Inspection·September 19, 2019

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to maintain a clean, sanitary and homelike environment. The facility also failed to ensure sufficient towels and wash cloths for resident use. This affected Residents #32, #67 and #22 and had the potential to affect all 84 residents residing in the facility. Findings include: 1. Observations of the resident environment on 09/16/19 at 11:35 A.M. revealed a large window in the hall between rooms [ROOM NUMBERS]. The window sill shelf appeared to be warped and in disrepair. The top portion of the window sill appeared to be removed and partially covered with black colored plastic. Interview on 09/16/19 at 11:37 A.M. with Registered Nurse (RN) #110 revealed the window sill had been like that for three weeks, and she had not seen anyone working on it. Observation at 11:57 A.M. of the paper towel dispenser in Resident #32's bathroom revealed it was broken. Interview on 09/16/19 at 12:11 P.M. with State Tested Nurse Aide (STNA) #123 verified the paper towel dispenser was broken but stated she didn't know how long it was broken. STNA #123 stated Resident #32 does use her bathroom. Observation and interview at 1:57 P.M. with Interim Maintenance Director (MD) #97 of the window on the 600 unit. MD #97 stated the air conditioner was leaking and caused water damaged. MD #97 stated the shelf in the window sill was compressed cheap wood which was why it appeared in disrepair from the water. MD #97 stated the plan was to replace the shelf with more durable material. MD #97 stated he was notified immediately about the window and had removed the damaged wood on top of the window sill after spraying mold. MD #97 stated he then placed the plastic over the exposed area. MD #97 stated that was three weeks ago, and he had not been able to fix the window because he was the only maintenance person. Observation on 09/17/19 at 1:58 P.M. with MD #97 of the paper towel dispenser in Resident #32's bathroom. Interview at this time with MD #97 revealed the paper towel rack wasn't broken but not installed properly. MD #97 stated he needed a key to unlock it and to fix it. MD #97 stated he wasn't aware it wasn't working properly. Interview on 09/18/19 07:54 A.M. with Housekeeper (HK) #179 revealed she knew Resident #32's paper towel dispenser was broken and had not been able to replenish the paper towels. HK #179 stated she told MD #97 one week ago that Resident #32's paper towel dispenser was broken. Review of the maintenance logs dated 06/19/19 to 09/03/19 was silent for window leak and room [ROOM NUMBER]'s broken paper towel dispenser. The facility did not have a policy related to maintenance. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366179 If continuation sheet Page 2 of 11 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 366179 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solon Pointe at Emerald Ridge 5625 Emerald Ridge Parkway Solon, OH 44139 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 2. Observations on 09/18/19 at 10:12 A.M. of the 700-unit dining room revealed food particles on floor and various food splatters in the microwave. This was verified at the time of observation by Activity Assistant (AA) #8. Observation on 09/18/19 at 10:21 A.M. of Resident #67's bed side table was chipped, and the covering was peeling. At this time this was verified by STNA #134. Observation on 09/18/19 at 10:23 A.M. of Resident #22's bathroom baseboards were dirty in the bathroom and appeared to have bowel movement on the baseboard near the toilet. This was verified at the time of observation by Licensed Practical Nurse (LPN) #88. Observation on 09/18/19 at 10:25 A.M. of the 800-unit dining room revealed food crumbs were all over the dining room floor, and the microwave had dried food residue in it. This was verified at the time of observation by STNA #134. Interview on 09/18/19 at 7:54 A.M. with Housekeeper (HK) #179 stated daily cleaning included pulling the trash from utility room and the nurse's station, and then start on the resident's rooms. HK #179 stated start with pulling the trash from the bathroom, clean the sink, mirror, commode, and the mop the floor. HK #179 stated then the toilet paper and paper towels are replenished. HK #179 stated resident rooms were usually deep cleaned when the resident moved out or a new resident moved in. HK #179 stated deep cleaning involved moving the furniture out and cleaning everything including the furniture. Review of the facility's housekeeping procedures titled Daily Work Assignment, revised 06/13/19, included timeframes to clean resident rooms following the 5 & 7 step cleaning process and the dining rooms after breakfast and lunch. The 5 & 7 step cleaning process included, spot clean walls, partitions, light fixtures and doors, horizontal cleaning surfaces, dust mop the floor, and damp mop the floor. 3. During Resident Council on 09/16/19 at 3:30 P.M. Residents #68, #80, and #74 revealed there were not enough linens. Interviews on 09/17/19 at 6:30 P.M. STNA #150 stated she worked evenings and at times there was enough linen, but not usually. She stated staff would have to go to laundry and get some if they did not have enough. Inventory taken for the [NAME] unit by STNA #150 revealed there were four bath towels and ten wash clothes for a census of 16 residents. Interview on 09/17/19 at 6:33 A.M. with STNA #148 stated there was not enough linen. Staff have to go to laundry or another unit to get some. Inventory taken for the Purple unit and Rust unit by STNA #148 revealed that neither linen storage cart had any towels or wash cloths on them. The census for the purple unit was 17, and the census for the Rust unit was 16. Interview on 09/17/19 at 6:47 A.M. with STNA #171 stated she worked evenings. Inventory taken for the Maple unit (2nd floor) by STNA #171 revealed there were no bath towels and no wash clothes for a census of 17 residents. On 09/17/19 at 7:10 A.M. inventory of the laundry department of the extra linen was taken by Corporate Administrator #172 revealed four bath towels and eight wash clothes. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366179 If continuation sheet Page 3 of 11 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 366179 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solon Pointe at Emerald Ridge 5625 Emerald Ridge Parkway Solon, OH 44139 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 Interview on 09/17/19 at 7:18 A.M. Director of Housekeeping (DOH) #184 revealed he had an emergency stock available in case nursing ran short. Observation at this time of the emergency stock, inventory revealed 17 packs of wash clothes (50 each/pack) and 13 packs of towels (12/pack). Interview on 09/17/19 at approximately 7:20 A.M. with Registered Nurse (RN) #109 stated there was a key to get into the closet for the emergency stock. When RN #109 was asked to unlock the closet, she could not produce a key. Interview on 09/19/19 at 7:23 A.M. with Licensed Practical Nurse (LPN) #65 and RN #113 revealed they would get linens for the staff if laundry didn't have enough in stock. LPN #65 stated that she would have to look at other floors, and RN #113 stated that she would wash a dirty wash cloth by hand for the resident. Review of the facility par levels form titled Linen Delivery Schedule, dated 01/01/00 revealed par levels for [NAME] for the 7:00 A.M. to 3:00 P.M. shift was 22 for towels and 44 for wash cloths. The 3:00 P.M. to 11:00 P.M. shift was 33 for towels and 66 for washcloths. The Maple unit for the 7:00 A.M. to 3:00 P.M. shift was 40 for towels and 60 for wash cloths. The 3:00 P.M. to 11:00 P.M. shift was 60 for towels and 120 for washcloths. The Chestnut unit for the 7:00 A.M. to 3:00 P.M. shift was 42 for towels and 63 for wash cloths. The 3:00 P.M. to 11:00 P.M. shift was 62 for towels and 126 for washcloths. This deficiency substantiates Complaint Number OH00106518. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366179 If continuation sheet Page 4 of 11 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 366179 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solon Pointe at Emerald Ridge 5625 Emerald Ridge Parkway Solon, OH 44139 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure Resident #44's representative received written notice of transfer to the hospital and bed hold notice. The facility also failed to ensure the long-term care Ombudsman received a copy of the transfers notice. This affected one of one resident reviewed for hospitalization. Findings include: Review of Resident #44 medical record revealed an initial admission date of 07/24/09. Diagnoses included unspecified dementia without behavioral disturbance, schizophrenia, malignant neoplasm of colon unspecified, and Alzheimer's disease with late onset. The significant change Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had impaired cognition and required total dependence of one staff for bed mobility and toilet use and total dependence of two staff for transfers. Review of the nursing note dated 07/14/2019 at 5:52 P.M. revealed a nurse placed a call to the local hospital for an update on Resident #44 and received confirmation that the resident was admitted . Review of the local hospital paperwork for Resident #44 revealed the resident was admitted to the hospital on [DATE]. Review of copies of the Ombudsman notifications sent via email dated 09/10/19 revealed none for Resident #44's hospitalization on 07/13/19. Interview on 09/18/19 at 12:09 P.M. with the Administrator verified the Ombudsman was not notified of Resident #44's transfer to hospital on [DATE]. Interview on 09/18/19 at 4:23 P.M. with Admissions Director (AD) #31 revealed he did not give Resident #44 or Resident #44's representative the written bed hold or transfer notice for Resident #44's hospitalization on 07/13/19. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366179 If continuation sheet Page 5 of 11 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 366179 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solon Pointe at Emerald Ridge 5625 Emerald Ridge Parkway Solon, OH 44139 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure Resident #44's representative received written notice of transfer to the hospital and bed hold notice. This affect one of one resident reviewed for hospitalization. Findings include: Review of Resident #44 medical record revealed an initial admission date of 07/24/09. Diagnoses included unspecified dementia without behavioral disturbance, schizophrenia, malignant neoplasm of colon unspecified, and Alzheimer's disease with late onset. The significant change Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had impaired cognition and required total dependence of one staff for bed mobility and toilet use and total dependence of two staff for transfers. Review of the nursing note dated 07/14/2019 at 5:52 P.M. revealed a nurse placed a call to the local hospital for an update on Resident #44 and received confirmation that the resident was admitted . Review of the local hospital paperwork for Resident #44 revealed the resident was admitted to the hospital on [DATE]. Interview on 09/18/19 at 4:23 P.M. with Admissions Director (AD) #31 revealed he did not give Resident #44 or Resident #44's representative the written bed hold or transfer notice for Resident #44's hospitalization on 07/13/19. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366179 If continuation sheet Page 6 of 11 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 366179 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solon Pointe at Emerald Ridge 5625 Emerald Ridge Parkway Solon, OH 44139 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) 3.0 assessment was coded accurately for Residents #16 and #84. This affected two of 22 residents reviewed for accuracy of assessments. The facility census was 84. Residents Affected - Few Findings include: 1. Record review of Resident #16 revealed an admission date of 01/01/14. Diagnoses included schizophrenia, vascular dementia without behavioral disturbance, and anxiety disorder. The quarterly MDS 3.0 assessment dated [DATE] revealed the resident received antidepressants daily. Review of the June 2019 and July 2019 Medication Administration Record (MAR) revealed Resident #16 did not receive antidepressants. Interview on 09/18/19 at 5:34 P.M. MDS Nurse #82 verified Resident #16 had not received antidepressants, and that the MDS 3.0 assessment dated [DATE] stating the resident received antidepressants was an error. 2. Record review of Resident #84 revealed an admission date of 07/24/19 and a discharge date of 08/05/19 with diagnoses that included urinary tract infection, unspecific abdominal pain and mild cognitive impairment. Review of Resident #84's quarterly MDS 3.0 assessment dated [DATE] indicated the resident was discharged to an acute care hospital. Review of Resident #84's medical record revealed that Resident #84 was discharged home with home health services. Interview on 09/19/19 at 9:51 A.M. with MDS Nurse #82 confirmed Resident #84's assessment should have been documented as a discharged home instead of an acute care hospital. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366179 If continuation sheet Page 7 of 11 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 366179 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solon Pointe at Emerald Ridge 5625 Emerald Ridge Parkway Solon, OH 44139 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observations, interview and policy review, the facility failed to secure medications properly during medication administration. This had the potential to affect one (Resident #57) of 32 resident reviewed for medication administration. Findings Include: Observations on 09/17/19 at 6:28 P.M. revealed a medication cart unlocked and medications in a cup placed on top of the cart. No staff were observed near the cart. Licensed Practical Nurse (LPN) #86 arrived at the cart at 6:23 P.M., observed this writer at cart and verified the unlocked cart and medications sitting on top of medication cart. Review of medications and Medication Administration Record (MAR) revealed medications for Resident #57 including Gabapentin (antiseizure and nerve pain medication), Senna (laxative), Tylenol (pain medication), Lipitor(cholesterol medication), Melatonin (sleep medication), Keppra (antiseizure medication), and Metoprolol (blood pressure medication). Interview during observations, LPN#86 stated that she knew it was wrong to leave medications on top of the unlocked medication cart. LPN#86 stated that the facility policy and procedure is to never leave medications out, and lock the unattended cart. Review of medication administration policy, dated 2018, revealed medication carts must always be locked when out of sight, and medications are not to be left on top of the medication cart. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366179 If continuation sheet Page 8 of 11 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 366179 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solon Pointe at Emerald Ridge 5625 Emerald Ridge Parkway Solon, OH 44139 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 0810 Provide special eating equipment and utensils for residents who need them and appropriate assistance. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure consistent use of adaptive equipment for one resident (Resident #46) of eight Residents (#2, #10, #28, #44, #46, #61, #62 and #77) observed for adaptive equipment. The facility census was 84. Residents Affected - Few Findings include: Review of Resident #46's medical record revealed an admission date of 05/14/19 with diagnoses including spinal stenosis, chronic kidney disease, schizoaffective disorder and heart failure. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #46 was cognitively intact and was on a therapeutic diet. Review of Resident #46's meal ticket revealed Resident #46 was on a carbohydrate-controlled diet with adaptive equipment to include built up utensils, two handled sippy cups, and a high sided plate. Observation of lunch meal on 09/18/19 at 12:35 P.M. revealed cups for beverages were located on the top of the food truck. There were plastic coffee mugs and plastic glasses, no sippy cups. Resident #46's tray was delivered to her room with her juice in a regular plastic glass. Interview at the time of observation with Dietary Manager #186 revealed that a two handled sippy cup should have been on the tray and usually they were with the other cups and glasses on the top of the truck. Dietary Manager #186 went to the kitchen for a two handled sippy cup. Review of policy dated July 2017 entitled, Assistance with Meals revealed that adaptive devices will be provided for residents who need or request them. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366179 If continuation sheet Page 9 of 11 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 366179 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solon Pointe at Emerald Ridge 5625 Emerald Ridge Parkway Solon, OH 44139 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, record review and interview, the facility failed to ensure proper sanitation and storage of dishes. This had the potential to affect 81 of 84 residents who ate meals in the facility's kitchen. Residents #182, #184 and #232 did not receive anything by mouth. Findings include: Observation on 09/18/19 at 10:09 A.M. of the dish washing machine revealed the machine was a low temperature machine which used a sanitizer and was beeping. Dietary Aide (DA) #49 was asked to test the proper sanitizer concentration of the dish machine and did not know how to test the sanitizer. Dietary Manager #186 and Regional Dietary Manager #185 could not find the test strips and verified the dish machine was beeping. Regional Dietary Manager #185 stated that the chemical company was called and are on the way. A return visit to the kitchen on 09/18/19 at 11:35 A.M. revealed Dish Machine Technician #187 was working on the dish machine and stated that the machine was beeping because no chemicals were going into the machine to clean or sanitize the dishes. The dish machine was operating correctly now, and the litmus paper read 50 parts per million (ppm) of the sanitizer which was recommended in the policy. Observation during interview with Dish Machine Technician #187 on 09/18/19 at 11:35 A.M. revealed that Regional Dietary Manager #185 was assisting rewashing dishes to ensure dishes were properly sanitized, two chipped plates were located on the clean side of the dish machine's drainboard. This surveyor and Corporate Dietary Manager #188 counted the plates that were currently stored in the plate warmer and revealed 12 of 66 plates in the plate warmer were chipped. A review of the dish machine log revealed no documentation of monitoring sanitizer concentration levels, this was verified by DM #186. A review of the undated policy entitled, Dish Machine Use revealed that there was no information regarding sanitizer concentrations but did reveal that cracked and chipped dishes shall be appropriately discarded. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366179 If continuation sheet Page 10 of 11 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 366179 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solon Pointe at Emerald Ridge 5625 Emerald Ridge Parkway Solon, OH 44139 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 observations, interview and policy review, the facility failed to adhere to infection control standards for cleaning glucometers. This had the potential to affect five (Residents #26, #31, #40, #46 and #54) of five residents who received blood sugar monitoring. The facility census was 84. Residents Affected - Few Findings Include: Observations on 09/17/19 at 4:27 P.M., Licensed Practical Nurse (LPN) #81 checked a blood sugar for Resident #26, placed the glucometer back in medication cart without sanitizing it. At 4:46 P.M., LPN#81 took the glucometer out of the cart, entered room of Resident #46, and placed glucometer on resident personal side table without sanitizing it. LPN #81, eventually, grabbed the glucometer and cleaned it with an alcohol pad and tested blood sugar. LPN #81 placed glucometer back in medication cart without sanitizing it. Interview during observation, LPN #81 was questioned about policy and procedure for cleaning the glucometer. LPN #81 stated that glucometers were to be cleaned using a Santi wipe (germicidal disposable wipe). LPN #81 stated the glucometer was cleaned with an alcohol wipe because there were no Santi wipes in the cart. LPN #81 verified the glucometer should have been cleaned with a Santi wipe, not an alcohol wipe. Review of cleaning glucometers policy, dated 2018, revealed all glucometers are to be cleaned with a Santi wipe, alcohol is not an acceptable product and should not be used to disinfect glucometers. This is an example of continued noncompliance from the survey completed on 08/13/19. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366179 If continuation sheet Page 11 of 11