Health inspection·November 16, 2023

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #71 had severely impaired cognition and scored two out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #71 required total dependence from one to two staff to complete Activities of Daily Living (ADLs). Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #71 had impaired cognition and scored eight out of 15 on the BIMS assessment. Resident #71 required extensive assistance to total dependence from one to two staff to complete ADLs. Review of the Statement of Expert Evaluation dated [DATE] and completed by Physician #208 revealed Resident #71 was aphasic but oriented. Resident #71 was reportedly married and had a living mother. The situation was complicated due to family dynamics regarding a legal next of kin. Resident #71 was not able to functionally care for himself but was able to participate in medical decisions with assistive devices due to aphasia. Physician #208's opinion was for guardianship to be denied. Review of the Statement of Expert Evaluation dated [DATE] and completed by Physician #208 revealed Resident #71 was not mentally impaired. Resident #71 appeared mentally intact upon assessment. Resident #71 had profound dysarthria (difficult or unclear articulation of speech that is otherwise linguistically normal) that limited his ability to communicate. Resident #71 used an iPad with a yes and no button. Physician #208's opinion was Resident #71 required assistance with Activities of Daily Living (ADLs), but was able to participate in medical decisions and guardianship should be denied. Review of the Statement of Expert Evaluation dated [DATE] and completed by Physician #208 revealed Resident #71 had aphasia (the loss of ability to understand or express speech, caused by brain damage) and an altered mental state. Resident #71 had impairments with orientation, speech, motor behavior, memory and judgement. Resident #71 exhibited inconsistencies with responses during the assessment. Resident #71 would not be capable of managing finances or personal property. Physician #208's opinion was that guardianship should be established. Interview on [DATE] at 1:39 P.M. with Social Services (SS) #179 revealed Resident #71 did not have a POA for healthcare in place and did not have a guardian appointed. SS #179 stated Physician #208 completed three expert evaluations on Resident #71 on [DATE], [DATE], and [DATE]. The physician's opinion was that Resident #71 was able to make decisions on [DATE] and [DATE]. The physician's opinion on [DATE] was that Resident #71 was not able to make decisions and agreed a guardian should be appointed. SS #179 confirmed prior to [DATE], the facility used Resident #71's wife as the resident's responsible party for healthcare decisions even though the resident's wife did not have POA for healthcare decisions in place. SS #179 confirmed there were not any legal documents in place that indicated Resident #71 could not make his own decisions. Resident #71 had a guardianship hearing scheduled in [DATE] (a year and six months after admission). Interview on [DATE] at 4:36 P.M. with Resident #71 revealed the resident used an iPad to answer yes and no. When asked if Resident #71 knew what Full Code and DNR meant, Resident #71 pressed the yes button on his iPad. However, Resident #71 was not able to elaborate or describe what either code status meant to demonstrate understanding. When asked if Resident #71 wanted to be a Full Code or DNR, Resident #71 did not respond. Interview on [DATE] at 9:08 A.M. with Physician #208 revealed she had been the facility's physician since [DATE] and had visited Resident #71 on multiple occasions. Physician #208 confirmed she completed three expert evaluations for court appointed guardianship on Resident #71. Two of her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365644 If continuation sheet Page 2 of 33 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 365644 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Winchester 36 Lehman Dr Canal Winchester, OH 43110 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few evaluations determined guardianship should be denied and the most recent evaluation, Physician #208 found that guardianship should be established for Resident #71. Physician #208 stated Resident #71 had severe aphasia and used an iPad to communicate mostly. During her first two evaluations, she allowed Resident #71 to use the iPad to answer questions and during her third evaluation, she presented other tools, such as a calendar, for Resident #71 to use to help answer questions. Physician #208 stated when Resident #71 was presented with the more unfamiliar objects, inconsistencies with responses arose. Physician #208 stated in her opinion, Resident #71 would be able to make some simple healthcare decisions but would not be able to fully understand more complex healthcare decisions and therefore, in her opinion, Resident #71 should have a court appointed guardian put into place for him. Review of the facility policy, Residents' Rights Regarding Treatment and Advanced Directives, dated [DATE], revealed the policy stated, the facility will identify or arrange for an appropriate representative for the resident to serve as primary decision maker if the resident is assessed as unable to make relevant health care decisions. During the care planning process, the facility will identify, clarify, and review with the resident or legal representative whether they desire to make any changes related to any advance directives. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365644 If continuation sheet Page 3 of 33 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 365644 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Winchester 36 Lehman Dr Canal Winchester, OH 43110 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 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm **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 export resident assessments in a timely manner. This affected 16 (Residents #5, #16, #25, #35, #38, #39, #40, #44, #48, #50, #51, #52, #56, #67, #74, and #83) of 19 resident assessments reviewed. The census was 88. Residents Affected - Some Findings Include: 1. Resident #5 was admitted to the facility on [DATE]. Her diagnoses were dementia, anemia, type II diabetes, depression, COPD, schizoaffective disorder, hyperlipidemia, hypothyroidism, dysphagia, schizophrenia, hypokalemia, aphasia, osteoarthritis, hypertension, cognitive communication deficit, altered mental status, and psychosis. Review of her Minimum Data Set (MDS) assessment, dated 07/06/23, revealed she had a severe cognitive impairment. Review of Resident #5 MDS assessments revealed the last assessment submitted to the Center for Medicare and Medicaid Services (CMS) was on 07/06/23. The facility had started/completed the her most recent MDS on 10/06/23, but due to the electronic medical records company having an error with their program, they could not submit the assessment until 11/01/23. As of 11/14/23, the assessment from 10/06/23 had not been submitted; it was documented as being ready to export. 2. Resident #16 was admitted to the facility on [DATE]. His diagnoses were hydrocephalus, hypertensive retinopathy, major depressive disorder, cognitive communication deficit, hyperlipidemia, hypercalcemia, spastic hemiplegia, type II diabetes, hypokalemia, anxiety disorder, hypertension, and depression. Review of his Minimum Data Set (MDS) assessment, dated 07/04/23, revealed he was cognitively intact. Review of Resident #16 MDS assessments revealed the last assessment submitted to the Center for Medicare and Medicaid Services (CMS) was on 07/04/23. The facility had started/completed the his most recent MDS on 10/02/23, but due to the electronic medical records company having an error with their program, they could not submit the assessment until 11/01/23. As of 11/14/23, the assessment from 10/02/23 had not been submitted; it was documented as being ready to export. 3. Resident #25 was admitted to the facility on [DATE]. Her diagnoses were bipolar disorder, dementia, major depressive disorder, anxiety disorder, psychosis, type II diabetes, insomnia, and dysphagia. Review of her Minimum Data Set (MDS) assessment, dated 07/03/23, revealed she was cognitively intact. Review of Resident #25 MDS assessments revealed the last assessment submitted to the Center for Medicare and Medicaid Services (CMS) was on 07/03/23. The facility had started/completed the her most recent MDS on 10/02/23, but due to the electronic medical records company having an error with their program, they could not submit the assessment until 11/01/23. As of 11/14/23, the assessment from 10/02/23 had not been submitted; it was documented as being ready to export. 4. Resident #35 was admitted to the facility on [DATE]. Her diagnoses were COPD, emphysema, chronic kidney disease, hypertensive heart disease, congestive heart failure, lymphedema, dermatitis, cognitive communication deficit, atherosclerotic heart disease, hypothyroidism, type II diabetes, hyperlipidemia, peripheral vascular disease, hypotension, opioid dependence, edema, chronic gout, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365644 If continuation sheet Page 4 of 33 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 365644 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Winchester 36 Lehman Dr Canal Winchester, OH 43110 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 0640 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some osteoarthritis. Review of her Minimum Data Set (MDS) assessment, dated 07/04/23, revealed she was cognitively intact. Review of Resident #35 MDS assessments revealed the last assessment submitted to the Center for Medicare and Medicaid Services (CMS) was on 07/04/23. The facility had started/completed the her most recent MDS on 10/04/23, but due to the electronic medical records company having an error with their program, they could not submit the assessment until 11/01/23. As of 11/14/23, the assessment from 10/04/23 had not been submitted; it was documented as being ready to export. 5. Resident #38 was admitted to the facility on [DATE]. His diagnoses were type II diabetes, insomnia, hypertension, anxiety disorder, dementia, chronic pain syndrome, schizoaffective disorder, hypo-osmolality and hyponatremia, hypothyroidism, cognitive communication deficit, and metabolic encephalopathy. Review of his Minimum Data Set (MDS) assessment, dated 07/04/23, revealed he had a mild cognitive impairment. Review of Resident #38 MDS assessments revealed the last assessment submitted to the Center for Medicare and Medicaid Services (CMS) was on 07/04/23. The facility had started/completed the his most recent MDS on 10/02/23, but due to the electronic medical records company having an error with their program, they could not submit the assessment until 11/01/23. As of 11/14/23, the assessment from 10/02/23 had not been submitted; it was documented as being ready to export. 6. Resident #39 was admitted to the facility on [DATE]. His diagnoses were frontotemporal neurocognitive disorder, hypertension, cognitive communication deficit, hyperlipidemia, hypertension, paranoid personality disorder, delusional disorder, dementia, and convulsions. Review of his Minimum Data Set (MDS) assessment, dated 07/07/23, revealed he had a severe cognitive impairment. Review of Resident #39 MDS assessments revealed the last assessment submitted to the Center for Medicare and Medicaid Services (CMS) was on 07/07/23. The facility had started/completed the his most recent MDS on 10/06/23, but due to the electronic medical records company having an error with their program, they could not submit the assessment until 11/01/23. As of 11/14/23, the assessment from 10/06/23 had not been submitted; it was documented as being ready to export. 7. Resident #40 was admitted to the facility on [DATE]. Her diagnoses were peripheral vascular disease, hypertension, COPD, hearing loss, muscle weakness, dementia, hyperlipidemia, and anemia. Review of her Minimum Data Set (MDS) assessment, dated 07/03/23, revealed she was cognitively intact. Review of Resident #40 MDS assessments revealed the last assessment submitted to the Center for Medicare and Medicaid Services (CMS) was on 07/03/23. The facility had started/completed the her most recent MDS on 10/03/23, but due to the electronic medical records company having an error with their program, they could not submit the assessment until 11/01/23. As of 11/14/23, the assessment from 10/03/23 had not been submitted; it was documented as being ready to export. 8. Resident #44 was admitted to the facility on [DATE]. Her diagnoses were acute respiratory failure, metabolic encephalopathy, schizophrenia, COPD, congestive heart failure, shortness of breath, muscle weakness, cognitive communication deficit, insomnia, and altered mental status. Review of her Minimum Data Set (MDS) assessment, dated 07/07/23, revealed she had a mild cognitive impairment. Review of Resident #44 MDS assessments revealed the last assessment submitted to the Center for Medicare and Medicaid Services (CMS) was on 07/07/23. The facility had started/completed the her most (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365644 If continuation sheet Page 5 of 33 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 365644 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Winchester 36 Lehman Dr Canal Winchester, OH 43110 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 0640 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some recent MDS on 10/07/23, but due to the electronic medical records company having an error with their program, they could not submit the assessment until 11/01/23. As of 11/14/23, the assessment from 10/07/23 had not been submitted; it was documented as being ready to export. 9. Resident #48 was admitted to the facility on [DATE]. Her diagnoses were congestive heart failure, anemia, type II diabetes, hypertension, major depressive disorder, chronic kidney disease (stage III), atherosclerotic heart disease, insomnia, vitamin B deficiency, vitamin D deficiency, anxiety disorder, osteoarthritis, hyperlipidemia, chronic obstructive pulmonary disease (COPD), and cognitive communication deficit. Review of her Minimum Data Set (MDS) assessment, dated 07/08/23, revealed she was cognitively intact. Review of Resident #48 MDS assessments revealed the last assessment submitted to the Center for Medicare and Medicaid Services (CMS) was on 07/08/23. The facility had started/completed the her most recent MDS on 10/06/23, but due to the electronic medical records company having an error with their program, they could not submit the assessment until 11/01/23. As of 11/14/23, the assessment from 10/06/23 had not been submitted; it was documented as being ready to export. 10. Resident #50 was admitted to the facility on [DATE]. His diagnoses were Alzheimer's disease, insomnia, hypertension, dysphagia, cognitive communication deficit, cerebral infarction, hyperlipidemia, altered mental status, delirium, hypotension, and COPD. Review of his Minimum Data Set (MDS) assessment, dated 07/03/23, revealed he was cognitively intact. Review of Resident #50 MDS assessments revealed the last assessment submitted to the Center for Medicare and Medicaid Services (CMS) was on 07/03/23. The facility had started/completed the his most recent MDS on 10/03/23, but due to the electronic medical records company having an error with their program, they could not submit the assessment until 11/01/23. As of 11/14/23, the assessment from 10/03/23 had not been submitted; it was documented as being ready to export. 11. Resident #51 was admitted to the facility on [DATE]. Her diagnoses were schizophrenia, encephalopathy, anemia, cognitive communication deficit, dysphagia, major depressive disorder, aphasia, and dementia. Review of her Minimum Data Set (MDS) assessment, dated 07/07/23, revealed she had a severe cognitive impairment. Review of Resident #51 MDS assessments revealed the last assessment submitted to the Center for Medicare and Medicaid Services (CMS) was on 07/07/23. The facility had started/completed the her most recent MDS on 10/07/23, but due to the electronic medical records company having an error with their program, they could not submit the assessment until 11/01/23. As of 11/14/23, the assessment from 10/07/23 had not been submitted; it was documented as being ready to export. 12. Resident #52 was admitted to the facility on [DATE]. His diagnoses were schizophrenia, hypertension, type II diabetes, hyperlipidemia, delusional disorder, dysphagia, major depressive disorder, and anxiety disorder. Review of his Minimum Data Set (MDS) assessment, dated 07/08/23, revealed he was cognitively intact. Review of Resident #52 MDS assessments revealed the last assessment submitted to the Center for Medicare and Medicaid Services (CMS) was on 07/08/23. The facility had started/completed the his most recent MDS on 10/08/23, but due to the electronic medical records company having an error with their program, they could not submit the assessment until 11/01/23. As of 11/14/23, the assessment from 10/08/23 had not been submitted; it was documented as being ready to export. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365644 If continuation sheet Page 6 of 33 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 365644 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Winchester 36 Lehman Dr Canal Winchester, OH 43110 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 0640 Level of Harm - Minimal harm or potential for actual harm 13. Resident #56 was admitted to the facility on [DATE]. His diagnoses were acute respiratory failure, psychosis, traumatic subdural hemorrhage, depression, hyperlipidemia, polyneuropathy, anemia, encephalopathy, anxiety disorder, dysphagia, hypertension, cognitive communication deficit, and type II diabetes. Review of his Minimum Data Set (MDS) assessment, dated 07/03/23, revealed he had a mild cognitive impairment. Residents Affected - Some Review of Resident #56 MDS assessments revealed the last assessment submitted to the Center for Medicare and Medicaid Services (CMS) was on 07/03/23. The facility had started/completed the his most recent MDS on 10/03/23, but due to the electronic medical records company having an error with their program, they could not submit the assessment until 11/01/23. As of 11/14/23, the assessment from 10/03/23 had not been submitted; it was documented as being ready to export. 14. Resident #67 was admitted to the facility on [DATE]. Her diagnoses were acute transverse myelitis, paraplegia, bipolar disorder, neuromuscular dysfunction, mood disorder, and depression. Review of her Minimum Data Set (MDS) assessment, dated 07/02/23, revealed she had a mild cognitive impairment. Review of Resident #67 MDS assessments revealed the last assessment submitted to the Center for Medicare and Medicaid Services (CMS) was on 07/02/23. The facility had started/completed the her most recent MDS on 10/02/23, but due to the electronic medical records company having an error with their program, they could not submit the assessment until 11/01/23. As of 11/14/23, the assessment from 10/02/23 had not been submitted; it was documented as being ready to export. 15. Resident #74 was admitted to the facility on [DATE]. His diagnoses were hemiplegia and hemiparesis, hypertension, congestive heart failure, cognitive communication deficit, hyperlipidemia, cerebral infarction, depression, aphasia, dysphagia, and anxiety disorder. Review of his Minimum Data Set (MDS) assessment, dated 07/06/23, revealed he had a mild cognitive impairment. Review of Resident #74 MDS assessments revealed the last assessment submitted to the Center for Medicare and Medicaid Services (CMS) was on 07/06/23. The facility had started/completed the his most recent MDS on 10/06/23, but due to the electronic medical records company having an error with their program, they could not submit the assessment until 11/01/23. As of 11/14/23, the assessment from 10/06/23 had not been submitted; it was documented as being ready to export. 16. Resident #83 was admitted to the facility on [DATE]. Her diagnoses were acute transverse myelitis, paraplegia, bipolar disorder, neuromuscular dysfunction, mood disorder, and depression. Review of her Minimum Data Set (MDS) assessment, dated 07/07/23, revealed she cognitively intact. Review of Resident #83 MDS assessments revealed the last assessment submitted to the Center for Medicare and Medicaid Services (CMS) was on 07/07/23. The facility had started/completed the her most recent MDS on 10/05/23, but due to the electronic medical records company having an error with their program, they could not submit the assessment until 11/01/23. As of 11/14/23, the assessment from 10/05/23 had not been submitted; it was documented as being ready to export. Interview with Regional MDS Director #205 on 11/15/23 at 10:02 A.M. revealed they had the MDS assessments completed by the required timeframe. She also confirmed they could not submit the MDS assessments from 10/01/23 to 11/01/23 due to an error within the electronic medical record system. She confirmed the error was fixed with the records system on 11/01/23 and the assessments should have been sent in after that. She confirmed as of 11/14/23, the assessments had not been sent int, which was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365644 If continuation sheet Page 7 of 33 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 365644 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Winchester 36 Lehman Dr Canal Winchester, OH 43110 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 0640 not completed in a timely manner. Level of Harm - Minimal harm or potential for actual harm Review of facility Maintaining MDS Assessment policy, dated 10/01/23, revealed MDS information will be readily and easily accessible for review by the state survey agency and CMS. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365644 If continuation sheet Page 8 of 33 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 365644 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Winchester 36 Lehman Dr Canal Winchester, OH 43110 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review, and facility policy review, the facility failed to accurately assess one resident's (Resident #71) cognition. This affected one resident (Resident #71) of one reviewed for appropriate cognitive status. The facility census was 88. Residents Affected - Few Findings Include: Review of the resident record for Resident #71 revealed an admission date on 06/03/22. Medical diagnoses included cerebral vascular accident (CVA) (stroke), cognitive communication deficit, encephalopathy, aphasia, seizures, and unspecified mood (affective) disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #71 had severely impaired cognition and scored two out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #71 had severely impaired cognition and scored two out of 15 on the BIMS assessment. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #71 had impaired cognition and scored six out of 15 on the BIMS assessment. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #71 had impaired cognition and scored six out of 15 on the BIMS assessment. Review of the annual MDS 3.0 assessment dated [DATE] revealed Resident #71 had severely impaired cognition and scored three out of 15 on the BIMS assessment. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #71 had impaired cognition and scored eight out of 15 on the BIMS assessment. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #71 had impaired cognition and scored ten out of 15 on the BIMS assessment. Review of the Statement of Expert Evaluation dated 09/06/23 and completed by Physician #208 revealed Resident #71 was aphasic but oriented. Resident #71 was reportedly married and had a living mother. The situation was complicated due to family dynamics regarding a legal next of kin. Resident #71 was not able to functionally care for himself but was able to participate in medical decisions with assistive devices due to aphasia. Physician #208's opinion was for guardianship to be denied. Review of the Statement of Expert Evaluation dated 09/27/23 and completed by Physician #208 revealed Resident #71 was not mentally impaired. Resident #71 appeared mentally intact upon assessment. Resident #71 had profound dysarthria (difficult or unclear articulation of speech that is otherwise linguistically normal) that limited his ability to communicate. Resident #71 used an iPad with a yes and no button. Physician #208's opinion was Resident #71 required assistance with Activities of Daily Living (ADLs), but was able to participate in medical decisions and guardianship should be denied. Review of the Statement of Expert Evaluation dated 10/11/23 and completed by Physician #208 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365644 If continuation sheet Page 9 of 33 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 365644 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Winchester 36 Lehman Dr Canal Winchester, OH 43110 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 0641 Level of Harm - Minimal harm or potential for actual harm revealed Resident #71 had aphasia (the loss of ability to understand or express speech, caused by brain damage) and an altered mental state. Resident #71 had impairments with orientation, speech, motor behavior, memory and judgement. Resident #71 exhibited inconsistencies with responses during the assessment. Resident #71 would not be capable of managing finances or personal property. Physician #208's opinion was that guardianship should be established. Residents Affected - Few At the time of the survey (over a year after Resident #71's admission), the facility had not determined whether or not Resident #71 needed assistance with healthcare decision making and had not identified a legal representative for the resident, if needed. Interview on 11/14/23 at 12:26 P.M. with Speech Therapist (ST) #207 revealed she had worked with Resident #71 on communication and swallowing. Resident #71 was last discharged from her caseload on 09/13/23 due to the resident reached the highest practical level. ST #207 stated Resident #71's communication abilities remained the same during each episode of therapy. ST #207 stated Resident #71 had severe expressive and receptive aphasia that would not improve. ST #207 stated she did not feel the BIMS assessment was a reliable or an accurate tool in assessing Resident #71's cognitive status due to the resident's severe aphasia. ST #207 stated she was not sure how Resident #71 received scores on the assessments because the resident was not able to complete the assessment. ST #207 stated she noted Resident #71 to have a BIMS of zero out of 15 upon initial evaluation and the score had not changed. ST #207 stated she felt Resident #71's use of the iPad was misleading because the resident was only 60% accurate when he used the iPad to communicate but a lot of people assume the resident was 100% accurate. ST #207 confirmed Resident #71's cognition had not been assessed accurately across various departments within the facility. Interview on 11/14/23 at 1:39 P.M. with Social Services (SS) #179 revealed she had completed the BIMS assessment with Resident #71 in the most recent MDS assessment. SS #179 stated Resident #71 used his iPad to respond to yes or no to questions. SS #179 confirmed she did not feel the BIMS assessment was an accurate depiction of Resident #71's cognitive status due to the resident's expressive and receptive aphasia. Interview on 11/15/23 at 9:08 A.M. with Physician #208 revealed she had been the facility's physician since March 2023 and had visited Resident #71 on multiple occasions. Physician #208 confirmed she completed three expert evaluations for court appointed guardianship on Resident #71. Two of her evaluations determined guardianship should be denied and the most recent evaluation, Physician #208 found that guardianship should be established for Resident #71. Physician #208 stated Resident #71 had severe aphasia and used an iPad to communicate mostly. During her first two evaluations, she allowed Resident #71 to use the iPad to answer questions and during her third evaluation, she presented other tools, such as a calendar, for Resident #71 to use to help answer questions. Physician #208 stated when Resident #71 was presented with the more unfamiliar objects, inconsistencies with responses arose. Physician #208 stated in her opinion, Resident #71 would be able to make some simple healthcare decisions but would not be able to fully understand more complex healthcare decisions and therefore, in her opinion, Resident #71 should have a court appointed guardian put into place for him. Review of the facility policy, CMS's RAI Version 3.0 Manual, Section C: Cognitive Patterns, dated October 2023, revealed the policy stated, the items in this section are intended to determine the resident's attention, orientation, and ability to register and recall new information and whether the resident has signs and symptoms of delirium. These items are crucial factors in many care-planning decisions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365644 If continuation sheet Page 10 of 33 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 365644 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Winchester 36 Lehman Dr Canal Winchester, OH 43110 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 0641 This deficiency represents noncompliance investigated under Complaint Number OH00147681. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365644 If continuation sheet Page 11 of 33 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 365644 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Winchester 36 Lehman Dr Canal Winchester, OH 43110 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 observation, record review, interview and facility policy review, the facility failed to develop and implement a comprehensive plan of care for three residents (#33, #53, #61) in the area of contractures and antipsychotic medication use. This affected one (Resident #61) of one resident reviewed for contractures and two (Resident #33 and Resident #53) of five residents reviewed for unnecessary medications. The facility census was 88. Findings Include: 1. Review of the medical record for Resident #53 revealed an initial admission date of 10/30/20 with the latest readmission of 06/12/22 with diagnoses including fracture of upper end of right tibia, severe morbid obesity, dependence on respirator, bipolar disorder, osteoarthritis, spinal stenosis lumbar region, obstructive sleep apnea, dysphagia, major depressive disorder, pain, chronic respiratory failure, polyneuropathy, chronic allergic conjunctivitis, overactive bladder, gastro-esophageal reflux and on 06/01/22 the diagnoses of schizophrenia was added. Review of the resident's quarterly minimum data set (MDS) assessment dated [DATE] revealed the resident has a moderate cognitive deficit. The assessment indicated the resident had displayed no behaviors and received antipsychotic medication on a routine basis. Review of the medical record revealed the resident had no care plan addressing the use of the antipsychotic medication, Seroquel or the target behaviors for the use of the antipsychotic medications. Review of the monthly physician orders for November 2023 identified orders dated 05/05/23 Seroquel 25 milligrams (mg) with the special instructions to administer two tablets by mouth daily at bedtime for schizophrenia. On 11/16/23 at 9:20 A.M., interview Director of Nursing (DON) #140 verified the facility had not developed and implemented a plan of care addressing the use of the antipsychotic medication, Seroquel or had not identified target behaviors for the use of the antipsychotic medications. 2. Review of the medical record for Resident #61 revealed an initial admission date of 09/13/23 with the diagnoses including encephalopathy, anxiety disorder, depression, urinary tract infection, hypotension, bradycardia and cerebrovascular accident with left sided hemiplegia. Review of the admission assessment with baseline plan of care dated 09/13/23 revealed the resident was admitted to the facility with a left hand/palm contracture. Review of the plan of care revealed the resident had no care plan addressing the care of the contracture to the resident's left hand/wrist. Review of the resident's comprehensive MDS assessment dated [DATE] revealed the resident had a moderate cognitive impairment. The resident required extensive assistance of two staff for bed mobility, transfers, toileting, dressing, personal hygiene and was dependent on one staff for bathing. The assessment indicated the resident had no functional impairment to the upper or lower extremities. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365644 If continuation sheet Page 12 of 33 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 365644 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Winchester 36 Lehman Dr Canal Winchester, OH 43110 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 On 11/16/23 at 11:22 A.M., interview with Registered Nurse (RN) #107 verified the comprehensive MDS dated [DATE] failed to capture the resident's contractures to the left hand/wrist and the facility had not developed and implemented a comprehensive plan of care related to the resident's left hand/wrist contractures. 3. Review of the medical record for Resident #33 revealed an admission date on 09/16/21. Medical diagnoses included Alzheimer's Disease, mood (affective) disorder, vascular dementia with other behavioral disturbance, and major depressive disorder. Review of the physician orders dated November 2023 revealed Resident #33 had an order for Seroquel (an antipsychotic medication) 50 milligrams (mg) at bedtime for mood disorder related to dementia. The order was dated 08/28/23. Review of the Medication Administration Records dated September 2023, October 2023, and November 2023 revealed Resident #33 received Seroquel daily as ordered. Review of the significant change MDS 3.0 assessment dated [DATE] revealed Resident #33 had severely impaired cognition and scored six out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #33 required extensive assistance to total dependence from one to two staff to complete Activities of Daily Living (ADLs). Resident #33 received daily antipsychotic medication. Review of the care plan revised 09/21/23 revealed the care plan did not address Resident #33's antipsychotic medication use. Interview on 11/15/23 at 4:50 P.M. with Regional Nurse (RGN) #203 confirmed Resident #33's care plan did not address the use of antipsychotic medication. Review of the facility policy, Comprehensive Care Plans, dated 08/22/22, revealed the policy stated, the facility would develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365644 If continuation sheet Page 13 of 33 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 365644 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Winchester 36 Lehman Dr Canal Winchester, OH 43110 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 medical record review, staff interviews, and facility policy review, the facility failed to revise a comprehensive care plan to specifically address one resident's (Resident #71) cognitive status changes and whether or not a legal resident representative was needed for healthcare decision making. This affected one resident (Resident #71) of 20 residents reviewed for care plans. The facility census was 88. Findings Include: Review of the resident record for Resident #71 revealed an admission date on 06/03/22. Medical diagnoses included cerebral vascular accident (CVA) (stroke), cognitive communication deficit, encephalopathy, aphasia, seizures, and unspecified mood (affective) disorder. Review of the Durable Power of Attorney for Management of Property and Personal Affairs dated 01/24/22 revealed Resident #71 named his wife to be Power of Attorney (POA) for finances only. There was not a POA for healthcare decisions named for Resident #71. Review of Resident #71's facesheet revealed the resident was his own responsible partly and guarantor. Resident #71's wife was listed as an emergency contact only. Review of the admission Assessment with Baseline Care Plan dated 06/03/22 revealed the code status section of the assessment was not completed. Resident #71 was alert to person with unclear verbal communication. Resident #71 had impaired cognition or decision making skills noted. Review of the care plan dated 06/03/22 revealed Resident #71 had impaired cognitive process for daily decision making and was at risk for further decline in cognitive status. Interventions included communicate with staff, family, physician/Certified Nurse Practitioner (CNP) regarding resident's needs. The care plan did not identify a specific resident representative and did not indicate specifically whether or not Resident #71 was able to make healthcare decisions for himself. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #71 had severely impaired cognition and scored two out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #71 had severely impaired cognition and scored two out of 15 on the BIMS assessment. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #71 had impaired cognition and scored six out of 15 on the BIMS assessment. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #71 had impaired cognition and scored six out of 15 on the BIMS assessment. Review of the annual MDS 3.0 assessment dated [DATE] revealed Resident #71 had severely impaired cognition and scored three out of 15 on the BIMS assessment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365644 If continuation sheet Page 14 of 33 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 365644 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Winchester 36 Lehman Dr Canal Winchester, OH 43110 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 Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #71 had impaired cognition and scored eight out of 15 on the BIMS assessment. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #71 had impaired cognition and scored ten out of 15 on the BIMS assessment. Residents Affected - Few Review of the Statement of Expert Evaluation dated 09/06/23 and completed by Physician #208 revealed Resident #71 was aphasic but oriented. Resident #71 was reportedly married and had a living mother. The situation was complicated due to family dynamics regarding a legal next of kin. Resident #71 was not able to functionally care for himself but was able to participate in medical decisions with assistive devices due to aphasia. Physician #208's opinion was for guardianship to be denied. Review of the Statement of Expert Evaluation dated 09/27/23 and completed by Physician #208 revealed Resident #71 was not mentally impaired. Resident #71 appeared mentally intact upon assessment. Resident #71 had profound dysarthria (difficult or unclear articulation of speech that is otherwise linguistically normal) that limited his ability to communicate. Resident #71 used an iPad with a yes and no button. Physician #208's opinion was Resident #71 required assistance with Activities of Daily Living (ADLs), but was able to participate in medical decisions and guardianship should be denied. Review of the Statement of Expert Evaluation dated 10/11/23 and completed by Physician #208 revealed Resident #71 had aphasia (the loss of ability to understand or express speech, caused by brain damage) and an altered mental state. Resident #71 had impairments with orientation, speech, motor behavior, memory and judgement. Resident #71 exhibited inconsistencies with responses during the assessment. Resident #71 would not be capable of managing finances or personal property. Physician #208's opinion was that guardianship should be established. Interview on 11/14/23 at 12:26 P.M. with Speech Therapist (ST) #207 revealed she had worked with Resident #71 on communication and swallowing. Resident #71 was last discharged from her caseload on 09/13/23 due to the resident reached the highest practical level. ST #207 stated Resident #71's communication abilities remained the same during each episode of therapy. ST #207 stated Resident #71 had severe expressive and receptive aphasia that would not improve. ST #207 stated she did not feel the BIMS assessment was a reliable or an accurate tool in assessing Resident #71's cognitive status due to the resident's severe aphasia. ST #207 stated she was not sure how Resident #71 received scores on the assessments because the resident was not able to complete the assessment. ST #207 stated she noted Resident #71 to have a BIMS of zero out of 15 upon initial evaluation and the score had not changed. ST #207 stated she felt Resident #71's use of the iPad was misleading because the resident was only 60% accurate when he used the iPad to communicate but a lot of people assume the resident was 100% accurate. ST #207 confirmed Resident #71's cognition had not been assessed accurately across various departments within the facility. Interview on 11/14/23 at 1:39 P.M. with Social Services (SS) #179 revealed Resident #71 did not have a POA for healthcare in place and did not have a guardian appointed. SS #179 stated Physician #208 completed three expert evaluations on Resident #71 on 09/06/23, 09/27/23, and 10/11/23. The physician's opinion was that Resident #71 was able to make decisions on 09/06/23 and 09/27/23. The physician's opinion on 10/11/23 was that Resident #71 was not able to make decisions and agreed a guardian should be appointed. SS #179 confirmed prior to September 2023, the facility used Resident #71's wife as the resident's responsible party for healthcare decisions even though the resident's wife did not have POA for healthcare decisions in place. SS #179 confirmed there were not any legal documents in place that indicated Resident #71 could not make his own decisions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365644 If continuation sheet Page 15 of 33 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 365644 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Winchester 36 Lehman Dr Canal Winchester, OH 43110 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 Interview on 11/15/23 at 9:08 A.M. with Physician #208 revealed she had been the facility's physician since March 2023 and had visited Resident #71 on multiple occasions. Physician #208 confirmed she completed three expert evaluations for court appointed guardianship on Resident #71. Two of her evaluations determined guardianship should be denied and the most recent evaluation, Physician #208 found that guardianship should be established for Resident #71. Physician #208 stated Resident #71 had severe aphasia and used an iPad to communicate mostly. During her first two evaluations, she allowed Resident #71 to use the iPad to answer questions and during her third evaluation, she presented other tools, such as a calendar, for Resident #71 to use to help answer questions. Physician #208 stated when Resident #71 was presented with the more unfamiliar objects, inconsistencies with responses arose. Physician #208 stated in her opinion, Resident #71 would be able to make some simple healthcare decisions but would not be able to fully understand more complex healthcare decisions and therefore, in her opinion, Resident #71 should have a court appointed guardian put into place for him. Review of the facility policy, Comprehensive Care Plans, dated 08/22/22, revealed the policy stated, the comprehensive care plan will describe, at a minimum, the following: the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being, resident specific interventions that reflect the resident's needs and preferences, and identify tools used for communication. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. Alternative interventions will be documented, as needed. This deficiency represents noncompliance investigated under Complaint Number OH00147681. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365644 If continuation sheet Page 16 of 33 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 365644 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Winchester 36 Lehman Dr Canal Winchester, OH 43110 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 - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, facility policy and procedure review and interview, the facility failed to implement interventions to prevent the development of a pressure ulcer for Resident #79. Residents Affected - Few Actual harm occurred on 08/10/23 when Resident #79, who was moderately cognitively impaired, at risk for pressure ulcer development and required extensive assistance from staff for bed mobility, developed an unstageable (Dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/ edges of the wound.) pressure ulcer to the right heel. There was no evidence of adequate and necessary interventions in place prior to the development of the ulcer. This affected one resident (#79) of three residents reviewed for pressure ulcers. The census was 88. Findings Include: Review of the medical record for Resident #79 revealed an initial admission date of 12/06/22 with diagnoses including psoriatic arthritis, diabetes mellitus, anemia, cachexia, candidal esophagitis, gastro-esophageal reflux disease, legal blindness, depression, insomnia, seborrheic dermatitis, bilateral corneal pannus, bilateral age-related nuclear cataract, vitamin D deficiency and history of other mental and behavioral disorders. Review of the resident's admission assessment with baseline care plan dated 12/06/22 revealed the resident was admitted with no pressure ulcer/injuries. Review of the plan of care dated 12/06/22 revealed the resident had potential for alteration in skin integrity related to incontinence. Interventions included educated resident/family on skin breakdown, risk factors and preventative measures, encourage to float heels while in bed, encourage to turn and reposition every two hours and as needed, keep nail edges smooth and trimmed as tolerated, pressure reducing cushion to chair/bed, provide assistance with hygiene including peri-care as needed, record meal intake percentages per facility policy, trim nails each shower day as tolerated and use barrier cream with showers and incontinent episodes. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a moderate cognitive deficit. The resident required extensive assistance of one staff member with bed mobility, toilet use, dressing and personal hygiene. The assessment indicated the resident was always incontinent of both bowel and bladder. The assessment indicated the resident was at risk for skin breakdown and had no skin issues. Review of the weekly skin observation dated 08/07/23 revealed the resident had no skin issues. Review of the progress note dated 08/10/23 at 2:09 P.M. revealed a State Tested Nursing Assistant (STNA) found a pressure wound to the right heel during care. The wound nurse, Director of Nursing (DON) and physician were notified of the wound. Review of the weekly skin observation dated 08/10/23 revealed the resident was noted to have a Stage III (full-thickness tissue loss into subcutaneous tissue but does not go into the muscle or bone) pressure ulcer to the right heel. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365644 If continuation sheet Page 17 of 33 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 365644 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Winchester 36 Lehman Dr Canal Winchester, OH 43110 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 - Actual harm Review of the weekly skin grid pressure dated 08/10/23 revealed the resident was observed to have an unstageable pressure ulcer to the right heel measuring 7.5 centimeters (cm) in length by 11.5 cm width and described as having moderate serous drainage, necrotic tissue present, 10% dermis and 80% subcutaneous tissue. Residents Affected - Few Review of the progress note dated 08/11/23 revealed the Nurse Practitioner (NP) was notified of the wound, treatment orders were put in place as well as heelzup (device used to elevate the heels of the bed) while in bed as tolerated. Review of the weekly skin grid pressure dated 08/15/23 revealed the unstageable pressure ulcer to the right heel measured 3.5 cm by 8.5 cm by 0.1 cm and described as having moderate amount of serous drainage, 30% thick adherent devitalized necrotic tissue, 10% dermis/subcutaneous tissue and 60% slough. The facility determined the wound had improved with this assessment. Review of the weekly skin grid pressure dated 08/22/23 revealed the unstageable pressure ulcer was now classified as a Stage III pressure ulcer measuring 2.2 cm by 6.8 cm by 0.1 cm and described as having a moderate amount of serous drainage, 10% thick adherent devitalized necrotic tissue, 20% slough, 30% granulation and 40% dermis/subcutaneous tissue. The wound bed was pink/black and yellow in color. Surgical excision debridement was performed. The facility determined the wound had improved with this assessment. Review of the weekly skin grid pressure dated 08/29/23 revealed the Stage III pressure ulcer measured 2.2 cm by 6.3 cm by 0.1 cm and described as having a moderate amount of serous drainage, 10% thick adherent devitalized necrotic tissue, 20% slough, 30% granulation and 10% dermis/subcutaneous tissue and 30% skin. The wound bed was pink/black and yellow in color. Surgical excision debridement was performed. The facility determined the wound had improved with this assessment. Review of the plan of care dated 09/01/23 (following the wound development) revealed the resident was noncompliant with care/treatment as ordered by physician, does not follow physician ordered diet and would refuse meals, refuse medications, refuse to be turned and repositioned, refuse treatments, refuse to be weighed, had the tendency to refuse accuchecks and refused breathing treatments. Interventions included if appropriate, stop care when resident is upset and try again later, educate resident as to the negative consequences of not following physician orders, notify the physician/NP of refusals of medications and treatments and praise all attempts to cooperate with care giving efforts and any improvement in behavior. Review of the weekly skin grid pressure dated 09/05/23 revealed the Stage III pressure ulcer measured 4.2 cm by 6.5 cm by 0.1 cm and described as having a moderate amount of serous drainage, 10% thick adherent devitalized necrotic tissue, 20% slough and 70% dermis/subcutaneous tissue. The wound bed was pink/black and yellow in color. Surgical excision debridement was performed. The facility determined the wound had declined with this assessment. Review of the weekly skin grid pressure dated 09/12/23 revealed the wound had declined to a 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. Often includes undermining and tunneling) pressure ulcer measuring 5.5 cm by 7.4 cm by 1.0 cm with 100% thick adherent devitalized necrotic tissue. Surgical excision debridement performed by physician. The wound had a moderate amount of serous drainage, and the wound bed was black and dark brown. The facility determined the wound had improved with this assessment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365644 If continuation sheet Page 18 of 33 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 365644 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Winchester 36 Lehman Dr Canal Winchester, OH 43110 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 - Actual harm Review of the weekly skin grid pressure dated 09/19/23 revealed the Stage IV pressure ulcer measured 5.0 cm by 6.5 cm by 1.0 cm with 100% thick adherent devitalized necrotic tissue. Surgical excision debridement performed by physician. The wound had a moderate amount of serous drainage, and the wound bed was black and dark brown. The facility determined the wound had improved with this assessment. Residents Affected - Few Review of the weekly skin grid pressure dated 09/26/23 revealed the Stage IV pressure ulcer measured 4.5 cm by 6.0 cm by 1.0 cm with 80% thick adherent devitalized necrotic tissue. Surgical excision debridement performed by physician. The wound had a moderate amount of serous drainage, and the wound bed was black and dark brown. Review of the weekly skin grid pressure dated 10/03/23 revealed the Stage IV pressure ulcer measured 4.0 cm by 5.8 cm by 1.0 cm with 70% thick adherent devitalized necrotic tissue and 30% dermis/subcutaneous/tendon. Surgical excision debridement performed by physician. The wound had a moderate amount of serous drainage, and the wound bed was dark brown and pink. The facility determined the wound had improved with this assessment. Review of the weekly skin grid pressure dated 10/10/23 revealed the Stage IV pressure ulcer measured 4.5 cm by 5.5 cm by 1.0 cm with 40% thick adherent devitalized necrotic tissue and 30% granulation tissue and 30% dermis/subcutaneous/tendon. Surgical excision debridement performed by physician. The wound had a moderate amount of serous drainage, and the wound bed was gray/brown and pink. The facility determined the wound had improved with this assessment. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a moderate cognitive deficit. The assessment indicated the resident was always incontinent of both bowel and bladder. The assessment indicated the resident was at risk for skin breakdown and had one Stage IV pressure ulcer no present on admission. The facility implemented the interventions pressure reducing device to bed/chair, nutrition, or hydration intervention to manage skin problems, pressure injury care and applications of ointments/medications other than to feet. Review of the weekly skin grid pressure dated 10/17/23 revealed the Stage IV pressure ulcer measured 4.0 cm by 5.7 cm by 1.0 cm with 30% thick adherent devitalized necrotic tissue and 70% granular, tissue with the edges indurated and rolled in. The wound had a moderate amount of serous drainage. The facility determined the wound had improved with this assessment. Review of the weekly skin grid pressure dated 10/24/23 revealed the Stage IV pressure ulcer measured 4.5 cm by 5.5 cm by 1.0 cm with 20% thick adherent devitalized necrotic tissue and 80% granular. The wound had a moderate amount of serous drainage. The facility determined the wound had improved with this assessment. Review of the weekly skin grid pressure dated 10/31/23 revealed the Stage IV pressure ulcer measured 4.3 cm by 4.1 cm by 1.0 cm with 20% thick adherent devitalized necrotic tissue and 80% granular. The wound had a moderate amount of serous drainage, and the wound bed was gray/brown and pink. The facility determined the wound had improved. Review of the weekly skin grid pressure dated 11/07/23 revealed the Stage IV pressure ulcer measured 4.2 cm by 4.0 cm by 0.5 cm with 10% thick adherent devitalized necrotic tissue and 90% granular. The wound had a moderate amount of serous drainage, and the wound bed was brown and red. The facility determined the wound had improved. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365644 If continuation sheet Page 19 of 33 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 365644 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Winchester 36 Lehman Dr Canal Winchester, OH 43110 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 - Actual harm Residents Affected - Few Review of the monthly physician orders for November 2023 identified orders dated 05/03/23 diabetic protein based food snack at bedtime, 09/07/23 encourage resident to keep nail edges smooth and trimmed, 09/12/23 prevalon boots to bilateral lower extremities while in bed as tolerated, 09/17/23 remove foot board from bed, 10/23/23 turn left to right side as tolerated, and 11/07/23 cleanse right heel with normal saline (NS) and apply Mesalt, cover with island dressing daily until resolved. Observation on 11/16/23 at 10:49 A.M. of Registered Nurse (RN) #150 and Licensed Practical Nurse (LPN) #132 provide the physician ordered treatment for Resident #79 revealed the nurses washed their hands. LPN #150 removed the soiled dressing and washed her hands, donned gloves. RN #150 set-up the required supplies on a barrier on the resident's bedside table. RN #150 washed her hands then cleansed the heel wound with normal saline and 4X4 while LPN #132 held the resident's foot up. RN #150 pat the wound dry with a 4X4, applied Mesalt and covered the wound with an island dressing. The wound was beefy round in color. On 11/16/23 at 9:50 A.M., an interview with Registered Nurse (RN) #107 verified the facility had inadequate preventative measures in place leading to the development of a pressure ulcer for Resident #79. Review of the facility policy titled, Skin Care, last revised 11/2018 revealed the facility will provide the care necessary to ensure the resident does not develop pressure injuries, unless clinically unavoidable. Skill will be observed upon admission and routinely throughout the resident's stay. Preventative care plans will be developed and implemented for each resident. Residents identified will be encouraged/assisted to turn and reposition. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365644 If continuation sheet Page 20 of 33 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 365644 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Winchester 36 Lehman Dr Canal Winchester, OH 43110 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews, record review, and facility policy review, the facility failed to ensure one resident's (Resident #239) vital signs were checked upon returning from dialysis treatments. This affected one resident (Resident #239) of one reviewed for dialysis. The facility census was 88. Residents Affected - Few Findings Include: Review of the medical record for Resident #239 revealed and initial admission date on 10/24/23 and a readmission date on 11/03/23. Medical diagnoses included cognitive deficit deficit, end stage renal disease, and acute kidney failure. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #239 had intact cognition and scored 13 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #239's function level varied from supervision with eating to total dependence with personal hygiene. Resident #239 required maximal assistance with lower dressing, bathing, and toileting. Resident #239 did not require dialysis at the time of the assessment. Additional MDS assessments had not been processed at the time of the survey. Review of the physician orders dated November 2023 revealed an order for dialysis on Monday, Wednesday, and Friday to an outside dialysis center dated 11/07/23. Review of the Medication Administration Record (MAR) dated November 2023 revealed Resident #239 attended dialysis treatments as ordered. Review of the care plan revised 11/11/23 revealed Resident #239 was at risk for potential complications related to renal failure requiring dialysis treatment. Interventions included obtain vital signs and weight per protocol and report significant changes in pulse, respirations, and blood pressure immediately. Review of the Dialysis Communications Forms dated 11/06/23, 11/08/23, 11/10/23, and 11/13/23 revealed Resident #239's vital signs were not monitored upon returning to the facility from dialysis treatments. Interview on 11/14/23 at 5:40 P.M. with Resident #239 revealed she had not been sent with Dialysis Communication Forms to all dialysis treatments. Resident #239 stated the dialysis center checked her vital signs but the facility did not check her vital signs upon returning to the facility after dialysis treatments. Interview on 11/15/23 at 11:00 A.M. with Regional Nurse (RGN) #203 confirmed Resident #239's vital signs were not being monitored upon returning to the facility from the dialysis center. Review of the facility policy, Monitoring/Communication Re: Dialysis Residents, revised 07/2018, revealed the policy stated, staff observe for significant change in status prior to going to dialysis, and upon return. The physician/Certified Nurse Practitioner (CNP) will be notified of a significant change in status or other concerns. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365644 If continuation sheet Page 21 of 33 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 365644 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Winchester 36 Lehman Dr Canal Winchester, OH 43110 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #28 revealed an initial admission date of 11/27/17 with the most recent readmission of 01/23/18 with the diagnoses including chronic obstructive pulmonary disease (COPD), traumatic brain injury (TBI), schizoaffective disorder, right sided hemiplegia, epilepsy, major depressive disorder, cardiomyopathy, dementia with mild behavioral disturbance, vitamin D deficiency, post traumatic stress disorder (PTSD) and psychosis. Review of the plan of care dated 05/01/20 revealed the resident had potential for adverse side effects of psychotropic drug use, antidepressant, TBI and major depressive disorder, 03/01/21 voices wants to kill himself at times, receiving antidepressant and antipsychotic medications. Interventions included continue to offer counseling despite previous refusals, document side effects of medication, notify physician of any mental status changes that occur, observe and document any abnormal behavior or moods and obtain vital signs as ordered and report abnormalities to physician. Review of the pharmacy recommendation dated 02/10/23 revealed the pharmacist recommended a gradual dose reduction (GDR) for the medication Seroquel 25 mg by mouth twice daily. The physician addressed the recommendation on 02/13/23 and declined the recommendation checking the box GDR contraindicated as continued use in accordance with current relevant standards of practice and the following rationale. Further review revealed no documented rationale to decline the GDR. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderate cognitive deficit. The assessment indicated the resident had hallucinations and delusions. The assessment indicated the resident received antipsychotic, antidepressant on a routine basis. The facility had not attempted a gradual dose reduction (GDR) and the physician had no documented a GDR as clinically contraindicated. Review of the monthly physician orders for November 2023 identified orders 08/29/23 Seroquel 25 mg by mouth twice daily for behaviors and 08/29/23 Seroquel 50 mg by mouth twice daily for schizoaffective disorder bipolar type. On 11/14/23 at 4:33 P.M., interview with Director of Nursing (DON) #140 verified the pharmacy recommendation dated 02/10/23 had no documented justification to decline the recommended GDR for the antipsychotic medication Seroquel. Review of the facility policy, Medication Regimen Review, undated, revealed the policy stated, timelines and responsibilities for Medication Regimen Review (MRR) included: facility staff shall act upon all recommendation according to procedures for addressing medication regimen review irregularities. Furthermore, the pharmacist does not need to document a continuing irregularity in the report each month if the attending physician has documented a valid clinical rationale for rejecting the pharmacist's recommendation. Based on medical record review, staff interview, review of pharmacy recommendations, and facility policy review, the facility failed to timely address a pharmacy recommendation for one resident (Resident #33) and failed to provide a rationale for declining a Gradual Dose Reduction (GDR) for two residents (Residents #28 and #33). This affected two residents (Residents #28 and #33) of five reviewed for unnecessary medications. The facility census was 88. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365644 If continuation sheet Page 22 of 33 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 365644 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Winchester 36 Lehman Dr Canal Winchester, OH 43110 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 0756 Findings Include: Level of Harm - Minimal harm or potential for actual harm 1. Review of the medical record for Resident #33 revealed an admission date on 09/16/21. Medical diagnoses included Alzheimer's Disease, mood (affective} disorder, vascular dementia with other behavioral disturbance, and major depressive disorder. Residents Affected - Few Review of the pharmacy recommendation dated 04/10/23 revealed Resident #33 received a current dose of Seroquel (Quetiapine) 75 milligrams once daily without an attempted Gradual Dose Reduction (GDR). The recommendation was to consider a GDR while monitoring for re-emergence of behavioral and/or withdrawal symptoms. There was no rationale documented related to why the GDR was contraindicated. The pharmacy recommendation was reviewed and declined by the physician or Certified Nurse Practitioner (CNP) on 05/05/23 (nearly one month later). Interview on 11/15/23 at 4:50 P.M. with Regional Nurse (RGN) #203 confirmed the pharmacy recommendation dated 04/10/23 was not addressed until 05/05/23 (nearly one month later). RGN #203 did not know why there was a delay in addressing the recommendation and confirmed there was not a documented rationale provided for why the GDR recommended was contraindicated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365644 If continuation sheet Page 23 of 33 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 365644 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Winchester 36 Lehman Dr Canal Winchester, OH 43110 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 medical record review and staff interview, the facility failed to ensure parameters for when the physician should be notified were provided for one resident's (Resident #33) insulin orders. This affected one resident (Resident #33) of five reviewed for unnecessary medications. The facility census was 88. Residents Affected - Few Findings Include: Review of the medical record for Resident #33 revealed an admission date on 09/16/21. Medical diagnoses included Alzheimer's Disease, Type II Diabetes Mellitus with neuropathy and chronic kidney disease, mood (affective} disorder, vascular dementia with other behavioral disturbance, and major depressive disorder. Review of the physician orders dated November 2023 revealed Resident #33 had the following insulin orders: Humalog Infection Solution inject five units subcutaneously at bedtime dated 06/22/23, Insulin Glargine Solution inject 20 units subcutaneously one time a day upon rise dated 07/29/23, Insulin Glargine Solution inject 30 units subcutaneously at bedtime dated 07/28/23, and Trulicity Subcutaneous Solution inject 4.5 milligrams (mg) subcutaneously every Tuesday upon rise dated 06/27/23. None of the insulin orders included parameters to notify the physician for staff to follow. Resident #33 also had an order for accuchecks to be completed twice daily dated 06/22/23. Review of blood glucose levels dated from 07/28/23 through 11/10/23 revealed Resident #33's blood glucose levels ranged from 51 to 390. Review of the significant change Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #33 had impaired cognition and scored six out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #33 required extensive assistance to total dependence on one to two staff to complete Activities of Daily Living (ADLs). Resident #33 received daily insulin injections. Review of the care plan revised 09/21/23 revealed Resident #33 was at risk for hyper/hypoglycemia due to diagnosis of diabetes. Interventions included be alert for signs and symptoms of hypoglycemia including blood sugars less than 50 mg/dl and be alert for signs and symptoms of hyperglycemia including blood sugars greater than 200 mg/dl. Interview on 11/16/23 at 1:24 P.M. with Regional Nurse (RGN) #203 confirmed Resident #33's insulin orders did not include any parameters to notify the physician. RGN #203 stated the orders should include parameters. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365644 If continuation sheet Page 24 of 33 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 365644 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Winchester 36 Lehman Dr Canal Winchester, OH 43110 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 record review and interview, the facility failed to identify target behaviors for the use of antipsychotic medications for three residents (#28, #33, #53) and failed to monitor for side effects of antipsychotic medication use for one resident (#33). This affected three of five residents reviewed for unnecessary medications. The facility census was 88. Findings Include: 1. Review of the medical record for Resident #28 revealed an initial admission date of 11/27/17 with the most recent readmission of 01/23/18 with the diagnoses including chronic obstructive pulmonary disease (COPD), traumatic brain injury, schizoaffective disorder, right sided hemiplegia, epilepsy, major depressive disorder, cardiomyopathy, dementia with mild behavioral disturbance, vitamin D deficiency, post traumatic stress disorder (PTSD) and psychosis. Review of the plan of care dated 05/01/20 revealed the resident had potential for adverse side effects of psychotropic drug use, antidepressant, TBI and major depressive disorder, 03/01/21 voices wants to kill himself at times, receiving antidepressant and antipsychotic medications. Interventions included continue to offer counseling despite previous refusals, document side effects of medication, notify physician of any mental status changes that occur, observe and document any abnormal behavior or moods and obtain vital signs as ordered and report abnormalities to physician. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderate cognitive deficit. The assessment indicated the resident had hallucinations and delusions. The assessment indicated the resident received antipsychotic on a routine basis. Review of the monthly physician orders for November 2023 identified orders dated 08/29/23 Seroquel 25 mg by mouth twice daily for behaviors and Seroquel 50 mg by mouth twice daily for schizoaffective disorder bipolar type. The facility increased the resident's Seroquel on 08/29/23 from 50 mg by mouth to twice daily to 75 mg by mouth twice daily following a failed GDR. Review of the resident's treatment administration record revealed the resident is monitored for sadness, irritability, and withdrawn for the use of the medication Seroquel. On 11/14/23 at 4:33 P.M., interview with Director of Nursing (DON) #140 verified the identified target behaviors were not appropriate for the use of the antipsychotic medication Seroquel. 2. Review of the medical record for Resident #53 revealed an initial admission date of 10/30/20 with the latest readmission of 06/12/22 with diagnoses including fracture of upper end of right tibia, severe morbid obesity, dependence on respirator, bipolar disorder, osteoarthritis, spinal stenosis lumbar region, obstructive sleep apnea, dysphagia, major depressive disorder, pain, chronic respiratory failure, polyneuropathy, chronic allergic conjunctivitis, overactive bladder, gastro-esophageal reflux and on 06/01/22 the diagnoses of schizophrenia was added. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365644 If continuation sheet Page 25 of 33 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 365644 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Winchester 36 Lehman Dr Canal Winchester, OH 43110 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 Review of the resident's quarterly MDS assessment dated [DATE] revealed the resident has a moderate cognitive deficit. The assessment indicated the resident had displayed no behaviors, received antipsychotic medications on a routine basis. The assessment indicated the diagnoses depression, bipolar disorder and schizophrenia were active diagnoses. Review of the medical record revealed the resident had no care plan addressing the use of the antipsychotic medication or the target behaviors for the use of the antipsychotic medications. Review of the monthly physician orders for November 2023 identified orders dated 05/05/23 Seroquel 25 mg with the special instructions to administer two tablets by mouth daily at bedtime for schizophrenia. Review of the treatment administration record (TAR) revealed the facility monitored the resident for increased behaviors, increased agitation, and lethargy of the use of Seroquel. On 11/16/23 at 9:20 A.M., interview with DON #140 verified the identified target behaviors were not appropriate for the use of the antipsychotic medication Seroquel. 3. Review of the medical record for Resident #33 revealed an admission date on 09/16/21. Medical diagnoses included Alzheimer's Disease, mood (affective} disorder, vascular dementia with other behavioral disturbance, and major depressive disorder. Review of the physician orders dated November 2023 revealed Resident #33 had an order for Seroquel (an antipsychotic medication) 50 milligrams (mg) at bedtime for mood disorder related to dementia. The order was dated 08/28/23. There were no orders to monitor for specific target behaviors or side effects of the antipsychotic medication. Review of the Medication Administration Records dated September 2023, October 2023, and November 2023 revealed Resident #33 received Seroquel daily as ordered. Review of the significant change Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #33 had severely impaired cognition and scored six out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #33 required extensive assistance to total dependence from one to two staff to complete Activities of Daily Living (ADLs). Resident #33 received daily antipsychotic medication. Review of the behavior monitoring task dated from 10/16/23 through 11/16/23 revealed Resident #33 was noted to yell or scream on three days out of 30. There were no other behaviors noted for Resident #33. Review of the care plan revised 09/21/23 revealed the care plan did not address Resident #33's antipsychotic medication use or monitoring for target behaviors and side effects of the medication. Interview on 11/16/23 at 1:24 P.M. with Regional Nurse (RGN) #203 confirmed there were not any target behaviors indicated for Resident #33. Also, RGN #203 confirmed there was not any orders or care plan to monitor for side effects of the antipsychotic medication, Seroquel. A facility policy was requested related to antipsychotic medications. The policy, Medication Regimen Review, undated, was provided. However, upon review of the policy, the policy does not address (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365644 If continuation sheet Page 26 of 33 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 365644 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Winchester 36 Lehman Dr Canal Winchester, OH 43110 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 antipsychotic medications specifically. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365644 If continuation sheet Page 27 of 33 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 365644 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Winchester 36 Lehman Dr Canal Winchester, OH 43110 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 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. 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 interview, the facility failed to obtain laboratory tests for residents as physician ordered. This affected two (Resident #28 and Resident #53) of five residents reviewed for unnecessary medications. The facility census was 88. Residents Affected - Few Findings Include: 1. Review of the medical record for Resident #28 revealed an initial admission date of 11/27/17 with the most recent readmission of 01/23/18 with the diagnoses including chronic obstructive pulmonary disease (COPD), traumatic brain injury, schizoaffective disorder, right sided hemiplegia, epilepsy, major depressive disorder, cardiomyopathy, dementia with mild behavioral disturbance, vitamin D deficiency, post traumatic stress disorder (PTSD) and psychosis. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderate cognitive deficit. Review of the monthly physician orders for November 2023 identified orders dated 02/10/22 Depakote level and liver function test (LFT), every three months, 02/16/22 complete metabolic [NAME] (CMP), complete blood count (CBC) every six months and Fasting Lipid Panel annually. Review of the resident's laboratory results revealed no LFT results for June 2023 and no CMP/CBC results for September 2023. Review of the resident's discontinued physician orders revealed no order for the CMP/CBC to be drawn in June 2023 On 11/15/23 at 10:48 A.M., interview with Registered Nurse (RN) #107 verified the LFT, CBC and CMP were not obtained as physician ordered. 2. Review of the medical record for Resident #53 revealed an initial admission date of 10/30/20 with the latest readmission of 06/12/22 with diagnoses including fracture of upper end of right tibia, severe morbid obesity, dependence on respirator, bipolar disorder, osteoarthritis, spinal stenosis lumbar region, obstructive sleep apnea, dysphagia, major depressive disorder, pain, chronic respiratory failure, polyneuropathy, chronic allergic conjunctivitis, overactive bladder, gastro-esophageal reflux and on 06/01/22 the diagnoses of schizophrenia was added. Review of the pharmacy recommendation dated 09/05/23 revealed the pharmacist recommended a Hemoglobin A1c (HgbA1c) next lab day and yearly thereafter due to the use of the antipsychotic medication Seroquel use. Review of the resident's quarterly MDS assessment dated [DATE] revealed the resident has a moderate cognitive deficit. Review of the monthly physician orders for November 2023 identified orders dated 09/08/23 for HgbA1c today and yearly. Review of the resident's medical record revealed no HgbA1c results for the physician order dated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365644 If continuation sheet Page 28 of 33 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 365644 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Winchester 36 Lehman Dr Canal Winchester, OH 43110 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 0770 09/08/23. Level of Harm - Minimal harm or potential for actual harm On 11/16/23 at 9:20 A.M., interview Director of Nursing (DON) #140 verified HgbA1c was not obtained on 09/08/23 as physician ordered. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365644 If continuation sheet Page 29 of 33 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 365644 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Winchester 36 Lehman Dr Canal Winchester, OH 43110 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observations, staff interviews, and facility policy review, the facility failed to ensure pureed food was an appropriate smooth texture prior to serving to residents on a pureed diet and required surveyor intervention for safety. This had the potential to affect nine residents (Residents #7, #49, #39, #5, #75, #4, #81, #64, and #52) who were on a prescribed pureed diet. The facility census was 88. Findings Include: 1. Observation on 11/15/23 at 10:48 A.M. with [NAME] #117 revealed the cook was preparing pureed Italian blend vegetables. [NAME] #117 confirmed the menu for lunch was Italian blend mixed vegetables and barbeque chicken. The recipes were observed to the left of [NAME] #117 during preparation. Vegetables in the Italian vegetable mix include carrots, green beans, cauliflower, and broccoli. Dietary Manager (DM) #178 was present for observation. Observation and interview on 11/15/23 at 10:54 A.M. revealed [NAME] #117 stopped puree machine and stated the vegetable mix was the proper texture for serving to residents. The surveyor present tasted the vegetable mix for proper texture. The pureed vegetable mix required some chewing and did not have a smooth texture. Interview on 11/15/23 at 10:55 A.M., [NAME] #117 and DM #178 were asked to taste the puree and they both said it was okay to serve. [NAME] #117 transferred the pureed vegetable mix from the blender into a metal container, covered it, and placed the container in the steamer to keep warm until it was time to place it on the tray line. Another Healthcare Facility Surveyor was asked to taste the food. Observation on 11/15/23 at 11:25 A.M., the second surveyor tasted the mixed vegetable puree and said it didn't have a smooth texture. The surveyor opened her mouth to show there was a chunk of cauliflower on her tongue. Interview on 11/15/23 at 11:25 A.M. with DM #178 confirmed they would puree the vegetable mix more. Review of the Vegetable Italian Blend recipe notes, 1. Remove portions to be pureed from the regular prepared vegetable. 2. Place in food processor and process until fine in consistency. 2. Observation on 11/15/23 at 10:57 A.M. with [NAME] #117 revealed the cook was preparing barbeque chicken to puree. The recipes were observed to the left of [NAME] #117 during preparation. Dietary Manager (DM) #178 was present for observation. Observation and interview on 11/15/23 at 11:01 A.M. revealed [NAME] #117 stopped puree machine and stated the barbeque chicken was the proper texture for serving to residents. The surveyor present tasted the barbeque chicken for proper texture. The barbeque chicken required chewing, was stringy, and did not have a smooth texture. Interview on 11/15/23 at 11:01 A.M. [NAME] #117 and DM #178 were asked to taste the puree and they both said it was okay to serve. [NAME] #117 transferred the barbeque chicken from the blender into a metal container, covered it, and placed the container in the steamer to keep warm until it was time (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365644 If continuation sheet Page 30 of 33 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 365644 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Winchester 36 Lehman Dr Canal Winchester, OH 43110 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 0805 to place it on the tray line. Level of Harm - Minimal harm or potential for actual harm Another Healthcare Facility Surveyor was asked to taste the food. Observation on 11/15/23 at 11:18 A.M., the second surveyor tasted the barbeque chicken and said it didn't have a smooth texture. The surveyor opened her mouth to show there was a chunk of chicken on her tongue. Residents Affected - Some Interview on 11/15/23 at 11:18 A.M. with DM #178 confirmed they would puree the barbeque chicken more. Review of the barbeque chicken recipe notes, 1. Place prepared BBQ chicken in food processor. 2. Add hot broth (base and water) and process until smooth in texture. Review of the facility policy, Dysphagia Puree (Level 1) Diet, dated 2008 revealed the policy stated, All foods are pureed to simulate a soft food bolus, eliminating the whole chewing phase. The policy also states All foods must be the consistency of moist mashed potatoes or pudding. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365644 If continuation sheet Page 31 of 33 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 365644 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Winchester 36 Lehman Dr Canal Winchester, OH 43110 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 - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and facility policy review, the facility failed to keep clean drying dishware in a clean dry location and not exposed to dust or other contamination. This had the potential to affect 87 out of 88 residents who receive beverages from the facility. The facility census was 88. Findings include: Observation on 11/13/23 at 11:27 A.M. revealed a recently cleaned rack of mugs and cups air drying on the end of the dishwasher line. Observed a ceiling tile with light pink insulation and dust hanging down from both ends of the ceiling tile and a ceiling vent next to the ceiling tile that was covered in dust. The tiles were above the clean rack of mugs and cups. Interview on 11/13/23 at 11:27 A.M. with Corporate Food Service Director #208 confirmed the ceiling area could be cleaner and there is pink dust at the end of the ceiling vents. Review of the undated Dish Machine Cleaning policy and the weekly Cleaning chart both do not indicate the area above where air drying is taking place. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365644 If continuation sheet Page 32 of 33 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 365644 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Winchester 36 Lehman Dr Canal Winchester, OH 43110 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 0908 Keep all essential equipment working safely. 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 and interviews, the facility failed to maintain one resident's (Resident #239) wheelchair in proper working order. This affected one of 22 sampled residents. The facility census was 88. Residents Affected - Few Findings Include: Review of the medical record for Resident #239 revealed an initial admission date of 10/24/23 with the latest readmission of 11/03/23 with diagnoses including cognitive communication deficit, retention of urine, end stage renal disease, dependence on hemodialysis and acute kidney failure. Review of the resident's comprehensive Minimum Data Set (MDS) dated [DATE] revealed the resident had no cognitive deficit. On 11/13/23 at 4:22 P.M., interview with Resident #239 revealed she had two different foot pedals to her wheelchair and the left foot pedal would not latch causing her legs spread when moved. Resident #239 revealed this caused her pain to her hips and legs. The resident revealed her transport driver who transports her to dialysis three times a week, as well as herself had asked the facility more than one to be repaired. On 11/14/23 at 2:45 P.M., observation of the resident's wheelchair sitting outside the resident's door revealed two foot pedals were sitting on the seat of the wheelchair. One right foot pedal was black and latched when attached to the wheelchair. The left foot pedal was blue and would not latch when put on the wheelchair. Interview with State Tested Nursing Assistant (STNA) #190 at the time of the observation revealed the ambulance driver had asked for the wheelchair to be repaired but the facility had not repaired the chair. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365644 If continuation sheet Page 33 of 33