Health inspection·September 27, 2023

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few transfer. The STNA continued to place the resident's hands on the wheelchair instructing the resident to transfer. The STNA exited the room leaving the resident sitting on the side of the bed. Further review of the motion video footage revealed the resident grew tired and was having difficulty sitting on the side of the bed. The STNA did not return to the resident's room unit 6:23 P.M. The STNA stated, Are you ready to stand up now? The STNA placed his right had on the right arm rest and instructed him to scoot himself around. Further observation revealed the STNA pulled him over into the wheelchair using the back of his pants with the resident telling her not to do that. The motion video footage showed the resident's door remained open. On 09/20/23 at 12:20 P.M., interview with Resident #66 revealed he did not like the STNA #148. He said she always comes in and states, Look at you, you pissed your pants. He said she hit him in the back of the head while he was trying to transfer into bed. He said she then shoved him down onto the bed. He said she left him laying across the bed nude. Interview on 09/21/23 at 9:35 A.M. with the resident's family revealed resident called and reported STNA #138 had abused him. The family reviewed the motion video footage from the electronic monitoring device they placed in the resident's room. The family revealed they felt the resident was not being treated with respect and dignity. On 09/21/23 at 10:45 A.M., interview with the Director of Nursing (DON) #163 verified the STNA #148 was not treating Resident #66 with dignity after watching the motion video footage provided by the family. This deficiency represents non-compliance investigated under Master Complaint Number OH00146438. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365673 If continuation sheet Page 2 of 7 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 09/27/2023 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation of video footage, staff interviews, and review of facility policy and procedure, the facility failed to ensure a resident was free from abuse. This affected one (#66) of three residents reviewed for abuse. The facility census was 74. Findings Include: Review of the medical record for Resident #66 revealed an initial admission date of 02/03/23 with diagnoses including cerebrovascular accident (CVA) with left sided hemiplegia, aphasia, dysphagia, hypertension, hyperlipidemia, chronic obstructive pulmonary disease (COPD), polyneuropathy, vascular dementia with behavioral disturbances, major depressive disorder, constipation, cannabis use, nicotine dependence, and history of COVID-19. Review of the plan of care dated 02/13/23 revealed the resident required assistance with activities of daily living (ADL) related to CVA with left sided hemiplegia. Interventions included assist in choosing appropriate clothing as needed, check nails daily for length and cleanliness, trim and clean as necessary, encourage and allow resident to complete self care as able, inspect skin condition daily during personal care and report an impaired areas to charge nurse, keep call light in reach while in bed, observe for changes in ADL ability and adjust assistance as needed, provide incontinence care with routine rounds and as needed, resident is totally dependent and does not participate in any aspect of the task for bathing, resident requires set-up and/or clean-up for meals, requires one assist with oral hygiene, locomotion on/off the unit (motorized wheelchair), resident requires weight bearing assistance including holding, lifting or supporting trunk or limbs, resident requires one to two assist for bed mobility, transfers, dressing, toileting, and personal hygiene, staff will assist as needed with daily hygiene and will assist with showering and therapy as ordered for improvement in ADL, self care. Review of the plan of care dated 05/09/23 revealed the resident does not conform to/understand boundaries of socially accepted behaviors, resident made negative statements towards others and had the potential to continue. Interventions included discuss with resident in a straight forward, but kind manner that his behavior is unacceptable, remind resident of needs to respect other resident rights and remove from anger inducing situation immediately. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderate cognitive deficit. Review of the mood and behavior revealed the resident displayed no behaviors. The resident required extensive assistance of two residents for bed mobility, transfers, toilet use, dressing, personal hygiene, shower and supervision with eating and locomotion on/off the unit. The resident is occasionally incontinent of both bowel and bladder. Review of the motion video footage dated 09/07/23 at 11:15 P.M., revealed State Tested Nursing Assistant (STNA) #148 was observed telling the resident she was there to put him to bed to clean his wheelchair. Resident #66 was visibly agitated and was reluctant to be assisted to bed. The STNA stated, I don't got time to play all night, so you want me to put you to bed I'm here, if not I am going to go. STNA #148 continued to tell the resident she had to clean his wheelchair. Review of the motion video footage dated 09/07/23 at 11:20 P.M., revealed STNA #148 was standing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365673 If continuation sheet Page 3 of 7 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 09/27/2023 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few behind the resident sitting in his wheelchair with the door open telling him to go ahead and stand up. I will get it out. The STNA then tried to pull his incontinence brief out of the back of his pants. The resident struggled using the head board of his bed and his right hand to stand with no assistance or safety measures in place by the STNA. The STNA attempted to pull the incontinence brief again and the resident yelled to stop and fell onto his bed. STNA #148 then pulled the incontinence brief out the front of his pants when she pulled him up by his affected weak arm. STNA #148 then let the resident fall back onto the very edge of the bed. The resident yelled out Oh, as the STNA pulled the brief out of his pants. Resident #66, who was at high risk for falls was left sitting on the very edge of the bed while STNA #148 walked to the bathroom to throw away the incontinence brief. The STNA then placed the resident's wheelchair in the bathroom. The STNA exited the room and the resident yelled out, where is my damn wheelchair? The STNA entered the room and told Resident #66 his wheelchair was in the bathroom. The resident requested the wheelchair be placed by his bed. STNA #148 provided care the resident with to the resident with his door open and the hallway visible. Review of the motion video footage dated 09/21/23 at 5:12 A.M. revealed an unknown STNA moved the resident's wheelchair in front of the resident while he was sitting on the bed. The STNA instructed the resident to pull himself up using the wheelchair. The STNA stood by him while he struggled to stand up. The STNA pulled the residents pants up and the resident fell back onto the bed. The resident continued to tell the STNA he was unable to use the wheelchair to transfer. The STNA continued to place the resident's hands on the wheelchair instructing the resident to transfer. The STNA exited the room leaving the resident sitting on the side of the bed. Further review of the motion video footage revealed the resident grew tired and was having difficulty sitting on the side of the bed. The STNA did not return to the resident's room unit 6:23 P.M. The STNA stated, Are you ready to stand up now? The STNA placed his right had on the right arm rest and instructed him to scoot himself around. Further observation revealed the STNA pulled him over into the wheelchair using the back of his pants with the resident telling her not to do that. On 09/20/23 at 12:20 P.M., interview with Resident #66 revealed he did not like the STNA #148. He said she always comes in and states, Look at you, you pissed you pants. He said she hit him in the back of the head while he was trying to transfer into bed. He said she then shoved him down onto the bed. He said she left him laying across the bed nude. Interview on 09/21/23 at 9:35 A.M. with the resident's family revealed resident called and reported STNA #138 had abused him. The family reviewed the motion video footage from the electronic monitoring device they placed in the resident's room. The family revealed they were appalled at the treatment the resident was shown and felt the staff were abusing him. The family felt the resident was being punished related to the inability to transfer himself the morning of 09/21/23. On 09/21/23 at 10:45 A.M., interview with the Director of Nursing (DON) #163 verified the STNA #148 abused Resident #66 after watching the motion video footage provided by the family. Review of facility policy titled Abuse, Neglect, Exploitation & Misappropriation of Resident Property, last reviewed 10/20, revealed the facility will not tolerate Abuse, Neglect and Exploitation of its residents or the Misappropriation of resident property. It is the facility's policy to investigate all alleged violations involving abuse, neglect, exploitation and mistreatment of a resident or property. This deficiency represents non-compliance investigated under Master Complaint Number OH00146438. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365673 If continuation sheet Page 4 of 7 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 09/27/2023 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview and facility policy review, the facility failed to ensure one resident (#66), who was dependent on staff received routine nail care. This affected one (Resident #66) of three residents reviewed for activities of daily living (ADL). The facility census was 74. Residents Affected - Few Findings Include: Review of the medical record for Resident #66 revealed an initial admission date of 02/03/23 with diagnoses including cerebrovascular accident (CVA) with left sided hemiplegia, aphasia, dysphagia, hypertension, hyperlipidemia, chronic obstructive pulmonary disease (COPD), polyneuropathy, vascular dementia with behavioral disturbances, major depressive disorder, constipation, cannabis use, nicotine dependence, and history of COVID-19. Review of the plan of care dated 02/13/23 revealed the resident required assistance with activities of daily living (ADL) related to CVA with left sided hemiplegia. Interventions included assist in choosing appropriate clothing as needed, check nails daily for length and cleanliness, trim and clean as necessary, encourage and allow resident to complete self care as able, inspect skin condition daily during personal care and report an impaired areas to charge nurse, keep call light in reach while in bed, observe for changes in ADL ability and adjust assistance as needed, provide incontinence care with routine rounds and as needed, resident is totally dependent and does not participate in any aspect of the task for bathing, resident requires set-up and/or clean-up for meals, requires one assist with oral hygiene, locomotion on/off the unit (motorized wheelchair), resident requires weight bearing assistance including holding, lifting or supporting trunk or limbs, resident requires one to two assist for bed mobility, transfers, dressing, toileting, and personal hygiene, staff will assist as needed with daily hygiene and will assist with showering and therapy as ordered for improvement in ADL, self care. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderate cognitive deficit. Review of the mood and behavior revealed the resident displayed no behaviors. The resident required extensive assistance of two staff for personal hygiene, including nail care. Observation on 09/18/23 at 12:20 P.M. with Resident #66 revealed his finger nails were long, jagged and had a brown substance under them. Interview with Resident #66 at the time of the observation revealed he had asked for his nails to be cut but the aides never cuts them. Interview on 09/18/23 at 2:45 P.M. with State Tested Nursing Assistant (STNA) #178 verified the resident's fingernails were long, jagged and dirty. Review of the facility policy titled, Nail Care, last revised on 04/01/23 revealed the purpose of the procedure is to provide guidelines for the provision of care to a resident's nails for good grooming and health. Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis. This deficiency represents non-compliance investigated under Master Complaint Number OH00146239 and Complaint Number OH00146239. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365673 If continuation sheet Page 5 of 7 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 09/27/2023 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation of video footage, record review, interviews, and facility policy review, the facility failed to ensure one resident (#66) who was at high risk for falls and had a history of falls received the care and supervision for safe transfers. This affected one (Resident #66) of three residents reviewed for transfers. The facility census was 74. Findings Include: Review of the medical record for Resident #66 revealed an initial admission date of 02/03/23 with diagnoses including cerebrovascular accident (CVA) with left sided hemiplegia, aphasia, dysphagia, hypertension, hyperlipidemia, chronic obstructive pulmonary disease (COPD), polyneuropathy, vascular dementia with behavioral disturbances, major depressive disorder, constipation, cannabis use, nicotine dependence, and history of COVID-19. Review of the plan of care dated 02/13/23 revealed the resident required assistance with activities of daily living (ADL) related to CVA with left sided hemiplegia. Interventions included assist in choosing appropriate clothing as needed, check nails daily for length and cleanliness, trim and clean as necessary, encourage and allow resident to complete self care as able, inspect skin condition daily during personal care and report an impaired areas to charge nurse, keep call light in reach while in bed, observe for changes in ADL ability and adjust assistance as needed, provide incontinence care with routine rounds and as needed, resident is totally dependent and does not participate in any aspect of the task for bathing, resident requires set-up and/or clean-up for meals, requires one assist with oral hygiene, locomotion on/off the unit (motorized wheelchair), resident requires weight bearing assistance including holding, lifting or supporting trunk or limbs, resident requires one to two assist for bed mobility, transfers, dressing, toileting, and personal hygiene, staff will assist as needed with daily hygiene and will assist with showering and therapy as ordered for improvement in ADL, self care. Review of the plan of care dated 03/21/23 revealed the resident was at risk for falls related to age, decrease physical function, diagnosis of hemiplegia to left side and vascular dementia. Interventions included assist with transfers as needed, dycem to wheelchair, encourage resident to participate in therapies as ordered, encourage resident to use assistive device for transfers/ambulation, ensure call light within reach at all times, fall mat on left side of bed when resident is in bed, non-skid footwear while out of bed and high-low bed to be in lowest position while occupied. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderate cognitive deficit. Review of the mood and behavior revealed the resident displayed no behaviors. The resident required extensive assistance of two residents for transfers. Review of the fall risk assessment dated [DATE] revealed the resident was at high risk for falls. Review of the motion video footage dated 09/07/23 at 11:20 P.M., revealed State Tested Nursing Assistant (STNA) #148 was standing behind the resident sitting in his wheelchair with the door open telling him to go ahead and stand up. I will get it out. The STNA then tried to pull his incontinence brief out of the back of his pants. The resident struggled using the head board of his bed and his right hand to stand with no assistance or safety measures in place by the STNA. The STNA attempted to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365673 If continuation sheet Page 6 of 7 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 09/27/2023 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 0689 Level of Harm - Minimal harm or potential for actual harm pull the incontinence brief again and the resident yelled to stop and fell onto his bed. STNA #148 then pulled the incontinence brief out the front of his pants when she pulled him up by his affected weak arm. STNA #148 then let the resident fall back onto the very edge of the bed. The resident yelled out Oh, as the STNA pulled the brief out of his pants. Resident #66, who was at high risk for falls was left sitting on the very edge of the bed while STNA #148 walked to the bathroom to throw away the incontinence brief. Residents Affected - Few Review of the motion video footage dated 09/21/23 at 5:12 A.M. revealed an unknown STNA moved the resident's wheelchair in front of the resident while he was sitting on the bed. The STNA instructed the resident to pull himself up using the wheelchair. The STNA stood by him while he struggled to stand up. The STNA pulled the residents pants up and the resident fell back onto the bed. Further observation revealed the resident had regular white socks on. The resident continued to tell the STNA he was unable to use the wheelchair to transfer. The STNA continued to place the resident's hands on the wheelchair instructing the resident to transfer. The STNA was exited the room leaving the resident sitting on the side of the bed. The STNA did not return to the resident's room unit 6:23 P.M. The STNA placed his right had on the right arm rest and instructed him to scoot himself around. Further observation revealed the STNA pulled him over into the wheelchair using the back of his pants. The STNA had no gait belt on the resident. On 09/21/23 at 10:45 A.M., interview with the Director of Nursing (DON) #163 verified the staff were transferring the resident unsafely and had the potential for falls. Review of the facility policy titled, Safe Resident Handling/Transfers, last revised 10/01/22 revealed it was the policy of the facility to ensure that residents are handled and transferred safely to prevent or minimize risks and provide and promote safe, secure and comfortable experience for the resident while keeping the employee safe in accordance with current standards and guidelines. This deficiency represents non-compliance investigated under Master Complaint Number OH00146438. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365673 If continuation sheet Page 7 of 7