Health inspection·September 5, 2019

F 0550 Level of Harm - Minimal harm or potential for actual harm Interview with Administrator on 09/03/19 at 6:20 P.M. revealed that STNA #16 did not know the residents well and verified that STNA should have asked the residents their name and served the residents table by table. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366359 If continuation sheet Page 2 of 9 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 366359 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Larchwood Care 4110 Rocky River Drive Cleveland, OH 44135 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on record review and staff interview, the facility failed to check all potential new hires against the State Nurse Aide Registry (NAR) to ensure no employee had a finding entered into the State NAR concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property. This affected all non-STNA (state tested nursing aide) staff who were hired by the facility in the past year, including: seven registered nurses, 11 licensed practical nurses (LPN), 10 dietary workers, six housekeeping staff, two administration workers, one social services staff member and one activities professional. This had the potential to affect all 64 residents admitted to the facility at the time of the survey. Residents Affected - Many Findings include: Interview with Human Resources Director #901 on 09/05/19 at 10:53 A.M. revealed the facility only checked newly hired nursing aides in the State NAR. Other staff members did not receive NAR checks. Review of a list of new hires in the past year (since 08/16/18) revealed the facility hired seven registered nurses, 11 licensed practical nurses, 10 dietary workers, six housekeeping staff, two administration workers, one social services staff member and one activities professional within the past year. Record review of seven employee files (State Tested Nurse Aides (STNA) #401, #402, #403, LPNs #404, #405, Administrator, and Social Service Director #407) revealed no evidence non-STNA staff were checked in the State NAR for concerns related to abuse or other mistreatment of residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366359 If continuation sheet Page 3 of 9 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 366359 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Larchwood Care 4110 Rocky River Drive Cleveland, OH 44135 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 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. Based on observation, interviews and review of menus, the facility failed to provide meals that met daily nutritional needs. This affected 10 (#1, #3, #5, #9, #10, #32, #37, #42, #50 and #65) of 12 residents observed during the lunch meal on 09/03/19 beginning at 12:05 P.M. on the second floor dining room and Resident's #11, #18, #20, #41 and #56 who voiced concerns at the resident group meeting. The facility census was 64. Findings include: The menu posted for the lunch meal on 09/03/19 included beefsteak, buttery seasoned rice, glazed carrots, strawberry shortcake and a beverage of choice. At 12:16 P.M. the steam table arrived in the second floor dining room. Residents #1, #3, #5, #9, #10, #32, #37, #42, #50 and #65 received regular or ground meals. None of the 10 residents received a vegetable. An unfrosted piece of cake in a plastic baggy was given to the 10 residents. Interview with State Tested Nurse Aide #14 on 09/03/19 at 12:29 P.M. verified the residents who received pureed meals received a green vegetable identified as zucchini, she verified the residents who were provided regular and ground diets did not receive a vegetable and verified the residents received a plain piece of cake. Interview with Dietary Aide #49 on 09/03/19 at 12:35 P.M. verified she forgot to bring up a pan of vegetables for the regular and ground diets. She said the pureed vegetable was zucchini. She verified residents just got plain cake and not strawberry shortcake as posted on the menu. Interview with the Dietary Manager #44 on 09/03/19 at 12:40 P.M. said the strawberries were spoiled and had to be thrown out. He did verify the facility did have canned strawberry that could have been substituted but was not. He said he also changed the menu to glazed carrots because he did not know they had zucchini in the walk-in refrigerator. During a group interview conducted on 09/04/19 at 10:13 A.M., with Resident's #11, #18, #20, #41 and #56 present, reported not receiving a vegetable at the lunch meal on 09/03/19. They reported the menu was not always followed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366359 If continuation sheet Page 4 of 9 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 366359 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Larchwood Care 4110 Rocky River Drive Cleveland, OH 44135 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that resident food preferences were honored. This affected five residents (#7, #13, #15, #53, and #56) of 64 residents that take food by mouth. Findings include: 1. Review of resident's medical record revealed Resident #7 was admitted on [DATE] with diagnoses including but not limited to epilepsy, heart failure, chronic obstructive pulmonary disease, and cerebral infarction without residual deficits. Resident # 7's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was moderately cognitively impaired and required extensive assistance with two people for most Activities of Daily Living (ADLs) except eating is supervision with set up only. Further review of Resident #7's medical record revealed that she had a weight loss and was receiving nutritional supplements to promote extra calories which resulted in a weight gain. Her body mass index (BMI) was 17.5 which indicates underweight for her height and weight. 2. Review of resident's medical record revealed Resident #15 was admitted on [DATE] with diagnoses including but not limited to anemia, Parkinson's disease, seizure disorder and schizophrenia. Resident # 15's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was moderately cognitively impaired and required extensive assistance with one person for most Activities of Daily Living (ADLs) except eating is limited assistance with one person. Further review of Resident #15's medical record revealed that he had a weight loss and was receiving nutritional supplements to promote extra calories which resulted in a weight gain. 3. Review of resident's medical record revealed Resident #56 was admitted on [DATE] with diagnoses including but not limited to depression, hypokalemia, and schizophrenia. Resident # 56's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had intact cognition and required supervision without set up for most Activities of Daily Living (ADLs) except eating is supervision with set up. Further review of Resident #56's medical record revealed that he had a weight loss and was receiving nutritional supplements to promote extra calories which resulted in a weight gain. Interviews on 09/03/19 between 9:36 A.M. through 4:39 P.M. with Residents #7, #13, #15, #53 and #56 revealed the facility did not honor food preferences. Residents #7, #15 and #56 stated that they do not get enough food to eat. Phone interview with Registered Dietitian (RD) #99 with Dietary Manager (DM) #44 and Administrator #101 present on 09/05/19 at 9:32 A.M. revealed Dietary Manager (DM) #44 usually obtains food preferences and the RD #99 only speaks to residents upon admission. The software program got changed recently and lost all the residents food preferences but started obtaining preferences last week and still need to be put in the system. Review of the undated policy and procedure titled liberalized geriatric diet indicated personal food preferences would be addressed on an individualized basis and assessment however, there was no evidence resident food preferences were obtained on the quarterly or annual nutritional assessments. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366359 If continuation sheet Page 5 of 9 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 366359 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Larchwood Care 4110 Rocky River Drive Cleveland, OH 44135 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, record review and interview, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner, and food products were covered properly and dated when opened. This had the potential to affect 64 out of 64 residents who ate meals prepared in the facility's kitchen. Findings include: Observations during the initial tour of the kitchen on 09/03/19 from 8:12 A.M. through 8:49 A.M. with Dietary Manager (DM) #44 revealed food residue and crumbs located on the bottom of the steamer and bottom shelf of the steamtable, crab cakes and hamburgers were not labeled and dated in the walk-in freezer, sliced salami and shredded cheese was not labeled or dated in the walk-in refrigerator and dried grease drippings were on the steamtable near the knobs. Interview with DM #10 on 09/04/19 at 9:003 A.M. verified the observations above and he said has been employed at the facility for two weeks, the kitchen could be cleaner, but he has been working on training the staff. Review of posted work cleaning schedules revealed that all work surfaces would be cleaned daily. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366359 If continuation sheet Page 6 of 9 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 366359 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Larchwood Care 4110 Rocky River Drive Cleveland, OH 44135 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview and policy review, the facility failed to ensure oxygen concentrators were maintained in a clean and sanitary condition. This affected two residents (Residents #21 and #53) of four residents identified with oxygen concentrators in the facility. Residents Affected - Few Findings include: Review of the medical record revealed Resident #21 was admitted to the facility on [DATE] with diagnoses including acute and chronic respiratory failure, pneumonia and congestive heart failure. Review of the comprehensive assessment (MDS 3.0) dated 06/08/19 indicated he used oxygen. Review of the plan of care indicated he had oxygen therapy related to respiratory failure and congestive heart failure. On 09/03/19 at 11:50 A.M. Resident #21 was observed seated in his wheelchair using oxygen via a concentrator and nasal cannula. The back of the oxygen concentrator had a black removable filter that was thick with white dust. On 09/04/19 at 11:55 A.M., during interview, State Tested Nurse Aide (STNA) #17 verified the condition of the filter as dirty. On 09/04/19 at 1:37 P.M. Licensed Practical Nurse (LPN) #74 verified Resident #21's filter was dirty. She was not aware of who was responsible for cleaning the vents or filters. 2. On 09/04/19 at 2:11 P.M., with the director of nursing observation and interview revealed the vent on Resident #53's oxygen concentrator was observed to have thick brown dust. Interview with the director of nursing on 09/04/19 at 2:11 P.M. said it was the responsibility of the Hospice company or the oxygen company to clean them. Review of oxygen administration policy dated 07/01/18 indicated staff should perform hand hygiene and don gloves when administering oxygen or when in contact with oxygen equipment. Follow manufacturer recommendations for the frequency and cleaning equipment filters. Cleaning and care of equipment shall be in accordance with the facility policies for such equipment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366359 If continuation sheet Page 7 of 9 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 366359 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Larchwood Care 4110 Rocky River Drive Cleveland, OH 44135 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. 3. The second floor dining room was observed on 09/03/19 at 12:05 P.M. State Tested Nurse Aide #14 verified the windows were covered with a moderate amount of debris making it difficult to look outside. The two portable air-conditioning units vents and extending hose were heavily soiled with dust, lint and food debris. The Speech Therapist #103 was observed to move a chair out of service saying it was too wobbly and chose another chair to sit on. The steam table was observed to be soiled with dried food drips and food debris on the sides and heavier at the bottom. The castors were heavily soiled with dirt, debris and gunk. Dietary Aide #49 was observed pulling out a tray to set a plate on and the tray was soiled with loose dried food debris. Interview with State Tested Nurse Aide #14 on 09/03/19 at 12:29 P.M. verified the condition of the above items. Based on observation and interview the facility failed to maintain the environment in a clean and sanitary manner. This affected Residents #20, #7, #39, #23, #13, #22, #37, #64 and #4. The facility census was 64. Findings include: 1. Observations during the initial tour of the facility and screening of residents for the annual survey on 09/02/19 from 8:17 A.M. to 11:37 A.M. revealed the following: Resident #20's ceiling had mold on the bathroom ceiling and paint was peeling on the wall in his room. This was verified at the time of observation on 09/02/19 at 9:31 A.M. by Maintenance Assistant #85. Resident #7's carpet was stained and near the window, there was dried food stain on the carpet. This was verified at the time of observation by Housekeeper #54 on 09/02/19 at 9:35 A.M. Resident #39's ceiling had mold on the bathroom ceiling. This was verified at the time of observation on 09/02/19 at 9:36 A.M. by Director of Nursing #100. Resident #23's ceiling paint was peeling and holes in the wall in his room. This was verified at the time of observation on 09/02/19 at 11:04 A.M. by Director of Nursing #100. Interview on 09/03/19 at 2:30 P.M. with the Director of Maintenance and Housekeeping # 84 revealed the facility has plans to change the carpeting in residents' rooms. They started with assisted living and the dining room on the first floor. Resident rooms are cleaned daily Review of policy entitled, Routine Cleaning dated 2018 revealed that rooms should be cleaned routinely. 2. Observation on 09/03/19 between 9:00 A.M. and 11:30 A.M. revealed the second-floor hallway had large, black stains in the carpeting throughout the hall. Resident ' s #13, #22, #37 and #64 had light beige carpeting with large black stains throughout. Resident #4 had a hole that broke through the drywall approximately 5 long and 4 inches wide. Interview on 09/03/19 with Resident #4 and Resident's #4's family member at 11:37 A. M. revealed the hole in the wall had been there for several months. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366359 If continuation sheet Page 8 of 9 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 366359 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Larchwood Care 4110 Rocky River Drive Cleveland, OH 44135 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 0921 Interview on 09/04/19 with Licensed Practical Nurse (LPN) #78 at 4:15 P.M. verified the findings. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366359 If continuation sheet Page 9 of 9