Inspection·August 24, 2023

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, review of the facility policy, and record review, the facility failed to ensure the resident's pre-admission screening and resident interview (PASARR) assessment was completed accurately to include all the resident's mental health diagnoses. This affected one (Resident #66) of two residents reviewed for PASARR assessments. The facility census was 62. Findings include: Review of the medical record for Resident #66 revealed an admission date of 01/26/23. Diagnoses included schizophrenia and psychotic disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #66 was cognitively intact. Review of the PASARR assessment dated [DATE] revealed Resident #66 was marked to have a diagnosis of schizophrenia. Psychotic disorder was not marked as a diagnosis for Resident #66. Interview on 08/22/23 at 2:25 P.M. with Social Services Designee (SSD) #121 revealed she completed the resident's PASARR assessments. SSD #123 denied having knowledge of a diagnosis not matching the medical record and the PASARR's documentation. Interview on 08/22/23 at 2:48 P.M. with the Director of Nursing (DON) confirmed the PASARR diagnosis did not match the diagnosis list in the medical record for Resident #66. The DON confirmed psychotic disorder was not listed on the completed PASARR for Resident #66. Review of the facility policy titled Pre-admission Screening and Resident Review, dated 05/2022, revealed the facility would coordinate assessments with the preadmission review program. The policy did not include any language about ensuring all mental health diagnoses are included on the PASARR assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365329 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 365329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2023 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)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, review of the facility policy, and record review, the facility failed to ensure a resident receiving an as needed psychotropic medication had an end date and/or was re-evaluated by the medical provider every 14 days. This affected one (Resident #66) of five residents reviewed for unnecessary medication. The facility census was 62. Findings include: Review of the medical record for Resident #66 revealed an admission date of 01/26/23. Diagnoses included schizophrenia, psychotic disorder, and anxiety. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #66 was cognitively intact. Review of Psychiatric Practitioner notes dated 06/29/23 revealed Resident #66 was having anxiety and a new medication would be started, Vistaril 25 milligrams (mg) as needed (PRN) every six hours for anxiety. Review of Resident #66's physician orders dated 06/29/23 revealed an order for Vistaril (Hydroxyzine Pamoate) 25 mg capsule with instructions to administer one capsule by mouth every six hours PRN for anxiety. There was no stop date to the PRN psychotropic medication. Further review of Resident #66's medical record from 06/30/23 to 08/22/23 revealed there was no documentation for the re-assessment of Vistaril and the continued rationale for the use of PRN psychotropic medication. Review of Medication Administration Report dated 07/2023 and 08/2023 revealed Resident #66 received Vistaril PRN multiple times on the following dates: once on 07/03/23, 07/06/23, 07/08/23, 07/12/23, 07/14/23, 07/15/23, 07/16/23, 07/17/23, 07/18/23, 07/19/23, 07/20/23, 07/21/23, 07/22/23, 07/23/23, 07/24/23, 07/25/23, 07/26/23, 07/28/23, 07/29/23, 07/30/23, 07/31/23, 08/01/23, 08/02/23, 08/05/23, 08/08/23, 08/09/23, 08/11/23, 08/12/23, 08/13/23, 08/14/23, 08/15/23, 08/16/23, 08/17/23, 08/19/23, and 08/20/23 and was administered the medication twice daily on 07/07/23, 07/10/23, and 07/11/23. Interview on 08/22/23 at 3:42 P.M. with the Director of Nursing (DON) and MDS Nurse #182 verified Resident #66 had an order for Vistaril PRN for anxiety. The DON and MDS Nurse #182 verified the facility no evidence the medical provider had reviewed the resident for appropriateness of the PRN psychotropic medication order to be continued including a stop date and medical reasoning for the continued use of the medication. Subsequent interview on 08/22/23 at 5:00 P.M. with DON revealed the facility's system generated a reorder of Vistaril for every 14 days and confirmed there was no documentation or reasoning for the continuation. Review of the facility policy titled Psychotropic Drug Use, dated 01/2023, revealed the resident would only receive psychotropic medications when necessary to treat specific conditions. An unnecessary drug was defines as a medication for an excessive duration or without adequate monitoring. PRN doses should be limited to 14 days or can be extended beyond 14 days through documentation in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365329 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 365329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2023 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)

F 0758 medical record by the medical practitioner why this should occur. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365329 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 365329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2023 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)

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and medical record reviews, the facility failed to ensure the resident's medical record was accurate. This affected two (Residents #11 and #34) of 19 residents reviewed for medical record accuracy. The facility census was 62. Findings include: 1. Review of the medical record for Resident #34 revealed an admission date of 05/04/18. Diagnoses included Alzheimer's disease, anemia, and dementia. Review of the Resident #34's nursing progress notes dated 01/17/23 and 02/05/23 revealed she was being treated for some kind of rash. Review of Resident #34's care conference documentation dated 03/22/23 revealed Resident #34 continued to have a rash on her entire body. Review of the state tested nursing aide (STNA) shower sheets dated from 01/02/23 to 06/29/23 revealed Resident #34 had a rash on her body during a six-month time frame. Review of Resident #34's Hand-Skin Observation sheets completed weekly from 01/3/23 to 07/23/23 revealed the weekly observation sheets were completed inaccurately as they indicated Resident #34 did not have a rash. Review of the Resident #34's Dermatologist visit note dated 06/27/23 revealed Resident #34 was seen by the dermatologist and evaluated for a rash on Resident #34's body that she has been dealing with for the last six months. Interview on 08/24/23 at 9:19 A.M. with the Director of Nursing (DON) confirmed Resident #34's Hand-Skin Observation sheets from 01/03/23 to 07/23/23 did not indicate Resident #34 had a rash. The DON confirmed the observation sheets were completed inaccurately as Resident #34 did have a rash during this time. Subsequent interview on 08/24/23 at 3:30 P. M. with the DON confirmed the facility does not have a policy or procedure how to complete the Hand-Skin observation sheets. 2. Review of the medical record for Resident #11 revealed an admission date of 10/09/21. Diagnoses included dementia, anxiety, osteoporosis, pulmonary fibrosis, and collar bone fracture. Review of the progress notes dated 05/30/23 revealed Resident #11's roommate was heard yelling and staff entered the room and found Resident #11 on the floor. Resident appeared agitated and was guarding her left bicep area with no visible injury. Review of the pain assessment from the fall investigation dated 05/30/23 revealed Resident #11 had reported pain to the left shoulder and left bicep area. Resident #11 reported that it hurts a little bit and had marked vocal complaints of pain and marked protective body movements or postures including bracing, guarding, or rubbing. Review of the hospice notes dated 05/30/23 revealed Resident #11 had complained of pain and rated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365329 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 365329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2023 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)

F 0842 the pain at a four out of 10. Level of Harm - Minimal harm or potential for actual harm Review of the fall incident investigation dated 05/30/23 revealed Resident #11 had no injuries or pain. This was marked differently that the progress notes, hospice notes, and pain assessment dated [DATE]. Residents Affected - Few The progress note dated 06/01/23 revealed Resident #11 complained of left shoulder pain and was guarding and grimacing when the left shoulder was touched and moved. An X-ray was pending. A later note on 06/01/23 revealed the resident was transferred to the hospital for an arm sling. Review of physician orders for 06/01/23 identified orders for stat x-ray of the left shoulder. Review of the x-ray result dated 06/01/23 revealed an acute non-displaced distal clavicle fracture. The progress note dated 06/07/23 revealed the interdisciplinary (IDT) team met to discuss Resident #11's fall on 05/30/23 and revealed no injuries were noted. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 had one fall with no injury. On 08/21/23, an amendment was made to the MDS assessment dated [DATE] and revealed Resident #11 had one fall with major injury. Interview on 08/21/23 at 3:21 P.M. with the Director of Nursing (DON) and MDS Nurse #182 revealed they were unaware of the resident's fracture not being documented as a fall with major injury on the MDS assessment dated [DATE]. MDS Nurse #182 made an amendment to the MDS assessment on 08/21/23. Subsequent interviews on 08/24/23 at 9:40 A.M. with the DON verified the progress notes, hospice notes, and pain assessment did not match the facility's fall incident investigation. The DON verified the resident's pain and injuries sustained from the fall did not match. The DON also confirmed the resident's pain should have been documented consistently through the fall investigation forms instead of the fall investigations saying no pain and the pain assessment saying verbal and non-verbal indicators of pain were present. At 4:00 P.M., the DON acknowledged concerns related to documentation and the thoroughness and accuracy of documentation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365329 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 365329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2023 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)

F 0921 Level of Harm - Minimal harm or potential for actual harm Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observations, staff and resident interviews, the facility failed to ensure a safe environment for residents, staff, and visitors. This had the potential to affect all 62 residents residing in the facility. Residents Affected - Many Findings include: The initial tour was conducted on 08/21/23 from 8:30 A. M. to 9:00 A.M. and revealed the entry way into the facility contained two glass doors. The first entry door (from the outside, door number one) from the bottom of the glass door closest to the floor extending up three quarters of the door and the entire width of the door, the glass was shattered. It appeared to have a shattered circle of glass in the center of the door with extending cracked glass to forming sharp lines of cracked glass extending in every direction. The area resembled a sun beam design or a spider web effect. Four feet in front of the first entry glass door was another glass door into the lobby of the facility. Door number two was shattered at the bottom right side about 24 inches wide and extended up to the middle of the door, the shattered glass was covered with a two-inch tape on both sides. There were no particles of glass in the area. The shattered glass remained inside the two door frames. Interview with the Administrator on 08/21/23 at 2:48 P. M. revealed on 07/27/23, a resident was attempting to exit the building, and hit the glass with his wheelchair causing the door number two's glass to break. Two days later on 07/29/23, after business hours, the first entry door (door number one) was locked. An unidentified person who appeared to be intoxicated attempted to enter the locked facility. The person kicked the glass door and cracked the glass. Per the direction of the corporate office, Maintenance Director #165 was instructed to place tape over each crack on the doors. The Administrator explained they had a company come and give an estimate to replace the doors. The process continues as the facility was in the process of obtaining additional bids for replacement of the doors. Observation on 08/24/23, at 2:00 P. M. revealed there was a sign on the entry door and door number two that stated, Close door gently to prevent slamming. Thank you. Interview on 08/24/34 at 2:13 P.M. with the Maintenance Director #165 confirmed the outside door was covered with duct tape while the inside door has some special glass tape to prevent further breakage. The additional areas of cracked glass were covered with a generic clear tape. Observation of the doors accompanied by Maintenance Director #165 confirmed the outside glass door had a new area of cracked glass that was not covered with tape. Interview on 08/24/23 at 2:15 P.M. with Resident #9 stated the doors have been shattered since July. The facility has many residents who go outside to sit, and they must be careful when exiting the building to prevent the shattered doors from further cracking. Interview on 08/24/23 at 2:30 P.M. with Licensed Practical Nurse (LPN) #182 stated the facility has 40 residents who use a wheelchair to enter and exit the building. LPN #182 stated several residents liked to sit outside this time of year. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365329 If continuation sheet Page 7 of 7