Health inspection·October 6, 2022

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure staff properly wore personal protective equipment (PPE) while entering a resident room that was positive with COVID-19 and while in resident care areas. This had the potential to affect 46 residents (#2, #5, #8, #10, #17, #20, #21, #23, #27, #29, #33, #34, #36, #37, #39, #48, #50, #51, #53, #55, #59, #65, #66, #68, #71, #73, #75, #83, #85, #93, #103, #104, #105, #110, #116, #117, #118, #121, #125, #128, #129, #130, #131, #132, #133, and #378) who all resided on units C and D. The facility census was 127. Residents Affected - Some Findings include: Observation on 10/03/22 at 11:18 A.M. of Licensed Practical Nurse (LPN) #507 sitting at nurses' station on unit C with no mask on face but wearing goggles. Observed in the common area near the nurse's station but greater than six feet were Residents #34 and #116. Interview at this time with LPN #507 verified the identified finding and stated she will put it on when around residents. Observation on 10/03/22 at 11:45 A.M. of State Tested Nurse Aide (STNA) #508 don a gown and gloves but already had on goggles and a black mask, enter Resident #128's room and close the door behind him. Observed outside of Resident #128's room a sign for contact precautions and a sign on a cart with PPE that read Use Personal Protective Equipment (PPE) when caring for patients with confirmed or suspected COVID-19). Observed STNA #508 exit Resident #128 's room with the gown and gloves doffed. Interview at this time with STNA #508 verified he was wearing a black surgical mask when he entered the resident's room and did not put on a N95. STNA #508 stated he was supposed to put on a N95 mask prior to entering the resident's room. Observation on 10/03/22 at 12:09 P.M. of LPN #507 exiting Resident #128's room wearing only a black cloth mask and goggles. Interview at this time with LPN #507 stated she put gloves on and entered the resident's room to hand him his pills and doffed the gloves prior to exiting the room. LPN #507 stated she did not don a gown or put on a N95 mask. LPN #507 stated Resident #128 was in transmission-based precautions due to being positive for COVID-19. Interviews on 10/03/22 at 12:20 P.M. and 12:45 P.M. with the Director of Nursing (DON) who was also the infection control preventionist revealed staff should have a mask on while at nurses' station unless drinking or eating. DON stated when staff enter resident rooms that were positive with COVID-19 they should wear eyewear, N95 mask, gown, and gloves. DON stated they did not have a policy for what staff should wear while at nursing station but stated they followed Centers for Disease Control and Prevention (CDC) guidance for community transmission. DON stated since they were in a county that was in the red indicating high transmission rate for COVID-19 staff were to wear a mask and eye protection. Observation on 10/03/22 at 3:04 P.M. of Maintenance Staff (MS) #509 walking down the hall on unit D with his facemask and goggles not properly on, exposing his mouth and eyes. Observed MS #509 then enter Resident #50's room. Interview at this time with MS #509 verified the observation and had pulled up his mask and goggles properly. Review of the facility policy titled, Donning and Doffing PPE for COVID-19, revised 02/02/22, revealed the policy did not specify the use of a N95 mask or higher respirator when entering a resident's room with confirmed or suspected COVID-19. The policy did indicate to put on isolation gown, respirator and/or facemask, eye protection, gloves and enter the isolation area/room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365800 If continuation sheet Page 2 of 4 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 365800 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chardon Woods 12340 Bass Lake Road Chardon, OH 44024 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Review of the CDC website, Interim Infection Prevention and Control Recommendations for Healthcare Personnel (HCP) During the Coronavirus Disease 2019 (COVID-19) Pandemic updated 09/23/22 revealed when SARS-CoV-2 Community Transmission levels are high, source control is recommended for everyone in a healthcare setting when they are in areas of the healthcare facility where they could encounter patients. HCP could choose not to wear source control when they are in well-defined areas that are restricted from patient access (e.g., staff meeting rooms) if they do not otherwise meet the criteria described below and Community Levels are not also high. Source control options for HCP include: A NIOSH-approved particulate respirator with N95 filters or higher; A respirator approved under standards used in other countries that are similar to NIOSH-approved N95 filtering facepiece respirators (Note: These should not be used instead of a NIOSH-approved respirator when respiratory protection is indicated); A barrier face covering that meets ASTM F3502-21 requirements including Workplace Performance and Workplace Performance Plus masks; OR A well-fitting facemask. When Community Levels are high, source control is recommended for everyone. HCP who enters the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). Event ID: Facility ID: 365800 If continuation sheet Page 3 of 4 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 365800 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chardon Woods 12340 Bass Lake Road Chardon, OH 44024 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure all resident rooms had call lights in place. This affected two of ten residents on the secured G unit reviewed for accessible call lights (Resident #4 and #40). The total census was 127. Residents Affected - Few Findings include: 1. Record review of Resident #40 revealed she was admitted [DATE] and had diagnoses including dementia, major depressive disorder, and unspecified psychosis. Review of her care plan revealed no mention of any prohibition against keeping a call light in the room. Observation of Resident #40's room on 10/03/22 at 9:36 A.M. revealed she had no bedside call light or cord either plugged into the bedside socket or visible elsewhere in the room. Observation of Resident #40 at this time revealed she was not interviewable. The surveyor confirmed the above observation with Licensed Practical Nurse (LPN) #401 on 10/03/22 at 9:40 A.M. 2. Record review of Resident #4 revealed she was admitted [DATE] and had diagnoses including dementia, paranoid schizophrenia, and depression. Review of her care plan revealed no mention of any prohibition against keeping a call light in the room. Observation of Resident #4's room on 10/05/22 at 10:08 A.M. revealed she had no bedside call light or cord either plugged into the bedside socket or visible elsewhere in the room. Observation of Resident #40 at this time revealed she was not interviewable. The surveyor confirmed the above observation with LPN #401 on 10/05/22 at 10:21 A.M. Interview with her at this time revealed she believed Resident #4 was able to use a call light and had done so in the past. She did not believe Resident #40 was able to use a call light. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365800 If continuation sheet Page 4 of 4