Health inspection·April 23, 2024

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and review of the menu and spreadsheet, the facility failed to ensure foods were served in appropriate quantities. This affected 49 residents receiving food from the kitchen as four residents (#2, #7, #47, #54) were ordered nothing-by-mouth (NPO) and four additional residents (#12, #31, #43 and #56) were scheduled to receive a different entree at the meal as they were on a regular No Added Salt (NAS) diet. Facility census was 57. Findings include: Review of a menu for Week 1, Tuesday for lunch revealed a meal consisting of baked macaroni and cheese, tomatoes [NAME], rosemary dinner roll and fruit cocktail. An alternate was listed as marinated chicken thigh, green beans and mashed potatoes. Review of the diet guide sheet for Tuesday (Day 3) Lunch corresponding to 04/16/24 revealed for the entrée of macaroni and cheese, residents were to receive one cup (eight ounces) of baked macaroni and cheese on a regular, dysphagia advanced (mechanical), dysphagia mechanical and carbohydrate controlled (CCD) diets. Residents on a pureed diet were also to receive eight ounces of pureed baked macaroni and cheese. Residents on a two-gram sodium, CCD/two-gram sodium, CCD-Renal, Renal or TLC diet were to receive a meal of hamburger streak, brown gravy and buttered macaroni noodles. Observation of lunch service on 04/16/24 starting at 12:16 P.M. revealed [NAME] #141 took temperatures of the foods to be served. Tray service started at 12:21 P.M. [NAME] #141 was observed using a gray #8-scoop (serving four ounces) to serve the regular and pureed baked macaroni and cheese consistently throughout service. During an interview on 04/16/24 at 1:01 P.M. Dietary District Manager (DDM) #132 and Dietetic Technician Registered (DTR) #140 were made aware the #8-scoop of the regular and pureed macaroni and cheese did not follow the menu as written, as the four ounces served was only half of the amount residents were supposed to receive. Review of a diet list as of 04/15/24 revealed four residents (#2, #7, #47, #54) were ordered NPO and four additional residents (#12, #31, #43 and #56) were scheduled to receive a different entree at the meal as they were on a regular NAS diet. This deficiency represents non-compliance investigated under Complaint Number OH00152484 and Complaint Number OH00152455. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366114 If continuation sheet Page 2 of 7 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 366114 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Lyndhurst 1575 Brainard Rd Lyndhurst, OH 44124 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 and policy review, the facility failed to ensure a clean and sanitary kitchen environment including labeling and dating food, discarding expired food and appropriate monitoring of the low-temperature dish machine. This had the potential to affect 53 residents receiving food from the kitchen as four residents (Residents #2, #7, #47 and #54) received nothing-by-mouth (NPO). Facility census was 57. Findings include: 1. Observation of the kitchen on 04/15/24 from 8:32 A.M. to 9:13 A.M. with District Dietary Manager (DDM) #132 revealed the following areas of concern: • In the walk-in cooler, there were packs of sliced cheese and turkey that lacked labels and dates. There was a loosely wrapped package of hard-boiled eggs that were not labeled or dated. There was an additional package of white cheese slices not dated and sausage that had an illegible date. There was a cut of pork wrapped in foil with writing on the foil indicating it was fully cooked but no date was on the foil. There was a package of corned beef that was opened and not dated. • In the walk-in freezer, there were bags of sausage crumbles and chicken patties that lacked dates. The floor of the walk-in freezer had debris and ice-build up. • In the walk in produce cooler, there was a container of cut cantaloupe that did not have a date and there was a container of pre-made salad mix with an illegible date. • The slicer had a bag over it and the surveyor requested the bag to be removed to better observe the slicer. Upon further inspection, the bottom face of the slicer blade had a ring of unidentifiable debris on it and did not appear clean. • In the dishroom, the temperature and sanitizer log was not complete. The dish machine was a low-temperature machine utilizing chlorine as a sanitizing agent, however, test strips for the chlorine sanitizer were unavailable for further testing. • In the dry stock room, nine loaves of bread were not dated and had blue mold on them. There was a high quantity of expired bread including one bag of hamburger buns dated 03/16/24, seven bags of buns dated 03/23/24, 12 bags of buns dated 04/08/24 and two bags of buns dated 04/13/24. There was an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366114 If continuation sheet Page 3 of 7 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 366114 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Lyndhurst 1575 Brainard Rd Lyndhurst, OH 44124 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 undated package of hot dog buns with blue mold and and expired pack of hot dog buns dated 04/06/24. Level of Harm - Minimal harm or potential for actual harm Interviews with DDM #132 verified the above findings at the time of observation. DDM #132 verified foods were to be labeled and dated and discarded when out of date or not fit for consumption, such as with moldy bread. DDM #132 confirmed the slicer was not clean and verified the lack of test strips for the dish machine as well as the incomplete log. Residents Affected - Many Review of the undated document, Sunday Cleaning Assignments, revealed staff were to deep clean the slicer, mixer and microwave. Review of the facility policy, Food Storage: Cold Foods, revised February 2023 revealed all foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross-contamination. Review of the April 2024 dishmachine log on 04/16/24 revealed it was now filled out. Follow-up interview on 04/16/24 at 9:23 A.M. with DDM #132 confirmed the dishwasher log had been incomplete on 04/15/24 during tour with the surveyor but now had been filled out upon receipt on 04/16/24. DDM #132 could not identify which staff member(s) had filled out the log for further review. 2. Observation of the dish machine on 04/16/24 starting at 12:22 P.M. with DDM #132 revealed the facility had obtained chlorine test strips to test the level of the sanitizer in the low temperature machine. Strips were attempted to be tested with three different passes through the dish machine but the strip would only turn a very faint purple color indicating a very low concentration of the sanitizer. Interview on 04/16/24 at 12:32 P.M. with DDM #132 confirmed the sanitizer was not meeting the needed 50-100 parts per million (ppm) required for effective sanitation. DDM #132 stated he would now be calling Ecolab to come out and service the dish machine. Review of the facility policy, Warewashing, revised February 2023 revealed all dish machine water temperatures will be maintained in accordance with manufacturer recommendations for high temperature or low temperature machines. Temperature and/or sanitizer concentration logs will be completed as appropriate. This deficiency represents non-compliance investigated under Complaint Number OH00152455. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366114 If continuation sheet Page 4 of 7 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 366114 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Lyndhurst 1575 Brainard Rd Lyndhurst, OH 44124 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 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and facility policy review, the facility failed to ensure trash including biohazardous waste was collected and stored appropriately. This had the potential to affect all 57 residents residing in the facility. Residents Affected - Many Findings include: 1. Observation on 04/15/24 starting at 9:13 A.M. with District Dietary Manager (DDM) #132 revealed multiple dumpsters were placed in the parking lot area behind the facility. DDM #132 took the surveyor to the designated dietary dumpster which was open and had a pile of debris next to the dumpster including cut up onions, leaves and Christmas lights. There was a broken dresser, chair and couch near the dumpster. Observation continued to the right most point of the parking lot where snow plow markers, a box, trash and takeout were all outside of the dumpster. A wooden open gated area near this dumpster contained a red biohazard barrel and a bookshelf. Interview with DDM #132 at the time of observation verified the dumpster area was not reasonably clean and that the biohazardous waste should not have been in the parking lot. 2. A second observation on 04/15/24 starting at 9:29 A.M. with Director of Maintenance (DOM) #75 revealed there was additional debris to the left of the dietary dumpster including a large pile of mattresses and chairs. The biohazard barrel remained in the wooden open gated area in the right-most corner of the parking lot. DOM #75 then took the surveyor to the first-floor biohazard room on the Critical Recovery Unit (CRU). Upon opening the door, the room was full and overflowing with at least five red bags and a large box with a red bag. Interview with DOM #75 at the time of observation verified the dumpster area was not reasonably clean and shared the furniture to the left of the dietary dumpster was waste between the assisted living facility next door and this facility and had been there at least one month. DOM #75 indicated the right most dumpster was used by State Tested Nursing Assistants (STNAs) with trash from the trash rooms. DOM #75 confirmed the biohazardous waste barrel should not have been outside of the facility as there were designated areas in the facility for biohazardous waste. DOM #75 also confirmed the biohazard room was overly full and indicated the facility needed to get the biohazardous waste picked up. Review of the facility policy, Dispose of Garbage and Refuse, dated August 2017 revealed the Dining Services Director coordinates with the Director of Maintenance to ensure the area surrounding the exterior area of the dumpster is maintained in a manner free of rubbish or other debris. Review of the facility policy, Medical Waste Storage, dated 2001 revealed containers of medical waste will be stored in the following locations: designated biohazard rooms on the first and second floor. Medical wastes must be stored so that it is protected from animals and does not provide a food source for insects and rodents. Should our medical waste storage area become full or the maximum number of storage days be exceeded, the infection preventionist or designee will notify the appropriate personnel/agencies and request the waste be removed promptly. This deficiency represents non-compliance investigated under Complaint Number OH00152455. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366114 If continuation sheet Page 5 of 7 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 366114 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Lyndhurst 1575 Brainard Rd Lyndhurst, OH 44124 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 Based on observation, interview, record review and facility document review, the facility failed to ensure washing machines hit minimum required temperatures for hot water processing. These findings had the potential to affect all 57 residents within the facility. Residents Affected - Many Findings include: Observation on 04/16/24 starting at 8:13 A.M. revealed the soiled linen laundry room contained three washers. The washers did not have a temperature gauge on them. No temperature logs were observed. On the wall there was a listing of different laundry cycles but this lacked temperature information. Laundry Aide (LA) #139 donned a gown and gloves then started to load linens into the washing machine, breaking open clear bags and putting the items in the drum of the washing machine. When the surveyor inquired about temperatures during the wash cycle, LA #139 placed a yellow plate thermometer into the wash and started the cycle. Interview on 04/16/24 at 7:45 A.M. with Housekeeping and Laundry Supervisor (HLS) #138 revealed the washing machine got to a temperature of 140 degrees Fahrenheit (F). HLS #138 was asked if this was the maximum temperature of the wash cycle and HLS #138 indicated he did not know. Interview on 04/16/24 at 7:59 A.M. with Director of Maintenance (DOM) #75 revealed the washer was supposed to reach 140 degrees F but he had seen up to 150 degrees F. DOM #75 indicated there had been a boiler issue about a month and a half ago but it was fixed. DOM #75 was asked for manufacturer's instructions for the washing machine at the time of the interview. Interview on 04/16/24 at 8:13 A.M. with LA #139 stated the laundry got really hot because steam comes off of it but could not quantify an actual temperature. Observation on 04/16/24 at 9:11 A.M. revealed the wash cycle was now complete. LA #139 donned gloves and placed the washed linens into a large yellow cart. LA #139 pulled out the yellow plate thermometer which read: maximum temperature, 150.6 degrees F and current temperature, 143.4 degrees F. LA #139 verified the maximum temperature on the sensor read 150.6 degrees F from the wash cycle at the time of the observation and stated the washing machine usually ran around 140 degrees F and this was the highest. LA #139 stated all of the washing machines ran at the same temperature. Interview on 04/16/24 at 3:03 P.M. with the Administrator revealed the facility did not check temperatures regarding the washing machines and had no further documentation to provide. Interview on 04/16/24 at 3:19 P.M. with Housekeeping and Laundry District Manager (HLDM) #137 indicated she thought maintenance staff checked hot water temperatures relative to the washing machines. A voicemail was left on 04/16/24 at 4:14 P.M. for Service Technician (ST) #142 inquiring about the washing machine temperatures and products used. A voicemail on 04/16/24 at 4:32 P.M. indicated laundry was hygienically clean and there were three or four rinses per cycle. No temperature information was provided regarding the washing machines. Interview on 04/16/24 at 4:33 P.M. with the Director of Nursing (DON), who was also the facility's infection preventionist, revealed there was no further documentation to provide regarding the washing machine and its minimum temperature during processing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366114 If continuation sheet Page 6 of 7 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 366114 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Lyndhurst 1575 Brainard Rd Lyndhurst, OH 44124 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 - Many During an interview on 04/18/24 at 4:46 P.M. Regional Clinical Director (RCD) #145 was made aware at of the time of the interview the facility had not furnished adequate evidence to show the washing machines were meeting or exceeding 160 degrees F for hot water processing as required. Review of the User's Guide for Frontload Washers by Alliance Laundry Systems, dated November 2017, revealed hot water was most effective for cleaning but did not state what temperature the machine would get to during a cycle. Review of a letter titled Ecolab Recommendations for Laundering Wash Temperature, dated 05/11/20 revealed if hot-water laundry cycles are used, wash with detergent in water at or above 160 degrees F or hotter for 25 or more minutes. This deficiency represents non-compliance investigated under Complaint Number OH00152455 and is an example of continued non-compliance from the survey dated 03/05/24. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366114 If continuation sheet Page 7 of 7