Inspection·December 18, 2023

F 0580 due to diagnosis of COVID-19 and to isolate the resident for 10 days. Level of Harm - Minimal harm or potential for actual harm Review of the facility's COVID -19 tracking revealed Resident #57 tested positive for COVID-19 on 12/10/23. Residents Affected - Some Resident #57's record had no documentation that the responsible party was notified of the resident's change in condition, testing positive for COVID-19, or requiring isolation in the facility. 3. Review of Resident #01's medical record revealed the resident was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, paranoid schizophrenia, weakness, hypertension and cardiac murmur. Resident #01 had family listed as her responsible party over her care. The medical record did not have documented evidence that the family was notified that the resident was cohorting with a COVID-19 positive roommate. Review of the facility's COVID -19 tracking revealed Resident #01 was negative for COVID-19. 4. Review of Resident #04's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia, anxiety, pneumonia, dysphagia, pulmonary fibrosis, chronic obstructive pulmonary disease, weakness and cognitive communication deficit. Resident #04 had a family listed as her responsible party over her care. The medical record also not have documented evidence that the family was notified that the resident was cohorting with a COVID-19 positive roommate. Review of the facility's COVID -19 tracking revealed Resident #04 was negative for COVID-19. 5. Review of Resident #08's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, depression, heart failure, pulmonary hypertension and type two diabetes. Resident #08 had a family listed as responsible party over his care. The medical record did not have documented evidence that the family was notified that the resident was cohorting with a COVID-19 positive roommate. Review of the facility's COVID -19 tracking revealed Resident #08 was negative for COVID-19. 6. Review of Resident #20's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including dissociative and conversion disorder, weakness, cognitive communication deficit, anxiety, epilepsy, hypertensive heart disease, myalgia, and obesity. Resident #20 had a family over her care. The medical record did not have documented evidence that the family was notified that the resident was cohorting with a COVID-19 positive roommate. Review of the facility's COVID-19 tracking revealed Resident #20 was negative for COVID-19. 7. Review of Resident #32's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including anemia, hypertension, assist for personal care, unspecified psychosis. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365329 If continuation sheet Page 2 of 12 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 12/18/2023 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident #32 had a guardian over his care. The medical record did not have documented evidence that the guardian was notified that the resident was cohorting with a COVID-19 positive roommate. Review of the facility's COVID -19 tracking revealed Resident #32 was negative for COVID-19. 8. Review of Resident #63's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including hypertension, depression, and weakness. Resident #63 had a family listed as her responsible party over her care. The medical record did not have documented evidence that the family was notified that the resident was cohorting with a COVID-19 positive roommate. Review of the facility's COVID -19 tracking revealed Resident #63 was negative for COVID-19. Interview with the Director of Nursing on 12/13/23 at 4:00 P.M. confirmed the findings. Review of the facility policy titled, Initiating Transmission-Based Precautions (TBA)(Isolation)(contact, Enhanced, Airborne, Droplet) dated 08/2011 revised 05/2023 revealed when Transmission-Based Precautions are implemented, the following is recommended: provide a private room as available, cohort residents with the same pathogen as able, ensure that an appropriate linen barrel/hamper and waste container, with appropriate liner, are placed in or near the resident's room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365329 If continuation sheet Page 3 of 12 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 12/18/2023 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility staff interview, and policy review, the facility failed to update care plans for three (#21, #57 and #61) of four residents reviewed for being COVID-19 positive. The total facility census was 64. Findings include: 1. Review of Resident #21's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including obstructive hydrocephalus, bradycardia, dementia, epilepsy, chronic obstructive pulmonary disease, bipolar disorder, and depression. Review of the 10/12/23 state optional Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had mild cognitive impairment, no behaviors, required extensive assist from one for bed mobility, transfers, toileting and supervision for eating. The resident had order for isolation and observation due to positive COVID status for 10 days dated 12/04/23. Care plans reviewed revealed the resident is long term care at the facility. That she likes to spend most of her time outside her room in communal areas and will watch tv and will participate regularly in bingo and group discussions. The care plan included a plan that she has demonstrated a refusal or inability to wear a mask when outside her room. The care plan had no documentation regarding the resident being positive for COVID-19, or being in isolation. 2. Review of Resident #57's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including infection to skin and subcutaneous tissue, venous insufficiency, need for assistance with personal care, hypertension, chest pain, and weakness. Review of the state other MDS 3.0 dated 10/06/23 revealed the resident is cognitively intact and had no behaviors. Resident #57 required no help from staff for bed mobility, transfers, eating and personal hygiene. Review of Resident #57's orders revealed the resident had order for vital signs due to COVID positive results and for isolation for 10 days due to COVID positive status dated 12/11/23. Review of facility COVID -19 tracking revealed the resident tested positive for COVID-19 on 12/10/23. Review of care plans revealed the resident had a care plan dated 12/10/23 that stated she had the potential for or required an actual isolation related to COVID -19 if she developed a fever (2 degrees over baseline 100.4), cough, difficulty breathing or shortness of breath. The care plan did not state that she required isolation due to being COVID-19 positive. 3. Review of Resident #61's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including acute kidney failure, type two diabetes, anxiety, heart failure, asthma, chest pain, weakness, obesity, depression and need for assistance with personal cares. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365329 If continuation sheet Page 4 of 12 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 12/18/2023 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the 11/21/23 state other MDS 3.0 assessment revealed the resident is cognitively intact, had no behaviors, required supervision for bed mobility, transfers, eating and personal hygiene. Review of facility COVID-19 documentation revealed the resident tested positive for COVID-19 on 12/04/23. Review of care plans revealed the resident had a care plan dated 12/04/23 that stated he had the potential for or require an actual isolation related to COVID -19 if he developed a fever (2 degrees over baseline 100.4), cough, difficulty breathing or shortness of breath. The care plan did not state that he required isolation due to being COVID-19 positive. Interview with the Director of Nursing on 12/13/23 at 4:00 P,M. confirmed the residents' care plans were not updated to reflect the residents' diagnosis of COVID-19 or their being in isolation. Review of the policy titled, F656, F657, F658 Comprehensive Care Plans, dated 09/2012 last revised 09/2023 revealed the facility's care planning/Interdisciplinary team in coordination with the resident, his/her family or representative(sponsor), develops and maintains a comprehensive care plan for each resident that identified the highest level of functioning the resident may be expected to attain. The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS and physician's orders. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365329 If continuation sheet Page 5 of 12 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 12/18/2023 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 facility staff interview, the facility failed to monitor six (#01, #04, #08, #20, #32, and #63) of six residents who were COVID-19 negative and remained in a room with a COVID-19 positive roommate for signs and symptoms of COVID-19. The total facility census was 64. Residents Affected - Some Findings include: 1. Review of Resident #01's medical record revealed the resident was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, paranoid schizophrenia, weakness, hypertension and cardiac murmur. Resident #01's medical record lacked evidence that the resident was having her temperature taken daily or was being observed daily for signs and symptoms of COVID-19. Review of the facility's COVID -19 tracking revealed Resident #01 was negative for COVID-19, but remained in a room with a COVID-19 positive roommate. 2. Review of Resident #04's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia, anxiety, pneumonia, dysphagia, pulmonary fibrosis, chronic obstructive pulmonary disease, weakness and cognitive communication deficit. Resident #04's medical record lacked evidence that the resident was having her temperature taken daily or was being observed daily for signs and symptoms of COVID-19. Review of the facility's COVID-19 tracking revealed Resident #04 was negative for COVID-19, but remained in a room with a COVID-19 positive roommate. 3. Review of Resident #08's medical record revealed the resident was admitted to 11/10/23 with diagnoses including chronic obstructive pulmonary disease, depression, heart failure, pulmonary hypertension and type two diabetes. Resident #08's medical record lacked evidence that the resident had his temperature taken daily or was being observed daily for signs and symptoms of COVID-19. Review of the facility's COVID -19 tracking revealed Resident #08 was negative for COVID-19, but remained in a room with a COVID-19 positive roommate. 4. Review of Resident #20's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including dissociate and conversion disorder, weakness, cognitive communication deficit, anxiety, epilepsy, hypertensive heart disease, myalgia, and obesity. Resident #20's medical record lacked evidence that the resident was having her temperature taken daily or was being observed daily for signs and symptoms of COVID-19. Review of the facility's COVID -19 tracking revealed Resident #20 was negative for COVID-19, but remained in a room with a COVID-19 positive roommate. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365329 If continuation sheet Page 6 of 12 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 12/18/2023 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 0684 Level of Harm - Minimal harm or potential for actual harm 5. Review of Resident #32's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including anemia, hypertension, assist for personal care, and unspecified psychosis. Resident #32's medical record lacked evidence the resident was having his temperature taken daily or was being observed daily for signs and symptoms of COVID-19. Residents Affected - Some Review of the facility's COVID -19 tracking revealed Resident #32 was negative for COVID-19, but remained in a room with a COVID-19 positive roommate. 6. Review of Resident #63's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including hypertension, depression and weakness. Resident #63's medical record lacked evidence that the resident was having her temperature taken daily or was being observed daily for signs and symptoms of COVID-19. Review of the facility's COVID -19 tracking revealed Resident #63 was negative for COVID-19, but remained in a room with a COVID-19 positive roommate. Interview with the Director of Nursing on 12/14/23 at 4:00 P.M. confirmed Resident #01, #04, #08, #20, #32, and #63 remained in a room with a COVID-19 positive roommate and the facility was not monitoring the residents daily for signs or symptoms of COVID-19. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365329 If continuation sheet Page 7 of 12 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 12/18/2023 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Immediate jeopardy to resident health or safety Based on Nursing Home Guidance from the Centers for Disease Control (CDC), medical record review, observation, interview with residents, interview with facility staff, and review of facility policy, the facility failed to appropriately implement the isolation procedures and use of Personal Protective Equipment (PPE) to prevent the spread of the SARS-CoV-2 virus (COVID-19) among facility residents. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, negative health outcomes, and/or death when the facility staff failed to require 13 residents (#19, #21, #42, #46, #47, #51, #55, #56, #59, #61, #62, #64, and #65) who were positive for COVID-19 to remain in isolation from the onset of the outbreak on 11/25/23. As of 12/12/23, 20 residents were identified as COVID-19 positive (Residents #02, #03, #05, #06, #07, #10, #19, #21, #31, #43, #45, #46, #47, #50, #51, #57, #58, #60, #61, and #62). These 20 residents are located throughout the facility since the facility does not have a dedicated COVID-19 unit. The facility also allowed six residents (#01, #04, #08, #20, #32, and #63) who were COVID-19 negative to remain in a room with a COVID-19 positive roommate. Licensed Practical Nurse (LPN) #215 was observed not to change her mask when exiting a COVID-19 positive resident's room (#50) and State Tested Nursing Assistant (STNA) #275 failed to utilize proper PPE when coming into contact with a COVID-19 positive resident (#45) when the staff member was observed to not utilize a gown, gloves, or eye protection when in the resident's room. STNA #275 also did not change her face mask when exiting the room. No trash receptacles were placed close to the door in the COVID-19 positive rooms for staff to discard used PPE upon exit from the room. Additionally, the facility failed to implement staff COVID-19 testing strategies when the COVID-19 outbreak occurred on 11/25/23. Failure of the facility to have systems in place to prevent the transmission and spread of COVID-19 to the vulnerable population of the facility placed all 64 residents at potential risk for contracting the virus. The total facility census was 64. Residents Affected - Many On 12/13/23 at 1:11 P.M., the Administrator, Director of Nursing (DON) and Regional Director of Operations (RDO) #530 were notified Immediate Jeopardy began on 11/25/23 when the facility did not implement isolation procedures and COVID-19 positive residents were allowed to be out of their rooms if they wore source control. The facility had six residents (#01, #04, #08, #20, #32, and #63) who were COVID-19 negative but remained in a room with a COVID-19 positive roommate. LPN #215 exited a COVID-19 positive room and did not change her mask when exiting the room, STNA #275 did not use proper PPE when coming into contact with a COVID-19 positive resident, and the facility had no formal staff COVID-19 testing occurring since the COVID-19 outbreak. No trash receptacles were placed close to the door in the COVID-19 positive rooms for staff to discard used PPE upon exit from the room. As of 12/12/23, 20 residents were identified as COVID-19 positive and are located throughout the facility since the facility does not have a dedicated COVID-19 unit. The Immediate Jeopardy was removed on 12/15/23 when the facility implemented the following corrective actions: • On 12/07/23 at 3:00 P.M., RDO #530 educated the Administrator on COVID policies. • On 12/13/23 at 2:30 P.M., the Administrator educated all department heads including the DON, Human Resource Director (HRD) #535, Maintenance #520, Receptionist #540, Dietary Manager #515, Housekeeping Manager #505, Unit Manager #550, MDS Nurse #260, Therapy Director #500, Business Office Manager (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365329 If continuation sheet Page 8 of 12 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 12/18/2023 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 0880 Level of Harm - Immediate jeopardy to resident health or safety #510, Activities Director #570, Admissions Director #580, and Social Service Director #230 on the COVID policies. Education of floor staff (Nurse, STNA, Dietary, Laundry, housekeeping, receptionist, Maintenance, Activities, SS, therapy) by the DON, MDS Nurse #260, Unit Manager #550, Dietary Manager #515, Housekeeping Manager #505, Therapy Director #500, and/or HRD #535 on COVID policy, proper PPE (don/doff) on 12/13/23 on Carefeed via Read & Sign, or prior to the start of their next scheduled shift completed by 12/14/23 at 4:30 P.M. Residents Affected - Many • On 12/13/23 by 4:30 P.M., audits of rooms were completed by Housekeeping Manager #505 for proper trash bins in COVID positive rooms. • Scheduled staff testing for COVID-twice a week on Tuesdays and Fridays or when symptomatic by DON/Infection Preventionist (IP)/Designee. Positive staff will be removed from the schedule, removed from the facility, and will follow isolation precautions/rules for their symptoms. Employees will follow Return to Work Guidelines per Centers for Medicare & Medicaid Services (CMS), CDC, State and local guidelines, and company policy, 12/12/23 at 5:10 P.M. • (For healthcare personnel (HCP) who were initially suspected of having COVID-19 but, following evaluation, another diagnosis is suspected or confirmed, return-to-work decisions should be based on their other suspected or confirmed diagnoses. Either antigen test (ex, Binax Now, Quidel, BD Veritor) or NAAT (PCR) testing can be utilized. It is not recommended to test staff who are COVID-19 recovered in the past 30 days. Inform the staff member to self-monitor for fever and symptoms consistent with COVID-19 and not to report to work when ill or testing positive for COVID-19. Confer with the staff member to work restrict if: The staff member is unable to wear source control for 10 days following exposure. They are personally moderately to severely immunocompromised. They work solely on units with residents who are moderately or severely compromised and are unable to be reassigned or they are assigned to a unit that is currently in outbreak and the transmission is not controlled with initial interventions and they are unable to be re-assigned). We will either follow Table 1 Return to Work Criteria, Confirmed Infection, Conventional Staffing or Table 2 Return to work Criteria, Confirmed Infection, Contingency and Crisis Staffing. • Residents are educated on COVID-19 policies and in room isolation requirement on COVID -19 positive date by DON/IP/Designee, at time of event. • Re-testing of all negative residents-twice a week on Tuesdays and Fridays or when symptomatic by DON/IP/Designee, initiated 12/07/23. If a resident is COVID-19 positive they will be immediately provided a private room as available and will be cohorted with residents with the same pathogen as able. • (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365329 If continuation sheet Page 9 of 12 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 12/18/2023 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 0880 On 12/13/23 by 5:15 P.M., the DON/IP/Designee re-located all non-COVID-19 positive residents. Level of Harm - Immediate jeopardy to resident health or safety • On 12/13/23, the DON/IP/Designee ensured all residents are cohorted with like status, and documented, educated, and will monitor (signs and symptoms) those who refused room moves. Residents Affected - Many • Starting on 12/15/23, the Administrator/DON/designee to monitor the education through completion. Any staff on paid time off (PTO) will be educated prior to working, and any new hires will be educated during orientation. This monitoring will be conducted weekly for four weeks, then monthly times two. • Starting on 12/15/23, the DON/designee to monitor resident testing until the outbreak has ended. This monitoring will be conducted weekly for four weeks, then monthly times two. • Starting on 12/15/23, the DON/Human Resources (HR)/Designee to monitor staff testing until the outbreak has ended. This monitoring will be conducted weekly for four weeks, then monthly times two. Although the Immediate Jeopardy was removed on 12/15/23, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Interview with the Administrator and the DON on 12/12/23 at 9:25 A.M. confirmed the facility is in COVID-19 outbreak status and the facility had their first COVID-19 positive resident on 11/25/23. The Administrator and DON confirmed there were currently 20 residents (Residents #02, #03, #05, #06, #07, #10, #19, #21, #31, #43, #45, #46, #47, #50, #51, #57, #58, #60, #61, and #62) who were COVID-19 positive and there was not a dedicated COVID-19 unit. The Administrator confirmed at the beginning of the COVID-19 outbreak, COVID-19 positive residents were allowed to be out of their rooms if they wore source control and maintained social distance. Interview with LPN #200, LPN #260, Housekeeper #235 and Social Services #230 on 12/12/23 from 11:32 A.M. to 1:12 P.M. all confirmed the facility did allow COVID-19 residents to be out of their rooms and in common areas until last week. Observation on 12/12/23 at 11:32 A.M. revealed LPN #215 took medication into a resident (#50) in an isolation room, and the LPN donned gloves and gown and had on a surgical mask and glasses. The resident was heard to refuse the medications and the nurse was observed to remove the gown and place it in a small, resident room sized trash can by the door, dump the medication in the sharp's container, remove her gloves with the medication cup in the gloves, exit the room, complete hand hygiene with hand sanitizer and discard her gloves in the medication cart trash can. The nurse continued to wear (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365329 If continuation sheet Page 10 of 12 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 12/18/2023 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 0880 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many the same surgical mask she had on prior to entering the isolation room. The nurse verified the facility staff were wearing surgical masks and verified she should have removed her mask prior to exiting the isolation room but she had not. Observation of State Tested Nursing Assistant (STNA) #275 on 12/13/23 at 10:10 A.M. revealed the STNA was observed in a COVID-19 positive resident's (#45) room, with a face mask in place as the only PPE in use. There was PPE outside the door and signage on the door indicating staff were to wear a gown, gloves, mask, and eye protection if entering the room. The STNA was observed to exit the room carrying a large Styrofoam cup and walk down the hallway. Interview with STNA #275 on 12/13/23 at 10:12 A.M. confirmed she had exited the resident's room with a large cup. The STNA stated yea I didn't have any PPE on. I was just getting this cup. She verified she did not remove her mask and was wearing the same surgical mask she had on while she was in the room. She stated she had performed hand hygiene and then obtained more large Styrofoam cups from the kitchen. Interview with the DON on 12/12/23 at 11:40 A.M. confirmed the staff are not being tested by the facility for COVID-19 but have been told if they feel sick, they need to test and if they are positive, they come to the facility to test and have their result verified. The DON stated the staff are allowed to test anytime they want but it is not tracked at the facility. The DON verified the residents are currently being tested on Tuesdays and Fridays. Observation of all isolation rooms on 12/12/23 at 4:15 P.M. revealed there were no trash receptacles close to the door for staff to discard used PPE upon exit from the room. Interviews with LPN #200, LPN #210, and LPN #215 on 12/13/23 at 7:45 A.M. confirmed there were no trash receptacles near the doors to discard their PPE and it made it difficult to properly remove their PPE and exit the isolation rooms. The facility had six residents (#01, #04, #08, #20, #32, and #63) who were COVID-19 negative but remained in a room with a COVID-19 positive roommate. Review of the facility policy titled, Initiating Transmission-Based Precautions (TBA)(Isolation)(contact, Enhanced, Airborne, Droplet) dated 08/2011 revised 05/2023 revealed when Transmission-Based Precautions are implemented, the following is recommended: provide a private room as available, cohort residents with the same pathogen as able, ensure that an appropriate linen barrel/hamper and waste container, with appropriate liner, are placed in or near the resident's room. Review of the CDC guidance for transmission-based precautions regarding COVID -19 revealed: Patient Placement • Place a patient with suspected or confirmed SARS-CoV-2 infection in a single-person room. The door should be kept closed (if safe to do so). Ideally, the patient should have a dedicated bathroom. • If cohorting, only patients with the same respiratory pathogen should be housed in the same room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365329 If continuation sheet Page 11 of 12 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 12/18/2023 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 0880 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many Multidrug-resistant organisms (MDRO) colonization status and/or presence of other communicable disease should also be taken into consideration during the cohorting process. • Facilities could consider designating entire units within the facility, with dedicated HCP, to care for patients with SARS-CoV-2 infection when the number of patients with SARS-CoV-2 infection is high. Dedicated means that HCP are assigned to care only for these patients during their shifts. Dedicated units and/or HCP might not be feasible due to staffing crises or a small number of patients with SARS-CoV-2 infection. • Limit transport and movement of the patient outside of the room to medically essential purposes. • Communicate information about patients with suspected or confirmed SARS-CoV-2 infection to appropriate personnel before transferring them to other departments in the facility (e.g., radiology) and to other healthcare facilities. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html?CDC_AA_refVal=https%3A%2F% This deficiency represents non-compliance investigated under Complaint Number OH00148969 and OH00148956. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365329 If continuation sheet Page 12 of 12