Health inspection·November 21, 2023

F 0755 solution 20 mg per 5 ml equals one mg). This order was discontinued on [DATE]. Level of Harm - Minimal harm or potential for actual harm Review of Resident #84's physician Telephone Orders dated [DATE] at 11:00 A.M. and written by Hospice Nurse #28 revealed orders for Morphine 20 mg per ml, give 10 mg every six hours ATC (around the clock) scheduled for SOB, pain. Further review revealed additional orders for Morphine 20 mg per ml, give 10 mg every two hours as needed for SOB, pain. Residents Affected - Few Review of Resident #84's electronic physician orders dated [DATE] at 4:39 P.M. revealed orders for Morphine Sulfate oral solution 20 mg per 5 ml, give 10 mg by mouth every six hours for SOB. This order was discontinued on [DATE] at 4:58 P.M. Review of Resident #84's electronic physician orders dated [DATE] at 4:52 P.M. revealed orders for Morphine Sulfate oral solution 10 mg per 5 ml, give 5 ml by mouth every six hours for SOB. This order was discontinued on [DATE]. Review of Resident #84's electronic physician orders dated [DATE] at 5:02 P.M. revealed orders for Morphine Sulfate oral solution 20 mg per 5 ml, give 0.25 ml by mouth every two hours as needed for SOB, pain, and restlessness. This order was discontinued on [DATE]. Review of Resident #84's physician Telephone Orders dated [DATE] revealed orders for Morphine 100 mg per 5 ml, give 10 mg (0.5 ml), every six hours scheduled for SOB, pain. Further review revealed additional orders for Morphine 100 mg per 5 ml, give 10 mg every two hours as needed SOB, Pain. On [DATE] Hospice Nurse (HN) #25 wrote on the Telephone order that she added 10 mg equaled 0.5 ml to prevent future confusion. Review of Resident #84's Controlled Substance Accountability Sheet (was handwritten and did not have a printed pharmacy label) revealed Morphine 100 milligram (mg) per 5 milliliters (ml), take 0.25 ml by mouth or under the tongue every three hours as needed for SOB (shortness of breath), pain or restlessness. Further review revealed on [DATE] at 12:00 P.M. Licensed Practical Nurse #10 administered 5 ml (100 mg) of morphine 100 mg per 5 ml to Resident #84. Review of Resident #84's Medication Administration Record (MAR) dated [DATE] at 12:00 P.M. revealed Morphine Sulfate Oral Solution 10 mg per 5 ml, give 5 ml by mouth every six hours for SOB was administered to Resident #84 by LPN #10. Review of Resident #84's electronic physician orders dated [DATE] at 2:34 P.M. revealed orders for Morphine Sulfate (concentrate) oral solution 20 mg per ml, give 0.5 ml by mouth every six hours for SOB related to malignant neoplasm of unspecified part of unspecified bronchus or lung. This order was discontinued on [DATE]. Review of Resident #84's electronic physician orders dated [DATE] at 2:44 P.M. revealed orders for Morphine Sulfate (concentrate) oral solution 20 mg per ml, give 0.25 ml by mouth every two hours as needed for SOB, pain related to malignant neoplasm of unspecified part of unspecified bronchus or lung. This order was discontinued [DATE]. Review of Resident #84's progress notes revealed a late entry noted dated [DATE] at 3:18 P.M. indicated order was clarified and changed in the electronic record, and resident's daughter notified. Review of Resident #84's progress notes revealed a late entry note dated [DATE] at 4:40 P.M. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366394 If continuation sheet Page 2 of 15 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 366394 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avenue Care and Rehabilitation Center, The 4120 Interchange Corporate Center Road Warrensville Heights, OH 44128 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few note stated Resident #84's daughter expressed concern about Resident #84 not looking right. Resident #84 was assessed and was responsive to stimulation, no distress was observed and Resident #84 had normal respirations. Review of Resident #84's physician orders dated [DATE] at 7:03 P.M. revealed orders for Narcan (Naloxone HCl (hydrochloride) nasal liquid 4 milligram (mg) per 0.1 milliliter (ml), one spray alternating nostrils as needed for respiratory distress related to malignant neoplasm of unspecified part of unspecified bronchus or lung. Review of Resident #84's Medication Administration Record (MAR) dated [DATE] revealed Narcan (Naloxone HCl (hydrochloride) nasal liquid 4 mg per 0.1 milliliter (ml), one spray was administered at 7:03 P.M. and was effective. Review of Resident #84's progress notes revealed a late entry note dated [DATE] at 8:34 P.M. revealed morphine order clarified, Resident #84 was lethargic with decreased respirations. Physician #24 was notified and gave a new order for Narcan 4 mg. Narcan was administered with effectiveness. Review of Resident #84's progress notes revealed a late entry order clarification note dated [DATE] at 8:38 P.M. revealed Resident #84 remained alert for a small period of time and then became lethargic. Physician #24 was notified and ordered Narcan 4 milligram (mg) and repeat as necessary. Report any new changes in condition. Family at bedside, Narcan was effective and Resident #84 was alert and oriented, back to baseline. Review of Resident #84's physician orders dated [DATE] at 1:13 P.M. revealed orders for Morphine Sulfate (Concentrate) Oral Solution 20 mg per ml, give 0.25 ml by mouth every six hours for pain related to malignant neoplasm of unspecified part of unspecified bronchus or lung, chest pain, or shortness of breath. Further review revealed orders at 1:18 P.M. for Morphine Sulfate (Concentrate) Oral Solution 20 mg per ml, give 0.25 ml by mouth every two hours as needed for pain. Review of Resident #84's facility pharmacy packing slip dated [DATE] revealed two bottles of Morphine Sulfate Solution 100 mg per 5 ml were delivered to the facility. Observation on [DATE] at 4:05 P.M. of Resident #84 revealed he was lying in bed with the head of the bed slightly elevated. Resident #84 looked at the surveyor, but did not speak or answer questions. Resident #84 was breathing slowly and heavily during observation. Interview on [DATE] at 4:05 P.M. with Daughter #26 indicated on [DATE] at around 11:00 A.M. LPN #10 entered Resident #84's room and asked Daughter #26 if she would like her to wake Resident #84 to give him pain medicine. Daughter #26 stated Resident #84 received morphine and then left the room to participate in an Activity program. Later Daughter #26 indicated she told the nurses several times she did not like the way Resident #84 looked, but the nurses said he was just tired. Daughter #26 revealed Resident #84 was supposed to receive 0.5 mg of morphine by mouth, and LPN #10 told her she administered 5 ml of morphine to him. Daughter #26 stated she asked if she could see the syringe LPN #10 used to administer Resident #84's morphine because the syringe LPN #10 used looked different than the syringe which was used at home to administer Resident #84's morphine. Daughter #26 stated when LPN #10 looked at the syringe with her LPN #10 realized she gave Resident #84 an incorrect dose of morphine. Daughter #26 stated the she had LPN #10 come in the room because Resident #84 would breathe a couple times, then there would be a long pause before he breathed again. Daughter #26 stated after that Resident #84 received Narcan. Daughter #26 stated after the Narcan was administered Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366394 If continuation sheet Page 3 of 15 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 366394 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avenue Care and Rehabilitation Center, The 4120 Interchange Corporate Center Road Warrensville Heights, OH 44128 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few #84 would seem alright for awhile then he would become lethargic again. Daughter #26 stated she was not in denial about Resident #84's dying, but if the correct dose of morphine had been given she could guarantee he would not be in the state he was in now. Daughter #26 stated she did not know how many incorrect doses of morphine Resident #84 received. Daughter #26 indicated on [DATE] the Director of Nursing talked to her and apologized for the error. Daughter #26 stated LPN #10 told her she thought it was a high dose of morphine and if she thought that why did she give the 5 ml of morphine which was a high dose. Daughter #26 stated she felt there should be a report filed about the incident. Interview on [DATE] at 6:10 A.M. with LPN #14 revealed she worked on the nursing unit Resident #84 resided on, but he was never or rarely in her assignment. LPN #14 stated Resident #84 was not in her assignment, but she often assisted the nurse who was assigned to the area Resident #84 resided. LPN #14 stated she put morphine orders in Resident #84's electronic record on [DATE] to assist LPN #16 and on [DATE] to help LPN #27. When asked about Resident #84's Telephone Order date of [DATE], LPN #14 stated the Telephone Order was written by Hospice Nurse (HN) #28 and dated [DATE] but the Telephone Order was actually written and put in the electronic record on [DATE]. LPN #14 stated Hospice Nurses usually wrote orders for residents receiving hospice services and the facility nurses put the orders in the electronic record. LPN #14 stated when she searched for Morphine in the system to enter the order in Resident #84's electronic orders she could not find the concentrated Morphine 20 mg per ml. LPN #14 stated Morphine 20 mg per ml was not a choice she could choose in the electronic system used by the facility, and she chose the Morphine which most closely resembled the order. LPN #14 stated on [DATE] she chose the Morphine 20 mg per 5 ml option and on [DATE] she chose the Morphine 10 mg per 5 ml choice and also Morphine 20 mg per 5 ml choice. LPN #14 stated she did not ask the Director of Nursing for assistance in locating the concentrated Morphine 20 mg per ml in the system. LPN #14 stated a Nurse Practitioner was in the facility and helped her pick the Morphine dose which most closely resembled the orders. LPN #14 stated the Morphine she ordered which was 10 mg per 5 ml and 20 mg per 5 ml was never delivered by the pharmacy so the open bottle of morphine Resident #84 brought with him to the facility was used by the nurses to administer Morphine (Morphine Sulfate Concentrate 100 mg per 5 ml). LPN #14 stated she did not administer Morphine to Resident #84, she only helped put orders in his electronic record. LPN #14 indicated Resident #84 was admitted with a comfort care kit which included the concentrated Morphine 20 mg per ml. LPN #14 stated the Morphine 20 mg per ml did not come with a box, it was in a baggie, was opened, did not have a plunger and did not have a seal. LPN #14 stated Daughter #26 brought the box for the Morphine in later. LPN #14 revealed she did not think she verified Resident #84's orders with Physician #24 because she was assisting LPN #16 and LPN #16 probably verified the orders. LPN #14 indicated she thought Hospice nurses took care of resident's Morphine and called the Hospice physician for orders and a signed prescription. LPN #14 stated facility nurses did not have to call our own doctor to get a signed prescription. When asked about the orders on [DATE] and [DATE] for Morphine Sulfate 20 mg per 5 ml and the amount to be administered (0.25 ml) equaled 1 mg LPN #14 stated 0.25 ml equaled 5 mg. Interview on [DATE] at 9:27 A.M. of Hospice Nurse (HN) #25 revealed Resident #84 was on home hospice care and was admitted to the facility after Daughter #26 felt like she could not care for him at home. HN #25 stated Resident #84 had a Hospice home team and when he was admitted to the facility he changed to a Hospice facility team. HN #25 confirmed Resident #84 brought medications from home to the facility. HN #25 stated HN #28 was covering the weekend and wrote a Telephone Order which was correct but not clear. HN #25 stated the facility nurse on duty the day of the Morphine incident mixed up the concentration of Morphine with the dose ordered and accidentally gave Morphine 5 ml by mouth which was 100 mg of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366394 If continuation sheet Page 4 of 15 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 366394 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avenue Care and Rehabilitation Center, The 4120 Interchange Corporate Center Road Warrensville Heights, OH 44128 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Morphine instead of the 10 mg ordered. HN #25 stated after Resident #84 was administered 100 mg of Morphine by mouth he was groggy for a period of hours and was given Narcan times one dose. HN #25 stated Resident #84 was in decline since he received the Narcan, and did not think he received any additional Morphine after the 100 mg was given. HN #25 indicated the Morphine was being held until [DATE] to let it disperse from his system. HN #25 stated she called the coroner and the coroner told her she did not have to call him when Resident #25 passed because an acute overdose of Morphine did not cause his death. HN #25 stated the nurse did not realize she was giving the incorrect dose of Morphine, and did say to Daughter #26 she thought it was a higher dose than normal, but did not call to clarify before administering the Morphine. HN #25 indicated she told the facility nurses if there were any questions about the orders to call for clarification. HN #25 stated she spoke with the Director of Nursing (DON) and told her the concentrated morphine was administered with a one ml syringe. HN #25 stated she did not place Morphine orders for Resident #84 because the nurse on duty told her his medications were in place. HN #25 stated Physician #24 was Resident #84's primary care physician and in facilities the primary care physician was contacted first for orders and if that wasn't successful then the Hospice nurses would use the Hospice physician. Interview on [DATE] at 10:12 A.M. of Hospice Nurse (HN) #28 revealed she made a mistake on the date of the Telephone Orders she placed and the date of the Telephone Order was [DATE] and not [DATE]. HN #28 stated she told the nurse on duty and the nurse said the date did not matter because the correct date was in the system and would be on the order after it was placed in the electronic system. HN #28 stated on [DATE] Resident #84 was very SOB and the nurses were not doing a lot about the SOB so she stayed about an hour and a half. HN #28 stated the orders the facility had for Resident #84 did not match the orders that were in the Hospice system. HN #28 stated Resident #84 was receiving Morphine 0.25 ml every three hours as needed and did not have a scheduled dose of Morphine ordered. HN #28 stated the Hospice orders had a scheduled dose of Morphine 10 mg (0.5 ml) and an as needed dose of Morphine 5 mg (0.25 ml) ordered. HN #28 stated the Hospice Nurse Practitioner told her she could give Resident #84 scheduled and as needed Morphine and approved the orders. HN #28 indicated Resident #84 only received 0.25 ml of Morphine and needed to receive another 0.25 ml to complete the full dose (10 mg) of the scheduled Morphine which was in the Hospice orders. HN #28 stated LPN #27 showed her the handwritten Hospice orders which were not the same as the orders in the Hospice electronic system. HN #28 stated the Telephone Orders she wrote on [DATE] were the same as the orders in the Hospice electronic system. HN #28 stated she told LPN #27 Resident #84 needed another Morphine 0.25 ml to complete the scheduled dose but did not know if LPN #27 administered it because HN #28 had to leave the facility to continue her work assignment. HN #28 stated it did not make sense that Resident #84 was given 100 mg of Morphine because the concentrated Morphine came with its own 1 ml syringe. Interview on [DATE] at 11:16 A.M. of LPN #10 revealed on [DATE] Resident #84 had a scheduled dose of Morphine due at 12:00 P.M. LPN #10 stated Resident #84's orders stated to give 5 ml and she gave him 5 ml from the Morphine bottle which was in the medication cart. LPN #10 stated after she gave Morphine 5 ml to Resident #84 she realized the Morphine in the medication cart was 20 mg per ml and not 10 mg per 5 ml. LPN #10 stated Resident #84 was given 100 mg of Morphine by mouth, and she immediately contacted Resident #84's physician. LPN #10 stated Daughter #26 was notified and Resident #84's Morphine orders were clarified. LPN #10 stated she kept assessing Resident #84 and it took about three hours for him to become lethargic. LPN #10 indicated she took Resident #84's vital signs and documented the vital signs on Resident #84's neuro check sheet which was on paper and not in the electronic medical record. Physician #24 gave orders to monitor Resident #84. LPN #10 stated Resident #24's vital signs changed and he (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366394 If continuation sheet Page 5 of 15 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 366394 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avenue Care and Rehabilitation Center, The 4120 Interchange Corporate Center Road Warrensville Heights, OH 44128 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few developed apnea (stop breathing or have almost no airflow). LPN #10 stated Resident #84 received Narcan when he developed apnea. LPN #10 stated she thought the 5 ml was weird but Resident #84's MAR made it seem like she should give Morphine 5 ml. LPN #10 revealed the orders in Resident #84's MAR were very confusing. Interview on [DATE] at 12:45 P.M. of the DON revealed Resident #84 was admitted on [DATE] and was receiving hospice services. The DON stated hospice provided orders and the orders would have been verified with Physician #24. The DON stated the Hospice home care team could have communicated more effectively with the Hospice facility team to help prevent Resident #84's Morphine mistake. The DON stated Resident #84's Morphine was initially ordered by Hospice and was 0.25 ml every three hours as needed. The DON stated HN #28 came in on the weekend and bumped the Morphine up to 0.5 ml on a scheduled basis. The DON stated LPN #14 was helping the other nurses on [DATE] and [DATE] when she placed Resident #84's Morphine order incorrectly in the electronic system. The DON stated LPN #14 did not ask for help or tell her she could not find the correct Morphine concentration when she placed the order in the system. Observation on [DATE] at 12:45 P.M. with the DON of Resident #84's open Morphine bottle revealed Morphine Sulfate 100 mg per 5 ml. Interview on [DATE] at 1:32 P.M. of Physician #24 revealed giving 100 mg of Morphine by mouth could depress respirations and cause respiratory arrest. Physician #24 stated Resident #84 was monitored continuously after he received Morphine 100 mg by mouth. Physician #24 stated he called an emergency room physician to ask if Resident #84 should be transported to the Emergency Department and the emergency room physician told him if Resident #84 was stable he could be monitored at the facility after Narcan was administered. Physician #24 stated Resident #84 had one dose of 100 mg of Morphine, it could potentially induce respiratory failure, but it did not. Physician #24 stated Morphine would not have a lingering effect on Resident #84. Interview on [DATE] at 1:51 P.M. of Pharmacist #29 revealed he worked for the facility pharmacy. Pharmacist #29 stated the pharmacy did not receive orders and Resident #84 did not have Morphine dispensed from the pharmacy until [DATE] at 7:00 P.M. which was after the incident when Resident #94 received Morphine 100 mg by mouth. Pharmacist #29 stated an order for Resident #84's Morphine might have been sent to the pharmacy but it would not have been filled until there was a signed prescription from the physician. Pharmacist #29 stated the facility pharmacy would have no eyes on medications brought from home including Morphine and would not know what was brought from home. Pharmacist #29 stated the facility pharmacy could not repackage medications and would never approve the use of another pharmacy's controlled two substance (Morphine). Interview on [DATE] at 2:29 P.M. of the DON, the Administrator and Regional Nurse #30 revealed LPN #30 might have seen orders from Hospice for Resident #84 but there was not a valid prescription for Morphine. Regional Nurse #30 stated LPN #14 knew Resident #84's family brought his medications including a bottle of Morphine to the facility and the medications were filled at an outside pharmacy and not the facility pharmacy. Regional Nurse #30 stated she thought LPN #14 saw Resident #84's Morphine bottle was labeled 100 mg per 5 ml, saw Morphine 20 mg per 5 ml in the electronic system and did not realize what she had was different from the template. Regional Nurse #30 stated Resident #84's Morphine orders were probably sitting in the queue at the facility pharmacy waiting for a prescription from the physician. Interview on [DATE] at 8:04 A.M. of LPN #16 revealed she verified Resident #84's orders with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366394 If continuation sheet Page 6 of 15 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 366394 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avenue Care and Rehabilitation Center, The 4120 Interchange Corporate Center Road Warrensville Heights, OH 44128 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Physician #24 when Resident #84 was admitted to the facility. LPN #16 confirmed there was no documentation in Resident #84's progress notes stating she verified his orders with Physician #24. LPN #16 stated Resident #84 brought his medications from home, she made sure the medications including the Morphine bottle matched the Hospice orders. LPN #16 stated Resident #84's Morphine bottle was opened and had been used prior to his admittance to the facility. LPN #16 stated LPN #14 helped her and placed Resident #84's orders including Morphine in the electronic system. LPN #16 stated Resident #84's Morphine order changed a few times. Interview on [DATE] at 9:41 A.M. of Hospice Chief Quality Officer (HCQO) #31 revealed the facility was provided handwritten orders for Resident #84 when he was admitted to the facility. HCQO #31 stated the facility would not be able to view orders in the Hospice electronic system and that was the reason orders were handwritten and given to the facility. HCQO #31 stated the handwritten Hospice orders including Morphine needed to be verified by Resident #84's physician. HCQO #31 confirmed the facility was not given Resident #84's most recent Hospice Morphine orders and that was why HN #28 called the Hospice Nurse Practitioner on [DATE] and updated Resident #84's Morphine Orders via a Telephone Order. Interview on [DATE] at 10:11 A.M. of the DON revealed the facility would accept Resident #84's medications from home. The DON stated the Hospice nurses provided Resident #84's orders, and the facility nurses would verify the orders with the facility physician. The DON stated Resident #84's Morphine which was brought from home was alright for the facility to use even if the bottle was open and unsealed. The DON stated Resident #84's Morphine was filled from an outside pharmacy and Physician #24 (Resident #84's physician) did not know Resident #84 and would direct the facility to get a prescription from hospice. The DON stated the facility physicians would not give a signed prescription for a Hospice resident. The DON indicated Physician #24 gave the okay to continue doing what hospice was doing. The DON confirmed the facility would not know what happened to the Morphine bottle after it was opened at home and it was not uncommon to accept open bottles of Morphine from resident's receiving Hospice services admitted to the facility. The DON stated she was not sure if Physician #24 was aware Resident #84's Morphine bottle was opened and unsealed. Interview on [DATE] at 10:22 A.M. of Physician #24 revealed he did not remember being called to verify Resident #84's medications by a facility nurse, but he was called to verify so many orders it was hard to remember all the residents. Physician #24 stated he would always want to write a new prescription for Morphine, and he did not know Resident #84 brought a bottle of Morphine with him when he was admitted to the facility. Physician #24 stated he would order Resident #84's Morphine from the facility pharmacy. Physician #24 stated he would not okay the use of an open bottle of Morphine brought to the facility from home. Review of the facility policy titled Medication Ordering and Receiving from Pharmacy and Medications Brought to the Facility by a Resident or Responsible Party, undated, included medications brought into the facility by a resident or responsible party were used only upon written order by the resident's attending physician, after the contents were verified, and if the packaging meets the facility's guidelines. Unauthorized medications were not accepted by the facility. Use of medications brought to the facility by a resident or responsible party was allowed only when the following conditions were met; the medication was ordered by the resident's physician and entered in the resident's medical record for bedside storage and self-administration by the resident, the medication container was clearly labeled in accordance with the facility procedures for medication labeling and packaged in a manner consistent with facility guidelines for medications. Medications not ordered by the resident's physician, or unacceptable for other reasons, are returned to the responsible party or designated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366394 If continuation sheet Page 7 of 15 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 366394 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avenue Care and Rehabilitation Center, The 4120 Interchange Corporate Center Road Warrensville Heights, OH 44128 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 0755 agent. Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled Medication Administration-General Guidelines revised 08/2014, included the Five Rights, the right resident, right drug, right dose, right route and right time were applied for each medication being administered. A triple check of these five rights is recommended at three steps in the process of preparation of a medication for administration, when the medication was selected, when the dose was removed from the container, and just after the dose was prepared and the medication put away. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366394 If continuation sheet Page 8 of 15 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 366394 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avenue Care and Rehabilitation Center, The 4120 Interchange Corporate Center Road Warrensville Heights, OH 44128 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of facility policy, the facility failed to ensure Resident #84 was free from significant medication error. Residents Affected - Few Actual Harm occurred on [DATE] at 12:00 P.M. when Resident #84 who received Hospice services was administered 5 milliliters (ml) of Morphine Concentrate 20 milligrams (mg) per ml by mouth which equaled 100 mg medication, ten times the amount ordered, resulting in a medication overdose. Resident #84 was monitored by the facility nurses for respiratory distress and failure and was administered Narcan for respiratory distress on [DATE] at 7:03 P.M. This affected one resident (Resident #84) out of five reviewed for medication administration. The facility census was 79. Findings include: Review of Resident #84's medical record revealed an admission date of [DATE] and diagnoses included malignant neoplasm of unspecified part of unspecified bronchus or lung, secondary neoplasm of the brain and chronic obstructive pulmonary disease. Resident #84 expired at the facility on [DATE]. Review of Resident #84's Nursing admission assessment dated [DATE] did not specify Resident #84's orientation to time, place, person or if he was disoriented. The Assessment stated Resident #84 was friendly, cooperative and non-questioning. Review of Resident #84's Nursing admission Care Plan dated [DATE] included Resident #84 had pain. Resident #84 would be as comfortable as possible. Interventions included to monitor pain and administer pain medications as ordered. Review of Resident #84's progress notes dated [DATE] at 2:41 P.M. included Resident #84 was admitted to the facility and received hospice services. Resident #84 was alert and oriented to time, place and had moments of forgetfulness. Review of Resident #84's progress notes dated [DATE] through [DATE] did not reveal documentation Physician #24 was contacted to verify Resident #24's admission orders. Review of Resident #84's Hospice handwritten orders, undated, included Morphine Concentrate 20 mg per ml, give 0.25 ml (5 mg) by mouth, sublingual (under tongue), every three hours as needed for shortness of breath, pain, restlessness. Review of Resident #84's electronic physician orders dated [DATE] at 2:37 P.M. revealed Morphine Sulfate oral solution 20 milligram (mg) per 5 milliliters (ml), give 0.25 ml by mouth every three hours as needed for SOB (shortness of breath), pain and restlessness (0.25 ml of Morphine Sulfate oral solution 20 mg per 5 ml equals one mg). This order was discontinued on [DATE]. Review of Resident #84's physician Telephone Orders dated [DATE] at 11:00 A.M. and written by Hospice Nurse #28 revealed orders for Morphine 20 mg per ml, give 10 mg every six hours ATC (around the clock) scheduled for SOB, pain. Further review revealed additional orders for Morphine 20 mg per ml, give 10 mg every two hours as needed for SOB, pain. Review of Resident #84's electronic physician orders dated [DATE] at 4:39 P.M. revealed orders for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366394 If continuation sheet Page 9 of 15 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 366394 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avenue Care and Rehabilitation Center, The 4120 Interchange Corporate Center Road Warrensville Heights, OH 44128 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 Morphine Sulfate oral solution 20 mg per 5 ml, give 10 mg by mouth every six hours for SOB. This order was discontinued on [DATE] at 4:58 P.M. Level of Harm - Actual harm Residents Affected - Few Review of Resident #84's electronic physician orders dated [DATE] at 4:52 P.M. revealed orders for Morphine Sulfate oral solution 10 mg per 5 ml, give 5 ml by mouth every six hours for SOB. This order was discontinued on [DATE]. Review of Resident #84's electronic physician orders dated [DATE] at 5:02 P.M. revealed orders for Morphine Sulfate oral solution 20 mg per 5 ml, give 0.25 ml by mouth every two hours as needed for SOB, pain, and restlessness. This order was discontinued on [DATE]. Review of Resident #84's physician Telephone Orders dated [DATE] revealed orders for Morphine 100 mg per 5 ml, give 10 mg (0.5 ml), every six hours scheduled for SOB, pain. Further review revealed additional orders for Morphine 100 mg per 5 ml, give 10 mg every two hours as needed SOB, Pain. On [DATE] Hospice Nurse (HN) #25 wrote on the Telephone order that she added 10 mg equaled 0.5 ml to prevent future confusion. Review of Resident #84's Controlled Substance Accountability Sheet (was handwritten and did not have a printed pharmacy label) revealed Morphine 100 milligram (mg) per 5 milliliters (ml), take 0.25 ml by mouth or under the tongue every three hours as needed for SOB (shortness of breath), pain or restlessness. Further review revealed on [DATE] at 12:00 P.M. Licensed Practical Nurse #10 administered 5 ml (100 mg) of morphine 100 mg per 5 ml to Resident #84. Review of Resident #84's Medication Administration Record (MAR) dated [DATE] at 12:00 P.M. revealed Morphine Sulfate Oral Solution 10 mg per 5 ml, give 5 ml by mouth every six hours for SOB was administered to Resident #84 by LPN #10. Review of Resident #84's electronic physician orders dated [DATE] at 2:34 P.M. revealed orders for Morphine Sulfate (concentrate) oral solution 20 mg per ml, give 0.5 ml by mouth every six hours for SOB related to malignant neoplasm of unspecified part of unspecified bronchus or lung. This order was discontinued on [DATE]. Review of Resident #84's electronic physician orders dated [DATE] at 2:44 P.M. revealed orders for Morphine Sulfate (concentrate) oral solution 20 mg per ml, give 0.25 ml by mouth every two hours as needed for SOB, pain related to malignant neoplasm of unspecified part of unspecified bronchus or lung. This order was discontinued [DATE]. Review of Resident #84's progress notes revealed a late entry noted dated [DATE] at 3:18 P.M. indicated order was clarified and changed in the electronic record, and resident's daughter notified. Review of Resident #84's progress notes revealed a late entry note dated [DATE] at 4:40 P.M. The note stated Resident #84's daughter expressed concern about Resident #84 not looking right. Resident #84 was assessed and was responsive to stimulation, no distress was observed and Resident #84 had normal respirations. Review of Resident #84's physician orders dated [DATE] at 7:03 P.M. revealed orders for Narcan (Naloxone HCl (hydrochloride) nasal liquid 4 milligram (mg) per 0.1 milliliter (ml), one spray alternating nostrils as needed for respiratory distress related to malignant neoplasm of unspecified part of unspecified bronchus or lung. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366394 If continuation sheet Page 10 of 15 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 366394 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avenue Care and Rehabilitation Center, The 4120 Interchange Corporate Center Road Warrensville Heights, OH 44128 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 Review of Resident #84's Medication Administration Record (MAR) dated [DATE] revealed Narcan (Naloxone HCl (hydrochloride) nasal liquid 4 mg per 0.1 milliliter (ml), one spray was administered at 7:03 P.M. and was effective. Review of Resident #84's progress notes revealed a late entry note dated [DATE] at 8:34 P.M. revealed morphine order clarified, Resident #84 was lethargic with decreased respirations. Physician #24 was notified and gave a new order for Narcan 4 mg. Narcan was administered with effectiveness. Review of Resident #84's progress notes revealed a late entry order clarification note dated [DATE] at 8:38 P.M. revealed Resident #84 remained alert for a small period of time and then became lethargic. Physician #24 was notified and ordered Narcan 4 milligram (mg) and repeat as necessary. Report any new changes in condition. Family at bedside, Narcan was effective and Resident #84 was alert and oriented, back to baseline. Review of Resident #84's physician orders dated [DATE] at 1:13 P.M. revealed orders for Morphine Sulfate (Concentrate) Oral Solution 20 mg per ml, give 0.25 ml by mouth every six hours for pain related to malignant neoplasm of unspecified part of unspecified bronchus or lung, chest pain, or shortness of breath. Further review revealed orders at 1:18 P.M. for Morphine Sulfate (Concentrate) Oral Solution 20 mg per ml, give 0.25 ml by mouth every two hours as needed for pain. Review of Resident #84's facility pharmacy packing slip dated [DATE] revealed two bottles of Morphine Sulfate Solution 100 mg per 5 ml were delivered to the facility. Observation on [DATE] at 4:05 P.M. of Resident #84 revealed he was lying in bed with the head of the bed slightly elevated. Resident #84 looked at the surveyor, but did not speak or answer questions. Resident #84 was breathing slowly and heavily during observation. Interview on [DATE] at 4:05 P.M. with Daughter #26 indicated on [DATE] at around 11:00 A.M. LPN #10 entered Resident #84's room and asked Daughter #26 if she would like her to wake Resident #84 to give him pain medicine. Daughter #26 stated Resident #84 received morphine and then left the room to participate in an Activity program. Later Daughter #26 indicated she told the nurses several times she did not like the way Resident #84 looked, but the nurses said he was just tired. Daughter #26 revealed Resident #84 was supposed to receive 0.5 mg of morphine by mouth, and LPN #10 told her she administered 5 ml of morphine to him. Daughter #26 stated she asked if she could see the syringe LPN #10 used to administer Resident #84's morphine because the syringe LPN #10 used looked different than the syringe which was used at home to administer Resident #84's morphine. Daughter #26 stated when LPN #10 looked at the syringe with her LPN #10 realized she gave Resident #84 an incorrect dose of morphine. Daughter #26 stated the she had LPN #10 come in the room because Resident #84 would breathe a couple times, then there would be a long pause before he breathed again. Daughter #26 stated after that Resident #84 received Narcan. Daughter #26 stated after the Narcan was administered Resident #84 would seem alright for awhile then he would become lethargic again. Daughter #26 stated she was not in denial about Resident #84's dying, but if the correct dose of morphine had been given she could guarantee he would not be in the state he was in now. Daughter #26 stated she did not know how many incorrect doses of morphine Resident #84 received. Daughter #26 indicated on [DATE] the Director of Nursing talked to her and apologized for the error. Daughter #26 stated LPN #10 told her she thought it was a high dose of morphine and if she thought that why did she give the 5 ml of morphine which was a high dose. Daughter #26 stated she felt there should be a report filed about the incident. Interview on [DATE] at 6:10 A.M. with LPN #14 revealed she worked on the nursing unit Resident #84 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366394 If continuation sheet Page 11 of 15 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 366394 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avenue Care and Rehabilitation Center, The 4120 Interchange Corporate Center Road Warrensville Heights, OH 44128 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 resided on, but he was never or rarely in her assignment. LPN #14 stated Resident #84 was not in her assignment, but she often assisted the nurse who was assigned to the area Resident #84 resided. LPN #14 stated she put morphine orders in Resident #84's electronic record on [DATE] to assist LPN #16 and on [DATE] to help LPN #27. When asked about Resident #84's Telephone Order date of [DATE], LPN #14 stated the Telephone Order was written by Hospice Nurse (HN) #28 and dated [DATE] but the Telephone Order was actually written and put in the electronic record on [DATE]. LPN #14 stated Hospice Nurses usually wrote orders for residents receiving hospice services and the facility nurses put the orders in the electronic record. LPN #14 stated when she searched for Morphine in the system to enter the order in Resident #84's electronic orders she could not find the concentrated Morphine 20 mg per ml. LPN #14 stated Morphine 20 mg per ml was not a choice she could choose in the electronic system used by the facility, and she chose the Morphine which most closely resembled the order. LPN #14 stated on [DATE] she chose the Morphine 20 mg per 5 ml option and on [DATE] she chose the Morphine 10 mg per 5 ml choice and also Morphine 20 mg per 5 ml choice. LPN #14 stated she did not ask the Director of Nursing for assistance in locating the concentrated Morphine 20 mg per ml in the system. LPN #14 stated a Nurse Practitioner was in the facility and helped her pick the Morphine dose which most closely resembled the orders. LPN #14 stated the Morphine she ordered which was 10 mg per 5 ml and 20 mg per 5 ml was never delivered by the pharmacy so the open bottle of morphine Resident #84 brought with him to the facility was used by the nurses to administer Morphine (Morphine Sulfate Concentrate 100 mg per 5 ml). LPN #14 stated she did not administer Morphine to Resident #84, she only helped put orders in his electronic record. LPN #14 indicated Resident #84 was admitted with a comfort care kit which included the concentrated Morphine 20 mg per ml. LPN #14 stated the Morphine 20 mg per ml did not come with a box, it was in a baggie, was opened, did not have a plunger and did not have a seal. LPN #14 stated Daughter #26 brought the box for the Morphine in later. LPN #14 revealed she did not think she verified Resident #84's orders with Physician #24 because she was assisting LPN #16 and LPN #16 probably verified the orders. LPN #14 indicated she thought Hospice nurses took care of resident's Morphine and called the Hospice physician for orders and a signed prescription. LPN #14 stated facility nurses did not have to call our own doctor to get a signed prescription. When asked about the orders on [DATE] and [DATE] for Morphine Sulfate 20 mg per 5 ml and the amount to be administered (0.25 ml) equaled 1 mg LPN #14 stated 0.25 ml equaled 5 mg. Interview on [DATE] at 9:27 A.M. of Hospice Nurse (HN) #25 revealed Resident #84 was on home hospice care and was admitted to the facility after Daughter #26 felt like she could not care for him at home. HN #25 stated Resident #84 had a Hospice home team and when he was admitted to the facility he changed to a Hospice facility team. HN #25 confirmed Resident #84 brought medications from home to the facility. HN #25 stated HN #28 was covering the weekend and wrote a Telephone Order which was correct but not clear. HN #25 stated the facility nurse on duty the day of the Morphine incident mixed up the concentration of Morphine with the dose ordered and accidentally gave Morphine 5 ml by mouth which was 100 mg of Morphine instead of the 10 mg ordered. HN #25 stated after Resident #84 was administered 100 mg of Morphine by mouth he was groggy for a period of hours and was given Narcan times one dose. HN #25 stated Resident #84 was in decline since he received the Narcan, and did not think he received any additional Morphine after the 100 mg was given. HN #25 indicated the Morphine was being held until [DATE] to let it disperse from his system. HN #25 stated she called the coroner and the coroner told her she did not have to call him when Resident #25 passed because an acute overdose of Morphine did not cause his death. HN #25 stated the nurse did not realize she was giving the incorrect dose of Morphine, and did say to Daughter #26 she thought it was a higher dose than normal, but did not call to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366394 If continuation sheet Page 12 of 15 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 366394 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avenue Care and Rehabilitation Center, The 4120 Interchange Corporate Center Road Warrensville Heights, OH 44128 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 clarify before administering the Morphine. HN #25 indicated she told the facility nurses if there were any questions about the orders to call for clarification. HN #25 stated she spoke with the Director of Nursing (DON) and told her the concentrated morphine was administered with a one ml syringe. HN #25 stated she did not place Morphine orders for Resident #84 because the nurse on duty told her his medications were in place. HN #25 stated Physician #24 was Resident #84's primary care physician and in facilities the primary care physician was contacted first for orders and if that wasn't successful then the Hospice nurses would use the Hospice physician. Interview on [DATE] at 10:12 A.M. of Hospice Nurse (HN) #28 revealed she made a mistake on the date of the Telephone Orders she placed and the date of the Telephone Order was [DATE] and not [DATE]. HN #28 stated she told the nurse on duty and the nurse said the date did not matter because the correct date was in the system and would be on the order after it was placed in the electronic system. HN #28 stated on [DATE] Resident #84 was very SOB and the nurses were not doing a lot about the SOB so she stayed about an hour and a half. HN #28 stated the orders the facility had for Resident #84 did not match the orders that were in the Hospice system. HN #28 stated Resident #84 was receiving Morphine 0.25 ml every three hours as needed and did not have a scheduled dose of Morphine ordered. HN #28 stated the Hospice orders had a scheduled dose of Morphine 10 mg (0.5 ml) and an as needed dose of Morphine 5 mg (0.25 ml) ordered. HN #28 stated the Hospice Nurse Practitioner told her she could give Resident #84 scheduled and as needed Morphine and approved the orders. HN #28 indicated Resident #84 only received 0.25 ml of Morphine and needed to receive another 0.25 ml to complete the full dose (10 mg) of the scheduled Morphine which was in the Hospice orders. HN #28 stated LPN #27 showed her the handwritten Hospice orders which were not the same as the orders in the Hospice electronic system. HN #28 stated the Telephone Orders she wrote on [DATE] were the same as the orders in the Hospice electronic system. HN #28 stated she told LPN #27 Resident #84 needed another Morphine 0.25 ml to complete the scheduled dose but did not know if LPN #27 administered it because HN #28 had to leave the facility to continue her work assignment. HN #28 stated it did not make sense that Resident #84 was given 100 mg of Morphine because the concentrated Morphine came with its own 1 ml syringe. Interview on [DATE] at 11:16 A.M. of LPN #10 revealed on [DATE] Resident #84 had a scheduled dose of Morphine due at 12:00 P.M. LPN #10 stated Resident #84's orders stated to give 5 ml and she gave him 5 ml from the Morphine bottle which was in the medication cart. LPN #10 stated after she gave Morphine 5 ml to Resident #84 she realized the Morphine in the medication cart was 20 mg per ml and not 10 mg per 5 ml. LPN #10 stated Resident #84 was given 100 mg of Morphine by mouth, and she immediately contacted Resident #84's physician. LPN #10 stated Daughter #26 was notified and Resident #84's Morphine orders were clarified. LPN #10 stated she kept assessing Resident #84 and it took about three hours for him to become lethargic. LPN #10 indicated she took Resident #84's vital signs and documented the vital signs on Resident #84's neuro check sheet which was on paper and not in the electronic medical record. Physician #24 gave orders to monitor Resident #84. LPN #10 stated Resident #24's vital signs changed and he developed apnea (stop breathing or have almost no airflow). LPN #10 stated Resident #84 received Narcan when he developed apnea. LPN #10 stated she thought the 5 ml was weird but Resident #84's MAR made it seem like she should give Morphine 5 ml. LPN #10 revealed the orders in Resident #84's MAR were very confusing. Interview on [DATE] at 12:45 P.M. of the DON revealed Resident #84 was admitted on [DATE] and was receiving hospice services. The DON stated hospice provided orders and the orders would have been verified with Physician #24. The DON stated the Hospice home care team could have communicated more effectively with the Hospice facility team to help prevent Resident #84's Morphine mistake. The DON stated Resident #84's Morphine was initially ordered by Hospice and was 0.25 ml (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366394 If continuation sheet Page 13 of 15 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 366394 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avenue Care and Rehabilitation Center, The 4120 Interchange Corporate Center Road Warrensville Heights, OH 44128 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 every three hours as needed. The DON stated HN #28 came in on the weekend and bumped the Morphine up to 0.5 ml on a scheduled basis. The DON stated LPN #14 was helping the other nurses on [DATE] and [DATE] when she placed Resident #84's Morphine order incorrectly in the electronic system. The DON stated LPN #14 did not ask for help or tell her she could not find the correct Morphine concentration when she placed the order in the system. Observation on [DATE] at 12:45 P.M. with the DON of Resident #84's open Morphine bottle revealed Morphine Sulfate 100 mg per 5 ml. Interview on [DATE] at 1:32 P.M. of Physician #24 revealed giving 100 mg of Morphine by mouth could depress respirations and cause respiratory arrest. Physician #24 stated Resident #84 was monitored continuously after he received Morphine 100 mg by mouth. Physician #24 stated he called an emergency room physician to ask if Resident #84 should be transported to the Emergency Department and the emergency room physician told him if Resident #84 was stable he could be monitored at the facility after Narcan was administered. Physician #24 stated Resident #84 had one dose of 100 mg of Morphine, it could potentially induce respiratory failure, but it did not. Physician #24 stated Morphine would not have a lingering effect on Resident #84. Interview on [DATE] at 1:51 P.M. of Pharmacist #29 revealed he worked for the facility pharmacy. Pharmacist #29 stated the pharmacy did not receive orders and Resident #84 did not have Morphine dispensed from the pharmacy until [DATE] at 7:00 P.M. which was after the incident when Resident #94 received Morphine 100 mg by mouth. Pharmacist #29 stated an order for Resident #84's Morphine might have been sent to the pharmacy but it would not have been filled until there was a signed prescription from the physician. Pharmacist #29 stated the facility pharmacy would have no eyes on medications brought from home including Morphine and would not know what was brought from home. Pharmacist #29 stated the facility pharmacy could not repackage medications and would never approve the use of another pharmacy's controlled two substance (Morphine). Interview on [DATE] at 2:29 P.M. of the DON, the Administrator and Regional Nurse #30 revealed LPN #30 might have seen orders from Hospice for Resident #84 but there was not a valid prescription for Morphine. Regional Nurse #30 stated LPN #14 knew Resident #84's family brought his medications including a bottle of Morphine to the facility and the medications were filled at an outside pharmacy and not the facility pharmacy. Regional Nurse #30 stated she thought LPN #14 saw Resident #84's Morphine bottle was labeled 100 mg per 5 ml, saw Morphine 20 mg per 5 ml in the electronic system and did not realize what she had was different from the template. Regional Nurse #30 stated Resident #84's Morphine orders were probably sitting in the queue at the facility pharmacy waiting for a prescription from the physician. Interview on [DATE] at 8:04 A.M. of LPN #16 revealed she verified Resident #84's orders with Physician #24 when Resident #84 was admitted to the facility. LPN #16 confirmed there was no documentation in Resident #84's progress notes stating she verified his orders with Physician #24. LPN #16 stated Resident #84 brought his medications from home, she made sure the medications including the Morphine bottle matched the Hospice orders. LPN #16 stated Resident #84's Morphine bottle was opened and had been used prior to his admittance to the facility. LPN #16 stated LPN #14 helped her and placed Resident #84's orders including Morphine in the electronic system. LPN #16 stated Resident #84's Morphine order changed a few times. Interview on [DATE] at 9:41 A.M. of Hospice Chief Quality Officer (HCQO) #31 revealed the facility was provided handwritten orders for Resident #84 when he was admitted to the facility. HCQO #31 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366394 If continuation sheet Page 14 of 15 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 366394 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avenue Care and Rehabilitation Center, The 4120 Interchange Corporate Center Road Warrensville Heights, OH 44128 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 stated the facility would not be able to view orders in the Hospice electronic system and that was the reason orders were handwritten and given to the facility. HCQO #31 stated the handwritten Hospice orders including Morphine needed to be verified by Resident #84's physician. HCQO #31 confirmed the facility was not given Resident #84's most recent Hospice Morphine orders and that was why HN #28 called the Hospice Nurse Practitioner on [DATE] and updated Resident #84's Morphine Orders via a Telephone Order. Interview on [DATE] at 10:11 A.M. of the DON revealed the facility would accept Resident #84's medications from home. The DON stated the Hospice nurses provided Resident #84's orders, and the facility nurses would verify the orders with the facility physician. The DON stated Resident #84's Morphine which was brought from home was alright for the facility to use even if the bottle was open and unsealed. The DON stated Resident #84's Morphine was filled from an outside pharmacy and Physician #24 (Resident #84's physician) did not know Resident #84 and would direct the facility to get a prescription from hospice. The DON stated the facility physicians would not give a signed prescription for a Hospice resident. The DON indicated Physician #24 gave the okay to continue doing what hospice was doing. The DON confirmed the facility would not know what happened to the Morphine bottle after it was opened at home and it was not uncommon to accept open bottles of Morphine from resident's receiving Hospice services admitted to the facility. The DON stated she was not sure if Physician #24 was aware Resident #84's Morphine bottle was opened and unsealed. Interview on [DATE] at 10:22 A.M. of Physician #24 revealed he did not remember being called to verify Resident #84's medications by a facility nurse, but he was called to verify so many orders it was hard to remember all the residents. Physician #24 stated he would always want to write a new prescription for Morphine, and he did not know Resident #84 brought a bottle of Morphine with him when he was admitted to the facility. Physician #24 stated he would order Resident #84's Morphine from the facility pharmacy. Physician #24 stated he would not okay the use of an open bottle of Morphine brought to the facility from home. Review of the facility policy titled Medication Ordering and Receiving from Pharmacy and Medications Brought to the Facility by a Resident or Responsible Party, undated, included medications brought into the facility by a resident or responsible party were used only upon written order by the resident's attending physician, after the contents were verified, and if the packaging meets the facility's guidelines. Unauthorized medications were not accepted by the facility. Use of medications brought to the facility by a resident or responsible party was allowed only when the following conditions were met; the medication was ordered by the resident's physician and entered in the resident's medical record for bedside storage and self-administration by the resident, the medication container was clearly labeled in accordance with the facility procedures for medication labeling and packaged in a manner consistent with facility guidelines for medications. Medications not ordered by the resident's physician, or unacceptable for other reasons, are returned to the responsible party or designated agent. Review of the facility policy titled Medication Administration-General Guidelines revised 08/2014, included the Five Rights, the right resident, right drug, right dose, right route and right time were applied for each medication being administered. A triple check of these five rights is recommended at three steps in the process of preparation of a medication for administration, when the medication was selected, when the dose was removed from the container, and just after the dose was prepared and the medication put away. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366394 If continuation sheet Page 15 of 15