Health inspection·March 21, 2019

F 0602 Protect each resident from the wrongful use of the resident's belongings or money. Level of Harm - Minimal harm or potential for actual harm Based on resident interview, staff interview, review of the facility Self-Reported Incident (SRI) investigation and the police report, Residents Affected - Few the facility failed to ensure Resident #43 was free from misappropriation of her wallet. This affected one resident reviewed for misappropriation of property. The facility census was 86. Findings include: Review of the medical record for Resident #43 revealed an admission date of 01/23/19 with diagnoses including Guillain-Barre Syndrome, acute pancreatitis, calculus of bile duct with cholangitis and hypertension. The admission Minimum Data Set, an assessment tool, Version 3.0 dated 01/30/19, indicated the resident was cognitively intact with a BIMS (Brief Interview for Mental Status) score of 13. During an interview with Resident #43 on 03/19/19 at 01:40 P.M., she indicated she noticed her wallet missing on 02/16/19 and notified facility staff. Resident #43 indicated her wallet contained credit cards and identification, but no cash. She stated that as of 03/19/19, there were no charges posted to her credit cards. Review of the facility's investigation into the incident of 02/16/19 revealed interviews with staff and Residents. All staff denied knowledge of the missing wallet. The Administrator indicated Residents in the facility were also interviewed and no other Resident reported any missing items. During an interview on 03/21/19 at 11:59 A.M., the Administrator confirmed that Resident #43 had reported her wallet missing on 02/16/19. The Administrator indicated a Self-Report Incident (SRI) was completed and the facility immediately began an investigation The Administrator reported just as she was about to finalize the investigation, she received a telephone call from a police department in another city. They indicated they had arrested a State Tested Nurse Aide (STNA) #496 identified as employed by the facility during a traffic stop, and found a wallet that did not belong to her. The Administrator indicated it was confirmed the wallet belonged to Resident #43. The Administrator stated that she had interviewed STNA #496 on 02/18/19 at 03:00 P.M. and the employee had lied to my face and then went to the Resident and told her she was asked about the wallet. The Administrator indicated she was told that STNA #496 had fake plates on her vehicle and there were two warrants out for her arrest related to traffic tickets. The Administrator indicated that STNA #496 underwent a background check, and received training on abuse, neglect and misappropriation during her orientation upon hire, during all staff meetings and every time there was an incident. The Administrator indicated STNA #496 was hired in December 2018 and there were no red flags. Review of STNA #496's personnel record revealed a background check, references and an acknowledgement of the facility's Abuse policy. STNA #496's employment was terminated on 02/21/19 due to failure or refusal to cooperate fully with a facility investigation. Review of the policy titled Abuse/Neglect/Involuntary Seclusion/Misappropriation Prevention and dated 10/2017 indicated it is the policy of this facility that all residents will be free from verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion, neglect and/or misappropriation of residents' property. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366428 If continuation sheet Page 2 of 6 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 366428 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE O'Neill Healthcare Fairview Park 20770 Lorain Road Fairview Park, OH 44126 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 0602 Level of Harm - Minimal harm or potential for actual harm Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongs or money without the resident's consent. Misappropriation means depriving, defrauding or otherwise obtaining the real or personal property of a resident by any means prohibited by the Revised Code. Residents Affected - Few This deficiency substantiates Self-Reported Incident Investigation Control Number OH00102851. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366428 If continuation sheet Page 3 of 6 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 366428 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE O'Neill Healthcare Fairview Park 20770 Lorain Road Fairview Park, OH 44126 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 observation, interview, and record review the facility failed to maintain sanitary conditions in the south and north dietary serveries. This had the potential to affect 85 of 86 residents currently residing in the facility. Resident #285 was identified as receiving nothing by mouth. The facility census was 86. Findings include: Tour of the North nursing unit dietary servery on 03/18/19 at 9:53 A.M. with Dietary Manager (DM) #21 revealed the microwave was dingy white in appearance and on the inside were various dried on food debris. The inner lower paneling was chipped away in three quarter sized areas revealing rusted metal. The upper portion of the inner paneling appeared warped. In the freezer there were brownish stains on the top shelf of the freezer door. Tour of the South nursing unit dietary servery on 03/18/19 at 9:57 A.M. with DM #21 revealed the microwave had various dried on food debris and a burnt area on the inside wall of the microwave. The refrigerator needed some spot cleaning throughout and the top shelf of the inside freezer door had a brownish dried on spill. Interview on 03/18/19 between 9:53 A.M. and 9:57 A.M. DM #21 confirmed the observations and stated the microwave in the North servery needed to be replaced. DM #21 stated the housekeeping staff were responsible for cleaning the serveries. Review of the undated facility policy titled Dietary Department Guidelines, revealed all food preparation equipment, dishes, and utensils must be maintained in a clean, sanitary, and safe manner. Any piece of equipment, dish, or utensil will be discarded when it is cracked, broken, discolored or abraded. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366428 If continuation sheet Page 4 of 6 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 366428 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE O'Neill Healthcare Fairview Park 20770 Lorain Road Fairview Park, OH 44126 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure proper infection control procedures were followed related to isolation procedures when entering and exiting rooms for residents under contact and droplet precautions. This had the potential to affect all 86 residents currently residing in the facility. Residents Affected - Many Findings include: 1. Record review revealed Resident #340 was admitted to the facility on [DATE] with diagnoses including fracture of the sacrum, fracture of the right wrist and hand, peripheral neuropathy, polyosteoarthritis, generalized muscle weakness, abnormalities of gait and mobility, asthma, major depression and anxiety disorder. Review of the interim baseline care plan indicated Resident #340 was placed on contact isolation precautions related to a diagnosis of shingles. On 03/18/19 at 5:30 P.M., observation revealed a sign posted on the outside of the door of Resident #340's room indicating isolation was in progress along with personal protective equipment located by the door including gloves, gowns and masks. While standing outside of the room, State Tested Nurse Aide (STNA) #68 entered the room and delivered the resident's tray. Upon exiting the Resident's room, STNA #68 proceeded to the meal cart to retrieve another tray to deliver to another resident. On 03/18/19 at 5:35 P.M., an interview with STNA #68 verified he exited Resident #340's room without washing his hands or using hand sanitizer. STNA #340 proceeded to enter another resident's room and use the resident's bathroom to wash his hands before continuing with the tray pass. Review of the undated facility policy titled Procedures for Airborne, Contact, and Droplet Isolation, revealed under the Contact Precautions section, to wear clean gloves when entering the resident area, remove gloves before leaving the resident area, and to wash hands immediately or use alcohol hand sanitizer. 2. Record review of Resident #34 revealed an admission date of 07/14/17. Diagnoses included age related osteoporosis, chronic kidney disease, and major depressive disorder. The quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively impaired. Review of the nursing note dated 03/12/2019 at 5:01 P.M. Resident #34 had a fever of 101.0 degrees Fahrenheit (F) a non-productive cough and wheezing. A nursing note dated 03/14/19 at 5:23 A.M. revealed Resident #34's influenza (flu) swab was positive. Review of Resident #34's care plan dated 03/19/19 revealed Resident #34 was on droplet precautions due to the flu. The interventions included to follow infection control measures per the facility's protocol for droplet precautions. Observation on 03/19/19 at 10:21 A.M. revealed Housekeeping Aide (HA) #35 exiting Resident #34's room without a mask on after having vacuumed the floor. The family member that was in the resident's room was wearing a mask. Interview at this time with HA #35 confirmed she didn't have a mask on and stated she forgot to put one on while in Resident #34's room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366428 If continuation sheet Page 5 of 6 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 366428 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE O'Neill Healthcare Fairview Park 20770 Lorain Road Fairview Park, OH 44126 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Review of the undated facility policy titled Procedures for Airborne, Contact, and Droplet Isolation, revealed under the Droplet Precautions section, to wear a mask when working within three feet the resident. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366428 If continuation sheet Page 6 of 6