Inspection·May 14, 2019

F 0578 chest, code blue was called as well as 911. Level of Harm - Minimal harm or potential for actual harm Interview on [DATE] at 8:57 A.M. with RN #901 revealed she called a Code Blue and 911 for Residents Affected - Few Resident #57 on [DATE] when the pulse oximetry level was 49% on two liters of oxygen via nasal cannula. RN #901 revealed she looked up the code status in the hard chart and found it to be DNRCC-Arrest. RN #901 confirmed rescue breaths were done on Resident #57 using an ambu bag although they did not completed chest compressions. Interview on [DATE] at 1:01 P.M. with Licensed Practical Nurse (LPN) #903 revealed she and RN #902 provided rescue breaths per ambu bag to Resident #57 who had a code status of DNRCC-Arrest. Review of the facility's DNRCC-Arrest guidelines dated 02/15 revealed, providing respiratory assistance other than administering oxygen, will not be administered. Review of the facility policy titled, Emergency Management dated 11/2013 revealed the resident's preference for advanced directives would be recorded in their medical record and further used in the development of the resident's plan of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366343 If continuation sheet Page 2 of 11 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 366343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Royalton Post Acute 9055 West Sprague Road Parma, OH 44133 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 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm Based on record review and resident interview the facility failed to ensure it had evening weekend activities in-place to engage the residents. This affected Residents #5 #9, #18, #22 and #27. The facility census was 111. Residents Affected - Some Findings Include: During the resident council meeting on 05/08/19 between 1:30 P.M. and 1:50 P.M., Residents #5 #9,#18, #22 and #27 voiced concerns related to the lack of evening activities on the weekends. Resident #18 notably described the facility as dull on weekend evenings. Review of the resident council meeting minutes revealed concerns regarding lack of evening activities were brought to the facility's attention in October 2018. Review of the activity calendar for the current month noted three identical activities and times on each Sunday and Saturday. The last activity was scheduled at 2:00 P.M. Activities Director (AD) #998 verified the lack of activities during the evenings on Saturday and Sunday in an interview on 05/08/19 at 1:55 P.M. AD #998 also noted she was aware of the residents' concerns regarding evening weekend activities for awhile and that the facility had been working on it. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366343 If continuation sheet Page 3 of 11 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 366343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Royalton Post Acute 9055 West Sprague Road Parma, OH 44133 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 - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, review of the medical record, police report, emergency room documentation, accuweather.com, timeanddate.com, and the facility's Wandering And Exit Seeking policy and procedure, the facility failed to provide adequate supervision to prevent the elopement of one resident (Resident #204) who was assessed with severe cognitive impairment and exit seeking behaviors. This resulted in Immediate Jeopardy on 05/09/19 at approximately 5:45 A.M. when Resident #204 exited the facility without staff knowledge. The likelihood of actual harm that was Immediate Jeopardy occurred when Resident #204 was found on his knees in his bare feet at the bottom of a ravine with an incline of approximately 70 degrees next to a creek. The ravine contained heavy brush, weeds, downed trees, rocks, and large tree branches. When found, Resident #204 was cold and had cuts, bruises and abrasions to his face, arms and feet. This affected one of nine residents reviewed for elopement risk and wandering behaviors. The facility identified nine residents (Residents #7, #17, #25, #42, #51 #75, #78, #81 and #204) at risk for elopement. The facility census was 111. On 05/09/19 at 4:40 P.M., the Administrator, Director of Nursing (DON) and Corporate Nurse #619 were notified Immediate Jeopardy began on 05/09/19 at 5:45 A.M. when Resident #204, who was at risk for elopement and exhibited a desire to leave the facility, was identified as missing from the facility. Resident #204 was subsequently found at 6:37 A.M. at the bottom of a steep ravine next to a creek on his knees in his bare feet with cuts, bruises and abrasions. Resident #204 was transferred to the local hospital via emergency medical services (EMS). The Immediate Jeopardy was removed on 05/09/19 at 10:30 P.M. when the facility implemented the following corrective actions: • On 05/09/19 at 6:37 A.M., Resident #204 was located and transported to the local hospital at approximately 7:06 A.M. via EMS. • On 05/09/19 at 8:00 A.M., Secure Care devices (bracelets that signal a door alarm when exiting) were validated for placement and function by Scheduler #613. Eight residents (Residents #7, #17, #25, #42, #51 #75, #78, and #81) were identified with a need for Secure Care bracelets and were verified to have bracelets in place and the devices were functioning, • On 05/09/19 at 8:15 A.M., Maintenance Director (MD) #612 completed a door check on all doors with no negative findings. All exit doors were armed with the Secure Care wander management system and functioned as designed. • On 05/09/19 at 8:30 A.M., a missing resident drill was conducted by the DON with licensed practical nurses (LPNs), registered nurses (RNs), state tested nurse aides (STNAs), activity staff and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366343 If continuation sheet Page 4 of 11 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 366343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Royalton Post Acute 9055 West Sprague Road Parma, OH 44133 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 housekeeping personnel currently in the building participating. Staff responded appropriately and followed all facility procedures. Level of Harm - Immediate jeopardy to resident health or safety • Residents Affected - Few On 05/09/19, at 12:30 P.M., the contracted maintenance company for the Secure Care security system conducted a maintenance and inspection check of all doors. All doors were functioning properly. • On 05/09/19 by 4:00 P.M., all residents identified with exit seeking behaviors (Residents #7, #17, #25, #42, #51 #75, #78, #81) were re-assessed and care plans were updated accordingly by Licensed Social Worker (LSW) #605. • On 05/09/19 by 5:00 P.M., all residents not previously identified as a risk for exit seeking behaviors were re-assessed for current risk and care plans were reviewed and revised as indicated by LSW #605. • On 05/09/19 at 10:30 P.M. staff had received education by the Administrator or DON regarding indicators of elopement and possible interventions, and review of the company's behavior practice guide including missing resident actions. This was confirmed by review of education sign in sheets. Any staff not in-serviced would not be allowed to work until education was provided by the respective department heads. • Beginning on 05/09/19, Maintenance Director #612 will complete audits of all door alarms weekly for four weeks. • Beginning on 05/09/19, the DON will complete an exit seeking audit (tool used for monitoring for elopement interventions and wandering status/behaviors for those identified at risk) weekly for four weeks and all results will be brought to the Quality Assurance Committee for evaluation and/or additional monitoring. • Interviews on 05/10/19 between 5:44 A.M. and 1:23 P.M. with STNAs #615, #617, #618, and LPNs #607 and #617, who represented all shifts, revealed staff were knowledgeable of facility policies and procedures regarding elopement and what to do in the event of missing persons. Although the Immediate Jeopardy was removed on 05/09/19 at 10:30 P.M., the deficiency remained at a Severity Level 2 (no actual harm with the potential for minimal harm that is not Immediate Jeopardy) as the facility was continuing with staff in-services and was in the process of monitoring staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366343 If continuation sheet Page 5 of 11 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 366343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Royalton Post Acute 9055 West Sprague Road Parma, OH 44133 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 exit doors to ensure compliance and determine if further action required. Level of Harm - Immediate jeopardy to resident health or safety Findings Include: Residents Affected - Few Review of Resident #204's medical record revealed he was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, high blood pressure, major depressive disorder, anxiety disorder and dementia with behavioral disturbance Review of the admission Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #204 had severe cognitive impairment with no behaviors and required limited to extensive assistance of staff for activities of daily living. Review of Resident #204's care plan dated 02/18/19 revealed he was at risk for elopement due to dementia and exit seeking behaviors. Interventions included completing a resident identity sheet due to risk factors, Secure Care device placement to left ankle, accompany to meals and activities, and engage in activities/tasks to keep occupied. Review of the medical record revealed Resident #204 was sent to a local psychiatric hospital on [DATE] for suicidal ideations. Resident #204 returned to the facility on [DATE]. Review of physician's orders for Resident #204 revealed an order dated 05/03/19 for Wanderguard (Secure Care device) placement to the left ankle. Review of the behavioral symptom assessment completed by LSW #605 dated 05/06/19 indicated Resident #204 had exit seeking, unsafe and impulse behaviors. Observation of Resident #204 on 05/06/19 at 7:57 P.M. revealed he walked with a slow shuffling gait. Resident #204 was aware of self but confused to time, place, and situation. Resident #204 was unable to provide meaningful information when interviewed. Review of the nursing progress note written by LPN #606 dated 05/08/19 and timed 8:56 P.M. revealed the resident had exit seeking behaviors noted all day and was observed wandering in and out of other patients' rooms. Review of a facility incident report dated 05/09/19 revealed Resident #204 was unable to be located when LPN #607 entered his room to give morning medication at approximately 5:45 A.M. The report indicated Resident #204 was located in a ravine with heavy brush, weeds, downed trees and tree branches, with a steep approximately 70-degree angle with no shoes on. Observation on 05/09/19 at approximately 9:30 A.M. revealed the 200 unit where Resident #204 resided had three alarmed doors at the end of each of the three hallways. Further observation revealed all facility exit doors were alarmed. The facility was encircled by a paved lighted parking lot. Approximately 20 yards behind the rear parking lot was a heavily wooded area with an approximate 70 degree drop to a creek. The wooded area was covered with dead leaves, downed trees, tree limbs, rocks, weeds and bushes. Upon walking to the area where Resident #204 was found, the terrain was slippery and difficult to traverse. Review of daily historical temperatures on accuweather.com revealed a low temperature of 52 degrees Fahrenheit (F) on 05/09/19. Review of sunrise times on timeanddate.com revealed sunrise on 05/09/19 was 6:14 A.M. Review of LPN #607's statement dated 05/09/19 revealed Resident #204 was observed trying to get into the nurses' station restroom at approximately 5:00 A.M. Resident #204 was subsequently redirected back to his room by LPN #607, toileted and put back to bed. Upon re-entering Resident #204's room to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366343 If continuation sheet Page 6 of 11 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 366343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Royalton Post Acute 9055 West Sprague Road Parma, OH 44133 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 - Immediate jeopardy to resident health or safety give medication at 5:45 A.M. LPN #607 noted Resident #204 was not in his room. An immediate search was started and a Dr. Walker (missing resident) announcement was made via the overhead paging system. Review of RN #608's statement dated 05/09/19 revealed she was made aware at 5:45 A.M. that Resident #204 was missing by LPN #607 and other staff members on the unit. RN #608 assisted with the search of Resident #204 on his unit and other areas of the building. Residents Affected - Few Review of STNA #609's statement dated 05/09/19 revealed she made no observations of restlessness or wandering behaviors throughout the night (by Resident #204). Review of STNA #611's statement dated 05/09/19 revealed she made observations of restless behaviors by Resident #204 between 12:15 A.M. and 12:30 A.M. STNA #611 indicated she sat with Resident #204 to calm him and assisted him back to bed after he calmed down. Review of the police report dated 05/09/19 revealed the police were dispatched to the facility at 6:26 A.M. for a report of a missing male (Resident #204). The report indicated Resident #204 was last seen at 5:30 A.M. in his bed and he was wearing a white shirt and plaid pajama pants. Resident #204 was found at 6:37 A.M. The narrative read Send squad he's cold and scraped up, he was by the creek. EMS arrived and transported Resident #204 to a local hospital at approximately 7:06 A.M. Review of the Emergency Documentation from the hospital dated 05/09/19 revealed Resident #204 was found down a 60 foot embankment in a creek. His tympanic (ear) temperature en route was 90 degrees F (normal oral temperature 98.6 degrees F and a tympanic temperature is 0.5 to 1 degree higher than an oral temperature), blood pressure 129/84 (normal less then 120 systolic and less than 80 diastolic) and heart rate 130 beats per minute (normal 60-100). Resident #204 did not remember the fall and denied pain. The resident stated the only thing that is bothering me is my cold feet! He was covered head to toe in abrasions. The physical exam revealed Resident #204's skin was warm and dry, cyanotic (bluish discoloration) left foot, head to toe abrasions, dry blood in mouth, right lateral chest wall ecchymosis (the escape of blood into the tissues from ruptured blood vessels), bilateral knee swelling and ecchymosis over right flank. Review of radiology reports revealed no fractures. The notes section of the documentation indicated Resident #204 was found to be hypothermic and treated with a Bair Hugger (convective temperature management system used to maintain core body temperature) as well as warmed intravenous fluids. He was admitted for additional evaluation and treatment. Interview with LPN #607 via telephone on 05/09/19 at 11:15 A.M. revealed Resident #204 went to bed on 05/09/19 at approximately 3:45 A.M. At approximately 5:00 A.M., Resident #204 was observed trying to enter the staff bathroom located at the nurses' station. LPN #607 redirected Resident #204 back to his room, took the resident to the bathroom and laid Resident #204 back in his bed at approximately 5:15 A.M. Upon reentering Resident #204's room to give morning medication, Resident #204 was not in his room. LPN #607 started an immediate headcount of all residents and a Dr. Walker (missing resident) page was announced over the facility loud speaker. LPN #607 indicated a local ambulance service arrived to drop off a resident from the local emergency room between 5:00 A.M. and 5:30 A.M. and set off the alarm to the main entrance of the facility twice. LPN #607 did not recall hearing any other alarms between 5:00 A.M. and 6:00 A.M. on 05/09/19. Interview with the DON on 05/09/19 at 11:49 A.M. revealed she arrived at the facility at approximately 5:00 A.M. Upon hearing the over-head page of Dr Walker over the loud speaker, the DON gathered information about what was going on and began an outside perimeter search of the building. The DON (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366343 If continuation sheet Page 7 of 11 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 366343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Royalton Post Acute 9055 West Sprague Road Parma, OH 44133 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 - Immediate jeopardy to resident health or safety said Resident #204 was found in a ravine behind the facility near a creek by herself, the administrator and night shift supervisor (RN #614). Resident #204 was on his knees wearing flannel pajama pants, a polo shirt and no shoes. He had scratches, cuts and bruises on his arms, legs and face. The DON indicated upon Resident #204 being found, staff were instructed to call local EMS for transport to a local hospital for evaluation. Resident #204 was escorted up the ravine by the local police department, placed in an ambulance and transported to a local hospital at approximately 6:35 A.M. on 05/09/19. Residents Affected - Few Interview with the Administrator on 05/09/19 at 11:55 A.M. revealed she arrived at the facility at 6:00 A.M. on 05/09/19. Upon arriving the to the facility, the Administrator was made aware of the situation and began assisting with the search process. At approximately 6:20 A.M., the Administrator contacted the local police department to assist in the search for the resident. Immediately following her phone call to the local police department, the Administrator contacted the spouse of Resident #204. The spouse of Resident #204 noted that Resident #204 enjoyed the outdoors and being in the woods and suggested to look in the wooded area behind the facility. The Administrator verified Resident #204 was found at the bottom of a ravine near a creek at approximately 6:30 A.M. After the resident was found, the Administrator tested Resident #204's Secure Care device and verified it was functioning with all facility exit doors. Interview with RN #608 on 05/09/19 at 1:57 P.M. revealed she last observed Resident #204 attempting to enter the bathroom located at the nurses' station at approximately 5:00 A.M. RN #608 was made aware Resident #204 was missing via the Dr. Walker page and assisted in the head count and search of the interior building for Resident #204. RN #608 denied hearing any door alarms go off in the building between 5:00 A.M. and 6:00 A.M. on 05/09/19. Interview with STNA #609 on 05/10/19 at 5:50 A.M. revealed she last saw Resident #204 at the nurses' station around 4:45 A.M. STNA #609 was made aware Resident #204 was missing by other staff members and the Doctor Walker overhead page. After finding Resident #204, STNA #609 was asked to bring shoes and a blanket to Resident #204 down in the ravine area. STNA #609 noted Resident #204 was wearing a polo shirt, pajama pants and no shoes and had cuts and scratches on his arms. STNA #609 denied hearing any door alarms going off from 5:00 A.M. to 6:00 A.M. on 05/10/19. Interviews on 05/10/19 between 5:55 A.M. and 6:00 A.M. with STNAs #610 and #611 revealed they noted Resident #204 being at or around the nurses' station between 4:00 A.M. and 5:00 A.M. Both STNAs, who were working on the unit where Resident #204 resided, were notified of Resident #204 missing by their coworkers and the Doctor Walker overhead page. Both STNAs denied hearing any door alarms going off between 5:00 A.M. and 6:00 A.M. Interview with Maintenance Director #612 on 05/10/19 at 1:11 P.M. revealed he was made aware of the elopement upon arrival to the facility around 7:30 A.M. on 05/09/19. Upon notification, MD #612 verified all doors were functioning properly and he contacted the company in charge of the monitoring system to come to the facility to check the system. Following inspection, the company indicated all exit door alarms were functioning as expected. Review of the facility's undated wandering and exit seeking policy revealed wandering was a behavioral symptom of special concern in the elderly and, or dementia population. Wandering was believed to be related to an individual's unmet need. The policy indicated the interdisciplinary team would evaluate the patient's history and current clinical conditions to identify patients at risks for wandering or exit seeking and develop a specific plan of care. Interventions that could be considered (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366343 If continuation sheet Page 8 of 11 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 366343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Royalton Post Acute 9055 West Sprague Road Parma, OH 44133 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 - Immediate jeopardy to resident health or safety included structured activity program, patient room placement in relation to egress doors, personal security bracelet and safe wandering interventions. This deficiency substantiates Complaint Number OH00104311. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366343 If continuation sheet Page 9 of 11 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 366343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Royalton Post Acute 9055 West Sprague Road Parma, OH 44133 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 0711 Level of Harm - Potential for minimal harm Residents Affected - Some Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. Based on record review and staff interview the facility failed to ensure monthly physician orders were signed and dated as required. This affected three (Residents #10, #24 and #89) of twenty six residents reviewed. The facility census was 111. Findings Include: Review of the medical records for Residents #10, #24 and #89 on 05/07/19 between 1:00 P.M. and 2:00 P.M. revealed the following: 1. The monthly physician orders for Resident #10 for April 2019, March 2019, February 2019, January 2019, December 2019, November 2018 and October 2018 were not signed by the resident's physician (Physician #975). 2. The monthly physician orders for Resident #24 for April 2019, March 2019, February 2019 and January 2019 were not signed by the resident's physician (Physician #975). 3. The monthly physician orders sheets for Resident #89 for April 2019, March 2019, February 2019, January 2019, December 2019 and were not signed by the resident's physician (Physician #975). Interview with Unit Manager #990 on 05/07/19 at 2:15 P.M. verified the physician orders were not signed. Review of the physician visit schedule revealed Physician #975 was present in the facility on 04/22/19, 03/25/19, 02/21/19 and 01/21/19. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366343 If continuation sheet Page 10 of 11 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 366343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Royalton Post Acute 9055 West Sprague Road Parma, OH 44133 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and interview the facility failed to maintain sanitary conditions in the kitchen. This had the potential to affect all residents except seven residents, #43, #258, #99, #70, #54, #97, and #93, who received nothing by mouth. Findings include: Tour of the kitchen on 05/06/19 from 8:04 P.M. to 9:18 P.M. with [NAME] #700 revealed the kitchen was partially closed down for the evening and [NAME] #700 was in the process of cleaning the slicer. [NAME] #700 indicated after cleaning the slicer he was leaving for the evening. Observations of the reach in cooler revealed various containers of thickened liquids stored within. The bottom shelf had a clearish colored wet spill and various dried stains throughout. The coffee machine had a moderate amount of lime buildup on the hot water spout and a smaller spout that dripped water was completely covered with lime. The two coffee spouts appeared cleaned but the tubing above both coffee spouts were partially covered with a caked on black substance. The stove top and the shelf above the stove top had a moderate amount of white food particles. The shelf above the stove top was also greasy. The steamer next to the stove was greasy and slightly discolored. Interview on 05/06/19 between 8:04 P.M. to 9:18: P.M. with [NAME] #700 verified the above findings and indicated the food particles on the stove and shelf was cream of wheat from the morning. Interview on 05/07/19 at 5:27 P.M. with Dietary Supervisor (DS) #701 revealed the facility did not have a cleaning policy, the cleaning schedule provided direction to staff. DS #701 stated there was not a cleaning schedule for the coffee maker but it was cleaned weekly by either himself or [NAME] #700. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366343 If continuation sheet Page 11 of 11