Inspection·October 19, 2022

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Agency STNA #100's witness statement dated 10/01/22 revealed on that day she turned off the air conditioner and Resident #60 stated she wanted it back on. Agency STNA #100 told her it was freezing in the room but she would turn it back on after she got Resident #60 up. Agency STNA #100 reported she put the hoyer pad on the bed and was slightly tucking it under her leg when Resident #60 told her to wait for her to turn. Agency STNA #100 revealed she was just putting it on the bed, Resident #60 told her not to yell at her. Agency STNA #100 told Resident #60 not to yell at her, because she had been doing this a while and was just doing her job. Interview on 10/13/22 at 11:19 A.M. with the Administrator revealed she felt the situation was not abusive but it was unacceptable. The Administrator confirmed the residents have the right to choose the temperature in their rooms. Review of the policy Resident rights Guidelines for All Nursing Procedures dated October 2010, revealed residents had the freedom of choice and dignity and respect. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365425 If continuation sheet Page 2 of 39 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 365425 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Newark 75 McMillen Drive Newark, OH 43055 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 0568 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. Based on financial record review and staff interview, the facility failed to maintain resident financial records according to established standards. This affected 64 (Residents #19, #31, #86, #8, #81, #47, #1, #58, #21, #7, #53, #45, #10, #18, #39, #85, #36, #67, #74, #49, #2, #6, #69, #51, #34, #44, #80, #60, #5, #11, #77, #50, #88, #66, #55, #79, #75, #89, #90, #76, #32, #72, #40, #17, #38, #64, #28, #91, #71, #23, #70, #29, #9, #46, #78, #57, #20, #41, #92, #25, #65, #42, #13, and #43) of 64 residents who have personal funds accounts with the facility. The census was 85. Findings Include: Review of Residents #34, #80, #23, and #41 financial records revealed they did not have quarterly statements available for review. Two more residents were requested, and they were not available for review as well. Interview with Administrator on 10/12/22 at 2:27 P.M. confirmed they do not have resident fund quarterly statements for any of the residents. She confirmed they have a new business office manager, who is trying to fix things, but they currently do not have any quarterly statements of current residents to review. The Administrator verified the facility managed resident funds for Residents #19, #31, #86, #8, #81, #47, #1, #58, #21, #7, #53, #45, #10, #18, #39, #85, #36, #67, #74, #49, #2, #6, #69, #51, #34, #44, #80, #60, #5, #11, #77, #50, #88, #66, #55, #79, #75, #89, #90, #76, #32, #72, #40, #17, #38, #64, #28, #91, #71, #23, #70, #29, #9, #46, #78, #57, #20, #41, #92, #25, #65, #42, #13, and #43. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365425 If continuation sheet Page 3 of 39 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 365425 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Newark 75 McMillen Drive Newark, OH 43055 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 financial record review and staff interview, the facility failed to provide evidence that spend down notifications were given as required. This affected seven (Residents #45, #34, #80, #38, #64, #23, and #41) of 64 residents who have personal funds accounts with the facility. The census was 85. Residents Affected - Few Findings Include: Review of the following residents personal funds accounts revealed they had a total amount of money within $200 of the allowed amount ($2,000), and there was no evidence the facility had provided the resident with a spend down notification: Resident #45 had a current total amount of $2,121.92 in her personal funds account. Resident #34 had a current total amount of $3,210.99 in her personal funds account. Resident #80 had a current total amount of $9,187.03 in her personal funds account. Resident #38 had a current total amount of $2,509.55 in her personal funds account. Resident #64 had a current total amount of $2,146.11 in her personal funds account. Resident #23 had a current total amount of $6,345.58 in her personal funds account. Resident #41 had a current total amount of $7,419.17 in her personal funds account. Interview with Administrator on 10/12/22 at 2:27 P.M. confirmed they have no evidence that any of the above residents received a spend down notice as their accounts reached the limit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365425 If continuation sheet Page 4 of 39 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 365425 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Newark 75 McMillen Drive Newark, OH 43055 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and refusal of care policy review, the facility failed to ensure the physician was notified of a resident's refusal of medication. This affected one (Resident #85) of the one resident reviewed for physician notification. The facility census was 85. Findings include: Review of the medical record for Resident #85 revealed an initial admission date of 06/23/16 with a re-entry date of 08/25/20 and a discharge date of 08/17/22. Diagnoses included diabetes, heart disease, heart failure, and hypertension. Review of Resident #85's annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 01 indicating a severely impaired cognition for daily decision making abilities with disorganized thinking. Resident #85 was noted to display physical and verbal behaviors and rejection of care. Resident #85 required extensive assistance from two staff members for bed mobility and transfers and extensive assistance from one staff member for dressing, toilet use, and personal hygiene. No bilateral upper or lower extremity impairment noted and required the assistance of a walker and/or wheelchair for mobility. Review of the plan of care dated 01/15/21 and revised on 08/21/22 revealed Resident #85 has an impaired metabolic status related to diabetes, and hyperlipidemia. Interventions include to administer medications as ordered, diet as ordered, and monitor labs and testing. Review of the plan of care dated 01/15/21 and revised 08/21/22 revealed Resident #85 displayed behaviors related to refusing care. Interventions include to administer medication as ordered, attempt to redirect, encourage to participate in care, monitor and document episodes. Review of Resident #85's physician orders for August 2022 revealed the following: -Aspirin 81 milligram (mg) tablet, give one tablet daily for anticoagulant. -Atorvastatin Calcium 80 mg tablet, give one tablet at bedtime for hyperlipidemia. -Cholecalciferol 25 micrograms (mcg) tablet, give two tablets daily for deficiency. -Cymbalta 60 mg capsule, give one capsule in the morning for major depressive disorder. -Exelon patch 9.5 mg per 24 hours, apply one patch transdermal in the morning for psychotherapeutic and neurological agents. -Lexapro 10 mg tablet, give one tablet daily for depression. -Lisinopril 5 mg tablet, give one tablet daily for hypertension. -Norvasc 5 mg tablet, give one tablet daily for hypertension. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365425 If continuation sheet Page 5 of 39 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 365425 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Newark 75 McMillen Drive Newark, OH 43055 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0580 Level of Harm - Minimal harm or potential for actual harm -Novolin 70/30 suspension, 100 unit/milliliter (ml), inject 10 units subcutaneously daily at 4:00 P.M. for diabetes, holf dor blood glucose reading below 60. -Novolin 70/30 suspension, 100 units/ml, inject 20 units subcutaneously daily at 8:00 A.M. for diabetes. Hold for blood glucose below 60. Residents Affected - Few -Plavix 75 mg tablet, give one tablet daily for anti-coagulation. -Polyethylene Glycol Powder, 17 grams daily in the morning for constipation. -Terazosin 1 mg capsule, give one capsule at bedtime for hypertension. -Tresiba FlexTouch solution pen 100 units/ml, inject 50 units subcutaneously daily upon rising for diabetes. -Tylenol 8 hour arthritis pain 650 mg tablet, give one tablet at bedtime for pain. -Vitamins/Minerals tablet, give one tablet at bedtime for supplement. -Cimetidine 400 mg tablet, give two tablets daily for ulcers. -Divalproex Sodium 500 mg tablet, give one tablet two times a day for anti-psychotic. -Lyrica 150 mg tablet, give one capsule two times a day for pain. -Metoprolol Tartrate 25 mg tablet, give one tablet two times a day for hypertension. Review of progress notes for Resident #85 from 07/03/22 through 08/16/22 revealed Resident #85 had refused all prescribed medication a total of 15 days. Review revealed none of these refused medications were documented to have been reported to the physician. Interview on 10/17/22 at 2:00 P.M. with Registered Nurse (RN) #93 confirmed Resident #85's medical record lacked documentation that indicated the physician had been notified of medications being refused. Review of facility policy titled Requesting, Refusing and/or Discontinuing Care or Treatment, revised 05/2017 revealed, The healthcare practitioner must be notified of refusal of treatment, in a time frame determined by the resident's condition and potential serious consequences of the request. For example, a resident's refusal to take a diuretic while experiencing acute congestive heart failure should be reported immediately, while a refusal to take a blood pressure medications while the blood pressure is well controlled can be reported within 24 hours. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365425 If continuation sheet Page 6 of 39 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 365425 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Newark 75 McMillen Drive Newark, OH 43055 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of liability notices, review of quarterly statements, resident interview, and staff interview, the facility failed to ensure residents received the appropriate liability notices when their Medicare (MCR) Part A services ended and ensure a Medicaid (MCD) eligible resident received appropriate notification of charges. This affected three (Resident #32, #37, and #65) of three residents reviewed for liability notices and one (Resident #60) of one residents reviewed for resident billing and charges. Residents Affected - Some Findings include: 1. A review of Resident #32's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included a stroke with hemiplegia (paralysis) and hemiparesis (weakness) affecting the left non-dominant side, aphasia, hypertension, atrial fibrillation, and peripheral vascular disease. A review of Resident #32's census list revealed she had a payer change on 05/17/22 and again on 05/28/22. The census list did not specify what the change in payer status was. A review of a Centers for MCR and MCD Services (CMS) form 20052 (SNF Beneficiary Protection Notification Review) revealed Resident #32 had a start date of MCR Part A skilled service on 05/17/22. The last covered day of MCR Part A service was on 05/27/22. The form indicated the facility/ provider initiated the discharge from MCR Part A services when benefit days had not been exhausted. The resident remained in the facility after her MCR Part A services ended. The facility indicated the resident was not provided a CMS form 10123 or a CMS form 10055 as required. The reason the forms were not provided by the facility was due to staffing shortages and turnover. 2. A review of Resident #37's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included quadriplegia, status post gastrostomy tube, and neuromuscular dysfunction of the bladder. A review of Resident #37's census list revealed the resident was admitted on [DATE]. He was indicated to have had a payer change on 07/16/22. A review of a Centers for MCR and MCD Services (CMS) form 20052 (SNF Beneficiary Protection Notification Review) revealed Resident #37's MCR Part A skilled services start date was 05/27/22. The last covered day of MCR Part A services was on 07/15/22. The facility initiated the discharge from MCR Part A services when benefit days were not exhausted. The resident remained in the facility after his MCR Part A services ended. The facility indicated the resident was not provided CMS form 10123 or CMS form 10055 as required and the reason for not being provided those notices were due to staffing shortages and turnover. 3. A review of Resident #65's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included dementia, hypertension, adult onset diabetes mellitus and Covid-19 (09/19/22). A review of Resident #65's census list revealed he had a payer change on 09/19/22. He had a second payer change on 10/01/22. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365425 If continuation sheet Page 7 of 39 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 365425 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Newark 75 McMillen Drive Newark, OH 43055 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of a Centers for MCR and MCD Services (CMS) form 20052 (SNF Beneficiary Protection Notification Review) revealed Resident #65 had a MCR Part A skilled service episode with a start date of 09/19/22. The last covered day for MCR Part A service was on 09/30/22. The facility/ provider initiated the discharge from MCR Part A services when benefit days were not exhausted. The resident was indicated to have received CMS form 10123 but was not given a CMS form 10055 as required when remaining in the facility after his MCR Part A services ended. The reason the notice was not provided was due to staffing shortages and turnover. On 10/13/22 at 3:07 P.M., an interview with the facility's Administrator revealed she had been the facility's Administrator for about a month now. During that time, the facility's social worker had been off on medical leave. She reported she had little contact with the social worker before the social worker went on medical leave. She had noticed concerns with things not being completed by the social worker as they should have been to include liability notices. They brought in a social worker from a sister facility and completed audits to identify what was not being done. They identified liability notices were not being provided as required and were in the process of addressing the issue through their Quality Assurance process but it was a work in progress. They were still in the process of developing a plan to correct that issue. The facility was asked to provide a policy on Liability Notices for MCR Part A services. No policy was provided. 4. Record review revealed Resident #60 was admitted to the facility on [DATE]. Her diagnoses were acute pancreatitis, osteomyelitis, chronic obstructive pulmonary disease, type II diabetes, chronic respiratory failure, obstructive sleep apnea, peripheral vascular disease, major depressive disorder, heart failure, rheumatoid arthritis, anemia, hyperlipidemia, schizophrenia, anxiety disorder, chronic pain syndrome, and chronic kidney disease (stage III). Review of her Minimum Data Set (MDS) assessment, dated 10/14/22, revealed she was cognitively intact. Review of Resident #60's financial/billing records revealed the following charges and reversals on billing statements: December 2021 statement had the following charges: $187.35 (dated 10/09/21 - 10/13/21), $283.13 (10/26/21 - 10/28/21), and $545.42 (11/02/21 - 11/11/21). Then, January 2022 statement had a reversal of charges/credits for these three charges. January 2022 statement had the following charges: $1,222 (dated 01/01/22 - 01/31/22), and $1,222 (12/25/21 - 12/31/21). In the same statement, there was a reversal of charges/credits for these two charges. February 2022 statement had a charge of $1,222 (dated 01/19/22 - 01/31/22), and $1,222 (dated 02/01/22 - 02/28/22). Then, in March 2022 statement, there was a reversal of those two charges/credits. March 2022 statement had a charge of $1,222 (dated 01/19/22 - 01/29/22), $997.18 (dated 02/07/22 02/28/22), and $1,222 (dated 03/01/22 - 03/31/22). Then, in April 2022 statement, there was a reversal of the $997.18 charge/credit (dated 02/07/22 - 02/28/22) and the $1,222 charge/credit (dated 03/01/22 03/31/22). April 2022 statement had a charge of $1,222 (dated 04/01/22 - 04/30/22). Then, in May 2022 statement, there was a reversal of the $1,222 charge/credit. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365425 If continuation sheet Page 8 of 39 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 365425 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Newark 75 McMillen Drive Newark, OH 43055 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 Level of Harm - Minimal harm or potential for actual harm May 2022 statement had a charge of $1,222 (dated 05/01/22 - 05/31/22). Then, in June 2022 statement, there was a reversal of the $1,222 charge/credit. June 2022 statement had charges of $751.52 (dated 05/20/22 - 05/31/22), and $1,222 (dated 06/01/22 0 06/30/22). Then, in July 2022 statement, both charges were reversed/credited. Residents Affected - Some Interview with Resident #60 on 10/11/22 at approximately 2:00 P.M. confirmed that she was confused about her charges to her billing statements. She confirmed she was on Medicaid and was receiving social security payments as well. She was not sure why she had some of the charges on her account; she felt that she was charged twice in multiple months. She confirmed the facility tried to explain it to her, but it did not make sense. She confirmed she never received anything in writing about the charges to her account; they verbally tried to explain the charges to her. Interview with Regional [NAME] President #200 on 10/13/22 at 2:07 P.M. and 3:50 P.M. confirmed it could be confusing to someone just looking at the statements, and what they are actually being charged. She stated there were multiple entries on Resident #60's billing statements that were not correct, so they made revisions to the statements and put them in accurately. But again, she confirmed that it could be deemed confusing to a resident to understand the charges with the mistakes. Interview with Registered Nurse (RN) #93 on 10/17/22 at 1:15 P.M. confirmed they do not have any evidence to support Resident #60 received anything in writing about the changes in her billing statements, clarification when she had questions about the billing statements, or evidence to support the charges were clarified with her. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365425 If continuation sheet Page 9 of 39 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 365425 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Newark 75 McMillen Drive Newark, OH 43055 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to complete Pre-admission Screening and Resident Review (PASARR) timely for Resident #12 and accurately for Resident #28. This affected two residents (#12 and #28) of four reviewed for PASARR's. The facility census was 85. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #12 revealed an initial admission on [DATE], her diagnoses included Parkinson's disease, chronic kidney disease stage three, bipolar disorder, colostomy status, and mild intellectual disabilities. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #12 had impaired cognition. Review of the hospital exemption from preadmission screening notification dated 03/21/22 revealed Resident #12 had a mood disorder and a panic or other severe anxiety disorder. The document indicated the nursing facility was responsible for initiating a resident review prior to the 30th day following admission from the hospital. Review of the medical record on 10/11/22 revealed no evidence a PASARR was completed. Review of the PASARR dated 10/12/22 revealed it was completed and results were obtained indicating a referral was made for a level two evaluation. Interview on 10/17/22 at 1:58 P.M. with Registered Nurse (RN) #93 confirmed Resident #12's PASARR was not completed in a timely manner. 2. Review of the medical record for Resident #28 revealed an admission date of 08/04/22 with diagnoses including chronic obstructive pulmonary disease, encephalopathy, dementia with behavioral disturbance, and major depressive disorder. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #28 had impaired cognition. Review of Resident #28's physician's orders for October 2022 revealed an order for Seroquel Tablet 25 milligrams (mg) for mood disorder, Depakote Sprinkles Capsule Delayed Release 125 mg for mood disorder, and Buspirone 10 mg for anxiety. Review of the PASARR dated 08/04/22 revealed Resident #28 was not indicated as having any mental disorders. Interview on 10/13/22 at 2:45 P.M. with RN #93 confirmed Resident #28 had the diagnoses she was receiving medications for; she additionally confirmed the PASARR did not reflect these diagnoses. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365425 If continuation sheet Page 10 of 39 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 365425 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Newark 75 McMillen Drive Newark, OH 43055 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 record review, observation, and staff interview, the facility failed to ensure residents had active care plans in place in the areas of contractures and oxygen use. This affected three (Resident #9, #54 and #73) of 27 residents reviewed for care plans. Findings include: 1. A review of Resident #9's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included chronic obstructive pulmonary disease (COPD), sleep apnea, and vascular dementia. A review of Resident #9's active physician's orders revealed the resident had an order in place to receive oxygen at 2 liters per minute (LPM) via nasal cannula every shift. The order was not added to the physician's orders until 10/11/22. A review of Resident #9's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues. He was able to make himself understood and was able to understand others. His cognition was moderately impaired. He was not known to display any behaviors nor was he known to reject care. He was independent and did not require any set up help for most of his activities of daily living. His diagnosis coded as being active problems included COPD and oxygen therapy was indicated to have been provided while a resident in the facility. A review of Resident #9's active care plans revealed he did not have a care plan in place to address his diagnosis of COPD or the use of oxygen on a continuous basis every shift. Findings were verified by Licensed Practical Nurse (LPN) #36. On 10/12/22 at 10:52 A.M., observations of Resident #9 noted him to have the use of oxygen while in his room. The oxygen was provided via a concentrator and it was set at 5 LPM via nasal cannula. There was a humidified oxygen bottle attached to the concentrator that the oxygen tubing was connected to but the humidified oxygen bottle was empty. On 10/12/22 at 11:14 A.M., an interview with State Tested Nursing Assistant (STNA) #70 revealed she had worked at the facility for two and a half months now. She worked all units but felt she was familiar with Resident #9 and his care. She was not aware of the resident having the use of oxygen. She reported he was pretty independent with his care but they still checked on him every couple of hours. She stated the resident's use of oxygen would be communicated to them through the nurse but would also be on the resident's kardex that identified a resident's specific care needs. On 10/12/22 at 11:16 A.M., an interview with LPN #36 revealed she had worked at the facility for a year now and was assigned on the unit where Resident #9 resided. Resident #9 had been on that unit for two months now. She described him as being independent but would use his call light or he would come and let them know when he needed something. She confirmed the resident had the use of oxygen and would wear it when he wanted to. She stated he wore it about 99% of the time when he was in his room. He did not like to wear it when he came out of the room as he would refuse to allow them to put an oxygen tank on the back of his wheelchair. She reported he was to be on oxygen at 2 LPM for his COPD and verified that by checking his physician's orders. She also confirmed the physician's orders (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365425 If continuation sheet Page 11 of 39 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 365425 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Newark 75 McMillen Drive Newark, OH 43055 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 did not specify his oxygen was to be humidified. She stated typically, if oxygen was at 2 LPM, it did not need to be humidified. She denied that she had known the resident to adjust his own oxygen flow rate. She also denied she checked the resident's concentrator every shift to make sure it was set at the correct flow rate ordered by the physician. She was asked to go to the resident's room and check his oxygen. She verified the oxygen was set at 5 LPM and his humidified oxygen bottle was empty. She acknowledged a person with COPD should not have a flow rate set at 5 LPM (as was set for the resident) as it could cause them to lose the drive to breathe. She stated he normally told them when his humidified oxygen bottle was empty. She acknowledged the oxygen flow rate had been on 5 LPM and the humidified oxygen bottle had been empty for the past two days, both days in which she worked. She denied she checked the flow rate or ensured the humidification bottle was not empty when she was in his room the past couple of days. She stated, when she was in the room to give medications, she just ensured the concentrator was running and he had his nasal cannula in place. She confirmed the resident's active care plans did not include a care plan to address the resident's diagnosis of COPD or his use of oxygen. She also verified there was no information on the nursing assistant's kardex that informed the aides the resident had the use of oxygen. 2 (a.) A review of Resident #54's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included a stroke with hemiplegia/ hemiparesis of the left non-dominant side, aphasia (no speech), and muscle weakness. A review of Resident #54's occupational therapy (OT) notes revealed an OT Evaluation and Plan of Treatment for a between 05/21/19 and 06/19/22 revealed the resident was known to have a contracture to the left hand. The OT Discharge Summary for a date of service between 05/21/19 and 06/10/19 revealed therapy was unable to trial at that time as the resident was still resistive to any touch to the left upper extremity (LUE). On one occasion, the resident was observed with a palm guard in her left hand that had been placed by nursing. A review of Resident #54's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any speech. She was rarely/ never understood and rarely/ never was able to understand others. Her cognitive skills for daily decision making was severely impaired. The resident was known to have physical behaviors directed at others and other behaviors not directed at others but was not indicated to reject care. The resident required an extensive assist of two for dressing and had a functional limitation in range of motion on one side of her upper extremity. The resident was not indicated to have been provided any therapy or restorative nursing programs for range of motion or splint/ brace assistance. A review of Resident #54's active care plans revealed she did not have a care plan in place to address any contractures or limitations in her functional range of motion. None of her care plans included an intervention for the use of an orthotic device as part of contracture management/ prevention for her flaccid LUE. On 10/11/22 at 2:12 P.M., an observation or Resident #54 noted her to have a flaccid left upper extremity. Her left hand was noted to be in a closed fist position with her thumb between the index and middle finger. She was not noted to have any orthotic devises in place for contracture management or prevention. There were no hand rolls or rolled washcloths in place with any observations made through 10/17/22. The resident had her left arm drawn up across her chest or would have it lying down across her upper thigh with her left hand always in a clenched fist position. The thumb was always between the index finger and her middle finger when observations were made. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365425 If continuation sheet Page 12 of 39 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 365425 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Newark 75 McMillen Drive Newark, OH 43055 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 On 10/17/22 at 11:29 A.M., an interview with LPN #36 revealed she thought Resident #54's left hand was contracted but she was not for sure. She stated the resident may be able to open her hand with passive ROM but you also may get bit trying. The resident's left thumb was noted to cause her discomfort. She thought there might have been a sign posted on the wall that directed on the use of a brace. An observation of the resident's room, at the time of the interview, revealed there was a sign posted on the wall by the head of the bed that instructed staff to Please put palm guard on the resident's left hand when she was out of bed. They were instructed to take it off while the resident was in bed. The note advised the staff that the left thumb did not move too well and they were not to force movement. LPN #36 verified Resident #54 was not wearing a palm guard and searched her room for evidence she had one. She was not able to find the palm guard in the resident's room. On 10/17/22 at 2:00 P.M., an interview with RN #93 revealed they did not have an order for the use of any palm guards or any other orthotics for the resident. She acknowledged the resident's active care plans did not include a care plan to address the resident's known contracture to the left hand. She was not sure what happened to the use of a palm guard to the resident's left hand as indicated on the sign posted on the wall. She was not able to find any evidence of the resident being non-compliant with its use or any other documentation to support a reason it was no longer being used. 2 (b.) A review of Resident #54's active physician's orders revealed the resident had an order in place to receive Colace (stool softener) 100 milligrams (mg) by mouth twice a day for constipation. She also had an order to receive Miralax (bulk forming laxative) 17 Grams (Gm) by mouth daily for constipation. Both medications had been ordered since 07/10/19. A review of Resident #54's active care plans revealed the resident did not have a care plan in place to address her diagnosis of constipation despite being on scheduled medications to manage her constipation. Findings were verified by RN #93. On 10/17/22 at 2:00 P.M., an interview with RN #93 confirmed Resident #54 did not have a care plan in place for her diagnosis of constipation. She acknowledged the resident was receiving both Colace and Miralax for constipation on a scheduled basis and should have had a care plan. 3. Review of the medical record revealed Resident #73 admitted on [DATE] with diagnoses including traumatic subarachnoid hemorrhage with loss of consciousness, acute respiratory failure with hypoxia, encounter for attention to tracheostomy, encounter for attention to gastrostomy, metabolic encephalopathy, and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #73 was rarely or never understood. The resident had a limitation in range of motion (ROM) of both sides of her upper and lower extremities. Review of the physician's order dated 10/07/22 revealed an order to apply hand and elbow splints on both arms and hands for eight hours daily and then remove. Review of the occupational therapy Discharge summary dated [DATE], revealed the therapist recommended Resident #73's bilateral hand rolls be used as tolerated. Additionally, a restorative nursing program was recommended bilateral upper extremity range of motion with slow gentle ROM provided to decrease spasticity. Review of the plan of care revealed it did not address Resident #73's contractures or interventions (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365425 If continuation sheet Page 13 of 39 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 365425 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Newark 75 McMillen Drive Newark, OH 43055 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 for the contractures. Level of Harm - Minimal harm or potential for actual harm Review of the physician's order dated 10/07/22 revealed an order to apply hand and elbow splints on both arms and hands for eight hours daily and then remove. Residents Affected - Few Review of the occupational therapy Discharge summary dated [DATE] revealed the therapist recommended Resident #73's bilateral hand rolls be used as tolerated. Additionally, a restorative nursing program was recommended bilateral upper extremity range of motion with slow gentle ROM provided to decrease spasticity. Interview on 10/17/22 at 1:58 P.M. with Registered Nurse #93 confirmed Resident #73's plan of care should have addressed his contractures. Review of the policy Restorative Nursing Services revised August 2018, revealed residents may be started on a restorative nursing program upon admission, during their stay, or when discharged from therapy. Restorative goals and objectives should be individualized, resident-centered, and outlined in the resident's plan of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365425 If continuation sheet Page 14 of 39 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 365425 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Newark 75 McMillen Drive Newark, OH 43055 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, and staff interview, the facility failed to ensure care planning conferences were held for residents and residents and/ or their families were invited to attend. This affected two (Resident #27 and #39) of two residents reviewed for care planning conferences. Findings include: 1. A review of Resident #27's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included chronic renal failure, heart failure, adult onset diabetes mellitus and an altered mental status. A review of Resident #27's Minimum Data Set (MDS) assessments that had been completed revealed the resident had an admission MDS completed on 02/13/22. Quarterly MDS assessments were completed on 05/19/22 and again on 08/15/22. A review of Resident #27's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues and was cognitively intact. He was not known to display any behaviors nor was he known to reject care. He was independent and only needed supervision with his activities of daily living. A review of Resident #27's active care plans revealed he had a care plan in place to address his discharge planning. The care plan indicated he was a short term stay with plans to be discharged back into the community. Resident #27's medical record was absent for any documented evidence of a care planning conference having been held on the resident's behalf since his admission to the facility on [DATE]. There was no evidence an admission care planning conference being held or quarterly care planning conferences being held to include the resident and/ or his family in his plan of care development. On 10/11/22 at 2:37 P.M., an interview with Resident #27 revealed he had not been a part of any care planning conferences that had been held on his behalf since he had been admitted into the facility. He denied he had been invited to attend any such conferences and was not familiar that they were supposed to be held. On 10/13/22 at 3:07 P.M., an interview with the facility's Administrator revealed they were not able to find documentation of any care planning conferences being held for Resident #27 since his admission on [DATE]. She stated she started a month ago as the facility's administrator and had started noticing some things were not being done as they should have been, which included care planning conferences. Their social worker, who was responsible for care conferences, had been off the past month on medical leave. They had another social worker from a sister facility come in and do audits. It was determined through those audits that care planning conferences were not being held as required. They were still in the process of implementing their QA process to develop a plan to correct the issue, but it remained a work in progress and they were still working their plan. The facility was asked to provide a policy on care planning conferences. The facility's administrator denied they had one. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365425 If continuation sheet Page 15 of 39 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 365425 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Newark 75 McMillen Drive Newark, OH 43055 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 2. A review of Resident #39's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included unspecified dementia, major depressive disorder, adult onset diabetes mellitus, hypertension, and need for assistance with personal care. A review of Resident #39's MDS assessments revealed the resident has had an annual MDS assessment completed on 01/12/22. Quarterly MDS assessments were completed on 04/14/22, and 07/29/22. A quarterly MDS assessment dated [DATE] was still in progress. A review of Resident #39's quarterly MDS dated [DATE] revealed the resident did not have any communication issues and her cognition was moderately impaired. No behaviors or rejection of care was noted. The resident was the only one who was indicated to have participated in the assessment and did not have plans to return to the community. A review of Resident #39's care plans revealed it was her plan to remain in the facility long term. Resident #39's medical record was absent for any documented evidence of quarterly care planning conferences being held when quarterly MDS assessments were completed in April and July 2022. The last documented care planning conference held for the resident was on 11/24/21. Findings were verified by the facility's Administrator. On 10/11/22 at 1:04 P.M., an interview with Resident #39 revealed she had not been invited to attend any care planning conferences that she could recall. She was not familiar with what a care planning conference should entail and not heard the facility's department heads met to review her orders, treatments and plan of care. On 10/13/22 at 3:07 P.M., an interview with the facility's Administrator revealed they were not able to find documentation of any care planning conferences being held for Resident #39 since the one that was held on 11/24/21. She started a month ago as the facility's administrator and had noticed some things were not being done as they should be to include care planning conferences. Their social worker, who was responsible for care conferences, had been off the past month on medical leave. She had another social worker from a sister facility come in and do audits to see what all was not being done. One of the things was holding care planning conferences as required. They were still in the process of addressing the concern through their QA process. They have not finalized their corrective action plan so it was still a work in progress. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365425 If continuation sheet Page 16 of 39 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 365425 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Newark 75 McMillen Drive Newark, OH 43055 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 record review, resident interview, staff interview, and policy review, the facility failed to ensure a resident was provided assistance with showers/ bathing as desired. This affected two (Residents #9, and #20) of four residents reviewed for activities of daily living (ADL's). Residents Affected - Few Findings include: 1. A review of Resident #9's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included vascular dementia, major depressive disorder, chronic obstructive pulmonary disease, muscle weakness, adult failure to thrive, unsteadiness on feet, and lack of coordination. A review of Resident #9's admission assessment dated [DATE] revealed it was the resident's preference to receive a bath/ shower twice a week. It was not clear what shift or days of the week the resident preferred or was scheduled to receive that bathing activity. A review of Resident #9's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues and his cognition was moderately impaired. He was not indicated to have displayed any behaviors nor was he known to reject care during the seven days of that assessment reference period. He was independent with no set up help for transfers, ambulation, and personal hygiene. Bathing activity was not indicated to have occurred during the assessment period. A review of Resident #9's care plans revealed he had a care plan in place that indicated he preferred showers on nights. The care plan did not specify how often he was to be showered or on what nights. The interventions included providing showers as per his preference. He also had a care plan for assistance needed with ADL's related to having weakness. The goals were for the resident to be well groomed and free of odors at all times, he would participate as able in his ADL self care, and was to be clean/ odor-free/ appropriately dressed on a daily basis. The interventions on that care plan included the resident requiring physical help with bathing, staff would assist as needed with daily hygiene and would assist with showering residents as per facility policy weekly. His care plans did not indicate he was known to refuse any showers when offered. A review of Resident #9's kardex (care plan used by the nursing assistants to identify a resident's care needs) revealed the resident was identified as requiring physical help with bathing. Under resident care, it indicated showers would be provided as per his preference. It did not specify what his preferences were regarding the frequency in which he was showered. A review of Resident #9's bathing/ showering documentation, under the task tab of the electronic health record (EHR), revealed the resident was only marked as having received two bathing activities during the past 30 days. He was indicated to have been given a bath on 09/18/22 and a shower on 09/23/22. He was indicated to have refused a bathing/ shower activity on 09/25/22. On 10/12/22 at 1:45 P.M., an interview with Resident #9 revealed he did not know what days or nights he was scheduled to receive a shower. He stated they (staff) offered him showers when they wanted to offer them and not per his preference. He confirmed he may have refused a shower as documented on 09/25/22 as indicated in the facility's documentation. He recalled the staff member came in and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365425 If continuation sheet Page 17 of 39 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 365425 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Newark 75 McMillen Drive Newark, OH 43055 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few said lets get a shower, but he was not prepared to take one at that time. If he knew what days he was going to receive a shower, he would be more willing to accept them. He would like to know the day ahead that he would be receiving a shower so he could be ready for it. On 10/12/22 at 2:35 P.M., an interview with State Tested Nursing Assistant (STNA) #70 revealed a resident's kardex would tell them when a shower was scheduled for a particular resident on a particular day. If it was due on that shift, it would pop up on their kardex. If it was not due on that day or on that shift, it would not show up on the kardex. They also had a shower book that had a shower schedule in it, but the kardex was the most up to date and what they went by. On 10/12/22 at 2:38 P.M., an interview with RN #93 revealed Resident #9 was scheduled for showers every Sunday and Thursday on the night shift. She was only able to provide paper shower sheets for the two baths/ showers that had been documented as being provided under the task tab of the EHR. She denied she was able to find any other evidence of the resident having been assisted with a shower on his scheduled shower days on 09/20/22, 09/30/22, 10/03/22, 10/06/22 or 10/10/22. A review of the facility's Personal Care Procedure revised July 2018 revealed it was the policy of the facility to provide/ assist resident care and hygiene to each resident based on their individual status and needs. That included such things as baths/ showers. Bath/ showers could be given at any time the resident chose to receive them. They could be done in the morning, before bed or any other time of the resident's preference. A shower might only be necessary two to three times a week, if the resident chose that. A bed bath should be given on days a resident did not get a shower per their preference. They were to document care given in the STNA's POC or the nurses' notes. They were also to complete shower sheets for scheduled/ as needed showers given or refused. 2. Review of the medical record for Resident #20 revealed an initial admission date of 02/04/12 and a re-entry date of 03/01/12. Diagnoses included lack of coordination, muscle weakness, major depressive disorder recurrent, dementia without behavioral disturbance. Review of Resident #20's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 07 indicating a severely impaired cognition for daily decision making abilities. Resident #20 did exhibit behaviors including rejection of care. Resident #20 was independent with set up assistance only for bed mobility, transfers, ambulation, mobility, dressing and requires supervision with set up assist for eating and toilet use and supervision from one staff member for personal hygiene. Resident #20 was noted to be independent with no assistance needed for bathing. The resident was noted to be free from impairment to the bilateral upper and lower extremities and always continent of bowel and bladder function. Review of the plan of care dated 01/15/21 and revised 01/18/21 revealed Resident #20 had an activity of daily living (ADL) self-care performance deficit related to cerebral vascular accident (CVA), dementia, depression, fluctuating ADLs, generalized weakness. Interventions included staff are to assist with ADL. Review of the plan of care dated 08/14/21 and revised 04/08/22 revealed Resident #20 prefers showers on nightshift. Review of the nursing annual assessment dated [DATE] revealed Resident #20 was independent for bathing and prefers a shower. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365425 If continuation sheet Page 18 of 39 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 365425 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Newark 75 McMillen Drive Newark, OH 43055 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #20's completed care task for bathing/showering and review of completed shower sheets revealed Resident #20 had not received a bath or shower from 07/10/22 through 07/16/22 nor had she received a bath or shower from 08/01/22 through 08/13/22. Review revealed Resident #20 received a bed bath on days bathing was completed. Interview on 10/17/22 at 2:30 P.M. with Registered Nurse (RN) #93 confirmed Resident #20 likes showers completed on Mondays and Thursdays and in the evening. RN #93 also verified that when a resident receives a bath or shower or even refuses this care, it should be documented in the electronic medical record under task and/or complete a shower sheet. Review of facility policy titled Personal Care Procedure, revised 07/2018 revealed It is the policy of this facility to provide/assist resident care and hygiene to each resident based on their individual status and needs. Bath/shower may be given at any time the resident chooses. A shower may only be necessary 2-3 times per week if the resident chooses this. A bed bath should be give on days a resident does not get a shower per their preference. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365425 If continuation sheet Page 19 of 39 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 365425 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Newark 75 McMillen Drive Newark, OH 43055 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of Resident #54's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included a history of a stroke with hemiplegia affecting the left non-dominant side, MoyaMoya disease (narrowing of the blood vessels that supply the brain with blood), aphasia, muscle weakness, difficulty walking, unsteadiness on feet and major depressive disorder. A review of Resident #54's therapy notes revealed an Occupational Therapy (OT) Evaluation and Plan of Treatment for a certification period of 05/21/19 through 06/19/22 that indicated the resident was known to have a contracture to her left hand. The OT Discharge Summary for the date of service between 05/21/19 and 06/10/19 revealed therapy was unable to trial at that time as the resident was still resistive to any touch to the left upper extremity (LUE). On one occasion, during the resident's treatment period, the resident was observed with a palm guard in her left hand as placed by nursing. Quarterly therapy screens/ range of motion (ROM) assessments had been completed with the last one done on 09/26/22. The quarterly screens did not indicate if any contractures existed at that time, only whether there was a change. A review of Resident #9's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no speech. She rarely/ never was able to make herself understood and rarely/ never was able to understand others. Her cognitive skills for daily decision making was severely impaired. The resident was indicated to have displayed physical behaviors and other behaviors not directed at others one to three days of the assessment period, but was not known to reject care. She required an extensive assist of two for dressing. She had a functional limitation in her range of motion affecting on one side of her upper extremity. She was not recorded as having received any therapy minutes to include any restorative nursing for ROM or splint/ brace assistance. A review of Resident #54's active care plans revealed she did not have a care plan in place to address contractures or for the prevention of, following a known history of a stroke with left sided hemiplegia (paralysis). None of the existing care plans included the use of any orthotics, hand roll, or washcloth in her left hand to prevent the worsening of the contracture she was known to have in her left hand. The care plans did not show the resident had been known to refuse the use of any such appliances/ interventions to her left hand contracture. A review of Resident #54's active physician's orders revealed there were no orders in place for the use of any splints/ braces, hand rolls or roll washcloths to manage or prevent worsening of her existing contracture. On 10/11/22 at 2:12 P.M., observations of Resident #54 noted her to be up in her wheelchair with her left arm drawn up and across her torso. The resident's left hand was noted to be in a closed fist position. She was not noted to have any splints/ braces, hand rolls, or rolled washcloths in place to help manage/ prevent her existing contracture from worsening. Subsequent observations made on 10/12/22, 10/13/22 and 10/17/22 revealed her left hand remained in a closed fist position. The resident was noted to have her thumb between her index and middle finger. She was not known at any time to have any orthotic devices in place or a rolled washcloth in her contracted left hand. On 10/17/22 at 11:29 A.M., an interview with LPN #36 revealed she thought the resident's left hand was contracted but she was not for sure. The resident may be able to open her hand with passive ROM (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365425 If continuation sheet Page 20 of 39 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 365425 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Newark 75 McMillen Drive Newark, OH 43055 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few but you may also get bit when trying. The resident's left thumb was noted to cause her discomfort. She thought there was a sign posted on the wall that directed the staff on the use of an orthotic. An observation of the resident's room, at the time of the interview, revealed there was a sign posted on the wall by the head of the bed. The sign instructed staff to Please put palm guard on the resident's left hand when she was out of bed. The sign also instructed the staff to take it off while the resident was in bed. The note also advised the staff that the left thumb did not move too well and they were not to force movement. LPN #36 confirmed Resident #54 was not wearing a palm guard and she was unable to locate it in the resident's room. On 10/17/22 at 1:07 P.M., an interview with Certified Occupational Therapist Assistant COTA) #170 revealed Resident #54 was known to have a contracture to her left hand that had been there when the therapy department worked with the resident back in May or June 2019. There was mention of the use of an elbow splint and resting hand splint as one of her goals in the therapy notes. The note indicated a palm guard was in place per nursing at the time the therapy note was written. She confirmed the resident had been resistive to any touch of her left upper extremity when therapy tried to work with her and they were not able to trial any new orthotics. She verified therapy screens were being completed quarterly, but they did not due any hands on assessments during those evaluations. She denied they were permitted to touch the resident during those screens so they did not test her ROM to see if the contracture was getting worse. They would go by what was reported by nursing if a contracture had in fact worsened. She denied they had any way to show if the resident's contracture had worsened or if it was the same as it was when she was seen by therapy back in 2019. On 10/17/22 at 2:00 P.M., an interview with RN #93 revealed Resident #54 did not have an order for the use of any palm guards or any other orthotics for the resident's contracture management. She acknowledged the resident's active care plans did not include a care plan to address the resident's known contracture to the left hand. She was asked to provide any documentation they had on the use of the palm guard or any other intervention they were using to address the resident's contracture. She was also asked to provide any documentation they had to support why the palm guard was no longer being used for the resident as the sign in her room indicated should have been. She returned two hours later and denied she was able to find any documentation to support why the palm guard was not being used. She denied they had any documented evidence the resident was refusing the use of the palm guard. Based on observation, interview, and record review the facility failed to provide adequate care for Resident #54 and Resident #73 who had contractures. This affected two residents (#54 and #73) of two residents reviewed for limited range of motion. The facility census was 85. Findings include: 1. Review of the medical record revealed Resident #73 admitted on [DATE] with diagnoses including traumatic subarachnoid hemorrhage with loss of consciousness, acute respiratory failure with hypoxia, encounter for attention to tracheostomy, encounter for attention to gastrostomy, metabolic encephalopathy, and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #73 was rarely or never understood. The resident had a limitation in range of motion (ROM) of both sides of her upper and lower extremities. Review of the plan of care revealed it did not address Resident #73's contractures. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365425 If continuation sheet Page 21 of 39 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 365425 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Newark 75 McMillen Drive Newark, OH 43055 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the physician's order dated 10/07/22 revealed an order to apply hand and elbow splints on both of Resident #73's arms and hands for eight hours daily and then remove. Review of the occupational therapy Discharge summary dated [DATE] revealed the therapist recommended Resident #73's bilateral hand rolls be used as tolerated. Additionally, a restorative nursing program was recommended bilateral upper extremity range of motion with slow gentle ROM provided to decrease spasticity. Review of the occupational therapy note dated 08/26/22 revealed the occupational therapist discussed discharge recommendations with Resident #73's family which included continuing ROM, upper extremity orthotics and rolls, and skin protection as tolerated. Review of Resident #73's medical record revealed no documentation related to ROM or hand rolls. Interview on 10/11/22 at 1:43 P.M. with Resident #73's father revealed he was worried his sons contractures. He felt the orthotics were not applied as ordered, he was worried about how tight Resident #73's hands were clenched. Interview on 10/12/22 at 2:41 P.M. with Resident #73's mother revealed she was told the nurse aides were supposed to do ongoing therapy with her son, but she had not seen any evidence that this was occurring. Observation and interview on 10/17/22 starting at 12:15 P.M. revealed Resident #73's hands were contracted into tight fists. A green hand roll was observed on the floor on the left side of the bed. Interview with Licensed Practical Nurse #102 confirmed it was a hand roll on the floor. She reported therapy must have been using it because nursing staff does not put it in place. She was unaware of any restorative ROM for Resident #73. Interview on 10/17/22 at 1:07 P.M. with Occupational Therapist #101 revealed Resident #73 had hand rolls provided by the family. They reported therapy did put the hand rolls back in place after his sessions. She reported the hand rolls could continue to be used as tolerated. Occupational Therapist #101 reported it was recommended that ROM continue due to the residents varied tone. She reported nursing was to provide orthotics and range of motion. Interview on 10/17/22 at 1:58 P.M. with Registered Nurse #93 confirmed the hand rolls were not in his medical record, she was unsure if he needed them due to his splints. RN #93 confirmed restorative therapy could be documented in the medical record and did not appear in Resident #73's record. RN #93 revealed she would expect the nurses to provide ROM when they applied the splints but did not know if that is when it occurred. Review of the policy Restorative Nursing Services revised August 2018, revealed residents may be started on a restorative nursing program upon admission, during their stay, or when discharged from therapy. Restorative goals and objectives should be individualized, resident-centered, and outlined in the resident's plan of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365425 If continuation sheet Page 22 of 39 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 365425 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Newark 75 McMillen Drive Newark, OH 43055 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 observation, interview, and record review revealed the facility failed to ensure Resident #60 received the required two-person assistance with transfers. This affected one resident (#60) of four reviewed for accident hazards. The facility census was 85. Findings include: Observation on 10/17/22 from 1:28 P.M. to 1:37 P.M. revealed State Tested Nursing Aide (STNA) #39 pushing a hoyer lift into Resident #60's room and closing the door at 1:37 P.M. STNA #39 exited the room by herself. Interview on 10/17/22 at 1:37 P.M. with STNA #39 verified she transferred Resident #60 using a hoyer lift by herself. She confirmed a transfer with hoyer lift required two staff members, but she was the only aide on the unit and Resident #60 needed to be transferred and placed on the bed pan immediately. Review of the medical record for Resident #60 revealed an admission date of 09/14/21 with diagnoses including chronic obstructive pulmonary disease, type two diabetes mellitus, rheumatoid arthritis, schizophrenia, morbid obesity, and neuromuscular dysfunction of the bladder. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #60 had intact cognition. She required the extensive assistance of two persons for transfers. Review of the plan of care dated 04/22/22 revealed Resident #60 required assistance for activities of daily living related to immobility, obesity, non-weight bearing status, and partial foot amputation. Interventions included the extensive assistance of two persons for transfers Review of the [NAME] for Resident #60 revealed she required the extensive assistance of two persons for transfers. Review of the policy Hoyer Lift Transfer dated July 2018, revealed a hoyer lift always required the use of two people. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365425 If continuation sheet Page 23 of 39 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 365425 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Newark 75 McMillen Drive Newark, OH 43055 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident interview, staff interview, and policy review, the facility failed to ensure a resident received oxygen at the appropriate flow rate as ordered by the physician. This affected one (Resident #9) of three residents reviewed for respiratory care. Residents Affected - Few Findings include: A review of Resident #9's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included chronic obstructive pulmonary disease (COPD), sleep apnea, atrial fibrillation and vascular dementia. A review of Resident #9's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues and his cognition was moderately impaired. He was not known to display any behaviors nor was he indicated to reject care. He was independent with no set up help needed for transfers and ambulation. His active diagnoses coded included COPD. Oxygen therapy was indicated to have been provided while a resident in the facility. A review of Resident #9's active care plans revealed the resident did not have a care plan in place to address his diagnosis of COPD or his use of oxygen. The [NAME] used by the nursing assistants to identify a resident's care needs revealed it did not provide any indication of the resident having the use of oxygen on a continuous basis. A review of Resident #9's physician's orders revealed he had an order to receive oxygen at 2 liters per minute (LPM) via nasal cannula every shift. The order for oxygen had been initiated on 10/11/22 despite it being used when the resident's quarterly MDS was completed on 07/15/22. The orders did not indicate the resident's oxygen was to be humidified when used. On 10/11/22 at 1:55 P.M., an observation of Resident #9 noted him to be in his room with his oxygen on via nasal cannula. The resident's oxygen flow rate was set at 5 LPM per a concentrator. He was noted to have a humidified oxygen bottle attached to the concentrator that the oxygen tubing was connected to. The humidified oxygen bottle was empty. An interview with the resident at the time of the observation revealed he adjusted the oxygen flow rate himself. He claimed the staff just brought his concentrator into his room and left it for him to manage. He denied they provided him with any directions on its use. On 10/12/22 at 10:52 A.M., a subsequent observation of Resident #9 noted him to be sitting up in his wheelchair in his room. His oxygen remained on and the oxygen flow rate was still set on 5 LPM and his humidified oxygen bottle remained empty. On 10/12/22 at 11:14 A.M., an interview with State Tested Nursing Assistant (STNA) #70 revealed she had worked at the facility for two and a half months now. She worked all units to include Resident #9's unit and felt she was familiar with his care. She was not aware of the resident having the use of oxygen. She reported he was pretty independent with his care but they still checked on him every couple of hours. She stated the resident's use of oxygen would be communicated to them through the nurse. It would also be in their POC ([NAME]) that identified a resident's specific care needs. On 10/12/22 at 11:16 A.M., an interview with Licensed Practical Nurse (LPN) #36 revealed she had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365425 If continuation sheet Page 24 of 39 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 365425 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Newark 75 McMillen Drive Newark, OH 43055 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few worked at the facility for a year now and was usually on the unit Resident #9 was on. She stated he moved to that unit about two months ago. He was pretty independent but would use his call light or come and let them know when he needed something. She reported the nurses assisted him with his oxygen concentrator in addition to giving him his medications. She stated he wore the oxygen when he wanted to. She estimated he wore it about 99% of the time when he was in his room. He did not like wearing it when he came out of his room as he felt he did not need it. He did not like using the oxygen tanks on the back of his wheelchair. She reported he was on oxygen at 2 LPM for his COPD. She checked his physician's orders and verified he was to be on 2 liters per nasal cannula on a continuous basis. She confirmed his physician's orders did not specify his oxygen had to be humidified. She stated typically, if oxygen was at 2 LPM, it did not need to be humidified. She denied that she had known the resident to adjust his own oxygen flow rate on his own. She denied she checked the resident's concentrator every shift to make sure it was set at the proper flow rate ordered by the physician. When she entered his room to give him his medications, she just checked to make sure the concentrator was on and he was wearing it. She was asked to go to the resident's room and check his oxygen. She verified the oxygen was set at 5 LPM and his humidified oxygen bottle was empty. She acknowledged both the incorrect flow rate and the empty humidified oxygen bottle had been like that for the past two days. She confirmed she was on duty on that hall yesterday as well. She was asked why a resident with the diagnosis of COPD should not have their oxygen flow rate at 5 LPM per nasal cannula. She replied it would make the resident's lungs explode. She then acknowledged that a high oxygen flow rate for someone with COPD could result in the resident losing their drive to breathe. She stated he normally told them when his humidified oxygen bottle was empty. She confirmed the resident's active care plans did not include a care plan to address his COPD diagnosis or the use of oxygen. She verified there was nothing on the resident's [NAME] used by the aides to indicate he had the use of oxygen. A review of the facility's Oxygen Therapy policy (undated) from Advantage Respiratory Services revealed the procedure included explaining the purpose and procedure of oxygen therapy to the resident, assemble oxygen source equipment and delivery device according to the physician's order, attach humidifier if necessary and fill to proper level with distilled water if not pre-filled, and adjust the flow knob to the flow rate prescribed reading the center of the flow ball. Routine maintenance included refilling the humidifier daily with distilled water. Pre-filled humidifiers were to be changes as needed. Hazards of oxygen therapy / Adverse Reactions indicated in residents with COPD hypoventilation, there was a great risk due to the hypoxic drive of ventilation in those residents. Excessive oxygenation could lead to respiratory depression and even death in that type of resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365425 If continuation sheet Page 25 of 39 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 365425 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Newark 75 McMillen Drive Newark, OH 43055 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and policy review, the facility failed to ensure their consulting pharmacist made recommendations for gradual dose reduction (GDR) attempts with the use of psychotropic medications as required during their monthly medication regimen review. The facility also failed to ensure pharmacy recommendations were followed up on or responded to timely by the physician. This affected four (Resident #4, #47, #54 and #60) of five residents reviewed for unnecessary medications. Findings include: 1. A review of Resident #54's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included a history of a stroke with hemiplegia affecting her left non-dominant side, MoyaMoya disease (a narrowing of the blood vessels that supplied the brain with blood), aphasia, major depressive disorder, and restlessness and agitation. A review of Resident #54's active physician's orders revealed the resident had an order to receive Klonopin (an anti-anxiety medication) 1 milligram (mg) twice a day for seizures (not in diagnosis or medical history). She also received Klonopin 2 mg by mouth every night at bedtime for seizures. The orders for the use of Klonopin had been in place since 05/29/21. The physician's orders also indicated the resident was to be monitored for agitation, restlessness and being withdrawn in relation to the use of Klonopin. In addition, Resident #54 had an order to receive Olanzapine (Zyprexa) 5 mg by mouth twice a day in the morning and evening and 20 mg by mouth every night at bedtime for severe, recurrent major depressive disorder with psychotic symptoms. That order was last modified on 10/12/21. A review of Resident #54's medication regimen reviews completed during the past 12 months revealed the pharmacist made a recommendation on 04/27/22 for the physician to consider a GDR for the use of the Zyprexa. The pharmacist indicated the resident's Zyprexa dose was last changed on 10/13/21, when she was to continue Zyprexa 20 mg by mouth every night at bedtime and Zyprexa 5 mg was added to give in the morning and evening between the hours of 4:00 P.M. to 6:00 P.M. The recommendation indicated the intent was to achieve the minimal effective dose and help the facility comply with federal dosage reduction guidelines. There was no evidence of the physician responding to that recommendation. There was also no evidence the facility's consulting pharmacist had recommended a GDR for the use of Klonopin that was not being used for seizure disorder as indicated in the physician's orders. On 10/17/22 at 2:00 P.M., a follow up interview with Registered Nurse (RN) #93 revealed she could not find any documentation to support the physician responded to the pharmacist's recommendation for a GDR consideration for Zyprexa on 04/27/22. She also could not find evidence of the pharmacist making any recommendations for a GDR consideration for the use of Klonopin that had been ordered since 05/29/21. She confirmed the physician order specified the Klonopin was being used for seizure disorder, but the resident did not have that in her medical history. She verified the orders included the target behaviors of agitation, restlessness and being withdrawn for which the Klonopin was being used for. A review of the facility's policy on Consulting Pharmacist's Monthly Drug Review revealed any medication irregularities noted by the consulting pharmacist during the monthly review should be documented on a separate, written report. The report should include, at a minimum, the resident's name, the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365425 If continuation sheet Page 26 of 39 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 365425 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Newark 75 McMillen Drive Newark, OH 43055 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some relevant drug and the irregularity identified by the pharmacist. The written report should be sent via fax, email etc. to the resident's attending physician, the Director of Nursing and the facility's Medical Director. The resident's attending physician must document in the medical record that the identified irregularity had been reviewed, and what, if any action has been taken to address it. If there was to be no change in the medication, the attending physician must document their rationale in the resident's medical record at the physician's next visit or within an (unspecified) timeframe. 3. Record review revealed Resident #4 was admitted to the facility on [DATE]. Her diagnoses were dementia, insomnia, osteoarthritis, Alzheimer's disease, anxiety disorder, depression, chronic kidney disease, difficulty in walking, and lack of coordination. Review of her Minimum Data Set (MDS) assessment, dated 07/11/22, revealed she had a severe cognitive impairment. Review of Resident #4 pharmacy recommendations revealed the following were not addressed in a timely manner: February 2022 - the use/justification of quetiapine needed clarified. There was no evidence this was addressed. March 2022 - the use/justification of quetiapine needed clarified. There was no evidence this was addressed. April 2022 - the use/justification of quetiapine needed clarified, a new order for Melatonin was added on 03/25/22, but needed clarification if the prior as needed order needed to be canceled, consider a dose reduction for Tramadol, and review for the need of as needed Haldoperidol (continue for 14 days or discontinue). There was no evidence that any of these recommendations were addressed by the physician. May 2022 - the use/justification for olanzapine needed clarified and an order for Melatonin was added on 03/25/22, but needed clarification if the prior as needed order needed to be canceled. These recommendations were not addressed until 07/19/22. June 2022 - the use/justification for olanzapine needed clarified and an order for Melatonin was added on 03/25/22, but needed clarification if the prior as needed order needed to be canceled. These recommendations were not addressed until 07/19/22. Also, recommendation to discontinue the use of Tramadol. This recommendation was not addressed. 4. Record review revealed Resident #47 was admitted to the facility on [DATE]. Her diagnoses were senile degeneration of brain, chronic kidney disease, depression, anemia, hyperlipidemia, delirium, dementia, and other lack of coordination. Review of her MDS assessment, dated 09/01/22, revealed her cognitive assessment could not be completed due to her inability to answer the questions. This deemed her to have a significant cognitive impairment. Review of Resident #47 pharmacy recommendations revealed the following were not addressed in a timely manner: February 2022 - the use/justification for quetiapine and Triamcinolone Cream needed clarified. There was no documentation to support this was addressed. March 2022 - review of the as needed order of Clonazepam to either be extended or discontinued. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365425 If continuation sheet Page 27 of 39 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 365425 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Newark 75 McMillen Drive Newark, OH 43055 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 0756 This recommendation was not addressed until 05/04/22. Level of Harm - Minimal harm or potential for actual harm April 2022 - review of the as needed order of Clonazepam to either be extended or discontinued. This recommendation was not addressed until 05/04/22. Residents Affected - Some May 2022 - review of the as needed order of Clonazepam to either be extended or discontinued. There was no evidence this recommendation was addressed. June 2022 - review of the as needed order of Clonazepam to either be extended or discontinued and use/justification of Triamcinolone Cream needed clarified. There was no evidence these recommendations were addressed. July 2022 - review of the as needed order of Clonazepam to either be extended or discontinued and a recommendation for a gradual dose reduction (GDR) for Paroxetine. There was no evidence these recommendations were addressed. August 2022 - the use/justification of Triamcinolone Cream needed clarified. There was no evidence to support this was addressed. Interview with Registered Nurse (RN) #93 on 10/13/22 at 11:53 A.M. confirmed the dates and information listed in the pharmacy recommendation binder and/or the electronic records are accurate and what they have. She confirmed they did not have a consistent Director of Nursing (DON) for many months. The pharmacy would email the pharmacy recommendations to the DON, and if they don't have a DON or the DON is not staying on top of that task, the recommendations will stay in the e-mail box and won't be addressed timely. Review of the facility Consulting Pharmacist Monthly Drug Review policy, (dated 2016) revealed the facility's consulting pharmacist must conduct a monthly drug regimen review and report any identified medication irregularities in accordance with this policy. Any medication irregularities noted by the consultant pharmacist during the monthly review shall be documented on a separate, written report. The written report shall be sent (via email, fax, etc) to the resident's attending physician, the DON, and the medical director. The resident's attending physician must document in the medical record that the identified irregularity has been reviewed, and what, if any action has been taken to address it. If there is to be no change in the medication, the attending physician must document his or her rationale in the resident's medical record at the physician's visit or within (time frame). The time frame was not specified in the policy. 2. Review of the medical record for Resident #60 revealed an admission date of 09/14/21 with diagnoses including chronic obstructive pulmonary disease, type two diabetes mellitus, rheumatoid arthritis, schizophrenia, morbid obesity, and neuromuscular dysfunction of the bladder. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #60 had intact cognition. Review of the Pharmacist's Medication Regimen Review dated 03/28/22, revealed the pharmacist indicated the word units should be included with each dose of insulin according to best practices with insulin administration. An additional recommendation was that the instruction if blood glucose is below 80 mg/dl, give half of the dose of Humulin R U-500 insulin was included with the sliding scale order, however, they believed it should have been included with the scheduled order instead. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365425 If continuation sheet Page 28 of 39 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 365425 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Newark 75 McMillen Drive Newark, OH 43055 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 0756 Level of Harm - Minimal harm or potential for actual harm pharmacist asked that this was reviewed with endocrinology and the order be updated. There was no evidence the physician addressed the recommendation. Review of the recommendations awaiting response report dated 04/27/22, revealed the pharmacist's recommendations from 03/28/22 had not been addressed. Residents Affected - Some Review of the pharmacist's recommendation dated 05/24/22 revealed the pharmacist once again recommended if blood glucose is below 80 mg/dl, give half of the dose of Humulin R U-500 insulin was included with the sliding scale order, however, they believed it should have been included with the scheduled order instead. The pharmacist asked that this was reviewed with endocrinology and the order be updated. They also recommended the new order for bedtime sliding scale insulin had the correct insulin listed; Humulin R versus Humulin R U-500. There was no evidence the physician addressed the recommendation. Review of the recommendations awaiting response report dated 06/15/22 revealed the pharmacist's recommendations from 05/24/22 had not been addressed. Review of the Pharmacist's Medication Regimen Review dated 06/14/22 indicated the word units should be included with each dose of insulin per best practices with insulin administration. There was no evidence the physician addressed the recommendation. Review of the pharmacists Medication Regimen Review dated 07/11/22 revealed the pharmacist once again recommended if blood glucose is below 80 mg/dl, give half of the dose of Humulin R U-500 insulin was included with the sliding scale order, however, they believed it should have been included with the scheduled order instead. There was no evidence the physician addressed the recommendation. Interview on 10/17/22 at 1:58 P.M. with Registered Nurse (RN) #93 confirmed Resident #60's pharmacist recommendations had not been addressed by the physician. RN #93 related this to frequent changes in administrative nursing staff. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365425 If continuation sheet Page 29 of 39 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 365425 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Newark 75 McMillen Drive Newark, OH 43055 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and review of the facility's drug reference information, the facility failed to ensure a resident receiving Digoxin had their apical pulse checked prior to the administration of the medication. This affected one (Resident #27) of five residents reviewed for unnecessary medications. Residents Affected - Few Findings include: A review of Resident #27's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included atrial fibrillation. A review of Resident #27's physician's orders revealed he had an order to receive Digoxin 250 micrograms (mcg) by mouth every morning for atrial fibrillation. The order had been in place since 02/07/22. The physician's orders did not include any parameters to hold the medication if the resident's apical pulse was less than 60 beats per minute. A review of Resident #27's medication administration record (MAR's) for October 2022 revealed the resident was receiving Digoxin 250 mcg by mouth every morning as ordered. There was no documented evidence of the resident's apical pulse being checked daily before the Digoxin was administered. A review of Resident #27's electronic health record (EHR) revealed there was no documented evidence of the resident's pulse being checked daily before the administration of the Digoxin. The last pulse recorded was under the vital signs tab of the EHR 09/06/22, which was 72 BPM. No other pulses had been recorded as having been checked since the resident was started on Digoxin on 02/07/22. On 10/13/22 at 1:26 P.M., an interview with Licensed Practical Nurse (LPN) #17 revealed the electronic medication administration record (eMAR) did not prompt them to obtain Resident #27's apical pulse prior to the administration of the resident's Digoxin. She confirmed she has given the resident his Digoxin and denied she was prompted to check and record his apical pulse before she gave him the medication. She denied that she would check it every time and maybe checked it once a week or so. She confirmed the order did not include any parameters in which to hold the medication. She stated it was likely how it was put into the EHR as to why it did not prompt them to enter a pulse before giving it. If the order would have included parameters in which to hold the medication, she believed the eMAR would have required them to enter a pulse before giving the medication. She acknowledged the need to check an apical pulse before giving Digoxin and confirmed they were doing it for other residents receiving that medication. On 10/13/22 at 2:10 P.M., an interview with Registered Nurse (RN) #93 revealed the facility did not have a drug reference book that they had for reference. The nurses would look up medications on their cell phones if they had any concerns or questions about a medication. She denied they instructed the nurses to use a particular website as a drug reference and indicated any could be used. She also stated they had their contracted pharmacy they could get information from. She questioned whether you had to check a pulse prior to the administration of Digoxin. She was asked to provide any documentation they had to justify not checking the resident's apical pulse prior to the administration of Digoxin and any drug reference source they would use that indicated the same. On 10/13/22 at 2:42 P.M., a follow up interview with RN #93 revealed she found drug information and printed that information from Drugs.com for review. Under tips, it indicated your doctor may advise (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365425 If continuation sheet Page 30 of 39 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 365425 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Newark 75 McMillen Drive Newark, OH 43055 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 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete you to record your heart rate and blood pressure daily while taking Digoxin. She was shown information that was pulled from the same site (Drugs.com) that indicated your blood pressure and heart rate would need to be checked daily. She did not provide any information specific to Digoxin from their contracted pharmacy company that showed an apical pulse was not necessary to be checked prior to giving Digoxin. She was asked to provide any information from the resident's attending physician to support not needing to check the resident's apical pulse prior to the administration of the Digoxin. No information from the physician was provided. Event ID: Facility ID: 365425 If continuation sheet Page 31 of 39 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 365425 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Newark 75 McMillen Drive Newark, OH 43055 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility failed to ensure residents receiving psychotropic medications had an adequate indication for use, gradual dose reductions (GDR's) were attempted, and were monitored appropriately for side effects associated with their use. This affected two (Resident #4 and #54) of five residents reviewed for unnecessary medications. Findings include: 1. A review of Resident #54's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included a history of a stroke with hemiplegia to the left non-dominant side, MoyaMoya disease (narrowing of the blood vessels that supplied the brain with blood), aphasia, restlessness and agitation and major depressive disorder. A review of Resident #54's active physician's orders revealed the resident had an order to receive Klonopin (an anti-anxiety medication) 1 milligram (mg) by mouth (po) two times a day and 2 mg po at bedtime for seizures (not in medical history). The physician's orders identified the target behaviors for which the Klonopin was being used that included agitation, restlessness, and withdrawn behaviors. The order had been in place since 05/29/21. The resident also had an order to receive Zyprexa (an antipsychotic) 5 mg po every morning and evening and 20 mg po every night at bedtime for severe, recurrent major depressive disorder with psychotic symptoms. That order had been in place since 10/12/21. A review of Resident #54's medication regimen reviews revealed the resident's medications were reviewed monthly for irregularities. A pharmacy recommendation was made on 04/27/22 as a result of those reviews that recommended the physician consider a GDR for the use of Zyprexa as the resident had been on the same dose since 10/13/21. The physician did not respond to the pharmacist's recommendation and no dosage reduction attempts had been made or addressed for the Zyprexa in the past year. There was also no evidence of a GDR being recommended or attempted for the resident's Klonopin since she was started on it on 05/29/21. A review of Resident #54's assessments revealed the last time the resident had an Abnormal Involuntary Movement (AIMS) assessment done was on 08/20/21. No abnormal involuntary movements were noted at that time. There was no evidence of any additional AIMS assessments being completed despite the resident continued to receive Zyprexa on a daily basis. On 10/17/22 at 2:00 P.M., an interview with Registered Nurse (RN) #93 revealed she was not able to find evidence of an AIMS assessment being completed for Resident #54 after 08/20/21. She was asked how often AIMS assessment should be completed for residents receiving antipsychotic medications and stated they should be completed quarterly. She denied they had evidence of GDR's being attempted for the Klonopin or Zyprexa. She confirmed a recommendation had been made by the pharmacist for the physician to consider a GDR for the use of Zyprexa on 04/27/22, but the physician did not respond to that recommendation. She acknowledged the resident's medical record indicated the Klonopin was being used for seizure disorder but the resident did not have that diagnosis as part of her medical history. She denied there was any evidence of the consulting pharmacist making any recommendations for a GDR consideration for the use of Klonopin, but thought it may have been related to the order indicating (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365425 If continuation sheet Page 32 of 39 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 365425 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Newark 75 McMillen Drive Newark, OH 43055 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few it was being used for seizures and not for anxiety/ agitation. She acknowledged GDR's should be attempted for psychotropic medications twice in the first year after they had been started in two separate quarters with a month in between attempts. They then should be attempted annually thereafter, or at least addressed by the physician. A review of the facility's policy on AIMS Assessments revised March 2016 revealed it was the intent of the facility that residents who were on psychoactive medications be routinely monitored for indications of side effects. The AIMS assessment would be used to assess the baseline status of a resident who was admitted on a psychoactive medication or who was put on one after admission. Residents who were on a psychoactive medication would have the AIMS completed routinely, and prn if they demonstrated signs/ symptoms that might indicate the resident was having side effects. 2. Record review revealed Resident #4 was admitted to the facility on [DATE]. Her diagnoses were dementia, insomnia, osteoarthritis, Alzheimer's disease, anxiety disorder, depression, chronic kidney disease, difficulty in walking, and lack of coordination. Review of her Minimum Data Set (MDS) assessment, dated 07/11/22, revealed she had a severe cognitive impairment. Review of Resident #4 physician orders revealed she was prescribed Zyprexa five milligrams (mg) twice daily for dementia with behavioral disturbances. Review of Resident #4 progress notes, dated 04/11/22, 05/11/22, 06/01/22, and 09/19/22, confirmed she was prescribed a variety of psychotropic medications (Seroquel, Zyprexa, Klonopin) for the diagnosis of dementia. There was no other documentation to support the psychotropic medications ordered (including the current order of Zyprexa) was for any other diagnosis than dementia. Interview with Registered Nurse (RN) #93 on 10/13/22 at 2:06 P.M. and 10/17/22 at 12:27 P.M. confirmed that dementia is not a proper diagnosis for the use of a psychotropic medication. She confirmed Resident #4 progress notes and physician orders for Zyprexa was for dementia, and it shouldn't have been. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365425 If continuation sheet Page 33 of 39 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 365425 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Newark 75 McMillen Drive Newark, OH 43055 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 - Some 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** 4. Record review revealed Resident #81 was admitted to the facility on [DATE]. Her diagnoses were dysphagia, difficulty walking, dementia, anxiety disorder, insomnia, osteoporosis, major depressive disorder, personal history of malignant neoplasm of breast, type II diabetes, brief psychotic disorder, nicotine dependence, and malignant neoplasm of right female breast. Review of her Minimum Data Set (MDS) assessment, dated 10/02/22, revealed her cognitive status could not be assessed due to her inability to answer the questions. This confirmed that she had a severe cognitive impairment. Review of Resident #81's medical records revealed there was no evidence that her hospice notes were in the facility. When it was requested to the facility to get the hospice notes for Resident #81, they contacted the hospice agency and had them all faxed over on 10/13/22. Interview with Licensed Practical Nurse (LPN) #21 and LPN #17 on 10/18/22 at 10:17 A.M. confirmed they did not have Resident #81 hospice notes in the facility. They confirmed those that are on hospice services, have hospice notes either in a binder behind the nurse's desk, or it is scanned into the electronic medical records. They confirmed there was nothing in Resident #81 electronic records regarding her hospice notes. 3. Review of the medical record for Resident #62 revealed an admission date of 09/09/22. Diagnoses included lack of coordination, need for assistance with personal care, and heart failure. Review of Resident #62's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating an intact cognition for daily decision making abilities. Resident #62 was noted to require supervision from one staff member for bed mobility and limited assistance from two staff members for transfers. Noted to be free from impairment to the bilateral upper and lower extremities. Review of progress note dated 10/07/22 at 9:26 P.M. completed by Licensed Practical Nurse (LPN) #102 revealed, Resident fell in her room at 9:30 P.M. unwitnessed. Resident was observed on left side lying on the floor in her room. Resident denies hitting her head. The aide working on the hall observed the resident on the floor after a cry out for help. Resident explained that her foot got caught in her wheelchair trying to transfer herself from her wheelchair to her bed. Resident expressed pain in right knee. Full assessment was completed and neuro checks has been initiated. Resident had no injuries or open wounds or open skin, no bruising at this time but will continue to monitor. Resident was given acetaminophen with her bedtime medication before the fall. Resident declines going to hospital. After full assessment, resident has normal vitals. The resident was placed back into wheelchair, resident wanted to go smoke at the smoke break. physician was notified, all other responsible parties has been notified. Review of progress note dated 10/08/22 at 12:07 P.M. created by LPN #104 revealed, Blood sugar reading of 91, not given. Review of progress note dated 10/08/22 at 9:15 P.M. created by LPN #106 revealed, Patient returned to facility transportation. Per discharge paperwork patient has a right tibia/fibula fracture. No change in medication. As needed pain medication order still in place. Patient has a soft cast on right leg. Several follow up appointments noted in discharge paperwork. Representative notified of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365425 If continuation sheet Page 34 of 39 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 365425 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Newark 75 McMillen Drive Newark, OH 43055 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 appointments by nursing supervisor. This nurse contacted physician to update provider on patient condition. No new orders at this time. Interview on 10/17/22 at 1:30 P.M. with Registered Nurse (RN) #93 verified Resident #62's medical record did not reflect the resident's transfer to the hospital for a post fall evaluation. Residents Affected - Some Review of the facility's policies revealed the facility did not provide a policy regarding medical record documentation. Based on observation, interview, and record review, the facility failed to maintain accurate and complete records relating to catheter care for Resident #60, diagnoses for Resident #28, hospitalization for Resident #62, and hospice for Resident #81. This affected four residents (#28, #60, #62, and #81) of 27 records reviewed. The facility census was 85. Findings include: 1. Observation on 10/11/22 at 4:26 P.M. revealed Resident #60 had a catheter. Review of the medical record for Resident #60 revealed an admission date of 09/14/21 with diagnoses including chronic obstructive pulmonary disease, type two diabetes mellitus, rheumatoid arthritis, schizophrenia, morbid obesity, and neuromuscular dysfunction of the bladder. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #60 had intact cognition. Resident #60 had an indwelling urinary catheter. Review of the plan of care dated 09/06/22 revealed Resident #60 had the potential for complications related to the use of a Foley catheter. Interventions included assisting with Foley catheter care as needed, educating the resident to report signs of a urinary tract infection (UTI), reevaluating the need for a catheter, and observing for signs of a UTI. Review of the physician's orders from 08/01/22 to 10/11/22 revealed no order for a catheter or for catheter care. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) from 08/01/22 to 10/11/22 revealed no documented catheter care. Interview on 10/17/22 at 10:54 A.M. with Registered Nurse (RN) #93 confirmed an order for catheter and catheter care was absent from Resident #60's medical record for 08/01/22 through 10/11/22 and she had a catheter during that time. 2. Review of the medical record for Resident #28 revealed an admission date of 08/04/22 with diagnoses including chronic obstructive pulmonary disease, encephalopathy, dementia with behavioral disturbance, and major depressive disorder. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #28 had impaired cognition. Review of Resident #28's physician's orders for October 2022 revealed an order for Seroquel Tablet 25 milligrams (mg) for mood disorder, Depakote Sprinkles Capsule Delayed Release 125 mg for mood (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365425 If continuation sheet Page 35 of 39 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 365425 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Newark 75 McMillen Drive Newark, OH 43055 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 disorder, and Buspirone 10 mg for anxiety. Level of Harm - Minimal harm or potential for actual harm Interview on 10/13/22 at 2:45 P.M. with RN #93 confirmed Resident #28 had the diagnoses she was receiving medications for as they were contained in the orders from her previous facility. RN #93 additionally confirmed the diagnosis list did not reflect these diagnoses. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365425 If continuation sheet Page 36 of 39 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 365425 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Newark 75 McMillen Drive Newark, OH 43055 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. A review of Resident #72's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included chronic kidney disease, benign prostatic hypertrophy without lower urinary tract symptoms, and need for assistance with personal care. Residents Affected - Many A review of Resident #72's laboratory tests revealed a urinalysis (U/A) was collected on 10/07/22. The final urine culture results on 10/09/22 showed the resident had greater than 100,000 colonies/milliliter of Proteus Mirabilis and Klebsiella Pneumoniae. The Klebsiella Pneumoniae was a possible extended spectrum beta-Lactamase (ESBL) producing strain and may have resistance to treatments with penicillins, Cephalosporins and Aztreonam. The organisms were sensitive to Gentamicin, Imipenem, and Meropenem. The physician was notified of the results. A review of Resident #72's physician's orders revealed the resident was placed in contact isolation every shift for 10 days. The order was given on 10/10/22. The resident was also started on Meropenem 1 Gram intravenously every eight hours for seven days for the treatment of a urinary tract infection (UTI). The antibiotic was supposed to be given between 10/10/22 and 10/17/22. A review of Resident #72's treatment administration record (TAR) for October 2022 revealed the nurses were initialing the TAR to show the resident was placed in contact isolation every shift. The first date the resident was indicated to be in contact isolation was beginning with the day shift on 10/10/22. A review of Resident #72's nurses' progress notes revealed there was no documentation in the progress notes of the resident being in contact isolation precautions. On 10/12/22 at 2:23 P.M., an observation of Resident #72 noted him to be in his room in bed. A urinal was noted to be sitting on his bedside table next to the bed. He was not noted to have a sign posted at his door to reflect he was in contact isolation precautions. There was also no personal protective equipment (PPE) bin hanging on the door as was noted with other rooms of residents in transmission based precautions (TBP's). On 10/12/22 at 3:52 P.M., an interview with non-certified Nursing Assistant #91 revealed she had worked at the facility for about 10 months now. She predominantly worked on Unit 1 and was familiar with Resident #72. She reported he required an extensive assist with care and used a urinal most of the time when he needed to void. He was also known to be incontinent of his bladder at times. They emptied his urinal and assisted him with incontinent care when needed. She was not aware of him being on any type of TBP's. She stated, if a resident was on TBP's, they would have a bin on their door with PPE and they would also be told in report. She denied she had been told Resident #72 was in contact isolation precautions. On 10/12/22 at 3:56 P.M., an interview with LPN #36 confirmed Resident #72 was known to have ESBL in his urine and was on an antibiotic that was started on Monday (10/10/22). She also confirmed the resident was known to be incontinent of his bladder but was also known to use a urinal at times. It was mainly at night when he would be incontinent of urine. She denied she was aware of him being on any type of TBP's and confirmed he was not in contact isolation precautions at that time. She was then asked if a resident with ESBL in his urine should be in contact isolation. She checked the resident's physician's orders and confirmed he was placed in contact isolation precautions beginning on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365425 If continuation sheet Page 37 of 39 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 365425 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Newark 75 McMillen Drive Newark, OH 43055 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 10/10/22 and it was to continue for 10 days. She denied a sign was posted outside his room to identify him as being in contact isolation and denied he had any PPE in a bin outside his room. She confirmed staff should be wearing PPE to include a gown and gloves when entering that room. A review of the facility's policy on Isolation Precautions revised February 2019 revealed the facility employed general infection control procedures designed to minimize the risk of a resident or staff member acquiring or spreading communicable diseases. When indicated and appropriate level of isolation precautions would be implemented. TBP's were used specifically for residents with known or suspected disease which was spread by airborne transmission, droplet transmission or contact transmission. Orders for specific isolation were to be obtained from the physician. When TBP's were implemented, an isolation cart would be used for supplies. They were to place the cart outside of the room when possible. Appropriate containers were to be placed in the room for linens and trash. A sign was to be placed on the resident's door or doorframe directing visitors to see a nurse before entering the room. Based on observation, interview, and record review, the facility failed to follow droplet precautions during meal pass and did not implement isolation precautions for Resident #72 as ordered. This affected seven residents (#12, #72, #73, #83, #84, #285, and #286) and had the potential to affect all 85 residents residing in the facility. Findings include: 1. Observation on 10/11/22 from 12:15 P.M. to 12:28 P.M. of meal pass revealed State Tested Nursing Aide (STNA) #89 enter Resident #84's room. Resident #84 had a sign indicating droplet precautions and personal protective equipment (PPE) on his door. STNA #89 placed a meal tray on Resident #84's bedside table and moved the bedside tablet in front of him. STNA #89 was wearing an N-95 mask and eye protection. STNA #89 exited Resident #84's room, she did not sanitize her hands, replace her mask, or clean her eye protection. She then entered Resident #73's room and adjusted his pillow. STNA #89 applied a gown and gloves and entered Resident #286's room and delivered a lunch tray. Resident #286 had a sign on her door indicating droplet precautions with PPE on the door. STNA #89 exited Resident #286's room, she changed her N95 mask and did not sanitize her hands after, she did not clean her eye protection. STNA #89 then put on a gown and gloves and entered Resident #12's room with a meal tray. Resident #12 had PPE and a sign indicating droplet precautions on the door. When STNA #89 exited the room, she changed her N95 mask and did not sanitize her hands after, she did not clean her eye protection. She then grabbed a meal tray and entered Resident #285's room. Resident #285 had PPE and a sign indicating droplet precautions on the door. STNA #89 exited the room and changed her N95 mask she did not sanitize her hands after and did not clean her eye protection. STNA #89 then entered Resident #83's room and delivered a meal tray. Interview on 10/11/22 at 12:29 P.M. with STNA #89 confirmed she went in Resident #84's room and delivered his meal tray without additional PPE and without sanitizing her hands, she reported she did not realize he was on precautions. However, STNA #89 confirmed their was a sign and PPE on his door. STNA #89 confirmed the observations, she reported she did not sanitize her goggles because she just replaced them every few hours. Review of the medical record revealed Resident #12 admitted on [DATE] with re-entry on 10/01/22 with diagnoses including Parkinson's disease, chronic kidney disease stage three, type two diabetes mellitus, bipolar disorder colostomy status, mild intellectual disabilities, COVID-19 as of 10/01/22 and Pneumonia as of 10/03/22. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365425 If continuation sheet Page 38 of 39 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 365425 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Newark 75 McMillen Drive Newark, OH 43055 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Review of the physician's order for Resident #12 from 10/03/22 to 10/11/22 revealed the resident required isolation due to positive COVID status. Review of the medical record revealed Resident #73 admitted on [DATE] with diagnoses including traumatic subarachnoid hemorrhage with loss of consciousness, acute respiratory failure with hypoxia, encounter for attention to tracheostomy, encounter for attention to gastrostomy, metabolic encephalopathy, and anxiety disorder. Review of the medical record revealed Resident #83 admitted on [DATE] with diagnoses including Alzheimer's disease, dementia, hypertension, chronic obstructive pulmonary disease, moderate protein-calorie malnutrition, and mood disorder. Review of the medical record revealed Resident #84 admitted on [DATE] with diagnoses including cerebral infarction, acute and chronic respiratory failure with hypoxia, severe protein-calorie malnutrition, hemiplegia and hemiparesis following cerebral infarction, bipolar disorder, and dysphagia. Review of the medical record revealed Resident #286 admitted on [DATE] with diagnoses including borderline personality disorder, gastro-esophageal reflux disease, bipolar disorder, spinal stenosis, and fusion of spine. Review of the medical record revealed Resident #285 revealed the resident admitted on [DATE] with a diagnosis of atherosclerotic heart disease. Review of the staff schedule for 10/11/22 revealed STNA #89 was assigned unit four. Review of the policy titled Transmission-Based Precautions dated 08/01/22, revealed droplet precautions were intended to prevent the transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions. For droplet precautions staff should wear gloves, gowns, and masks. Review of the Center's for Disease Control's (CDC) COVID-19 eye protection guidelines dated 09/13/21, revealed reusable eye protection should be cleaned and disinfected after each resident encounter. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365425 If continuation sheet Page 39 of 39