Inspection·July 28, 2023

F 0602 Level of Harm - Minimal harm or potential for actual harm Property, last revised 10/2020 revealed the facility will not tolerate Abuse, Neglect, Exploitation of its residents or the Misappropriation of Resident property. Misappropriation is defined as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. Residents Affected - Few This deficiency represents non-compliance investigated under Complaint Number OH00144749. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365435 If continuation sheet Page 2 of 4 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 07/28/2023 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview and facility policy review, the facility failed to maintain acceptable infection control practices to prevent cross contamination of two Stage IV (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed) pressure ulcers during an observed dressing change for Resident #44. This affected one resident (#44) of three residents reviewed for pressure ulcers. The facility census was 90. Residents Affected - Few Findings Include: Review of the medical record for Resident #44 revealed an initial admission date of 09/29/20 with the latest readmission of 09/22/21. Diagnoses including schizophrenia, low back pain, Stage IV pressure ulcer to left buttocks, morbid obesity, anxiety disorder, hyperlipidemia, Vitamin D deficiency, hypothyroidism, bipolar disorder, tremor, anemia, major depressive disorder, insomnia, epilepsy, carpal tunnel syndrome, asthma, gastroesophageal reflux disease (GERD), osteoarthritis (OA), lumbar spina bifida, diabetes mellitus, hypertension and left below the knee amputation. Review of the plan of care dated 01/26/23 revealed the resident had an actual area of skin impairment related to Stage IV pressure ulcer to left ischial and right ischial, Interventions included encourage resident to lay down throughout the day to relieve pressure, air mattress as ordered, encourage to relieve pressure to wound areas, evaluate pain and provide pain relieving interventions as ordered, followed by Nurse Practitioner (NP) and wound care consultants, initiate wound treatment, continue wound treatment as ordered, nursing to observe dressing daily to ensure that the dressing remains intact and there are no signs/symptoms of infection or increased drainage, observe for clinical changes, resident prefers to use scooter without ROHO cushion, refer to dietician to determine need/no need for dietary interventions and skin observation and document on bath/shower days. Review of the resident's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had no cognitive deficit. The resident required extensive assistance of two for bed mobility and toilet use and dependent on two for transfers. The assessment indicated the resident has an indwelling urinary catheter and was frequently incontinent of bowel. The assessment indicated the resident was at risk for skin breakdown and had one unhealed Stage IV pressure ulcer that was present on admission. Review of the monthly physician orders for July 2023 revealed an order (initiated 03/15/23) to pack wound to left ischium with half strength Dakins soaked Kerlix roll, cover with bordered dressing and change daily and cleanse wound to right ischium with half strength Dakins', pat dry, pack with half strength soaked gauze daily and as needed. Review of a weekly pressure skin grid dated 07/24/23 revealed the resident had a Stage IV pressure ulcer to the right ischium measuring 2.0 centimeters (cm) by 1.0 cm by 3.0 cm. The wound had tunneling at 12 o'clock measuring 2.8 cm. The wound had attached wound edges and macerated peri-wound with a moderate amount of serous drainage. The wound was determined to have been unchanged. Review of the weekly pressure skin grid dated 07/24/23 revealed the resident had a Stage IV pressure ulcer to the left ischium measuring 1 0 cm by 3.0 cm by 4.0 cm with 100% granulation bed, unattached edges, macerated edges and moderate serosanguinous drainage. The wound had tunneling around the clock measuring 4.0 cm. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365435 If continuation sheet Page 3 of 4 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 07/28/2023 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 07/28/23 at 10:30 A.M., observation of Licensed Practical Nurse (LPN) #110 and #124 provide the physician ordered treatment to Resident #44's Stage IV pressure ulcer to the right and left ischium revealed the LPN's washed their hands and set up the required supplies on a barrier after sanitizing the bedside table. LPN #124 cleansed hands and donned gloves. LPN #124 cleansed the wound to the right ischium with wound cleanser and drain sponge, then dried the wound using a drain sponge. LPN #124 then cleansed the wound with wound cleanser and drain sponge, then dried the wound using a drain sponge. LPN #124 then sanitized her hands and donned gloves. LPN #124 cut two pieces of Kerlix and placed in one half Dakins' solution. LPN #124 then packed the Dakins' soaked packing in the wound to the right ischium using a Q-tip. LPN #124 then obtained another Q-tip and packed the wound to the left ischium with the Dakins' soaked Kerlix. LPN #124 sanitized her hands and donned a pair of gloves. LPN #124 then covered the right ischium wound with a bordered gauze. LPN #124 then covered the wound to the left ischium with a boarded gauze dressing. LPN #124 verified the dressing changes to the two Stage IV pressure ulcers were completed together instead of separate to prevent potential cross contamination. Review of the facility policy titled, Pressure Injury Prevention and Management, dated 08/22/22 revealed the facility was committed to the prevention of avoidable pressure injuries, unless clinically unavoidable and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries. This deficiency represents non-compliance investigated under Complaint Number OH00144381. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365435 If continuation sheet Page 4 of 4