Inspection·February 14, 2024

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 record review, staff interview, review of the grievance log, review of a fall investigation, and facility policy review, the facility failed to timely notify one resident's (Resident #101) representative of a fall resulting in hospitalization. This affected one (Resident #101) of three residents reviewed for notification of changes. The facility census was 95. Findings Include: Review of the closed medical record for former Resident #101 revealed an initial admission date on 01/15/14, a readmission date on 04/16/16, and a discharge date on 01/03/24 due to passing away. Medical diagnoses included dementia with behavioral disturbance, traumatic subdural hemorrhage without loss of consciousness, weakness, unsteadiness on feet, lack of coordination, cognitive communication deficit, anxiety disorder, post-traumatic stress disorder (PTSD), major depressive disorder with psychotic symptoms, and peripheral vascular disease. Review of Resident #101's profile revealed the resident's daughter was the resident's responsible party and was listed as Emergency Contact #1. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #101 was rarely or never understood. Resident #101 had severely impaired cognition, displayed inattention and disorganized thinking. Resident #101 rejected care one to three days out of the review period. Resident #101 required stand by assistance with bed mobility and partial to moderate assistance from staff to complete transfers and ambulation. Resident #101 had one fall since admission or prior assessment with a major injury. Review of the progress notes for Resident #101 revealed on 12/20/23 at 4:49 P.M., Resident #101 was observed sleeping on a bed in another resident's room. Moments later a nurse walked by and witnessed Resident #101 lying on the floor with his head covered in blood. One nurse held pressure to the resident's head while another nurse prepared paperwork and called emergency medical services (911). On 12/20/23 at 9:00 P.M. (approximately four hours later), Registered Nurse (RN) #222 spoke with Resident #101's daughter regarding the resident's status. On 12/21/23 at 1:37 A.M., Resident #101 returned to the facility at 10:20 P.M. from the hospital. Bruising was noted to the resident's orbital (eye) area up to the right side of his forehead/temple area. There was an open area noted to the corner of the eye area. On 12/21/23 at 6:12 A.M., Licensed Practical Nurse (LPN) #220 noted per the report from the hospital, Resident #101 sustained a subdural hematoma. On 01/03/24 at 7:42 P.M., Resident #101 passed away in the facility at approximately 6:40 P.M. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 365425 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 02/14/2024 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)