Inspection·December 6, 2023

F 0880 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many On 11/29/23, the Regional Clinical Service Manager educated the Administrator and DON on COVID-19 guidelines, Transmission Based Precautions guidelines, ensuring availability of PPE, and Hand Hygiene. • On 11/29/23, the Administrator and DON educated Administrative staff Medicaid Liaison #379, Minimum Data Set (MDS) Registered Nurse (RN) #380, MDS LPN #395, Business Office Manager #346, Infection Control/Wound Nurse RN #445, Housekeeping Director #430, Licensed Social Worker (LSW) #405, Registered Dietitian #391, Director of Rehab #449, Nursing Scheduler #419, Unit Manager RN #360, Human Resources/Payroll #424, Social Service Designee (SSD) #437, Maintenance Director #399, and Food Service Director #325 on policies COVID-19 guidelines, Transmission Based Precautions guidelines, including ensuring availability of PPE, and Hand Hygiene. • On 11/29/23, an Ad Hoc Resident Council meeting was held with the Activities Director, Administrator and five residents to review policies of Infection Control Practices including but not limited to handwashing and source control. • On 11/29/23, Administrative Staff as listed above educated all direct care staff on policies including COVID-19 guidelines, Transmission Based Precautions guidelines, including ensuring availability of PPE, and Hand Hygiene. The training included the appropriate use of PPE, including what to wear and when to utilize it, and when to dispose or change it. Any remaining staff not educated on 11/29/23 would be removed from the schedule after 11/29/23, pending completion of mandatory education. Education/Training was completed for 33 nurses, 40 nursing assistants, six activity staff, 10 environmental services staff and 13 dietary staff. • On 11/29/23, the facility Unit Managers on both East and [NAME] Units completed COVID-19 screens on all residents not in transmission-based precautions for COVID-19 with no adverse findings. • On 11/29/23, the Clinical Service Manager and or DON completed audits of screening of all staff, with no adverse findings. • Beginning 11/29/23, an ongoing observational audit would be completed by the Administrator/Designee daily on each shift throughout the building to ensure proper infection control practices for four weeks, then randomly thereafter. Audits would include proper hygiene, proper donning and doffing of PPE, and availability of PPE. • (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366343 If continuation sheet Page 2 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2023 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 0880 Level of Harm - Immediate jeopardy to resident health or safety Beginning 11/29/23, the facility would continue to test both residents and staff for 14 days following the last positive staff or resident. The facility would also test any resident or staff member who exhibited symptoms which would include fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body ache, headache, new loss of taste or smell, sore throat and cold like symptoms. • Residents Affected - Many Observations on 11/30/23 from 7:45 A.M. through 4:45 P.M., revealed facility staff providing care for residents were wearing correct PPE and performing hand hygiene. All halls had PPE stocked on the doors for access to correct PPE for residents with COVID-19. • Interviews on 11/30/23 between 8:00 A.M. and 4:45 P.M., with RN #450, Housekeeper #375, #306, LPN #438, STNA #330, #364, #441, and Scheduler #419, verified they had been educated on COVID-19 isolation precautions, the proper PPE to wear in the room of a resident who was positive for COVID-19, donning and doffing of PPE and hand hygiene. Although the Immediate Jeopardy was removed on 11/30/23, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: The facility had 43 residents test positive for COVID-19 from 11/11/23 through 11/26/23. On 11/11/23, Resident #97, #67, #80, and #88 tested positive for COVID-19. On 11/12/23 Resident #31, #75, #93, #16, #10, #95, #43, #38, #87, and #17 tested positive for COVID-19. On 11/14/23 Resident #34, #36, and #25 tested positive for COVID-19. On 11/16/23 Resident #78 tested positive for COVID-19. On 11/17/23 Resident #44, #81, #47, #83, #49, #51, #30, #33, #82, #69, #1, #79, and #74 tested positive for COVID-19. On 11/19/23 Resident #21 and #24 tested positive for COVID-19. On 11/21/23 Resident #62, #14 and #58 tested positive for COVID-19. On 11/23/23 Resident #37 and #77 tested positive for COVID-19. On 11/24/23 Resident #6, #11, #45, and #65 tested positive for COVID- 19 and on 11/26/23 Resident #61 tested positive for COVID-19. The facility had 12 staff members test positive for COVID-19 from 11/11/23 through 11/25/23. On 11/11/23, STNA #362, and #364 tested positive for COVID-19. On 11/12/23, RN #436 tested positive for COVID-19. On 11/14/23, RN #388 tested positive for COVID-19. On 11/15/23, Nurse Aid in Training #311 tested positive for COVID-19. On 11/17/23, STNA #384 and Admissions #386 tested positive for COVID-19. On 11/18/23, LPN #431 tested positive for COVID-19. On 11/22/23, LPN #420 tested positive for COVID-19. On 11/24/23, STNA #429 tested positive for COVID-19. On 11/25/23, Admissions #312 and Receptionist #322 tested positive for COVID-19. Per the Administrator four additional staff had tested positive for COVID-19 but did not work more than 48 hours prior to testing. An interview with the facility Infection Preventionist #445 on 11/28/23 at 3:31 P.M., revealed the facility had completed contact tracing and were unable to determine the initial source (staff or visitor) of COVID-19 in the facility. Both staff and residents tested positive initially on 11/11/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366343 If continuation sheet Page 3 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2023 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 0880 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many During the onsite investigation the following concerns were identified placing additional residents at risk for serious illness/complications from contracting COVID-19: On 11/28/23 at 12:15 P.M., State Tested Nursing Assistant (STNA) #384 was observed passing trays to residents served from the meal cart. STNA #384 was observed to be wearing an N95 mask that was visibly soiled with an orange/brown dried substance. STNA #384 donned a gown, gloves and face shield and entered Resident #37's room (Resident #37 had a diagnosis of COVID-19) with a lunch tray. Upon exit, STNA #384 did not doff the soiled N95 mask or the face shield. STNA #384 went back to the food cart, obtained another food tray, and went to pass the tray to Resident #29, a resident who was not diagnosed with COVID-19. The surveyor intervened prior to the STNA entering Resident #29's room and the STNA confirmed he did not remove or change his N95 mask or clean his face shield before or after exiting Resident #37's room and prior to going to assist another resident who was not COVID-19 positive. STNA #384 verified his N95 mask was soiled. STNA #384 then took off his N95 mask and face shield and placed it on top of Resident #37's isolation cart. STNA #384 revealed he was going to leave the mask and face shield there so he could use it again when he goes back in the room (Resident #37's room) later. On 11/28/23 at 12:27 P.M., STNA #384 was observed exiting Resident #24's room (Resident #24 had tested positive for COVID-19). STNA #384 was observed hanging his N95 mask on the inside of Resident #24's door. STNA #384 revealed he was saving the PPE to reuse it later and stated this was how they did it every day, staff would hang their PPE on the door or in the bathroom to reuse. Interview on 11/28/23 between 1:45 P.M. and 2:00 P.M., with LPN #383 and LPN #431 revealed they worked with COVID-19 positive and non-COVID-19 positive residents during the same shift. LPN #383 and #431 revealed they wore the same N-95 mask throughout the day as long as they covered it with a surgical mask when entering a COVID-19 positive room. LPN #383 revealed she also wore the same face shield throughout the day as long as she cleaned it once a day. Observation on 11/28/23 at 2:10 P.M. revealed the call light was activated above the door of Resident #37's room. Observation revealed RN Unit Manager (UM)/ADON #380 was in her office located at the entrance to the hall. RN UM/ADON #380 was observed exiting her office picking up an N95 mask and face shield off her desk. The face shield had two initials marked in black marker in the corner of the face shield. The face shield was visibly smudged with multiple fingerprints. RN UM/ADON #380 donned the N95 mask and face shield retrieved from her office, donned gloves and a gown from the isolation cart and entered Resident #37's room. Observation revealed at 2:15 P.M., RN UM/ADON #380 exited the room and walked up the hall toward her office with the N95 mask still on, while wiping off her faces shield. Upon entering her office, RN UM/ADON #380 removed the N95 mask and laid it on top of her desk. RN UM/ADON #380 confirmed she did not change her N95 mask after exiting Resident #37's room and revealed she could reuse the facemask when covered by a face shield. On 11/28/23 between 3:45 and 4:05 P.M., STNA #451 was observed wearing a surgical mask and face shield while assisting residents and throughout the halls. At 4:05 P.M., STNA #451 donned a gown to enter Resident #24's room. A sign posted on Resident #24's door to his room included the required PPE to wear when entering (an N95 mask, gown, gloves, and eye protection). STNA #451 did not don an N95 mask or gloves. STNA #451 entered Resident #24's room. While entering Resident #24's room, an N95 mask fell off the door onto the floor. Observation revealed a gown, and a face shield were also hanging on the door. STNA #451 confirmed the PPE hanging on the door and stated, sometimes they do that. STNA #451 revealed she would get the gloves in the resident's room as there were none on the isolation cart and closed the door. Upon exiting the resident's room, STNA #451 confirmed she did not wear an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366343 If continuation sheet Page 4 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2023 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 0880 Level of Harm - Immediate jeopardy to resident health or safety N95 mask into the room or gloves. STNA #451 began walking up the hall, she did not remove her surgical mask or face shield she had been wearing. STNA #451 revealed she did not need to wear an N95 mask when she wore a face shield, she only needed a surgical mask, and she did not need to change the surgical mask. STNA #451 confirmed she did not clean her face shield and stated, she only needed to clean the face shield at the end of her shift. STNA #451 then entered Resident #69's room who was not on isolation for COVID-19 and observed to physically assist Resident #69. Residents Affected - Many Interview on 11/28/23 at 4:15 P.M., with the DON revealed staff should be wearing an N95 mask, face shield, gown and gloves when entering a resident room with COVID-19. When doffing PPE, the staff could reuse the face shield if they cleaned it with soap and water after each use. The DON revealed all other PPE should be disposed of after each use. The DON confirmed the facility did not have a shortage of PPE and stated staff should not be saving PPE (other than the face shield after cleansed). The DON revealed the last education provided to staff regarding COVID-19 and donning and doffing PPE was completed on 10/05/23. Interview on 11/29/23 at 8:30 A.M., with the Administrator revealed she reported positive COVID-19 cases weekly via e-mail to the local Health Department. The Administrator stated the Health Department never gave advice or communicated back to her regarding the positive COVID-19 cases. During an interview with the DON on 11/29/23 at 11:16 A.M., the DON confirmed there was no education provided to staff on donning and or doffing PPE on or after the outbreak of COVID-19 on 11/11/23. The DON revealed there was no oversight to assure staff were donning or doffing PPE appropriately to prevent the spread of COVID-19 to additional residents. Interview on 11/29/23 at 3:15 P.M., with Medical Director #448 revealed he was made aware of the positive COVID-19 cases at the facility. Medical Director #448 revealed he instructed the facility to follow the protocols with donning and doffing PPE. Interview on 11/30/23 at 2:56 P.M., with the Communicable Disease Investigator (CDI) #452 representing the Local Health Department (LHD) revealed the facility contact person, CDI #453, did not work at the department anymore. The facility had been submitting their COVID-19-line list weekly. Where the facility was sending the information to, was not being monitored by the local health department due to the assigned person no longer being with the department and the information the facility was sending was going into an empty box. CDI #452 revealed the facility was not reassigned to another CDI. CDI #452 confirmed this was an oversight on their end, but the facility was still required to include the information to physicians at the County Board of Health, and they did not. Interview on 11/30/23 at 3:10 P.M., with the Administrator confirmed the facility had not been sending the COVID-19- line list to physicians at the County Board of Health. Interview on 11/30/23 at 3:20 P.M., with CDI #452 revealed if the HD was aware of the outbreak at the facility, the advice to the facility would have included outbreak testing every three to seven days, recommendations to encourage mask wearing for all staff. Visitors should also be encouraged, and education to staff on hand hygiene, including donning and doffing, should have been reviewed along with the most recent CMS guidelines. Interview on 12/01/23 at 12:45 P.M., with the DON revealed testing for residents and staff was every three to seven days and they would test anytime if a resident had symptoms of COVID-19. The DON revealed nurses were to observe signs and symptoms of COVID-19 during daily care. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366343 If continuation sheet Page 5 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2023 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 0880 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many Review of the policy provided for donning and doffing titled, COVID-19 Infection Prevention and Control Practice Audit, updated 07/25/22, revealed Health Care Personnel wear the following PPE in all Transmission Based Precaution rooms to include gloves, gown, N95 and eye protection. Review of the CDC guidelines titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, May 8, 2023, revealed Recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed SARS-CoV-2 infection Health Care Professionals (HCP) who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to standard precautions and use a National Institute for Occupational Safety and Health (NIOSH) approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). This deficiency represents the non-compliance discovered during the investigation of Master Complaint OH000148588. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366343 If continuation sheet Page 6 of 6