Health inspection·July 3, 2019

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a table was provided in a timely manner for Resident #298's suction machine. This affected one of one resident reviewed for tracheostomy care. The facility census was 48. Residents Affected - Few Findings include: Review of Resident #198's medical record revealed the resident was admitted to the facility 02/06/19 and readmitted on [DATE] with diagnoses of anxiety disorder, depressed disorder, tracheostomy, chronic obstructive pulmonary disease (COPD), schizophrenia and ataxia. Review of Resident #198's admission Minimum Data Set 3.0 assessment dated [DATE] revealed the resident was independent and required set up only for all areas of activities of daily living. Review of Resident #198's plan of care dated 06/22/19 revealed the resident had a tracheostomy related to impaired breathing mechanics. Interventions included: ensure that trach ties are always secured. Monitor/document for restlessness, agitation, confusion, increased heart rate (tachycardia), and slow heart rate (bradycardia). Suction as necessary. Use one humidification device each evening for tracheostomy. Observation of Resident #198's room on 07/01/19 at 1:56 P.M. revealed the resident's suction machine was located on the floor and not within reach if the resident required emergency suctioning. The observations were verified with Registered Nurse (RN) #303 on 07/01/19 at 1:56 P.M. Interview with Resident #198 on 07/01/19 at 2:20 P.M. revealed she independently suctioned herself and cleaned her tracheostomy stoma without supervision of staff. Resident #198 stated she had asked the facility for a table to place her suction machine. Resident #198 stated in case of an emergency she would have to pick up the suction machine off of the floor to use it if she had a mucous plug or trouble breathing. Observation of Resident #198's room on 07/02/19 at 12:22 P.M. revealed the resident's suction machine was located on the floor and not within reach if the resident required emergency suctioning. The observation was verified with RN #303 on 07/02/19 at 12:22 P.M. Interview with RN #303 on 0702/19 at 1:22 P.M. verified the resident needed a table to place the suction machine and aerosol nebulizer on. RN #303 verified the suction machine was not within reach if the resident required emergency suctioning through her tracheostomy. Observation of Resident #198's room on 07/03/19 at 8:10 A.M. revealed the resident's suction machine was in direct contact with the soiled floor and uncovered. A table for the suction machine was not provided until 07/03/19 at 12:00 P.M. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366355 If continuation sheet Page 2 of 13 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 366355 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Singleton Health Care Center 1867 East 82nd Street Cleveland, OH 44103 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 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure Resident #37 was provided privacy during incontinence care. this affected one resident observed for incontinence care. The facility census was 48. Residents Affected - Few Findings include: Review of Resident #37's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder, dementia with behavioral disturbance, paranoid schizophrenia, lymphedema, and insomnia. Review of Resident #37's quarterly Minimum Data Set 3.0 assessment dated [DATE] revealed the resident required extensive assist of two persons for bed mobility and transfers. Resident #37 required and extensive assist of one person for dressing, toilet use and personal hygiene. Review of Resident #37's plan of care dated 07/02/19 revealed the resident had a behavior problem related to exposing self and urinating on the floor. Interventions included: administer medications as ordered. Monitor/document for side effects and effectiveness. Anticipate and meet needs. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. Resident to keep urinal with him throughout the day. Observation of Resident #37's bowel incontinence care with State Tested Nursing Assistant (STNA) # 300 revealed the resident had been incontinent of bowel. STNA #300 removed his pants and instructed the resident to sit in the wheelchair until she could obtain wash cloths and towels to complete his incontinence care. STNA #300 left the room, left resident 337's door wide open with the resident genitals exposed to any resident of visitor passing the room. Interview with Registered Nurse (RN) # 303 on 07/01/19 t 1:20 P.M. verified all staff were to provide privacy when completing incontinence care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366355 If continuation sheet Page 3 of 13 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 366355 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Singleton Health Care Center 1867 East 82nd Street Cleveland, OH 44103 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement Resident #37's plan of care to ensure his wheelchair brakes could be locked to prevent the wheelchair from pushing backward when the resident stood up. This affected one of four residents observed for wheelchair brakes in good repair. The facility census was 48. Finding include: Review of Resident #37's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder, dementia with behavioral disturbance, paranoid schizophrenia, lymphedema, and insomnia. Review of Resident #37's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident required an extensive assist of two persons for bed mobility and transfers. Resident #37 required extensive assist of one person for dressing, toilet use and personal hygiene. Resident #37's MDS 3.0 dated 05/14/19 also revealed the resident had unsteady balance when moving from a seated position to a standing position, was not steady when walking or turning around and facing the opposite side. Review of Resident #37's plan of care dated 09/06/18 revealed the resident was at risk for falls related to gait/balance problems. Interventions included: anticipate and meet needs. Be sure call light is within reach and encourage to use it for assistance as needed. Respond promptly to all requests for assistance. Bed Alarm. Chair Alarm. Educate resident to ensure he is sitting all the way in his wheelchair. Educate resident to lock wheelchair prior to attempting to transfer out of wheelchair. Educated resident to call for assistance when wanting to transfer out of bed. Fix wheelchair locks, and ensure wheelchair is working properly before use. Follow fall protocol. Observation of Resident #37 on 07/01/19 at 12:38 P.M. revealed State Tested Nurse Aide (STNA) #300 verbally prompt Resident #37 to self-propel himself to the sink. Resident #37 was incontinent of bowel movement and needed to be washed up. Resident #37 was able to self-propel the wheelchair with the brakes locked in place. STNA #300 had the resident stand at the sink and hold onto the sink while she cleaned him up. Resident #37 was unsteady as he stood holding on to the sink. Resident #37 stated he couldn't stand much longer and was told he had to stand while he was cleaned up. Resident #37 was unsteady as STNA #300 transferred the resident from the seated position in the wheelchair to a standing position. STNA #300 did not obtain a second person to provide assistance to ensure the resident did not fall while trying to hold onto the sink. Interview with Registered Nurse (RN) #303 on 07/02/19 at 11:10 A.M. verified STNA #300 should have obtained a second staff member to help with Resident #37. RN #303 further stated night shift was to check Resident #37's brakes on a nightly basis and let maintenance know if the brakes needed tightening. RN #303 stated she could not find documented evidence maintenance had been notified of the resident's wheelchair brakes not locking properly. Interview with Maintenance Director (MD) #304 on 07/02/19 at 10:55 A.M. revealed he was unaware Resident #37's wheelchair brakes needed tightened. MD #304 stated normally staff would send him a work order and he would tighten the brakes the same day. MD #304 verified at 11:50 A.M. he did not have a work order to tighten the resident's wheelchair brakes. MD #304 verified the brakes were loose and the brakes had to be tightened to work properly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366355 If continuation sheet Page 4 of 13 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 366355 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Singleton Health Care Center 1867 East 82nd Street Cleveland, OH 44103 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 0661 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. Based on record review and interview, the facility failed to ensure residents received all required information upon their discharge. This affected one (Resident #49) of one resident reviewed for appropriate discharge. The total census was 48. Findings include: Record review of Resident #49 revealed the resident was admitted to the facility 10/17/18 and had diagnoses including hemiplegia, post-traumatic seizures, and other specified mental disorders. He was discharged from the facility on 05/06/19. His discharge instructions dated 05/06/19 revealed that he was discharged to a group home, was to follow up with his primary care provider, and had medications called in to a pharmacy. No evidence could be found in the instructions or elsewhere that the resident received discharge information including a summary of his stay or status, reconciliation of the discharge medications, a post-discharge plan or care, or instructions clarifying any specifics of his care needs. Interview with Assistant Administrator #202 on 07/03/19 at 8:56 A.M. confirmed the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366355 If continuation sheet Page 5 of 13 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 366355 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Singleton Health Care Center 1867 East 82nd Street Cleveland, OH 44103 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 and record review, the facility failed to provide supervision to prevent Resident #11 from obtaining a lighter. This affected one of five residents identified as residents who smoked. The facility census was 48. Findings include: Review of Resident #11's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including Huntington's Disease, chorea, convulsions, aphasia, intracranial injury without loss of consciousness, atherosclerotic heart disease and nicotine dependence. Review of Resident #11's quarterly Minimum Data Set 3.0 assessment dated [DATE] revealed the resident was independent and required no set up for bed mobility, transfers, dressing, eating, toilet use and personal hygiene. Review of Resident #11's plan of care dated 04/03/19 revealed the resident was a smoker. Goals included the resident would always be kept safe while smoking. Interventions included resident was not to have any lighters or matches in his or her possession. Resident to remain compliant of the smoking policy always. Staff to keep cigarettes in a designated area, giving each resident one cigarette at a time. Staff to educate and encourage resident to start a smoking cessation program. Review of Resident #11's smoking assessment dated [DATE] revealed the resident was alert and oriented to person, place and time. Resident #11 was deemed independent for skills in making daily decisions. The resident's clothing was free of burns, vision was adequate for holding a cigarette and extinguishing it properly and the resident was physically able to smoke. Resident #11 was deemed safe to independently smoke. Observation of Resident #11 on 07/01/19 at 9:10 A.M. revealed the resident was lying on his right side facing the wall. Resident #11 had a cigarette lighter in his bed, in plain sight, on top of his bed, laying near his buttocks. The observation was verified with Registered Nurse (RN) #303 on 07/01/19 at 9:11 A.M. Interview with RN #303 on 07/01/19 at 9:11 A.M. verified Resident #11 was independent in smoking, and no resident was to have a cigarette lighter in their room. RN #303 stated she had no idea how the resident would have obtained the lighter because staff were the only ones to have access to the lighter. Review of the facility's Smoking Policy revised 07/03/18 revealed for the safety of the residents and staff smoking would only be permitted indoors in the smoking room located on the first floor next to the dining room. Outdoor smoking would be permitted on the front porch off the main dining room effective from October through April and in the back courtyard effective May through September. No person (staff, resident, or visitor) would be permitted to smoke in any other areas of the building. Smoking in resident rooms was strictly prohibited. No resident would be permitted to keep matches or a lighter. The facility provided a lighter in the smoke room that residents must use to light their cigarettes. In the event that the facility discovered or suspected that a resident was non compliant with the policy it was to be reported immediately to the supervisor. If the suspicion was confirmed by the supervisor, the supervisor would contact the Director of Nursing to inform her of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366355 If continuation sheet Page 6 of 13 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 366355 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Singleton Health Care Center 1867 East 82nd Street Cleveland, OH 44103 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 situation. The Director of Nursing would initiate a room sweep to ensure all smoking related materials were safely secured. The Director of Nursing would notify the administrator immediately and the administrator might initiate a 15-minute check depending on the seriousness of the offense. A 30-day discharge might be initiated depending on the seriousness of the offense. Failure by staff to report any noncompliance would result in disciplinary action. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366355 If continuation sheet Page 7 of 13 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 366355 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Singleton Health Care Center 1867 East 82nd Street Cleveland, OH 44103 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure Resident #36's oxygen tank was handled appropriately and was not empty while in use. This affected one of three residents observed in the dining room with a portable oxygen tank in use. The facility census was 48. Residents Affected - Few Findings include: Review of Resident #36's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including heart failure, acute respiratory failure, chronic obstructive pulmonary disease COPD), dysphagia, multiple myeloma, and insomnia. Review of Resident #36's 14-day Minimum Data Set assessment dated [DATE] revealed the resident required limited assistance from one person for bed mobility, transfers, dressing, toilet use and personal hygiene. Review of Resident #36's plan of care dated 05/03/19 revealed the resident had COPD related to smoking. Interventions included check resident Pulse-oximetery every shift to ensure greater than 90%. Educate resident on the risk factors of continuing to smoke and encourage resident to quit. Give oxygen therapy as ordered by the physician. Monitor for difficulty breathing (dyspnea) on exertion. Remind resident not to push beyond endurance. Monitor for signs and symptoms of acute respiratory insufficiency: anxiety, confusion, restlessness, shortness of breath at rest, cyanosis, somnolence. Monitor/document/report to physician as needed any signs and symptoms of respiratory infection: fever, chills, increase in sputum (document the amount, color and consistency), chest pain, increased difficulty breathing, increased coughing and wheezing. Observation on 07/01/19 at 11:55 A.M. revealed Resident #36 seated at a table with a portable oxygen tank on back of the wheelchair with a nasal cannula hooked to it. The tank gauge was in red and on zero. The resident was not in respiratory distress. State Tested Nurse Aide (STNA) #300 was observed getting the dining room ready for lunch. At 12:10 P.M. the surveyor asked STNA #300 if the tank was empty. STNA #300 stated the tank was empty, unhooked the nasal cannula and removed the oxygen tank from the wheelchair. STNA #300 took the empty oxygen tank to the B unit and returned with a new oxygen tank. STNA #300 hooked up the nasal cannula connecter to the flow meter on the tank, adjusted the flow to three liter/minute. The surveyor asked STNA #300 to obtain a nurse to check the resident's pulse oxygenation. Registered Nurse (RN) #303 came to the dining room at 12:12 P.M. and checked the resident pulse oxygenation which was 92% on three liter of oxygen per minute via a nasal cannula. Interview with the Director of Nursing (DON) on 07/02/19 at 2:34 P.M. revealed nursing staff was to ensure the tank was full and if getting low STNA's were to inform the nurse and the nurse would provide a new tank to replace the empty tank. Review of the facility's Care of Oxygen Policy and Procedure (no date) revealed there must be a physician's order for oxygen use which included the route and liter flow or specific oxygen concentration, and how the oxygen was to be administered. Only licensed nurses were authorized to set up oxygen administration or make changes to oxygen administration. Staff members must be instructed to notify the Unit Nurse if the oxygen canister was low or empty, the resident removed the face mask or cannula or disconnected any of the tubing. The Unit Nurse must instruct staff members that they must not disconnect any of the oxygen tubing or change the flow rate of the oxygen. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366355 If continuation sheet Page 8 of 13 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 366355 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Singleton Health Care Center 1867 East 82nd Street Cleveland, OH 44103 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure bed rails were only applied for residents with appropriate consent, assessment, and documentation. This affected one (Resident #43) of one resident reviewed for restraints. The total census was 48. Findings include: Observation of Resident #43 on 07/01/19 at 2:47 revealed he had two quarter-length bedrails pulled up on each side of his bed. Record review of Resident #43 revealed he was admitted to the facility on [DATE], and was identified by the facility as having severe cognitive impairment, and required supervision for bed mobility and transfers. He had diagnoses including hallucinations and vascular dementia. The review revealed no evidence of any orders or care plan for bed rails, no signs of an assessment for risk of entrapment or restraint, no evidence of informed consent for bed rails, and no mention of their use in the progress notes. These findings were confirmed with the Director of Nursing on 07/02/19 at 11:37 A.M. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366355 If continuation sheet Page 9 of 13 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 366355 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Singleton Health Care Center 1867 East 82nd Street Cleveland, OH 44103 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review, and interview, the facility failed to ensure medications were administered with an error rate of less than 5%. This affected one (Resident #35) of four residents observed during medication administration. Two errors occurred within 27 observed opportunities for error, creating a medication error rate of 7.4%. The total census was 48. Residents Affected - Few Findings include: Observation of a medication pass for Resident #35 by Registered Nurse (RN) #201 on 07/02/19 at 8:14 A.M. revealed the nurse administered one tablet of hydrochlorothiazide (a diuretic) 25 milligrams (mg), and one tablet of vitamin D3 2000 international units (iu) to the resident. Record review of Resident #35 revealed no order for hydrochlorothiazide at a dose of 25 mg, but there was an active order dated 05/17/19 in place for it to be given at a dose of 50 mg once per day. There was also no active order for vitamin D3, however there was one in place dated 12/05/18 for vitamin D2 to be given at 2000 iu once per day. Neither order included mention of any allowance for substitutions. Interview with RN #201 on 07/02/19 at 11:04 A.M. confirmed the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366355 If continuation sheet Page 10 of 13 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 366355 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Singleton Health Care Center 1867 East 82nd Street Cleveland, OH 44103 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and interview, the facility failed to ensure staff did not handle resident food with their bare hands. This affected one resident (Resident #32) of 48 residents who consumed food prepared and handled by facility staff. The total census was 48. Findings include: Observation of the A-section dining room on 07/01/19 at 12:31 P.M. revealed State Tested Nursing Aide (STNA) #204 to assist with the feeding of Resident #32. During the process, STNA #204 picked up a grilled cheese sandwich with her bare hands and held it up for Resident #32 to take bites. Interview with STNA #204 immediately following the above observation confirmed she had helped feed the resident by picking up food with bare hands. Record review of the facility's food safety policy dated 04/11/18 revealed no specific prohibition of staff touching food with bare hands. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366355 If continuation sheet Page 11 of 13 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 366355 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Singleton Health Care Center 1867 East 82nd Street Cleveland, OH 44103 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not ensure Resident #4's medical record was accurate. This affected one of 16 residents reviewed. The facility census was 48. Findings include: Review of Resident #4's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including cognitive impairment, depression, retention of urine, diabetes type II, alcohol induced chronic pancreatitis and dementia. Review of Resident #4's quarterly minimum data Set 3.0 assessment dated [DATE] revealed the resident required limited assistance and set up for all activities of daily living skills. Review of Resident #4's plan of care (no date) revealed the resident had a problematic manner in which the resident acts are characterized by ineffective coping; verbal/ physical aggression related to: yelling at and threatening staff. Interventions included approach the resident slowly and from the front; be sure you have the resident's attention before speaking or touching; discuss resident's options for appropriate channeling of anger with resident; do not argue or condemn resident; do not make unrealistic demands on resident; do not physically restrain; allow resident to pace where he/she can be observed; document summary of each episode; note cause and successful interventions, include frequency and duration. On 07/01/19 between 9:15 A.M. to 9:55 A.M. Resident #4 was observed to become upset over a financial situation, scream, use profanity, make threatening gestures, threaten staff and other residents to the point authorities were called to the facility to deescalate the behavior. Resident #4 was escorted from the facility to a receiving hospital for a psychiatric evaluation. As of 07/03/19, Resident #4 had not returned to the facility. Further review of Resident #4's nurse's notes, physician progress notes, and telephone orders revealed no documentation regarding the incident or condition of the resident when the resident left the facility. After the surveyor discussed with facility, a late entry was entered into Resident 34's record indicating the resident had been transported to the hospital. The observation was verified with the Administrator on 07/02/19 at 1:58 P.M. Interview with the Administrator on 07/02/19 verified the medical record lacked documented evidence of Resident #4's behavior and ultimate transfer from the facility to the hospital with authorities for a psychiatric evaluation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366355 If continuation sheet Page 12 of 13 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 366355 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Singleton Health Care Center 1867 East 82nd Street Cleveland, OH 44103 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not ensure Resident #198's suction machine was kept in a sanitary manner. This affected one of one resident observed requiring a suction machine for emergency tracheostomy suctioning. The facility census was 48. Residents Affected - Few Findings include: Review of Resident #198's medical record revealed the resident was admitted to the facility 02/06/19 and readmitted on [DATE] with diagnoses of anxiety disorder, depressed disorder, tracheostomy, chronic obstructive pulmonary disease (COPD), schizophrenia and ataxia. Review of Resident #198's admission Minimum Data Set 3.0 assessment dated [DATE] revealed the resident was independent and required set up only for all areas of activities of daily living. Review of Resident #198's plan of care dated 06/22/19 revealed the resident had a tracheostomy related to impaired breathing mechanics. Interventions included: ensure that trach ties always secured. Monitor/document for restlessness, agitation, confusion, increased heart rate (tachycardia), and slow heart rate (bradycardia). Suction as necessary. Use one humidification device each evening for tracheostomy. Observation of Resident #198's room on 07/01/19 at 1:56 P.M., 07/22/19 at 12:22 P.M. and 07/03/19 at 8:10 A.M. revealed the resident's suction machine was in direct contact with the soiled floor and uncovered. The observation was verified with Registered Nurse (RN) #303 on 07/01/19 at 1:56 P.M. and 07/02/19 at 12:22 P.M. Interview with RN #303 on 07/02/19 at 12:22 P.M. verified the resident needed a table to place the suction machine and aerosol nebulizer on. RN #303 verified the suction machine was not to be placed on the floor due to cross contamination. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366355 If continuation sheet Page 13 of 13