Inspection·July 23, 2024

F 0573 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Medical Records #506 received an email requesting her to call the facility owner and following the phone call was told to email Resident #197's attorney and tell them the facility attorneys will further assist her. Medical Records #506 provided the contact information for the facility attorney. Interview on 07/18/24 at 9:37 A.M. with Social Services Assistant #501 stated she never received a medical request from a representative for Resident #197. Interview on 07/18/24 at 9:52 A.M. with the Administrator revealed he had received electronic text from the facility owner who stated the facility attorneys are handling the medical record request. This deficiency represents non-compliance investigated under Complaint Number OH00155587. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365071 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 365071 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beachwood Pointe Care Center 23900 Chagrin Blvd Beachwood, OH 44122 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation and interview the facility failed to maintain resident rooms in a safe, sanitary, and homelike condition. This affected seven residents (Resident #6, #16, #40, #43, #68, #71, and #85 ) of 97 resident rooms observed for physical environment. The facility census was 97. Findings include: During the screening process of the facility annual survey on 07/15/24 and 07/16/24, the following concerns were identified and verified with the Director of Nursing and the Administrator at approximately 7:56 A.M. on 07/16/24. • The rooms for Residents #16, #40 and #43 had chipped wall paint, the window shade and privacy curtains had brown stains and splatter marks. Also, the room for Resident #6 included one inch diameter holes around four bolts in the wall behind her bed. • The room for Resident #71 had a four foot by four foot patch on the wall of bare wall. The room also had chipped wall paint, the window shade and privacy curtains had brown stains and splatter marks. • The room for Resident #68 had no transition between the bathroom and room hallway. The tile floor at the entrance into the bathroom was chipped and jagged, easily catching on the residents wheeled walker. • The room for Resident #85 had peeling paint on the door, missing slats in the vertical blinds, and stained privacy curtain and ceiling tiles. Interview on 07/15/24 at 11:37 AM with Maintenance Director #640 revealed the resident rooms were observed at least weekly. The facility had a program called Angel Walks. Each manager had assigned rooms, and they inspect them weekly and turn in the paperwork at the Wednesday morning meeting for review. The concerns were entered in the Work Order log and maintenance departments electronic log. Interview on 07/15/24 at 12:21 P.M. with Resident #71 ' s family revealed the bathroom had peeling paint and no supplies like toilet paper or paper towels. Observation and interview with LPN #526 on 07/16/24 at 10:25 A.M. of Resident #71's room confirmed the peeling paint and lack of supplies. Observations on 07/16/24 at 10:36 A.M. of Resident #68 ' s room revealed her dresser was missing the bottom drawer. Observation confirmed with LPN #570. Resident #68 revealed at the time of the observation the bottom drawer had been missing for a year. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365071 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 365071 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beachwood Pointe Care Center 23900 Chagrin Blvd Beachwood, OH 44122 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 0584 This deficiency represents noncompliance identified during the investigation of Complaint Number OH00154805. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365071 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 365071 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beachwood Pointe Care Center 23900 Chagrin Blvd Beachwood, OH 44122 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 - Some 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** 4. Review of the medical record for Resident #7 revealed an admission date of 06/03/22. Diagnoses included unspecified dementia without behavioral disturbance, osteoarthritis, and primary hypertension. Review of the comprehensive MDS 3.0 assessment, dated 06/14/24 , revealed the resident had severely impaired cognition. The MDS revealed the resident was on Hospice services Review of physicians orders on 06/02/24 revealed a physician order for admit to hospice services. Review of the plan of care dated 07/16/24 revealed there was no evidence of a care plan for Resident #7 being on hospice services and/or coordination with hospice services . . Interview on 07/22/24 at 5:27 P.M. with the Director of Nursing (DON) revealed there was no care plan for hospice services and/or the admission of the resident to hospice services. Based on interviews and record reviews, the facility failed to ensure care plans reflected resident needs regarding Activities of Daily Living (ADL), hospice, wound care and behaviors. This affected five Residents (#7, #16, #60, #74, and #197) of 25 resident records reviewed. The facility census was 97. Findings include: 1. Review of Resident #16's medical record revealed and admission date of 02/23/24 with diagnoses including spastic hemiplegia, osteoarthritis, hypertension, and hyperlipidemia. Resident #16 required repositioning by staff. Review of Resident #16's care plans revealed no focus area, goals, or interventions for positioning or repositioning the resident. Interview on 07/17/24 at 10:19 A.M. with Licensed Practical Nurse (LPN) #610 revealed Resident #16 went out with family a lot and attended activities. LPN #610 said the aides and nurses needed to reposition her frequently throughout the day because she would slump over in the chair if not repositioned. Interview on 07/18/24 at 11:18 A.M. with Minimum Data Set (MDS) Coordinator #647 confirmed Resident #16 did not have a care plan for positioning, but needed to have one written. MDS Coordinator #647 entered the care plan during the interview and said she would have it carry over to the resident Kardex for the aides to access so they would know her needs for frequent repositioning. 2. Review of the medical record for Resident #60 revealed an admission date of 05/17/24. Diagnoses included delirium, type one diabetes, neuromuscular dysfunction of the bladder, reflux. Review of the comprehensive MDS 3.0 assessment, dated 05/30/24, revealed the resident had one stage III pressure ulcer. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365071 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 365071 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beachwood Pointe Care Center 23900 Chagrin Blvd Beachwood, OH 44122 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 Review of the plan of care dated 06/18/24 revealed there was no evidence of a care plan for stage III pressure ulcer or skin impairment. Review of the wound assessment dated [DATE] revealed the resident had a left heel pressure/ deep tissue injury that was acquired on 05/17/24 and improving. Residents Affected - Some Interview on 07/17/24 at 11:30 A.M. with the Director of Nursing (DON) revealed there was no care plan developed for wound management. 3 . Review of the medical record for Resident #74 revealed an admission date of 06/09/23. Diagnoses included post-traumatic stress disorder (PSTD). Review of the comprehensive Minimum Data Set MDS 3.0 assessment, dated 06/22/24, revealed the resident had intact cognition. The assessment identified the resident had a diagnosis of PTSD. Review of the plan of care dated 06/18/24 revealed there was no evidence of a care plan for PTSD. Review of the psychiatric note date 07/05/24 revealed the resident reported having flash backs of past trauma. He was reminded that he was receiving counseling from outside providers. The resident expressed that he did not know that the social workers were the therapists for PTSD. The physician explained to the patient that some social workers have the training to be therapists and they are experienced with managing PTSD related issues. Interview on 07/28/24 at 5:40 P.M. with the MDS Nurse #647 verified the resident had a diagnosis of PTSD and there was no care plan developed. 5. Review of the closed medical record for Resident #197 revealed an admission date of 09/09/23 and discharge date of 10/17/23. Diagnoses included but were not limited to complete traumatic amputation between right hip and knee. This resident had a surgical wound to the amputation site. Review of 09/22/23 admission MDS 3.0 assessment for Resident #197 revealed a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. Resident #197 was receiving post-surgical wound care. Review of Resident #197's care plan revealed it was initiated on 09/11/23 but there was no evidence of a wound care plan until 10/11/23 and no interventions were listed. Interview on 07/23/24 at 10:20 A.M. with MDS Coordinator #697 confirmed Resident #197's wound care plan was not initiated until 10/11/23 and no interventions were listed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365071 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 365071 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beachwood Pointe Care Center 23900 Chagrin Blvd Beachwood, OH 44122 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 closed record review, interview and review of facility policy, the facility did not ensure a STAT (urgent) urinalysis test was obtained according to the physician order delaying treatment of a urinary tract infection (UTI) for Resident #197. This affected one resident (Resident #197) of 25 residents reviewed for physician orders. The facility census was 97. Residents Affected - Few Findings included: Review of the closed medical record for Resident #197 revealed an admission date of 09/09/23 and discharge date of 10/17/23. Diagnoses included but were not limited to complete traumatic amputation between right hip and knee, peripheral vascular disease, hypertension, chronic obstructive pulmonary disease and unspecified severe-protein-calorie malnutrition. Review of the facility admission assessment for Resident #197 completed on 09/09/23 revealed Resident #197 was noted to have an indwelling catheter. Review of the 09/22/23 admission Minimum Data Set (MDS) 3.0 assessment for Resident #197 revealed a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. Resident #197 was noted to have an indwelling catheter. Review of the physician order dated 09/26/23 for Resident #197 revealed an order for a STAT (urgent) urinalysis with culture and sensitivity (UA/CS) test. Further review of the closed medical record revealed the STAT UA/CS ordered on 09/26/23 was not collected until 10/04/23 and was reported on 10/04/23 revealing the urine results were abnormal with mucos, few bacteria, three plus (3+) blood and two plus (2+) leucocytes (white blood cells in urine that can indicate infection) in the collected urine. Review of the 10/04/23 nursing progress note for Resident #197 revealed urinalysis results were reported to the Nurse Practitioner with no new orders. Review of physician orders dated 10/06/23 for Resident #197 revealed an order for Macrobid (an antibiotic) oral capsule 100 milligram. Give one table twice daily for seven days for a urinary tract infection (UTI). Review of the facility infection control log for 10/23 revealed Resident #197 was noted to have a UTI on 10/06/23 and was started on Macrobid for seven days until 10/13/23. Interview on 07/22/24 at 10:13 A.M. with the Director of Nursing (DON) revealed the facility did not get the 09/26/23 STAT UA/CS order completed until 10/04/23 and the DON had no documented evidence of attempts made to collect the urine sample until 10/04/23. The DON verified the results were abnormal and former Resident #197 had been started on an antibiodic to treat UTI on 10/06/23. Phone interview on 07/23/24 at 7:44 A.M. with Nurse Practitioner #665 revealed when she ordered a STAT lab, she would expect it to be completed within three days at the most if it fell near the weekend. Interview on 07/23/24 at 9:45 A.M. with the DON revealed on 10/06/23 the nurse practitioner looked (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365071 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 365071 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beachwood Pointe Care Center 23900 Chagrin Blvd Beachwood, OH 44122 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 Level of Harm - Minimal harm or potential for actual harm over the urinalysis results and ordered the Macrobid to treat the UTI based on sensitivity of the bacteria to the Macrobid. Review of the undated facility policy called; Lab Results revealed the policy did not give guidance regarding timeframes for obtaining lab samples nor STAT labs. Residents Affected - Few This deficiency represents non-compliance investigated under Complaint Number OH00155587. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365071 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 365071 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beachwood Pointe Care Center 23900 Chagrin Blvd Beachwood, OH 44122 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on record review and interview the facility failed to ensure pharmacy recommendations were addressed for Resident #46. This affected one Resident (#46) of five residents reviewed for unnecessary medications. The facility census was 97. Finding Include: Review of the medical record for Resident #46 revealed an admission date of 10/02/19. Diagnoses included chronic respiratory failure, hypertension, and dementia. The record revealed the last lipid panel ( a blood test used to check the amount of cholesterol in the blood) was completed on 06/22/22. The resident was taking Lipitor (a drug used to lower cholesterol in the blood) Review of the pharmacy recommendation dated 09/20/23 recommended a lipid panel now and annually to monitor Lipitor. The recommendation was signed by the physician on 10/10/23 indicating a lipid panel should be completed as ordered. Review of the laboratory order created on 10/10/23 at 1:43 P.M. revealed an order for a lipid profile panel to be completed on 10/02/24. Interview on 07/17/24 at 2:00 P.M. with the Director of Nursing (DON) revealed the order for the lipid panel had been submitted to the laboratory on 10/10/23 but the laboratory made a mistake and assigned a collection date of 10/02/24. The DON verified a lipid panel was not completed per pharmacy recommendations and the last lipid panel completed was 06/22/22. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365071 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 365071 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beachwood Pointe Care Center 23900 Chagrin Blvd Beachwood, OH 44122 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 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on record review and interview the facility failed to employ a qualified dietary manager to carry out the functions of the food service department. This had the potential to affect all 94 residents receiving food from the facility kitchen. The facility identified three residents (#8, #91 and #201) who received nothing by mouth. The facility census was 97. Findings include: Review of Dietary Manager (DM) #574's employee file revealed no formal certified dietary manager training and documentation for the SERV Safe course revealed DM #574 had not passed the course. Interview on 07/15/24 at 8:50 A.M. with DM #574 revealed she had been the dietary manager for about four months. DM #574 stated she completed a SERV Safe course prior to starting as the dietary manager, did not pass the course and did not have any additional formal training to qualify her as the DM. Interview on 07/22/24 at 9:10 A.M. with Dietitian #664 confirmed she only worked at the facility seven to ten hours per week so she was not full-time in the facility. Interview on 07/22/24 at 1:42 P.M. with the Administrator confirmed the facility did not employ a full-time dietitian and DM #574 was not a certified dietary manager nor had any additional formal training to qualify her to act as the DM. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365071 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 365071 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beachwood Pointe Care Center 23900 Chagrin Blvd Beachwood, OH 44122 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on record review, observation, interview and review of facility policy the facility did not ensure the pureed menu was followed for residents requiring a pureed diet. This affected three residents (#38, #71 and #350) of three residents who required pureed diets. The facility census was 97. Findings include: Review of the medical record for Resident #38 revealed an admission date of 04/24/24. Diagnoses included but were not limited to congestive heart failure, hypertension, renal insufficiency, and diabetes mellitus. Resident #38's diet order was a regular pureed diet with thin liquids. Review of the medical record for Resident #71 revealed an admission date of 01/31/22. Diagnoses included but were not limited to hypertension, hyperlipidemia, and dementia. Resident #71's diet order was a regular pureed diet with thin liquids. Review of the medical record for Resident #350 revealed an admission date of 07/15/24. Diagnoses included but were not limited to chronic bronchitis, chronic obstructive pulmonary disease, type II diabetes mellitus, and chronic kidney disease. Resident #71's diet order was a regular pureed diet with honey thick consistency liquids. Review of the facility week one lunch menu production sheet for Wednesday 07/17/24 revealed residents with a pureed diet were to receive a number eight scoop of pureed chicken, a four-ounce scoop of mashed potatoes, a number eight scoop of pureed vegetable blend, a #16 scoop of pureed bread, a number eight scoop of pureed cookie, and four ounces of milk. Interview and observation on 07/17/24 at 10:07 A.M. with [NAME] #577 revealed she was pureeing the meat and vegetables for the lunch meal. [NAME] #577 stated the only two items she was pureeing was the chicken and mixed vegetables since the residents were getting mashed potatoes. Observation on 07/17/24 at 1:42 P.M. of the lunch tray line revealed Resident #350 received pureed chicken, pureed mixed vegetables, mashed potatoes, a pureed cookie and honey thick milk. Interview at the time of the observation with DM #574 confirmed pureed bread was listed on the lunch menu but was not prepared for the pureed residents so there would be no pureed bread served to residents requiring a pureed diet. Review of the 2024 facility policy called; Puree Food Preparation revealed residents receiving puree diets should always receive portions equivalent to those served on the regular or therapeutic diet ordered per facility policy and procedure. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365071 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 365071 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beachwood Pointe Care Center 23900 Chagrin Blvd Beachwood, OH 44122 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, staff interview and facility policy review, the facility failed to store, prepare and serve foods under sanitary conditions and to prevent the potential for food born illness. This had the potential to affect 94 residents receiving meals from the facility. The facility identified three residents (#8, #91, and #201) who received nothing by mouth. The facility census was 97. Findings include: 1. Initial tour of the facility kitchen on 07/15/24 at 8:50 A.M. with Dietary Manager (DM) #574 revealed the following concerns which were verified by DM #574 at the time of the observations: In the cooling unit there was a quart of whole milk with a best by date of 07/11/24. The milk had visibly separated and had white chunks floating in it. There were also 12 four-ounce containers of yogurt with an expiration date of 07/10/24. Also in the kitchen was observed multiple (between 10 to 50 of each) individual packets of mustard, mayonnaise, ketchup, French dressing, sugar-free breakfast syrup, reduced-sugar blackberry, strawberry and grape spread, red-hot sauce, BBQ sauce, tartar sauce, ranch dressing, blue cheese dressing and caesar dressing that had been removed from the original box which was no longer in the kitchen and the packets did not have a use-by nor date of expiration on them. 2. Observation on 07/15/24 at 9:10 A.M. with [NAME] #577 confirmed there was a kitchen cleaning schedule posted in the kitchen, but there weren't any daily or weekly check-off cleaning logs to ensure cleaning was being completed on all shifts in the kitchen. Observation on 07/15/24 at 9:20 A.M. with DM #574 revealed the three-compartment sink had food particles stuck to all four sides of the middle sink about two inches up from the bottom. DM #574 stated the sink had not been used since yesterday and it should have been cleaned prior to the end of the shift. DM #574 verified the finding at the time of the observation. Observation on 07/15/24 at 9:35 A.M. with DM #574 revealed underneath the three compartment sink there was a bucket of chemical sanitizer and the bucket was empty. DM #574 proceeded to test the level of chemical sanitizer in the rinse water in the sink and the test strip did not change color indicating there was no sanitizer in the water. DM #574 verified the sanitizer bucket was empty and no sanitizer was in the rinse water. DM #574 replaced the sanitizer with a full bucket of sanitizer upon this finding. 3. Observation on 07/15/24 at approximately 9:40 A.M. with DM #574 revealed the facility had a high-temperature dish machine. Review of the facility dish machine temperature log dated for July 2024 revealed temperatures for the wash and rinse were not recorded for lunch and dinner on 07/08/24. Interview on 07/17/24 at 10:25 A.M. with DM #574 verified the dish machine temperature log was not completed for lunch and dinner on 07/08/24 and should have been. 4. Observations on 07/15/24 at 1:22 P.M. with Licensed Practical Nurse (LPN) #526 revealed the third-floor dining room refrigerator had a concern/temperature log posted on it and dated for June 2024 but it was not filled out indicating the temperatures were not being monitored on that refrigerator. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365071 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 365071 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beachwood Pointe Care Center 23900 Chagrin Blvd Beachwood, OH 44122 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 LPN #526 verified resident foods were stored in this refrigerator. Level of Harm - Minimal harm or potential for actual harm Interview on 07/17/24 at 10:47 A.M. with LPN #646 confirmed the third-floor dining room refrigerator still had the concern/temperature log for June 2024 that was devoid of any documentation. Residents Affected - Many Observation on 07/22/24 at 9:49 A.M. with Dietitian #664 revealed the first and second floor/unit refrigerators for the residents did not have temperature monitoring logs for the month of July. Dietitian #664 confirmed the observation and stated monitoring logs should have been in place. 5. Review of the kitchen food temperature log dated 06/14 to 06/20 revealed no evidence of temperatures being recorded for breakfast, lunch and dinner on Thursday, Friday and Saturday of that week. Interview on 07/17/24 at 10:25 A.M. with DM #574 confirmed the 06/14 to 06/20 kitchen food temperatures logs were not complete, and DM #574 was unable to provide any completed temperature logs for the week of 07/14/24 to 07/17/24 breakfast. Review of the 2023 facility policy called; Cleaning and Sanitation of Dining and Food Service areas revealed the director of food and nutrition services will determine all cleaning and sanitation tasks needed for the department. A cleaning schedule will be posted for all cleaning tasks, and staff will initial the tasks as completed. Review of the 2023 facility policy called; Cleaning Dishes/Dish Machine revealed prior to use, proper temperatures and/or chemical concentrations and machine function should be verified. Confirm that soap and rinse dispensers are filled and have enough cleaning product for the shift. Review of the August 2017 revised facility policy called; Food Storage-Labeling and Dating revealed all food must have a date that includes month/day/year on the package indicating the date in which it entered the facility. All items removed from its original packaging must be dated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365071 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 365071 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beachwood Pointe Care Center 23900 Chagrin Blvd Beachwood, OH 44122 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on closed record review and interview the facility did not ensure physician ordered treatments were consistently documented in the medical record for Resident #197. This affected one resident ( Resident #197) of 25 resident records reviewed for physician orders. The facility census was 97. Findings included: Review of the physician order dated 09/09/23 for Resident #197 revealed an order to complete a Braden assessment (skin assessment) every week times four weeks. Review of the physician order dated 09/14/23 for Resident #197 revealed an order for catheter care every shift. Review of the physician order dated 09/14/23 for Resident #197 revealed an order for no compression (shrinker, ace wrap) to right above knee amputation. Review of the physician order dated 09/15/23 for Resident #197 revealed an order for treatment to right stump: cleanse with normal saline, apply Betadine and cover with ABD (sterile, padded) bandage as needed and every night shift. Review of the 09/23 Treatment Administration Record (TAR) for Resident #197 revealed no evidence of the Braden assessment being documented on 09/10/23, 09/17/23 and 10/01/23, no evidence of catheter care being completed on the night shift for 09/21/23, 09/22/23 and 09/30/23, no evidence of no compression (shrinker, ace wrap) to right above knee amputation for 09/21/23, 09/22/23, and 09/30/23 and no evidence of treatment for the right stump as ordered for 09/22/23 and 09/30/23. Interview on 07/22/24 at 10:13 A.M. with the Director of Nursing (DON) confirmed she was unable to provide evidence of documentation for the physician orders for weekly Braden assessments, wound treatment, catheter care or order for no compression to the amputation stump as ordered by the physician for the missing dates listed above. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365071 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 365071 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beachwood Pointe Care Center 23900 Chagrin Blvd Beachwood, OH 44122 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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and review of facility policy the facility failed to ensure Resident #46 had a functional call light. This affected one resident (# 46) of 24 residents reviewed for call lights. The facility census was 97. Residents Affected - Few Findings Include: Interview with Resident #46 on 07/15/24 at 2:30 P.M. revealed her call light had not been lighting up when she pressed the call button. Observation of Resident #46's call light on 07/15/24 at 2:35 P.M. with the facility's Director of Maintenance (DOM) revealed the call light above the resident's door was not working when activated. The DOM stated he had replaced the bulb several days earlier. The DOM shook the call light above the door, the call light lit up, and the DOM stated it must have been loose wiring attached to the bulb so he would fix it. Review of the undated facility policy titled Call Light revealed resident call lights were to be checked by nursing and maintenance on a regular basis to test if functioning. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365071 If continuation sheet Page 15 of 15