Health inspection·July 27, 2023

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 record reviews, observations and interviews the facility failed to ensure a clean, safe, homelike environment. This affected four residents (#43, #04 #10 and #42) out of the four residents reviewed for environment. The facility census was 63. Findings include: 1. Review of the medical record for Resident #43 revealed the resident was admitted to the facility on [DATE] with diagnosis including, osteoarthritis, acute kidney failure, epilepsy, and anxiety disorder. Review of the [NAME] Data Set (MDS) assessment dated [DATE] for Resident #43, revealed the resident had intact cognition. Observation of Resident #43's bathroom on 07/27/23 at 9:45 A.M. revealed an area behind the toilet that was approximately three feet wide with crumbling, grayish colored drywall consistent with the drywall previously being wet and the base board below it had separated from the wall. There were pieces of crumbled drywall along the floor. The area of drywall also contained a three-inch hole and the wallboard from the adjoining bathroom was visible through the hole. Interview with Resident #43 on 07/27/23 at 9:46 A.M., revealed the area in the bathroom had been caused by a leaking toilet approximately two weeks ago. Resident #43 stated he did not like how the wall looked. Resident #43 further stated, the maintenance staff knew about the wall. Interview with the Administrator on 07/27/23 at 9:58 A.M., verified Resident #43's drywall behind his toilet had been wet. The area was caused a leaking toilet discovered two weeks ago. The maintenance staff had to repair another room first before fixing Resident #43's room. Administrator stated there were no other rooms available to move Resident #43 while the facility fixed the resident's bathroom wall. Administrator stated once the other room was completed, the facility would move Resident #43 to that room while her bathroom's wall was being repaired. 2. Review of the medical record for Resident #04, revealed the resident was admitted to the facility on [DATE] with the diagnoses including paranoid schizophrenia, chronic obstructive pulmonary disease (COPD), high blood pressure, and Parkinson's Disease. Review of the MDS dated [DATE] for Resident #04, revealed the resident had intact cognition. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 365329 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 365329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Marion 175 Community Drive Marion, OH 43302 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)