Health inspection·May 26, 2022

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. Based on record review, interview and facility policy review, the facility failed to report to the State agency an alleged violation involving physical abuse between Residents #24 and #31. This affected two residents (#24 and #31) of five residents (#24, #26, #31, #48 and #148) reviewed for abuse, neglect, exploitation, and misappropriation. The facility census was 49. Findings include: Review of the medical record for Resident #24 revealed an admission date of 09/16/17. Diagnoses included schizoaffective disorder bipolar type, vascular dementia without behavioral disturbance, and bipolar disorder. Review of the nursing progress note dated 03/26/22 at 2:35 P.M. by Registered Nurse (RN) #212 revealed Resident #24 was going into the B side television room at 11:00 P.M. when he was witnessed hitting another resident. Resident #24 stated he was defending himself because another resident was the aggressor. Interview on 05/24/22 at 11:24 A.M. with the Administrator verified Resident #24 had a physical altercation with Resident #31 on 03/25/22. The Administrator confirmed there was no self-reported incident (SRI) filed to the State agency or an investigation completed through the abuse, neglect, exploitation, and misappropriation process. Review of a one page investigation form dated 03/28/22 provided by the Administrator revealed an incident occurred on 03/25/22 which was reported by a nurse (unnamed) as a physical altercation between Residents #24 and #31. The Administrator viewed camera footage and saw Resident #31 walk quickly toward Resident #24 and grab a wet floor sign on the ground next to Resident #24 then Resident #24 hit Resident #31. Review of the medical record for Resident #31 revealed an admission date of 01/15/16. Diagnoses included schizophrenia, dementia, intellectual disabilities, impulse disorder, and expressive language disorder. Review of the nursing progress note dated 03/26/22 at 2:29 P.M. created by RN #212 revealed Resident #31 was in the B side television room when he was hit by another resident. When questioned Resident #31 stated hit me and there were no bruises noted. Review of the nursing progress note dated 03/26/22 at 3:32 P.M. created by Licensed Practical Nurse (LPN) #266 revealed after the resident to resident altercation, Resident #31 was quiet during the shift with no behaviors. Interview on 05/25/22 at 11:53 A.M. with the Administrator verified the Director of Nursing (DON) reported the incident to the Administrator on 03/26/22 by phone who received the report from LPN #252 on 03/25/22. Interview on 05/25/22 at 3:02 P.M. with RN #212 confirmed on 03/25/22 at 11:00 P.M. Residents #24 and #31 had an altercation which RN #212 did not see but heard. RN #212 indicated LPN #252 witnessed the incident and saw the hitting between Residents #24 and #31. RN #212 verified contacting the DON (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366355 If continuation sheet Page 2 of 8 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 05/26/2022 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 0609 and the nurse practitioner after the incident occurred. Level of Harm - Minimal harm or potential for actual harm Interview on 05/25/22 at 3:16 P.M. with LPN #252 verified on 03/25/22 at 11:00 P.M. Resident #24 hit Resident #31, and stated they were both attempting to hit each other. LPN #252 confirmed RN #212 reported the incident to the DON at the time it occurred. Residents Affected - Few Interview on 05/25/22 at 11:53 A.M. with the Administrator verified the one page investigation form dated 03/28/22 was the only documentation available regarding the incident between Residents #24 and #31. The Administrator stated the incident happened over the weekend so on the following Monday, 03/28/22, she looked at the camera footage of the incident. The Administrator indicated believing since there were no injuries it was okay to wait until Monday to look at the camera footage and stated since it was not a big event it was recorded in a soft file, not as an allegation of physical abuse or SRI to the State agency. The Administrator confirmed LPN #252 witnessed the incident and since there were no negative outcomes or an actual injury it was decided not to report it through the abuse process. The Administrator further stated there were two criteria used to decide whether to file a SRI to the State agency after receiving an allegation of abuse which was whether there was a negative outcome such as a bruise or an actual injury or how public it was such as if there was a family member upset or a witness from the outside; otherwise, I could report five or six things a day. The Administrator verified for all alleged abuse incidents she completed a brief investigation to determine if a physical or emotional outcome occurred, and if not then it was not reported but soft files were kept of her actions. The Administrator stated there were times an SRI was filed with bad outcomes such as incidents with a lot of drama. Interview on 05/25/22 at 1:59 P.M. with the DON verified LPN #252 contacted her by telephone on 03/25/22 after the incident occurred and reported Residents #26 and #31 were arguing and swinging at each other. LPN #252 believed Resident #26 may have hit Resident #31 and reported one or two other residents also saw it happen. Interview on 05/26/22 at 9:32 A.M. with the DON confirmed the alleged physical altercation between Residents #26 and #31 occurred on 03/25/22 in the evening, and RN #212 contacted her by telephone after the incident occurred. The DON verified reporting the incident to the Administrator by telephone on 03/26/22 the next morning. Review of facility policy, Abuse Prevention Policy, revised 05/15/19 revealed all allegations of abuse must be reported to the Administrator and DON immediately, and the Administrator will initiate an investigation and submit a report to the State agency online reporting system immediately and complete the investigation no later than five days after the event. Examples of abuse include either reacting inappropriately to a situation such as pushing, poking, or slapping a resident or intentionally doing bodily harm. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366355 If continuation sheet Page 3 of 8 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 05/26/2022 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on record review, interview and facility policy review, the facility failed to complete a thorough investigation involving an alleged violation of physical abuse between Residents #24 and #31. This affected two residents (#24 and #31) of five residents (#24, #26, #31, #48 and #148) reviewed for abuse, neglect, exploitation, and misappropriation. The facility census was 49. Residents Affected - Few Findings include: Review of the medical record for Resident #24 revealed an admission date of 09/16/17. Diagnoses included schizoaffective disorder bipolar type, vascular dementia without behavioral disturbance, and bipolar disorder. Review of the nursing progress note dated 03/26/22 at 2:35 P.M. by Registered Nurse (RN) #212 revealed Resident #24 was going into the B side television room at 11:00 P.M. when he was witnessed hitting another resident. Resident #24 stated he was defending himself because another resident was the aggressor. Interview on 05/24/22 at 11:24 A.M. with the Administrator verified Resident #24 had a physical altercation with Resident #31 on 03/25/22. The Administrator confirmed there was no self-reported incident (SRI) filed to the State agency or an investigation completed through the abuse, neglect, exploitation, and misappropriation process. Review of a one page investigation form dated 03/28/22 provided by the Administrator revealed an incident occurred on 03/25/22 which was reported by a nurse (unnamed) as a physical altercation between Residents #24 and #31. The Administrator viewed camera footage and saw Resident #31 walk quickly toward Resident #24 and grab a wet floor sign on the ground next to Resident #24 then Resident #24 hit Resident #31. Review of the medical record for Resident #31 revealed an admission date of 01/15/16. Diagnoses included schizophrenia, dementia, intellectual disabilities, impulse disorder, and expressive language disorder. Review of the nursing progress note dated 03/26/22 at 2:29 P.M. created by RN #212 revealed Resident #31 was in the B side television room when he was hit by another resident. When questioned Resident #31 stated hit me and there were no bruises noted. Review of the nursing progress note dated 03/26/22 at 3:32 P.M. created by Licensed Practical Nurse (LPN) #266 revealed after the resident to resident altercation, Resident #31 was quiet during the shift with no behaviors. Interview on 05/25/22 at 11:53 A.M. with the Administrator verified the Director of Nursing (DON) reported the incident to the Administrator on 03/26/22 by phone who received the report from LPN #252 on 03/25/22. Interview on 05/25/22 at 3:02 P.M. with RN #212 confirmed on 03/25/22 at 11:00 P.M. Residents #24 and #31 had an altercation which RN #212 did not see but heard. RN #212 indicated LPN #252 witnessed the incident and saw the hitting between Residents #24 and #31. RN #212 verified contacting the DON and the nurse practitioner after the incident occurred. RN #212 stated a facility incident report (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366355 If continuation sheet Page 4 of 8 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 05/26/2022 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 0610 was completed. Level of Harm - Minimal harm or potential for actual harm Interview on 05/25/22 at 3:16 P.M. with LPN #252 verified on 03/25/22 at 11:00 P.M. Resident #24 hit Resident #31, and stated they were both attempting to hit each other. LPN #252 confirmed RN #212 reported the incident to the DON at the time it occurred and a facility incident report was completed. Residents Affected - Few Interview on 05/25/22 at 11:53 A.M. with the Administrator verified the one page investigation form dated 03/28/22 was the only documentation available regarding the incident between Residents #24 and #31. The Administrator stated the incident happened over the weekend so on the following Monday, 03/28/22, she looked at the camera footage of the incident. The Administrator indicated believing since there were no injuries it was okay to wait until Monday to look at the camera footage and stated since it was not a big event it was recorded in a soft file, not as an allegation of physical abuse or SRI to the State agency. The Administrator confirmed LPN #252 witnessed the incident and since there were no negative outcomes or an actual injury it was decided not to report it or investigate through the abuse process. The Administrator confirmed there were no witness statements obtained from the perpetrator, victim, or witnesses from the reported physical altercation between Residents #26 and #31 on 03/25/22. Interview on 05/25/22 at 1:59 P.M. with the DON verified LPN #252 contacted her by telephone on 03/25/22 after the incident occurred and reported Residents #26 and #31 were arguing and swinging at each other. LPN #252 believed Resident #26 may have hit Resident #31 and reported one or two other residents also saw it happen. Interview on 05/26/22 at 9:32 A.M. with the DON confirmed the alleged physical altercation between Residents #26 and #31 occurred on 03/25/22 in the evening, and RN #212 contacted her by telephone after the incident occurred. The DON verified reporting the incident to the Administrator by telephone on 03/26/22 the next morning. Review of facility policy, Abuse Prevention Policy, revised 05/15/19 revealed all allegations of abuse must be reported to the Administrator and Director of Nursing immediately, and the Administrator will initiate an investigation and submit a report to the State agency online reporting system immediately and complete the investigation no later than five days after the event. Examples of abuse include either reacting inappropriately to a situation such as pushing, poking, or slapping a resident or intentionally doing bodily harm. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366355 If continuation sheet Page 5 of 8 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 05/26/2022 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 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. Level of Harm - Minimal harm or potential for actual harm Based on record review, observations, and interviews the facility administration failed to ensure its resources were effectively and efficiently managed to attain and maintain the highest practicable physical, mental, and psychosocial well-being of all 48 residents residing in the facility. The facility census was 49. Residents Affected - Many Findings include: The following concerns were identified during the annual survey: 1. Review of the medical records of Residents #26 and #31 revealed documentation Resident #24 was witnessed hitting Resident #31. Interview on 05/25/22 at 11:53 A.M. with the Administrator revealed the Director of Nursing (DON) reported the physical altercation to the Administrator on 03/26/22 by phone who received the report from Licensed Practical Nurse (LPN) #252 on 03/25/22 after the incident occurred. The Administrator confirmed not reporting the allegation of physical abuse to the State agency or conducting a thorough investigation as required. There were no witness statements obtained from the perpetrator, victim, or witnesses. 2. Review of facility personnel files revealed Registered Nurse (RN) #260, Housekeeper #262, Licensed Practical Nurse (LPN) #218, and State Tested Nursing Assistant (STNA) #202 were not checked against the Ohio Nurse Aide Registry (NAR) prior to or on their first day of work/hire to ensure the employee did not have a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property as required. Interview on 05/26/22 at 2:57 P.M. with the Administrator revealed she was aware of the need to check the NAR for all employees but did not make sure it was being done. 3. Review of resident personal fund accounts revealed on 05/23/22 the total of all active resident funds was $60,518.11. The facility only secured a surety bond with a value of $20,000.00. Interview on 05/25/22 at 10:30 A.M. with the Administrator confirmed the surety bond was not the appropriate amount on 05/23/22 as required. The Administrator indicated when the survey process began on 05/23/22, she realized the surety bond was not the correct value and increased the surety bond value on 05/24/22 to $75,000.00. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366355 If continuation sheet Page 6 of 8 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 05/26/2022 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, record review, facility policy review, and review of guidelines from the Centers for Disease Control and Prevention, the facility failed to maintain infection control practices to prevent the spread of infectious diseases by failing to ensure the appropriate storage of clean linen and handling of soiled linen. This had the potential to affect all 49 residents who resided in the facility. Residents Affected - Many Findings include: 1. Observation on 05/23/22 at 12:23 P.M. revealed a clean linen cart with three shelves located next to room [ROOM NUMBER]. Each shelf was stocked with bed linens, incontinence pads, gowns, washcloths, and briefs. There was one sheet applied to the highest shelf which left the lower two shelves with clean linen exposed. Interview at the time of the observation with the Director of Nursing (DON) verified the clean linen cart located next to room [ROOM NUMBER] was not covered as required. Observation on 05/23/22 at 12:25 P.M. revealed a clean linen cart with three shelves located next to room [ROOM NUMBER]. Each shelf was stocked with bed linens, incontinence pads, towels, washcloths, and pillow cases. There was one sheet applied to the highest shelf which left the lower two shelves with clean linen exposed. Interview at the time of the observation with DON verified the clean linen cart located next to room [ROOM NUMBER] was not covered as required. Observation on 05/23/22 at 12:27 P.M. revealed a clean linen cart with three shelves located next to room [ROOM NUMBER]. Each shelf was stocked with bed linens, incontinence pads, briefs, and gowns. There was one sheet applied to the highest shelf which left the lower two shelves with clean linen exposed. Interview at the time of the observation with the DON verified the clean linen cart located next to room [ROOM NUMBER] was not covered as required. Observation on 05/23/22 at 12:29 P.M. revealed a clean linen cart with three shelves located between room [ROOM NUMBER] and room [ROOM NUMBER]. Each shelf was stocked with bed linens, incontinence pads, towels, and washcloths. There was one sheet applied to the highest shelf which left the lower two shelves with clean linen exposed. Interview at the time of the observation with the DON verified the clean linen cart located between Rom 120 and room [ROOM NUMBER] was not covered as required. Review of facility policy, Clean Linen Storage, effective 10/20/21, revealed State Tested Nursing Assistants were to keep clean linen cart covered at all times, and to ensure linen was handled and stored in a manner to keep it free from contamination. Review of Best Practices for Management of Clean Linen, last reviewed on 03/27/20, from the Centers for Disease Control and Prevention's Healthcare-Associated Infections (HAIs) Appendix D: Linen and Laundry Management, located at https://www.cdc.gov/hai/prevent/resource-limited/laundry.html#anchor_1585334108204 revealed to store clean linens in a manner that prevents risk of contamination by dust, debris, soiled linens, or other soiled items. 2. On 05/25/22 at 9:01 A.M. observation of urinary catheter care performed by State Tested Nursing Assistant (STNA) #229 for Resident #43 revealed STNA #229 carrying soiled linens with dirty gloves approximately fifteen feet into the hallway to discard the soiled linen in the soiled linen cart and dirty gloves into the trash can; both located in the hallway outside of room [ROOM NUMBER]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366355 If continuation sheet Page 7 of 8 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 05/26/2022 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete On 05/25/22 at 9:14 A.M. interview with STNA #229 verified she walked into the hallway carrying soiled linen with dirty gloves. STNA #229 stated she normally would bag the soiled linens after use in the resident's room, discard her dirty gloves, perform hand hygiene, and discard of the bagged soiled linen in the appropriate soiled linen cart. Review of the facility's policy, Linen Management, dated 03/25/20, revealed soiled linen would be placed into designated bags or other appropriate containers at the point of use. Event ID: Facility ID: 366355 If continuation sheet Page 8 of 8