Inspection·May 26, 2021

F 0550 Level of Harm - Minimal harm or potential for actual harm On 05/19/21 at 8:00 A.M. interview with RN #5 revealed she forgot to knock on the resident's door before entering. On 05/20/21 at 10:00 A.M. interview with the Administrator revealed all staff were required to knock on every door and ask permission to enter the room. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365435 If continuation sheet Page 2 of 29 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 365435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Logan 300 Arlington Avenue Logan, OH 43138 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 and staff interview the facility failed to ensure residents received the appropriate liability notices and/ or received timely notification when their skilled services ended. This affected two residents (#32 and #68) of three residents reviewed for liability notices. Residents Affected - Few Findings include: 1. A review of Resident #32's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including closed fracture of the left ankle, muscle weakness, reduced mobility, difficulty in walking and need for assistance with personal care. A review of Resident #32's nurses' progress notes revealed the resident was admitted to the facility on [DATE] for occupational therapy, physical therapy, and medical management following a surgical repair of a left ankle fracture. He was discharged home on [DATE]. A review of Resident #32's Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review form revealed the resident's Medicare (MCR) Part A skilled service episode start date was on 03/22/21. His last covered day of Part A service was indicated to be 05/17/21. The facility indicated they initiated the discharge from MCR Part A services when the resident's benefit days were not exhausted. The facility indicated a Centers for Medicare and Medicaid Services (CMS) form 10055 was issued to the resident but a CMS 10123 form was not issued as required. The facility indicated a CMS 10123 form was not provided to the resident as they marked the box indicating the beneficiary initiated the discharge. If the beneficiary initiated the discharge, the facility was to provide documentation of those circumstances such as the resident asked the doctor to go home, got orders and discharged the same day or the resident discharged against medical advice (AMA). No documentation was provided to reflect any of those situations applied. On 05/25/21 at 1:30 P.M., an interview with Registered Nurse (RN) #101 revealed she was one of the Minimum Data Set (MDS) nurses who were responsible for completing the MCR liability notices when a resident's skilled service ended. She confirmed she was the one who filled out the liability notice forms for Resident #32. She was not aware there were two different CMS forms to use and did not know which CMS form was required when a resident's skilled service ended and they were discharged home or remained in the facility. She stated she just grabbed a form to fill it out without knowing there were two different ones to choose from. 2. A review of Resident #68's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, atherosclerotic heart disease and hypothyroidism. She remained in the facility after her skilled service for therapy ended. A review of Resident #68's SNF Beneficiary Protection Notification Review form revealed her MCR Part A skilled service episode start date was 04/16/21. Her last covered day of Part A services was 05/12/21. A review of Resident #68's CMS 10123 form (Notice of MCR Non-Coverage) revealed she was not provided notice of her skilled service ending until 05/11/21, the day before her skilled service ended. She did not receive at least a 48 hour notice before the ending of her skilled service as required. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365435 If continuation sheet Page 3 of 29 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 365435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Logan 300 Arlington Avenue Logan, OH 43138 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 Findings were verified by RN #67. Level of Harm - Minimal harm or potential for actual harm On 05/25/21 at 1:32 P.M., an interview with RN #67 revealed she was one of two staff members that were responsible for issuing the MCR Part A liability notices to the residents when their skilled service ended. She acknowledged Resident #68 was not given a 48 hour notice before her skilled service ended as the date of her last covered Part A service was on 05/12/21 and a notice was not provided until 05/11/21. She stated she attempted to contact the resident's grandson but was unable to reach him. She reported she then went to Resident #68 on 05/11/21 and found out by the resident she was her own responsible party. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365435 If continuation sheet Page 4 of 29 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 365435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Logan 300 Arlington Avenue Logan, OH 43138 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 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on observation, staff interview and policy review the facility failed to maintain confidentiality of medical records for Resident #89 when the resident's list of medications was viewable on the computer monitor located on the medication cart on the 700 Hall. This affected one resident (#89) of 92 residents residing in the facility. Residents Affected - Few Findings include: On 05/19/21 at 8:15 A.M. Licensed Practical Nurse (LPN) #78 was observed administering medications to Resident #89. After obtaining and preparing the medications, the nurse left the medication cart to administer the medications to the resident without securing the computer monitor on the 700 Hall medication cart. The medication cart was in the middle of the hallway and viewable to anyone who passed by. Resident #89's name and medication list were clearly viewable on the monitor. The nurse left the medication cart unattended from 8:15 AM to 8:17 AM. An interview with LPN #78 on 05/19/21 at 8:18 A.M. revealed she should have locked the computer monitor before stepping away from the medication cart. On 05/20/21 at 1:45 P.M. an observation of the 700 Hall revealed the medication cart was in the hallway unattended. There were no staff members in sight of the cart. The computer monitor on top of the cart was open and Resident #89's name and medication list were clearly visible for anyone to see. The computer monitor was open until 1:50 PM. An interview with the Regional Director of Nursing (RDON) #142, on 05/20/21 at 1:50 P.M. revealed resident's personal and medical information should always be protected. The RDON revealed all computer monitors should be locked before stepping away from the medication carts. A review of the facility policy titled Confidentiality of Information and Personal Privacy with a revision date of 10/2017 revealed the facility would protect and safeguard resident confidentiality and personal privacy. Access to resident personal and medical records would be limited to authorized staff and business associates. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365435 If continuation sheet Page 5 of 29 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 365435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Logan 300 Arlington Avenue Logan, OH 43138 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility self reporting incidents (SRI's), record review, interview and policy review the facility failed to ensure Resident #67 and Resident #40 were free from incidents of resident to resident sexual abuse. The facility also failed to recognize sexually inappropriate behaviors as sexual abuse and failed to substantiate allegations of sexual abuse when they occurred. This affected two residents (#40 and #67) of two residents reviewed in two separate SRI's involving allegations of sexual abuse. Findings include: A review of Resident #67's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including schizophrenia, major depressive disorder, panic disorder, hemiplegia (paralysis) and hemiparesis (weakness) following a stroke affecting her left non-dominant side. A review of an incident report for Resident #67 regarding an incident occurring on 04/14/21 revealed Resident #67 was sitting in the front common area alongside a male resident when he reportedly grabbed her left arm and touched her breast. The resident reported Resident #19 grabbed her left arm and touched her breast. A review of a Brief Interview for Mental Status (BIMS) assessment for Resident #67 completed on 04/16/21, as part of the facility's investigation, revealed the resident's cognition was moderately impaired. A witness statement from Resident #67, that was obtained by the facility's social worker, revealed the social worker asked the resident if she felt safe and if she was afraid. Resident #67 stated she did feel safe and was not afraid, as long as Resident #19 stayed away from her. Resident #67 reported to the social worker Resident #19 grabbed her by the arm and pushed her arm toward her breast, attempting to grab her breast. A review of Resident #19's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including mood disorder, major depressive disorder and other specified mental disorders due to known physiological conditions. The resident was noted to have sexually inappropriate behaviors in the past to include touching female breasts in November 2019 and again in January 2020. He had been involved in six facility SRI's since November 2019, with four of those SRI's involving allegations of sexual abuse and touching the breasts of female residents. His cognition was noted to be moderately impaired. A review of an incident report for Resident #19 regarding the incident occurring on 04/14/21 revealed Resident #19 was sitting in the common area and it was reported that he had inappropriately touched two female residents' breasts. The resident denied doing so when questioned about the alleged incident. A review of a Psych 360 note dated 04/16/21 revealed Resident #19 was seen on that date for a follow up evaluation and a medication check. The visit was completed by teleconference with assistance from a nurse at Psych 360. The note indicated Resident #19 had been having increased sexual behaviors and grabbed the breast of a female. He had been known to have sexual behaviors in the past. The psychiatrist ordered the resident to receive Tagamet 200 milligrams (mg) by mouth twice a day for sexual behaviors. Non-pharmacological interventions (NPI's) were identified for the facility to follow in an effort to manage his sexually inappropriate behaviors. One of the interventions recommended (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365435 If continuation sheet Page 6 of 29 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 365435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Logan 300 Arlington Avenue Logan, OH 43138 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few included seating the aggressive resident away from residents he had targeted during social gatherings. There was an addendum added to the psychiatric evaluation note dated 04/22/21 which revealed the incident regarding the alleged inappropriate sexual behavior (grabbing a female's breasts) was investigated by the administration of the facility and was found to be unsubstantiated. It was found that Resident#19 did not grab anyone in the breasts. As a result of the facility's investigation, the psychiatrist discontinued the use of Tagamet for sexually inappropriate behaviors. A review of Resident #19's care plans revealed the facility initiated a care plan for him displaying sexually inappropriate behaviors. The care plan was initiated on 04/19/21. The goal was for the resident to interact and socialize with female/ male peers in an appropriate manner. Interventions included limiting any at risk situations. A review of a facility SRI, tracking number 204931 dated 04/15/21 revealed the facility reported an allegation of sexual abuse involving Resident #19 and Resident #67. Resident #19 was identified as the alleged perpetrator and Resident #67 was identified as the involved resident. The initial source of the allegation was indicated to be a staff member. The date and time of the occurrence was on 04/14/21 at 12:35 P.M. A narrative summary of the incident revealed Resident #67 alleged Resident #19 had reached around and touched her in the breast. The incident was not witnessed but Resident #67 was able to provide meaningful information when she was interviewed. The facility's narrative summary of the incident revealed social services interviewed Resident #67 later and she reported Resident #19 grabbed her by the arm and pushed her arm towards her breast, attempting to grab her breast. Due to the facility's investigation, it was believed Resident #67 was not sexually abused. The facility unsubstantiated the allegation indicating the evidence did not support abuse occurred. As a result of it's investigation, the facility had Resident #19 seen by Psych 360, a consulting psychiatric service used by the facility. On 05/19/21 at 12:45 P.M., an interview with Resident #67 deemed her to be able to be interviewed as she was alert and oriented and responded appropriately to questions asked. Her short term memory was intact but she had a little difficulty with long term memory and required prompting to recall things that happened in her recent past. She was asked vague questions regarding any prior resident to resident altercations she may have had and she denied any concerns. She was asked if she ever had any issues with Resident #19 and denied so. She was then asked if any resident had ever inappropriately touched her and then she recalled the incident occurring on 04/14/21 involving Resident #19. She could not recall the exact date or how long ago it was but gave information consistent with some of what was recorded in SRI with tracking number 204931. She reported Resident #19 grabbed her arm and tried to touch her breast at which time she told him to stop. She reported her and Resident #40 were in the lounge area. Resident #19 was trying to mess around with Resident #40's breasts too. She claimed he was also trying to put his hands down Resident #40's pants. She stated she grabbed his hand and pulled him away from Resident #40 and that was when Resident #19 tried to touch her breast. She stated Resident #19 held her arm down with one of his arms while using his other hand to try to get in her blouse so he could put his hand on her breast. She stated he put his hand on her upper breast area and his hand was in direct contact with her skin. On 05/20/21 at 12:34 P.M., an interview with the facility's Administrator revealed the incident on 04/14/21 that involved Resident #19 and #67 was not made known to the staff until 04/15/21. It was noted by the facility's prior Interim Director of Nursing (DON) that the incident was alleged to have occurred when Resident #67 pointed out Resident #19 as the man that touched her inappropriately the day before. She stated it was at that point they initiated their investigation. She denied any of the facility's staff had any prior knowledge of the incident occurring before it was reported to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365435 If continuation sheet Page 7 of 29 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 365435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Logan 300 Arlington Avenue Logan, OH 43138 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interim DON on 04/15/21. She reported their investigation determined sexual abuse did not occur as there were no witnesses to the alleged incident. She confirmed Resident #19 was seen by 360 psych on 04/16/21 and started on Tagamet for sexual behaviors. She was asked why the Tagamet had been discontinued and she replied, you would have to ask nursing that. She denied she was part of any discussions regarding the Tagamet being discontinued based on their investigation. She verified the addendum note from 360 psych indicated it was concluded the resident did not grab anyone in the breast, which was why the Tagamet was discontinued. She was asked, with the resident's known history of sexually inappropriate behaviors and Resident #67 alleging he had touched her breast, if discontinuing the Tagamet solely based on the outcome of their investigation was in the residents' best interests. She acknowledged, even though their investigation could not conclude sexual abuse occurred based on a lack of any witnesses it could not be concluded that sexual abuse did not occur. She acknowledged, with Resident #19's history of past sexually inappropriate behaviors and Resident #67's reports of what happened it could not be ruled out that sexual abuse did not occur as indicated by Resident #67, they just did not have enough evidence through any witnesses to confirm that it had. A review of a SRI with tracking number 205383 for an allegation of sexual abuse dated 04/26/21 revealed Resident #19 was again identified as the alleged perpetrator. The other involved resident was Resident #40. A staff member was the initial source of the allegation and State Tested Nursing Assistant (STNA) #107 was identified as the witness to the alleged incident. A brief description of the allegation revealed Resident #19 was observed touching the breast of Resident #40. Both involved residents were able to provide meaningful information when interviewed despite Resident #40's cognition being severely impaired and Resident #19's cognition being moderately impaired. The date and time of the occurrence was 04/26/21 at 8:30 A.M. and it occurred in the front lobby (where the prior incident with Resident #67 occurred on 04/14/21). The narrative summary of incident indicated STNA #107 notified the nurse Resident #19 was being sexually inappropriate with Resident #40 in the front lobby. Resident #19 was observed reaching out towards the resident's breast area. Resident #40 was known to yell out frequently for her mother and brother. Resident #19 was known to be passive and it was thought that it was possible Resident #19 was trying to comfort Resident #40. It was believed, based on the facility's investigation, sexual abuse was inconclusive due to the cognition of both residents. The facility's administrator completed the investigation. As a result of the investigation, Resident #19 was placed on frequent checks, evaluated in the emergency room and seen by Psych 360. A review of Resident #40's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including weakness, reduced mobility, anoxic brain damage, difficulty walking, bipolar disorder, major depressive disorder, anxiety disorder, post traumatic stress disorder, borderline personality disorder and pseudobulbar affect (condition of uncontrollable laughing or crying in inappropriate situations in which those responses were not typical). A review of the incident report for Resident #40 for the alleged incident occurring on 04/26/21 at 11:23 A.M. revealed it was reported the resident was in the lobby with Resident #19. STNA #107 reported she saw Resident #19 reach out and grab Resident #40's right breast. She immediately intervened and separated the residents. Resident #19 went back to his room and was placed on 1:1 (supervision) along with redirection. Resident #40 was not able to provide a description of the incident due to her severely impaired cognition. A review of the incident report for Resident #19 for the alleged incident occurring on 04/26/21 at 11:23 A.M. revealed Resident #19 was in the 100 hall lobby. There was a female resident (Resident #40) sitting in the lobby as well when it was witnessed by a staff member (STNA) that Resident #19 grabbed the breast of the female resident. The STNA intervened and separated the residents. Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365435 If continuation sheet Page 8 of 29 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 365435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Logan 300 Arlington Avenue Logan, OH 43138 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few #19 returned to his room and 1:1 was provided. The physician was notified and a new order was received to send the resident to the emergency room (ER) for a psychiatric evaluation. All responsible parties were notified. A written statement by the facility's licensed social worker from an interview with Resident #40 revealed the resident had a Brief Interview for Mental Status (BIMS) score of four, which indicated her cognition was severely impaired. The social worker asked Resident #40 if another resident touched her inappropriately that morning and she responded yes. The social worker then asked Resident #40 if the resident grabbed her breast and she stated yes. She was then asked if she was afraid and feels safe and the resident reported she did feel safe. She did not show any outward signs of fear or anxiety. A written statement by the facility's licensed social worker from an interview with Resident #19 revealed Resident #19 had a BIMS score of nine, which indicated his cognition was moderately impaired. The social worker asked Resident #19 if he touched another resident inappropriately that morning and the resident denied doing so. Resident #19 was on 1:1 and was sitting in the activity room. A written statement from STNA #107 (witness to incident), as part of the facility's investigation, revealed she was walking off of the 200 hall and back towards the 100 hall when she looked over in the lobby where Resident #40 was sitting. She noticed Resident #19 was touching Resident #40 inappropriately on her breast. She then told Resident #19 he better go back to his room until someone came to talk to him. When she said Resident #40's name, Resident #40 then stated she was about to punch him. Resident #40 was facing the TV and Resident #19 was next to her facing the 100 hall when the incident happened. She then followed Resident #19 to his room and reported the incident to the nurse and then the facility's Assistant Director of Nursing (ADON). A nurse's progress note for Resident #19 (included as part of the facility's investigation) revealed the nurse documented, at approximately 8:30 A.M., an aide from the 100 hall came to her on the 300 hall with Resident #19 and stated he was being sexually inappropriate with a female resident on the 100 hall. The nurse stayed with the resident and notified the DON and ADON of the resident's actions. Resident #19 was then placed on one on one with facility staff. He was transferred to the hospital for an evaluation on 04/26/21 at 12:15 P.M. and returned to the facility around 6:18 P.M. He remained on one on one supervision until he was eventually transferred out to a sister facility on 04/29/21 at 3:10 P.M. On 05/19/21 at 12:30 P.M., an interview with STNA #107 (witness to incident on 04/26/21) revealed she had worked at the facility for ten years. She reported she was a float aide but did work the 100/ 200 hall at times. She confirmed she was working on 04/26/21 when the incident occurred between Resident #19 and #40. She stated Resident #40 was sitting in her wheelchair facing the TV and Resident #19 was facing her. He was in a wheelchair next to Resident #40 sitting in hers. His hand was groping/ caressing Resident #40's breast. She stated she called his name and he dropped his hand. When she called out Resident #40's name, Resident #40 told her, if she did not say anything to Resident #19, she was going to punch him. She confirmed his hand was on her breast and in direct contact with Resident #40. She said it was obvious what he was doing and thought Resident #19 had displayed those behaviors before or at least was accused of doing that type of thing. She considered what she saw sexual abuse. She stated she was asked by the nurse and the ADON if Resident #19's hand was in contact with Resident #40's breast and she told them it was. She confirmed she separated the two residents and took Resident #19 back to his room, which was on the 300 hall. She told the 300 hall nurse what he had done and then told the ADON. They provided one on one supervision to Resident #19 and it was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365435 If continuation sheet Page 9 of 29 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 365435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Logan 300 Arlington Avenue Logan, OH 43138 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 0600 continued until he was transferred to an all male facility. Level of Harm - Minimal harm or potential for actual harm On 05/20/21 at 9:21 A.M., an interview with Registered Nurse (RN) #37 revealed he was aware of Resident #19's past sexually inappropriate behaviors and the two incidents that occurred on 04/14/21 and 04/26/21 involving Resident #67 and #40. He confirmed he had been told of the incident on 04/14/21 and reported it to the facility's Administrator, as she was the facility's abuse coordinator. He was then asked about the incident occurring on 04/26/21 between Resident #19 and Resident #40. He confirmed he had been part of that investigation and completed the incident report on behalf of Resident #19's involvement in the incident. He confirmed STNA #107 originally reported it to him. He was told Resident #19 reached out and grabbed Resident #40's breast and was doing a squeezing motion. Resident #40 confirmed Resident #19 did touch her breast but Resident #19 denied doing so when asked. He was asked to re-interview STNA #107 to make sure she did not misconstrue what she saw. He stated STNA #107's report of the incident remained the same. STNA #107 also informed him it had happened before and no one was doing anything about it. He stated he felt something needed to be done about it so he did one on one with the resident until he was sent to the hospital for an evaluation. He reported when Resident #19 got back from the hospital he was placed on every 15 minute checks until he was transferred out of the facility on 04/29/21. He stated he felt the follow up from the facility was lacking. He stated the incident on 04/14/21 of alleged sexual abuse was unsubstantiated but he was not sure it should have been. As a result of the facility's investigation unsubstantiating the allegation of sexual abuse, the team decided to take him off the Tagamet that was initially ordered to treat his sexually inappropriate behaviors. It was considered an unnecessary medication due to it being used for a behavior the facility determined did not occur. He was asked to contact the psychiatrist to see if the Tagamet could be discontinued in which it was. He agreed the facility's investigation into the allegation of sexual abuse on 04/14/21 only showed it could not be substantiated due to the lack of witnesses not that the sexual abuse did not occur. Resident #19's daughter was okay with him receiving the Tagamet as she knew how her dad was. He was not able to explain why the second incident for the allegation of sexual abuse on 04/26/21 was unsubstantiated since they had a witness to the alleged incident that confirmed Resident #19 was touching and squeezing the breast of Resident #40. Residents Affected - Few On 05/20/21 at 12:34 P.M., an interview with the facility's Administrator revealed she could not explain why Resident #19 was allowed to be in the common area of the 100/ 200 hall on 04/26/21, after the first alleged incident occurred in the same area on 04/14/21. She confirmed he resided on the 300 hall, which was the in the middle of the building between the 100/200 hall and the 600/ 700 hall. She acknowledged the psychiatrist from Psych 360 provided them with NPI's to deal with Resident #19's sexually inappropriate behaviors which included seating the aggressive resident away from residents he tended to target during social gatherings. She denied a lack of supervision resulted in allowing the second incident to occur. She was then asked why the facility unsubstantiated the allegation of sexual abuse for the incident on 04/26/21 between Resident #19 and #40 when they had STNA #107 witness the alleged abuse. She reported STNA #107 was inconsistent in what she said as she first said he grabbed Resident #40 with both hands and then indicated it was with only one hand. She reported Resident #19 had paralysis and did not have the use of both hands. She also stated she did not see how it was possible when Resident #40 was in a wheelchair that sat higher up than Resident #19 and she also had a tray in front of her which she did not see how it was possible for him to reach her chest area. She was told the investigation indicated Resident #40 was facing the TV in the common area and Resident #19 was next to her facing the hallway and was not in front of her as she was explaining. She acknowledged STNA #107's witness statement indicated Resident #19 did come in contact with Resident #40's breast and she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365435 If continuation sheet Page 10 of 29 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 365435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Logan 300 Arlington Avenue Logan, OH 43138 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few reported he squeezed her breasts. That was reported to the ADON as well, when he talked with STNA #107 and the ADON reported she was consistent in what she reported with the incident. She acknowledged STNA #107 was interviewed and described Resident #19's actions as groping/ caressing Resident #40's breast. She was asked what she considered to be the definition of sexual abuse. She stated it was taking advantage of a male or female resident by touching, sexual intercourse or unwanted advances. She was asked if touching the breast area of a female resident who was not cognitively intact enough to give consent met the definition of sexual abuse and she reported it did. She was then asked, why she did not substantiate the allegation of sexual abuse at the conclusion of their investigation into the incident on 04/26/21 between Resident #19 and #40 when she had a staff member witness the touching and groping of a females breast, she stated maybe she should have. A review of the facility abuse policy, revised October 2020 revealed the facility would not tolerate abuse of it's residents. Abuse was defined as the willful infliction of injury with resulting physical harm, pain or mental anguish and included sexual abuse. Sexual abuse was defined as non-consensual sexual contact of any type with a resident. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365435 If continuation sheet Page 11 of 29 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 365435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Logan 300 Arlington Avenue Logan, OH 43138 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed medical record review and staff interview the facility failed to provide written notice of the bed hold policy to Resident #99 and the resident's representative when the resident was transferred to the hospital. This affected one resident (#99) of one resident reviewed for hospitalization. Findings include: Review of the closed medical record for Resident #99 revealed an admission date of 03/10/21 with diagnoses including cirrhosis of the liver. A Minimum Data Set assessment completed 03/17/21 indicated the resident had severely impaired cognition. Review of nurse's notes for 03/22/21 at 9:50 A.M. revealed the nurse practitioner was in to assess the resident due to a noted weight gain with distended abdomen. An order was received to send the resident to the hospital. The note revealed the responsible party and resident were aware and agreed with the plan. The resident was then transferred to the hospital. There was no evidence in the closed medical record the resident or resident's representative were provided with a notice of the bed hold policy when the resident was transferred to the hospital on [DATE]. The resident did not return to the facility. Interview with the Administrator and Regional Director of Nursing #142 on 05/20/21 at 11:20 A.M. revealed Resident #99 went to another nursing home closer to his sister after discharge from the hospital and had since passed away. Interview with Regional Director of Nursing #42 on 05/20/21 at 1:15 P.M. confirmed there was no evidence the resident or responsible party were provided with a notice of the bed hold policy at the time of discharge to the hospital on [DATE]. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365435 If continuation sheet Page 12 of 29 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 365435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Logan 300 Arlington Avenue Logan, OH 43138 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 - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and policy review the facility failed to implement a comprehensive and individualized restorative nursing ambulation program to ensure Resident #40 received the assistance needed for ambulation to maintain the resident's highest level of functioning ability. Residents Affected - Few Actual Harm occurred for Resident #40 when the resident experienced a decline in functional ability, from only requiring minimum staff assist with the ability to ambulate 50 feet to requiring maximum staff assist with the ability to only ambulate five feet four months after her physical therapy ended and she was referred to a restorative maintenance program for ambulation that was not implemented. This affected one resident (#40) of five residents reviewed for restorative nursing services. Findings include: A review of Resident #40's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including anoxic brain damage, extrapyramidal and movement disorder, difficulty in walking, reduced mobility, weakness, osteoarthritis, chronic pain, abnormal posture, lack of coordination, contracture in the lower leg, bipolar disorder, borderline personality disorder and anxiety disorder. A review of Resident #40's physical therapy discharge summary for dates of service between 12/10/20 and 01/05/21 revealed the resident required contact guard assist (CGA) at the time of her discharge on [DATE] and was able to ambulate 50 feet. Her prognosis at the time of her discharge to maintain her current level of function was indicated to be good with consistent staff follow through. Her discharge recommendations included a functional maintenance program/ restorative nursing program and assistive device for safe functional mobility. A restorative nursing program was recommended to facilitate the resident to maintain her current level of function and in order to prevent a decline. The development of an instruction in a restorative nursing program that included ambulation and transfers was to be implemented. A review of a therapy discharge recommendation sheet for Resident #40 dated 01/05/20 informational provided instructions for the nursing staff to ambulate the resident up to 50 feet with one person assist and another person to follow with a wheelchair. The resident was to use a front wheeled walker when ambulating. A review of Resident #40's physician's orders revealed no evidence of the resident being on any type of restorative nursing program for transfers or ambulation. The physician's orders did include an order for the resident to be seen by physical therapy (PT) or a physical therapy assistant (PTA) for therapeutic exercise/ activity, transfer/ balance training, gait training and resident/ staff education. The order for PT was given on 05/18/21. Resident #40's medical record was absent for any evidence of her receiving restorative nursing services for transfers and ambulation between 01/05/21 when she was initially discontinued from PT and 05/18/21, when PT was ordered again. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365435 If continuation sheet Page 13 of 29 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 365435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Logan 300 Arlington Avenue Logan, OH 43138 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 - Actual harm Residents Affected - Few A review of Resident #40's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had adequate hearing and vision. Her speech was clear and she was usually able to make herself understood and was usually able to understand others. Her cognition was severely impaired. Physical behaviors occurred four to six days of the assessment period and verbal behaviors directed at others occurred daily. No rejection of care was noted. She required the extensive assist of two staff for bed mobility, transfers and ambulation in her room. Ambulation in the hall only occurred once or twice and she was a one person assist during those times. There was no indication of her receiving any therapy at that time. The end date of her occupational therapy was 02/03/21 and the end date for PT was 01/05/21. The MDS did not indicate the resident received any restorative nursing services during the look back period of the MDS assessment. A review of Resident #40's care plans revealed she had a care plan in place for activities of daily living (ADL) self care performance deficit and physical mobility deficit related to muscle weakness, difficulty in walking, muscle contracture of the lower leg, tremors, reduced mobility, and an extrapyramidal and movement disorder. Interventions included walking with the assistance of one and a walker and PT/ OT evaluation and treatment as per the physician's orders. Resident #40 had a care plan in place for the potential risk for falls. Her care plans did not include anything regarding her receiving restorative nursing services for ambulation. A review of Resident #40's documentation of walking in her room or corridor for the past 30 days located under the task tab of the electronic health record (EHR) revealed ambulation was not attempted due to the resident's medical condition or safety concerns. There was no evidence of any referrals to physical therapy prior to 05/18/21 when staff deemed the resident's medical condition did not allow them to ambulate her or there were safety concerns. A review of Resident #40's PT evaluation and plan of treatment for a certification period between 05/17/21 and 07/15/21 revealed the resident was referred to PT due to exacerbation of decrease in strength, decrease in functional mobility and reduced functional activity tolerance as well as two falls. Her prior level of function was indicated to be a minimum assist for transfers, minimum assist for level surfaces and a distance level surface of 50 feet with the use of a front wheeled walker. She had been more shaky and declined with the ability to transfer/ ambulate with less safety and two falls. She had been able to safely transfer with minimum staff assist and walk with one assist prior with the use of a front wheeled walker (FWW). Her functional assessment at the time of the evaluation revealed she was a moderate assist with sit to stand transfers, maximum assist with stand pivot, maximum assist with level surfaces and her distance level surfaces was five feet using a FWW. On 05/24/21 at 10:57 A.M., an interview with State Tested Nursing Assistant (STNA) #72 revealed she had been employed by the facility since February 2021 and was familiar with Resident #40. She reported the resident had required limited assist of one for transfers and was able to ambulate to the bathroom with a one person assist. She denied she used a walker when ambulating the resident. She reported the resident shook and her legs were unstable so they had to keep a hold of her. She denied the resident was part of a restorative nursing program in which they ambulated her on a regular basis. She stated they had walked her a few times with a two person assist when the resident asked them to. She was able to ambulate short distances like from the TV area to the nurses station but again stated they had no routine or program they were following. She speculated the resident may ask to walk maybe one or two times a week. She denied a walker was used when walking the resident in the hall either. She reported the resident's ability to ambulate hadn't really changed from her perspective but felt if therapy worked with her more she would be able to walk better. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365435 If continuation sheet Page 14 of 29 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 365435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Logan 300 Arlington Avenue Logan, OH 43138 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 - Actual harm Residents Affected - Few On 05/24/21 at 11:43 A.M., an interview with Registered Nurse (RN) #37 revealed the facility did not have a restorative nursing program. RN #37 revealed he had been employed for a few months and denied they had a restorative program during that time. He felt Resident #40 would benefit from an ambulation program. He also denied he had ever seen a walker in the resident's room or known her to use one when going to the bathroom or ambulating for any other reason. A review of the facility's restorative nursing services policy revised August 2018 revealed a restorative nursing program was utilized to assist residents to achieve and/ or maintain their optimal functional level consistent with their capabilities, goals and preferences. Restorative nursing care consisted of nursing interventions that may or may not be accompanied by formalized rehabilitative services. Residents may be started on a restorative nursing program upon admission, during the course of stay or when discharged from rehabilitative care. Restorative goals and objectives were individualized and resident centered, and were outlined in the resident's plan of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365435 If continuation sheet Page 15 of 29 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 365435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Logan 300 Arlington Avenue Logan, OH 43138 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 0687 Provide appropriate foot care. Level of Harm - Minimal harm or potential for actual harm Based on observation, medical record review and interview the facility failed to ensure Resident #67 received podiatry services. This affected one resident (#67) of five residents reviewed for activities of daily living. Residents Affected - Few Findings include: Review of Resident #67's medical record revealed an original admission date of 10/10/20 with the latest readmission of 12/20/20. Diagnoses included insomnia, chronic kidney disease, Parkinson's disease, dysphagia, hypothyroidism, gout, panic disorder, gastro-esophageal reflux, gastroparesis, schizophrenia, convulsions, major depressive disorder, hypertension, chronic pain, cerebral infarction with left sided hemiplegia, congestive heart failure and atrial fibrillation. Review of the resident's monthly physician's orders revealed an order dated 12/20/20 that indicated it was okay to utilize facility ancillary services: podiatrist. Review of the resident's most recent quarterly Minimum Data Set (MDS) 3.0 assessment revealed the resident had clear speech, understood others, made herself understood and had a moderate cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of 10. The resident required extensive assistance from one staff for bed mobility, transfers, personal hygiene and ambulation. On 05/17/21 at 11:59 A.M. observation of Resident #67's feet revealed her toenails were long and unkempt. At the time of the observation, interview with Resident #67 revealed her nails were so long it hurt to wear her shoes. On 05/19/21 at 1:31 P.M. interview with Regional Director of Nursing (RDON) #142 verified the resident had not been seen by the facility podiatrist and the resident's toenails were long and unkempt. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365435 If continuation sheet Page 16 of 29 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 365435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Logan 300 Arlington Avenue Logan, OH 43138 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, record review and staff interview the facility failed to ensure Resident #40's fall prevention interventions were in place as per the physician's orders and plan of care. This affected one resident (#40) of six residents reviewed for accidents. Findings include: A review of Resident #40's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including weakness, reduced mobility, difficulty walking, need for assistance with personal care, extrapyramidal and movement disorder, anoxic brain damage, convulsions, hypotension, abnormal posture, lack of coordination, contracture of a muscle in the lower leg, restlessness and agitation, anxiety disorder and borderline personality disorder. A review of Resident #40's active care plans revealed the resident had the potential risk for falls. Her fall prevention interventions included two assist the resident to the bathroom with use of a walker with care rounds, bilateral assist bars to bed at all times to promote independence in bed mobility and encourage tissues to be in reach while in bed. A review of Resident #40's physician's orders revealed the use of assist handles to her bed for increased independence with bed mobility. The order had been in place since 09/17/19. A review of Resident #40's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/02/21 revealed the resident had adequate hearing and vision. She had clear speech and was usually able to make herself understood and was usually able to understand others. Her cognition was severely impaired. Physical behaviors occurred four to six days of the seven day assessment period and verbal behaviors directed at others occurred daily. She was not known to reject care. The resident required the extensive assist of two staff for bed mobility, transfers and ambulation in her room. Ambulation in the hall only occurred once or twice and she was a one person assist. She required extensive assist of one staff for locomotion on the unit and toilet use. She was identified as having had one fall with no injury since her prior assessment. On 05/24/21 at 10:57 A.M., an interview with State Tested Nursing Assistant (STNA) #72 revealed she had been employed at the facility since February 2021. She was familiar with the resident and last cared for her this past weekend. She reported the resident was a limited assist of one for transfers. She was able to be ambulated to the bathroom with the assist of one. She denied a walker was used during ambulation. She stated staff tried to keep the resident's bedside table by her bed with commonly used items such as her water and remote control in reach. She was asked if there were any fall interventions that involved her box of tissues and she reported they were usually on her bedside table next to the bed. On 05/24/71 at 11:18 A.M., an observation of Resident #40 noted her to be lying in bed. The resident's bed did not have assist handles attached to it nor was her box of tissues noted to be in reach. The tissues were on top of a night stand away from the resident's bed and against the wall by the bathroom door. There was no evidence of a walker being in the resident's room to be used during ambulation. Findings were verified by Licensed Practical Nurse (LPN) #75. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365435 If continuation sheet Page 17 of 29 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 365435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Logan 300 Arlington Avenue Logan, OH 43138 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete On 05/24/21 at 11:18 A.M., an interview with LPN #75 revealed Resident #40 should have her box of tissues in her reach as that was one of her fall prevention interventions. She stated she would have to check to see why the resident did not have assist handles on her bed as per physician's orders and plan of care. On 05/24/21 at 11:36 A.M., an interview with Registered Nurse (RN) #37 revealed he was not sure why Resident #40 did not have assist handles on her bed. RN #37 suspected they may have switched the resident's bed out and did not put the assist bars back on her new bed. He was not sure how long they had been off her bed. He also denied knowledge of the resident having a walker in her room to be used when ambulating. He could not recall the last time he saw the resident with a walker in her room. He acknowledged the assist handles and the use of a walker while ambulating were part of the resident's fall prevention interventions as part of her plan of care. Event ID: Facility ID: 365435 If continuation sheet Page 18 of 29 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 365435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Logan 300 Arlington Avenue Logan, OH 43138 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on observation, medical record review, interview and facility policy and procedure review the facility failed to assess and monitor Resident #53's hemodialysis access site to her left clavicle area and failed to ensure the access site was accurately reflected in the resident's end stage renal failure plan of care. This affected one resident (#53) of one resident reviewed for hemodialysis. The facility identified two residents receiving hemodialysis. Residents Affected - Few Findings include: Review of Resident #53's medical record revealed an original admission date of 05/25/20 with the latest readmission of 10/20/20 with the admitting diagnoses of end stage renal failure (ESRF) with hemodialysis, hepatic failure, alcoholic cirrhosis of liver, diabetes mellitus and chronic viral hepatitis C. Review of the plan of care, dated 10/20/20 revealed the resident was at risk for complications related to diagnoses of ESRF requiring dialysis. Interventions included auscultate shunt site for bruit and thrill per protocol or every shift. Document presence or absence and notify the physician and the dialysis center of absent thrill/bruit, observe shunt site daily for signs and symptoms of infection or bleeding and protect shunt site from injury. Review of the resident's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/05/21 revealed the resident had clear speech, understood others, made herself understood and had no cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of 13. The assessment indicated the resident received dialysis. Review of the resident's monthly physician's orders for May 2021 identified no orders related to the resident's shunt site/central line to her left clavicle area used for hemodialysis. On 05/20/21 at 1:30 P.M. observation of the resident's hemodialysis access site revealed a central line to her left clavicle area with the dressing dry and intact. On 05/20/21 at 1:40 P.M. interview with the Regional Director of Nursing (RDON) #142 verified the resident had a central line located in her left clavicle area for hemodialysis and not a shunt (as referenced in the resident's current plan of care). Review of the facility policy titled, Dialysis Care revealed it was the policy of the facility to ensure residents who were undergoing dialysis treatments were safe, well assessed and that the facility meet the needs of the resident in collaboration with the dialysis unit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365435 If continuation sheet Page 19 of 29 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 365435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Logan 300 Arlington Avenue Logan, OH 43138 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 and staff interview the facility failed to ensure resident's drug regimens were free from unnecessary medications. Non-pharmacological interventions were not attempted prior to administering pain medication and parameters were not in place for as needed anti-hypertensive and/or pain medications for Resident #30 and Resident #37. This affected two residents (#30 and #37) of five residents reviewed for unnecessary medication use. Residents Affected - Few Findings include: 1. Record review for Resident #30 revealed the resident was admitted to the facility on [DATE] with diagnoses including anxiety disorder, post traumatic stress disorder, dementia and essential hypertension. A review of Resident #30's physician orders, dated May 2021 revealed the resident was ordered Hydralazine HCL 25 milligram (mg) every eight hours as needed for hypertension. The order was dated 06/05/20. The medication order had no parameters as to when to give the medication or for what level of hypertension. A review of Resident #30's Medication Administration Record (MAR) dated 05/2021 revealed the Hydralazine was administered on 05/15/21. There was no blood pressure recorded on the MAR or in the progress notes. An interview with Registered Nurse (RN) #5 on 05/25/21 at 7:35 A.M. verified the order for the resident's Hydralazine had no parameters. The RN revealed she would have to call the physician to see at what level of hypertension to give the medication. An interview with Regional Director of Nursing (RDON) #142 on 05/25/21 at 9:30 A.M. revealed the anti-hypertensive medication, Hydralazine, needed parameters as when to administer. The RDON revealed she would ensure the physician was notified an an order clarification would be obtained. 2. Record review for Resident #37 revealed the resident was admitted to the facility on [DATE] with diagnoses including peripheral vascular disease, essential hypertension, malignant neoplasm of colon and acquired absence of left leg below the knee. A review of Resident #37's physician orders, dated May 2021 revealed the resident was ordered Tramadol HCL 50 milligram (mg) every six hours as needed, for pain (order date of 02/10/20). The resident was also ordered Acetaminophen 650 mg every six hours, as needed for pain (order date 01/14/20). Neither order contained parameters as to which pain medication should be given and for what level of pain. A review of the May 2021 Medication Administration Record (MAR) revealed the resident received had received Tramadol HCL 50 mg nine times, as needed for pain levels ranging from a four to ten, on a pain scale of one to ten. The resident also has received Acetaminophen 650 mg four times, as needed for pain levels ranging from six to ten, on a scale of one to ten. Further review of Resident #37's record revealed there was no evidence non-pharmacological interventions were attempted or documented for the as needed Tramadol order in May of 2021. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365435 If continuation sheet Page 20 of 29 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 365435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Logan 300 Arlington Avenue Logan, OH 43138 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 An interview with RN #5 on 05/19/21 at 8:30 A.M. verified there were no written directions as to what level of pain indicated what, as needed pain medication should be administered. The RN revealed she would give both as needed pain medications if the resident complained of pain. The RN revealed non-pharmacological interventions were to be documented on the MAR or in the resident's progress notes if they were attempted. Residents Affected - Few An interview with RDON #142, on 05/25/21 at 10:35 A.M. revealed the as needed Tramadol and Acetaminophen orders should both have parameters as to when to give the pain medication and for what level of pain. The RDON verified no non-pharmacological interventions were attempted prior to the administration of the as needed Tramadol administrations for the dates reviewed in May 2021. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365435 If continuation sheet Page 21 of 29 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 365435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Logan 300 Arlington Avenue Logan, OH 43138 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, staff interview and policy review the facility failed to ensure all drugs and biological's were kept locked, stored, and labeled, in accordance with currently accepted professional principles. The 700 Hall medication cart was left unlocked and unattended. Medication in the 300 Hall Medication Room and 300 Hall medication cart were not labeled when opened or discarded when expired. This affected two residents (#37 and #87) and had the potential to affect all residents on the 300 and 700 Halls. The facility census was 92. Findings include: 1. On 05/19/21 at 8:15 A.M. an observation of medication administration revealed Licensed Practical Nurse (LPN) #78 did not lock her medication cart or close the top drawer completely after she had prepared medications for administration and left the cart. The medication cart was unattended and located in the middle of the hallway. The medication cart was left unlocked, unattended, and out of sight of the nurse from 8:15 A.M. to 8:17 A.M. No other staff members were in the hall at the time of the observation. An interview with LPN #78 on 05/19/21 at 8:20 A.M. revealed she usually pulls the medication cart up to the door of the room she was administering medications in. The LPN revealed she had forgotten to lock her cart. The LPN revealed she had not realized the top drawer was not completely shut. A review of the facility policy titled Storage of Medications, dated April 2007 revealed compartments containing drugs and biologicals shall be locked when not in use. 2. On 05/19/21 at 8:05 A.M. observation of the 300 Hall medication cart revealed revealed Lantus Insulin for Resident #37 and Resident #87 was opened and not labeled with a date it had been opened or the date it expired. On 05/19/21 at 8:12 A.M. interview with Registered Nurse (RN) #5 revealed all medications should be labeled with a date when opened. The RN revealed all expired medications should be discarded upon their expiration date. A review of the facility policy titled Storage of Medications, dated April 2007 revealed the facility should not use discontinued or outdated drugs. 3. On 05/19/21 at 8:10 A.M. observation of the 300 Hall Medication Room revealed the following stock medications were being stored, yet were expired: 1 bottle of Ocular Vitamins with an expiration date of 03/2021 1 bottle of Biotin 30 micrograms (mcg) with an expiration date of 04/2021 1 bottle of Swish/Swallow Antacid Diphenhydramine with a discard by date of 05/18/21 On 05/19/21 at 8:12 A.M. interview with RN #5 revealed all expired medications should be discarded upon their expiration date. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365435 If continuation sheet Page 22 of 29 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 365435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Logan 300 Arlington Avenue Logan, OH 43138 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 0761 A review of the facility policy titled Storage of Medications, dated April 2007 revealed the facility should not use discontinued or outdated drugs. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365435 If continuation sheet Page 23 of 29 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 365435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Logan 300 Arlington Avenue Logan, OH 43138 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review and interview the facility failed to ensure each resident received and the facility provided food that conserved flavor and food that was palatable. This affected three residents (#87, #53 and #67) and had the potential to affect 90 of 90 residents who received meal trays from the kitchen with the exception of Resident #9 and Resident #46 who received nothing by mouth. Residents Affected - Many Findings include: Review of the facility planned menu for the lunch meal on 05/20/21 revealed the meal consisted of thyme chicken, scalloped corn, green beans, coconut cream pie and a dinner roll. On 05/20/21 at 1:30 P.M. interview with Resident #87 revealed concerns related to the facility meals/food items. The resident indicated the lunch meal served on this date had no taste and was undesirable. On 05/20/21 at 1:34 P.M. interview with Resident #53 revealed she did not eat the lunch meal on this date or when served on the menu because this particular meal had no flavor. On 05/20/21 at 1:38 P.M. interview with Resident #67 revealed she didn't eat the chicken during the lunch meal on this date because it was too watery. Based on the resident meal concerns, a test tray was requested for the 05/20/21 lunch meal. The chicken appeared to have a rubbery consistency and had excessive water expelling from it while being cut. The green beans very bland and had no flavor. At the time the test tray was completed, the concern was shared with the regional dietary manager. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365435 If continuation sheet Page 24 of 29 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 365435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Logan 300 Arlington Avenue Logan, OH 43138 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, staff interview and policy review the facility failed to store food in accordance with acceptable standards for food service safety to prevent spoilage and unauthorized access. An unlocked nourishment cabinet, on the secured 400 Hall contained expired and unlabeled food items. This had the potential to affect all 13 residents (#77, #7, #4, #54, #73, #20, #30, #81, #55, #71, #29, #147, and #62) who resided on the 400 Hall. The facility census was 92. Findings include: On 05/25/21 at 7:45 A.M. an observation on the secured 400 Hall revealed the nutrition cabinet was unlocked. The cabinet was in the common area used by the residents on the hall. The cabinet contained the following items: One container of peanut butter, opened, not dated, with no name and no expiration date. One bag of corn chips, opened, not dated, with no name and an expiration date of 05/03/21. One pudding cup, half open, not dated, with no name and no expiration date. Three pieces of chocolate candy, half opened, with no date, no name and no expiration date. One container of thick and easy, covered with a paper towel, with no date, no name and no expiration date. An interview with Registered Nurse (RN) #5 on 05/25/21 at 07:55 A.M. revealed the cabinet should always be kept locked and the food items should be labeled and dated when opened. The facility identified 13 residents, Resident #77, #7, #4, #54, #73, #20, #30, #81, #55, #71, #29, #147 and #62 who resided on the secured 400 Hall who would have access to the food items in the nutrition cabinet. A review of the facility policy titled Storing Dry Food, dated 2002 revealed all food items should be labeled when opened and the use by date should be part of the labeling. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365435 If continuation sheet Page 25 of 29 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 365435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Logan 300 Arlington Avenue Logan, OH 43138 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, staff interview and policy review the facility failed to maintain adequate infection control practices during medication administration to prevent the spread of infection. Registered Nurse (RN) #5 failed to wash/sanitize her hands during the medication administration procedure for Resident #37 and failed to provide a barrier for an insulin syringe resulting in the syringe being placed directly on the resident's bedside table. This affected one resident (#37) of three residents observed for medication administration. Residents Affected - Few Findings include: On 05/19/21 at 7:44 A.M. RN #5 was observed administering medications to Resident #37. During the observation, the RN failed to wash or sanitize her hands before or after preparing the medications and before administering the medications, which included an insulin injection to Resident #37. During the observation, the RN was observed to prepare insulin for injection to the resident. The RN placed the insulin syringe directly on the resident's bedside table without first sanitizing the table or placing a barrier between the syringe and the table. On 05/19/21 at 7:46 A.M. interview with RN #5 revealed the nurse stated she forgot to sanitize her hands and place a barrier on the table before placing the insulin syringe on it. The nurse verified she should have washed her hands and used a barrier on the table. A review of the facility policy titled Administering Medications dated 2012 revealed staff shall follow established infection control procedures (handwashing, antiseptic technique, gloves, etc) for the administration of medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365435 If continuation sheet Page 26 of 29 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 365435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Logan 300 Arlington Avenue Logan, OH 43138 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on review of the facility antibiotic surveillance logs, medical record review, staff interview and review of the facility policy related to antibiotic stewardship the facility failed to maintain an effective and comprehensive antibiotic stewardship program to ensure the appropriate use of antibiotics for residents related to urinary tract infections. This affected three residents (#12, #64 and #77) of 92 residents residing in the facility. Residents Affected - Few Findings include: 1. Review of a facility antibiotic surveillance log for May 2021 revealed Resident #64 was listed as having a urinary tract infection and received an antibiotic. Under the column of McGeer's criteria met, it was documented no. (McGeer's criteria is criteria that define infections and is used to maintain consistency in the determination of infections. Residents must meet criteria from two categories including symptoms of a urinary tract infection and a urine culture indicating a urinary tract infection to meet the criteria for a urinary tract infection). Review of the medical record for Resident #64 revealed an admission date of 11/03/19. Review of nurse's notes revealed on 05/06/21 at 6:47 P.M. the resident was taking fluids well and voiding in ample amounts without complaints of dysuria (painful or difficult urination). On 05/07/21 at 12:53 A.M. no urinary complaints voiced. Drinking well. Voiding in good quantity. There was no further documentation related to symptoms of a urinary tract infection. On 05/10/21 an order was received for a urine culture. (No reason documented). Review of the urine culture results reported on 05/13/21 revealed organisms of Escherichia Coli with a growth of 20-25,000 CFU/mL and Streptococcus Bovis with a growth of 26-30,000 CFU/mL. (The McGeer form used by the facility stated resident must have at least 100,000 CFU/mL to meet the second criteria. Nurse's notes on 05/17/21 at 11:42 A.M. revealed a new order was received for the antibiotic, Levofloxacin 250 milligrams daily for three days for a urinary tract infection. There was no documentation from the physician regarding the need for an antibiotic for a urinary tract infection. Interview with Regional Director of Nursing (DON) #142 on 05/25/21 at 3:00 P.M. confirmed there was no documentation from the physician to indicate why antibiotics were necessary for Resident #64 for a urinary tract infection based on the fact there were no symptoms documented and the urine culture had growth <100,000 CFU/mL. The resident did not meet the McGeer's criteria for antibiotic use. 2. Review of a facility antibiotic surveillance log for May 2021 revealed Resident #12 had a urinary tract infection with proteus, onset date 04/30/21. The log revealed McGeer's criteria was met and the resident received the antibiotic, Macrobid. Review of the McGeer form completed for Resident #12 revealed symptoms of urinary tract infection were marked. However, the second criteria of at least 100,000 CFU/mL was not marked. The form documented the resident met the criteria for a urinary tract infection even though both criteria were not met, as required. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365435 If continuation sheet Page 27 of 29 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 365435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Logan 300 Arlington Avenue Logan, OH 43138 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 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the medical record for Resident #12 revealed an admission date of 11/16/15. A nurse's note on 04/28/21 at 3:24 P.M. revealed a urinalysis was pending as the resident expressed burning with urination. On 04/29/21 at 12:09 A.M. it was noted the resident complained of lower back pain. No further symptoms were documented. Review of a urine culture result revealed a report on 05/01/21 which indicated an organism of proteus mirabilis with a growth of 30-40,000 CFU/mL. A nurse's note on 05/01/21 at 7:03 P.M. revealed a new order was received for an antibiotic (Macrobid twice daily for seven days for treatment of urinary tract infection). Review of the urine culture results for 05/01/21 revealed Macrobid was not listed under antibiotic sensitivity as a medication the organism was sensitive to. There was no documentation from the physician regarding the need for an antibiotic for a urinary tract infection. Interview with Regional Director of Nursing (DON) #142 on 05/25/21 at 3:00 P.M. confirmed there was no documentation from the physician to indicate why antibiotics were necessary for Resident #12 for a urinary tract infection based on the fact the urine culture had growth <100,000 CFU/mL. In addition, she further confirmed the antibiotic used was not listed on the urine culture indicating if it was effective against the organism identified. 3. Review of a facility antibiotic surveillance log for April 2021 revealed Resident #77 was listed as having a urinary tract infection and received the antibiotic Amoxicillin. Under the column of McGeer's criteria met, it was documented yes. Review of the McGeer form completed for Resident #77 revealed symptoms of urinary tract infection were marked. However, the second criteria of at least 100,000 CFU/mL was not marked. The form documented that the resident did not meet the criteria for a urinary tract infection. Review of the medical record for Resident #77 revealed an admission date of 06/12/20. Review of nurse's notes revealed on 04/23/21 at 2:33 A.M. the resident was noted to be awake several times this shift going through her closet and dresser rearranging clothes. Noted to have urinated and had a bowel movement on a pile of clothes. On 04/23/21 the physician's assistant was updated on increased incontinence and urinating on clothing. A new order was obtained for a urine culture. On 04/24/21 at 1:42 A.M. nurse's notes indicated the urine test was pending. It further revealed the resident had no behaviors or incontinence noted. On 04/25/21 at 2:02 A.M. nurse's notes indicated the resident had no complaints of pain or burning on urination and had no urinating in inappropriate places. On 04/25/21 at 12:36 P.M. the resident denied pain and stated no increase in urinary frequency. Urine test pending. On 04/26/21 at 11:14 A.M. nurse's notes revealed waiting on labs to come back. No complaints of pain. Review of urine culture results revealed the specimen had been collected on 04/23/21 and reported on 04/25/21. The culture showed 10,000-49,000 CFU/mL of Beta Hemolytic Streptococcus Group B. Susceptibility testing was not done by the lab. Review of nurse's notes on 04/26/21 at 12:12 P.M. revealed the nurse practitioner was notified of the urine culture results and a new order was received for the antibiotic Amoxicillin 500 milligrams (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365435 If continuation sheet Page 28 of 29 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 365435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Logan 300 Arlington Avenue Logan, OH 43138 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 0881 twice daily for seven days. Level of Harm - Minimal harm or potential for actual harm Review of a physician's progress note, dated 04/26/21 revealed the resident was being seen for follow up on a urine culture. The note revealed the resident was being seen due to abnormal urine culture showing 10,000-49,000 CFU/mL of group b strep. She was eating and drinking well. There were no symptoms of a urinary tract infection documented. The note revealed acute uti and indicated to let provider know if symptoms were not improved. However, what those symptoms included were not documented. Residents Affected - Few Interview with Regional Director of Nursing (DON) #142 on 05/25/21 at 3:00 P.M. confirmed there was no documentation from the physician to indicate why antibiotics were necessary for Resident #12 for a urinary tract infection based on the fact the urine culture had growth <100,000 CFU/mL. Review of the undated facility policy titled Antibiotic Stewardship revealed antibiotics were powerful tools for fighting and preventing infections. However, widespread use of antibiotics had resulted in an alarming increase in antibiotic-resistant infections and a subsequent need to rely on broad-spectrum antibiotics that might be more toxic and expensive. In addition to the development of antibiotic resistance, antibiotic use was associated with an increased risk of Clostridium difficile infection and adverse drug reactions. Since antibiotics were frequently over or inappropriately prescribed, a concerted effort to decrease or eliminate inappropriate use can make a big impact on resident safety and the reduction of adverse events. It further revealed it was the policy to maintain an antibiotic stewardship program with the mission of promoting the appropriate use of antibiotics to treat infections and reduce possible adverse events associated with antibiotic use. The policy included two levels of criteria to be met for a urinary tract infection. Criteria one included meeting criteria for symptoms including dysuria, fever, hematuria, pain, marked increase in incontinence, urgency or frequency. Criteria two included at least 10 to the fifth power CFU/mL of no more than two species of microorganisms in a voided urine sample or at least 10 to the second power of any number of organisms in a specimen collected by straight catheterization. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365435 If continuation sheet Page 29 of 29