Inspection·October 13, 2022

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Medical record review for Resident #18 revealed an admission date of 07/08/22 with diagnoses including heart disease and Alzheimer's dementia. Review of the Minimum Data Set assessment dated [DATE] revealed the resident had moderately impaired cognition and received hospice services. Review of the care conference documentation revealed evidence of a phone care conference on 07/13/22 conducted with the resident, her responsible party and SSD #89. There was no evidence other team members were included in the phone conferences to discuss the resident's care. Interview with SSD #89 on 10/13/22 at 10:45 A.M. verified no other facility team members were part of the phone initial care conference on 07/13/22 she conducted with the resident and her responsible party. SSD #89 verified there was no staff from nursing, administration, dietary or activities participating in the care conference conducted with the resident. 4. Medical record review for Resident #20 revealed an admission date of 06/09/21 with diagnoses including dementia without behaviors, psychotic mood disturbance, anxiety, major depression. Review of the Minimum Data Set assessment dated [DATE] revealed the resident had severely impaired cognition with her daughter as the responsible party. Review of the care conference documentation revealed evidence of phone care conferences on 02/11/22, 05/06/22 and 09/01/22 conducted with the resident, her daughter and SSD #89. There was no evidence other team members were included in the phone conferences to discuss the resident's care. Interview with SSD #89 on 10/13/22 at 10:45 A.M. verified no other facility team members were part of the phone care conferences on 02/11/22, 05/06/22 and 09/01/22 she conducted with the resident and her daughter. SSD #89 verified there was no staff from nursing, administration, dietary or activities participating in the care conferences. Review of the policy titled Resident's First Meeting Guidelines revised 09/03/21 revealed care conference meetings were to facilitate communication regarding the care plan, medical condition and care needs between the resident, resident representative and staff providing care. The meetings should be attended by a nursing designee, Administrator if applicable, SSD, dietary and activity staff. Each staff reviewed their respective care plans with the resident and resident representative with encouraged participation. Based on medical record review, staff and resident interviews, and review of facility policy, the facility failed to have care conferences for residents. The facility also failed to ensure interdisciplinary team members (IDT) were present at care conferences. This affected four (#12, #18, #20, and #30) of four reviewed for care plans. The census was 60. Findings include: 1. Review of Resident #12's medical record revealed an admission date of 08/07/20. Diagnoses listed included hemiplegia and hemiparesis, chronic kidney disease, type 2 diabetes mellitus, aphasia, dysphagia, and major depressive disorder. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366384 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 366384 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cypress Pointe Health Campus 600 West National Road Englewood, OH 45322 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 0657 Level of Harm - Minimal harm or potential for actual harm Review of Minimum Data Set (MDS) assessments revealed an annual assessment was completed on 07/13/22. Further review of Resident #12's medical record revealed no evidence of a care conference being completed from 07/13/22 to 10/12/22. Residents Affected - Some Review of care conference documentation dated 01/07/22 and 04/05/22 revealed the only staff member present during care conferences was the Social Service Director (SSD) #89. Interview with SSD #89 on 10/12/22 at 2:58 P.M. confirmed there was no care conference held for Resident #12 after the annual MDS dated [DATE]. SSD #89 confirmed care conferences should be held at least quarterly. SSD #89 also confirmed she was the only staff member present during care conferences held on 01/07/22 and 04/05/22 for Resident #12. 2. Record review for Resident #30 revealed an admission date of 07/31/20. His diagnoses included; hypertensive chronic kidney disease, orthostatic hypertension, chronic osteomyelitis, seizures, hyperlipidemia, hypothyroidism, anxiety disorder, and essential primary hypertension. Review of the quarterly MDS assessment, dated 08/09/22, revealed he had intact cognition. Further review of the MDS assessment revealed he required extensive assistance from staff with bed mobility, transfers, dressing, toilet use, and personal hygiene. Resident #30 required supervision from staff with eating. Review of the care conference notes for Resident #30 reveled he had a meeting with the SSD #89 on 09/07/22, 06/24/22, 04/04/22, and 01/05/22 to discuss his plan of care. However, no other IDT members were present. Interview on 10/11/22 at 9:19 A.M. with Resident #30 revealed he has never attended a care conference meeting with members of the IDT team. Interview on 10/12/22 at 3:42 P.M. with SSD #89 confirmed the facility has not provided an IDT team meeting or care conference for Resident #30 in the past year. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366384 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 366384 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cypress Pointe Health Campus 600 West National Road Englewood, OH 45322 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 medical record review, staff interview and policy review, the facility failed to ensure pharmacy recommendations were addressed by the physician in a timely manner. This affected two (#24 and #49) of five residents reviewed for to unnecessary medications. The facility census was 60. Findings include: 1. Review of the Resident #24's chart revealed Resident #24 admitted to the facility on [DATE] with diagnoses including cerebral atherosclerosis, difficulty in walking, muscle weakness, cognitive communication deficit, dysphagia, type two diabetes mellitus with diabetic neuropathy, retention of urine, hyperlipidemia, major depressive disorder, unspecified cataract, heart failure, legal blindness, hallucinations, and unspecified dementia with behavioral disturbance. Review of Resident #24's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident to be severely cognitively impaired and Resident #24 required extensive assistance with bed mobility, transfers, dressing, eating, toileting, and personal hygiene. Resident #24 also received insulin, antipsychotic, antianxiety, antidepressant, diuretic, and opioid medications during the assessment review period. Review of Resident #24's pharmacy recommendation dated 04/30/22 revealed Resident #24 was on Ativan one milligrams (mg) twice a day, Celexa 10 mg daily, and Seroquel 25 mg twice a day. Per Centers for Medicare and Medicaid Services (CMS) guidelines, please consider a gradual dose reduction or document the need for the current dose. Further review of the pharmacy recommendation revealed Resident #24's physician was notified of the pharmacy recommendation on 08/10/22. Resident #24's physician did not respond to Resident #24's pharmacy recommendation. Interview on 10/12/22 at 2:07 P.M. with Corporate Registered Nurse (CRN) #800 verified Resident #24's physician was not notified of Resident #24's pharmacy recommendation dated 04/30/22, until 08/10/22 and Resident #24's physician did not address the pharmacy recommendation. 2. Review of the Resident #49's chart revealed Resident #49 admitted to the facility on [DATE] with diagnoses including fracture of unspecified part of neck of left femur, acute respiratory failure with hypoxia, cerebral atherosclerosis, anemia, dehydration, Alzheimer's disease, unspecified dementia, anxiety disorder, hyperlipidemia, low back pain, constipation, other amnesia, and history of falling. Review of Resident #49's quarterly MDS assessment dated [DATE] revealed the resident to be severely cognitively impaired and Resident #49 required extensive assistance with bed mobility, transfers, and dressing. Resident #39 was also totally dependent on staff for toileting, and personal hygiene. Resident #49 received antipsychotic, antianxiety, antidepressant and opioid medications during the review period. Review of Resident #49's pharmacy recommendation dated 04/18/22 revealed to consider reducing Resident #49's Lorazepam. Further review of the pharmacy recommendation revealed Resident #49's physician was notified of the pharmacy recommendation on 08/17/22. Resident 49's physician did not respond to Resident #49's pharmacy recommendation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366384 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 366384 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cypress Pointe Health Campus 600 West National Road Englewood, OH 45322 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 Review of Resident #49's pharmacy recommendation dated 08/29/22 revealed the physician should consider a gradual dose reduction on Resident #49's Buspar, Depakote, Lorazepam, Seroquel, Sertraline and Trazodone. Further review of the pharmacy recommendation revealed Resident #49's physician was notified of the pharmacy recommendation on 09/16/22. Resident 49's physician did not respond to Resident #49's pharmacy recommendation. Residents Affected - Few Interview on 10/13/22 at 11:30 A.M. with the Director of Nursing (DON) verified Resident #49's physician was not notified of Resident #49's pharmacy recommendation dated 04/18/22 until 08/17/22 and Resident #49's physician did not address the pharmacy recommendation dated 04/18/22. The DON also verified Resident #49's physician was not notified of Resident #49's pharmacy recommendation dated 08/29/22 until 09/16/22 and physician did not address the pharmacy recommendation dated 08/29/22. Review of the facility's medication regimen review policy dated November 2018 revealed recommendations will be acted upon and documented by the facility personnel or prescriber. The prescriber accepts and acts upon suggestions or rejects and provides an explanation for disagreeing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366384 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 366384 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cypress Pointe Health Campus 600 West National Road Englewood, OH 45322 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 medical record review, observation, staff interview, review of facility policy, and review of manufacturer guidelines, the facility failed to ensure staff primed an insulin pen devices before administration resulting in a significant medication error. This affected one (#24) of four residents observed for medication administration. The census was 60. Residents Affected - Few Findings include: Review of Resident #24's medical record revealed an admission date of 05/21/18. Diagnoses listed included muscle weakness, dysphagia, type two diabetes mellitus, hypertension, legal blindness, and major depressive disorder. Resident #24 was assessed as being severely cognitively impaired and requiring extensive assistance in a significant change Minimum Data Set (MDS) assessment dated [DATE]. Review of physician orders revealed an order dated 09/29/22 for a Basaglar Kwikpen (insulin pen) 100 units per milliliter (units/ml), inject 15 units subcutaneously (SQ) twice a day. An order dated 08/21/21 was for Novolog Flexpen (insulin pen) 100 units/ml per sliding scale SQ before meals. Observation on 10/13/22 at 7:47 A.M. revealed Licensed Practical Nurse (LPN) #16 preparing insulin pens for Resident #24. LPN #16 prepared a Novolog Flexpen by connecting a new needle and dialing the insulin pen to four units. LPN #16 did not prime the pen needle. LPN #16 also prepared a Basaglar Kwikpen by connecting a new needle and dialing the insulin pen to 15 units. LPN #16 did not prime the pen needle. Observation on 10/13/22 at 7:52 A.M. revealed LPN #16 administered the Novolog Flexpen four units and Basaglar Kwikpen 15 units to Resident #24. Interview with LPN #16 on 10/13/22 at 7:58 A.M. confirmed she had not primed Resident #24's Novolog Flexpen needle or Basaglar Kwikpen needle before dialing up the required dose of insulin. Review of the facility's policy titled Specific Medication Administration Procedures dated revised January 2018 revealed for insulin pen devices staff should dial dose as instructed by pen manufacturer. Review of manufacturer instructions for the Novolog Flexpen before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing, turn the dose selector to select 2. Hold your NovoLog FlexPen with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge . Keep the needle pointing upwards, press the push-button all the way in. The dose selector returns to 0. A drop of insulin should appear at the needle tip. If not, change the needle and repeat the procedure no more than six times. If you do not see a drop of insulin after six times, do not use the NovoLog FlexPen and contact the manufacturer. A small air bubble may remain at the needle tip, but it will not be injected. Review of manufacturer instructions for use for Basaglar Kwikpen revealed priming means removing the air from the needle and cartridge that may collect during normal use. It is important to prime your pen before each injection so that it will work correctly. If you do not prime before each injection, you may get too much or too little insulin. To prime your pen, turn the dose knob to select two (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366384 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 366384 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cypress Pointe Health Campus 600 West National Road Englewood, OH 45322 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 Level of Harm - Minimal harm or potential for actual harm units. Hold your pen with the needle pointing up. Tap the cartridge holder gently to collect air bubbles at the top. Continue holding your pen with needle pointing up. Push the dose knob in until it stops, and 0 is seen in the dose window. Hold the dose knob in and count to five slowly. You should see insulin at the tip of the needle. If you do not see insulin, repeat the priming steps, but not more than four times. If you still do not see insulin, change the needle and repeat the priming steps. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366384 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 366384 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cypress Pointe Health Campus 600 West National Road Englewood, OH 45322 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 - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, review of the facility census, review of a list of diet orders, staff interview and policy review, the facility failed to ensure the legacy kitchen was free from expired food items and a food item was stored in a sanitary manner in the 200 unit nutritional freezer. This had the potential to affect 10 (#14, #15, #25, #33, #35, #36, #37, #38, #45, and #55) out of ten residents that resided on the Legacy unit and 13 (#1, #2, #3, #5, #6, #8, #9, #13, #16, #17, #46, #48, and #57) out of 13 residents that resided on the 200 unit. The facility census was 60. Findings include: 1. Observation of the Legacy kitchen on 10/13/22 at 7:55 A.M. revealed there were two gallons of expired whole milk that were half empty dated 10/11/22 and one full gallon of expired whole milk dated 10/12/22 in the reach in refrigerator. Interview on 10/13/22 at 7:55 A.M. with [NAME] #6 verified there were two gallons of expired whole milk that were half empty dated 10/11/22 and one full gallon of expired whole milk dated 10/12/22 in the Legacy unit kitchen refrigerator. Review of the facility census dated 10/10/22 revealed Resident #14, #15, #25, #33, #35, #36, #37, #38, #45, and #55 resided in the Legacy unit. Further review of a list of diet order for the Legacy unit dated 10/13/22 revealed no residents received no food by mouth. 2. Observation of the 200 unit nourishment and supplement freezer on 10/13/22 at 10:35 A.M. revealed there to be a milkshake cup with a lid and straw in it that was not labeled or dated. The straw was uncovered and open to air in the freezer. Interview with Licensed Practical Nurse (LPN) #32 on 10/13/22 at 10:35 A.M. verified there to be a milkshake cup with a lid and straw in it that was not labeled or dated. The straw was uncovered and open to air in the freezer. Review of the facility census revealed Resident #1, #2, #3, #5, #6, #8, #9, #13, #16, #17, #46, #48, and #57 resided on the 200 unit. Further review of a list of diet order for the 200 unit dated 10/13/22 revealed no residents received no food by mouth. Review of the facility's food labeling and dating policy dated 04/26/22 revealed all food items must be properly covered and not exposed to air prior to being labeled and dated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366384 If continuation sheet Page 8 of 8