interdisciplinary team (IDT) fall review for Resident #33 revealed Resident #33 was observed sitting on the bathroom floor next to toilet with a walker in front of him. Resident #33 stated he lost his footing and fell. The new interventions included an x-ray and send out to the ER for evaluation. No witness statements were provided as part of the facility fall investigation. There was no documented evidence that a root cause analysis was completed, no evidence that the care planned fall prevention interventions were in place at the time of the fall, and no evidence of new fall prevention interventions being initiated following the incident to prevent additional falls from occurring. Review of the physician visit dated 10/21/24 at 7:25 P.M. revealed Resident #33 has had chronic distal radius and ulnar fractures present with ultimately no new issues since his fall. Review of the nursing progress note dated 12/05/24 at 3:17 A.M. revealed a nurse was alerted by unidentified Certified Nursing Assistant (CNA) Resident #33 was found on the floor, sitting on his buttocks next to the chair in his room. Resident #33 stated he missed the chair as he was trying to sit back down. Review of the nursing progress note dated 12/05/24 at 3:21 A.M. for Resident #33 revealed an unwitnessed fall. The assessment revealed no apparent injuries. Review of the nursing fall assessment dated [DATE] revealed an unwitnessed fall in Resident #33's room. Resident #33 was found on the floor, sitting on his buttocks next to his chair when the nurse entered the room. Resident #33 stated he missed his chair when trying to sit back down. Non-skid socks and a walker were noted to be present. No injuries were noted. No witness statements were provided. Review of the 12/05/24 fall risk calculation for Resident #33 revealed he was evaluated to be at high risk for falls. Resident #33 was noted to be easily distracted, had periods of altered perception or awareness, and had episodes of disorganized speech. Resident #33 was noted to have lower extremity weakness, gait disturbance, and require an assistive device for mobility. Resident #33 was noted to require assistance with bed mobility, transfers and ambulation. Review of the 12/06/24 IDT fall review for Resident #33 revealed the resident stated he had gone to the bathroom and upon returning, he missed the recliner when sitting down. No injuries were noted. The new intervention was lab work to rule out Covid-19 due to increased weakness. No staff witness statements were provided as part of the facility fall investigation. There was no documented evidence that a root cause analysis was completed, no evidence the care planned fall prevention interventions (except for non-skid socks) were in place at the time of the fall, and no evidence of new fall prevention intervention(s) being implemented to prevent additional falls. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #33 had a BIMS score of 11, indicating moderate cognitive impairment. The assessment revealed Resident #33 required (staff) supervision to touching assistance with toileting transfers and ambulation ten feet and refused to ambulate 50 feet. The assessment also revealed the resident had a history of two or more falls since (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366272 If continuation sheet Page 12 of 23 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 04/09/2025 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 0689 the last assessment (09/23/24). Level of Harm - Actual harm Review of the 12/23/24 fall risk calculation assessment for Resident #33 revealed the resident had mental status fluctuations, lower extremity weakness, gait disturbance, required an assistive device for mobility and required assistance for bed mobility, transfers, and ambulation. There was no documented evidence that new fall prevention interventions were implemented at this time to mitigate the resident's risk for falls and/or injury associated with continued falls. Residents Affected - Few Review of the nursing progress note dated 01/29/25 at 6:29 P.M. written by Licensed Practical Nurse (LPN) #819 revealed Resident #33 lost his balance and fell on the floor in his bathroom. Vital signs were stable. Resident #33 complained of pain to the left wrist. An order was obtained for x-rays. Neurological checks were within normal limits. Review of the x-ray report dated 01/29/25 for Resident #33 revealed the left forearm x-ray revealed a nondisplaced fracture of the distal radius. Moderate degenerative changes are noted. No noted bony lesions. Diffuse osteopenia was demonstrated. Mild soft tissue swelling was noted. Review of the 01/29/25 fall risk calculation assessment for Resident #33 revealed the resident had no problems with mental status, behaviors, or communications. Resident #33 was noted to have gait disturbance, required an assistive device for mobility, was independent for mobility and continent. No witness statements were provided as part of the facility fall investigation. There was no documented evidence that a root cause analysis was completed, no evidence the care planned fall prevention interventions were in place at the time of the fall, and no evidence of new fall prevention interventions being initiated following the incident to prevent additional falls. Review of the nursing fall assessment dated [DATE] for Resident #33 revealed it was incomplete. Resident #33's fall assessment revealed the resident had an unwitnessed fall on 01/29/25 at 6:15 P.M. Resident #33 was found on the floor in the bathroom. Resident #33 stated he lost his balance when he was walking, trying to go from the bathroom to his chair. A nursing assessment was completed, neurological checks were started, and an x-ray was ordered for left wrist pain. No witness statements were provided as part of the facility fall investigation to determine a root cause or the circumstances of the fall. Review of the nursing progress note dated 01/30/25 at 2:30 A.M. for Resident #33 revealed a fracture to the left wrist. An order to obtain an orthopedic consult and Ace wrap to the left wrist. Review of the nursing progress noted dated 01/30/25 at 6:16 P.M. for Resident #33 revealed he returned from orthopedic consult and returned with a cast placed on the left upper extremity. Resident #33 was to be non-weight bearing to the left upper extremity until cleared by the orthopedic physician. Follow up in two weeks. Review of the IDT fall review dated 01/30/25 at 12:12 P.M. for Resident #33 revealed the fall occurred in the resident's bathroom when the resident was attempting to self-toilet. An intervention was initiated for a therapy evaluation for toileting. No staff witness statements were provided as part of the facility investigation. There was no documented evidence that a root cause analysis was completed and no evidence the care planned fall prevention interventions were in place at the time of the fall to prevent additional falls from occurring. Review of the 01/30/25 orthopedic consult revealed Resident #33 was placed in an arm cast and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366272 If continuation sheet Page 13 of 23 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 04/09/2025 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 0689 Level of Harm - Actual harm Residents Affected - Few should be non-weight bearing to the left upper extremity until the follow up appointment. An order for one tablet of 50 milligram (mg) of Tramadol (Ultram), a narcotic pain medication, to be given by mouth every eight hours as needed for severe pain. Review of the physician orders dated 01/30/25 at 6:30 P.M. for Resident #33 revealed an order for Tramadol (Ultram) 50 mg, one tablet to be given by mouth every eight hours as needed for severe pain. Review of the 01/2025 Medication Administration Record (MAR) for Resident #33 revealed an order for a 500 mg tablet of Acetaminophen (analgesic) to be given every eight hours as needed for pain. Review of the 01/25 MAR indicated no pain medication was given prior to the fall on 01/29/25. Review of the orthopedic physician note dated 02/17/25 revealed repeat x-rays today demonstrate stable interval healing of the non-displaced left distal radius fracture subtle increase sclerotic callus formation noted about the fracture plane with no worsening or additional acute abnormality noted. Review of the 02/2025 MAR for Resident #33 revealed 19 doses of the as needed Tramadol 50 mg were administered for pain as a result of the fall/fracture. Interview on 04/01/25 at 3:56 P.M. with Regional Director of Clinical Services (RDCS) #894 confirmed the facility did not have staff witness statements as part of the fall investigations completed for the falls sustained by Resident #33 on 10/20/24, 12/05/24, and 01/29/25. RDCS #894 stated staff were supposed to provide witness statements, but they had not been consistent. Nurses were supposed to complete the Fall User Defined Assessment (UDA) assessment, and the IDT completed the Fall Review UDA, and there should be a documented pain assessment. An investigation following a fall ideally should include the nurse assessments, neurological checks, witness statements, and a root cause analysis regardless of whether staff witnessed the fall. RDCS #894 revealed the facility should have implemented new fall prevention intervention(s) after each fall and updated the care plan, so all staff knew the type of assistance a resident required and what fall prevention interventions were to be in place. Interview on 04/02/25 at 10:46 A.M. with CNA #853 revealed prior to Resident #33's fall on 01/29/25, Resident #33 was inconsistent and would sometimes put on the call light to use the bathroom, but other times would walk to the bathroom by himself with his walker. The CNA revealed Resident #33 was supposed to use his call light; staff would assist him to the bathroom and stay in the room until he was done, assist him to clean up, and then assist him back to bed. Interview on 04/03/25 at 7:39 A.M. with CNA #806 revealed Resident #33 was impulsive and tried to self-transfer and self-toilet almost daily. The CNA revealed she would check on him every two hours and encourage him to use his call light. CNA #806 confirmed Resident #33 required assistance to the bathroom and stated once in the bathroom he would use the call light when finished. CNA #806 stated if he was more than a few minutes, she would check to see if he needed assistance. A telephone interview on 04/03/25 at 9:40 A.M. with Licensed Practical Nurse (LPN) #819 revealed she was the nurse working with Resident #33 on 01/29/25; however, she did not recall the details of the resident's fall on this date, nor could she recall which CNA notified her of the fall. LPN #819 confirmed Resident #33 required moderate assistance for toileting and required staff to assist him to the bathroom and monitor him while in there for his safety. A telephone interview on 04/03/25 at 12:00 P.M. with CNA #952 revealed on 01/29/25 she was passing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366272 If continuation sheet Page 14 of 23 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 04/09/2025 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 0689 Level of Harm - Actual harm Residents Affected - Few dinner trays and was aware Resident #33 was already in the bathroom as the resident's call light was on, so she stated she went to assist him. CNA #952 stated she wiped the resident and assisted the resident to pull up his pants and then stated she asked him if he needed anything else. She stated Resident #33 stated he did not need further assistance, so she left the room and continued passing dinner trays. CNA #952 stated she heard screaming and ran to Resident #33's room and found him on the bathroom floor. CNA #952 stated she yelled for the nurse. CNA #952 stated she had recently started working at the facility and was told Resident #33 was independent but would ring when he needed assistance. CNA #952 stated she was not aware the resident was a fall risk and needed more frequent checks. LPN #819 assessed Resident #33, and they assisted him back to his recliner. CNA #952 stated Resident #33 indicated his wrist hurt at the time of the fall. Interview on 04/03/25 at 2:24 P.M. with the Director of Nursing (DON) confirmed if a resident was a fall risk, the staff should stay in the room while the resident was in the bathroom. The DON also verified the facility did not have staff witness statements as part of the fall investigation for this fall. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366272 If continuation sheet Page 15 of 23 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 04/09/2025 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 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure follow-up dental appointments were provided as indicated. This affected one resident (#6) out of one resident reviewed for dental services. The facility census was 57. Residents Affected - Few Findings include: Review of Resident #6's medical record revealed an admission date of 07/12/20 with diagnosis including heart failure, morbid obesity, hemiplegia and hemiparesis following cerebral infraction affecting left non-dominate side, idiopathic neuropathy, hypertensive heart disease with heart failure, venous insufficiency, atrial fibrillation, peripheral vascular disease, primary osteoarthritis, major depressive disorder, anemia, insomnia, hyperlipidemia, tinnitus, gastro-esophageal reflux disease, and vitamin D deficiency. Review of a dental note for Resident #6 revealed she was seen by a consultant dentist on 02/11/25 for mouth pain. The dentist indicated a referral for a consult with Oral Maxillofacial Surgeon was needed. An interview on 03/31/25 at 09:58 A.M. with Resident #6 revealed she needed a follow-up dental appointment since January, and the appointment had not been scheduled. Interview on 04/01/25 at 01:12 P.M. with Unit Manager #832 revealed she was told on 03/28/25 that Resident #6 needed follow-up dental appointment scheduled. Unit Manager #832 confirmed the appointment was not scheduled in a timely manner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366272 If continuation sheet Page 16 of 23 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 04/09/2025 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 0847 Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. Level of Harm - Minimal harm or potential for actual harm Based on review of the Arbitration Agreement and interviews the facility failed to ensure the resident or representative had the right to rescind the agreement within 30 calendar days after signing it. This affected four residents (#41, #46, #315, and #318) of five residents reviewed for arbitration agreements. The facility identified 33 residents who agreed to the facility's binding arbitration agreement upon admission. The facility census was 57. Residents Affected - Some Findings include: 1. Review of the medical record for Resident #41 revealed an admission date of 10/30/24. Review of the Arbitration Agreement revealed Resident #41 and the facility entered into an agreement that if a dispute arises between them, they desire to avoid costly and time-consuming litigation. The agreement stated the agreement may be terminated by either the resident or the facility upon written notice given to the other party within 21 days of the execution of the agreement. The agreement was signed by Resident #41 and Admissions Director (AD) #899 on 11/08/24. 2. Review of the medical record for Resident #46 revealed an admission date of 01/28/25. Review of the Arbitration Agreement revealed Resident #46 and the facility entered into an agreement that if a dispute arises between them, they desire to avoid costly and time-consuming litigation. The agreement stated the agreement may be terminated by either the resident or the facility upon written notice given to the other party within 21 days of the execution of the agreement. The agreement was signed by Resident #46's authorized representative and AD #899 on 01/30/25. 3. Review of the medical record for Resident #315 revealed an admission date of 03/24/25. Review of the Arbitration Agreement revealed Resident #315 and the facility entered into an agreement that if a dispute arises between them, they desire to avoid costly and time-consuming litigation. The agreement stated the agreement may be terminated by either the resident or the facility upon written notice given to the other party within 21 days of the execution of the agreement. The agreement was signed by Resident #315 and a facility staff member on 03/28/25. 4. Review of the medical record for Resident #318 revealed an admission date of 03/11/25. Review of the Arbitration Agreement revealed Resident #318 and the facility entered into an agreement that if a dispute arises between them, they desire to avoid costly and time-consuming litigation. The agreement stated the agreement may be terminated by either the resident or the facility upon written notice given to the other party within 21 days of the execution of the agreement. The agreement was signed by Resident #318 and a facility staff member on 03/28/25. Interviews on 04/02/25 at 3:27 P.M. and 3:39 P.M. with the Admissions Director (AD) #899 revealed the company's Arbitration Agreement was last revised on 03/03/21. AD #399 confirmed the Arbitration Agreements for Residents #41, #46, #315, and #318 all noted the resident had 21 days to rescind after exection of the agreement. AD #899 reviewed regulation for Arbitration Agreements and confirmed the resident or responsible party should have 30 days to rescind after signing the agreement. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366272 If continuation sheet Page 17 of 23 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 04/09/2025 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, staff interview, medical record review, policy review, and signage review, the facility failed to ensure enhanced barrier precautions were in place for residents as required. This affected three Residents (#33, #315, and #317) of 15 residents identified as requiring enhanced barrier precautions. The facility census was 57. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #315 revealed an admission date of 03/24/25 and diagnoses including metabolic encephalopathy, acute kidney failure, alcohol abuse, anxiety disorder, and atherosclerotic heart disease. Review of the physician's orders dated 03/30/25 for Resident #315 revealed an order for intravenous midline site for intravenous antibiotic administration. Review of the physician's order dated 03/31/25 for Resident #315 revealed order for enhanced barrier precautions (EBP) related to intravenous access. Observation on 03/31/25 at 10:36 A.M. revealed Resident #315 was sitting up in bed with visible intravenous access to the left arm. There was no evidence of EBP, including signage or personal protective equipment (PPE), in place at the time of observation. Observation and interview on 03/31/25 at 11:57 A.M. with the Director of Nursing (DON) confirmed EBP were not in place for Resident #315 for intravenous access. The DON indicated PPE for EBP was kept in resident bathrooms and signs were posted on name cards by doorway to room. 2. Review of the medical record for Resident #317 revealed an admission date of 03/20/25 and diagnoses including acute kidney failure, pneumonia, elevated white blood cell count, obstructive and reflux uropathy, benign prostatic hyperplasia with lower urinary tract symptoms, and dementia. Review of the physician's order dated 03/21/25 for Resident #317 revealed an order for a Foley (indwelling urinary) catheter due to urine retention. Review of the physician's order dated 03/31/25 for Resident #317 revealed an order for EBP due to the presence of a Foley catheter. Observation on 03/31/25 at 11:56 A.M. revealed Resident #317 sitting in a recliner chair with a Foley catheter bag attached to the dresser. There was no evidence of EBP, including signage or PPE, in place at the time of observation. Observation and interview on 03/31/25 at 11:57 A.M. with Director of Nursing (DON) confirmed EBP were not in place for Resident #317's Foley catheter. The DON indicated Resident #317 has had a Foley catheter in place since admission. The DON indicated PPE for EBP was kept in resident bathrooms and signs were posted on name cards by the doorway to the room. 3. Review of the medical record for Resident #33 revealed an admission date of 10/29/21. Diagnoses included but were not limited to unspecified fracture of the lower end of the left radius, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366272 If continuation sheet Page 18 of 23 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 04/09/2025 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few generalized idiopathic epilepsy and epileptic syndromes, aphasia, history of falling, unspecified convulsions, obesity and history of transient ischemic attacks. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] for Resident #33 revealed a Brief Interview of Mental Status (BIMS) score of 09 which indicated moderate cognitive impairment. Review of activities of daily living (ADLs) revealed Resident #33 used a walker, required supervision to walk ten feet and required moderate assistance for toileting. No skin breakdown or behaviors of refusals were noted. Review of a wound physician note dated 03/05/25 for Resident #33 revealed an initial evaluation for wound that developed in the facility. Wound #1 was found on the sacrum-sacral split which was classified as moisture associated skin damage (MASD) which was linear superficial opening. Wound #2 was a pressure wound located on the buttock and was classified as a deep tissue injury (DTI). Review of the care plan revised on 03/06/25 for Resident #33 revealed a need for Enhanced Barrier Precautions related to increased risk of Multidrug Resistant Organisms (MDRO) acquisition related to wound. Interventions listed were don (put on) appropriate personal protective equipment prior to providing high- contact resident care plan activities such as: dressing, bathing/showering, transferring, providing activities of daily living (ADLs). Hygiene, changing linens, changing briefs or assisting with toileting, or wound care. An intervention of enhanced barrier precautions was listed as initiated on 03/06/25. Review of the physician orders dated 03/31/25 for Resident #33 revealed an order to maintain enhanced barrier precaution due to wound. Interview on 04/02/25 at 4:26 P.M. with the DON confirmed enhanced barrier precautions (EBP) were not started for Resident #33 until 03/31/25, after the annual survey process had begun and a list of residents with EBP were requested by the survey team. Review of signage for EBP developed by Centers for Disease Control and Prevention (CDC) undated revealed everyone must clean hands before and after entering. Providers and staff were to wear gown and gloves for high-contact resident care activities. Review of the facility policy Enhanced Barrier Precautions (EBP) Policy dated March 2024 revealed enhanced barrier precautions would be used during high contact resident care activities for residents known to be colonized or infected with an multi-drug resistant organism (MDRO) or those residents at risk for acquiring an MDRO due to chronic wounds and indwelling medical devices. PPE would include use of gown and gloves. High contact activities would include dressing, bathing, transfers, hygiene, changing of linens, toileting or incontinence care, medical device care, and wound care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366272 If continuation sheet Page 19 of 23 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 04/09/2025 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm Based on record review, interview, facility policy review, the facility failed to ensure residents were assessed for vaccination status and offered the influenza and/or pneumococcal vaccines. This affected three residents (#59, #315, and #317) of six residents reviewed for vaccines. The facility census was 57. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #59 revealed an admission date of 01/25/25 with diagnoses including left artificial joint, loose left hip artificial joint, diabetes mellitus, congestive heart failure, chronic kidney disease, rheumatoid arthritis, iron deficiency anemia, hypothyroidism, depression, anxiety, cardiac/vascular implant, and insomnia. Review of Resident #59's physical medical record revealed no influenza vaccination assessment and consent forms. Resident #59's medical record revealed no documentation or influenza vaccinations being offered for the 2024-2025 influenza season. Interview on 04/02/25 at 10:49 A.M. with Unit Manager #832 confirmed the above findings. 2. Review of the medical record for Resident #315 revealed an admission date of 03/24/25 and diagnoses including metabolic encephalopathy, pancytopenia, cerebral infarction (stroke), acute kidney failure, alcohol abuse, osteoarthritis, atherosclerosis heart disease, panic disorder, anxiety, depression, insomnia, and gastroesophageal reflux disease. Review of Resident #315's physical medical record revealed the pneumococcal vaccination assessment and consent form was not filled out or signed. Resident #315's medical record revealed no documentation of pneumococcal vaccination being offered. Interview on 04/02/25 at 10:46 A.M. with Unit Manager #832 confirmed the above findings. 3. Review of the medical record for Resident #317 revealed an admission date of 03/20/25 with diagnoses including acute kidney failure, pneumonia, expressive language disorder, malnutrition, hypertensive heart disease and kidney disease, dementia, fibromyalgia, spondylosis (degeneration of the spine), rheumatoid arthritis, depression, anxiety, obstructive uropathy, insomnia, gastroesophageal reflux disease, psychoactive substance abuse, radiculopathy (pinched spinal nerve), and iron deficiency anemia. Review of Resident #317's physical medical record revealed no pneumococcal or influenza vaccination assessment and consent forms. Resident #317's medical record revealed no documentation of pneumococcal or influenza vaccinations being offered. Interview on 04/02/25 at 10:49 A.M. with Unit Manager #832 confirmed the above findings. Review of the undated facility policy titled Infection Control indicated the purpose of the policy was to ensure the health and well-being of residents by monitoring and evaluating symptoms and appropriately responding to and manage confirmed infectious processes in order to treat, contain and prevent spread. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366272 If continuation sheet Page 20 of 23 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 04/09/2025 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 0883 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the facility policy Influenza Vaccine Protocol dated 11/2024 indicated it was the policy of the facility to offer recommended influenza vaccine to all residents, in an effort to avoid illness and minimize facility outbreaks. All current residents will, unless otherwise contraindicated by medical conditions or manufacturer guidelines will be offered the flu vaccine annually. Vaccinations will be available each year, in October. All new admissions to the facility from October 1, through the end of Mach the following year will be offered the flu vaccine at admission, unless otherwise contraindicated or vaccination was already received. Education materials in regard to risks or benefits of the influenza vaccine will be provided to residents and family member/resident representative, upon admission if admitted during the flu season (October through March) and annually to current residents and their family member/resident representative. Consent for receipt, or refusal of all vaccines will be placed in the resident's chart. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366272 If continuation sheet Page 21 of 23 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 04/09/2025 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 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Based on record review, interview, and review of facility policy, the facility failed to ensure the COVID-19 vaccine was timely offered to residents. This affected three residents (#59, #315, and #317) of six residents reviewed for vaccines. The facility census was 57. Findings include: 1. Review of Resident #59's medical record revealed an admission date of 01/25/25 with diagnoses including left artificial joint, loose left hip artificial joint, diabetes mellitus, congestive heart failure, chronic kidney disease, rheumatoid arthritis, iron deficiency anemia, hypothyroidism, depression, anxiety, cardiac/vascular implant, and insomnia. A review of Resident #59's medical record revealed the facility did not offer the COVID-19 (corona virus 19) vaccine to Resident #59. The consent for the COVID-19 vaccine was unsigned, undated, and the information on the consent had not been completed. Interview on 04/02/25 at 10:49 A.M. with Unit Manager #832 confirmed the above findings. 2. Review of Resident #315's medical record revealed an admission date of 03/24/25 and diagnoses including metabolic encephalopathy, pancytopenia, cerebral infarction (stroke), acute kidney failure, alcohol abuse, osteoarthritis, atherosclerosis heart disease, panic disorder, anxiety, depression, insomnia, and gastroesophageal reflux disease. Review of Resident #315's physical medical record revealed COVID-19 vaccination assessment and consent form was not filled out or signed. Resident #315's medical record revealed no documentation of COVID-19 vaccination being offered. Interview on 04/02/25 at 10:46 A.M. with Unit Manager #832 confirmed above findings. 3. Review of Resident #317's medical record revealed an admission date of 03/20/25 with diagnoses including acute kidney failure, pneumonia, expressive language disorder, malnutrition, hypertensive heart disease and kidney disease, dementia, fibromyalgia, spondylosis (degeneration of the spine), rheumatoid arthritis, depression, anxiety, obstructive uropathy, insomnia, gastroesophageal reflux disease, psychoactive substance abuse, radiculopathy (pinched spinal nerve), and iron deficiency anemia. Review of Resident #317's physical medical record revealed no COVID-19 vaccination assessment and consent form. Resident #317's electronic medical record revealed no documentation of COVID-19 vaccination being offered. Interview on 04/02/25 at 10:49 A.M. with Unit Manager #832 confirmed the above findings. Review of the undated facility policy titled Infection Control indicated the purpose of the policy was to ensure the health and well-being of residents by monitoring and evaluating symptoms and appropriately responding to and manage confirmed infectious processes in order to treat, contain and prevent spread. The facility will follow infection control processes as recommended by APIC (The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366272 If continuation sheet Page 22 of 23 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 04/09/2025 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 0887 Association for Professionals in Infection Control and Epidemiology) and the CDC (Centers for Disease Control and Prevention). Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366272 If continuation sheet Page 23 of 23