Health inspection·June 20, 2023

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few occlusion and stenosis of unspecified carotid artery, psychotic disorder with delusions due to known physiological condition, other symbolic dysfunctions, insomnia, anxiety disorder, cognitive communication deficit, and mood disorder. Review of her Minimum Data Set (MDS) assessment, dated 04/19/23, revealed she had a mild cognitive impairment. Review of Resident #59 PASRR document, dated 08/24/20, revealed under Section C, the document indicated she did not have a diagnosis of dementia. Also, review of Section D, the diagnoses listed were panic or other severe anxiety disorder and depressive disorder. But review of her diagnoses list, she also had the following diagnoses that should have been indicated/updated on her PASRR document: neurocognitive disorder with lewy bodies, which was added on 01/08/21, psychotic disorder with delusions due to known physiological condition, which was added on 07/23/21, and mood disorder, which was added on 06/13/23. Interview with Social Services #300 on 11/09/22 at 10:37 A.M., 11:15 A.M., and 1:45 P.M. confirmed that PASRR documents are to be updated when there is a significant change in the resident's condition, and the PASRR document answers would change. She confirmed the PASRR documents were not accurate for Resident #59 and she updated them to be accurate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365435 If continuation sheet Page 2 of 15 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 06/20/2023 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 0646 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #61 was admitted to the facility on [DATE] with diagnosis including non traumatic intracerebral hemorrhage, atrial fibrillation, congestive heart failure, hemiplegia of right side related to cerebral infarction, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/03/23, revealed he was cognitively intact. Review of Resident #61 PASRR document, dated 10/19/19, revealed under Section D, the only diagnosis listed was major depressive disorder. But review of the diagnoses list revealed Resident #61 also had the following diagnoses that should have been indicated/updated on his PASRR document: anxiety disorder 02/17/22, unspecified mood disorder 05/26/22, and schizoaffective disorder dated 07/07/21. There was no documentation to support these significant mental health changes were communicated to the state mental health agency. Interview with Social Services #300 on 11/09/22 at 10:37 A.M., 11:15 A.M., and 1:45 P.M. confirmed that PASRR documents are to be updated when there is a significant change in the resident's condition, and the PASRR document answers would change. She confirmed the PASRR documents were not accurate for Resident #59 and she updated them to be accurate. She also confirmed there was no documentation to support the state mental health agency was updated with these significant changes. She confirmed that with the significant changes being reported to the state mental health agency that Resident #59 was referred further for level II services. Review of facility Resident Assessment - Coordination with PASRR Program policy, dated 10/01/22, revealed the facility coordinates assessments with the preadmission screening and resident review (PASRR) program under Medicaid to ensure individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health agency or intellectual disability authority for a level II resident review. Based on medical record review and staff interview, the facility failed to ensure all significant mental health changes were communicated to the state mental health agency. This affected two (Resident #59 and Resident #61) of three residents reviewed for PASRR documents. The census was 98. Findings Include: 1. Resident #59 was admitted to the facility on [DATE]. Her diagnoses were neurocognitive disorder with lewy bodies, chronic obstructive pulmonary disease, major depressive disorder, hyperlipidemia, occlusion and stenosis of unspecified carotid artery, psychotic disorder with delusions due to known physiological condition, other symbolic dysfunctions, insomnia, anxiety disorder, cognitive communication deficit, and mood disorder. Review of her Minimum Data Set (MDS) assessment, dated 04/19/23, revealed she had a mild cognitive impairment. Review of Resident #59 PASRR document, dated 08/24/20, revealed under Section C, the document indicated she did not have a diagnosis of dementia. Also, review of Section D, the diagnoses listed were panic or other severe anxiety disorder and depressive disorder. But review of her diagnoses list, she also had the following diagnoses that should have been indicated/updated on her PASRR document: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365435 If continuation sheet Page 3 of 15 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 06/20/2023 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 0646 Level of Harm - Minimal harm or potential for actual harm neurocognitive disorder with lewy bodies, which was added on 01/08/21, psychotic disorder with delusions due to known physiological condition, which was added on 07/23/21, and mood disorder, which was added on 06/13/23. There was no documentation to support these significant mental health changes were communicated to the state mental health agency. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365435 If continuation sheet Page 4 of 15 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 06/20/2023 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to implement a care plan related to non compliance/refusal of activities of daily living care for Resident #61. This affected one resident (Resident #61) of four residents reviewed for activities of daily living care. The facility census was 98. Findings include: Resident #61 was admitted to the facility on [DATE] with diagnoses including hemiplegia to right side related to cerebral infarction, non traumatic intracerebral hemorrhage, atrial fibrillation, congestive heart failure, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #61 was cognitively intact with no behaviors. Resident #61 required extensive assistance of two persons for bed mobility, transfers, dressing, toilet use, personal hygiene and total dependence of two persons for bathing. Review of the nursing progress notes dated 01/01/23 through 06/10/23 revealed random non compliance with care and treatment. Review of the plan of care revealed no plan to address Resident #61 non compliance and or refusal of care of activities of daily living. An interview on 06/14/23 at 8:00 A.M. with State Tested Nursing Assistant (STNA) #111 revealed Resident #61 often refused to allow the staff to provide care such as clipping his nails, shaving, bathing, turning repositioning, and getting up out of bed. An interview on 06/14/23 at 9:18 A.M. with MDS Nurse #21 confirmed Resident #61 did not have a plan of care addressing his noncompliance/refusal of care related to activities of daily living. Review of the facility policy titled Comprehensive Care Plans dated 08/22/22 revealed the facility would attempt alternate methods for refusal of treatment and services and document such attempts in the clinical record, including discussion with the resident and/or resident representative. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365435 If continuation sheet Page 5 of 15 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 06/20/2023 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to revise the plan of care of Resident #2 related to being up in his power wheelchair. This affected one ( Resident #2) of five residents reviewed for updated care plan. The facility census was 98. Findings include: Review of the medical record for Resident #2 revealed an admission date of 06/08/22 with diagnoses including quadriplegia, peripheral vascular disease, neuralgia, neuritis, depression, chronic pain, wheelchair dependent and on 03/26/23 a diagnosis of fracture of upper end of right humerus. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #2 was cognitively intact, and was total dependence on two persons for bed mobility, transfers, toileting and bathing. Resident #2 required supervision with locomotion. Review of the progress notes for Resident #2 revealed a Nurse Practioner (NP) note dated 05/10/23 revealed the orthopedic physician wrote an order on 05/09/23 for Resident #2 stating it was okay for the resident to use his motorized wheelchair. Review of the power wheelchair mobility indoor driving assessment and experience check list dated 05/26/23 completed by therapy with Resident #2 revealed the resident safely maneuvered his power wheelchair. A power wheelchair mobility community driving assessment dated [DATE] completed by therapy with Resident #2 revealed the resident passed the test and was safe to drive his power wheelchair in the community. Review of the plan of care dated and last revised on 03/27/23 revealed Resident #2 used a power wheelchair for locomotion. The goal was for Resident #2 to demonstrate safe usage and operation of the power wheelchair for mobility independently with the use of the interventions through the review period. The interventions included the power wheelchair use independently was on hold until medically cleared, the resident would complete and pass the therapy assessment for safe operation of the power wheelchair when medically cleared to participate, upon successful completion of the power wheelchair assessment the resident will review the power wheelchair usage agreement with the Interdisciplinary team with a full agreement to practice safety. An interview on 06/11/23 at 2:20 P.M. with Resident #2 stated he had an accident in the parking lot/driveway of the facility back in March while in his wheelchair. Resident #2 stated he was permitted to go outside and off facility property in his power wheelchair. He was returning to the facility, when the wind (it was a windy day) started to blow his hat off. Resident #2 stated he can only use one arm, that arm and hand was operating the wheelchair, so he stopped, and was backing up to turn his wheelchair when the wheelchair went in to one of those deep pot holes in the parking lot and flipped him over. He broke his arm near his shoulder. Resident #2 stated when he returned from the hospital, he was not able to operate his wheelchair safely due to his right arm fracture and pain medications. Resident #2 stated he was seen by orthopedic physician, and around 05/10/23 the orthopedic physician released him to be able to use his power wheelchair if he passed the safe driving course. Resident #2 stated he passed the safe driving course and was now able to use his chair to get out of his room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365435 If continuation sheet Page 6 of 15 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 06/20/2023 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An observation on 06/12/23 at 3:30 P.M. of Resident #2 revealed he was up in his power wheelchair in the therapy department. Resident #2 operated the chair safely. An interview on 06/12/23 at 3:45 P.M. with Physical Therapist (PT) #22 revealed Resident #2 was deemed unsafe to drive the power wheelchair by the physician right after his accident in 03/23. However, since then the physician released him to be up in his power wheelchair after passing the driver safety course with therapy. PT #22 stated he completed the safety course with Resident #2 around the last week of 05/23. Resident #2 passed the course was able to drive his power wheelchair safely. An interview on 06/14/23 at 9:18 A.M. with the MDS Nurse #21 revealed care plans were updated with new orders, change of condition, quarterly, annually and as needed. MDS Nurse #21 stated Resident #2's plan of care related to his power wheelchair was not updated to reflect his ability to be up independently in the chair. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365435 If continuation sheet Page 7 of 15 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 06/20/2023 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record Review of Resident #34 on 06/12/23 at 1:22 P.M. revealed this resident was admitted to the facility on [DATE] with the following medical diagnoses: hemiparesis and hemiplegia, aphagia, cerebral infarction, dysphagia, right hand contracture, thrombophilia, homocystinuria, antiphospholipid syndrome, constipation, epilepsy, duodenal and stomach fistula, cognitive communication deficit, reduced mobility, gastrostomy, and retention of urine. This resident is alert and oriented to person, place, and time with a current BIMS score of 15 out of 15 on the most recent MDS assessment completed on 04/07/23, indicating no cognitive impairment. Resident was diagnosed with a right hand contracture on his admission assessment. Review of Occupational Therapy Notes from 07/28/21 through 09/21/21 revealed this resident was fitted and received services for a right hand splint to prevent worsening to his contracture. The resident had received the splint during this time, with proper fitting and acceptance of the appliance. Notes reflect that on 06/13/23, Occupational Therapy determined the resident had communicated he does not wear the splint because he does not like it. Therapy to rescreen the resident if a different splint is acceptable and if the resident is agreeable to wearing a new hand splint. Review of Physician Orders revealed no outstanding orders for the care of a contracture to the resident's right hand. Review of the Plan of Care revealed no care plan in place for services being provided to prevent a decline in rage of motion due to right hand contracture. Observation of Resident #34 on 06/12/23 at 09:28 A.M. revealed this resident has a severe contracture to his right arm and hand. No splints or corrective devices were noted during this observation. Interview with the Director of Nursing on 06/13/23 at 10:45 A.M. verified the facility is unable to provide any information in regards to nursing care for splinting or daily maintenance of contractures for Resident #34. She stated the resident had been last seen by the therapy department for treatment of his right hand in 2021. She verified there was no other information available for care or medical management of the contracture for this resident. Interview with Resident #34 on 06/14/23 at 10:07 A.M. revealed he has not worn the splint for his right hand for a very long time. He stated it is a custom made, self-donning splint that was provided by the therapy department. Resident could not confirm if his hand has gotten worse, and also denied pain. Resident stated the splint has not been used in so long, that he does not even know where it is located in his room. Observation of Resident #34 on 06/14/23 at 10:07 A.M. revealed no splint device in place. Resident's hand is contracted, but easily opens to reveal the palm of his hand. Fingers are hard to reposition, but no skin issues were observed due to the contracture. Resident denied pain when questioned. Interview with Licensed Practical Nurse #170 on 06/14/23 at 10:21 A.M. verified she is unaware of any splint device or range of motion being ordered for Resident #34. She stated she has been employed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365435 If continuation sheet Page 8 of 15 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 06/20/2023 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 0688 with the facility for a long time, and she has never seen him wearing one. Level of Harm - Minimal harm or potential for actual harm 06/14/23 10:43 AM Interview with Licensed Practical Nurse #133 verified she has no knowledge of a splint device ever being used for Resident #34. Residents Affected - Few Review of the facility policy titled Prevention of Decline in Range of Motion, revised 10/01/22, revealed the facility in collaboration with the medical director, director of nurses and as appropriate, physical/occupational consultant shall establish and utilize a systemic approach for prevention of decline in range of motion, including the assessment, appropriate care planning, and preventive care. Based on observations, interviews, record reviews, and review of facility policy, the facility failed to ensure residents received care and services to prevent worsening of contracture's. This affected two residents (#18 and #34) out of the four residents reviewed for limited range of motion during the annual survey. The facility census was 98. Findings include: 1. Record review for Resident #18 revealed this resident was admitted to the facility on [DATE] and had diagnoses including multiple sclerosis, need for assistance with personal care, muscle weakness, and reduced mobility. Review of the admission/5-day Minimum Data Set (MDS) assessment, dated 05/28/23, revealed this resident had mildly impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 11 out of 15. This resident was assessed to require extensive assistance from two staff members for bed mobility, transfers, and toileting and to require extensive assistance from one staff member for eating. This resident was assessed to have functional limitation in range of motion to bilateral upper extremities. Review of the active care plans for this resident revealed no plan of care related to contracture's. Further record review for this resident revealed no instruction for providing care to the residents existing contracture's to prevent worsening. Observation on 06/11/23 at 2:35 P.M. revealed Resident #18 was lying in bed with both hands observed to be severely contracted with no splints or devices in place. Interview with Registered Nurse (RN) #163 on 06/11/23 at 2:41 P.M. verified both hands of Resident #18 were severely contracted and there were not orders for splints or other devices to be in place. Observation on 06/13/23 at 10:25 A.M. revealed Resident #18 was lying in bed with both hands observed to be severely contracted with no splints or devices in place. Interview with Licensed Practical Nurse (LPN) #156 on 06/13/23 at 10:55 A.M. revealed the facility did not have a restorative program in place. LPN #156 stated the State Tested Nursing Assistants (STNA's) provided range of motion exercises to residents during care. Interviews with State Tested Nursing Assistant (STNA) #126 and STNA #204 on 06/13/23 at 11:20 A.M. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365435 If continuation sheet Page 9 of 15 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 06/20/2023 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete revealed neither employee had received training on completing range of motion exercises with residents to prevent the development or worsening of contracture's. Both STNA's denied knowledge of where to look to see if a resident needed range of motion exercises completed during care. Interview with the Director of Nursing (DON) on 06/13/23 at 11:45 A.M. verified Resident #18 had contracture's and there was not a plan of care in place to provide instruction to staff on care and services necessary to prevent the worsening of the residents existing contracture's. Event ID: Facility ID: 365435 If continuation sheet Page 10 of 15 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 06/20/2023 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 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few Based on observation, record review and interview the facility failed to maintain the outside physical environment in a safe manner to prevent Resident #2 from sustaining a fall with injury. Actual harm occurred on 03/25/23 when Resident #2, who was independent with the use of a motorized (power) wheelchair sustained a fall in the parking lot, when his wheelchair fell into a pot hole resulting in a proximal humerus fracture to his right arm. The resident had increased pain to the area and was unable to use the motorized wheelchair for independent mobility for a period of time following the incident/injury. This affected one resident (#2) of five residents reviewed for accidents. The facility census was 98. Findings include: Review of the medical record for Resident #2 revealed an admission date of 06/08/22 with diagnoses including quadriplegia, peripheral vascular disease, neuralgia, neuritis, depression, chronic pain, wheelchair dependent and on 03/26/23 a diagnosis of fracture of upper end of right humerus. Review of a power wheelchair mobility indoor driving assessment and experience check list dated 12/20/22 revealed Resident #2 was able to safely maneuver the wheelchair including backing up and rate of speed. No updated assessment for the use of the power wheelchair had been completed between this assessment and 03/25/23. Review of a nursing progress note, dated 03/25/23 at 2:14 P.M. revealed a change in surface in the parking lot at 1:30 P.M. (resulting in a resident fall). A full nursing assessment was completed and the resident was assisted back to an upright position. Resident #2 was complaining of pain. The physician was notified and gave an order to send Resident #2 to the emergency room for evaluation and treatment of his injuries. The resident's guardian was notified. Review of the local emergency department notes dated 03/25/23 revealed Resident #2 had an x-ray of right upper extremity that showed a right proximal humerus fracture. Review of the imaging report from the local hospital dated 03/25/23 revealed the resident had an impacted angulated fracture of the anatomic neck of the proximal right humerus. New orders were provided to continue with pain management, ice the area and use a sling to right arm. Review of the facility incident report/investigation, dated 03/26/23 at 1:53 P.M. revealed Resident #2 was witnessed by a staff member tipped forward in his power wheelchair after hitting a pot hole in the (facility) parking lot. The resident was transported to local emergency department for evaluation. Resident #2 returned with diagnosis of right proximal humerus closed fracture injury that was identified as non-surgical. Resident #2 had a follow appointment with an orthopedic physician on 03/29/23. Resident #2 stated at the time of the incident, he was driving backwards due to the wind because he thought he was going to lose his hat. Interventions included to assess the wheelchair for damage and physical therapy services to assist with alternate mobility device until Resident #2 was released by physician to operate power wheelchair independently. The report also noted the power wheelchair representative was to be in the facility on 03/29/23 for assessment of damages to accessory applications to the chair and an order was received to place use of the power wheelchair on hold until the resident was medically cleared for use as the resident operated the wheelchair from the right (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365435 If continuation sheet Page 11 of 15 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 06/20/2023 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 - Actual harm side and currently had a right arm injury. A new power wheelchair assessment was to be initiated for indoor and outside of the facility when the resident was medically cleared to operate. The assessment revealed predisposing factor related to an uneven surface, physiological factors included pain and immobility and propelling in wheelchair without assistance. Residents Affected - Few A nursing note dated 03/26/23 at 6:53 P.M. revealed Resident #2 returned from the hospital at 12:30 P.M. The Certified Nurse Practitioner (CNP) documented in the progress notes on 03/27/23 at 12:00 A.M. Resident #2's x-ray results from local hospital revealed he had a fracture of right humerus and to follow up with orthopedic physician. The CNP noted per the facility staff, Resident #2 was on leave of absence on 03/25/23 and was riding backwards in his motorized wheelchair. Resident #2 hit a pothole, fell out of his chair and was evaluated at local emergency department. Resident #2 complained of moderate to severe pain of right upper extremity with movement (following the incident). A nursing progress note dated 03/29/23 at 6:27 A.M. revealed the Interdisciplinary Team (IDT) reviewed Resident #2's fall that occurred while he was utilizing his power wheelchair. The IDT was in agreement with immediate interventions of therapy referral, hold independent power wheelchair usage until medically cleared, staff to assist Resident #2 in regular wheelchair for mobility, require power wheelchair mobility operation assessment with therapy and review of safety compliance agreement. Review of the plan of care for Resident #2 dated 03/29/23 revealed potential risk for falls related to decreased physical function and use of a power wheelchair with a goal to be free from significant injury thought next review date. Interventions included encourage the resident to participate in therapy as ordered, ensure call light in reach at all times, a left grab bar to residents bed, use a mechanical lift for all transfers, observe for changes in ability to complete activities of daily living and adjust assistance provided accordingly, power wheelchair use on hold until medically cleared, encourage the resident to utilize alternative mobility chair with staff providing assistance for locomotion on and off the unit until medically cleared to use power wheelchair and therapy interventions to ensure safe usage of power wheelchair. Review of the orthopedic physician note dated 03/29/23 revealed Resident #2 was a quadriplegic who fell from his wheelchair after getting stuck in a pot hole several days ago and fell (out of the chair) on to his right shoulder. The resident was seen at local emergency department and radiographs showed a proximal humerus fracture. The resident was placed in a sling as the fracture was inoperable. Resident #2 complained of pain in the right shoulder area with movement. The orthopedic plan was to increase pain medications, use ice intermittently and wear sling. Review of the resident's pain assessments and medication administration records for March and April 2023 revealed Resident #2 had increased pain after the fall on 03/25/23 rating his pain a six on a scale of one to ten. On 03/27/23 Resident #2's pain level was rated a 10 out of 10 on the day shift and nine out of 10 on evening shift. On 03/28/23 Resident #2's pain level was rated a seven out of 10 on the day shift and nine out of 10 on the evening shift. On 03/29/23 Resident #2's pain level was rated a four out of 10 on day shift and eight out of 10 on the evening shift. As a result of the increased pain a new physician order was given to increase the resident's routine pain medication from Percocet 7.5 milligrams (mg)/325 mg by mouth two times daily to Percocet 10 mg/325 mg by mouth two times daily from 03/30/23 through 04/01/23. Resident #2 also received an extra dose of Percocet 10 mg/325 mg by mouth in the afternoon from 03/30/23 through 04/01/23 for uncontrolled pain. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/02/23 revealed Resident #2 was cognitively intact and required total dependence from two persons for bed mobility, transfers, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365435 If continuation sheet Page 12 of 15 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 06/20/2023 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 toileting and bathing. Resident #2 required supervision with locomotion and had impaired range of motion to bilateral upper and lower extremities. Resident #2 used a wheelchair for mobility. Level of Harm - Actual harm Residents Affected - Few An interview on 06/11/23 at 2:20 P.M. with Resident #2 revealed he had an incident in the parking lot/driveway of the facility back in March (2023) while in his power wheelchair. The resident stated as he was returning to the facility and the wind (it was a windy day) started to blow his hat off. Resident #2 stated he could only use one arm, that arm and hand was operating the wheelchair, so he stopped, and was backing up to turn his wheelchair when the wheelchair went in to one of those deep pot holes in the parking lot and flipped him over. The resident stated he broke his arm near his shoulder. Resident #2 stated when he returned from the hospital, he was not able to operate his wheelchair safely due to his right arm fracture and the pain medications he was on. Resident #2 stated he was seen by an orthopedic physician, and around the first of May 2023, the orthopedic physician released him to be able to use his power wheelchair if he passed a safe driving course. Resident #2 stated he passed the safe driving course and was now able to use his chair again to get out of his room. An interview on 06/12/23 at 3:45 P.M. with Physical Therapist (PT) #22 revealed all residents who have a power wheelchair have to complete an indoor safety evaluation and test and if the resident wanted to go outside or in the community, they had to pass the community outdoor evaluation and test. PT #22 revealed Resident #2 passed his first test when he came in to the facility a couple of years ago. PT #22 revealed Resident #2 had an incident recently outside of the building in the parking lot/driveway. Resident #2 was coming back towards the facility, it was a windy day, and his hat was blowing off. Resident #2 stated he had stopped and tried to change direction of the wheelchair and in doing so backed up into one of the huge pot holes out there in the driveway/parking lot area. The chair flipped him over resulting in a broken right humerus to the only good and usable limb the resident had. PT #22 stated the physician had written an order the resident was not safe to drive the power wheelchair and the resident was not allowed to be up in his chair; his only independence. PT #22 revealed some time passed and the doctor gave a new order for the resident to use the chair again. At that point, PT #22 completed the indoor and outdoor safety evaluations for Resident #2, who passed both tests. An interview on 06/13/23 at 8:30 A.M. with the Director of Nursing (DON) revealed the facility had three residents, Resident #2, Resident #31 and Resident #22 who were assessed to be able to go outside in their wheelchairs independently. Outside included the parking lot and driveway area per the DON. An observation on 06/13/23 at 8:40 A.M. revealed the facility driveway had 17 large pot holes from the facility sign to the the facility/building itself. There was a sign indicating to please drive slow and look out for our residents. An interview on 06/13/23 at 3:20 P.M. with the Administrator revealed he was aware of the large pot holes and poor surface of the driveway. The Administrator stated the Maintenance Director had received a few bids on repairing the driveway/parking lot area and when the companies were called only one stated they could actually complete the repairs. The Administrator stated it was still a work in progress. However, on this date (06/13/23), the Maintenance Director purchased several 50 pound bags of asphalt to fill the holes until it can be paved. An observation on 06/13/23 at 3:41 P.M. revealed the Maintenance Director was filling the pot holes with the bags of asphalt. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365435 If continuation sheet Page 13 of 15 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 06/20/2023 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and facility policy review, the facility failed to provide proper justification for the use of psychotropic medications. This affected two (Residents #21 and #64) of five residents reviewed for unnecessary medications. The census was 98. Findings Include: 1. Resident #21 was admitted to the facility on [DATE]. Her diagnoses were dementia, pneumonitis, delirium, muscle weakness, repeated falls, shortness of breath, anxiety disease, major depressive disorder, dysphagia, hyperlipidemia, hypertension, osteoarthritis, cognitive communication deficit, and traumatic subdural hemorrhage. Review of her Minimum Data Set (MDS) assessment, dated 04/02/23, revealed she had a significant cognitive impairment. Review of Resident #21 current physician orders revealed an order for Quetiapine 50 milligrams (mg) twice daily for paranoia and delusional disorder. Review of Resident #21 psychiatric notes, dated 11/09/22 and 01/10/23, revealed she was ordered Quetiapine for a mood disorder. But there was no evidence to support she had a mood disorder, other than listing it as the diagnosis for this medication. Review of Resident #21 MDS Assessment, section I, and current diagnoses list, revealed no diagnosis of mood disorder, paranoia or delusional disorder listed. Interview with Licensed Practical Nurse (LPN) #156 on 06/14/23 ay 11:48 A.M. confirmed they could not find clear and consistent justifications for the use of Resident #21 Quetiapine. 2. Resident #64 was admitted to the facility on [DATE]. Her diagnoses were type II diabetes, anxiety disorder, dementia, muscle weakness, difficulty in walking, need for assistance with personal care, patient's non-compliance with medical treatment, major depressive disorder, repeated falls, cognitive communication deficit, hyperlipidemia, mood disorder, anemia, insomnia, bipolar disorder, necrotizing fasciitis, mood disorder, and hypertension. Review of her MDS assessment, dated 05/22/23, revealed she was cognitively intact. Review of Resident #64 current physician orders revealed she was to be administered Quetiapine 200 mg at bed time for schizoaffective disorder (bipolar type), and Seroquel 150 mg twice daily for schizoaffective disorder. Review of Resident #64 MDS assessment, section I, revealed the diagnosis of schizophrenia and psychotic disorder were indicated as no for her having these diagnosis. Also, there was no indication within Section I, and her current diagnoses list in the electronic medical records, that she had a diagnosis of schizoaffective disorder. Review of Resident #64 psychiatric note, dated 05/15/23, revealed no diagnosis of schizoaffective disorder. Also, it was documented within this note that she was prescribed Seroquel for bipolar disorder; not schizoaffective disorder. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365435 If continuation sheet Page 14 of 15 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 06/20/2023 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Interview with LPN #156 on 06/14/23 at 11:31 A.M. confirmed she could not find data to support Resident #64 had a diagnosis of schizoaffective disorder, other than the physician orders for seroquel. She confirmed it was not clear what the justification for Resident #64 seroquel was for. Review of facility Use of Psychotropic Medication policy, dated 10/01/22, revealed residents are not given psychotropic drugs unless medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). Event ID: Facility ID: 365435 If continuation sheet Page 15 of 15