Health inspection·April 22, 2022

F 0578 Review of the facility's policy for advanced directives revised January 2022 revealed a copy of the advanced directive should be placed in the resident's chart in the event the directive should need to be implemented. 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: 366346 If continuation sheet Page 2 of 26 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 366346 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor of Grande Village 2610 East Aurora Road Twinsburg, OH 44087 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report suspicion of abuse to the State agency within the required time frame. This affected two residents (#5, and #15) of four residents reviewed regarding submitted Self-Reported Incidents (SRIs). Facility census was 76. Findings include: Review of the medical record for Resident #5 revealed an admission date of 11/16/20. Diagnosis included dementia without behavioral disturbance. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5's cognition was not assessed and the resident was independent with bed mobility, required limited assistance of one staff for transfers, and supervision of one staff for ambulation. Review of the progress note dated 03/30/22 at 5:33 P.M. revealed a state tested nurse aide (STNA) notified the nurse Resident #5 attempted an inappropriate sexual act with another resident (Resident #15). Both residents were placed on 15 minute checks for 24 hours. The Unit Manager and Administrator were notified to notify physician and family. Review of the medical record for Resident #15 revealed an admission date of 07/19/21. Diagnosis included dementia with behavioral disturbances. Review of the quarterly MDS assessment dated [DATE] revealed Resident #15 had severely impaired cognition and required supervision of one staff for bed mobility, and supervision with set up help for transfers, and ambulation. Review of the progress note dated 03/30/22 at 5:33 P.M. revealed the STNA notified the nurse Resident #15 attempted an inappropriate sexual act with another resident (Resident #5). Both residents were placed on 15 minute checks for 24 hours. The Unit manager and Administrator were notified to notify physician and family. Review of Self Reported Incident (SRI) number 219744 dated 03/31/22 timed 2:54 P.M. revealed an allegation or suspicion of sexual abuse with a date of discovery as 03/30/22 at 9:35 A.M. involving Residents #5 and #15. Interview on 04/21/22 at 9:27 A.M. with the Director of Nursing (DON) revealed they were made aware of the incident involving Residents #5 and #15 the morning of 03/30/22 as staff were coming into work. The DON stated the Administrator handled the SRI. Interview on 04/21/22 at 6:35 P.M. with the Administrator revealed the incident involving Resident #5 and #15 was reported the following day because he wavered because the incident involved residents with dementia. The Administrator stated he wanted to talk with the residents' families and was looking for guidance regarding abuse reporting. The Administrator stated looking back he should had reported the incident the day it occurred. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366346 If continuation sheet Page 3 of 26 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 366346 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor of Grande Village 2610 East Aurora Road Twinsburg, OH 44087 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on review of a facility Self-Reported Incident (SRI) and investigation, and staff interview, the facility failed to thoroughly investigate an allegation of sexual abuse for two residents (Residents #5 and #15). This affected two residents (Resident's #5 and #15) out of four residents reviewed for abuse. The facility census was 76. Residents Affected - Few Findings include: Review of the SRI dated 03/31/22 for alleged sexual abuse involving Residents #5 and #15 revealed Resident #5 and Resident #15 were witnessed by a State Tested Nurse Aide (STNA) attempting to engage in a sexual act. The witness statements in the investigative file included typed phone interviews completed by the Administrator. The witness statements were from Housekeeping Aide (HA) #580, STNA #586 and Agency Nurse #588. All three statements confirmed it looked like Residents #5 and #15 were attempting to engage in a sexual act. The statements were not signed and did not contain details regarding what was actually witnessed. Agency Nurse #588's typed statement indicated both residents were placed on 15 minute checks, skin checks were completed for both Resident #5 and #15 with no concerns, and family, physician and management were notified. Interview on 04/20/22 at 1:49 P.M. with the Director of Nursing (DON) revealed she became aware of an incident between Resident #5 and Resident #15 when she came to work 03/30/22. She was told both residents attempted to pull their pants down. The DON did not have any more specific details about the encounter. The DON indicated the Administrator was notified and began an investigation on 03/30/22. Interview on 04/21/22 at 9:00 A.M. with HA #580 revealed he walked past Resident #15's room and witnessed Resident #15 with his hands down Resident #5's pants. Resident #15 was sitting in a wheelchair and Resident #5 was standing in front of him with her pants pulled down to her upper thighs. HA #580 told STNA #586 what he witnessed. Interview on 04/21/22 at 9:53 A.M. with STNA #586 revealed she was in the nurses' station when HA #580 told her two residents (Resident #5 and Resident #15) were in a room kissing. She went to the room and asked both residents to come to the common area. She then asked another unidentified STNA to keep an eye on Resident #5 and #15 while she cared for another resident in a different area. When STNA #586 returned to the common area Residents #5 and #15 were no longer in the common area and had gone to Resident #5's room. Resident #5 had her pants down and she bent down to kiss Resident #15 who was sitting in a wheelchair. STNA #586 reported the situation to Agency Nurse #588. Review of the facility policy for abuse revised July 2021 revealed the Administrator would interview the resident, obtain a statement and review the resident's record. In the case of resident to resident abuse, the Administrator would refer to the interdisciplinary team to determine appropriate follow up interventions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366346 If continuation sheet Page 4 of 26 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 366346 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor of Grande Village 2610 East Aurora Road Twinsburg, OH 44087 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #30 revealed an admission date of 05/09/21. Diagnoses included cerebral infarction, dementia, Parkinson's disease, diabetes, and chronic atrial fibrillation. Resident #30 was transferred to the hospital on [DATE] and 02/23/22. Review of the annual Minimum Data Set (MDS) assessment, dated 03/30/22, revealed Resident #30 had moderately impaired cognition, required the extensive assistance of two people for bed mobility, transfers, and toileting, and extensive assistance of one was needed for locomotion, dressing and personal hygiene. Review of the Transfer/Discharge form dated 01/21/22 revealed Resident #30's daughter/ power of attorney (POA) was notified by phone, a written notice was not provided. Review of the Transfer/Discharge form from 02/23/22 revealed the Resident #30's daughter/ POA was notified by phone, a written notice was not provided. 4. Review of the medical record for Resident #50 revealed an admission date of 11/28/20. Diagnoses included metabolic encephalopathy, type 2 diabetes mellitus, seizures, protein-calorie malnutrition, and right and left leg below knee amputation. Review of the medical record for Resident #5 revealed an admission date of 11/16/20 with diagnoses of major depressive disorder, dementia, muscle weakness and hypoxemia. Review of the list of hospital transfers and discharges dated December 2021 through April 2022 revealed Resident #50 transferred to the hospital on [DATE], 12/22/21, and 03/01/22. Review of the Transfer/Discharge Notice forms dated 12/02/21, 12/22/21, and 03/01/22 revealed the form was reviewed with Resident #50's Power of Attorney (POA) via phone and did not list the reason for the hospital transfers. Interview on 04/21/22 at 8:22 A.M. with Admissions Staff (AS) #541 revealed she emailed the LTC Ombudsman the hospital transfers and discharges for December 2021, January 2022, and February 2022 on 04/20/22. AS #541 stated she usually emailed the list in the first couple days of the following month and could not find evidence that those months were sent prior to 04/20/22. AS #541 verified the hospital transfer notices did not provide the reason for the transfer and that she did not provide written notices to the residents' or their representatives. AS #541 stated she usually asked them if they wanted a copy and believed they had all declined. Reviewed the facility policy titled Transfer Discharge Notice Protocol, dated October 2018, revealed it was the policy of the facility for staff to complete the Transfer/Discharge Notice at the time of discharge or transfer. The notice should be signed by the resident (if able) at the time of discharge or transfer. If the discharge or transfer was emergent in nature, staff were to follow up with the family via phone and review the Transfer Discharge Notice. The tracker was to include the following information: Date of Discharge, Resident's Name, Discharge Destination, Date Written Notification Provided to Resident and or Resident Representative, Date of Re-admission, and, if applicable, Location of Alternate Discharge Location. At the beginning of each month, last month's tracker was to be submitted to the Ombudsman's office and the local state department of health, if so directed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366346 If continuation sheet Page 5 of 26 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 366346 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor of Grande Village 2610 East Aurora Road Twinsburg, OH 44087 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Based on staff interview and record review, the facility failed to ensure a resident received notice of discharge in a timely manner. This affected one resident ( Resident #20) of one resident reviewed for discharge from facility. The facility also failed to ensure written notice of hospital transfers including the reason for the transfer were given to the resident or their representative and were provided to the long term care (LTC) Ombudsman in a timely manner. This affected three residents (#30, #33, and #50) of three residents reviewed for hospitalization. The facility census was 76. Findings include: 1. Review of the medical record for Resident #20 revealed an admission date of 12/23/21. Diagnoses included dysphasia, schizophrenia, anxiety, and depression. Review of the accounting notes dated 03/17/22 revealed Resident #20 was provided with a 30-day discharge letter on 03/17/22. Review of the undated 30-day discharge notice, revealed Resident #20 would be discharged on 04/16/22 due to the resident being cut by insurance. Review of the discharge records for Resident #20, revealed the resident was discharged on 04/12/22. Interview on 04/20/22 at 12:31 P.M. with Business Office Manager (BOM) #518 verified the 30-day discharge notice was undated. BOM #518 said the discharge notice was given to Resident #20 on 03/17/22, which was not 30 days prior to the resident's discharge. 3. Review of the medical record for Resident #33 revealed an admission date of 02/10/22 with diagnoses of dementia, osteoarthritis and heart disease. Review of a progress note dated 02/03/22 revealed an X-ray ordered by the physician's assistant revealed a hip fracture and an order to send Resident #33 to the hospital. Review of a progress note dated 02/06/22 revealed Resident #33 was sent to the hospital because she was unable to bear weight on the right side of her body and appeared to be in pain when she moved. Resident #33 was admitted to the hospital for a right hip fracture. Review of the transfer and discharge notices from the facility for the month of February 2022 revealed there was no reason provided to Resident #33 for the transfer on 02/03/22 and there was no evidence of a transfer and discharge notice being provided to Resident #33 on 02/06/22. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366346 If continuation sheet Page 6 of 26 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 366346 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor of Grande Village 2610 East Aurora Road Twinsburg, OH 44087 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 0635 Provide doctor's orders for the resident's immediate care at the time the resident was admitted. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to obtain an order for dialysis upon admission for one (#279) out of one resident reviewed for dialysis services. The facility identified two current residents who received dialysis services. The facility census was 76. Residents Affected - Few Findings include: Review of the medical record for Resident #279 revealed the resident was admitted to the facility on [DATE]. Diagnoses included end stage renal disease, hypothyroidism, and anemia. Resident #279 was receiving dialysis services prior to admission. Further medical record review revealed documentation of Resident #279 receiving dialysis on 04/08/22, 04/11/22, 04/13/22, 04/15/22, 04/18/22, and 04/20/22. Review of Resident #279's admission physician orders and subsequent orders revealed an order for Resident #279 to receive dialysis every Monday, Wednesday, and Friday beginning on 04/13/22. There was no order for the resident to receive dialysis services prior to 04/13/22. Interview on 04/21/22 at 1:17 P.M. with the Director of Nursing verified Resident #279's medical record did not contain a physician's orders for dialysis prior to the resident receiving dialysis services on 04/08/22 and 04/11/22. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366346 If continuation sheet Page 7 of 26 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 366346 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor of Grande Village 2610 East Aurora Road Twinsburg, OH 44087 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 - Minimal harm or potential for actual harm 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 observation, interview, record review, and review of facility policy the facility failed to ensure care planned interventions were implemented to prevent one resident (Resident #7) from obtaining the code and entering a secured area on the nursing unit she resided on. This affected one resident (Resident #7) out of three residents reviewed for supervision. The facility census was 76. Findings include: Review of Resident #7's medical record revealed an admission date of 12/30/20 and diagnoses including dementia, type two diabetes mellitus, and macular degeneration. Review of Resident #7's care plan dated, 02/11/21 revealed Resident #7 had the potential for injury and was an identified wanderer related to Alzheimer's disease, dementia, confusion, and desire to go home. The goal indicated Resident #7 would wander in safe locations and would have safety maintained. Interventions included to know Resident #7's whereabouts, attempt to divert, determine pattern to wandering, report episodes, exit door alarms on and safety checks as needed. Review of Resident #7's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed Resident #7 was rarely or never understood. Resident #7 was independent for bed mobility, transfers, and toilet use. Resident #7 was always continent of urine and bowel, was steady at all times while walking, and required supervision for locomotion. Observation on 04/18/22 at 8:22 P.M. revealed Resident #7 sitting in the common area near the nurses station. Ongoing observation revealed Resident #7 standing up, walking to a door with the word SPA on it across from the nurses station, entering a code, opening the door, walking through the door and closing the door. Licensed Practical Nurse (LPN) #583 and State Tested Nursing Assistant (STNA) #584 were sitting in the nurses station talking to each other and did not observe Resident #7 using a code to open the door to the Spa room and enter. Resident #7 was in the Spa room five minutes then came out of the room and stated there were no paper towels in the bathroom to dry her hands. There were no staff members present in the SPA room. Interview on 04/18/22 at 8:26 P.M. with Business Office Manager (BOM) #518 confirmed Resident #7 was in the Spa room by herself, used a code to get in and was going to the bathroom. Interview on 04/18/22 at 8:41 P.M. with STNA #584 revealed this was her first time working in the facility, she didn't know the residents, but the residents were not supposed to know the code to the SPA room. Interview on 04/18/22 at 10:08 P.M. with the Director of Nursing (DON) revealed the residents should not know the code to the SPA room and she would get the code changed immediately. Interview on 04/18/22 at 10:10 P.M. of LPN #583 revealed BOM #518 informed her Resident #7 knew the code to the SPA room and was in the room unsupervised. LPN #583 stated she did not know Resident #7 entered the SPA room and the residents should be supervised when they were in the SPA room. Observation on 04/19/22 at 3:13 P.M. of the SPA bathroom revealed there was a large tub in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366346 If continuation sheet Page 8 of 26 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 366346 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor of Grande Village 2610 East Aurora Road Twinsburg, OH 44087 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 - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete center of the room, a room with a toilet, and a door which opened to a common area outside of the secured unit. The door opening to the common area outside the secured unit required a code to open. Review of the facility policy titled Dementia Care Policy, revised 03/2022, revealed it was the policy of the facility to provide competent care to any resident who displayed or was diagnosed with dementia. Appropriate treatment and services would be provided to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Event ID: Facility ID: 366346 If continuation sheet Page 9 of 26 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 366346 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor of Grande Village 2610 East Aurora Road Twinsburg, OH 44087 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observation, interview, record review, and review of the facility policy the facility failed to implement care planned interventions to ensure one resident's (Resident #46) incontinence care was completed timely. This affected one resident (Resident #46) out of three residents reviewed for incontinence care. The facility census was 76. Findings include: Review of Resident #46's medical record revealed an admission date of 08/13/16 and diagnoses including Alzheimer's disease, anxiety, dementia and restlessness, and agitation. Review of Resident #46's Quarterly Minimum Data Set (MDS) 3.0 assessment dated , 03/09/22, revealed Resident #46 was rarely or never understood. Resident #46 required the extensive assistance of two staff members for bed mobility, transfers, toilet use, and was always incontinent of urine and bowel. Resident #46 had little interest or pleasure in doing things, was feeling down, had trouble falling or staying asleep, was short tempered and easily annoyed. Review of Resident #46's care plan dated, 03/23/22 revealed Resident #46 was incontinent with the potential for decreased episodes of incontinence. Resident #46 had decreased mobility and functional incontinence and would have decreased episodes of incontinence. Interventions included to check and change every two hours and as needed. Resident #46 had a need for behavior to be monitored. Resident #46 had the potential for altered behavior patterns, disruptive interactions, disruptive verbally, yelling, resistive to care, violence, anger, agitation or anxiety. Resident #46 would cope with routine and occurrences of behaviors would be minimized. Interventions included to administer prescribed medication, observe for side effects, monitor effectiveness, assess for internal and external contributors, and consult with psychiatry if needed, requested per resident, family, physician. Resident #46 received psychotropic medications with the potential for falls, injury, potential for harmful side effects. Resident #46's symptoms would be controlled reduced with current medication with no adverse side effects to resident. Interventions included one to one visit as needed, involve family, make referrals, refer to psych services as needed, administer medications as ordered, monitor for side effects to medication and provide notification per facility protocol and follow up as ordered, monitor AIMS test per protocol and as needed, provide psychological care if symptoms become worse and medication was ineffective with families permission. Observations on 04/18/22 at 8:30 P.M., 9:30 P.M., 10:30 P.M. and 11:00 P.M. revealed Resident #46 sitting in her wheelchair continually propelling herself up and down the hallway and around the common area. Observation on 04/18/22 at 9:11 P.M. revealed Resident #46 sitting in her wheelchair propelling herself in the hall and urine was seen dripping off the bottom of the wheelchair onto the floor. Wet spots of urine could be seen on the floor trailing behind Resident #46. State Tested Nursing Assistant (STNA) #584 indicated Resident #46 was wet and a fighter, and she needed assistance to change her incontinence brief. STNA #584 stated she told Licensed Practical Nurse (LPN) #583 Resident #46 was wet and had urine dripping off the wheelchair onto the floor and she needed assistance. Resident #16 wearing non-skid socks, was following Resident #46's wheelchair and wiping the urine up with her socked foot. STNA #584 confirmed Resident #16 was wiping the urine up with her sock and stated she would change Resident #16's footwear soon. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366346 If continuation sheet Page 10 of 26 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 366346 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor of Grande Village 2610 East Aurora Road Twinsburg, OH 44087 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 04/18/22 at 9:18 P.M. of Resident #46 revealed LPN #583 and STNA #584 walked across the common area, made one attempt to push Resident #46's wheelchair, Resident #46 resisted and LPN #583 and STNA #584 walked away from Resident #46. LPN #583 stated Resident #46 did not want to lay down, STNA #584 was pregnant and she did not want her to get hurt so they were going to wait to change Resident #46. LPN #584 stated she administered Ativan (anti-anxiety) to Resident #46 and was going to wait a bit, then try to change her. LPN #584 verified Resident #46's incontinence brief was saturated with urine and dripping on the floor off the bottom of the wheelchair. LPN #584 and STNA #583 walked away from Resident #46. Observation on 04/18/22 at 9:44 P.M. of Resident #46 revealed LPN #583 and STNA #584 pushed Resident #46 in her room and attempted to put Resident #46 into bed to change her incontinence brief. Resident #46 was combative and spit on STNA #584's forehead. STNA #584 revealed this was the first night she worked in the facility and LPN #583 stated this was her second night working in the facility and both confirmed they did not know the residents and wished there was another STNA working who was familiar with the residents. Observation on 04/18/22 at 10:16 P.M. of LPN #583 revealed she walked out of the secured nursing unit to find the Director of Nursing (DON). LPN #583 stated she needed the assistance of the DON with Resident #46's care. The DON arrived at the secured unit, thought Resident #16 was Resident #46 and approached Resident #16 to provide incontinence care. After intervention of the surveyor the DON enlisted the assistance of LPN/Unit Manager/Restorative Nurse (LPN/UM/RN) #569 to provide care for Resident #46. The DON and LPN/UM/RN #569 stayed in the unit approximately 15 minutes then left the unit without providing incontinence care for Resident #46. Interview on 04/18/22 at 10:20 P.M. with LPN #583 indicated the DON told her to leave the resident alone for now and not attempt to provide incontinence care. Observation on 04/19/22 at 6:28 A.M. of Resident #46 revealed she was sitting in her wheelchair and continually propelling herself up and down the hallway and around the common area. Interview on 04/19/22 at 6:30 A.M. with LPN #583, STNA #584 and STNA #585 revealed Resident #46 did not sleep all night and continually propelled herself up and down the hallway and around the common areas. STNAs #584 and #585 stated if they attempted to provide care for Resident #46 during the night she was combative and tried to spit on them. LPN #583 stated she did not call Resident #46's physician, physician assistant, or responsible party regarding Resident #46's combativeness and refusal to allow incontinence care for nine hours. LPN #583 stated Resident #46 was in the same saturated incontinence brief all night, dripping urine from her wheelchair until 5:30 A.M. when she was changed. LPN #583 stated the DON did not call or return to the secured nursing unit after she left around 10:30 P.M. Observation on 04/19/22 at 2:39 P.M. of Resident #46 revealed STNA #586 and LPN #516 provided incontinence care. Resident #46 did not have redness or skin breakdown to her bottom. LPN #516 stated Resident #46 was lucky and had really good skin and didn't have skin breakdown even when she sat in a wet incontinence brief for a long time. Interview on 04/20/22 at 4:25 P.M. with the DON revealed Resident #46 was very combative and at those times she needed to be left alone until she calmed down. The DON stated Resident #46's physician should have been called and notified of her behaviors. The DON indicated Resident #46 was administered three medications on a regular schedule for her behaviors, and it was hard balancing her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366346 If continuation sheet Page 11 of 26 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 366346 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor of Grande Village 2610 East Aurora Road Twinsburg, OH 44087 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few medications with her behaviors and not have her overmedicated. The DON stated LPN #583 and STNA #584 were from an agency and were not used to working in a memory care unit. Interview on 04/20/22 at 4:57 P.M. with LPN/UM/RN #569 revealed Resident #46 was typically good with staff she knew, but she still could be combative. LPN/UM/RN #569 stated she told the DON staff must know how to approach Resident #46, and she felt like the approach LPN #583 and STNA #584 used was not conducive to her responding and allowing care. LPN/UM/RN #569 stated she didn't know Resident #46 had a urine saturated incontinence brief, or was not changed until 04/19/22 at 5:30 A.M. LPN/UM/RN #569 indicated she felt like Resident #46 could have been changed, and didn't know the staff was trying to provide incontinence care when she was on the unit on 04/18/22 at around 10:30 P.M. LPN/UM/RN #569 stated she worked so many hours on 04/18/22, she didn't know what was going on and that was why she did not take the lead for Resident #46's incontinence care. LPN/UM/RN #569 revealed LPN #583 should have called Resident #46's physician. Interview on 04/21/22 at 11:16 A.M. with the DON revealed she instructed LPN/UM/RN #569 and LPN #583 to call Resident #46's physician and notify him about the situation, thought the physician was called, and did not know why the physician was not called. The DON stated she felt bad about the way the situation was handled. Review of Resident #46's progress notes from 04/18/22 at 7:00 P.M. through 04/19/22 at 7:00 A.M. revealed a note written on 04/19/22 at 3:34 A.M. included Resident #46 was hitting, kicking and spitting at staff and refused to allow staff to change her incontinence brief. Resident #46 wandered and her behaviors significantly disrupted her care. Further review of Resident #46's progress notes did not reveal documentation the physician or responsible party was notified of the behaviors or resistance to care. Review of the facility policy titled Incontinence Care Protocol, revised 03/2022, revealed it was the policy of the facility to outline appropriate management for all residents with incontinence, to prevent loss of skin integrity. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366346 If continuation sheet Page 12 of 26 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 366346 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor of Grande Village 2610 East Aurora Road Twinsburg, OH 44087 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and review of the facility policy the facility failed to implement care planned interventions to timely identify a significant weight loss for Resident #75 and notify the dietitian. This affected one resident (Resident #75) out of one resident reviewed for weight loss. The facility census was 76. Residents Affected - Few Findings include: Review of the medical record for Resident #75 revealed an admission date of 01/28/22 with diagnoses of severe protein calorie malnutrition, acute cystitis with hematuria, muscle weakness, hypothyroidism, and hypertension. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated she was moderately cognitively impaired. The MDS also indicated the resident was malnourished. Review of Resident #75's admission weight on 01/28/22 revealed a weight of 120.0 pounds. Review of the care plan dated 01/31/22 revealed Resident #75 was at risk for decreased nutritional status and had a body mass index below normal limits. The goals were to be free from significant weight changes and maintain nutritional through comfort food and fluid preferences of choice until the next care plan review. The interventions were to monitor weight per protocol, monitor diet tolerance, meal intake and assist with meals and feeding as needed. Review of Resident #75's weight dated 02/17/22 revealed a weight of 97.3 pounds, indicating a 18.92 percent weight loss in 20 days. Review of the progress notes dated 02/18/22 revealed Resident #75 and family discussed their concerns about nutrition with the nurse and agreed nutrition played a big part in planning for the Resident 75's discharge. Resident #75 asked for a feeding tube and arrangements were initiated to transfer Resident #75 to the hospital for feeding tube insertion. It was ultimately decided by the family they would take Resident #75 to the hospital to have a total parenteral nutrition (TPN) line which would provide hydration and nutrition. Interview on 04/20/22 at 2:03 P.M. with the Director of Nursing (DON) revealed weights were to be obtained weekly for the first month for all new admissions. If a problem with weights was identified the dietitian and nurse practitioner were notified. After the dietitian and nurse practitioner were notified, documentation of the notification was completed in the resident's medical record. Interview with Dietitian #587 on 04/20/22 at 2:27 P.M. revealed she was told by the DON on 04/20/22 Resident #75 was refusing weights. Prior to this notification, she was not aware of Resident #75 having a weight loss. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366346 If continuation sheet Page 13 of 26 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 366346 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor of Grande Village 2610 East Aurora Road Twinsburg, OH 44087 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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on record review and staff interview the facility failed to maintain the services of a registered nurse for at least eight consecutive hours a day, seven days a week. This had the potential to affect all 76 residents currently residing in the facility. Findings include: Review of the staffing schedules from 04/14/22 through 04/17/22 revealed no registered nurses (RNs) were working in the facility on 04/17/22. Review of the posted nursing staff information for 04/17/22 revealed no RNs were present in the facility on this date. Interview on 04/21/22 at 6:46 P.M. with Human Resources #511 verified there were no RNs working in the facility on 04/17/22. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366346 If continuation sheet Page 14 of 26 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 366346 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor of Grande Village 2610 East Aurora Road Twinsburg, OH 44087 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 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation and staff interview the facility failed to ensure daily posted nursing staff information was posted and timely updated. This had the potential to affect all 76 residents residing in the facility. Residents Affected - Many Findings include: Observation on 04/18/22 at 8:33 P.M. revealed the daily posted nursing staff information was not posted. Interview at this time with the Administrator revealed the information was usually at the receptionist desk. The Administrator pointed to an empty plastic holder posted on wall behind the receptionist desk. Interview on 04/18/22 at 8:36 P.M. with the Administrator verified the daily posted nursing staff information was not posted. Observation on 04/19/22 at 9:49 A.M. revealed the daily posted nursing staff information was dated 04/18/22. Interview at this time with the Administrator and Receptionist #533 verified the daily posted nursing staff information was dated 04/18/22 and the information for 04/19/22 was not yet posted. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366346 If continuation sheet Page 15 of 26 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 366346 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor of Grande Village 2610 East Aurora Road Twinsburg, OH 44087 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 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #46's medical record revealed an admission date of 08/13/16 and diagnoses including Alzheimer's disease, anxiety, dementia and restlessness, and agitation. Residents Affected - Few Review of Resident #46's Quarterly Minimum Data Set (MDS) 3.0 assessment dated , 03/09/22, revealed Resident #46 was rarely or never understood. Resident #46 required the extensive assistance of two staff members for bed mobility, transfers, toilet use, and was always incontinent of urine and bowel. Resident #46 had little interest or pleasure in doing things, was feeling down, had trouble falling or staying asleep, was short tempered and easily annoyed. Review of Resident #46's care plan dated, 03/23/22 revealed Resident #46 was incontinent with the potential for decreased episodes of incontinence. Resident #46 had decreased mobility and functional incontinence and would have decreased episodes of incontinence. Interventions included to check and change every two hours and as needed. Resident #46 had a need for behavior to be monitored. Resident #46 had the potential for altered behavior patterns, disruptive interactions, disruptive verbally, yelling, resistive to care, violence, anger, agitation or anxiety. Resident #46 would cope with routine and occurrences of behaviors would be minimized. Interventions included to administer prescribed medication, observe for side effects, monitor effectiveness, assess for internal and external contributors, and consult with psychiatry if needed, requested per resident, family, physician. Resident #46 received psychotropic medications with the potential for falls, injury, potential for harmful side effects. Resident #46's symptoms would be controlled reduced with current medication with no adverse side effects to resident. Interventions included one to one visit as needed, involve family, make referrals, refer to psych services as needed, administer medications as ordered, monitor for side effects to medication and provide notification per facility protocol and follow up as ordered, monitor AIMS test per protocol and as needed, provide psychological care if symptoms become worse and medication was ineffective with families permission. Observations on 04/18/22 at 8:30 P.M., 9:30 P.M., 10:30 P.M. and 11:00 P.M. revealed Resident #46 sitting in her wheelchair continually propelling herself up and down the hallway and around the common area. Observation on 04/18/22 at 9:11 P.M. revealed Resident #46 sitting in her wheelchair propelling herself in the hall and urine was seen dripping off the bottom of the wheelchair onto the floor. Wet spots of urine could be seen on the floor trailing behind Resident #46. State Tested Nursing Assistant (STNA) #584 indicated Resident #46 was wet and a fighter, and she needed assistance to change her incontinence brief. STNA #584 stated she told Licensed Practical Nurse (LPN) #583 Resident #46 was wet and had urine dripping off the wheelchair onto the floor and she needed assistance. Resident #16 wearing non-skid socks, was following Resident #46's wheelchair and wiping the urine up with her socked foot. STNA #584 confirmed Resident #16 was wiping the urine up with her sock and stated she would change Resident #16's footwear soon. Observation on 04/18/22 at 9:18 P.M. of Resident #46 revealed LPN #583 and STNA #584 walked across the common area, made one attempt to push Resident #46's wheelchair, Resident #46 resisted and LPN #583 and STNA #584 walked away from Resident #46. LPN #583 stated Resident #46 did not want to lay down, STNA #584 was pregnant and she did not want her to get hurt so they were going to wait to change Resident #46. LPN #584 stated she administered Ativan (anti-anxiety) to Resident #46 and was going (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366346 If continuation sheet Page 16 of 26 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 366346 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor of Grande Village 2610 East Aurora Road Twinsburg, OH 44087 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 0744 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to wait a bit, then try to change her. LPN #584 verified Resident #46's incontinence brief was saturated with urine and dripping on the floor off the bottom of the wheelchair. LPN #584 and STNA #583 walked away from Resident #46. Observation on 04/18/22 at 9:44 P.M. of Resident #46 revealed LPN #583 and STNA #584 pushed Resident #46 in her room and attempted to put Resident #46 into bed to change her incontinence brief. Resident #46 was combative and spit on STNA #584's forehead. STNA #584 revealed this was the first night she worked in the facility and LPN #583 stated this was her second night working in the facility and both confirmed they did not know the residents and wished there was another STNA working who was familiar with the residents. Observation on 04/18/22 at 10:16 P.M. of LPN #583 revealed she walked out of the secured nursing unit to find the Director of Nursing (DON). LPN #583 stated she needed the assistance of the DON with Resident #46's care. The DON arrived at the secured unit, thought Resident #16 was Resident #46 and approached Resident #16 to provide incontinence care. After intervention of the surveyor the DON enlisted the assistance of LPN/Unit Manager/Restorative Nurse (LPN/UM/RN) #569 to provide care for Resident #46. The DON and LPN/UM/RN #569 stayed in the unit approximately 15 minutes then left the unit without providing incontinence care for Resident #46. Interview on 04/18/22 at 10:20 P.M. with LPN #583 indicated the DON told her to leave the resident alone for now and not attempt to provide incontinence care. Observation on 04/19/22 at 6:28 A.M. of Resident #46 revealed she was sitting in her wheelchair and continually propelling herself up and down the hallway and around the common area. Interview on 04/19/22 at 6:30 A.M. with LPN #583, STNA #584 and STNA #585 revealed Resident #46 did not sleep all night and continually propelled herself up and down the hallway and around the common areas. STNAs #584 and #585 stated if they attempted to provide care for Resident #46 during the night she was combative and tried to spit on them. LPN #583 stated she did not call Resident #46's physician, physician assistant, or responsible party regarding Resident #46's combativeness and refusal to allow incontinence care for nine hours. LPN #583 stated Resident #46 was in the same saturated incontinence brief all night, dripping urine from her wheelchair until 5:30 A.M. when she was changed. LPN #583 stated the DON did not call or return to the secured nursing unit after she left around 10:30 P.M. Observation on 04/19/22 at 2:39 P.M. of Resident #46 revealed STNA #586 and LPN #516 provided incontinence care. Resident #46 did not have redness or skin breakdown to her bottom. LPN #516 stated Resident #46 was lucky and had really good skin and didn't have skin breakdown even when she sat in a wet incontinence brief for a long time. Interview on 04/20/22 at 4:25 P.M. with the DON revealed Resident #46 was very combative and at those times she needed to be left alone until she calmed down. The DON stated Resident #46's physician should have been called and notified of her behaviors. The DON indicated Resident #46 was administered three medications on a regular schedule for her behaviors, and it was hard balancing her medications with her behaviors and not have her overmedicated. The DON stated LPN #583 and STNA #584 were from an agency and were not used to working in a memory care unit. Interview on 04/20/22 at 4:57 P.M. with LPN/UM/RN #569 revealed Resident #46 was typically good with staff she knew, but she still could be combative. LPN/UM/RN #569 stated she told the DON staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366346 If continuation sheet Page 17 of 26 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 366346 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor of Grande Village 2610 East Aurora Road Twinsburg, OH 44087 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 0744 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few must know how to approach Resident #46, and she felt like the approach LPN #583 and STNA #584 used was not conducive to her responding and allowing care. LPN/UM/RN #569 stated she didn't know Resident #46 had a urine saturated incontinence brief, or was not changed until 04/19/22 at 5:30 A.M. LPN/UM/RN #569 indicated she felt like Resident #46 could have been changed, and didn't know the staff was trying to provide incontinence care when she was on the unit on 04/18/22 at around 10:30 P.M. LPN/UM/RN #569 stated she worked so many hours on 04/18/22, she didn't know what was going on and that was why she did not take the lead for Resident #46's incontinence care. LPN/UM/RN #569 revealed LPN #583 should have called Resident #46's physician. Interview on 04/21/22 at 11:16 A.M. with the DON revealed she instructed LPN/UM/RN #569 and LPN #583 to call Resident #46's physician and notify him about the situation, thought the physician was called, and did not know why the physician was not called. The DON stated she felt bad about the way the situation was handled. Review of Resident #46's progress notes from 04/18/22 at 7:00 P.M. through 04/19/22 at 7:00 A.M. revealed a note written on 04/19/22 at 3:34 A.M. included Resident #46 was hitting, kicking and spitting at staff and refused to allow staff to change her incontinence brief. Resident #46 wandered and her behaviors significantly disrupted her care. Further review of Resident #46's progress notes did not reveal documentation the physician or responsible party was notified of the behaviors or resistance to care. Based on observation, interview, record review and review of the facility policy the facility failed to ensure appropriate supervision was provided Residents #5 and #15, and failed to ensure staff were knoweldgable regarding how to approach Resident #46 to ensure timely provision of incontinence care. This affected three of 25 residents residing on the secured dementia unit. The facility census was 76. Findings include: 1. Review of the medical record for Resident #5 revealed an admission date of 11/16/20 with diagnoses of major depressive disorder, dementia, muscle weakness and hypoxemia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #5 was rarely or never understood when communicating and needed substantial assistance in almost all activities of daily living (ADLs). Review of the care plan dated 04/19/22 for Resident #5 revealed a problem with disruptive sexual interaction and dementia with a goal to interact with others and staff appropriately. The interventions included to monitor behaviors and intervene when appropriate. Observation on 04/20/22 at 8:03 A.M. revealed Resident #5 sitting on the couch in the common area within view of staff. Interview on 04/21/22 at 9:00 A.M. with Housekeeping Aide #580 revealed he walked past Resident #15's room on 03/30/21 and witnessed Resident #15 with his hands down Resident #5's pants. Resident #15 was sitting in a wheelchair and Resident #5 was standing in front of him with her pants pulled down to her upper thighs. HA #580 immediately told StateTested Nurse Aide (STNA) #586 what he witnessed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366346 If continuation sheet Page 18 of 26 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 366346 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor of Grande Village 2610 East Aurora Road Twinsburg, OH 44087 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 0744 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 04/21/22 at 9:53 A.M. with STNA #586 revealed she was in the nurses' station on 03/30/22 when Housekeeping Aide (HA) #580 told her two residents (Resident #5 and Resident #15) were in a room kissing. She went to the room and asked both residents to come to the common area. She then asked another unidentified STNA to keep an eye on Resident #5 and #15 while she cared for another resident in a different area. When STNA #580 returned to the common area Residents #5 and #15 were no longer in the common area and had gone to Resident #5's room. Resident #5 had her pants down and she bent down to kiss Resident #15 who was sitting in a wheelchair. STNA #586 reported the situation to the nurse. STNA #586 revealed the other STNA working had never worked in the facility before and worked for a contracted agency. She said she had difficulty working with agency staff at times because they did not like to listen to other staff when asked to do something. Review of the facility policy for dementia care revised March 2022 revealed the facility would provide the necessary care and services for residents with dementia to include ensuring their dignity and safety. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366346 If continuation sheet Page 19 of 26 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 366346 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor of Grande Village 2610 East Aurora Road Twinsburg, OH 44087 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the attending physician documented in the resident's medical record that the pharmacist's drug reviews were reviewed and what, if any, action was taken to address the recommendations. This affected two residents (#25 and #33) of five residents (#25, #30, #31, #33, and #44) reviewed for unnecessary medications. The facility census was 76. Findings include: 1. Review of the medical record for Resident #25 revealed an admission date of 05/08/21. Diagnoses included Guillain-Barre syndrome, muscle weakness, and difficulty in walking, diastolic (congestive) heart failure. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25's cognition was not assessed and the resident required extensive assistance of two staff for bed mobility, extensive assistance of two staff for transfers, and total dependence of one staff for toilet use. Review of the pharmacy recommendation dated 12/22/21 revealed Resident #25 had an order for midodrine and the last administration time was after the evening meal. The recommendation indicated the manufacturer recommended avoiding dosing after the evening meal or within four hours of bedtime to prevent supine hypertension. In order to mitigate risk please adjust administration times accordingly. The recommendation indicated agreed and was signed but the signature was not dated. Review of the pharmacy recommendation dated 01/26/22 revealed the resident was receiving as needed pain therapy with tramadol on a regular daily basis (averaging more than two times per day). Unless drug-seeking behavior was noted, to enhance management of resident's pain please evaluate the need for scheduling this resident's pain medication and leave the as needed order for breakthrough pain. The pharmacy recommendation had a handwritten note that read verbal order (v.o.) not desired changed. This had been adjusted recently on 11/21/21. Review of the physician orders for April 2022 revealed orders for tramadol 50 milligrams (mg) by mouth every six hours as needed for pain and midodrine give five mg tablet by mouth three times a day for low blood pressure. Review of the Medication Administration Record (MAR) for April 2022 revealed Resident #25 received midodrine three times daily including at bedtime. The MAR also revealed the Resident #25 received tramadol one to three times daily between 04/01/22 and 04/21/22 except on 04/01/22, 04/09/22, and 04/16/22. Review of Resident #25's chart revealed no documentation from the resident's physician or nurse practitioner addressing the pharmacy recommendations dated 12/22/21 and 01/26/22. Interview on 04/21/22 at 1:19 P.M. with the Director of Nursing (DON) revealed she could not find any documentation from Resident #25' physician or the nurse practitioner addressing the pharmacy recommendations. The DON stated she did not know who signed the pharmacy recommendation dated 12/22/21 regarding the midodrine. The DON stated the resident laid in bed all the time and was not sure why they would have agreed to the pharmacy recommendation. The DON stated there had not been no issues (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366346 If continuation sheet Page 20 of 26 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 366346 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor of Grande Village 2610 East Aurora Road Twinsburg, OH 44087 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 0756 with the resident taking the medication. Level of Harm - Minimal harm or potential for actual harm 2. Review of the medical record for Resident #33 revealed an admission date of 02/10/22 with diagnoses of dementia, osteoarthritis, major depression and heart disease. Residents Affected - Few Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #33 was rarely or never understood when communicating. Review of the care plan dated 03/12/22 for Resident #33 revealed ineffective coping due to depression with interventions that included involvement with family, appropriate referrals, emotional support and psychiatry services as needed. Review of a Gradual Dose Reduction (GDR) request to the physician dated 07/24/21 revealed Pharmacist #589 asked the physician to consider a decrease in Sertraline (a medication used to treat depression) from 25 milligram (mg) every day to 25 mg every other day. A response from the physician dated 08/09/21 revealed Resident #33 had anxiety at times and referred to a note. Review of a GDR request to the physician dated 12/22/21 revealed Pharmacist #589 asked the physician to consider reducing Resident #33's Sertraline from 25 mg in the morning to 12.5 mg in the morning. There was no documentation from the physician the GRD had been addressed. Interview on 04/21/22 at 9:23 A.M. with the Director of Nursing confirmed there was no evidence the physician addressed the GDRs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366346 If continuation sheet Page 21 of 26 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 366346 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor of Grande Village 2610 East Aurora Road Twinsburg, OH 44087 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, and staff interview, the facility failed to ensure Resident #279 received medication per physician's order upon returning from dialysis. This affected one (Resident #279) of one resident reviewed for dialysis. The facility identified two current residents receiving dialysis. The facility census was 76. Residents Affected - Few Findings include: Review of the medical record for Resident #279 revealed the resident was admitted to the facility on [DATE]. Diagnoses included end stage renal disease, hypothyroidism, and anemia. Resident #279 was receiving dialysis services prior to admission. Review of the admission assessment dated [DATE] revealed Resident #279 was cognitively intact. Review of the physician orders for Resident #279 revealed an order dated 04/07/22 for two 800 milligram (mg) tablets of Sevelamer (phosphate binder) three times per day for chronic kidney disease. Further review of the medical record revealed Resident #279 received dialysis on 04/08/22, 04/11/22, 04/13/22, 04/15/22, 04/18/22, and 04/20/22 Review of the physician orders for Resident #279 revealed the previous order for Sevelamer was discontinued and a new order was started on 04/14/22 for two 800 mg tablets of Sevelamer to be given three times per day with the lunch dose to be given upon return from dialysis. Review of the Medication Administration Record (MAR) and corresponding nurses progress notes revealed Resident #279 did not receive the lunch dose of Sevelamer on 04/11/22, 04/13/22, 04/15/22, 04/18/22, or 04/20/22 upon returning from dialysis. Interview on 04/21/22 at 10:41 A.M. with Resident #279 revealed the resident was supposed to receive Sevelamer three times per day with meals and he did not receive it on Mondays, Wednesdays, or Fridays when returning from dialysis. Resident #279 stated they just don't bring it to me. Interview on 04/21/22 at 1:17 P.M. with the Director of Nursing verified there was no evidence Resident #279 received the medication (lunch dose) per physician order on 04/11/22, 04/13/22, 04/15/22, 04/18/22, or 04/20/22. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366346 If continuation sheet Page 22 of 26 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 366346 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor of Grande Village 2610 East Aurora Road Twinsburg, OH 44087 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview and review of facility policy the facility failed to date and store opened medications properly and failed to dispose of expired medications. This had the potential to affect all 76 residents residing in the facility. Findings include: Observation on 04/20/22 at 9:32 A.M. on the secured nursing unit revealed one five milliliter (ml) bottle of Sanofi brand influenza vaccine opened and undated in the refrigerator and one tuberculin (TB) purified protein derivative 0.1 ml bottle opened and undated. Interview with Licensed Practical Nurse (LPN) #659 at the time of the observation verified the influenza and TB vaccine bottles did not have an opened date. LPN #659 indicated the refrigerator was shared between the secured nursing unit and another nursing unit. Observation on 04/20/22 at 9:55 A.M. of the medication cart for the secured nursing unit revealed two one calcitonin nasal spray opened and undated, one fluticasone propionate for Resident #7 opened and undated, albuterol sulfate inhalation aerosol for Resident #3 opened and undated and a bottle of Nymic topical powder for Resident #36 opened and undated. The locked controlled medication box contained two cards of lorazapam 0.25 milligram (mg) for Resident #71, one card contained 30 pills and expired 11/18/21 and the other contained five pills and expired 01/07/22. Interview at the time of the observation with LPN #659 confirmed the expired medication, LPN #659 indicated the expired medication should have been sent back to the pharmacy since the residents were no longer residing on that hall. Two bottles of valproic acid 250 mg per 5 ml, one for Resident #71 and one for Resident #49 were opened and undated in the drawer of the medication cart. Observation on 04/20/22 at 10:31 A.M. of the refrigerator for Nursing Unit #1. The refrigerator had four vials of acetylcysteine 30 ml for Resident #2. Interview at the time of the observation with LPN #590 revealed Resident #2 was no longer at the facility. One bottle of Novolog insulin aspart injection 10 units per ml for Resident #55 was opened and undated, one Humulin Kwik pen for Resident #1 was opened and undated. Observation on 04/20/22 at 11:55 A.M. of the medicine cart for Nursing Unit #1 revealed omeprazole 20 mg had an expiration date which had been rubbed off and was not visible. One bottle of insulin Lispro was opened and undated as well as a Lantus pen for Resident #50 which was opened and undated. Interview on 04/20/22 with the Director of Nursing confirmed all opened medications should have an open date and expired medications should be discarded. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366346 If continuation sheet Page 23 of 26 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 366346 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor of Grande Village 2610 East Aurora Road Twinsburg, OH 44087 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 Based on observation, interview, record review, review of facility policy, and review of the Centers for Disease Control and Prevention (CDC) guidance, the facility failed to ensure appropriate use of personal protective equipment (PPE) for one resident (Resident #278) on Transmission Based Precautions (TBP), failed to enusre reusable non-critical care equipment was disinfected after each resident use, and failed to ensure linens for residents on TBP were processed appropriately in the laundry area. This had the potential to affect all residents residing in the facility. The facility census was 76. Residents Affected - Many Findings include: 1. Review of Resident #278's medical record revealed an admission date of 04/12/22 and diagnoses including diabetes mellitus, Bell's Palsy and hyperlipidemia. Resident #278 was on transmission based precautions due to being an unvaccinated new admission. Observation on 04/20/22 at 7:34 A.M. revealed a plastic cart with personal protective equipment (PPE) outside of Resident #278's room, a door covering with PPE, and a sign on the door for Transmission Based Precautions (TBP). Observation of Registered Nurse (RN) #535 revealed she walked out of Resident #278's room and was not wearing an N95 respirator, an isolation gown, gloves, or a face shield. RN #535 was wearing a surgical mask and confirmed she was not wearing PPE as indicated for TBP. RN #535 stated Resident #278 needed something and she went in the room without donning appropriate PPE. Observation on 04/20/22 at 7:39 A.M. of RN #535 revealed she did not change her surgical mask after walking out of Resident #278's room. Further observation revaled RN #535 prepared for the next resident and walked into Resident #44's room carrying a blood pressure cuff, thermometer, and a pulse oximeter. RN #535 took Resident #44's blood pressure, temperature and measured her oxygen saturation with the pulse oximeter, walked out of the room, placed them on top the medication cart and did not disinfect the the blood pressure cuff, thermometer, or pulse oximeter before using them on the next resident. RN #535 changed her sugical mask after exiting Resident #44's room and stated she forgot to change it after leaving Resident #278's room. Observation on 04/20/22 at 8:00 A.M. of RN #535 revealed she picked up the blood pressure cuff used for Resident #44, did not disinfect it, walked into Resident #275's room and took his blood pressure. RN #535 did not disinfect the blood pressure cuff after taking Resident #275's blood pressure and placed the cuff on the medication cart. Observation on 04/20/22 at 8:23 A.M. of RN #535 revealed she did not disinfect the blood pressure cuff, thermometer, and pulse oximeter, picked them up off the medication cart, carried them into Resident #276's room and took his blood pressure, temperature, and measured his oxygen saturation levels with the pulse oximeter. RN #535 did not disinfect the blood pressure cuff, thermometer, and pulse oximeter before placing them on the medication cart. RN #535 confirmed she did not disinfect the blood pressure cuff, thermometer, and pulse oximeter after using on Resident's #44, #275 and #276. Observation on 04/20/22 at 8:55 A.M. of Licensed Practical Nurse (LPN) #591 revealed she picked up a blood pressure cuff and pulse oximeter off the medication cart, walked into Resident #125's room, took her blood pressure and measured her oxygen saturation with the pulse oximeter, walked to the medication cart, did not disinfect the blood pressure cuff and pulse oximeter before or after placing them on the medication cart. LPN #591 began preparing for the next resident and confirmed she did (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366346 If continuation sheet Page 24 of 26 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 366346 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor of Grande Village 2610 East Aurora Road Twinsburg, OH 44087 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 not disinfect the blood pressure cuff or pulse oximeter after using for Resident #125. Level of Harm - Minimal harm or potential for actual harm Review of the CDC guidelines titled Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes, updated 02/02/22, included empiric use of Transmission-Based Precautions (quarantine) was recommended for residents who were newly admitted to the facility and for residents who have had close contact with someone with SARS CoV-2 infection if they were not up to date with all recommended COVID-19 vaccine doses. Residents Affected - Many 2. Interview on 04/21/22 at 1:04 P.M. with Housekeeping Director #517 revealed laundry received from an isolation room entered the laundry room in a yellow bag and should be washed on level three of the washing machine. Interview on 04/21/22 at 2:12 P.M. with Housekeeping Aide #506 revealed she did not separate isolation laundry from other soiled laundry. Yellow bagged laundry was emptied into the regular laundry and all was placed in the washing machine at the same time, on cycle one. Housekeeping Aide #506 indicated she did not use bleach with any of the laundry and did not wear gloves, eye protection or any other personal protective equipment (PPE) when doing laundry. Review of the facility policy for laundry, undated, revealed all laundry staff were to wear appropriate (PPE) at all times. Review of the facility policy on yellow bagged linen, undated, revealed staff would be in-serviced on washing contaminated linen and using the correct wash cycle. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366346 If continuation sheet Page 25 of 26 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 366346 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor of Grande Village 2610 East Aurora Road Twinsburg, OH 44087 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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm Based on observations and staff interviews, the facility failed to ensure call lights were in good repair and accessible to the resident. This affected one resident (#49) of one resident reviewed for physical environment. Facility census was 76. Residents Affected - Few Findings include: Observation on 04/19/22 at 8:58 A.M. revealed Resident #49's call light was on the floor and not accessible to the resident. Observation on 04/20/22 at 9:16 A.M. revealed Resident #49's call light cover was hanging off the wall and the call light cord was not accessible to the resident. Interview 04/20/22 at 9:19 A.M. with State Tested Nurse Aide (STNA) #584 verified the above observation. STNA #584 said she worked on Monday night, and the it was like that then. Observation on 04/20/22 at 9:23 A.M. with Maintenance Director (MD) #557 verified the call light cover was hanging off the wall and the call light cord was not accessible to the resident. MD #557 stated he was not made aware Resident #49's call light was not in working order. MD #557 immediately fixed Resident #49's call light and handed him the call light after testing it to see it was working. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366346 If continuation sheet Page 26 of 26