Health inspection·January 27, 2026

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, self-reported incident (SRI) investigation review, staff interview, and review of the facility's abuse policy and procedure, this facility failed to ensure an allegation of resident-to-resident sexual abuse was submitted to the appropriate state agency as required. This affected two (Resident #410 and #510) of the three residents reviewed for sexual abuse. The facility census was 87. Findings include:1.Review of the medical record for Resident #510 revealed an initial admission date of 07/31/2025 with a re-entry date of 08/20/2025 and a discharge date of 11/202/2025. Diagnoses included cognitive communication deficit, anxiety disorder, mood disorder, and need for assistance with personal care. Review of Resident #510's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a BIMS score of 10 out of 15 indicating a moderately impaired cognition for daily decision-making abilities. Review of the nursing progress note dated 11/14/25 at 2:44 P.M. created by the Director of Nursing (DON) revealed Resident #510 came to the Social Worker and Nurse Manager and expressed that another resident (Resident #410) touched her breast twice last night. Resident #510 stated at 9:30 P.M. last night another resident (Resident #510) entered my room, talking about buying her a pop. Asked her if she had a boyfriend and told her she had a supply of food in his room. She went down to his room, there were gallons of tea on the floor, he ended up grabbing her breast. She quickly left the room, and he came in blaring porn on his phone, and he touched her breast again. Immediately other residents were interviewed and placed on one on one. Resident #510 denies any allegations and states he is a good Christian man. Resident #410 is offered to go to the hospital and declines, head to toe assessment completed, no new skin issues noted or discolorations, resident denies pain, resident also declines to move rooms at this time, and resident has a normal mood and affect at this time. Resident #410 is not tearful and even states he is not a rapist; he is just a little boy. Resident #410 states her psychosocial needs are being met currently. Medical Director notified, Certified Nurse Practitioner (CNP) notified, power of attorney aware, administrator, regional staff, and DON aware. Fairfield sheriffs notified and will be sending out officer to take a report.Review of the Medical Record for Resident #410 revealed an admission date of 10/13/2025 and a discharge date of 12/19/2025. Diagnosis included acute respiratory failure with hypoxia, alcohol dependence and need for assistance for personal care. 2.Review of Resident #410's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating an intact cognition for daily decision-making abilities. Noted with no impairments to bilateral upper or lower extremities and required a wheelchair for mobility. Was noted to be occasionally incontinent of bladder and always continent of bowel. Received antidepressants and anticoagulant daily. Review of the plan of care dated 11/17/25 and revised on 12/29/25 revealed Resident #410 has been observed displaying sexually inappropriate behavior: Perceiving relationship with female or male peers is closer/more sexually oriented than it actually is, touching Interventions Page 1 of 4 365644 365644 01/27/2026 Embassy of Winchester 36 Lehman Dr Canal Winchester, OH 43110

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few include allowing opportunities for resident to express need for companionship, explain to resident relationships are important to their identity and self-esteem when done in a appropriate manner, limit any at risk situations, maintain resident's dignity, provide alternative activities as needed, provide cues as needed that behaviors is unacceptable and what expectations are, redirect from entering females or males rooms without permission. Provide one on one care which was initiated on 12/14/25.Interview on 01/27/2026 at 12:28 P.M. with the Director of Nursing (DON) when asked if she had an SRI for a sexual abuse that occurred on 11/14/25 between Resident #410 and Resident #510, she said she did. When asked why it was not submitted to the proper state agency, she said she would have the Administrator explain that. Interview on 01/27/26 at 12:40 P.M. with the Administrator and the DON revealed that a complete investigation had been completed but not submitted. The administrator claimed he was in the process of filling out the information for the report to be submitted and got distracted with a facility issue and failed to hit the submit button. Upon returning to work that following Monday he realized that it was never submitted and spoke with his cooperate team who said to just continue with the complete investigation. If the incident was submitted now, it will be considered late reporting. Resident #510 had medication changes, 1:1 supervision care which turned into every 15-minute checks, psych services were provided and a room change was completed. Shortly after this incident occurred, Resident #510 was discharged to the local hospital per own request and Resident #410 had discharged to a local assisted living as per previously planned. Review of the facility policy titled Abuse, Neglect and Exploitation, dated 01/01/2024 revealed Sexual Abuse is non-consensual sexual contact of any type with a resident. Also noted under section VII. Reporting/Response. The facility will have written procedure that include reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within specified time frames. This deficiency represents non compliance investigated under Master Complaint Number 2718652. 365644 Page 2 of 4 365644 01/27/2026 Embassy of Winchester 36 Lehman Dr Canal Winchester, OH 43110

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and facility policy review the facility failed to prepare and handle food in a sanitary manner. This affected 85 residents in the facility who receive food from the kitchen. The facility identified two residents who were nothing-by mouth (NPO). The facility census was 87.Finding include:Observation on 01/27/26 at 12:30 P.M. for lunch tray service revealed [NAME] #299 was not wearing a hair net while placing places into insulated plate base for lunch meal trays.Interview on 01/27/26 at 1:05 P.M. [NAME] #299 confirmed he did not wear hairnet during lunch service and was observed getting a hair net.Review of the facility's policy titled, Hair Restraints, not dated confirmed hair shall be restrained to prevent physical contamination of food. Hair restraints shall be worn by all employees while in the kitchen to cover all hair.Observation on 01/27/26 at 12:31 P.M revealed dietary manager #215 touching own face with hands on 01/27/26 at 12:35 P.M. and did not perform hang hygiene while serving trays during lunch tray service.Interview on 01/27/26 at 1:05 P.M with dietary manager #215 confirmed she did not perform hand hygiene during lunch tray service.Review of the facility's policy titled, Hand Hygiene. dated 10/01/22, it is confirmed all staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors.This applies to all staff working in all locations within the facility. Observation on 01/27/26 at 12:35 P.M., and 12:43 P.M., revealed [NAME] #141 not filling the 3/4 cup scoop of beef stroganoff fully leaving about a 1/4 of an inch of space for residents who required regular serving of food. Interview on 01/27/26 at 1:05 P.M with dietary manager #215 confirmed it is difficult to level some items when serving. No policy was received regarding meal portion sizes. This deficiency represents non compliance investigated under Master Complaint Number 2718652. 365644 Page 3 of 4 365644 01/27/2026 Embassy of Winchester 36 Lehman Dr Canal Winchester, OH 43110

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, medical record review, and facility policy review the facility failed to perform hand hygiene during incontinence care. This affected one (Resident #374) of one resident observed during incontinence care . The census was 87.Findings include:Review of Resident #374's medical record revealed an admission date of 11/27/23. Medical diagnoses include unspecified dementia, moderate with psychotic disturbance, moderate-protein calorie disturbance, essential (primary) hypertension, hyperlipidemia, anxiety, depression, atrial fibrillation, personal history of transient ischemic attack and cerebral infarction without residual deficits, dysarthria and anarthria, low back pain, and irritable bowel syndrome with constipation.Review of Resident #374's quarterly Minimum Data Set (MDS) 3.0 dated 01/09/26 revealed a Brief Interview for Mental Status (BIMS) score of 06 out of 15. Resident #374's functional abilities revealed Resident #374 was dependent on staff for toileting hygiene.Review of Resident #374's care plan dated 10/14/25 revealed Resident #374 always experiences bowel and frequently experiences bladder incontinence. Goal stating Resident #374's toileting needs will be met by staff, with interventions aimed at the prevention of infection and/ or skin impairment. Interventions include be aware of change sin urinary elimination, inspect for skin breakdown and intervene when needed, observe skin each time you are providing incontinence care and notify nurse of any new area of breakdown, observe urine color, odor, clarity, frequency and amount as needed, provide incontinence care with care rounds and as needed, apply moisture barrier and review labs as ordered. Resident #374 has a focus with assistance needed for activities of daily living (ADL's) related to cognitive impairment, personal history of transient ischemic attack and cerebral infarction without deficits. Resident #374's goal stating she will be groomed and free of odors at all times and will participate as able in ADL self-care. Interventions include apply house moisture barrier after each incontinence episode, keep call light in reach while in bed, resident it totally dependent and does not participate in any aspects of the task including toileting hygiene requiring assist one helper, and staff is to have witness with all care.Observation on 01/27/26 at 1:54 P.M revealed Certified Nursing Assistant (CNA) #313 performing perineal care for Resident #374 with the assistance of Registered Nurse (RN) #255. CNA #313 provided Resident #374 by pulling curtain and performed hang hygiene and applied personal protective equipment (PPE). CNA #313 then warmed water and prepared wash basins for care and set up for perineal care. CNA #313 then performed hand hygiene and placed clean gloves on. CNA #313 then removed Resident #374's brief and performed perineal care, washing and drying appropriately before asking RN #255 to assist with turning Resident #374 to clean her buttock. CNA #313 then washed, dried and applied barrier cream to Resident #374 buttock and applied a new brief. RN #255 assisted CNA #313 with placing new brief on Resident #374. CNA #313 then gave Resident #374's baby dolls to her using same gloves used during incontinence care.Interview on 01/27/26 at 2:15 P.M. with CNA #313 confirmed they did not perform hand hygiene and change gloves during incontinence care.Review of the facility's policy titled, Hand Hygiene. dated 10/01/22, it is confirmed all staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Hand hygiene should be performed using with soap and water or alcohol based hand rub when, during resident care, moving from a contaminated body site to a clean body site and after handling items potentially contaminated with blood, body fluids, secretions, and excretions.Review of the facility's policy titled, Perineal care dated 01/08/25, confirms after performing perineal care to remove gloves and perform hand hygiene and ensure call light is in reach. Residents Affected - Few 365644 Page 4 of 4