Inspection visit

InspectionMay 24, 2019

EMBASSY OF WILLARDCMS #36534336 citations on this visit

36 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 36 deficiencies, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure residents were dressed appropriately to maintain their dignity. This affected one (Resident #40) of four residents reviewed for dignity. The facility census was 45. Findings include: Review of Resident #40's medical record revealed an admission date of 04/30/18 with diagnoses including weakness, mild cognitive impairment, major depressive disorder anxiety and weakness. An annual minimum data set (MDS) assessment dated [DATE] indicated the resident had mild cognitive impairment and needed the extensive supervision of one person for dressing. Observation on 05/20/19 at 12:18 P.M. revealed Resident #40 seated on her bed. Resident #40 was wearing white socks that each had her initials largely written on each sock in black permanent marker. The initials were roughly two inches by two inches in size. Observation on 05/20/19 at 3:43 P.M. revealed Resident #40 seated next to two other residents. While she had shoes on at this time, the initials were still plainly visible to those passing by. Interview on 05/20/19 at 3:43 P.M. with the Director of Nursing (DON) verified Resident #40's socks did not promote dignity. A follow-up interview on 05/22/19 at 12:53 P.M. with Medical Records/Social Services Staff #61 revealed if families did not label a resident's laundry then the facility was to write the resident's initials on the garment really small with black permanent marker. 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 34 Event ID: 365343 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 365343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Willard 370 E Howard St Willard, OH 44890 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 0569 Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed to ensure a notice was given to residents when their account balance reached within $200 of the resource limit. This affected one (Resident #5) of 24 residents. The census was 45. Residents Affected - Few Findings include: Review of the resident fund accounts on 05/21/19 revealed Resident #5 was receiving Medicaid benefits. The account revealed a balance of $2,004.04 on 03/31/18 and on 04/30/19 a balance $2,064.44. A notification letter was issued to the Power of Attorney on 05/08/19 revealing an account balance of $2,064.44. Interview on 05/21/19 at 5:12 P.M. with Business Office Manager #64 revealed the spend down notice was not provided when the resident's balance came within $200 of Social Security resource limit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365343 If continuation sheet Page 2 of 34 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 365343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Willard 370 E Howard St Willard, OH 44890 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 0570 Assure the security of all personal funds of residents deposited with the facility. Level of Harm - Minimal harm or potential for actual harm Based on record review and staff interview, the facility failed to ensure the surety bond was sufficient to cover the total amount of all the resident's personal funds held in the facility account. This had the potential to affect 24 residents with personal funds managed by the facility. The facility census was 45. Residents Affected - Some Findings include: Record review of the facility's surety bond revealed coverage of $10,000.00. Review of the trust account balance dated 05/24/19 revealed a balance of $10,662.02. Interview with on 05/24/19 at 9:20 A.M. with Business Manager #64 verified the resident funds exceed the surety bond. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365343 If continuation sheet Page 3 of 34 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 365343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Willard 370 E Howard St Willard, OH 44890 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 0574 The resident has the right to receive notices in a format and a language he or she understands. Level of Harm - Minimal harm or potential for actual harm Based on observation and interview, the facility failed to provide information regarding contact information for State Survey Agency and State Long term Care Ombudsman in a written form the resident could understand. This had the potential to affect 45 residents residing in the facility. Residents Affected - Many Findings include: Observation of the posting of the State Survey Agency and State Long Term Care Ombudsman Agency contact information on 05/20/19 at 8:30 A.M., 1:20 P.M., 05/21/19 at 10:30 A.M. and 05/23/19 at 3:10 P.M. revealed the postings were in a glass case across from the nurse's station near the conference room. The posting was high in the upper left-hand corner of the glass case. The State Agency's information was written in a font so small it was barely readable to a person or normal height, but a resident attempting to read it from a wheelchair would be unable to read and understand the information. Interview with Resident Council President #21 on 05/21/19 at 12;30 P.M. revealed he had concerns because he could not read and understand the contact information posted in the glass case from his seated position in his wheelchair. Resident Council President # 21 stated the writing was too small and could not read and understand the information. A Group Meeting was held on 05/21/19 at 1:45 P.M. Resident #7 Resident # 8, Resident #16 and Resident #38 attended the meeting and expressed concerns they could not read or understand the State Survey Agency or the Long Term Ombudsman contact information. Each resident indicated the writing was in a glass case, and posting was too high and the writing too small; they could not read or understand the information. Interview with the Director of Nursing on 05/21/19 at 5:30 P.M. verified she checked the information for reading and understanding the contact information for State Survey Agency and The Long-Term Care Ombudsman in the glass case. The DON verified the printing of the information and the information hard to read and understand. The DON stated the information print needed to be enlarged and the information probably needed to be placed at a height where resident could read and understand the information. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365343 If continuation sheet Page 4 of 34 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 365343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Willard 370 E Howard St Willard, OH 44890 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 0577 Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. Level of Harm - Minimal harm or potential for actual harm Based on observation and interview, the facility failed to post the survey results for the past three years in a location that was readily accessible. This had the potential to affect 45 residents residing in the facility. Residents Affected - Many Findings include: Tour of the facility on 05/20/19 at 8:30 A.M. and 05/21/19 at 3:30 P.M. revealed the survey results for annual and complaint surveys within the last three years were not available for review by residents, visitors or staff. The observation was verified with the DON on 05/21/19 at 4:10 P.M. Interview with Resident Council President #21 on 05/21/19 at 12;30 P.M. revealed he could not find the survey results to review. A Group Meeting was held on 05/21/19 at 1:45 P.M. Resident #7 Resident # 8, Resident #16 and Resident #38 each of the residents voiced they did not know where the survey results for the past three years were located and did not know where to find them. Interview with the Director of Nursing (DON) on 05/21/19 at 5:30 P.M. verified she checked all the facility nurses' station and both lobby on the skilled and Assisted Living Areas and could not find the survey results. The DON stated she went to the Administrator's office and found the survey results in the office and not available to resident, visitors, or staff. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365343 If continuation sheet Page 5 of 34 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 365343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Willard 370 E Howard St Willard, OH 44890 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 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm Based on record review and staff interview, the facility failed to ensure appropriate beneficiary notification for residents discharged from Part A services. This affected two residents (Resident #10 and Resident # 92) of three reviewed for beneficiary notices. The census was 45. Residents Affected - Few Finding include: 1. Review of Resident #10's beneficiary notice revealed a discharged notice from Part A services with remaining benefit days left. The resident remained living in the facility. A Notice of Medicare Non-Coverage (NOMNC) was signed on 02/21/19 for services ending on 02/25/19. There was no evidence Resident #10 received the Skilled Nursing Advanced Beneficiary Notice (SNF-ABN). 2. Review of Resident #92's beneficiary notice revealed a discharge notice from Part A services with remaining benefit days left. The resident remained in the facility. A NOMNC was signed on 05/06/19 for services ending 05/08/19. There was no evidence Resident #92 received the SNF-ABN. Interview on 05/21/19 04:42 P.M. with Medical Records Clerk #61 revealed she only provided residents with Part A coverage a Notice of Medicare Non-Coverage and was unaware an SNF-ABN was required for residents who remained in the facility with skilled days left. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365343 If continuation sheet Page 6 of 34 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 365343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Willard 370 E Howard St Willard, OH 44890 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 - Few 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 and interview, the facility failed to provide a safe, clean comfortable environment. This affected two rooms in the facility. The census was 45. Finding include: Observation on 05/24/19 at 2:49 P.M. with the Maintenance Direct #37 and Maintenance Assistant #48 revealed the door frame on room [ROOM NUMBER] was broken off on the right side from the door handle down to the floor, leaving a jagged wooden edge exposed near the door handle. The door to room [ROOM NUMBER] had a large scrape about three inches wide running straight across the lower section. The brown finish was scraped off exposing a white base coat. The tray table in room [ROOM NUMBER] had a half inch thick stiff rubber facing that wrapped along the side of tray table. The rubber tubing was broken and was hanging of the side of the table leaving a rough edge. The night stand had a facing along the right side of the dresser that had pulled away and was sticking out. Interview on 05/24/19 at 3:10 P.M. with Maintenance Director #37 verified findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365343 If continuation sheet Page 7 of 34 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 365343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Willard 370 E Howard St Willard, OH 44890 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement care plans for which involved pressure areas, bowel care, dementia care, hydration and dialysis services. This affected five (Residents #10, #17, #19, #29 and #38) of 13 residents reviewed for the development and implementation of care plans. The facility census was 45 . Findings include: 1. Review of Resident #29's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including insomnia, transient ischemic attack and cerebral infarction without residual deficits, disorientation, Type II diabetes, depression, Dementia in other diseases classified elsewhere without behavioral disturbance, and anxiety. Review of Resident #29's significant change of condition assessment dated [DATE] revealed the resident was an extensive assist of one person for bed mobility, transfers and toilet use. Review of Resident #29's nursing notes from 05/01/19 to 05/23/19 revealed no evidence of documentation the resident had an open wound to his right buttock either pressure or non-pressure related or developed a plan of care for the wound. Review of Resident #29's plan of care dated 03/10/19 revealed the following notations with two different residents as being assessed with the same potential for pressure ulcers. First Notation documented Resident #29 had the potential for pressure ulcer development. (03/10/19) Second Notation also dated 03/10/19 indicated the name of a resident (unknown to the Director of Nursing) as having the potential for pressure ulcer development. The electronic plan of care addressed the potential for Resident #29 and indicated interventions were developed for the (name of the unknown) resident. Interventions for the unknown resident indicated the unknown resident and not Resident #29 will have intact skin, free of redness, blisters or discoloration. An additional intervention which matched Resident #29 medical condition indicated staff were to ensure the pressure adjusting cushion in chair when up. Nurse to do complete skin assessment at least weekly. Staff to inspect skin daily when giving care. Test pressure adjusting cushion weekly Resident #29 did not have a plan of care for any type of open wound. On 05/22/19 12;10 P.M. observation of Resident #29's incontinence care and mechanical transfer with State Tested Nursing Assistant (STNA) #29 and STNA #54 revealed the resident had a Stage II pressure ulcer (characterized by partial-thickness skin loss into but no deeper than the dermis) on his right buttock with the appearance of a small light brown crusted area in the middle with open area surrounding the crusty area. No drainage or odors to the area. The area was left uncovered and STNA #29 placed barrier cream over the area and placed a new incontinence brief. Resident #29 was a two-person mechanical lift from his bed to a recliner chair without incident. Resident #29 refused to be transferred to the wheelchair with the ROHO cushion. Interview with STNA #29 and STNA #54 on 05/22/19 at 12:15 P.M. revealed the area had healed but would open back up. The area had been open for a couple of weeks and the area may have been caused by the cushion on the wheelchair. STNA #29 and STNA #54 stated the nurse was aware of the area they were told to continue the barrier cream. STNA #29 and STNA #54 stated both the resident and the family (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365343 If continuation sheet Page 8 of 34 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 365343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Willard 370 E Howard St Willard, OH 44890 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 0656 Level of Harm - Minimal harm or potential for actual harm member stated the open area was caused by the cushion. STNA #29 and STNA #54 stated they were not sure if the nurses observed the area. STNA #29 and STNA #54 stated Resident #29 would not get up into his wheelchair because the cushion was too hard for him to sit comfortably on it. Neither STNA #29 or STNA #54 knew the identity of the resident who was listed on the same plan of care as Resident #29 with a potential for a pressure ulcer. Residents Affected - Few Interview with the Director of Nursing (DON) on 05/23/19 at 9:30 A.M. verified new nurses were completing the the plans of care. The nurses were using a pre-printed plan for the potential for pressure ulcers and did not develop a plan for the actual pressure ulcer the resident now had. The DON verified Resident #29 did not have a plan of care for the open area to the resident's right buttock. 2. Review of Resident #38's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including dysphagia, urinary tract infections, abnormal posture, muscle weakness and Parkinson's Disease. Review of Resident #38's significant change of condition Minimum Data Set (MDS) assessment dated [DATE] revealed the resident required the extensive assistance of one person for bed mobility, transfers, toilet use. The MDS assessments dated 01/04/19, 02/03/19 and 03/17/19 documented the resident was not on a bowel program, was frequently incontinent of stool and the areas which indicated constipation were neither marked yes or no. Resident #38 had been admitted to the hospital for bowel obstructions on 09/26/18, 02/03/19 and 03/17/19. Review of Resident #38's medical record revealed no plan of care had been developed to prevent Resident #38 from experiencing further bowel obstructions. This was verified through interview with the Director of Nursing on 05/23/19 at 3:10 PM 3. Review of Resident #17's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses which included diabetes type II, chronic kidney disease, chronic obstructive pulmonary disease (COPD), history of cerebral vascular accident (CVA), and paroxysmal atrial fibrillation. Resident #17 received hemodialysis three times a week on Monday, Wednesday and Friday. Review of Resident #17's quarterly MDS assessment dated [DATE] revealed the resident was an extensive assist of two persons for bed mobility, dressing. Resident #17 required total dependence of two persons for transfers and toilet use; and an extensive assist of one person for personal hygiene. Review of Resident #17's diet order dated 04/30/19 revealed the resident was ordered a double portion except in protein, no added salt, low concentrated sweets, avoid high calcium and high phosphorous foods. No potatoes. Review of Resident #17's physician's order monthly summary dated 05/01/19 to 05/31/19 revealed the resident was on a fluid restriction of 1500 milliliters (ml) of fluid per day, 720 ml for dietary needs and 780 ml for nursing needs. Review of Resident #17's plan of care (no date) completed by the dietitian, revealed the resident had nutritional problems or potential nutritional problem related to the resident received a therapeutic diet. Due to the diagnose of chronic kidney disease (CKD) Resident #17 received dialysis treatment and was not being followed by the dietitian currently for his dialysis. Fluids not ensured and monitored. Interventions included resident will maintain current body weight (CBW) without significant weight changes and will complete greater than 75 percent of meals. Resident will have intact skin. Administer medications as ordered. Monitor/Document for side effects and effectiveness. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365343 If continuation sheet Page 9 of 34 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 365343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Willard 370 E Howard St Willard, OH 44890 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 0656 Level of Harm - Minimal harm or potential for actual harm Monitor/record/report to physician as needed signs and symptom of malnutrition: Emaciation (Cachexia), muscle wasting, significant weight loss, three pounds s in 1 week, greater than five percent in one month, greater than 7.5 percent in three months and greater than ten percent in six months. Provide, serve diet as ordered. Monitor intake and record every meal. Registered Dietitian (RD) to evaluate and make diet change recommendations as needed. There was no plan of care addressing the daily fluid restriction. Residents Affected - Few Interview with Registered Dietitian (RD) #69 on 05/21/19 at 2: 40 P.M. with the Director of Nursing (DON) and Regional Nurse present revealed RD #69 was new and more interested in reviewing the clinical records than monitoring the resident's fluid intake. RD #69 verified Resident #17 did not have a plan of care to monitor his 1500 ml fluid restriction. 4. Record Review for Resident #19 revealed and admission date of 08/16/19 with diagnoses including anxiety, depression, dementia and heart disease. The MDS quarterly assessment dated [DATE] revealed Resident #19 was cognitively impaired and had mild depression. Review of the care plan dated 01/24/19 revealed Resident #19 had impaired thought process related to dementia and anxiety. The interventions included to communicate with resident, family and caregivers on resident's capabilities and to keep resident's routine consistent. Interview on 05/24/19 at 8:45 A.M. with Licensed Practical Nurse #7 and STNA #50 revealed Resident #19 was redirectable and effective interventions for his dementia included redirecting by playing music from his compact disc player, spending one on one time, walking, encouraging with snacks and pop from the vending machine. Interview with the DON on 05/22/19 at 5:15 P.M. verified the care plan was not person centered 5. Review of Resident #10's medical record revealed an admission date of 04/20/17 and diagnoses including diabetes, end stage renal disease (ESRD), peripheral vascular disease and hypertension (high blood pressure). An MDS assessment dated [DATE] revealed Resident #10 was cognitively intact, needed supervision with eating, received a therapeutic diet and was on dialysis services. Review of the May 2019 physician orders revealed Resident #10 received dialysis on Monday, Wednesday and Fridays. Review of a care plan for nutritional risk dated 11/05/18 revealed Resident #10 was at nutritional risk due to ESRD, diabetes, and hypertension. The only listed nutritional goal was for Resident #10 to maintain current body weight (CBW), to consume greater than 75 percent of meals and have skin healed by the review date of 08/10/19. Listed interventions included to administer medications as ordered; monitor/document/report to physician signs and symptoms of dysphagia (difficulty swallowing); monitor/document/report to physician signs and symptoms of malnutrition; obtain and monitor labwork as ordered; provide and serve diet as ordered - Resident #10 prefers to eat in the dining room; dietitian to evaluate and make diet change recommendations as needed. Interview on 05/23/19 at 2:47 P.M. with the DON verified Resident #10's nutrition care plan did not address dialysis services and coordination of nutritional care with the dialysis center. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365343 If continuation sheet Page 10 of 34 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 365343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Willard 370 E Howard St Willard, OH 44890 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 observation, interview and record review, the facility failed to ensure revisions were made to plans of care for hydration and supervision during meals. This affected two (Resident #10 and Resident #38) of 13 residents reviewed for care plan revision to ensure coordination of care. The facility census was 45. Findings include: 1. Review of Resident #38's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses of dysphagia, urinary tract infections, abnormal posture, muscle weakness and Parkinson's Disease. Review of Resident #38's plan of care revealed the resident had an activities of daily living (ADL) Self Care Performance Deficit. Interventions included for eating, that the resident was able to feed self after set up. Observation of Resident #38 at the lunch meal on 05/20/19 at 12:43 P.M. revealed his meal was placed in front of him by State Tested Nursing Assistant (STNA) #17. STNA #17 removed the lid to the plate and did not offer to cut up the chicken and dumplings, which was in a small high rim dessert bowl. Resident #38 picked up the large handle weight spoon and attempted to cut the chicken dumpling. Resident #38 was unable to cut the dumpling and he stabbed it with the spoon. When Resident #38 lifted the dumpling out of the dessert bowl it was the size of a small orange. Although staff were in the dining room, STNA # 7 did not assist the resident to cut the food up into smaller pieces. Resident #38 attempted to stick the dumpling into his mouth without the dumpling being cut up. When this did not work, he put it back into the dessert bowl and started to eat small bites off it without it being cut into smaller bites. No staff intervened to redirect the resident to take smaller bites or provide assistance when the resident was unable to cut the dumpling into smaller bites to prevent choking. Interview with the Director of Nursing (DON) on 05/20/19 at 2:50 P.M. verified Resident #38 plan of care was not revised to include the speech therapist recommendation for the resident to safely consume his meal. Interview with Speech Therapist (ST) #71 on 05/2/419 t 9:30 A.M. revealed the resident had been on speech therapy since 05/13/19 due to dysphagia, oropharyngeal phase. ST #71 stated goals were to improve swallowing ability to safely and efficiently swallow the least restrictive diet. ST #71 stated the resident's current diet was a regular diet with nectar tick liquids. The speech therapist stated the resident was to have close supervision and be reminded to slow his rate of eating or take smaller bites. ST #71 stated the resident required and assist for set up of his meal and cutting up his foods. The speech therapist verified the chicken dumpling should have been cut up into smaller pieces to prevent the potential of resident choking. The plan of care was not revised to ensure staff provided supervision and cueing to allow the resident to safely consume his meal 2. Review of Resident #10's medical record revealed an admission date of 04/20/17 and diagnoses including diabetes, end stage renal disease (ESRD), peripheral vascular disease and hypertension (high blood pressure). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365343 If continuation sheet Page 11 of 34 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 365343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Willard 370 E Howard St Willard, OH 44890 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 a care plan dated 09/27/18 revealed Resident #10 had potential for pressure ulcer development due to dialysis and incontinence. A listed goal included maintaining intact skin free of redness, blisters or discoloration through the review date of 08/21/19. Listed interventions included administering medications as ordered; administering treatments as ordered and monitoring for effectiveness; assess/record/monitor wound healing weekly; follow facility policies/protocols for the prevention/treatment of skin breakdown; inform resident/family of any new areas of skin breakdown; Resident #10 required nutritional supplements as ordered to promote wound healing and maintain good skin health; monitor nutritional status; monitor/document/report to physician changes in skin status; obtain and monitor lab/diagnostic work as ordered; pressure relieving device to bed and wheelchair; Resident #10 required assistance to turn/reposition frequently. An MDS assessment dated [DATE] revealed Resident #10 was cognitively intact, needed supervision with eating, received a therapeutic diet and was receiving hemodialysis. Review of a skin grid dated 05/19/19 revealed Resident #10 had a sacral wound measuring three centimeters (cm) by three cm by 0.5 cm that was tan, odorless and did not have undermining. Interview on 05/23/19 at 2:47 P.M. with the DON verified Resident #10's pressure ulcer care plan had not been updated to reflect his current wound. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365343 If continuation sheet Page 12 of 34 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 365343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Willard 370 E Howard St Willard, OH 44890 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 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. 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 a resident was provided assistance with dining. This affected one (Resident #38) of five residents observed for assistance during meals. The facility census was 45. Residents Affected - Few Findings include: Review of Resident #38's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses of dysphagia, urinary tract infections, abnormal posture, muscle weakness and Parkinson's Disease. Review of Resident #38's plan of care revealed the resident had an activities of daily living (ADL) Self Care Performance Deficit. Interventions included for eating, that the resident was able to feed self after set up Observation of Resident #38 at the lunch meal on 05/20/19 at 12:43 P.M. revealed his meal was placed in front of him by State Tested Nursing Assistant (STNA) #17. STNA #17 removed the lid to the plate and did not offer to cut up the chicken and dumplings, which was in a small high rim dessert bowl. Resident #38 picked up the large handle weight spoon and attempted to cut the chicken dumpling. Resident #38 was unable to cut the dumpling and he stabbed it with the spoon. When Resident #38 lifted the dumpling out of the dessert bowl it was the size of a small orange. Although staff were in the dining room, STNA # 7 did not assist the resident to cut the food up into smaller pieces. Resident #38 attempted to stick the dumpling into his mouth without the dumpling being cut up. When this did not work, he put it back into the dessert bowl and started to eat small bites off it without it being cut into smaller bites. No staff intervened to redirect the resident to take smaller bites or provide assistance when the resident was unable to cut the dumpling into smaller bites to prevent choking. Interview with the Director of Nursing (DON) on 05/20/19 at 2:50 P.M. verified Resident #38 required supervision and assistance to ensure the resident ate his meals safely. Interview with Speech therapist (ST) #71 on 05/2/419 t 9:30 A.M. revealed the resident had been on speech therapy since 05/13/19 due to dysphagia, oropharyngeal phase. ST #71 stated goals were to improve swallowing ability to safely and efficiently swallow the least restrictive diet. ST #71 stated the resident's current diet was a regular diet with nectar tick liquids. The speech therapist stated the resident was to have close supervision and be reminded to slow his rate of eating or take smaller bites. ST #71 stated the resident required and assist for set up of his meal and cutting up his foods. The speech therapist verified the chicken dumpling should have been cut up into smaller pieces to prevent the potential of resident choking. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365343 If continuation sheet Page 13 of 34 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 365343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Willard 370 E Howard St Willard, OH 44890 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 a resident received appropriate pressure ulcer care to prevent the development of an avoidable Stage II pressure ulcer (characterized by partial-thickness skin loss into but no deeper than the dermis) from a pressure relieving cushion on his adaptive wheelchair. This affected one (Resident #29) of two residents observed with a pressure ulcer. The facility census was 45. Residents Affected - Few Findings include: Review of Resident #29's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses of insomnia, transient ischemic attack and cerebral infarction without residual deficits, disorientation, type II diabetes, depression, dementia in other diseases classified elsewhere without behavioral disturbance, and anxiety. Review of Resident #29's significant change of condition Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was an extensive assist of one person for bed mobility, transfers and toilet use. Review of Resident #29 weekly skin assessment dated [DATE] to 05/20/19 revealed no pressure or non-pressure area with the resident's skin intact. Review of Resident #29's nursing notes from 05/01/19 to 05/23/19 revealed no evidence of nurses documented the resident had an open area to his right buttock. Nursing notes did not document any monitoring to the open area to the right buttocks except for the weekly skin grids which indicated no pressure or non-pressure open areas. Review of Resident #29's Medication Administration Record (MAR) dated 03/01/19 to 05/23/19 revealed documentation that zinc oxide was applied to buttocks twice a day until healed. The MAR nor physician order sheet reflected any change in treatment to the open area to the right buttock except for the zinc oxide nor had the pressure adjusting cushion been tested as indicated on the resident's plan of care. Review of Resident #29's plan of care dated 03/10/19 revealed the following notations with two different residents as being assessed with the same potential for pressure ulcers. First Notation documented Resident #29 had the potential for pressure ulcer development. (03/10/19) Second Notation also dated 03/10/19 indicated the name of a resident (unknown to the Director of Nursing) as had the potential for pressure ulcer development. The electronic plan of care addressed the potential for Resident #29 be then indicated interventions were developed for the unknown resident. Interventions for the unknown resident indicated the unknown resident and not Resident #29 will have intact skin, free of redness, blisters or discoloration. An additional intervention which matched Resident #29 medical condition indicated staff were to ensure the pressure adjusting cushion in chair when up. Nurse to do complete skin assessment at least weekly. Staff to inspect skin daily when giving care. Test pressure adjusting cushion weekly Resident #29 did not have a plan of care for any type of open area. Review of Resident#29's physician progress notes from January 2019 to May of 2019 revealed the facility provided no documented evidence the physician had been notified of the pressure or non-pressure open area on Resident #29's right buttock. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365343 If continuation sheet Page 14 of 34 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 365343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Willard 370 E Howard St Willard, OH 44890 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 05/22/19 12;10 P.M. observation of Resident #29's incontinence care and mechanical transfer with State Tested Nursing Assistant (STNA) #29 and STNA #54 revealed Resident #29 had a Stage II pressure ulcer on his right buttock. STNA #29 identified the area as a Stage II pressure area caused by the cushion on the resident's wheelchair. The right buttock open area was circular in nature and had a small light brown crusted area in the middle with open area surrounding the crust. No drainage or odors was noted to the area. The area did not have the appearance of a skin tear, rash or excoriation. The open area was left uncovered and STNA #54 placed barrier cream over the area, placed a new brief and pulled the residents shorts up over the area. No dressing was placed on the area as a protective cover. Resident #29 was a two-person mechanical lift from his bed to a recliner chair without incident. Resident #29 refused to be transferred to the wheelchair the cushion caused pain and kept the open area on his buttock open. Interview with STNA #29 and STNA #54 on 05/22/19 at 12:15 P.M. revealed the area had healed but would open back up. The area had been open for a couple of weeks and the area may have been caused by the cushion on the wheelchair. STNA #29 and STNA # 54 stated the nurse was aware of the area they were told to continue the barrier cream. STNA #29 and STNA #54 stated both the resident and the family member stated the open area was caused by the cushion. STNA #29 and STNA #54 stated they were not sure if the nurses observed the area. STNA #29 and STNA #54 stated Resident #29 would not get up into his custom chair because the cushion was too hard for his to sit comfortably on it. Nether STNA #29 of STNA #54 knew the resident who was listed on Resident #29 plan of care as also having the potential for a pressure ulcer. Interview with Resident #29's family member on 05/22/19 at 12:30 P.M. revealed the resident had the open area for at least two weeks and could not use his adaptive wheelchair because the chair did not fit the resident properly. The family member stated the cushion on the chair caused the open area on his buttock and when seated on the cushion the area remains open. The family member stated the resident had to use the recliner chair because it would cause pain and keep the area open. The family member stated physical therapy staff were here on Monday to look at the chair because the custom seat was the cause of his discomfort while resident was seated in the chair. This area opens, then heals, then re-opens because of the pressure of the wheelchair. The family member was concerned because staff were only putting a barrier cream in the area and not putting a dressing on top of it to protect the area. The family member felt the area had decline and became larger because the resident was seated in the wheelchair he could not get the pressure off the area. The family member was adamant the pressure adjusting cushion caused the area about two weeks ago and the pressure needed to be adjusted in the cushion. Therapy looked at the chair on Monday and still as of today nothing had been done to reduce the pressure to allow Resident #29 to get up his custom wheelchair. On 05/23/19 at 9:20 A.M. a second observation of Resident #29's right buttock was conducted with the Director of Nursing and Physical Therapist Assistant (PTA) # 75. The observation revealed a Stage II pressure ulcer, circular in nature and without jagged edges. The ulcer had been cleaned and was without the crusted area in the middle of the surrounding open area. No measurements were taken by the DON. Interview with Resident #29 with the DON and PTA #75 present on 05//23/19 at 9:25 A.M. revealed the resident stated again he had the open area for two weeks. Resident #29 stated the area was caused by his adaptive wheelchair, the cushion was too hard and hurt his buttocks. Resident #29 told the DON and PTA #75 the pressure in the ROHO cushion caused the open area and could not tolerate it and the cushion caused the area to become larger. When asked by PTA #75 why he did not get up in the adaptive wheelchair, Resident #29 stated the seat is too hard and hurts the open area, so he chooses to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365343 If continuation sheet Page 15 of 34 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 365343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Willard 370 E Howard St Willard, OH 44890 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few sit in his recliner because that does not cause pain to the area. Further interview with PTA #75 revealed he would have the cushion assessed and since it was a pressure cushion he would release some of the air in the cushion to reduce the pressure to the resident's buttocks. Interview with the Director of Nursing on 05/23/19 at 9:40 A.M. revealed she would contact the wound doctor and see if the resident would be assessed by the wound doctor to determine the type and care of the wound. The DON verified the resident did not have a plan of care for the wound. The DON verified it was undetermined if the open area improved or declined because she was unaware of the open area to Resident #29 right buttock. Review of the facility's policy and procedure Skin Care and Wound Prevention dated April 2008, revealed: Facility staff strive to prevent resident skin impairment and to promote the healing of existing wounds. The interdisciplinary team works with the resident and family to identify and implement interventions to prevent and tract skin impairment. The interdisciplinary team evaluate and documents skin impairment and preexisting signs to determine the type of skin impairment, underlying contributing conditions and treatment plan. The facility provides care for residents with different types of wounds which include but are not limited to: pressure ulcers, venous insufficiency ulcers, arterial ulcers, diabetic neuropathic ulcers, surgical wounds and skin tears. Prevention: 1. On admission, complete a head to toe skin assessment on all residents and document findings under in the EMR (Electronic Medical Record) system. 2. Complete the Braden Risk Assessment Scale in EMR to identify the resident's pressure ulcer risk indicators. 3. Assess skin weekly and document findings. Ongoing management: 1. Develop a skin and wound management plan of care. 2. Assess and document findings weekly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365343 If continuation sheet Page 16 of 34 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 365343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Willard 370 E Howard St Willard, OH 44890 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure one resident's (Resident #17) facility owned wheelchair was an appropriate size for safe transport to the dialysis center Additionally, the facility failed to ensure Resident #10 wore a smoking apron as assessed to need while smoking. This affected two of three residents reviewed for accidents. The facility census was 45. Findings include: 1. Review of Resident #17's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including diabetes type II, hypertension, anemia, gout, chronic kidney disease, Chronic Obstructive Pulmonary Disease (COPD), history of cerebral vascular accident (CVA), and paroxysmal atrial fibrillation. Resident #17 was transported to dialysis three times a week on Monday, Wednesday and Friday by the facility's transport van. Review of Resident #17's plan of care dated 08/16/18 revealed the resident had limited physical mobility. Interventions included an electric wheelchair for mobility in the community. Provide gentle range of motion as tolerated with daily care. Physical Therapy and Occupational Therapy referrals as ordered when necessary. Review of Resident #17's quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed the resident was an extensive assist of two persons for bed mobility and dressing. Resident #17 required total dependence of two persons for transfers and toilet use and an extensive assist of one person for personal hygiene. Review of Resident #17's nursing notes dated 04/03/19 at 12:30 P.M. revealed a nurse was called to the facility transport van. The driver said the resident had slid down in his wheelchair and assistance was needed. On arrival the nurse found Resident #17 had slid down so far in his chair that his seatbelt was up underneath his arm pits. The chair was fully locked in. His legs were resting on the floor of the bus not on the footrests. When the resident was asked what happened, he said his butt hurt so I slid down off of it. The driver said they were only a short distance away from the facility on the way back from his dialysis appointment. Resident #17 was repositioned back up onto his chair by five staff and three gait belts, then taken in the building to his room. Once in bed via the mechanical lift, the nurse assessed for injuries and noted a 2.5 centimeter (cm) by 0.5 cm skin tear to the right lateral lower extremity. Vital signs were taken and were within normal limits. The doctor was notified and orders were obtained for treatment to the skin tear. The resident's spouse was notified as was the Assistant Director of Nursing (ADON) The nurse's note indicated Resient #17 said this would not have happened if she (the driver) would not slam on the brakes when she drives An interview conducted with Resident #17 on 05/21/19 at 1:10 P.M. and 05/24/19 at 10:30 P.M. revealed the resident's own power wheelchair was too big to fit into the facility's 20 passenger transport van. Resident #17 stated on days he was transported to the dialysis center by the facility, he was placed in a smaller blue tilt in space wheelchair which was too small for his body and his feet did not fit on the wheelchair footrests. Resident #17 stated because he was too tall, the wheelchair back was tilted back to allow him to fit in the spot for the wheelchair to be hooked to the floor. Resident #17 stated this caused the shoulder seatbelt to be loose. Resident #17 stated he was on his way back from dialysis to the facility and was trying to adjust his position on the wheelchair. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365343 If continuation sheet Page 17 of 34 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 365343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Willard 370 E Howard St Willard, OH 44890 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #17 stated the blue tilt in space wheelchair was a smaller wheelchair than his power wheelchair and the seat caused pain on his excoriated buttocks. Resident #17 stated on the day the incident occurred, he attempted to change his seating position and the van driver slammed on the brakes which caused him to slide under the shoulder seatbelt. Resident #17 stated the shoulder seatbelt was loose, he slid under it and he stopped sliding when the seal belt became wedged under his arms pits and across his chest. Resident #17 stated he did not experience any respiratory distress but could not get himself free because he was hanging out the bottom of the wheelchair. Resident #17 stated the van driver drove to the facility and went into the facility to get help. Resident #17 stated it took five people to get him loose from the seatbelt and take him into the facility. Resident #17 stated the incident happened not too far from the facility and the van driver finished driving to the facility and obtained help. Resident #17 stated his chest and underarms were sore and he received a skin tear on his right lower leg. Resident #17 was adamant he was adjusting his position and did not slid down under the seatbelt on purpose. Resident #17 stated this was not the first time the van driver slammed on the brakes. Resident #17 stated the van driver had a habit of hitting the brakes hard and slamming the brakes on when she was driving the van. Resident #17 stated if the van driver had not slammed on the brakes this would not have happened. Interview with the Director of Nursing on 05/21/19 at 5:20 P.M. revealed Resident #17 was involved in an incident resulting in the resident becoming entrapped under the shoulder seat belt when the van driver slammed on the brakes. This caused the resident to slide under the shoulder seat belt up to his chest and under both arm pits entrapping the resident in the wheelchair. The DON stated when interviewing the van driver, a reason was not provided by the van driver as to why she slammed on the brakes. The DON verified the resident was too big for the facility's blue tilt in space transport chair. The DON verified through her investigation, the van driver had slammed on the brakes with other residents during transport. The DON verified the van driver was terminated from the facility due to this incident and two new van drivers now complete the transfers to appointments and dialysis. The DON verified Resident #17 had not been provided a wheelchair of proper size and the two new van drivers had not been in serviced on how to properly transport Resident #17. The DON further verified as of 05/24/19, Resident #17 continued to use the same blue tilt in space wheelchair for transport. Interview with Certified Occupational Therapy Assistant (COTA )#72 on 05/24/19 at 9:20 A.M. revealed on 04/03/19 (time unknown) she received a call to come to the transport van. COTA #72 stated she went to the van which was parked at the facility and discovered Resident #17 had slid out of the blue tilt in space wheelchair and was entrapped with the shoulder seatbelt around his chest and under both arm pits. COTA #72 stated because of his size, height of six feet seven inches and weight of 231 pounds, it took five staff to physically lift him to prevent further entrapment and injury. COTA #72 stated one person was pulling him up in the wheelchair by his shoulders to relieve pressure on his chest and underarms and four staff were using three gait belts on his legs and chest to lift the resident back in the chair. COTA #72 stated it was all five people could do was to lift him back in the chair and release the shoulder seatbelt. COTA #72 verified Resident #17's personal power wheelchair was too big for the facility van to transport the resident to the dialysis center. COTA #72 verified Resident #17 was transported in the smaller blue tilt in space wheelchair which does not fit him properly. COTA #72 stated because of his height, the blue title in space backrest had to be titled back to allow the wheelchair to fit into the van. This may have caused the shoulder seatbelt to be loose which allowed the resident to slide underneath it when the van driver slammed on the brakes. COTA #72 stated the to the best of her knowledge, Resident #17 had not been reassessed for a different transport wheelchair and the resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365343 If continuation sheet Page 18 of 34 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 365343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Willard 370 E Howard St Willard, OH 44890 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few continued to be transported in the same blue tilt in space wheelchair which was too small for the resident's size. 2. Review of Resident #10's medical record revealed an admission date of 04/20/17 and diagnoses including diabetes, end stage renal disease (ESRD), peripheral vascular disease and hypertension (high blood pressure). An MDS assessment dated [DATE] revealed Resident #10 was cognitively intact, needed supervision with eating, received a therapeutic diet and was on dialysis. Review of a smoking assessment dated [DATE] revealed Resident #10 could not light his own cigarette, needed a smoking apron, needed the facility to store his lighter and cigarettes and the plan of care was used to assure Resident #10 was safe while smoking. A prior smoking assessment dated [DATE] indicated Resident #10 needed a smoking apron, required supervision while smoking and the facility was to store his smoking materials. Review of Resident #10's plan of care dated 02/04/19 revealed risk for injury due to refusing to dress appropriately when going outside to smoke. A listed goal included smoking to not cause harm to self or put others at risk through 08/21/19. Listed interventions included educate Resident #10 to dress appropriately for the weather when going outside to smoke, validate resident concerns, smoking items to be kept at nurses' station, monitor when smoking to assure Resident #10's safety and arrange family meetings to elicit support as needed. No mention of a smoking apron was noted throughout Resident #10's entire care plan. Observation on 05/20/19 at 3:20 P.M. revealed Resident #10 in his wheelchair in his room with a pack of cigarettes on the counter. When asked how many cigarettes he had available, Resident #10 opened the pack and showed a lighter and 10 cigarettes that were inside the pack. Interview on 05/20/19 at 3:32 P.M. with Licensed Practical Nurse (LPN) #23 verified Resident #10 was a supervised smoker and should not have had access to the lighter or cigarettes in his room. Observation on 05/24/19 from 9:54 A.M. to 10:11 A.M. revealed five residents including Resident #10 in the interior courtyard of the facility for supervised smoking. Housekeeping Assistant (HA) #58 lit resident's cigarettes and a fire blanket as proper cigarette receptacle were on the premises. A locked box containing cigarettes was on the table. During the observation, Resident #10 was not wearing a smoking apron and no smoking aprons were available in the courtyard. Interview on 05/24/19 at 10:11 A.M. with HA #58 revealed she was unsure if the facility had smoking aprons and verified Resident #10 used to wear one. HA #58 indicated smoking materials were kept in a locked box which was then locked in the medication room on the unit. HA #58 also stated there was no documentation for her to refer to regarding what levels of assistance residents needed when smoking. Interview on 05/23/19 at 10:33 A.M. with the Director of Nursing (DON) revealed no residents at the facility currently needed a smoking apron. On 05/23/19 at 10:47 A.M. the Administrator showed the surveyor the utility closet, where there were two smoking aprons packed in boxes. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365343 If continuation sheet Page 19 of 34 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 365343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Willard 370 E Howard St Willard, OH 44890 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete A follow-up interview with the DON on 05/23/19 at 2:47 P.M. verified Resident #10's plan of care did not include a smoking apron. Review of the facility smoking policy revised 01/01/16 revealed residents were assessed for smoking upon admission, quarterly and with a significant change. Staff were to supervise residents who required assistance smoking, light all smoking products and provide other assistance and protective devices as needed. All smoking materials were to be kept in a secured area and distributed by facility staff for residents who need supervision. Visitors were required to give all resident smoking materials to facility staff for proper storage when indicated. Event ID: Facility ID: 365343 If continuation sheet Page 20 of 34 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 365343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Willard 370 E Howard St Willard, OH 44890 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 0690 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident with a known history of small bowel obstruction, received appropriate bowel care. This resulted in actual harm when Resident #38 experienced severe abdominal pain, loose stools, nausea and vomiting with abdominal distention on 09/26/18, 02/03/19 and 03/17/19, resulting in hospitalizations with nasogastric suctioning and resolution of the small bowel obstruction. This affected one of three residents sampled for bowel continence. The facility census was 45. Findings include: Review of Resident #38's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses of dysphagia, urinary tract infections, abnormal posture, muscle weakness and Parkinson's Disease. Review of Resident #38's significant change of condition Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed the resident required an extensive assist of one person for bed mobility, transfers and toilet use. The MDS assessments dated 01/04/19, 02/03/19 and 03/17/19 documented the resident was not on a bowel program and was frequently incontinent of stool. Review of Resident #38's medical record revealed the resident did not have a plan of care for bowel incontinence or a care plan to monitor the resident for signs and symptoms of a bowel obstruction. Review of Resident #38's nursing notes dated 09/25/18 at 10:00 P.M. revealed a call was placed to the physician informing the physician the resident had a large liquid emesis and continued to feel bad. The physician said to send resident to hospital for evaluation and treatment, due to abdominal distention, guarding left side, and vomiting. A call was placed to the local police department for 911 to transport the resident to the emergency department, an order was faxed to the primary care associate, spouse was made aware of transport as she was at the facility with resident. A call was placed to the hospital and spoke with the nurse, gave report on resident's condition, and that he was being sent to them. Resident #38 was admitted to the hospital on [DATE] for a small bowel obstruction. Review of Resident #38's hospital discharge record dated 09/26/18 revealed the resident was admitted with severe abdominal pain, abdominal distention and diagnosed with a small bowel obstruction Review of Resident #38 nursing notes dated 02/03/19 at 1:15 P.M. revealed the resident was having loose stools and complained of severe abdominal pain. His abdomen was very distended with hypoactive bowel sounds. Vital signs were obtained. The physician was notified, and an order was received to send Resident #38 to the emergency roomvia 911 for evaluation. The spouse was notified. Report was given to the nurse at the hospital. The hospital discharge for the second small bowel obstruction dated 02/03/19 was not provided by the facility Review of Resident #38's hospital discharge records dated 03/17/19 revealed the resident was admitted to the hospital for complaints of abdominal pain with nausea and vomiting. A CT scan had been done which showed a small bowel obstruction with transition in the medium ileum. A nasogastric tube was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365343 If continuation sheet Page 21 of 34 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 365343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Willard 370 E Howard St Willard, OH 44890 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 0690 placed. Surgery was consulted, and the resident was seen. The rsident was managed conservatively, nausea and abdominal pain resolved and the nasogastric tube was discontinued. Level of Harm - Actual harm Residents Affected - Few Nursing notes dated 03/29/19 at 5:20 P.M. revealed a late entry documenting the resident was readmitted from the hospital at 5:20 P.M. via squad on a cart, accompanied only by the two squad personnel. Review of Resident #38's bowel tracking record from 01/01/19 to 05/23/19 revealed some dates had been changed on some of the tracking forms, other dates had been scribbled and state tested nursing assistant's (STNA) documentation at the time of review was difficult to decipher. Interview with STNA #29 on 05/23/19 at 4:00 P.M. revealed STNAs are to document daily on the incontinence tracking form if the resident were incontinent of urine and stool. STNA #29 stated staff were to report any changes in the resident's condition, especially urine, if confusion, color change or odor. STNA # 29 stated as for documenting bowel movements, they mark if it is small, medium, large or loose. STNA #29 stated the bowel movements and urinary incontinency tracking are marked two times a day, once on day shift and once on night shift. STNA #29 stated aides worked 12-hour shifts. STNA #29 was not sure of the accuracy of the tracking because of the difference of opinions for the size and shape of the bowel movement. STNA #29 stated Resident #38 required help to transfer from the wheelchair to the toilet. Other times he was independent and would go to the toilet on his own and not tell staff if he had a bowel movement. STNA #29 stated she had not been educated on what to report to the nurse regarding how to monitor the resident for signs and symptoms of constipation or a bowel obstruction. Interview with the Director of Nursing (DON) on 05/23/19 at 4:45 P.M. revealed there was no documentation from the March 2019 hospital visit that documented when or why Resident #38 was transferred from the facility to the hospital. The DON verified the resident was sent to the hospital for a small bowel obstruction. The DON revealed the facility had a policy and procedure for Bowel and Bladder Assessment to identify individuals with reversible causes of incontinence and to institute the appropriate interventions to meet the resident's needs. The DON stated the facility had no written bowel protocol in place. Nurses were to monitor resident's bowel movements. If no bowel movement after three days, the resident was administered milk of magnesia. It not effective, the resident would be administered a suppository, if no results the resident was administered an enema. If no results from the enema, the physician was notified for further instructions. The DON verified the facility did not have standing orders to ensure this unwritten protocol was initiated. The DON verified as of 05/23/19 at 5:20 P.M. Resident #38 did not have a plan of care in place for monitoring bowel movements to prevent bowel obstruction. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365343 If continuation sheet Page 22 of 34 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 365343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Willard 370 E Howard St Willard, OH 44890 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident # 17's medical record review the resident was admitted to the facility on [DATE] with diagnoses which included diabetes type II, chronic kidney disease, COPD, history of CVA, and paroxysmal atrial fibrillation. Resident #17 received hemodialysis three times a week on Monday, Wednesday and Friday. Residents Affected - Few Review of Resident #17's quarterly MDS assessment dated [DATE] revealed the resident was an extensive assist of two persons for bed mobility, dressing; total dependence of two persons for transfers and toilet use; and an extensive assist of one person for personal hygiene. Review of Resident #17's diet order dated 04/30/19 revealed the resident was ordered a double portion except in protein, no added salt, low concentrated sweets, avoid high calcium and high phosphorous foods. No potatoes. Review of Resident #17's monthly physician order summary sheet dated 05/01/19 to 05/31/19 revealed the resident was on a fluid restriction of 1500 ml of fluid per day, with dietary allotted 720 ml and nursing allotted 780 ml. Observation of Resident #17 during the survey from 05/20/19 to 05/23/19 revealed the resident had a large Styrofoam glass filled with water setting on his bedside table. During the observations, the glass was always full. Interview with Resident #17 on 05/23/19 at 1:00 P.M. revealed he was on a 1500 ml fluid restriction. Resident #17 stated the fluid was split between his meals and his medication. Resident #17 stated he was not interviewed by the dietary department on how the fluid restriction would be monitored. Resident #17 stated neither the dietary department or the nursing department monitored his intake. Resident #17 stated when his glass was empty he would go the ice machine near the Assisted Living area, fill it and bring it back to his room. Resident #17 stated no staff asked him if he was following the 1500 ml fluid restriction. The glass was always full, and the resident stated staff thought he was not drinking the fluid, when in fact he was filling it. Interview with Registered Nurse (RN) #33 on 05/24/19 at 10:00 A.M. revealed nursing was to provide 780 ml per day of fluid. RN #33 stated the resident was non-complaint with care, but she was unaware he was not following the 1500 ml fluid restriction. Interview with RD #69 on 05/21/19 at 2: 40 PM with the DON and Regional Nurse present revealed RD #69 was new and more interested in reviewing the clinical records than monitoring the resident's fluid intake. RD #69 verified she had not interviewed or assessed Resident #17 to determine if the resident followed the 1500 ml fluid restriction required for dialysis. Based on record review and interview, the facility failed to ensure nutritional oversight and monitoring of high risk residents. This affected two (Resident #10 and Resident #17) of three residents reviewed for nutrition. Findings include: 1. Review of Resident #10's medical record revealed an admission date of 04/20/17 and diagnoses including diabetes, end stage renal disease (ESRD), peripheral vascular disease and hypertension (high blood pressure). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365343 If continuation sheet Page 23 of 34 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 365343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Willard 370 E Howard St Willard, OH 44890 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A minimum data set (MDS) assessment dated [DATE] revealed Resident #10 was cognitively intact, needed supervision with eating, received a therapeutic diet and was on dialysis services. Review of May 2019 physician's orders revealed Resident #10 attended dialysis on Mondays, Wednesdays and Fridays. Resident #10's diet order was listed as a no added salt, potassium restricted diet with large meat portions and diet desserts/condiments. Resident #10's supplement orders were listed as a 1.5 liter fluid restriction per day and a no added sugar supplement drink twice daily. Review of a dietary progress note written by Diet Technician Registered (DTR) #67 and dated 02/12/19 revealed will have Registered Dietitian (RD) follow for wounds and dialysis. No notes written by the facility's dietitian (RD #69) were available in the medical record. Review of a care plan for nutritional risk dated 11/05/18 revealed Resident #10 was at nutritional risk due to end stage renal disease (ESRD), diabetes, and hypertension (high blood pressure). The only listed nutritional goal was for Resident #10 to maintain current body weight (CBW), to consume greater than 75 percent of meals and have skin healed by review date of 08/10/19. Listed interventions included administer medications as ordered; monitor/document/report to physician signs and symptoms of dysphagia (difficulty swallowing); monitor/document/report to physician signs and symptoms of malnutrition; obtain and monitor labwork as ordered; provide and serve diet as ordered - Resident #10 prefers to eat in the dining room; dietitian to evaluate and make diet change recommendations as needed. Review of Resident #10's tray card diet ticket revealed an order in place for a regular, carbohydrate-controlled/no added salt, 1500 milliliter (mL) liberalized renal reduced concentrated sweets diet. Review of fluid restriction flow sheets from 03/01/19 through 05/12/19 revealed missing data on the following dates: 03/02/19 evening; 03/11/19 evening and night; 03/13/19 evening and night; 03/18/19 evening and night; 04/04/19 evening and night; 04/05/19 evening and night; 05/06/19 evening; 05/07/19 evening and night; 05/08/19 evening; 05/09/19 evening; 05/10/19 evening; 05/11/19 evening; 05/12/19 evening. Interview on 05/22/19 at 2:10 P.M. with RD #69, Corporate Director of Nursing (CDON) #70 and the Director of Nursing (DON) revealed RD #69 visited the facility once a month for clinical duties and the facility had DTR #67 at the facility weekly to assist her work. RD #69 admitted she did not oversee DTR #67's work at the facility and focused on completing MDS assessments and talking to residents at high nutritional risk, which she defined as residents with tube-feedings, total parenteral nutrition (TPN), wounds and hemodialysis. RD #69 described her workload as census-dependent and she was only allowed a certain amount of hours on site per her contract. When asked if she had seen Resident #10 or communicated with the dietitian at dialysis, RD #69 verified she had not and stated she would look at renal dialysis labs at the next MDS assessment for that resident. RD #69 had no additional knowledge to share regarding Resident #10's nutritional status. Phone interview on 05/22/19 at 2:59 P.M. with DTR #67 confirmed he did not monitor Resident #10's nutritional labs and he was not aware of Resident #10 having a fluid restriction. Interview on 05/22/19 at 3:02 P.M. with the DON verified the facility's expectation was that the Registered Dietitian would monitor labwork and collaborate with dialysis regarding any changes needed to the plan of care. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365343 If continuation sheet Page 24 of 34 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 365343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Willard 370 E Howard St Willard, OH 44890 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 0692 Level of Harm - Minimal harm or potential for actual harm A follow-up interview on 05/23/19 at 3:51 P.M. with the DON revealed fluid restriction sheets were completed by nursing staff and if concerns arose, both dietary and dialysis were to be notified if Resident #10 was noncompliant with his fluid restriction. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365343 If continuation sheet Page 25 of 34 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 365343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Willard 370 E Howard St Willard, OH 44890 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 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. 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 provide individualized dementia care for a resident. This affected one (Resident #29) of two residents reviewed for dementia care. The facility census was 45. Residents Affected - Few Findings include: Review of Resident #29's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses of insomnia, transient ischemic attack, cerebral infarction without residual deficits, disorientation, type II diabetes, and dementia in other disease is classified elsewhere without behavioral disturbance, and anxiety. Review of Resident #29's significant change of condition Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was an extensive assist of one person for bed mobility, transfers and toilet use. Review of Resident #29's plan of care dated 04/13/19 revealed the resident had chronic/progressive impaired thought processes characterized by: deficit in memory, judgement, decision making related to Anxiety and Dementia. Interventions include will be able to communicate basic needs daily through the review date. Will be able to communicate basic needs daily through the review date. Under cognition, the resident can remember simple basic 1-2 step instructions i.e. find room, read, sit for an hour, do puzzles etc. Communicate with the resident/family/caregivers regarding residents' capabilities and needs as needed. Observation of Resident #29 on 05/21/19 from 1:00 P.M. to 3:00 P.M., 05/22/19 from 10:30 A.M. to 2:30 P.M. and 05/23/19 from 11:10 A.M. to 2:30 P.M. revealed the resident sat in his recliner in his room, the room dark, with his wife visiting. Interview with the Director of Nursing (DON) on 05/23/19 at 2:38 P.M. verified Resident #38 had dementia and the facility had new nurses developing plans of care. The DON verified the nurse used a pre-printed plan of care for the resident's progressive cognitive impairment. The DON verified the plan of care was not individualized with the resident's preferences, goals individualized interventions to decrease periods of frustration and combativeness. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365343 If continuation sheet Page 26 of 34 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 365343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Willard 370 E Howard St Willard, OH 44890 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 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. Based on observation, menu spreadsheet review and interview, the facility failed to ensure dietary staff followed spreadsheets as written. This affected four residents (Resident #5, Resident #14, Resident #19 and Resident #31) of four residents identified by the facility as receiving mechanical soft diets. The facility census was 45 residents. Findings include: Review of the menu spreadsheet for Week 1, Day 3 corresponding to 05/21/19 revealed a lunch meal consisting of maple glazed fish, rosemary roasted potatoes, asparagus, fresh baked roll, chocolate satin pound cake, margarine and coffee or tea. Residents receiving a mechanical soft diet were to have a #6 scoop of ground fish with two ounces of gravy and asparagus had an x next to it on the spreadsheet. No alternate vegetables were listed. Observation of lunch meal service on 05/21/19 starting at 12:18 P.M. revealed [NAME] #41 collecting food temperatures with [NAME] #24 assisting. Portions for the food to be served were as follows: one filet glazed fish; one #8 scoop mashed potatoes; one #4 scoop baby carrots; one #4 spoodle asparagus; one roll; sloppy joe meat (ground meat consistency) and macaroni and cheese bites. The asparagus pieces and baby carrots were at least two inches in length. On 05/21/19 at 12:43 P.M. Resident #19's meal was plated and revealed a fish filet, one scoop of mashed potatoes with gravy, a roll and asparagus pieces. At 12:53 P.M. Resident #31's meal was plated and revealed mashed potatoes with gravy, a fish filet and asparagus pieces. At 12:56 P.M. observation of Resident # 5's tray revealed ground sloppy joe meat not on a bun, baby carrots and mashed potatoes with gravy. Interview with [NAME] #41 on 05/21/19 at 12:26 P.M. revealed baby carrots were an alternate for the meal and verified no other meats had been made. [NAME] #41 stated alternate food items were chosen by the cooks on a daily basis. Interview on 05/21/19 at 1:01 P.M. with Dietary Manager (DM) #2 verified staff did not follow the spreadsheet for residents receiving a mechanical soft diet. DM #2 confirmed the facility practice was for cooks to choose what meal alternates to prepare for the day's meals (i.e. cook's choice). DM #2 defined mechanical soft as being able to smash the food item with a fork and was not sure when asked about a facility diet manual. Interview on 05/22/19 at 2:10 P.M. with Registered Dietitian (RD) #69, Corporate Director of Nursing (CDON) #70 and the DON revealed RD #69 came to the facility one a day a month and did not have any culinary responsibilities. RD #69 verified baby carrots were not appropriate for residents receiving a mechanical soft diet and upon review of the provided menu spreadsheet for 05/21/19, RD #69 stated the x indicated it meant the food item should not be served and thus the asparagus should have not been served to residents on a mechanical diet as well. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365343 If continuation sheet Page 27 of 34 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 365343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Willard 370 E Howard St Willard, OH 44890 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation, policy review, menu spreadsheet review and interview, the facility failed to ensure dietary staff provided appropriate mechanically altered food. This affected four residents (Resident #5, Resident #14, Resident #19 and Resident #31) of four residents identified by the facility as receiving mechanical soft diets. The facility census was 45 residents. Findings include: Review of the menu spreadsheet for Week 1, Day 3 corresponding to 05/21/19 revealed a lunch meal consisting of maple glazed fish, rosemary roasted potatoes, asparagus, fresh baked roll, chocolate satin pound cake, margarine and coffee or tea. Residents receiving a mechanical soft diet were to have a #6 scoop of ground fish with two ounces of gravy and asparagus had an x next to it on the spreadsheet. No alternate vegetables were listed. Observation of lunch meal service on 05/21/19 starting at 12:18 P.M. revealed [NAME] #41 collecting food temperatures with [NAME] #24 assisting. Portions for the food to be served were as follows: one filet glazed fish; one #8 scoop mashed potatoes; one #4 scoop baby carrots; one #4 spoodle asparagus; one roll; sloppy joe meat (ground meat consistency) and macaroni and cheese bites. The asparagus pieces and baby carrots were at least two inches in length and appeared to be a choking hazard. On 05/21/19 at 12:43 P.M. Resident #19 's meal was plated and revealed a fish filet, one scoop of mashed potatoes with gravy, a roll and asparagus pieces. At 12:53 P.M. Resident #31's meal was plated and revealed mashed potatoes with gravy, a fish filet and asparagus pieces. At 12:56 P.M. observation of Resident # 5's tray revealed ground sloppy joe meat not on a bun, baby carrots and mashed potatoes with gravy. Interview with [NAME] #41 on 05/21/19 at 12:26 P.M. revealed baby carrots were an alternate for the meal and verified no other meats had been made. [NAME] #41 stated alternate food items were chosen by the cooks on a daily basis. Interview on 05/21/19 at 1:01 P.M. with Dietary Manager (DM) #2 verified staff did not follow the spreadsheet for residents receiving a mechanical soft diet. DM #2 confirmed the facility practice was for cooks to choose what meal alternates to prepare for the day's meals (i.e. cook's choice). DM #2 defined mechanical soft as being able to smash the food item with a fork and was not sure when asked about a facility diet manual. Interview on 05/22/19 at 2:10 P.M. with Registered Dietitian (RD) #69, Corporate Director of Nursing (CDON) #70 and the DON revealed RD #69 came to the facility one a day a month and did not have any culinary responsibilities. RD #69 verified baby carrots were not appropriate for residents receiving a mechanical soft diet and upon review of the provided menu spreadsheet for 05/21/19, RD #69 stated the x indicated it meant the food item should not be served and thus the asparagus should have not been served to residents on a mechanical diet as well. Interview on 05/24/19 at 4:08 P.M. with Speech Language Pathologist (SLP) #71 revealed the dietary department had not consulted with her regarding modified diet consistencies. Review of a handout titled Consistency Modified Diets (no date) revealed mechanical soft diets were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365343 If continuation sheet Page 28 of 34 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 365343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Willard 370 E Howard St Willard, OH 44890 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 0805 Level of Harm - Minimal harm or potential for actual harm for residents with limited chewing ability and included ground, moist meats, poultry and fish without bones, canned fruits and vegetables, well cooked soft vegetables, finely chopped fresh fruits and vegetables as tolerated and soft breads and desserts. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365343 If continuation sheet Page 29 of 34 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 365343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Willard 370 E Howard St Willard, OH 44890 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 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. Based on observation and interview, the facility failed to ensure adequate supplies of snack were available for residents. This had the potential to affect all 45 residents residing in the facility. Findings include: Observation of the snack refrigerator on 05/20/19 at 9:00 A.M. revealed the refrigerator contained 14 fruits cups from the previous night, 05/19/19. Interview with Resident Council President #21 on 05/21/19 at 12;30 P.M. revealed the council had concerns staff did not pass snacks at night on a consistent basis or there was an adequate amount/variety of snacks to choose from. Resident Council President #21 stated staff started at one end of the hall and when staff came to his room he chooses from packs of crackers. Resident #21 stated he choice would be a sandwich or something different than cheese or peanut butter crackers. A Group Meeting was held on 05/21/19 at 1:45 P.M. Resident #7 Resident # 8, Resident #16 and Resident #38 attended the meeting and expressed concerns they did not get snacks consistently or had a choice of snacks. Each resident stated they would prefer something different that crackers. Each resident stated staff did not consistently offer snacks. Review of the items the Dietary department places of the HS Snack Cart included the following: 45 sweets (cookies, fig bars) 45 fruits (oranges, apples, grapes) 45 salty snacks (peanut butter crackers, chips, pretzels) (8 half) sandwiches of lunch meat (4 half) sandwiches of peanut butter and jelly) Drinks: 2 pitchers of juice 1 pitcher of milk Thicken drinks (labeled) Cups Sippy cups A notation included: Be sure to have Mechanical soft options on snack cart. Examples: pudding, applesauce, custards, purred fruit, bananas, cottage cheese, yogurt, diced soft cookies moistened with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365343 If continuation sheet Page 30 of 34 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 365343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Willard 370 E Howard St Willard, OH 44890 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 0809 milk, ice cream, and V8 juice; sandwiches with ground meat, chicken salad, and egg salad. Level of Harm - Minimal harm or potential for actual harm Interview with the Director of Nursing (DON) on 05/21/19 at 5:30 P.M. stated there had been complaints from Resident Council concerning staff not consistently passing snacks. The DON stated staff now must sign when they start passing snacks and when they end passing snacks. The DON stated she was unaware the dietary department was not making an adequate amount and a variety of snacks to choose from. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365343 If continuation sheet Page 31 of 34 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 365343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Willard 370 E Howard St Willard, OH 44890 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 safe and sanitary kitchen environment. This affected all 45 residents receiving meals from the kitchen. The facility census was 45 residents. Findings include: 1. Observation and tour of the kitchen on 05/20/19 from 8:58 A.M. to 9:30 A.M. with Dietary Manager (DM) #2 revealed in the freezer there was an ice-covered plastic bag containing hot dogs that appeared to be freezer-burnt and in the reach-in cooler there was a bag of shredded cheddar cheese not sealed. At 9:06 A.M. observation of the interior of the ice machine revealed a pink-brown substance on the plastic lip that was palpable to touch and removable when a finger was swiped across it. At 9:08 A.M., observation of the dish machine and three compartment sink area revealed no test strips available to test the sanitizer and no evidence of logs to suggest monitoring of the sanitizer's strength and efficiency. At 9:16 A.M. while on tour of nourishment areas, 14 undated cups of fruit were observed on the assisted living (AL) wing's refrigerator. DM #2 verified the above findings at the time of observation. DM #2 stated the maintenance department was responsible for cleaning the ice machine but she was not sure how often that was completed. DM #2 stated an employee had dropped the sanitizer test strips into the sink and replacement strips were not yet available and verified no logs or other monitoring was done in regard to the sanitizer. Review of the facility's undated policy on ice machine sanitation revealed the dietary department was to clean the storage bin quarterly. Review of the facility's undated labeling and dating policy revealed all opened and leftover items need to be labeled with the date of opening/date stored and a discard/use by date. 2. Observation of lunch trayline on 05/21/19 starting at 12:18 P.M. revealed [NAME] #41 responsible for assembling meal trays with [NAME] #24 assisting. Both staff had gloves on. At 12:34 P.M. [NAME] #41 picked up her walkie-talkie to announce that hall's food was ready, then touched the door to the hallway and then touched another food cart. [NAME] #41 never changed her gloves or washed her hands during meal service until 12:58 P.M. Interview with DM #2 on 05/21/19 at 1:01 P.M. verified [NAME] #41's gloves should have been changed between tasks. Review of the facility's handwashing policy dated 2009 revealed guidelines for glove use included changing gloves frequently as they became soiled or between each task performed. Gloves did not replace the need for frequent hand washing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365343 If continuation sheet Page 32 of 34 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 365343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Willard 370 E Howard St Willard, OH 44890 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 record review and interview, the facility failed to accurately document a transfer to the emergency room. This affect one (Resident #28) of one reviewed for hospitalizations. The census was 45. Findings include: Record review for Resident #28 revealed an admission date of 05/14/19 with diagnoses including anxiety, bipolar disorder and right shoulder pain. The quarterly Minimum Data (MDS) assessment dated [DATE] revealed Resident #28 was cognitively intact and had pain. Review of hospital Discharge summary dated [DATE] revealed resident came to emergency room for concerns of a possible urinary tact infection and the physician at the facility would not repeat the labs. Results for the urinalysis were negative indicating no infection. Discharge instructions recommended following up with primary care physician. Review of progress note dated 12/21/19 revealed resident returned from the emergency room and had urinalysis and laboratory blood work. The medical record contained no documentation or information on the initial transfer to the emergency room. Interview on 05/22/19 at 11:07 A.M. with Resident # 28 revealed she did not trust her physician and requested to the emergency room. The facility transported her to emergency room. Interview on 05/23/19 at 2:13 P.M. with the Director of Nursing verified the findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365343 If continuation sheet Page 33 of 34 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 365343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Willard 370 E Howard St Willard, OH 44890 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Observation of the lunch meal on 05/20/19 at 12:43 P.M. revealed the Administrator sanitized her hands with alcohol based hand rub prior to passing trays. The Administrator had long black hair extending from below her shoulder, resting on her chest. Her hair was not restrained. At 12:47 P.M. the Administrator obtained Resident #23's lunch tray. As the Administrator bent down to give Resident #23's lunch tray, her hair fell from the left side rested on the top cover of the entree. The Administrator flipped the hair back, removed the cover to the entree and served the resident his lunch. Residents Affected - Many Interview with the Administrator on 05/20/19 at 12:50 P.M. verified her hair was not contained and was not to touch any food item. Based on observation, interview and record review, the facility failed to ensure hair was appropriately contained during meal service and failed to implement a facility-wide Legionella plan. This had the potential to affect all 45 residents residing in the facility. Findings include: 1. Review of the facility's Legionella risk assessment dated [DATE] revealed recommendations including maintaining a documented Legionella management program and conducting an annual risk assessment. No further monitoring or testing in regard to Legionella was available for review. An interview with Maintenance Director (MD) #37 on 05/24/19 at 12:47 P.M. verified the facility's Legionella plan was not fully implemented. Review of the facility's Legionella testing policy, dated July 2018, revealed the maintenance director or designee was to perform a visual inspection of all water sources in the facility on a quarterly basis. Inspections were to be performed and documented as follows: flushing of little used outlets was to be done weekly; hot and cold water temperatures were to be done monthly; showerhead descaling and disinfection was to be completed quarterly; potable water tank was to be inspected every six months; water softener was to be cleaned and disinfected annually; Legionella risk assessment and water testing was to be done every two years. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365343 If continuation sheet Page 34 of 34

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Citations

36 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0569GeneralS&S Dpotential for harm
F569 - Notice of certain balances
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
0570GeneralS&S Epotential for harm
F570 - Assurance of financial security
Assure the security of all personal funds of residents deposited with the facility.
0574GeneralS&S Fpotential for harm
F574 - The resident has the right to receive notices orally (meaning spoken) and in
The resident has the right to receive notices in a format and a language he or she understands.
0577GeneralS&S Fpotential for harm
F577 - The resident has the right to-
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
0582GeneralS&S Dpotential for harm
F582 - The facility must—
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
0656GeneralS&S Dpotential for harm
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
0657GeneralS&S Dpotential for harm
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
0676GeneralS&S Dpotential for harm
F676 - Based on the comprehensive assessment of a resident and consistent with
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
0686GeneralS&S Dpotential for harm
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
0689GeneralS&S Dpotential for harm
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
0690SeriousS&S Gactual harm
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
0692GeneralS&S Dpotential for harm
F692 - Assisted nutrition and hydration
Provide enough food/fluids to maintain a resident's health.
0744GeneralS&S Dpotential for harm
F744 - A resident who displays or is diagnosed with dementia, receives the
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
0803GeneralS&S Epotential for harm
F803 - Menus and nutritional adequacy
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.
0805GeneralS&S Epotential for harm
F805 - Food and drink
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
0809GeneralS&S Fpotential for harm
F809 - Frequency of Meals
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
0812GeneralS&S Fpotential for harm
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
0842GeneralS&S Dpotential for harm
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
0880GeneralS&S Fpotential for harm
F880 - Infection Control
Provide and implement an infection prevention and control program.
0226GeneralS&S Epotential for harm
Have horizontal exits used in accordance with safety requirements.
0006GeneralS&S Fpotential for harm
Conduct risk assessment and an All-Hazards approach.
0013GeneralS&S Fpotential for harm
Develop Emergency Preparedness policies and procedures.
0029GeneralS&S Fpotential for harm
Develop a communication plan.
0036GeneralS&S Fpotential for harm
Establish emergency prep training and testing.
0161GeneralS&S Epotential for harm
Use approved construction type or materials.
0222GeneralS&S Epotential for harm
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
0345GeneralS&S Fpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
0372GeneralS&S Epotential for harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
0712GeneralS&S Fpotential for harm
F712 - Frequency of physician visits
Have simulated fire drills held at unexpected times.
0753GeneralS&S Dpotential for harm
Have restrictions on the use of highly flammable decorations.
0918GeneralS&S Fpotential for harm
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
0919GeneralS&S Epotential for harm
F919 - Resident Call System
Meet requirements for the use of electrical equipment.
0920GeneralS&S Epotential for harm
F920 - Dining and Resident Activities
Ensure proper usage of power strips and extension cords.
0550GeneralS&S Dpotential for harm
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
0584GeneralS&S Dpotential for harm
F584 - Safe Environment
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.

FAQ · About this visit

Common questions about this visit

What happened during the May 24, 2019 survey of EMBASSY OF WILLARD?

This was a inspection survey of EMBASSY OF WILLARD on May 24, 2019. The surveyor cited 36 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at EMBASSY OF WILLARD on May 24, 2019?

Yes, 36 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

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Data from CMS Care Compare public records. Dataset last refreshed June 15, 2026. If you believe any information is inaccurate, report it here.

Inspection·May 24, 2019