Health inspection·October 18, 2019

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, record review and interview the facility failed to ensure Resident #37 received oxygen according to the physician's order. This affected one resident (#37) of nine residents who were ordered oxygen. Residents Affected - Few Findings Include: Record review revealed Resident #37 was admitted to the facility on [DATE] with diagnoses including hypothyroidism, pneumothorax, anxiety, schizophrenia and emphysema. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #37 was cognitively intact and required extensive assistance from staff for most activities of daily living including toileting and personal hygiene. Review of the physician's orders, dated October 2019 revealed an order for oxygen continuously at two liters via nasal cannula. On 10/17/19 at 9:10 A.M. Resident #37 was observed being wheeled back from the dining room into his room. The resident was observed with oxygen tubing in place in his nose. However, observation of the resident's oxygen tank revealed the tank was empty and the resident was not receiving any oxygen at this time. Interview with Stated Tested Nursing Assistant (STNA) #72 on 10/17/19 at 9:22 A.M. verified the resident's oxygen tank was empty and he was not receiving any oxygen via nasal cannula. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366308 If continuation sheet Page 2 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366308 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Algart Health Care 8902 Detroit Ave Cleveland, OH 44102 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to provide routine medications to Resident #64 as ordered by the physician. This affected one resident (#64) of three sampled residents. Findings Include: Review of Resident #64's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including acquired absence of left leg below the knee, anxiety disorder, embolism and thrombosis of arteries of the lower extremities and gastroesophageal reflux. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 09/25/19 revealed the resident was cognitively intact and she required extensive assistance from staff for bed mobility, dressing and personal hygiene. Resident #64 was totally dependent on staff for transfers and toileting. Review of the physician's orders for October 2019 revealed Resident #64 had an order for Omeprazole 40 milligram (mg) one time a day. There was no order for the resident to self-administer her medications. Review of Resident #64's record revealed Resident #64 did have an assessment for self -administering medications on 03/01/16 which sated the resident had no interest in self-administering her medications. On 10/16/19 another assessment for self-administering of medication was completed which showed again the resident was not interested in self-administering her medications. Observation of and interview with Resident #64 on 10/17/19 at 7:00 A.M. revealed Resident #64 was asleep in bed with her bedside tray positioned in front of her. On her bedside tray was a glass of water, three magazines, a notebook and a medication cup with one gray and purple capsule in it. Registered Nurse (RN) #20 who was also at the bedside, asked the resident what the pill was from. Resident #64 stated the night shift nurse told her to take the pill. Resident #64 stated she fell asleep and forgot to take it. Interview with RN #20 on 10/17/19 at 7:30 A.M. verified the resident had her morning dose of Omeprazole sitting at her bedside. Review of the policy titled Medication Administration, dated 03/2016 revealed self-administration of medications were typically not permitted. The exception to this would be written orders by the physician/nurse practitioner, as the resident was educated and demonstrated the ability to self-administer medications safely per order. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366308 If continuation sheet Page 3 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366308 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Algart Health Care 8902 Detroit Ave Cleveland, OH 44102 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on record review and interview the facility failed to ensure an as needed order for an anti anxiety medication for Resident #37 was limited to 14 days or was evaluated for the needed continuation of the medication. This affected one resident (#37) of five residents reviewed for unnecessary medication use. Findings Include: Record review revealed Resident #37 was admitted to this facility on 04/25/19 with diagnoses including hypothyroidism, pneumothorax, anxiety, schizophrenia and emphysema. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 08/08/19 revealed Resident #37 was cognitively intact. The assessment revealed the resident receive any antianxiety medication during the assessment reference period. Review of the physician's orders, dated September 2019 revealed on 09/10/19 the resident was ordered to receive Lorazepam (Ativan) Intersol 1 milligrams/milliliter, 0.5 milligrams (mg) every four hours as needed for anxiety and shortness of breath. This order was good for 14 days which was until 09/24/19. Review of the resident's medication administration record (MAR) for 10/2019 revealed the resident received the Ativan on 10/01/19, 10/11/19 and 10/12/19. Interview with Licensed Practical Nurse (LPN) #78 on 10/17/19 at 2:30 P.M. verified the Lorazepam medication was ordered on 09/10/19 and was not reordered or re-evaluated for the continued need for the medication. She also verified the resident received three doses of the medication in October 2019 after the 14th day of the prescription. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366308 If continuation sheet Page 4 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366308 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Algart Health Care 8902 Detroit Ave Cleveland, OH 44102 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, spread sheet review and interview the facility failed to serve meals according to the spread sheet during the lunch meal on 10/16/19. This affected seven residents (#5, #27, #39, #45, #49, #62 and #68) of seven who were ordered a pureed diet. The facility census was 71. Findings include: On 10/16/19 at 11:50 A.M. observation of the lunch meal revealed residents who were ordered pureed diets received pureed chicken, pureed mashed potatoes and pureed vegetable for lunch. Review of the lunch meal rotating spread sheet for Week 3 on Wednesday revealed residents with pureed diets would receive pureed lasagna with tomato sauce, pureed Italian vegetable with a half of cup of bread for lunch. Interview on 10/16/19 at 12:05 P.M. with the Dietary Manager verified residents who were to receive pureed diets did not receive what was on the planned menu/spreadsheet. Interview on 10/18/19 at 12:26 PM with the Dietitian revealed she reviewed the spreadsheets biannually. The facility identified seven residents, Resident #5, #27, #39, #45, #49, #62 and #68 who were ordered a pureed diet. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366308 If continuation sheet Page 5 of 5