Inspection·December 11, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete signs every 15 minutes until the resident's blood pressure stabilizes and place the resident in Trendelenburg position (head lower than feet to increase blood pressure). There was no documented evidence of the resident's POA being notified. Review of an occurrence note dated 11/11/25 at 1:17 P.M., revealed at 6:15 A.M., Resident #87 received the wrong medications. Resident #87 received the following medications Aspirin EC 81 mg, Coreg 25 mg, Clonidine 0.1 mg, Plavix 75 mg, Aricept 5 mg, Losartan 100 mg, Namenda 10 mg, Vitamin B complex tablet, and Hydralazine 50 mg. Review of the Interdisciplinary Team (IDT) note dated 11/11/25 at 1:21 P.M., revealed Resident #87 received the wrong medications during the morning medication administration. The on-call provider was contacted and ordered for all the resident's normal morning medications be held, give midodrine five mg one dose to help raise the resident's blood pressure and check vital signs every 15 minutes. The resident's blood pressure was still low, so the NP was notified and ordered another dose of midodrine five mg and start IV fluids. Resident #87 continued to complain of dizziness. Review of progress note dated 11/11/25 at 1:45 P.M., revealed Resident #87's was in up in a recliner and his blood pressure dropped. The resident was encouraged to get back in bed and elevate his legs. The NP was made aware and another as needed midodrine was administered for low blood pressure. There was no documented evidence that the resident's POA was contacted. Review of progress note dated 11/11/25 at 2:15 P.M., revealed Resident #87 continued to present with hypotension. The NP was made aware and another dose of midodrine was ordered to be given. There was no documented evidence that the resident's POA was contacted.Review of November 2025 Medication Administration Record (MAR) revealed Resident #87 received an as needed midodrine five mg on 11/11/25 at 2:37 P.M. due to blood pressure being below 100 mmHg systolic and again on 11/12/25 charted at 12:04 A.M. but given at 9:00 P.M. due to low blood pressure. The MAR indicated Resident #87 had a blood pressure of 88/56 mmHg at 7:00 A.M., 73/44 mmHg at 7:15 A.M., 88/51 mmHg at 7:30 A.M., 94/57 mmHg at 7:45 A.M. and 97/59 mmHg at 8:15 A.M. On 11/11/25 at 8:52 A.M. an Intravenous (IV) line to administer fluids for low blood pressure was attempted but could not be initiated. Interview on 12/11/25 at 10:30 A.M., Clinical Support Registered Nurse (CSRN) #130, verified the facility did not timely notify Residents #87's POA after the medication error incident on 11/11/25 at 6:15 A.M CSRN #130 verified the resident contacted his POA about the incident and the POA contacted the facility to discuss the incident. Interview on 12/11/25 at 10:51 A.M., Licensed Practical Nurse (LPN) #33 stated at the time of the incident she was being trained by LPN #62. LPN #33 stated LPN #62 was running behind on her medication pass and LPN #33 offered her assistance. LPN #62 gave LPN #33 a cup of medications and asked her to administer the medications to Resident #87. LPN #33 stated she did not check what medications were in the cup or verify the physician orders prior to giving the medications to Resident #87. LPN #33 verified Resident #87 received the wrong medications in error. Interview on 12/11/25 at 12:37 P.M., LPN #62 stated the medication error incident occurred towards the end of her shift (7:00 A.M.) and she was running behind on her medication pass. LPN #33 offered to assist her with medications. LPN #62 verified that she pulled the medication for Resident #102, gave the medication to LPN #33 and incorrectly instructed LPN #33 to give the medication to Resident #87. Review of the facility policy titled Notification of Change in Condition dated 12/17/24, revealed the resident representative should be notified of change in condition in a timely manner. This deficiency represents non-compliance investigated under Complaint Number 2674268. Event ID: Facility ID: 366384 If continuation sheet Page 2 of 5 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 12/11/2025 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 - Actual harm THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on closed medical record review, review of facility investigation, review of facility's timeline of events, review of the incident log, staff interviews, and policy review, the facility failed to ensure residents were free from significant medication errors when one (Resident #87) who was moderately cognitively impaired and dependent on staff for medication administration, received another resident's (Resident #102) morning medications. This resulted in Actual Harm for Resident #87 when the resident was administered medications in error on 11/11/25 at 6:15 A.M. and at 6:40 A.M., the resident became acutely symptomatic with dizziness and low blood pressure. The on-call Nurse Practitioner (NP) was contacted and ordered for the resident to receive midodrine (medication to elevated blood pressure) five milligram (mg) and vital signs to be monitored every 15 minutes. At 7:00 A.M, the resident's blood pressure was still low (73/44 millimeters of mercury [mmHg]) and the NP ordered another dose of midodrine five mgs and a bolus of intravenous (IV) fluids. From 7:15 A.M. through 8:15 A.M, the resident's blood pressure remained low and at 9:20 A.M. and Resident #87 started receiving IV fluids. The resident had two additional low blood pressure readings requiring midodrine five mg at 2:37 P.M. and again at 9:00 P.M. This affected one (Resident #87) of the three residents reviewed for medication administration. The facility census was 66.Findings include: Review of the closed medical record for Resident #87 revealed an admission date of 11/03/25 and discharged on 11/13/25. Diagnoses included fractured left femur, acute post hemorrhagic anemia, dementia, type two diabetes, hypertension, heart failure, and atherosclerotic heart disease. Review of the Incident log from 09/01/25 through 12/11/25 revealed a medication error on 11/11/25 at 6:55 A.M. involving Resident #87. Review of the Minimum Data Set (MDS) assessment for Resident #87 dated 11/10/25, revealed the resident was moderately cognitively impaired and dependent on staff for medication administration. Review of the blood pressure readings for Resident #87 on 11/11/25 revealed the residents blood pressure was 88/56 mmHg at 7:00 A.M, 80/50 mmHg at 7:15 A.M., 73/44 mmHg at 7:19 A.M., 88/51 mmHg at 7:38 A.M., 94/57 mmHg at 7:49 P.M., 97/59 mmHg at 8:04 A.M., 97/60 mmHg at 8:21 A.M., 102/60 mmHg at 8:37 A.M., 90/52 mmHg at 8:51 A.M., 98/59 mmHg at 9:15 A.M., 97/54 mmHg at 9:47 A.M., 90/52 mmHg at 10:05 A.M., 91/52 mmHg at 10:15 A.M, 79/38 mmHg at 11:07 A.M., 92/54 mmHg at 1:00 P.M., 88/56 mmHg at 1:45 P.M., 76/40 mmHg at 2:00 P.M., 75/48 mmHg at 2:15 P.M., 90/52 mmHg at 2:30 P.M. and 90/57 mmHg at 9:00 P.M.Review of the medication error investigation documents revealed on 11/11/25 at 6:55 A.M., Resident #87 was administered Resident #102's medication in error which included: Aspirin EC 81 mg, Coreg (slows heart rate) 25 mg, Clonidine (treats hypertension) 0.1 mg, Plavix (antiplatelet) 75 mg, Aricept (treats dementia caused by Alzheimer's disease ) 5 mg, Losartan (treats hypertension) 100 mg, Namenda (treats dementia caused by Alzheimer's disease) 10 mg, Vitamin B complex tablet, and Hydralazine (treat hypertension) 50 mg. Review of the Investigation Timeline of Events revealed on 11/11/25 at 6:15 A.M., Resident #87 was administered medication that was due to be administered to Resident #102. At 6:40 A.M., Resident #87 alerted staff that he was feeling dizzy, and LPN #62 realized a medication error had occurred. At 6:42 A.M., Resident #87 was ordered to receive midodrine five mg, vital signs every 15 minutes and hold his normal medications. At 7:00 A.M., resident #87's blood pressure was still low, and Nurse Practitioner (NP) was contacted and ordered another midodrine 5 mg and a 500 milliliter (mL) bolus of normal saline via intravenous (IV) fluids. At 9: 20 A.M. the resident's daughter called the facility after the resident called her to tell her about the medication error. An IV line was established, and the NP was notified of an IV line in place with fluids running. The last documented entry was at 4:00 P.M. which noted the resident was going to be monitored every hour through Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366384 If continuation sheet Page 3 of 5 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 12/11/2025 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 - Actual harm Residents Affected - Few the night. Review of the progress note dated 11/11/25 at 7:08 A.M., revealed Resident #87 received the wrong medication and the resident had a hypotensive event. New orders were received for midodrine five mgs, monitor vital signs every 15 minutes until the resident's blood pressure stabilizes and place the resident in Trendelenburg position (head lower than feet to increase blood pressure). Review of an occurrence note dated 11/11/25 at 1:17 P.M., revealed at 6:15 A.M., Resident #87 received the wrong medications. Resident #87 received the following medications Aspirin EC 81 mg, Coreg 25 mg, Clonidine 0.1 mg, Plavix 75 mg, Aricept 5 mg, Losartan 100 mg, Namenda 10 mg, Vitamin B complex tablet, and Hydralazine 50 mg. Review of the Interdisciplinary Team (IDT) note dated 11/11/25 at 1:21 P.M., revealed Resident #87 received the wrong medications during the morning medication administration. The on-call provider was contacted and ordered for all the resident's normal morning medications be held, give midodrine five mg one dose to help raise the resident's blood pressure and check vital signs every 15 minutes. The resident's blood pressure was still low, so the NP was notified and ordered another dose of midodrine five mg and start IV fluids. Resident #87 continued to complain of dizziness. Review of progress note dated 11/11/25 at 1:45 P.M., revealed Resident #87's was in up in a recliner and his blood pressure dropped. The resident was encouraged to get back in bed and elevate his legs. The NP was made aware and another as needed midodrine was administered for low blood pressure. Review of progress note dated 11/11/25 at 2:15 P.M., revealed Resident #87 continued to present with hypotension. The NP was made aware and another dose of midodrine was ordered to be given. Review of November 2025 Medication Administration Record (MAR) revealed Resident #87 received an as needed midodrine five mg on 11/11/25 at 2:37 P.M. due to blood pressure being below 100 mmHg systolic and again on 11/12/25 charted at 12:04 A.M. but given at 9:00 P.M. due to low blood pressure. The MAR indicated Resident #87 had a blood pressure of 88/56 mmHg at 7:00 A.M., 73/44 mmHg at 7:15 A.M., 88/51 mmHg at 7:30 A.M., 94/57 mmHg at 7:45 A.M. and 97/59 mmHg at 8:15 A.M. On 11/11/25 at 8:52 A.M. an Intravenous (IV) line to administer fluids for low blood pressure was attempted but could not be initiated. Interview on 12/11/25 at 10:51 A.M., Licensed Practical Nurse (LPN) #33 stated at the time of the incident she was being trained by LPN #62. LPN #33 stated LPN #62 was running behind on her medication pass and LPN #33 offered her assistance. LPN #62 gave LPN #33 a cup of medications and asked her to administer the medications to Resident #87. LPN #33 stated she did not check what medications were in the cup or verify the physician orders prior to giving the medications to Resident #87. LPN #33 verified Resident #87 received the wrong medications in error. Interview on 12/11/25 at 12:37 P.M., LPN #62 stated the medication error incident occurred towards the end of her shift (7:00 A.M.) and she was running behind on her medication pass. LPN #33 offered to assist her with medications. LPN #62 verified that she pulled the medication for Resident #102, gave the medication to LPN #33 and incorrectly instructed LPN #33 to give the medication to Resident #87. Review of the facility policy titled, Medication Administration, General Guidelines dated November 2018, revealed the five rights (right resident, right drug, right dose, right route, and right time) are applied for each medication being administered. The deficient practice was corrected on 11/18/25 when the facility implemented the following corrective actions: On 11/11/25 at 6:42 A.M., LPN #62 contacted the on-call provider. New orders of midodrine five mg and vital checks every 15 minutes were ordered for Resident #87. On 11/11/25 at 7:00 A.M., LPN #62 notified the NP. New orders for additional dose of midodrine five mg and 500 milliliters of bolus fluids IV for Resident #87. On 11/11/25, all residents on the 100-hall where LPN #33 and LPN #62 were assigned to, were audited for medication errors. No additional medication errors were identified. On 11/11/25, all staff received education on medication administration and medication error reporting guidelines. On 11/12/25, LPN #33 and LPN #62 received (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366384 If continuation sheet Page 4 of 5 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 12/11/2025 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 - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete disciplinary action forms. On 11/12/25, LPN #33 and LPN #62 completed the training course Medication Administration in Acute Care On 11/12/25, LPN #33 and LPN #62 were observed during medication administration and no errors occurred. On 11/18/25, the Director of Nursing (DON) began conducting medication administration observations of two nurses per week for four weeks and then monthly for one quarter. There were concerns identified. The audits will be presented in Quality Assurance Performance Improvement (QAPI) once completed. This deficiency represents non-compliance investigated under Complaint Number 2674268. Event ID: Facility ID: 366384 If continuation sheet Page 5 of 5