Health inspection·November 12, 2021

F 0656 Level of Harm - Minimal harm or potential for actual harm Review of the facility's policy titled Care Plan Policy And Procedure, revised December 2019, revealed the comprehensive care plan must be person centered, have measurable goals with appropriate interventions to assist with obtaining those goals and contain all necessary information to allow the resident to receive care while maintaining their highest practicable well-being and the comprehensive care plan must be updated quarterly and as necessary to ensure accuracy. Residents Affected - Few Based on medical record review, observation, staff interview, and review of the facility's policy, the facility failed to ensure comprehensive care plans were developed and the facility failed to implement fall interventions in the resident's care plan. This affected three (#2, #14 and #25) of 16 residents reviewed for care plans. The facility census was 37. Findings include: 1. Review of the medical record for Resident #2 revealed an admission date of 06/28/19 and a readmission date of 11/07/21. Diagnoses included infection pressure ulcer of sacral (bony area at the base of the spine) region, cellulitis (bacterial skin infection) of left lower limb, end stage renal disease, type II diabetes mellitus, hypotension, and morbid (severe) obesity due to excess calories. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/16/21, revealed Resident #2 was cognitively intact and had one stage IV pressure ulcer (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed). Review of a skin grid from 10/02/21 revealed a new wound was identified on 10/02/21. Resident #2 was referred to wound care. Review of the wound care notes from 10/14/21 through 11/03/21, revealed Resident #2 had a stage IV pressure injury of the sacrum. Resident #2 also had a history of stage IV pressure injury of the sacrum. Review of the plan of care, initiated 06/30/19, revealed there were no goals or interventions related to preventative skin care or the treatment of pressure ulcers for Resident #2. Interview on 11/09/21 at 8:31 A.M. with the Director of Nursing (DON) verified preventative skin care and pressure ulcer care should be care planned. The DON stated Resident #2 had a history of reoccurring pressure ulcers at an old surgical site. The DON verified Resident #2 should have preventative skin care in her plan of care, pressure ulcer care should have also been included in the plan of care, and Resident #2's plan of care did not include either. Review of the facility's policy titled Wound Care, revised November 2018, revealed wound care should be reviewed and/or revised in the resident's individualized care plan for skin treatment and prevention. Review of the faciliy's policy titled Skin Care, revised November 2018, revealed preventative care plans will be developed and implemented for each resident. 2. Review of the medical record for Resident #25 revealed an admission date of 08/11/21. Diagnoses included anxiety disorder, liver disorders in diseases classified elsewhere; alcohol abuse with intoxication, chronic obstructive pulmonary disease (COPD). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365343 If continuation sheet Page 2 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/12/2021 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 FORM CMS-2567 (02/99) Previous Versions Obsolete Review of the admission MDS assessment, dated 08/24/21, revealed Resident #25 was moderately cognitively impaired and received oxygen therapy. Review of the plan of care, initiated 08/14/21, revealed oxygen use and interventions were not identified. Interview on 11/09/21 at 8:31 A.M. with the Director of Nursing (DON) verified Resident #25's plan of care did not include goals or interventions related to oxygen use. The DON stated she noticed it was not care planned when she reviewed the resident's plan of care yesterday. The DON verified Resident #25 had been on oxygen as needed since his admission and it was not care planned. Event ID: Facility ID: 365343 If continuation sheet Page 3 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/12/2021 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 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, resident and staff interview, and review of the facility's policy, the facility failed to ensure residents received vision services. This affected one (#4) of one resident reviewed for vision services. The facility census was 37. Residents Affected - Few Findings include: Review of the medical record for Resident #4 revealed an admission date of 05/14/21 and a readmission date of 09/14/21. Diagnoses included type II diabetes mellitus with diabetic polyneuropathy. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/14/21, revealed Resident #4 was cognitively intact and did not wear corrective lenses. Interview on 11/07/21 at 9:49 A.M. with Resident #4 revealed he was unaware if vision services were available at the facility. Resident #4 stated he wore eyeglasses but had not had any since his admission because he had broken them and was not able to get out to see his eye doctor. Interview on 11/09/21 at 12:11 P.M. with Social Services Director (SSD) #246 verified Resident #4 had not been seen by the eye doctor since his admission to the facility. SSD #246 stated Resident #4 was out of the facility on 09/13/21 when the eye doctor was last onsite. SSD #246 verified Resident #4 was not identified to be seen by the eye doctor on 09/13/21 and would not have been seen if he was in the facility at the time. SSD #246 stated she was aware Resident #246 needed to be on the rotation for vision services but arrangements had not been made for the resident to be seen. Review of the facility's policy titled Ancillary Services, revised September 2019, revealed the facility will assist residents in obtaining routine and prompt vision care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365343 If continuation sheet Page 4 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/12/2021 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. Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure the resident's fall interventions were implemented to reduce the risk of injury. This affected one (#5) of one resident reviewed for falls. The facility census was 37. Findings include: Review of the medical record for Resident #5 revealed an admission date of 07/09/21. Diagnoses included type II diabetes mellitus with diabetic chronic kidney disease, cerebral infarction (stroke) without residual deficits, altered mental status, chronic kidney disease, stage III, vascular dementia without behavioral disturbance, and muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/14/21, revealed Resident #5 was severely cognitively impaired and required extensive two person assist with bed mobility, transfers, dressing, toilet use, and personal hygiene. In addition, Resident #5 had two or more falls since admission. Review of the plan of care, initiated 07/20/21, revealed Resident #5 was at risk for falls and potential injury. Interventions included a mat on the floor next to the bed. Review of the Fall Risk Assessment, dated 09/26/21, revealed Resident #5 was at moderate risk for falls. Observations on 11/07/21 from 10:44 A.M. through 12:15 P.M. revealed Resident #5 was in bed. A wheelchair was at the side of the bed, facing the bed. A fall mat was observed folded and leaning against the wall opposite the resident's bed, under a television mounted to the wall. Interview on 11/07/21 at 12:15 P.M. with State Tested Nurse Aide (STNA) #217 verified Resident #5 was in bed and the fall mat was not placed next to his bed as it should be. Interview on 11/09/21 at 10:14 A.M. with the Director of Nursing (DON) revealed Resident #5 believed he could walk, but he was unable to do so unassisted. The DON stated Resident #5 would attempt to get up on his own, resulting in falls, and the facility had implemented various interventions to decrease risk of falls and injury, including a fall mat next to his bed. Review of the facility's policy titled Fall Policy, revised October 2018, revealed it was the policy of the facility to implement appropriate interventions to attempt to reduce falls, accidents, and injuries related to falls. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365343 If continuation sheet Page 5 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/12/2021 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, observation, staff interview, and review of the facility's policy, the facility failed to ensure a physician order was obtained for oxygen administration and failed to date oxygen tubing per physician order. This affected one (#25) of one resident reviewed for oxygen administration. The facility identified eight residents receiving oxygen therapy. The facility census was 37. Residents Affected - Few Findings include: Review of the medical record for Resident #25 revealed an admission date of 08/11/21. Diagnoses included anxiety disorder and chronic obstructive pulmonary disease (COPD). Review of the admission Minimum Data Set (MDS) assessment, dated 08/24/21, revealed Resident #25 was moderately cognitively impaired and received oxygen therapy. Review of the physician's orders for Resident #25, dated 08/18/21, revealed an order to change and date oxygen tubing every Wednesday on night shift. There was no order for oxygen administration. Observation on 11/07/21 at 10:10 A.M. of Resident #25's oxygen tubing revealed the tubing was not labeled with the date it was changed. Interview on 11/08/21 at 9:29 A.M. with Assistant Director of Nursing (ADON) #207 revealed oxygen tubing was to be changed weekly and labeled with the date the tubing was changed. ADON #207 verified Resident #25's oxygen tubing was not dated per physician order. Interview on 11/08/21 at 2:53 P.M. with the Director of Nursing (DON) revealed oxygen administration required a physician's order. The DON verified there was no physician's order for Resident #25's oxygen administration and stated he had been on oxygen since admission to the facility. Review of the facility's policy titled Oxygen Administration, revised October 2010, revealed preparation for oxygen administration included verifying there was a physician's order. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365343 If continuation sheet Page 6 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/12/2021 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 Based on medical record review, staff interview, and review of the facility's policy, the facility failed to ensure a resident with dementia was adequately assessed and an individualized plan of care was developed to meet the resident's needs. This affected one (Resident #5) of three residents reviewed for dementia care. The facility census was 37. Residents Affected - Few Findings include: Review of the medical record for Resident #5 revealed an admission date of 07/09/21. Diagnoses included altered mental status and vascular dementia without behavioral disturbance. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/14/21, revealed Resident #5 was severely cognitively impaired and had a diagnosis of non-Alzheimer's dementia. Review of the plan of care initiated on 07/20/21 revealed no goals or interventions related to dementia care were identified for Resident #5. Interview on 11/09/21 at 10:14 A.M. with the Director of Nursing (DON) revealed Resident #5 had significant behavior concerns upon admission and was admitted to the facility after another facility refused to accept him back due to behavior. The DON stated Resident #14's behaviors had improved but he would become combative, resist care, and yell out. The DON verified Resident #5's plan of care did not address Resident #5's dementia care needs, including any interventions to assist the resident. The DON stated staff did provide redirection, supervision, snacks, and other interventions to address any behavioral concerns, but this was not addressed in the resident's plan of care. The DON verified there was no behavior tracking being completed for Resident #5 to determine the frequency of any behaviors, triggers to the behaviors, or the resident's response to any interventions implemented by the staff. Review of the facility's policy titled Behavioral Assessment, Intervention and Monitoring, revised March 2019, revealed current guidelines recommend the use of non-pharmacological interventions for behavioral or psychological symptoms of dementia. The interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress and potential safety risk to the resident, and develop a plan of care accordingly. Interventions will be individualized and part of an overall care environment that supports physical, functional and psychosocial needs, and strives to understand, prevent or relieve the resident's distress or loss of abilities. The care plan will include, at a minimum: a description of the behavioral symptoms, including: frequency, intensity, duration, outcomes, location, environment, and precipitating factors or situations. Targeted and individualized interventions for the behavioral and/or psychosocial symptoms, the rationale for the interventions and approaches, specific and measurable goals for targeted behaviors and how the staff will monitor for effectiveness of the interventions. Non-pharmacologic approaches will be utilized to the extent possible to avoid or reduce the use of antipsychotic medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365343 If continuation sheet Page 7 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/12/2021 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 Based on medical record review, observation, resident and staff interview, review of the Centers for Disease Control and Prevention's guidance, and review of the facility's policy, the facility failed to ensure newly admitted residents, who were unvaccinated for COVID-19, were placed on transmission-based precautions and staff wore appropriate personal protective equipment (PPE) to potentially limit the spread of COVID-19. This had the potential to affect 12 residents who were unvaccinated and residing in the facility. Residents Affected - Some Findings include: Review of the medical record for Resident #134 revealed an admission date of 11/01/21 and a readmission date of 11/05/21. Diagnoses included acute cystitis with hematuria and urinary tract infection (UTI). Review of the Medicare five-day Minimum Data Set (MDS) assessment, dated 11/02/21, revealed Resident #134 was cognitively intact. Review of the physician orders for November 2021 revealed no orders related to transmission-based precautions. Observation on 11/07/21 at 10:13 A.M. of Resident #134's room revealed a sign on the door stating Resident #134 must stay in the room for 14 days with Standard transmission based precautions. There was no personal protective equipment (PPE) cart observed by the resident's room. Interview at the time of the observation with Licensed Practical Nurse (LPN) #243 verified Resident #134 was a new admission to the facility. LPN #243 verified Resident #134 had to remain in her room to quarantine because she was a new admission and the only PPE required when entering the Resident's room was a surgical facemask and eye protection, and this PPE was required throughout the facility. LPN #243 verified there was no additional PPE was required, such as an N95 respirator, gown, or gloves. LPN #243 stated she was not sure if Resident #134 had been vaccinated for COVID-19. Observation on 11/07/21 at 11:56 A.M. revealed State Tested Nurse Aide (STNA) #232 exit Resident #134's room. STNA #232 was wearing goggles and surgical facemask. Interview at the time of the observation with STNA #232 revealed she had assisted Resident #134 with bed pan use. STNA #232 verified she wore a surgical facemask and goggles while assisting Resident #134 with care. In addition, STNA #232 stated she did wear gloves as part of standard precautions. STNA #232 stated she was not aware of any additional PPE needs when working with Resident #134, such as an N95 respirator and gown or the need to disinfect eye protection after providing care to the resident. Observation on 11/07/21 at 12:04 P.M. revealed Social Services Director (SSD) #246 enter Resident #134's room with a lunch tray. SSD #246 was wearing goggles and a surgical facemask. SSD #246 was observed at Resident #134's bedside, within six feet of the resident, and assisted with lunch set up. SSD #246 exited Resident #134's room and performed hand hygiene. SSD #246 did not disinfect her goggles upon exiting Resident #134's room. SSD #246 proceeded to deliver meal trays to Residents #25, #9, #133, and #22. Interview of SSD #246 at the time of the observation verified she wore a surgical facemask and goggles when she entered Resident #134's room and did not disinfect her goggles upon exiting the room. SSD #246 stated she was unaware if any additional PPE was needed when entering Resident #134's room and stated she guessed a gown and gloves would be needed if providing direct care. Interview on 11/07/21 at 1:51 P.M. with Resident #134 revealed she was not vaccinated for COVID-19. Resident #134 stated she had received information on the vaccine but was uncertain about getting (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365343 If continuation sheet Page 8 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/12/2021 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 it. Level of Harm - Minimal harm or potential for actual harm Interview on 11/08/21 at 9:57 A.M. with the Director of Nursing (DON) verified Resident #134 was a new admission to the facility, had not been vaccinated for COVID-19, and was not on droplet or contact precautions. The DON verified the only PPE staff had been required to wear when providing care to Resident #134 was a surgical facemask and eye protection, both of which were required throughout the facility. The DON stated all new admissions were tested for COVID-19 prior to admission and she had not considered new admissions could potentially be exposed after COVID-19 test specimens had been collected or that the viral load may not have been sufficient at the time of testing to result in an accurate test result. The DON stated she would follow up with the physician to obtain orders for the correct transmission-based precautions for Resident #134. Residents Affected - Some Review of the facility's policy titled Coronavirus (COVID-19) Prevention and Management, revised 06/18/21, revealed newly admitted or readmitted residents will be quarantined and placed on contact isolation and droplet isolation with a private room and bathroom as available and quarantined in their room except for medically necessary purposes for 14 days, unless they have been fully vaccinated and have no know direct exposure to a person diagnosed with COVID-19 in the past 14 days. The facility will ensure an adequate supply of personal protective equipment (PPE) is readily available in isolation carts. In addition, eye protection, N95, gown, and gloves will be donned prior to entry of a quarantine or isolation room. Review of the Centers for Disease Control and Prevention's guidance titled Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes, dated 09/10/21, revealed in general, all unvaccinated residents who are new admissions and readmissions should be placed in a 14-day quarantine, even if they have a negative test upon admission. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365343 If continuation sheet Page 9 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/12/2021 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, resident and staff interview, and review of the facility's policy, the facility failed to ensure resident rooms were maintained in good repair and resident room equipment was in operable condition. This affected two residents (#4 and #25) of two residents reviewed for physical environment. The facility census was 37. Findings include: 1. Observation on 11/07/21 at 9:35 A.M. of Resident #4's room revealed the corner of the wall near the sink and the bathroom door was damaged, exposing cracked and crumbling drywall and the baseboard was broken and pulled away from the wall. On the wall to the right of the bathroom door was an area, approximately two inches above the baseboard, approximately seven inches in length of exposed drywall. Observation of an area to the right of the window revealed seven smaller areas of exposed drywall. In addition, the left closet door handle was broken in half, exposing sharp metal edges. Interview with Resident #4 at the time of the observation revealed the walls had been damaged for some time. Resident #4 stated he believed the damage was the result of him hitting the wall with his wheelchair. Resident #4 denied any concerns with moving around his room and stated he was a bad driver. Resident #4 stated he had not had working heat in his room for approximately one week. Resident #4 denied being uncomfortable with the room temperature but stated it was getting colder outside and he was going to need heat. Observation at the time of the interview of the heating unit in Resident #4's room revealed the temperature was set at 88 degrees Fahrenheit (F) and was blowing cool air. After several minutes, the unit continued to blow cool air. Interview on 11/07/21 at 9:46 A.M. with State Tested Nurse Aide (STNA) #231 verified the damage to Resident #4's room walls, the broken baseboard, and the broken closet door. STNA #231 stated a maintenance request had been completed but she was unsure of the status. Interview on 11/07/21 at 11:43 A.M. with Maintenance Supervisor (MS) #249 verified the damage to Resident #4's room walls, baseboard, closet door handle, and the heat was not working in the Resident #14's room. MS #249 verified the unit located in Resident #4's room was the only source of heat for the room. Interview on 11/08/21 at 8:16 A.M. with MS #249 revealed he had changed the heating unit in Resident #4's room after the surveyor brought it to his attention that Resident #14 did not have heat. MS #249 stated he had been called the night of 11/06/21 at approximately 10:00 P.M. by nursing staff and was informed the unit was not working. He instructed nursing staff to reset the unit because that generally worked. MD #249 stated he did not hear back from anyone at the facility and assumed resetting the unit had resolved the issue and Resident #14 had heat. MD #249 verified he had not followed up to ensure Resident #4 had heat in his room. 2. Observation on 11/07/21 at 10:10 A.M. of Resident #25's room revealed the wall opposite the bathroom had an area approximately six inches wide by 12 inches long of cracked, crumbling, and exposed drywall. Interview on 11/07/21 at 11:47 A.M. with Maintenance Supervisor (MS) #249 verified the damage to the wall. MS #249 stated Resident #25 was having a behavior and kept running his wheelchair into the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365343 If continuation sheet Page 10 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/12/2021 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete wall, causing the damage. MS #249 stated the wall had been damaged approximately one week ago, he was made aware of the damage, but had not gotten to it yet because there were more important things to take care of at the facility. Review of the facility's policy titled Maintenance Service, revised December 2009, revealed the maintenance department was responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. Event ID: Facility ID: 365343 If continuation sheet Page 11 of 11