Inspection·October 30, 2025

F 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few included: analyze key times, places, circumstances, triggers and what de-escalates behaviors and document; assess the resident's coping skills and support system; assess the resident's understanding of the situation, allow time for the resident to express self and feelings to the situation; assess risks when the resident makes manipulative statements; evaluate for side effects of medications; monitor/document observed behaviors and attempted interventions in behavior log.Review of the care plan focus for Resident #82, revised [DATE], revealed that Resident #82 was assessed to have the potential for a mood problem displayed as anxiety or restlessness due to depression and anxiety. Suggested interventions included: assess/evaluate resident's behavior and cognition systematically and continually throughout the day and night as appropriate; discuss possibility of changes in mental status, agitation, confusion and restlessness with responsible party/family member; monitor for possibility of changes in mental status, agitation, confusion and restlessness; report to practitioner mood patterns of acute agitation, anxiety and/or restlessness; and to use the counseling source.Review of previous PHQ Questionnaire completed with Resident #82 on [DATE] revealed Resident #82 scored a 12 at that time, which indicated moderate depression.Review of the trauma evaluation completed on [DATE] for Resident #82 indicated trauma of forklift accident and triggers were nightmares. There was a ‘no' selected for the question of whether the resident had any new trauma or issues related to old trauma. There was no other information on this documentation regarding Resident #82's behaviors or triggers that would lead him to seek maladaptive coping strategies such as substance use. Review of the annual Minimum Data Set (MDS) assessment, dated [DATE], revealed Resident #82 had intact cognition. Resident #82 required setup or cleanup assistance for eating and oral hygiene. Resident #82 required partial/moderate assistance for upper body dressing, rolling left to right, and moving from sitting to lying position. Resident #82 was dependent on staff for toileting, showering/bathing, lower body dressing, putting on/taking off footwear, personal hygiene, chair to chair transfers and tub transfers. Resident #82 used a motorized wheelchair and was independent for wheeling 150 feet.Review of the plan of care for Resident #82, last reviewed by the facility on [DATE], revealed no mention of Resident #82's history of substance use, current substance use or previous homelessness. While the care plan mentioned that he was paraplegic, it was in the context of noting he had potential risk for falls. There was no mention in the care plan of trauma history related to the life-changing industrial accident or the death of both parents which eventually led to his homelessness. There was no mention in the care plan of his history of leaving the facility without signing out. Subsequently, there was no documentation of triggers that might lead Resident #82 to want to pursue illicit substance use. Additionally, there was no suggestion of actions to take in order to keep the resident safe when Resident #82 returned to the facility with an altered mental status and was presumed to be high. Review of physician orders for [DATE] for Resident #82 revealed no orders for Narcan and no orders for monitoring Resident #82 for potential adverse effects from any incidents of illicit substance use.Review of the nursing progress note from [DATE] at 8:11 P.M. revealed Resident #82 had left the building at 7:00 A.M. in his mechanical wheelchair and did not sign out in the leave of absence (LOA) book or tell anyone where he was going. Per the note, he returned at 11:30 A.M. with a known drug addict and appeared to be not acting normal. The nurse and the Administrator spoke with the resident and requested a urinalysis (drug screen). They also notified the CNP who put the resident's narcotics on hold and wrote the order for urinalysis. The resident agreed to the drug test but said he wanted to go with his friend and would be back in an hour. The note went on to say that he had not returned by 8:11 P.M.Review of the nursing progress note from [DATE] at 5:44 A.M. noted Resident #82 returned to the building at 5:30 A.M.Review of the nursing progress note from [DATE] at 12:27 A.M. revealed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365425 If continuation sheet Page 2 of 6 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 10/30/2025 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 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #82 and a visitor friend of his were following the Certified Nursing Assistants (CNA) around the building and making them uncomfortable. The note indicated the resident attempted to follow the aide into the bathroom and sat outside the door attempting to talk to the aide while the aide was using the restroom. The note went on to say that Resident #82 was acting erratically and listening to music loudly which upset other residents. The Administrator was notified and per the nursing note, suggested they ask the visitor to leave the building.Review of the nursing progress note from [DATE] at 1:21 P.M. revealed Resident #82 continued to refuse drug testing and continued with altered mental status. There was a new order to discontinue the resident's Oxycodone order. Review of the Medication Administration Report for [DATE] for Resident #82 revealed his order for Oxycodone 10 milligrams by mouth every 6 hours was held on [DATE] and [DATE] and discontinued on [DATE].Review of the nursing progress note from [DATE] at 1:53 P.M. revealed Resident #82 was sliding out of his chair, continued with altered mental status, slurred speech and his eyes were closed. Staff used a Hoyer lift to get the resident back in bed.Review of the nursing progress note from [DATE] at 2:03 P.M. revealed that while staff were preparing a bed for resident, they found weapons and tetrahydrocannabinol (THC) (a psychoactive compound found in the leaves and flowers of the cannabis plant) gummies and removed them from the residents area.Review of the nursing progress note from [DATE] at 6:07 P.M. revealed Resident #82 had been yelling out, was incoherent and mumbling. The nurse asked if he wanted dinner but was unable to understand his speech and left the resident in bed with call light in reach.Review of the nursing progress notes for Resident #82 for [DATE] at 8:20 P.M. revealed Resident #82 was reported to be not acting right and was noted to be yelling, screaming and exhibiting incoherent speech. The note indicated he had history of suspected substance use, and the resident refused a urine sample. He had low oxygen saturation at 58% (normal ranges from 92 to 100%) and appeared disoriented. With oxygen at 2 liters, they were able to increase his oxygen saturation to 67%. Facility staff called 911 due to his low oxygen levels and altered behavior. Emergency medical services (EMS) arrived and noted the resident to be alert and oriented and therefore they could not transport resident as he refused to go. The CNP was notified.Review of the physician progress note for Resident #82 posted [DATE] at 12:00 A.M. noted the purpose of the visit was a regulatory visit to address chronic conditions including chronic pain, insomnia, edema and leukocytosis. The progress note attributed Resident #82's insomnia to Resident #82 drinking several caffeinated beverages throughout the day and recommended for him to not have caffeine after 4:00 P.M. The note had no mention of the events of the previous week, how methamphetamines would contribute to insomnia, and there was no mention of the resident's history of substance use. Review of the CNP progress note from [DATE] at 11:02 A.M. revealed the CNP was seeing him for a follow up visit for cellulitis Resident #82 had in July that was since resolved with a 10 day course of cephalexin. The note indicated Resident #82 had increased bilateral lower extremity (BLE) edema and community acquired pneumonia (CAP), but had refused treatment. Per the note, on that day, Resident #82 told the CNP to go away because he didn't feel good. There was no mention in the note regarding the recent incident where the staff believed the resident to have used illicit substances in the past week or Resident #82's substance use history.Review of progress note dated [DATE] at 1:20 P.M. revealed a nurse had completed a Patient Health Questionnaire (PHQ) (screening tool for depression) evaluation for Resident #82 with a resulting score of 21, which indicated severe depression and a nine-point increase from the last assessment in [DATE]. No new interventions were in place after this noted increase in depression.Review of nursing progress note from [DATE] at 4:15 P.M. revealed an aide notified the nurse that Resident #82 was acting abnormal. The nurse noted the resident appeared anxious, but unable to express full thought process to the nurse (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365425 If continuation sheet Page 3 of 6 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 10/30/2025 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 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and was only responding with one or two words. The note indicated his verbal speech and responses were noted to be confused. The note indicated the resident said he was scared and wanted to go to the hospital, but was afraid to be alone. He was noted to be shaking. The nurse called the squad, administered oxygen for shortness of breath and anxiety. Review of hospital emergency department (ED) note dated [DATE] at 4:32 P.M. revealed Resident #82 presented to the emergency room (ER) due to concern worsening shortness of breath. The note indicated the residents history was limited. Resident #82 was found to be hypoxic (inadequate supply of oxygen) requiring a nonrebreather (device that delivers high concentration of oxygen). There was no mention in the ER note regarding recent suspected drug use. He was given new diagnoses of acute respiratory failure with hypoxia and hypercapnia, and pneumonia of both lungs due to infectious organism in an unspecified part of lung. Review of the hospital toxicology (drug) screen collected [DATE] for Resident #82 revealed only three substances were tested: acetaminophen (Tylenol), salicylate (such as aspirin) and ethanol (alcohol). Resident #82 tested negative for the alcohol.Review of the hospital physician documentation from [DATE] at 9:57 A.M. revealed while Resident #82 was in hospital, he had chronic hypoxemia on 3 liters of oxygen and the physician noted he previously did not have a pulmonary diagnosis. The physician attributed Resident #82's condition to his history of smoking and history of drug use and wrote that his status had worsened and therefore he needed to be intubated.Interview on [DATE] at 3:25 P.M. with Licensed Practical Nurse (LPN) #201 revealed she had seen rolled up dollar bills (drug paraphernalia typically used by drug users to snort powdered drugs) in Resident #82's room and that he had a couple of visitors who would come in at two or three in the morning and drop things off and he would act differently afterwards. She lamented that management wouldn't do anything and would state that the facility had a 24-hour visitation policy. She said a co-worker of hers had seen a crack pipe (drug paraphernalia used to heat and smoke crack cocaine) in the room and had written it up and the previous Director of Nursing (DON) made her friend change the writeup. LPN #201 cried as she shared that some of the staff were in recovery and would get nervous going into his room because you would never know what you would find. She said they would double glove for fear of fentanyl residue. Interview on [DATE] at 8:15 A.M. with Resident #75 revealed that Resident #82 would scream and yell and made her and her daughter uncomfortable. She said he played rap music really loud and she didn't like the language in the music. She said sometimes she would get her medication late or aides wouldn't be available to help her because they were taking care of [Resident #82]. Interview on [DATE] at 8:27 A.M. with Resident #68 revealed she kept her distance from [Resident #82] because he was cruel to her when he asked her to help him in his room. A couple of times he came into her room and asked her to rub his arm and she said he told her it soothed him. She did that twice but chose not to do it again because she didn't want it to be a habit. She said he was verbally abusive to staff and other residents. She said she hadn't had many conversations with him because she remembered him telling her about what he had done to somebody and how he got even, though Resident #68 did not elaborate as to what Resident #82 had done. She said she stayed away from him after hearing that. Interview on [DATE] at 8:51 A.M. with Certified Nursing Assistant #209 revealed she was close with Resident #82, but noted he was obnoxious with his music. She said his playing loud music would be during his moments when he was really high. She said his drug use was really bad the past four months. She said she never saw the drugs herself, but she could tell when he was high. She expressed sadness for him and noted he had depression from his accident. She said she was working one of the times when he came back to the facility from being out and he was really high, and he had a female friend and they were picking stuff up off the ground that weren't there. She said the night he came back at 5:30 A.M. he asked staff to lie for him (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365425 If continuation sheet Page 4 of 6 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 10/30/2025 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 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few but they didn't want to. She expressed sadness for the pain that he had in the days leading up to going to the hospital. She said she didn't think he was high then because he was moaning and groaning and he didn't do that when he was high.Interview on [DATE] at 9:08 A.M. with Certified Nursing Assistant #208 revealed she knew Resident #82 before he moved to the facility. She shared that he started using recreational drugs after his accident. She said she didn't believe his recreational drug use to be for pain control but rather for coping. She said before his accident he was young and fit and took pride in himself and after the accident he just didn't seem to care anymore. She shared that he had been living with his parents and then when they both died, he became homeless. She said she had seen some of the visitors that have come in were pretty [NAME]. She said she didn't know of any attempts to supervise visits. She said she saw a rolled up dollar bill in his room and heard about the other items that were removed from the room. She said she thought his hospitalization might be related to his drug use because his drug of choice was methamphetamine (meth) and his route of choice was smoking it. Interview on [DATE] at 9:54 A.M. with CNP #206 revealed he did not know why they didn't retain the diagnosis of drug abuse from when Resident #82 first moved to the facility. He said they should have left that on there. He said he believed the use of meth to be intermittent, although noted it had been a problem the past couple of years off and on. He noted he received a lot of calls from staff over the years. He said they would say that Resident #82 was confused, up all night and/or wired. In regards to the absence of a Narcan order, CNP #206 noted it may have been there when Resident #82 first came to facility and it would have been removed if it wasn't used. He said the facility had Narcan on site though. He confirmed he did not have a specific order for observations when Resident #82 would return high and that he would tell staff to keep an eye on the patient. He said that in the past, Resident #82 did test positive for meth which coincided with the insomnia. He discussed the challenge of pain management when Resident #82 would refuse a drug screen. He said he would have to take Resident #82 off of the opioids because they didn't want interactions. He said he would have conversations with Resident #82 about formal substance use disorder treatment any time he had to take Resident #82 off of his narcotics, however, Resident #82 would decline because Resident #82 feared losing access to his pain medicine. CNP #206 said he didn't know if he had documented these conversations. CNP #206 shared that they just recently made an appointment for Resident #82 to go to a pain clinic and that was the suggestion of the new Director of Nursing. He lamented that they probably should have done that a long time ago. He said he did not know that Resident #82 smoked his meth and thought that it could have a connection to his breathing issues. CNP #206 said he was not aware of how or when Resident #82 had his accident and that he didn't know that both parents were deceased . He had not noticed that the two significant incidents documented were the same week a year apart and didn't know if the month of October had any significance to Resident #82. He said knowing these type of things about Resident #82's past may have helped them provide better care.Interview on [DATE] at 1:34 P.M. with the Director of Nursing (DON) confirmed there was no update to the care plan after the PHQ results for Resident #82 went from a 12 to a 21 and indicated severe depression. She said he wasn't in his right state of mind for them to follow up. She did not know if he had seen a counselor more recently than [DATE]. She said the last few weeks she had heard about odd behaviors. The DON said she did not know or notice that the occurrences when Resident #82 returned to the facility with altered mental status were during the same week of October in 2024 and [DATE]. She said he never did agree to take a urine test when it was ordered earlier this [DATE]. Interview on [DATE] at 1:36 P.M. with Housekeeping Supervisor #211 revealed Resident #82 would frequently complain about not being able to sleep and other people would tell her that it was because he was high. Interview (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365425 If continuation sheet Page 5 of 6 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 10/30/2025 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 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete on [DATE] at 1:45 P.M. with Housekeeper #212 revealed that when they were cleaning Resident #82's room they found a pipe that you smoke out of, lighters and vapes.Interview on [DATE] at 1:47 P.M. with Hospital Representative #265 revealed the hospital would only do an abbreviated toxicology screen unless they knew they needed to run a full one. She noted the emergency department notes did not have reports of recent meth use.Review of Substance Abuse and Mental Health Services Administration publication, Treatment of Stimulant Use Disorders noted long term use of cocaine and methamphetamines can cause mood fluctuations, anxiety and depression, even when not using the drugs. A strong evidenced-based treatment for stimulant use disorder is the use of contingency management that incentivizes positive behaviors with small prizes or privileges.Review of Centers for Disease Control publication A Stimulant Guide, dated 2022 revealed signs and symptoms of a stimulant overdose included dilated pupils, dizziness, tremors, irritability, confusion, mood swings, panic, or extreme anxiety. Overdoses from stimulants such as methamphetamines may not result in loss of consciousness. The effects of stimulant use may cause someone to panic and act impulsively out of fear or self-defense. People who have used stimulants may experience sleep deprivation or paranoia leading to energetic or loud physical behaviors that could be interpreted as aggressive. Review of facility policy, Visitation, dated 2017, revealed the facility provides 24-hour access to all individuals visiting with the consent of the resident. Some visitation may be subject to reasonable restrictions as outlined in licensure and/or that protect the security of the facility's residents such as: Limiting or supervising visits from persons who are known or suspected to be abusive or exploitative to a resident; denying access to individuals who are found to have been committing criminal acts; and denying access to visitors who are inebriated or disruptive.Review of the undated facility policy, Abuse, Neglect, Exploration and Misappropriation of Resident's Property and Injuries of Unknown Sources, revealed the definition of neglect to be recklessly failing to provide a resident with any treatment, care, goods or services necessary to maintain the health or safety of the resident when the failure results in serious physical harm to the resident. Residents that may be at increased risk include behaviorally disturbed residents-aggressive, agitated. The policy further stated that the facility will strive to identify, correct and intervene in situations in which abuse, neglect more likely to occur, including: the assessment, care planning and monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as residents with a history of aggressive behaviors such as entering other residents' rooms, residents with self-injurious behaviors, residents with communication disorders, those that require heavy nursing care and/or totally dependent on staff.This deficiency represents non-compliance investigated under Complaint Number 2654456. Event ID: Facility ID: 365425 If continuation sheet Page 6 of 6