Health inspection·February 22, 2023

F 0573 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Let each resident or the resident's legal representative access or purchase copies of all the resident's records. Based on review of a medical record request document, staff interview and review of facility policy, the facility failed to provide copies of the medical record within two working days one (#166) of one resident reviewed for medical record requests. The facility census was 62. Findings include: Review of the medical record for Resident #166 revealed an admission date of 01/12/23 and a discharge date of 01/18/23. Diagnoses included chronic obstructive pulmonary disease, history of myocardial infarction, type two diabetes mellitus, hypertension atrial flutter, systolic heart failure, malignant neoplasm of part of the right bronchus or lung, and hyperlipidemia. Review of a medical record request document revealed medical records were requested by Resident #166 on 02/02/23. Interview on 02/16/23 at 11:31 A.M. the Director of Nursing (DON) revealed the facility had received a letter from the resident requesting medical records within the next 30 days. The DON stated the record request had been forwarded to their corporate office. The DON revealed the medical records had not yet been sent to Resident #166. The DON stated she had two more weeks before the records needed to be sent to the resident. Review of the facility policy titled Medical Record Request, dated 01/2023, revealed no specific timeframe to fulfill medical record requests. This deficiency represents non-compliance investigated under Master Complaint Number OH00139659 and Complaint Number OH00136948. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366477 If continuation sheet Page 2 of 13 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 366477 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avenue at North Ridgeville 6200 Lear Nagle Road North Ridgeville, OH 44039 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to complete a comprehensive care plan for urostomy care. This affected one (#62) of one resident reviewed for urostomy care. The facility census was 62. Findings include: Review of medical record revealed Resident #62 was admitted on [DATE] with diagnoses including obstruction of duodenum (part of the intestine), malignant neoplasm of the bladder, type II diabetes mellitus, and malignant neoplasm of lower lobe bronchus or lung. The resident had a urostomy and provided all the care for the ostomy. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident # 62 was cognitively intact. Resident #62 required supervision for toileting. The assessment revealed Resident #62 had an ostomy. Review of care plan dated 01/23/23 revealed Resident #62 had no care plan addressing urostomy care, monitoring, or ensuring adequate supplies. Interview with Licensed Practical Nurse (LPN) #531 on 02/15/23 at 4:51 P.M. verified Resident #62's comprehensive care plan dated 01/23/23 did not address the urostomy for Resident #62. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366477 If continuation sheet Page 3 of 13 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 366477 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avenue at North Ridgeville 6200 Lear Nagle Road North Ridgeville, OH 44039 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 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, family interview and staff interviews, the facility failed to provide appropriate communication tools for one (#9) out of one resident reviewed for communication needs. The census was 62. Residents Affected - Few Findings include: Review of the medical record revealed Resident #9 was admitted to the facility on [DATE]. Diagnoses included schizoaffective disorder, bipolar type, diabetes mellitus type 2, convulsions, intellectual disabilities, and schizophrenia. Review of the annual Minimum Data Set (MDS) assessment, dated 11/21/22, revealed Resident #9 had severe cognitive impairment and no verbal communicative ability. Resident #9 was determined to require extensive assistance from one to two persons for bed mobility, locomotion, dressing, eating and personal hygiene. Resident #8 was totally dependent for toileting and transfers. Review of the care plan dated 12/09/22, revealed Resident #9 had a cognitive loss. Interventions included staff anticipation of needs. The care plan revealed Resident #9 had a communication care area with interventions including presence of a Spanish/English communication board in the resident's room for family communication needs. An observation on 02/14/23 at 1:25 P.M. of Resident #9 revealed the resident provided no verbal or non-verbal response when asked questions in both Spanish and English. There was no communication board observed in the resident's room for the resident or the resident's family to use to communicate with facility staff. Interview on 02/14/23 at 1:25 P.M. Resident #9's mother stated in Spanish she could not communicate very well with workers. The resident's mother also stated she did not have any problems with facility workers, explaining the workers were very nice to her and to the resident. Interview on 02/15/23 at 2:40 P.M. Licensed Practical Nurse (LPN) #549 reported she was not aware of a communication board for Resident #9. LPN #549 reported Resident #9 made hand gestures when she wanted something to drink or cried out in pain. LPN #549 reported sometimes she would use a translation application on her cellular phone. Interview on 02/15/23 at 2:45 P.M. Registered Nurse (RN) #641 reported she was unaware if Resident #9 had a communication board in her room. RN #641 reported speech therapy provides communication boards for residents. RN #641 reported Resident #9 does understand simple commands from staff in English. Interview on 02/21/23 at 9:38 A.M. Physical Therapist/Therapy Manager (PTTM) #651 revealed Resident #9 comprehends and responds to commands in both Spanish and English. PTTM #651 reported new residents are assessed upon admission of their communication needs. If communication cards were needed, they were put into the residents' rooms. If the communication boards were no longer in a resident room he was unaware of where they were. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366477 If continuation sheet Page 4 of 13 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 366477 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avenue at North Ridgeville 6200 Lear Nagle Road North Ridgeville, OH 44039 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 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Interview on 02/21/23 at 10:20 A.M. Speech Therapist (ST) #652 stated Resident #9 had received a communication board and she was not aware of any issues with the communication board. ST #652 reported she was aware Resident #9 was non-verbal and aware the care plan stated to have the communication board in the resident's room. ST #652 reported Resident #9 had relocated to new rooms several times since her initial admission and reported the communication card may have been misplaced or lost. Event ID: Facility ID: 366477 If continuation sheet Page 5 of 13 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 366477 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avenue at North Ridgeville 6200 Lear Nagle Road North Ridgeville, OH 44039 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, observation, staff interview and review of facility policy, the facility failed to ensure wound treatments were completed per physician orders. This affected one (#1) of one resident reviewed for wounds. The facility census was 62. Residents Affected - Few Findings include: Medical record review revealed Resident #1 had an admission date of 05/26/21. Diagnoses included transient cerebral ischemic attack, Type two diabetes mellitus with diabetic nephropathy, mild protein calorie malnutrition, schizoaffective disorder bipolar type, anxiety disorder, dysphagia, major depressive disorder, obsessive compulsive disorder, atrial fibrillation, and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/15/22, revealed the resident had impaired cognition. Review of a skin assessment, dated 02/10/23, revealed the resident had a diabetic ulcer on the right heel measuring 0.3 centimeters (cm) in length by 0.4 cm in width by 0.1 cm in depth. The wound had no odor, no exudate, no tunneling and no undermining. The wound bed was 100 percent pink tissue. The surrounding skin was within normal limits, dry and intact. Review of a physician order dated 02/11/23 for the resident's right heel revealed to cleanse with normal saline and pat dry. Apply small amount of medi honey to wound base, cover with calcium alginate, then cover with ABD pad and wrap with kerlix. Change daily and as needed. Review of the Treatment Administration Record (TAR) revealed the treatment to the right heel was not completed on 02/13/23 and 02/14/23. Review of a nursing progress noted dated 02/13/23 at 11:38 P.M. revealed the resident refused the dressing change. Review of the nursing progress notes dated 02/14/23 revealed no documented refusals of care. Review of a nursing progress note on 02/15/23 at 12:22 A.M. revealed the dressing change was completed by the day nurse after shower. Observation on 02/15/23 at 1:36 P.M. with Registered Nurse (RN) #610 revealed the wound dressing on the resident's right heel was dated 02/12/23. RN #610 removed the dressing. There was a small black eschar circular scabbed area on the inner lateral side of the heel. RN #610 assessed the wound and applied gauze soaked with betadine to the wound. RN #610 covered the wound with an ABD pad and wrapped with kerlix. RN #610 dated the wound dressing 02/15/23. Interview on 02/15/23 beginning at 1:36 P.M., RN #610 verified the dressing to the resident's wound had not been changed since 02/12/23. RN #610 verified she had not applied the physician ordered dressing to the resident's wound. RN #610 stated the nurse practitioner would want the betadine instead of the medihoney. RN #610 stated she would call the nurse practitioner and get an order for the dressing she just applied to the wound. Review of the facility policy titled Skin Measurement/Skin Measurement, revised 08/2022, revealed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366477 If continuation sheet Page 6 of 13 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 366477 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avenue at North Ridgeville 6200 Lear Nagle Road North Ridgeville, OH 44039 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 0684 dressing changes/treatment were performed by the licensed nurse as per the physician's order and documented on the TAR. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366477 If continuation sheet Page 7 of 13 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 366477 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avenue at North Ridgeville 6200 Lear Nagle Road North Ridgeville, OH 44039 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 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm Based on record review, staff interview, and family interview, the facility failed to replace a resident's missing glasses. This affected one (#22) of two residents reviewed for missing items. The facility census was 62. Residents Affected - Few Findings include: Review of Resident #22's medical record revealed an admission date of 03/15/22. Diagnoses included vascular dementia, cerebrovascular disease, amyloidosis, chronic kidney disease stage three, and spinal stenosis. Review of Resident #22's quarterly Minimum Data Set (MDS) assessment, dated 01/19/23, revealed the resident had a low cognitive function. The resident had no noted behaviors. Resident #22 required an extensive assistance for all activities of daily living except eating which was supervised. Review of Resident #22's most recent care plan revealed the resident will have optimal visual ability due to glaucoma and required glasses. Interventions included the resident was to be encouraged to wear the glasses, to have the glasses readily available and the glasses were to be kept clean. Review of Resident #22's medical and social service notes revealed no mention of missing glasses. Interview with the family of Resident #22 on 02/13/23 revealed the resident had been missing her prescription glasses since October 2022. The family informed nursing staff who could not locate the glasses and this was reported to the previous Social Service Director. The Social Service Director informed the family a new pair of glasses would be ordered however, these were never received. Observation of Resident #22 on 02/13/23, 02/14/23, 02/15/23, 02/16/23, and 02/21/23 revealed the resident was not wearing glasses. Interview with Social Service Designee #611 on 02/14/23 at 3:22 P.M. revealed she had no documentation regarding Resident #22's missing eyewear and she had only been in the position for a month. Interview with Licensed Practical Nurse (LPN) #550 on 02/16/22 at 2:10 P.M. revealed she was aware Resident #22 had been missing her glasses for several months. She had no further information. Interview with the Director of Nursing (DON) on 02/21/23 at 10:03 A.M. revealed she was unaware Resident #22 was missing her glasses. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366477 If continuation sheet Page 8 of 13 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 366477 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avenue at North Ridgeville 6200 Lear Nagle Road North Ridgeville, OH 44039 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and observation, the facility failed to change oxygen tubing for the oxygen concentrator and tubing for the aerosol nebulizer for one (#8) of three residents reviewed for respiratory therapy. The facility census was 62. Residents Affected - Few Findings include: Review of the medical record revealed Resident #8 was admitted to the facility on [DATE]. Diagnoses included hypertension, heart disease, heart failure, respiratory failure and chronic obstructive pulmonary disease. The care plan dated 12/17/22 revealed Resident #8 was at risk for respiratory issues related to his diagnoses of chronic obstructive pulmonary disease and cardiac diseases. Interventions included to administer oxygen as ordered. Observation on 02/14/23 at 2:07 P.M. of Resident #8's room revealed the oxygen tubing for the oxygen concentrator was dated for 02/05/23 . The tubing connected to the nebulizer was dated 01/26/23. The resident was currently utilizing the oxygen tubing attached t o the concentrator via a nasal cannula. Observations on 02/15/23 at 2:49 P.M. and again on 02/16/23 at 3:03 P.M. revealed the oxygen tubing continued to be dated 02/05/23 and the nebulizer tubing dated 01/26/23. Interview on 02/15/23 at 2:49 P.M., Registered Nurse (RN) #610 stated all oxygen tubing, including for concentrators, oxygen tanks, and nebulizers, gets changed out for new tubing every Sunday on night shift. Interview on 02/16/23 at 3:21 P.M., Licensed Practical Nurse (LPN) #545 verified the tubing on the nebulizer for Resident #8 was dated for 01/26/23 and the oxygen tubing for the oxygen concentrator was dated for 02/05/23. LPN #545 also verified the orders for Resident #8 stated to change oxygen tubing once weekly, every Sunday. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366477 If continuation sheet Page 9 of 13 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 366477 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avenue at North Ridgeville 6200 Lear Nagle Road North Ridgeville, OH 44039 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on review medical records, review of guidelines from the National Library of Medicine/National Institute of Health, observation, staff interview and review of facility policy, the facility failed to ensure medications were administered per physician orders. This affected three (#166, #26, #22) of seven residents reviewed for medication administration. The facility census was 62. Residents Affected - Few 1. Review of the medical record for Resident #166 revealed an admission date of 01/12/23 and a discharge date of 01/18/23. Diagnoses included chronic obstructive pulmonary disease, history of myocardial infarction, type two diabetes mellitus, hypertension atrial flutter, systolic heart failure, malignant neoplasm of part of the right bronchus or lung, and hyperlipidemia. Review of the five day Minimum Data Set (MDS) assessment, dated 01/17/23, revealed the resident had intact cognition. Review of a nurses noted dated 01/12/23 at 2:34 P.M. revealed Resident #166 was admitted to the facility from the hospital. Review of physician orders for 01/18/23 revealed the resident was ordered MS Contin 15 extended release by mouth every 12 hours for pain. The resident was also ordered ezetimibe 10 mg tablet in the morning for hyperlipidemia and Januvia 50 mg in the morning for type two diabetes mellitus. Additionally there was a physician order for the antidiabetic medication Tradjenta five mg daily. The Tradjenta was noted as a therapeutic interchange. Review of Medication Administration Records (MAR) from 01/12/23 through 01/18/23 revealed the resident was not administered the MS Contin 15 mg tablet on 01/12/23. The resident was not administered the ezetimbe on 01/17/23 or 01/18/23. The resident was not administered the Januvia on 01/12/23, 01/13/23, 01/14/23, 01/15/23, 01/16/23, 01/17/23, or 01/18/23. The Tradjenta five mg was never administered on 01/12/23, 01/13/23, 01/14/23, 01/15/23, 01/16/23, 01/17/23, or 01/18/23. Review of the nursing progress notes dated 01/12/23 at 9:39 P.M. revealed the MS Contin oral tablet extended release 15 mg tablet was on order and not administered. Interview on 02/21/23 at 2:15 P.M. the Director of Nursing (DON) verified the resident was not administered the MS Contin 15 mg tablet on 01/12/23 or the ezetimbe on 01/17/23 or 01/18/23. The DON verified the resident was not administered the Januvia on 01/12/23, 01/13/23, 01/14/23, 01/15/23, 01/16/23, 01/17/23, or 01/18/23. Additionally the DON verified the Tradjenta five mg was never administered on 01/12/23, 01/13/23, 01/14/23, 01/15/23, 01/16/23, 01/17/23, or 01/18/23. Review of facility policy titled Medication Administration Preparation and General Guidelines, dated 10/2017, revealed medications are administered in accordance with written orders of the prescriber. 2. Medical record review revealed Resident #26 had an admission date of 01/04/23. Diagnoses included chronic kidney disease stage three, peripheral vascular disease, diabetes mellitus type two, hypothyroidism and hypertension. Review of the hospital discharge medication orders dated 01/04/23 revealed the resident was ordered Tresiba 100 units/milliliter (mL) subcutaneous solution, 10 units subcutaneous once a day in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366477 If continuation sheet Page 10 of 13 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 366477 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avenue at North Ridgeville 6200 Lear Nagle Road North Ridgeville, OH 44039 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 evening. Level of Harm - Minimal harm or potential for actual harm Review of a physician order dated 01/04/23 revealed Resident #26 was ordered the insulin Tresiba FlexTouch Solution Pen 10 units subcutaneously in the evening for diabetes mellitus. Residents Affected - Few Review of the MAR revealed the resident was not administered the Tresiba on 01/04/23, 01/05/23. Interview on 02/21/23 at 4:44 P.M., the DON verified the resident was not administered the medication on 01/04/23 and 01/05/23. 3. Review of Resident #22's medical record revealed an admission date of 03/15/22. Diagnoses included vascular dementia, cerebrovascular disease, amyloidosis, chronic kidney disease stage 3, and spinal stenosis. Review of Resident #22's medical record revealed a physician's order dated 09/30/22 for potassium Klor-Con extended release 10 milliequivalent (MEQ). Administer one tablet by mouth in the morning for supplement. Observation of medication administration on 02/14/23 at 7:39 A.M. revealed Licensed Practical Nurse (LPN) #550 crushed Resident #22's Klor-Con tablet prior to administering the medication. Interview with LPN #550 on 02/14/23 at 7:40 A.M. revealed Resident #22 was unable to swallow the potassium chloride tablet whole so all staff crushed the medication. Review of the National Library of Medicine/National Institute of Health website (htttps://dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl.cfm?setid=3aef07da-ca04-4fa4-a0ea-e84ee3fef555&type=display) revealed potassium chloride extended-release tablets were to be swallowed whole without crushing, chewing or sucking the tablets. Review of the facility policy titled Medication Administration Preparation and General Guidelines: revised 10/2017 revealed crushing tablets may require a physician's order per facility policy. Long acting or enteric-coated dosage forms should not be crushed. This deficiency represents non-compliance investigated under Master Complaint Number OH00139659 and Complaint Number 137031. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366477 If continuation sheet Page 11 of 13 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 366477 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avenue at North Ridgeville 6200 Lear Nagle Road North Ridgeville, OH 44039 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, review of weekly cleaning logs, and review of facility policy, the facility failed to maintain a clean and sanitary kitchen area. This had the potential to affect 61 residents who received meals in the facility. The facility identified Resident #37 as receiving nothing by mouth. The facility census was 62. Findings include: Observation of the kitchen during the initial tour with Dietary Manager (DM) #518 on 02/13/23 at 6:35 P.M. revealed three large bins with brown sugar, white sugar, and flour all containing a scoop lying in the bin. The under tray line freezer across from the fryer contained a bag of chicken breasts which was open. There was spilled food and food particles in the back of freezer. The under tray line cooler revealed tray of uncovered open hot dogs without a label/date. The walk-in cooler revealed uncovered prepared dish of cottage cheese with no label or date. Observation of walk-in freezer revealed open bags of fish and burgers and two dished up uncovered bowls of ice cream with no label or date. Observation under the three compartment sink revealed a a 22 quart tub about half full of dark brown liquid with floating food particles, uncovered and on a rack under sink area. Interview at the time of the observation with DM #518 identified this as old fryer grease and indicated they empty it every week and take out to dumpster. Observation of the oven, range, fryer, and grill top revealed food splatter down the sides and front of the equipment. There was a dark sticky substance on the grill top and fryer grease appeared dark and unable to see through. Observation of the microwave revealed food particles and splatter on the outside and inside. The microwave was sticky to touch. Interview on 02/13/23 6:50 P.M. with DM #518 verified above findings. Review of the undated facility policy titled General Sanitation of the Kitchen revealed food and nutrition services staff will maintain sanitation of the kitchen. Review of the undated facility policy titled Food Storage revealed all food will be stored under sanitary conditions. Review of the undated facility policy titled Food Safety and Sanitation revealed when a food package is opened, the items should be marked to indicate date opened. Review of Weekly Cleaning Lists revealed Dietary Aides and Cooks were responsible for cleaning refrigerators and freezers, removing unlabeled food items, and cleaning equipment after each use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366477 If continuation sheet Page 12 of 13 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 366477 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avenue at North Ridgeville 6200 Lear Nagle Road North Ridgeville, OH 44039 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm Based on review of immunization documentation, staff interview and review of facility policy, the facility failed to ensure a resident was offered a pneumococcal vaccination. This affected one (#10) of five residents reviewed for immunizations. The facility census was 62. Residents Affected - Few Findings include: Medical record review revealed Resident #10 had an admission date of 07/26/21. Diagnoses included Alzheimer's disease with late onset, depression and dementia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/17/23, revealed the resident had impaired cognition. Review of the immunization record revealed no documentation the resident had been offered or had refused a pneumococcal immunization. Interview on 02/16/23 at 11:38 A.M., Registered Nurse (RN) #609 verified there was no documentation in the medical record the resident had been offered or had refused a pneumococcal immunization. Review of the facility policy titled Influenza and Pneumococcal Immunization Policy, last revised 10/2022, revealed based upon assessment and the physician's recommendations, the resident will be offered the recommended pneumococcal immunization dose, unless medically contraindicated, or if the resident or the resident's legal representative refuses the immunization. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366477 If continuation sheet Page 13 of 13