Health inspection·November 22, 2022

F 0553 Level of Harm - Minimal harm or potential for actual harm Review of Medical record revealed the resident had documented one care plan meeting on 06/07/22. The medical record was silent to the resident having any additional care conferences while a resident at the facility Interview on 11/14/22 at 3:26 P.M., with Resident #24 stated he has not had a care plan meeting. Residents Affected - Some Interview on 11/15/22 at 4:00 P.M., with the SSD #346, confirmed the care plan meetings were not performed timely or on a quarterly schedule and confirmed the care plan meeting for Resident #24 occurred on 06/07/22. 3. Review of Resident #28's medical record revealed and admission date of 08/20/20, with the most recent hospitalization from 07/30/22 to 08/04/22. The resident diagnoses included dementia, history of falls, myasthenia gravis, unspecified symptoms and signs involving cognitive functions and awareness, cognitive communication deficit, problems related to unspecified psychosocial circumstances. Review of the quarterly MDS assessment dated [DATE] revealed the resident has clear speech, is usually understood and usually understands others and has adequate vision with corrective lenses. Resident is cognitively intact had no hallucinations, delusions, or behaviors. Resident #28 required total dependence for toileting, extensive assist for bed mobility, transfers, hygiene, and dressing, and required supervision for eating. Review of care conference documentation revealed the last care plan meeting for the resident was on 06/28/22. Interview on 11/14/22 at 3:14 P.M., with Resident #28 revealed the resident denied having participated in a care plan meeting. Interview on 11/15/22 at 4:00 P.M., with SSD #346, confirmed the care plan meetings were not performed timely or on a quarterly schedule; confirming the last care plan meeting with Resident #28 occurred on 06/28/22. 4. Review of resident medical record revealed the resident was admitted to the facility on [DATE] from another facility. Resident diagnoses include but are not limited to Parkinson's disease, type two diabetes, obesity, respiratory disorders paroxysmal atrial fibrillation, dysphagia, anxiety and depression. Review of most recent admission MDS assessment dated [DATE] revealed the resident was cognitively intact, had no behaviors, requires extensive assist with bed mobility, dressing, and eating, resident was coded as dependent on staff for transfers and toileting. Review of progress notes dated 10/31/22 at 4:02 P.M., indicating she met with the social worker and was admitted for long term placement to be closer to her sister. The resident is noted to be alert and oriented and able to make her needs known and declined counseling services at this time. The resident verified her sister is her power of attorney. Interview on 11/14/22 at 12:49 P.M., with Resident #117 revealed the resident had not had a car plan meeting. Interview on 11/15/22 at 4:00 P.M., with SSD #346 revealed the progress note on 10/31/22 at 4:02 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365673 If continuation sheet Page 2 of 36 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 365673 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Woodview 2770 Clime Road Columbus, OH 43223 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 0553 Level of Harm - Minimal harm or potential for actual harm P.M., was documenting of the residents care planning meeting. The SSD #346 was asked if any other members of the interdisciplinary team were included in the meeting; if the resident's care plans were reviewed; and the resident was able to participate in the care planning. SSD #346 confirmed she was the only person who met with the resident and the resident goals and care plans were not reviewed during this meeting. Residents Affected - Some 5. Review of the medical record for Resident #38 revealed an admission date of 01/14/21. Diagnoses included generalized anxiety disorder, malignant neoplasm of breast, malignant neoplasm of right kidney, edema of left orbit, cognitive communication deficit and unspecified dementia. Review of the quarterly MDS assessment dated [DATE] revealed Resident #38 had impaired cognition and scored a seven out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #38 required extensive assistance from one staff to complete personal hygiene task and supervision with set up help only to one staff to complete other Activities of Daily Living (ADLs). Review of the progress notes dated from 11/14/21 to current revealed Resident #38 had a quarterly care conference on 04/26/22. There was no evidence of any additional care conference being conducted. Review of the care plan revised 11/14/22 revealed Resident #38 chose to remain in the facility for long term care. The care plan did not address conducting quarterly care conferences. Interview on 11/15/22 at 11:18 A.M., via telephone with Resident #38's son revealed he had not been contacted by the facility regarding attending a care conference for the resident for a long time. Interview on 11/15/22 at 4:03 P.M., with SSD #346 confirmed quarterly care conferences had not been conducted for Resident #38. Review of the policy titled, Care Planning-Resident Participation, revised 10/01/22, revealed the facility policy stated, the facility will discuss the plan of care with the resident and/or representative at regularly scheduled care plan conferences, and allow them to see the care plan, initially, at routine intervals, and after significant changes. The facility will make an effort to schedule the conference at the best time of the day for the resident/resident's representative. The facility will obtain a signature from the resident and/or resident representative after discussion or viewing of the care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365673 If continuation sheet Page 3 of 36 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 365673 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Woodview 2770 Clime Road Columbus, OH 43223 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 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident interview, staff interviews, and medical record review, the facility failed to ensure a bed rail was installed as ordered to assist with bed mobility. The deficient practice affected one (#61) of one record reviewed for accommodations of needs. The facility census was 66. Residents Affected - Few Findings include: Review of the medical record for Resident #61 revealed and original admission date on 07/13/22 and a re-admission date on 09/20/22. Medical diagnoses included end stage renal disease, anxiety disorder, obesity, and personal history of stroke. Review of the physician orders dated November 2022 revealed Resident #61 had the following order: attach bed rails to bed approved by hospice dated 10/21/22. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #61 had intact cognition and scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #61 required total dependence on two staff for bed mobility, transfers, and toileting. Review of the plan of care revised 10/19/22 revealed Resident #61 elected hospice care services. Interventions included coordinate plan of care with resident, family, and hospice staff, and encourage physical mobility within the resident's ability. Observation and interview on 11/14/22 at 3:33 P.M., with Resident #61 revealed he had been waiting for a bed rail to be installed to the left side of his bed for three to four weeks. The resident stated he was not able to turn himself to the left side without the bed rail in place. There was not a bed rail observed on the left side of the resident's bed. There was a bed rail observed laying on the floor in Resident #61's closet. Observations on 11/15/22 at 3:16 P.M. and 11/16/22 at 4:19 P.M., revealed Resident #61 did not have a bed rail in place on the left side of his bed. A bed rail was observed on the floor of the resident's closet. Observation and interview on 11/16/22 at 6:29 P.M., with Licensed Practical Nurse (LPN) #341 confirmed there was not a bed rail in place on the left side of Resident #61's bed. LPN #341 asked Resident #61 to demonstrate ability to use the bed rail for assistance with bed mobility by using her arm at the approximate height as the bed rail. Resident #61 was able to grab a hold of LPN #341's arm and turn himself to the side holding on to the nurse's arm. Interview on 11/16/22 at 6:30 P.M., with the Director of Nursing (DON) confirmed Resident #61 had an order to have bed rails placed on both sides of his bed. The DON stated she thought the hospice provider was going to replace the resident's bed with bed enabler bars instead of bed rails but hospice placed an order to have bed rails installed instead and the order was missed. A facility policy related to accommodation of resident needs was requested during the survey but a policy was not produced. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365673 If continuation sheet Page 4 of 36 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 365673 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Woodview 2770 Clime Road Columbus, OH 43223 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 0572 Give residents a notice of rights, rules, services and charges. Level of Harm - Potential for minimal harm Based on observations and staff interviews, the facility failed to have the resident rights posted in the facility. This had the potential to affect 66 of 66 residents in the facility. Residents Affected - Many Findings include: Observation of the facility during the survey on days of 10/14/22, 10/15/22, 10/16/22, 10/17/22 and 10/21/22 revealed there were no postings of resident rights available for residents, in the facility. Interview on 10/21/22 at 9:35 A.M., with the Social Service Designee (SSD) #346 revealed there is a paper copy of the resident rights outside her office door on the main hallway. The SSD #346 went to the file holder which was approximately five feet off the floor and was a plastic file holder with multiple file folders in the holder. The SSD #346 was observed to remove a piece of paper from behind all of the file folders which listed the resident rights. The location of the paper being behind the other file folders prohibited the paper from being seen by looking at the file holder on the wall. When asked how a resident would know the paper with the resident rights was located behind the file folders or how a resident in a wheelchair would access the resident right paper the SSD #346 had no answer. Observation on 09/21/22 at 9:42 A.M., with the Administrator, revealed the entire facility was observed and there were no resident rights posted visibly in the facility for residents to read. The Administrator stated I know I have seen the rights posted somewhere in the facility. When the tour finished, at the Administrator's office door, there were two framed documents observed on the floor leaning against the wall; that stated Resident Rights. Admissions Coordinator (AC) # 333 was standing in the hallway by the framed resident rights documents and stated we found them. When the AC #333 was asked where the resident rights had been,AC #333 stated right there and pointed to the hallway. It was stated the rights were not sitting in the hallway during the timeframe of the survey and again it was asked where the resident right postings were located, and AC #333 stated they were in the Administrator's office. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365673 If continuation sheet Page 5 of 36 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 365673 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Woodview 2770 Clime Road Columbus, OH 43223 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to provide an appropriately completed Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN). This affected one (#61) of the three residents reviewed for Beneficiary Notices. The facility census was 66. Residents Affected - Few Finding include: Review of the medical record for Resident #61 revealed an admission date of 07/13/22 with an re-entry date of 09/20/22. Diagnoses included end stage renal disease, transient ischemic attach, and cerebral infarction. Review of Resident #61's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating an intact cognition for daily decision making abilities. Resident #61 was noted to reject care 1 to 3 days a week. Required total dependence from two staff members for bed mobility, transfers, toilet use, extensive assistance from two staff members for dressing, personal hygiene, supervision with set up help for eating. No noted impairment to bilateral upper or lower extremities and required the use of a wheelchair for mobility. Review of Notice of Medicare Non-Coverage (NOMNC) form provided to Resident #61 revealed the resident's skilled services will end on 09/02/22. Review of the SNFABN form provided to Resident #61 revealed that Beginning on 09/03/22 you may have to pay out of pocket for this care therapy services if you do not have other insurance that may cover these cost. Noted Care- Inpatient stay at this facility. Reason Medicare may not pay- Not participating with therapy. Estimated Cost- $240 per day. Interview on 11/15/22 at 4:00 P.M., with Social Services Designee #346 reveled the noted cost of $240 dollars was the price per day for Resident #61 to remain in the facility, not the cost of therapy services per day if paid out of pocket. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365673 If continuation sheet Page 6 of 36 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 365673 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Woodview 2770 Clime Road Columbus, OH 43223 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, medical record review, and policy review, the facility failed to ensure the residents resided in a safe, sanitary and homelike environment when there was wallpaper missing on the walls of a resident room affecting two (#59 and #24) and the facility failed to repair a hole in the back hallway floor, that was utilized by residents this had the potential to affect the 52 residents the facility identified as not being bedfast. The total facility census was 66. Findings include: 1. Review of Resident #59's medical record revealed the resident was admitted on [DATE] to the facility and the resident was moved into his current room on 05/27/22 and has remained in the current room since 05/27/22. Observations on 11/14/22 at 1:10 P.M., of Resident #59's room revealed the wall paper border in the room was torn and missing in large pieces around 75 percent of the room. Interview on 11/14/22 at 1:10 P.M., with Resident #59 stated the wallpaper has been that way since he admitted to the facility. 2. Review of Resident #24 medical record revealed the resident was admitted to the facility on [DATE] and was moved to his current room on 05/31/22 and has remained in this room since that time. Resident #24 and Resident #59 are roommates. Observation and interview with State Tested Nursing Assistant (STNA) #354 on 11/16/22 at 8:10 A.M., confirmed the wall paper in Resident 24's room was torn off in large sections over 75 percent of the room. 3. Observation of the back hallway on 11/14/22 at 1:15 P.M., revealed in the middle of the hallway there was observed to be a hole in the floor that was approximately six inches long, by two inches wide by two inches deep. Interview on 11/16/22 at 8:12 A.M., with Housekeeping Worker #327, confirmed the hallway was used by residents and has a hole in the flooring that is approximately six inches long, by two inches wide by two inches deep. Housekeeping Worker #327, stated the location of the hole was in the center of the back hallway between the central supply door and the laundry door. During the interview STNA # 354, was in the hallway and it was asked how long the hole had been in the floor and the STNA #354 stated it had been in the floor as long as she had worked at the facility and she had been employed six and a half years. The two employees verified the residents use the hallway to access the activity room and the smoking area at the facility, and to go from one side of the facility to the other. There are no resident rooms on the back hallway. The facility identified 52 residents that are not bed fast. Review of the undated policy titled Safe Homelike Environment undated revised 10/01/22 revealed: in accordance with residents' rights , the facility will provide a safe, clean, comfortable and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365673 If continuation sheet Page 7 of 36 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 365673 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Woodview 2770 Clime Road Columbus, OH 43223 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 0584 Level of Harm - Minimal harm or potential for actual harm homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. Definitions: Environment refers to any environment in the facility that is frequented by residents, including but not limited to the Residents' room, bathroom, hallways, dining areas, lobby , outdoor patios, therapy areas and activity areas. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365673 If continuation sheet Page 8 of 36 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 365673 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Woodview 2770 Clime Road Columbus, OH 43223 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the closed medical record for Resident #44 revealed an admission date on 11/13/21 and a discharge date on 10/29/22. Medical diagnoses included atrioventricular block, altered mental status, congestive heart failure (CHF), dependence on renal dialysis, and unspecified dementia. Review of the census for Resident #44 revealed the resident had been hospitalized from [DATE] to 07/21/22 and 10/26/22. The resident was discharged from the facility on 10/29/22 while in the hospital. Review of progress notes dated 07/16/22 at 6:45 P.M., revealed Resident #44 was sent to the emergency room due to chest pain and shortness of breath. On 10/26/22 at 7:24 P.M., Resident #44 was transferred to a local hospital due to complaint of shortness of breath. Review of the Bed Hold notices dated 07/21/22 and 10/26/22 revealed the notices did not explain or provide any information related to the facility's reserve bed payment policy. Interview on 11/17/22 at 5:07 P.M., with Business Office Manager (BOM) #332 confirmed the transfer notices did not include a written explanation of the facility's reserve bed payment policy or a room rate. BOM #332 stated the facility followed the Medicaid rate and the rate fluctuated. BOM #332 confirmed this was not written in the transfer notice. BOM #332 stated the policy was verbally explained to residents and/or representatives. A facility policy was requested mulitple times throughout the survey but a policy was not provided. Based on medical record review, and staff interview, this facility failed to ensure residents received accurate bed hold notices/reserve bed payment information and establish a written bed-hold and reserve bed payment policy. This affected two (#35 and #44) of the three residents reviewed for bed hold notices/ reserve bed payment. The facility census was 66. Findings include: 1. Review of medical record for Resident #35 revealed an initial admission date of 08/12/22 and a re-entry date of 11/08/22. Diagnosis included heart failure, chronic kidney disease stage 3, chronic obstructive pulmonary disease, and Atrial fibrillation. Review of Resident #35's medical record revealed in the resident's admission Paperwork dated 08/12/22, documented the resident had indicated that she would like the facility to hold her bed at the facility when transferred to the hospital, visits with friends or family, or any other leaves of absences. Review of progress note dated 11/02/22 at 5:20 P.M., created by Licensed Practical Nurse (LPN) #500 documented resident transferred to the hospital for shortness of breath, agitation, and wheezing, physician notified. Review of progress note dated 11/08/22 at 10:27 P.M. created by LPN #306 documented resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365673 If continuation sheet Page 9 of 36 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 365673 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Woodview 2770 Clime Road Columbus, OH 43223 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0625 re-admitted to facility this evening at 5:00 P.M. Level of Harm - Minimal harm or potential for actual harm Review of the medical record revealed no evidence of a Bed Hold Notice being provided at the time of the transfer or within 24 hours for the most recent hospital discharge that occurred on 11/02/22 through 11/08/22. Residents Affected - Few Interview on 11/21/22 at 12:20 P.M., with the Administrator revealed that due to Resident #35's payer being CareSource, which does not pay for bed holds, the facility did no issue Resident #35 with a bed hold notice or a reserve bed payment option. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365673 If continuation sheet Page 10 of 36 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 365673 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Woodview 2770 Clime Road Columbus, OH 43223 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 medical record reviews and staff interviews, the facility failed to ensure assessments accurately reflected resident's condition. This affected two (#59 and #65) of 22 resident assessments reviewed. The total facility census was 66. Residents Affected - Few Findings include: 1. Review of Resident #59's medical record revealed an admission date of 02/17/22, with diagnoses including: schizophrenia, insomnia, and weakness. Review of the most recent quarterly Minimum Data Set (MDS) assessment completed on 10/14/22, revealed the resident is cognitively intact, had no delusions, hallucinations or behaviors. The assessment had the resident coded as receiving seven days of antibiotics during the assessment look back period. Review of Resident #59's medication administration record (MAR) for October 2022 revealed the resident had no antibiotics used in his care during the entire month of October 2022. Review of physician orders revealed there were no orders for the resident to receive antibiotics during the month of October 2022. Interview on 11/17/22 at 4:30 P.M., with the Director of Nursing (DON), verified Resident #59's MDS was coded incorrectly for the resident as the resident had no antibiotics used in his care during the look back period. 2) Review of Resident #65's medical record revealed an admission date of 05/12/22 and a discharge date of 11/03/22. Diagnoses included heart disease, hypertension, and muscle weakness. Review of Resident #65's Death in Facility MDS assessment dated [DATE], revealed the resident passed away in the facility on 11/03/22. Review of progress note dated 11/03/22 at 9:33 A.M., created by Agency Licensed Practical Nurse (LPN) #33 revealed, Resident not responsive. Resident could not communicate. Vital signs blood pressure -155/81 milliliters of mercury (mmHg), Respiration - 19 breaths per minute, Temperature - 97.9 degrees Fahrenheit, and oxygen saturation at 93% room air. Resident was sweating and was a little cold to touch. Call placed to on call and ordered to send resident out to emergency room (ER). Review of progress note dated 11/03/22 at 11:01 P.M., created by Agency LPN #33 revealed, 911 team can in and took over care, sent resident to ER. Review of Resident #65's eInteract Transfer Form dated 11/03/22 revealed Resident #65 was transferred to the hospital due to an Altered Mental Status. Interview on 11/21/22 10:32 A.M., with the DON verified Resident #65's assessment documented the resident passed away in the facility. The DON verified this assessment was not correct since Resident #65 did not expire in the facility but was transferred out where he passed away at the hospital. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365673 If continuation sheet Page 11 of 36 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 365673 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Woodview 2770 Clime Road Columbus, OH 43223 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility failed to completed an updated PASARR screening when a Resident was diagnosed with a new mental illness. This affected one (#36) of the three residents reviewed for accurate PASARR screenings. The facility census was 66. Findings include: Review of medical record for Resident #36 revealed an admission date of 11/01/17 with a re-entry date of 11/08/19. Diagnoses included schizoaffective disorder identified on 04/06/21, major depressive disorder identified on 06/03/20, psychosis, and psychoactive substance dependence. Review of Resident #36's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident with a modified independence for daily cognitive decision making abilities. No behaviors noted with this assessment review. Resident #36 noted to receive antidepressants and opioids 7 days a week. No antipsychotics were received. Review of plan of care dated 11/13/17 revealed Resident #36 uses antidepressant medication related to depression. Interventions include to educate about risk or benefits and side effects of the use of antidepressants, administer medication as ordered, and observe and monitor for sign and symptoms of adverse reactions. Review of plan of care dated 04/12/18 revealed Resident #36 uses psychotropic medication related to behavior management. Interventions include to administer medication as ordered, and observe/record occurrence for target behavior. Review of Resident #36's physician orders for November 2022 revealed the following orders: Trazodone HCL 100 milligram (mg) tablet, give one tablet at night time for major depressive disorder (MDD). Review of Resident #36's Preadmission Screening/Resident Review (PAR/RR) Identification Screen dated 11/01/17 revealed under Section C: Medical Diagnosis, NA was noted for the question 2) Please indicate current diagnosis if different from diagnosis submitted at admission. No diagnosis was noted on this screening. Interview on 11/21/22 at 10:18 A.M., with Social Service Designee #346 confirmed the PASARR had not been completed with new diagnoses of major depressive disorder and schizoaffective disorder. SSD #346 stated an audit was completed in October and it was identified Resident #36 required an updated PASARR screening but it had not been completed yet. Review of the policy titled Resident Assessment-Coordination with Preadmission Screening and Resident Review (PASARR) Program, dated October 2019 revealed, any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365673 If continuation sheet Page 12 of 36 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 365673 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Woodview 2770 Clime Road Columbus, OH 43223 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities 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 policy review, the facility failed to complete a full resident review for a resident who enter the facility under the hospital exemption and remained in the facility longer than 30 days. This affected one (#59) of two residents reviewed for preadmission screening. The total facility census was 66. Residents Affected - Few Findings include: Review of Resident #59's medical record revealed an admission date of [DATE], with diagnoses including schizophrenia, insomnia, and weakness. Review of the most recent quarterly Minimum Data Set assessment completed on [DATE], revealed the resident is cognitively intact, had no delusions, hallucinations or behaviors during the review period. The assessment had the resident coded with the diagnosis of schizophrenia. The resident received seven days of antipsychotic, antidepressant, and antibiotic medication and four days of opioid medication. Review of the resident medical record revealed the resident had a hospital exemption review completed on [DATE] indicating the resident would be in the facility less than 30 days. The medical record was silent to any other Preadmission Screening and Resident Review (PASARR) assessment being completed. Interview on [DATE] at 8:33 A.M., with the Social Service Designee (SSD) #346 confirmed Resident #59's hospital exemption expired and the facility had not performed a Resident Review for the resident timely. SSD #346 stated a Resident Review was completed which indicated the resident needed a level II assessment completed due to his mental illness. The level II was completed on [DATE]. The SSD confirmed the facility did not timely complete the PASARR documents when the Hospital Exemption expired. Review of policy titled: Resident Assessment - Coordination with PASARR Program revealed: This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. Exceptions to the preadmission screening program include those individuals who: are readmitted directly from a hospital. and are admitted directly from a hospital, requires nursing facility services for the condition for which the individual received care in the hospital, and has been certified by the attending physician before admission that the individual is likely to require less than 30 days of nursing facility services. If a resident who was not screened due to an exception above and the resident remains in the facility longer than 30 days: The facility must screen the individual using the State's Level I screening process and refer any resident who has or may have MD, ID or a related condition to the appropriate state designated authority for Level II PASARR evaluation and determination. The Level II resident review must be completed within 40 calendar days of admission. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365673 If continuation sheet Page 13 of 36 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 365673 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Woodview 2770 Clime Road Columbus, OH 43223 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, staff interviews, and policy review, the facility failed to ensure residents had comprehensive care plans developed to addressed their individualized needs. This affected four ( #49, #59, and #38) of 22 residents reviewed for care plans. The total facility census was 66. Findings include: 1. Review of Resident #49's medical record revealed an admission date of 06/30/22, with diagnoses including myocardial infarction, tracheostomy status, and type two diabetes. Review of the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have a mental status change. The resident was coded as having a tracheostomy tube. Review of Resident #49's care plan revealed a care plan was in place related to the resident having a tracheostomy and the risk and complications of respiratory distress related to the tracheostomy tube. The care plan was silent to the type and size of tracheostomy tube the resident utilized and to what steps to take in the event of an emergency where the tracheostomy tube would dislodge from the resident. Interview on 11/17/22 at 4:29 P.M.,with the Director of Nursing (DON), verified the resident's care plan did not address the care needed for the tracheostomy tube including the size and type of tracheostomy tube the resident used and what to do in the case of an emergency dislodgement. 2. Review of Resident #59's medical record revealed an admission date of 02/17/22, with diagnoses including schizophrenia, insomnia, and weakness. Review of the most recent quarterly MDS assessment completed on 10/14/22, revealed the resident is cognitively intact, had no delusions, hallucinations or behaviors during the review period. The assessment had the resident coded with the diagnosis of schizophrenia and the resident was coded to have received seven days of antipsychotic, antidepressant, and antibiotic medication and four days of opioid medication. Review of Resident #59's care plans revealed there is no care plan in place to address the resident's diagnoses of schizophrenia. Interviewon 11/17/22 at 4:30 P.M., with the DON, verified the resident had no care plan to address his schizophrenia; the care the resident would require and what interventions staff could use to assist the resident to reach his highest level. 3. Review of the medical record for Resident #38 revealed an admission date of 01/14/21. Diagnoses included generalized anxiety disorder, malignant neoplasm of breast, malignant neoplasm of right kidney, edema of left orbit, cognitive communication deficit and unspecified dementia. Review of the quarterly MDS assessment dated [DATE] revealed Resident #38 had impaired cognition and scored a seven out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #38 required extensive assistance from one staff to complete personal hygiene task and supervision with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365673 If continuation sheet Page 14 of 36 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 365673 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Woodview 2770 Clime Road Columbus, OH 43223 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 set up help only to one staff to complete other Activities of Daily Living (ADLs). Level of Harm - Minimal harm or potential for actual harm Review of progress notes dated 09/11/22 at 11:58 A.M., documented Resident #38 was noted with swelling to left side of face below the eye. Physician advised to put ice on area and lay to the right side of her face and monitor. Residents Affected - Few Review of progress notes dated 09/15/22 at 9:45 A.M., revealed the Certified Nurse Practitioner (CNP) #100 saw Resident #38 for follow-up of orbital edema of left eye. Swelling was improved with as needed use of cold compress. Some residual swelling remained under the eye. Continue intermittent use of cold compress/ice. Review of progress notes dated 11/07/22 at 3:41 P.M., revealed the staff requested CNP #100 see Resident #38 for left eye edema. The CNP #100 had seen Resident #38 for the issue previously and no changes. Dependent edema below left eye noted. Continue with cool compress for 20 minutes three times daily as needed. Review of the care plan dated 01/14/21 and revised on 11/14/22 revealed the plan of care was absent for addressing the edema to Resident #38's left eye. Interview on 11/15/22 at 11:16 P.M., via telephone with Resident #38's son revealed the resident had swelling around her left eye. The resident's son stated, I don't feel her water issues are being addressed. Interview and observation on 11/15/22 at 3:45 P.M., with Resident #38 revealed the resident had swelling under her left eye. Resident #38 stated, it is always swollen. Resident #38 stated she slept on her left side all the time because it was comfortable. The resident denied any pain or trouble with her vision related to the swelling. Resident #38 stated she used cold packs on her eye sometimes for the swelling. Interview on 11/17/22 at 4:43 P.M., with the Director of Nursing (DON) confirmed Resident #38's care plan did not address edema to the resident's left eye. Review of the policy, Care Planning-Resident Participation, dated 10/01/22, revealed the policy stated, the facility supports the resident's right to be informed of, and participate in, his or her care planning and treatment (implementation of care). The facility will notify the resident and/or resident representative, in advance of the care to be furnished and the type of caregiver or professional that will furnish care, as well as changes to the plan of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365673 If continuation sheet Page 15 of 36 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 365673 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Woodview 2770 Clime Road Columbus, OH 43223 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 0679 Provide activities to meet all resident's needs. Level of Harm - Potential for minimal harm Based on activity calendar reviews, staff interview, and policy review, the facility failed to ensure meaningful activities were offered to residents daily and at various times throughout the day. The deficient practice affected had the potential to affect 66 of 66 residents residing in the facility. The facility census was 66. Residents Affected - Many Findings Include: Review of activity calendars dated from August 2022 through November 2022 revealed no activities were scheduled on the weekends in November 2022 and no activities were scheduled after 2:00 P.M. in the afternoon, there were not any evening activities offered. Interview on 11/16/22 at 1:30 P.M., with Activity Director (AD) #300 revealed she was the only activities staff person at the facility currently due to the activities aide quitting. AD #300 stated she worked Mondays through Friday until 5:00 P.M. AD #300 confirmed the last activity daily was scheduled at 2:00 P.M. and there were not any activities scheduled in the evenings due to not having any activities staff to run the activity. AD #300 stated she handed the activity calendars out to the residents but did not post the calendars in resident rooms. Review of the policy titled, Activity Program, revised 08/2022, revealed the policy stated, the facility provides activities that reflect the choices of the residents, are offered at various hours including morning, afternoon, evenings, holidays, and weekends, attempt to reflect interests, hobbies, and personal preferences of the residents, and appeal to men and women as well as those of various age groups residing in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365673 If continuation sheet Page 16 of 36 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 365673 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Woodview 2770 Clime Road Columbus, OH 43223 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interview, and policy review the facility failed to timely address a resident's constipation. This affected one (#117) of one reviewed for constipation. The facility census was 66. Residents Affected - Few Findings include: Review of Resident #117's medical record revealed an admission date of 10/27/22, from another skilled nursing facility to be closer to family. Resident #117's diagnoses included Parkinson's disease, type two diabetes, obesity, paroxysmal atrial fibrillation, dysphagia, anxiety and depression. Review of most recent admission MDS assessment dated [DATE] revealed the resident was cognitively intact, had no behaviors, resident was assessed as dependent on staff for transfers and toileting. Resident was assessed as always incontinent of bowel and bladder. Review of current monthly physician orders revealed orders for Miralax 17 grams daily, and an ordered Bisacodyl 10 milligram (mg), one suppository rectally every 24 hours as needed for constipation. Interview on 11/14/22 at 1:00 P.M., with Resident #117, revealed the resident stated she had a suppository a week ago and she has not had any results yet. The resident stated she has issues with constipation. Review of the Resident #117's medication administration record (MAR) revealed the resident received one dose of Bisacodyl on 11/16/22 at 3:17 A.M., no other as needed doses of Bisacodyl were provided to the resident in the month of November 2022. Review of Resident #117's bowel movement record task revealed the resident had no bowel movement from 11/02/22 through 11/09/22. Interview on 11/21/22 at 9:21 A.M.,with Licensed Practical Nurse (LPN) #401 confirmed Resident #117 did not have bowel movement tracking in the MAR or treatment administration record (TAR). LPN #401 stated if the nurses are to track a resident's bowel movements it is on the MAR or TAR. The State Tested Nursing Aides (STNA), who are working with the nurse, communicates to the nurse if the specific resident had a bowel movement or not. Observation and interview on 11/21/22 at 10:35 A.M., with LPN #401 confirmed the STNA resident task documentation revealed Resident #117 had no documented bowel movement from 11/02/22 to 11/09/22. Review of Resident #117's November 2022 MAR with LPN #401, confirmed there was no administration of the as needed Bisacodyl documented during this time. Interview on 11/21/22 at 10:29 A.M., with Director of Nursing (DON), confirmed the resident had no bowel movement form 11/02/22 to 11/09/22; the progress notes were silent to the resident's condition; and the medical record was silent to administration of Bisacodyl during this time period. Review of the policy titled Routine Bowel Regime undated and revised on August 2018 revealed: it is the policy of this facility that the bowel movements of residents are monitored. In general, it is expected residents will have a bowel movement at least every three days, unless a resident has a different typical routine of more or less often and resident has no indications of distress. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365673 If continuation sheet Page 17 of 36 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 365673 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Woodview 2770 Clime Road Columbus, OH 43223 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete The procedure included: resident's BM's will be documented by the STNA or nurse who observes or is notified by the resident or other person, and reviewed by the charge nurse routinely; if a resident does not have a BM for three days a nurse will assess and notify the physician if any issues are identified.; Residents who have been determined to have a typical BM schedule other than 3 days, will implement the BM protocol relevant to their personal routine; unless contraindicated, or the physician has given a different order; a laxative will be administered; if no results from the laxative, the nurse on the next shift will give a suppository; ff no results from the suppository, the nurse on the next shift will give an enema; if poor or no results, the physician will be notified for further direction; the results of each intervention will be documented; the physician will be notified of a resident who has not had a bowel movement or has only had occasional small or liquid bowel movements, and also has additional symptoms such as decreased or absent bowel sounds, vomiting, abdominal distention or pain, rectal bleeding or black, tarry stools; and the physician will be notified of patterns of not having routine bowel movements, for a review of the medications or other interventions. Event ID: Facility ID: 365673 If continuation sheet Page 18 of 36 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 365673 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Woodview 2770 Clime Road Columbus, OH 43223 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 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident # 28's record revealed an admission date of 08/20/20, with the most recent hospitalization from 07/30/22 to 08/04/22. Resident #28's diagnoses included: dementia, history of falls, myasthenia gravis, unspecified symptoms and signs involving cognitive functions and awareness, cognitive communication deficit, problems related to unspecified psychosocial circumstances. Residents Affected - Few Review of the quarterly MDS assessment dated [DATE] revealed the resident has clear speech, is usually understood and usually understands others and has adequate vision with corrective lenses. Resident is cognitively intact. Review of optometry visits revealed the resident was referred to have cataracts removed 12/16/21 and the surgery had yet to be completed. Interview on 11/14/22 at 3:15 P.M., with Resident #28 revealed the resident stated she was supposed to have cataract surgery but it has not been completed and she did not know why. Interview on 11/17/22 at 10:10 A.M., with SSD #346 confirmed Resident #28 had a referral from the eye provided to have cataract removal surgery since 12/16/21. SSD #346 stated she had surgery set up for 08/02/22 and the resident unfortunately was in the hospital at the time of the scheduled surgery. The SSD #346 confirmed the surgery had not been rescheduled. SSD #346 verified there has been a delay in resident receiving the referred service. Review of the undated policy titled, Hearing and Vision Services, revealed the policy stated, it is the policy of the facility to ensure all residents have access to hearing and vision services and receive adaptive equipment as indicated. Once vision or hearing services have been identified, the social worker/social service designee will assist the resident by making appointments and arranging for transportation. Based on medical record review, resident, family and staff interviews, and policy review, the facility failed to ensure vision services were arranged and received timely. The deficient practice affected two (#28 and #38) of two residents reviewed for communication and sensory services. The facility census was 66. Findings include: 1. Review of the medical record for Resident #38 revealed an admission date of 01/14/21. Diagnoses included generalized anxiety disorder, malignant neoplasm of breast, malignant neoplasm of right kidney, edema of left orbit, cognitive communication deficit and unspecified dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #38 had impaired cognition and required extensive assistance from one staff to complete personal hygiene task and supervision with set up help only to one staff to complete other Activities of Daily Living (ADLs). Review of the optometry consent form dated 05/25/21 revealed Resident #38 consented to receive optometrist services. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365673 If continuation sheet Page 19 of 36 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 365673 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Woodview 2770 Clime Road Columbus, OH 43223 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 0685 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of progress notes dated from 06/01/22 through current revealed Resident #38 was seen by the facility optometrist on 06/15/22. There were no additional notes related to the resident's scheduled appointment on 10/19/22. Review of the care plan dated 01/14/21 and revised 11/14/22 revealed Resident #38 was at risk for visual decline and wore prescription eye glasses. Interventions included to encourage resident to wear glasses, keep call light within reach, keep resident's glasses in a safe place when not in use, and keep room and hallways well lit and free of hazardous objects. The care plan did not address optometrist visits. Review of the list of residents scheduled to be seen by the eye doctor on 10/19/22 revealed Resident #38 was on the list to be seen. The list also showed Resident #38 was last seen on 06/15/22. Review of eye examination reports for residents who were seen in October 2022 revealed Resident #38 was not seen by the eye doctor on 10/19/22 as scheduled. Interview via telephone, on 11/15/22 at 11:13 A.M., with Resident #38's son revealed Resident #38 had cataracts and should see an eye doctor but he was not sure when the resident had an eye examination. Interview on 11/15/22 at 5:42 P.M., with Social Services Designee (SSD) #346 confirmed Resident #38 was not seen by the optometrist as scheduled on 10/19/22 and the missed visit had not been rescheduled. SSD #346 stated the optometrist was bought by another company effective 10/02/22 and was not able to make the scheduled visit in October to the facility. The optometrist's last visit to the facility was 09/21/22. SSD #346 stated she was working on obtaining new consent forms for the new company. SSD #346 stated residents were typically seen quarterly by the optometrist and Resident #38 was last seen in June 2022. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365673 If continuation sheet Page 20 of 36 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 365673 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Woodview 2770 Clime Road Columbus, OH 43223 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation of wound care, resident and staff interview, and review of hospice notes, National Pressure Injury Advisory Panel (NPIAP) guidelines review, the facility failed to identify a new pressure area, assess the wounds, and provides treatments. The deficient practice affected one (#61) of one reviewed for pressure ulcers. The facility census was 66. Residents Affected - Few Findings include: Review of the medical record for Resident #61 revealed an original admission date on 07/13/22 and a re-admission date on 09/20/22. Medical diagnoses included end stage renal disease, anxiety disorder, obesity, and personal history of stroke. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #61 had intact cognition and scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #61 required total dependence on two staff for bed mobility, transfers, and toileting. Resident #61 had one unstageable deep tissue injury noted on the assessment with pressure reducing devices in use and pressure ulcer care was provided. Review of care plan dated 07/14/22 and revised 10/19/22 revealed Resident #61 had an actual area of skin impairment related to pressure ulcer to right and left buttocks. The left buttocks was noted as resolved. Interventions included initiate wound treatment and continue treatment as ordered by the physician/CNP, nursing to observe the wound dressing daily to ensure the dressing remained intact and there were no signs or symptoms of infection, observe for clinical changes such as worsening of wound, and skin observation and documentation on bath/shower days with the charge nurse to notify the wound nurse, physician, and family of any new areas. The care plan did not indicate Resident #61 had any pressure ulcer areas to his spine or back. Review of the hospice visit note dated 10/31/22 revealed the hospice nurse noted Resident #61 had a mid back stage III pressure ulcer. The wound was cleansed with wound wash, calcium alginate was applied, and the wound was covered with a foam dressing. The treatment order was obtained from physician. The note stated the dressing should be changed daily. The facility staff nurse was to change the dressing twice a week and the additional dressing changes were to be completed by hospice. The area measured 1.6 centimeter (cm) length X 2.0 cm width X 0.1 cm depth and was described as full thickness. Facility staff nurse made aware to call hospice service with any issues. Review of the facility skin grid assessments dated 11/03/22 and 11/10/22 revealed Resident #61 only had a skin alteration to the right buttock. Review of additional hospice documentation dated 11/04/22, 11/09/22, and 11/11/22 revealed the hospice nurse did not assess the wound due to being completed by the facility staff. On 11/15/22, an assessment was not completed due to Resident #61's caregiver completed care. The documentation revealed the wound was not assessed again following the initial identification of the area on Resident #61's lower spine/mid back. Review of the progress noted dated 11/10/22 at 1:34 P.M., revealed wound rounds were completed with the Certified Nurse Practitioner (CNP) #1 for the right buttock. No new orders were received and all parties were notified. There was not any mention of an area to Resident #61's lower spine and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365673 If continuation sheet Page 21 of 36 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 365673 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Woodview 2770 Clime Road Columbus, OH 43223 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few there were not any additional progress notes related to a dressing being applied to the resident's lower spine. Interview on 11/14/22 at 3:29 P.M., with Resident #61 revealed he had developed pressure ulcer areas during his stay in the facility. Resident #61 stated he had one or two areas on his left buttocks and one on his back. Review of the facility skin grid assessments dated 11/15/22 revealed Resident #61 was noted to not have any new skin areas. Observation on 11/16/22 at 10:00 A.M., of Resident #61's right buttock dressing change revealed Licensed Practical Nurse (LPN) #343 performed the dressing change as ordered and followed appropriate infection control procedures. During the observation, there was a dressing observed on Resident #61's lower spine that was undated. LPN #343 was not sure why the dressing was in place and removed the dressing. Upon removal of the dressing, a wound to the back covered in slough was revealed. During the observation, Resident #61 stated the area had been present for a while but was not sure of the exact date it appeared. LPN #343 confirmed the dressing was undated. Review of the current physician orders on 11/16/22 at 10:19 A.M., with LPN #343 revealed there were not any orders in place for the wound on the resident's lower spine. LPN #343 stated she would measure the wound, cleanse it, and cover it with a dry dressing until the physician was able to provide the orders necessary for the treatment of the area. LPN #343 cleansed the area and the area measured 2.0 centimeters (cm) length X 1.0 cm width X 0.1 cm depth and the peri wound was red. Resident #61 was on an alternating pressure air mattress and received hospice services. A foam dressing was applied. Interview on 11/16/22 at 11:35 A.M., with the Chief Nursing Officer (CNO) #600 confirmed hospice identified the pressure area to Resident #61's lower spine/mid back on 10/31/22 and it measured 1.6 cm length X 2.0 cm width and was a Stage III pressure ulcer. CNO #600 confirmed the facility made wound rounds with the wound CNP #1 and there was no indication of the area note and there were no orders to treat the area provided. CNO #600 verified there was no assessment of the wound by the facility. CNO #600 stated he was talking to the hospice provider regarding communication with the facility. Interview on 11/16/22 at 12:23 P.M., with CNO #600 confirmed hospice documentation had an order for the wound on the initial assessment that was not communicated or signed by a physician in the facility. CNO #600 also confirmed the hospice documentation had four visits after the initial identification of the wound where the hospice provider did not assess the wound per their agreement. Review of the NPIAP guidelines dated 2014 pages 70-71 at https://npiap.com/general/custom.asp?page=2014Guidelines revealed facilities should educate health professionals on how to undertake a comprehensive skin assessment that includes the techniques for identifying blanching response, localized heat, edema, and induration. Further review of the guidelines revealed ongoing assessment of the skin was necessary in order to detect early signs of pressure damage. Visual assessment for erythema (redness of the skin) was the first component of every skin inspection. Skin redness and tissue edema resulting from capillary occlusion was a response to pressure. Further review revealed an unstageable pressure injury is obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage three or Stage four pressure injury will be revealed. Stable eschar (i.e., dry, adherent, intact without erythema or fluctuance) on the heel (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365673 If continuation sheet Page 22 of 36 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 365673 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Woodview 2770 Clime Road Columbus, OH 43223 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Minimal harm or potential for actual harm or ischemic limb should not be softened or removed. Staff should conduct a head-to-toe assessment with particular focus on skin overlying bony prominences including the sacrum, ischial tuberosities, greater trochanters and heels and each time the patient was repositioned was an opportunity to conduct a brief skin assessment. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365673 If continuation sheet Page 23 of 36 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 365673 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Woodview 2770 Clime Road Columbus, OH 43223 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, family and staff interviews, and review of therapy notes, the facility failed to ensure a resting hand splint was applied as ordered. This affected one (Resident #5) of three residents reviewed for position and mobility. The facility census was 66. Findings include: Review of the medical record for Resident #5 revealed an admission date on 04/19/22. Medical diagnoses included cognitive communication deficit, contracture of left hand, cerebral infarction (stroke) affecting left non-dominant side, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, and muscle weakness. Review of Resident #5's physician orders revealed Resident #5 had an order, dated 10/26/22, for occupational therapy (OT) to issue a left handed resting hand splint for patient to wear up to eight hours a day as well as skin checks after removing the splint. Review of Resident #5's physician orders revealed Resident #5 had an order, dated 02/23/22, for Resident #5 to wear left resting hand splint four to eight hours at a time with skin checks as needed, in order to prevent contractures to left hand. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/04/22, revealed Resident #5's short-term memory and long-term memory were intact and Resident #5 was alert and oriented. Resident #5 required extensive assistance from one staff for personal hygiene, toileting, dressing, and bed mobility tasks and total dependence from two staff for transfers. Resident #5 had an impairment of upper extremity (shoulder, elbow, wrist, or hand) on one side. Review of Resident #5's care plan, dated 10/19/22, revealed the care plan did not address Resident #5's contracture to her left hand or the need for a resting hand splint. Review of Occupational Therapy (OT) Discharge summary, dated [DATE], revealed Resident #5 was tolerating resting hand splint for four hours. Nursing and activities staff were instructed on splinting/orthotic schedule and self care/skin checks in order to preserve current level of function, and increase safety as well as reduce the risk of further medical complications that may result from impairments/condition with variable carryover demonstrated by caregivers. Observations on 11/15/22 at 10:24 A.M., on 11/15/22 at 3:02 P.M., on 11/16/22 at 10:22 A.M., on 11/16/22 at 4:04 P.M., and on 11/16/22 at 4:13 P.M., revealed Resident #5 was laying in bed without a resting hand splint in place. Interview and observation on 11/16/22 at 4:05 P.M. with Resident #5's husband in Resident #5's room revealed Resident #5's husband had not seen the resting hand splint in over one month. Resident #5's husband stated he had observed the hand splint on Resident #5 one time and had not seen it since. Interview and observation on 11/16/22 at 4:13 P.M. with Licensed Practical Nurse (LPN) #343 confirmed Resident #61 did not have a resting hand splint in place on her left hand. LPN #343 stated nursing was responsible for applying splints when ordered for residents. LPN #343 found the hand splint in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365673 If continuation sheet Page 24 of 36 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 365673 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Woodview 2770 Clime Road Columbus, OH 43223 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 a drawer in the resident's dresser in her room. Level of Harm - Minimal harm or potential for actual harm Interview on 11/16/22 at 6:00 P.M. with LPN #341 revealed she was not aware Resident #61 had an order for a resting hand splint. LPN #341 stated an order for a splint should appear on the Treatment Administration Record (TAR) however the order was not Resident #5's TAR. LPN #341 stated she was familiar with Resident #5 and had cared for her frequently. LPN #341 stated she had never placed a resting hand splint on Resident #5. LPN #341 looked at the order and stated the order did not have a specific shift assigned to it, therefore, it would not appear on the TAR and the nursing staff would not have been made aware of the order. Residents Affected - Few Interview on 11/16/22 at 6:30 P.M. with the Director of Nursing (DON) confirmed Resident #5's resting hand splint had not been placed on the resident due to how the order was written. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365673 If continuation sheet Page 25 of 36 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 365673 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Woodview 2770 Clime Road Columbus, OH 43223 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 0695 Provide safe and appropriate respiratory care for a resident when needed. 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, observation, staff interview, and policy review, the facility failed to ensure emergency tracheostomy supplies were readily available. This affected one (#49) of two residents reviewed for tracheostomy services. The facility census was 66. Residents Affected - Few Findings include: Review of Resident #49's medical record revealed the resident was admitted on [DATE] with diagnoses which included but were not limited to myocardial infarction, tracheostomy status, and type two diabetes. Review of the most recent quarterly Minimum Data Set assessment, dated 10/13/22, revealed Resident #49 was coded as having a tracheostomy tube. Review of Resident #49's physician orders revealed there was no order to address what to do with the tracheostomy tube in an emergency, or what type or size of tracheostomy tube Resident #49 utilized in her care. Review of Resident #49's care plan revealed a care plan was in place related to the resident having a tracheostomy and the risk and complications of respiratory distress related to the tracheostomy tube. The care plan was silent to the type and size of tracheostomy tube the resident utilized and what steps to take in the event of an emergency where the tracheostomy tube became dislodged from the resident. Observation of Resident #49's room on 11/15/22 at 7:51 A.M. revealed there was no emergency replacement tracheostomy tube in the room. Observation of Resident #49's room on 11/15/22 at 9:40 A.M. revealed there was no replacement tracheostomy tube visible in the resident room. Observation of Resident #49's room with Registered Nurse (RN) #308 on 11/15/22 at 3:15 P.M. confirmed Resident #49 had no replacement tracheostomy tube in the room. Observation of Resident #49's room on 11/16/22 at 8:07 A.M. revealed there was no replacement tracheostomy tube visible in the resident room. Observation of Resident #49's room on 11/16/22 at 9:40 A.M. with RN #335 confirmed Resident #49 had no replacement tracheostomy tube in the room. Observation of Resident #49's room on 11/16/22 at 3:30 P.M. revealed there was no replacement tracheostomy tube in the resident room. Observation of Resident #49's room on 11/17/22 at 8:59 A.M. with the Director of Nursing (DON) revealed the DON was able to find a replacement tracheostomy tube in the resident closet on the floor under other tracheostomy supplies. The DON confirmed the emergency tracheostomy tube was not easily found and would not have been available for timely use by staff in the event of an emergency. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365673 If continuation sheet Page 26 of 36 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 365673 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Woodview 2770 Clime Road Columbus, OH 43223 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Interview with the Director of Nursing (DON) on 11/17/22 at 4:29 P.M. verified Resident #49's care plan did not address the care needed for Resident #49's tracheostomy tube including the size and type of tracheostomy tube the resident used and what to do in the case of an emergency dislodgement. Review of the policy titled Tracheostomy Care, undated, revealed tracheostomy care will be provided according to the physician's orders, comprehensive assessment and the individualized care plan such as monitoring for residents specific risk for possible complications, psychosocial needs as well as suctioning as appropriate. The policy further revealed general considerations include provide tracheostomy care at least twice daily, and maintain a suction machine, a supply of suction catheters, correctly sized cannulas, and an ambu bag easily accessible for immediate emergency care. Event ID: Facility ID: 365673 If continuation sheet Page 27 of 36 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 365673 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Woodview 2770 Clime Road Columbus, OH 43223 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 0742 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. Based on medical record review, staff interview, and facility policy review, the facility failed to provide psychiatric services and/or alcohol counseling services as care planned for a resident with substance seeking behavior. This affected one (Resident #58) out of the one resident reviewed for behavioral health services. The facility census was 66. Findings include: Review of the medical record for Resident #58 revealed an admission date of 03/11/22. Diagnoses included hypertension, difficulty in walking, and chronic obstructive pulmonary disease. Review of Resident #58's quarterly Minimum Data Set assessment, dated 08/29/22, revealed Resident #58 had moderate cognitive impairment. Review of the plan of care, dated 08/09/22, revealed Resident #58 did not conform to or understand boundaries of socially accepted behaviors. Resident #58 was verbally abusive towards staff and used profanity with staff and residents. Resident #58 had the potential for continued behaviors. Interventions included to discuss with the resident in a straight forward, but kind manner, that his/her behavior is unacceptable. May use appropriate crisis prevention intervention techniques as needed. Refer to psychiatric services for evaluation if behaviors continue. Remind resident of needs to respect other resident rights and remove from anger inducing situations immediately. Review of the plan of care, dated 10/06/22, revealed Resident #58 had a history of substance seeking behavior including alcohol and narcotics and had potential for complications such as substance abuse, withdrawal symptoms, mood and/or behavioral disturbance. Interventions included to administer medication as ordered and observe for effectiveness and/or side effects. Discuss behavioral limits and expectations with the resident. If the resident returns from a leave of absence (LOA) and appears impaired, notify MD/NP (physician/nurse practitioner) for directions regarding administration of regularly scheduled medication. Keep physician notified of drug seeking behaviors and document the notifications, observe for indicators the resident may be storing drugs or alcohol in his/her room or on person and notify MD/NP if found. Offer resident alcoholic anonymous (AA) and counseling for alcohol consumption. Psychiatric referral as indicated to assist resident to manage substance abuse and develop coping skills. Review of the progress note, dated 08/08/22 at 12:00 A.M., created by Licensed Practical Nurse (LPN) #342 revealed, Resident #58 went LOA earlier and returned about 10:10 P.M. talking loudly and accusing staff of being slow delivering his medication. When it was pointed out that he was not present for the initial medication pass, Resident #58 became belligerant and continued to accuse staff of being slow with his medication. Instructed Resident #58 to return to his room and that his medication would be delivered. Resident #58 returned to his room and continued to talk loudly to his roommate. You know how they are. I'm calling my doctor tomorrow. and so on. Resident from across the hall walked to the entrance to Resident #58's room and asked Resident to Tone it down. Resident #58 became hostile and threatened physical violence to other Resident. Resident #58 stood up and postured self to fight. Resident from across the hall turned around and went back to his own room. Resident #58 followed other Resident to room and continued to yell and deliver a very profane diatribe to the other Resident, and continued to threaten physical violence. Resident #58 was redirected back to his room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365673 If continuation sheet Page 28 of 36 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 365673 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Woodview 2770 Clime Road Columbus, OH 43223 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 0742 It was obvious to everyone, Resident #58 was intoxicated. Level of Harm - Minimal harm or potential for actual harm Review of the progress note, dated 08/11/22 at 6:11 P.M., created by the Director of Nursing (DON) revealed, Clarification on incident documented on 08/08/22. Resident #58 returned from LOA and was noted to be very loud. He went to his room and a resident from across the hallway went to the doorway telling him to be more quiet. Resident #58 began yelling as the other resident walked away. The resident from across the hall is noted to have hearing deficit, and went back to his room. Resident #58 then got up to confront the other resident when staff stepped in and redirected Resident #58 with success. Residents Affected - Few Review of the progress note, dated 08/14/22 at 7:50 P.M., created by Licensed Practical Nurse (LPN) #321 revealed, This nurse walked up on Resident #58 sitting in another resident's room with a open can of a alcoholic beverage with 12% (percent) alc/vol (alcohol/volume). Resident #58 denied any knowledge of how the drink got into the other resident room. Review of the progress note, dated 09/30/22 at 8:30 P.M., created by LPN #342 revealed Resident #58 presently being loud, rude, slurring words at times, menacing, and threatening physical violence towards roommate. Resident #58 apparently was standing over roommate and threatened physical violence. Resident #58 redirected by charge nurse. Roommate denied being struck by Resident #58 each time when asked by this nurse. Incident verbal only. Roommate and family desired law enforcement intervention due to threats of physical violence. Resident #58 moved to another room on the other side of the building away from roommate and monitored closely by all staff. Resident #58 continued with loud and belligerant talk but less threatening and menacing after the move. Local police did arrive and spoke with roommate and left after this nurse assured officers that Resident #58 would not have access to roommate. Physician notified by this nurse of Resident #58's behavior and room change. No new orders. Review of the progress note, dated 10/12/22 at 5:06 A.M., created by Agency LPN #02 revealed, Resident #58 stood up threatening to hit nurse and pushing wheelchair towards nurse calling nurse racial slurs. When nurse noted Resident #58 in another resident's (female) room while both were sleeping and requested Resident #58 to come back when they were awake or to knock and wait for an answer before entering their room. Resident #58 was not happy, cursing and yelling until one of the female residents in said room woke up and talked to him. Review of the progress note, dated 10/12/22 at 6:17 A.M., created by LPN #342 revealed, Resident #58 has been imitating loud, belligerant, accusatory of staff, slurring of words, and with a strong odor to breath. Resident #58 redirected by this nurse when verbally attacking staff. Other nurse reported to this nurse that Resident #58 at one point had attacked her verbally and jumped out of his wheelchair and postured himself as if to fight. No physical contact made. Resident #58 apparently ended the interaction by calling the nurse the N word. Resident #58 presently sleeping in his bed. Review of the progress note, dated 10/19/22 at 11:37 P.M., created by the DON revealed, While passing ice water, found a cup in the room with some alcohol, and verified with another staff member. With Resident #58's consent, Resident #58 declined the cup that belonged to him but also states that he had a beer yesterday. Education was provided on safety and medication interaction with medications. Resident #58 voices understanding. Medical Director updated and would follow up with the patient on the next visit. Review of Resident #58's medical record revealed no evidence of care planned interventions having (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365673 If continuation sheet Page 29 of 36 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 365673 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Woodview 2770 Clime Road Columbus, OH 43223 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 0742 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few been implemented including referral for psychiatric services and/or AA counseling having been offered for the documented behaviors. Interview on 11/21/22 at 2:54 P.M. with Social Services #346 and the DON confirmed care planned interventions for Resident #58 regarding behaviors had not been implemented after each documented behavior. Review of the facility policy titled Behavioral Health Services, dated 10/2022, revealed it is the policy of this facility to ensure all residents receive necessary behavioral health services to assist them in reaching and maintaining their highest level of mental and psychosocial functioning. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365673 If continuation sheet Page 30 of 36 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 365673 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Woodview 2770 Clime Road Columbus, OH 43223 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility failed to adequately monitor residents who received psychotropic medications. This affected one (#59) out of five residents reviewed for unnecessary medications. The facility census was 66. Findings include: Review of Resident #59's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses which included but were not limited to schizophrenia, insomnia, and weakness. Review of the most recent quarterly Minimum Data Set assessment, completed on 10/14/22, revealed Resident #59 was cognitively intact, had no delusions, no hallucinations and no behaviors during the review period. Resident #59 was coded as having received seven days of antipsychotic and antidepressant during the review period. Review of Resident #59's physician orders revealed Resident #59 had orders for Remeron (antidepressant) 7.5 mg daily for depression, Trazodone (antidepressant) 100 mg daily for insomnia, and Haloperidol (antipsychotic) 10 mg daily for schizophrenia. Review of Resident #59's November 2022 Behavior Flow Record, Medication Administration Record, and Treatment Administration Record revealed there was no documentation of behavior monitoring or monitoring for potential side effects of the psychotropic medications ordered for Resident #59. Review of Resident #59's medical record revealed Resident #59 had an Abnormal Involuntary Movement Scale (AIMS) assessment completed on 02/17/22 with no adverse findings, and no subsequent assessments being completed. There was no evidence additional AIMS assessment's had been completed for Resident #59. Interview with the Director of Nursing (DON) on 11/17/22 at 4:30 P.M. confirmed Resident #59 had no behavior monitoring ordered or documented, and Resident #59 had no monitoring of potential side effects related to the use of psychotropic medications. Interview with the DON on 11/21/22 at 3:46 P.M. confirmed the Resident #59's only AIMS test was completed on 02/17/22 and the assessment had not been completed at the frequency required per the facility policy. Review of policy titled Psychotropic medication, revised 10/01/22, revealed residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). The policy revealed a psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include, but are not limited to the following categories: antipsychotics, antidepressants, anti-anxiety, and hypnotics. The policy revealed the attending physician will assume leadership in medication management by developing, monitoring, and modifying the medication regimen in collaboration with residents, their families and/or representatives, other (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365673 If continuation sheet Page 31 of 36 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 365673 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Woodview 2770 Clime Road Columbus, OH 43223 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete professionals, and the interdisciplinary team. The policy revealed the indications for use of any psychotropic drug will be documented in the medical record and non-pharmacological interventions that have been attempted, and the target symptoms for monitoring shall be included in the documentation. Residents who receive an antipsychotic medication will have an Abnormal Involuntary Movement Scale (AIMS) test performed on admission, quarterly, with a significant change in condition, change in antipsychotic medication, PRN or as per facility policy. Event ID: Facility ID: 365673 If continuation sheet Page 32 of 36 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 365673 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Woodview 2770 Clime Road Columbus, OH 43223 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 medical record review, facility staff interview, and policy review, the facility failed to perform laboratory tests as ordered. This affected one (#22) out of five residents reviewed for unnecessary medications. The facility census was 66. Residents Affected - Few Findings include: Review of Resident #22's medical record revealed the resident was admitted on [DATE] with diagnoses including diabetes type two, anoxic brain damage, and spastic hemiplegia affecting the right dominant side. Review of Resident #22's physician orders revealed Resident #22 had an order for a Hemoglobin A1C (lab test that measures average blood glucose over the past three months) level. Additionally, Resident #22 had an order for a Depakote level every six months. Review of Resident #22's laboratory test results revealed Resident #22 had a Depakote level obtained on 03/09/22, and there was no evidence a Hemoglobain A1C level was obtained. Interview with the Director of Nursing on 11/17/22 at 1:44 P.M. confirmed the facility did not complete laboratory testing for Resident #22 as ordered. Review of the policy titled Diagnostic Testing Services, last revised on 10/01/22, revealed the facility will provide the appropriate diagnostic services (laboratory and radiology) required to maintain the overall health of its residents and in accordance with State and Federal guidelines. The policy further revealed the facility will maintain a schedule of diagnostic tests (laboratory and radiology) in accordance with the physician's orders. No diagnostic tests will be performed without specific physician, physician assistant, nurse practitioner or clinical nurse specialist orders in accordance with State law to include scope of practice laws. All diagnostic test results will be filed in the resident's clinical record and will include the date, name, and address of the testing facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365673 If continuation sheet Page 33 of 36 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 365673 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Woodview 2770 Clime Road Columbus, OH 43223 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 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, family and staff interview, and policy review, the facility failed to provide timely dental services. This affected one (#22) of three residents reviewed for dental services. The facility census was 66. Residents Affected - Few Findings include: Review of Resident #22's medical record revealed the resident was admitted on [DATE] with diagnoses which included but were not limited to dysphagia, anoxic brain damage, spastic hemiplegia affecting the right dominant side, and depression. Review of the annual Minimum Data Set assessment dated [DATE] revealed Resident #22 was not in a persistent vegetative state, had unclear speech, was usually able to express ideas and wants, and understands others verbal content. Resident #22 was coded to have both short and long term memory problems. Review of Resident #22's Dental Summary Report dated 03/11/22 revealed Resident #22 was seen on this day by the dentist and had several maxillary teeth which were decayed and according to the resident caused pain when eating. The dentist note stated Resident #22's mandibular teeth have heavy calculus. The dentist ordered removal of all remaining maxillary teeth and root tips. The resident was referred to an outside dentist due to her medical conditions. No other dental notes were present in Resident #22's medical record. Observation of the resident's teeth on 11/17/22 at 8:55 A.M. revealed Resident #22 was missing the front four maxillary teeth, but all of the other maxillary teeth were present and were discolored. Interview with Resident #22's mother via phone on 11/15/22 at 9:32 A.M. revealed Resident #22 had her four front teeth removed and was supposed to have all the remaining teeth extracted however that had not occurred. Interview with the Director of Nursing on 11/17/22 at 12:03 P.M. confirmed the dentist recommended Resident #22 have all her maxillary teeth removed in the note on 03/11/22, however the extractions had not occurred. Review of the policy titled Dental Services, undated, revealed it is the policy of this facility to assist residents in obtaining routine (to the extent covered under the State plan) and emergency dental care. The policy further revealed residents and/or resident representatives, during the admission process, are notified of dental services available under the State plan (i.e. state-run programs), and of the potential charges that may apply in the case of routine or emergency dental care provided by outside resources. The facility will assist residents who are eligible and wish to participate to apply for reimbursement of dental services as an incurred medical expense under the State plan. The facility may charge a Medicare or private pay resident an additional amount of money for routine and emergency dental services. The Social Services Director maintains contact information for providers of dental services that are available to facility residents at a nominal cost. The facility will, if necessary or requested, assist the resident with making dental appointments and arranging transportation to and from the dental services location. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365673 If continuation sheet Page 34 of 36 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 365673 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Woodview 2770 Clime Road Columbus, OH 43223 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observations, review of menus, staff interview, and facility policy review, the facility failed to ensure the menu was followed to meet the nutritional needs of the residents. This had the potential to affect all 64 residents who received meals from the kitchen. The facility identified two residents (Resident #5 and Resident #30) who did not eat anything by mouth. The facility census was 66. Findings include: Review of the menu for the lunch meal on 11/16/22 revealed the menu included: egg salad sandwich, macaroni salad, cucumber salad, a cookie, and milk. Interview on 11/16/22 at 10:43 A.M. with [NAME] #301 revealed the menu was changed since the cucumber salad was not delivered. The interview revealed the substitution would be potato salad. Interview on 11/16/22 at 10:54 A.M. with Dietary Manager (DM) #401 confirmed potato salad was not an appropriate nutritional substitute for cucumber salad due to the high carbohydrate content. Observation of the lunch meal tray service on 11/16/22 at 11:47 A.M. revealed the foods served included an egg salad sandwich, macaroni salad, potato salad, a cookie, and milk. Interview on 11/17/22 at 2:07 P.M. with Registered Dietitian (RD) #400 confirmed substituting potato salad for cucumber salad was not an appropriate nutritional substitute. RD #400 stated an appropriate substitute would have been another vegetable with a lower carbohydrate content such as zucchini. Review of the facility policy, Menus, undated, revealed the policy stated, menus shall meet the nutritional needs of the residents in accordance with established national guidelines. Menus shall be written in advance and followed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365673 If continuation sheet Page 35 of 36 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 365673 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Woodview 2770 Clime Road Columbus, OH 43223 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, staff interview, and facility policy review, the facility failed to ensure food was stored and dated properly. This had the potential to affect all 64 residents who received meals from the kitchen. The facility identified two residents (Resident #5 and Resident #30) who did not eat anything by mouth. The facility census was 66. Findings include: Initial tour of the kitchen with Dietary Manager (DM) #401 revealed the following items were improperly stored and were not dated: In the freezer: A bag of frozen chicken breasts which was opened and was not dated. A bag of frozen hash brown patties which was opened and was not dated. A frozen bag of green beans which was opened and was not dated. In the refrigerator: A half-full bottle of Garlic Parmesan wing sauce which was not dated. A half-full tub of Sweet & Sour sauce which was not dated. A half-full tub of Gourmet Sweet Relish which was not dated. A quarter-full bottle of mustard which was not dated. A quarter-full tub of Mayonnaise which was not dated. Interview on 11/14/22 at 1:40 P.M. with DM #401 confirmed all of the above items were opened and not dated. Review of the facility policy, Food Storage, undated, revealed the policy stated, it is the policy of this facility that food storage areas be maintained in a clean, safe and sanitary manner. The policy did not address appropriate dating of food items. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365673 If continuation sheet Page 36 of 36