Inspection·May 18, 2023

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some was about ten days ago, and she wished it was more often. Resident #18 indicated she asked STNA #451 at 2:45 P.M. to assist her into bed before she left at 3:00 P.M. Resident #18 stated STNA #451 told her someone would be in to help or she would come back before she left. Resident #18 stated STNA #451 did not come back to assist her before she left the facility and neither did any other STNA's. Resident #18 stated she needed to lay down, had been waiting for over an hour, and she asked STNA #451 to help her before she left because after 3:00 P.M. 2. Review of Resident #5's medical record revealed an admission date of 10/22/21 and a re-entry date of 04/07/22. Resident #5's diagnoses included fracture of shaft of left fibula, need for assistance with personal care, Parkinson's Disease, type two diabetes mellitus with diabetic neuropathy and bipolar disorder. Review of Resident #5's Quarterly MDS assessment, dated 04/19/23, revealed Resident #5 was cognitively intact. Resident #5 required extensive assistance of one staff member for bed mobility, extensive assistance of two staff members for transfers, and had total dependence of one staff member for toilet use. Resident #5 was always incontinent of bowel. Resident #5 had a pressure ulcer. Review of Resident #5's care plan revised 03/29/23 included Resident #5 had an activities of daily living self-care performance deficit and assist with activities of daily living (for example, dressing, grooming, personal hygiene, locomotion, oral care, etcetera) as needed. Review of Resident #5's shower schedule undated revealed Resident #5 was scheduled to have showers during the day on Wednesday and Saturday. Review of Resident #5's shower sheets dated 05/01/23 through 05/14/23 revealed one shower sheet was filled out for 05/13/23 and did not specify if Resident #5 had a shower, bed bath, or refused. During interview on 05/15/23 at 2:05 P.M., Resident #5 could not remember the last time she had a shower or bed bath. 3. Review of Resident #34's medical record revealed an admission date of 12/16/21 and diagnoses included dementia, heart failure, and need for assistance with personal care. Review of Resident #34's quarterly MDS assessment, dated 04/06/23, revealed a Brief Interview for Mental Status was not completed as Resident #34 was rarely or never understood. Resident #34 required extensive assistance of one staff member for personal hygiene. Resident #34 was total dependence and a one person physical assist for bathing. Review of Resident #34's care plan revised 04/11/23 included Resident #34 needed assistance for activities of daily living and would be clean, odor-free and appropriately dressed on a daily basis. Interventions included staff would assist as needed with daily hygiene and would assist with showering Resident #34 as per facility policy weekly. Review of Resident #34's shower schedule undated revealed Resident #34 was scheduled for showers on day shift on Wednesday and Sundays. Review of Resident #34's State Tested Nursing Assistant (STNA) electronic medical record charting from 04/14/23 through 05/14/23 revealed on 05/10/23 documentation revealed Resident #34 received a shower. There was no further documentation Resident #34 received additional showers or bed baths. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365713 If continuation sheet Page 2 of 5 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 365713 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Painesville 70 Normandy Dr Painesville, OH 44077 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of shower sheets from 05/01/23 through 05/14/23 did not reveal any shower sheets for Resident #34. During observation on 05/15/23 at 7:53 A.M., Resident #34's hair was greasy. During interview on 05/15/23 at 2:37 P.M., STNA #409 confirmed Resident #34's hair looked greasy. STNA #409 stated Resident #34 had an appointment at the hair salon and the greasy look could be the product used on her hair, but the stylist washed Resident #34's hair only if she was specifically requested to. STNA #409 stated she did not shower Resident #34 or wash her hair recently, and did not always have Resident #34 assigned to her. Review of the facility policy titled Resident Care revised June 2018, included typical personal hygiene for a resident would include care of the skin to include routine and as needed bathing, foot care, shampoo and grooming of the hair per resident preference. Residents would be bathed or assisted to shower or bathe routinely and as needed per their preference with foot care given per order, need. This deficiency represents non-compliance investigated under Complaint Number OH00141719. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365713 If continuation sheet Page 3 of 5 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 365713 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Painesville 70 Normandy Dr Painesville, OH 44077 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 Based on observation, interview, record review and policy review, the facility failed to ensure a low air loss mattress was properly inflated to promote healing of a pressure ulcer. This affected one (Resident #5)of three residents reviewed for pressure ulcers. The facility census was 48. Residents Affected - Few Findings include: Review of Resident #5's medical record revealed an admission date of 10/22/21 and a re-entry date of 04/07/22. Resident #5's diagnoses included fracture of shaft of left fibula, need for assistance with personal care, Parkinson's Disease, type two diabetes mellitus with diabetic neuropathy and bipolar disorder. Review of Resident #5's Quarterly Minimum Data Set (MDS) assessment, dated 04/19/23, revealed Resident #5 was cognitively intact. Resident #5 required extensive assistance of one staff member for bed mobility, extensive assistance of two staff members for transfers, and had total dependence of one staff member for toilet use. Resident #5 was always incontinent of bowel. Resident #5 had a pressure ulcer. Review of Resident #5's wound care notes dated 05/10/23 and written by Wound Nurse Practitioner (WNP) #463 revealed Resident #5 had a Stage III sacral pressure ulcer, tissue bed was 75 percent granular and 25 percent slough, and measurements were a length of 1.5 centimeters (cm), width 1.0 cm and depth 0.1 cm. Resident #5 had a left heel stage three pressure ulcer, wound bed was 100 percent granular, and measurements were length of 4.0 cm, width of 2.0 cm, and depth 0.1 cm. During observation on 05/11/23 at 12:32 P.M., Resident #5 was lying at an angle in bed, her right leg hanging off the side of the bed and the head of bed was elevated about 30 degrees. Resident #5 stated her back hurt and she told an unidentified nurse about it a half hour ago. State Tested Nursing Assistant (STNA) #412 was in the room at the time of the observation and confirmed Resident #5 was lying in an awkward position and in pain. STNA #412 lowered the head of her bed until she was administered medication for pain. During observation on 05/11/23 at 1:12 P.M. Resident #5 was lying on a low air loss mattress but the mattress was not turned on and inflated. Resident #5 was resting on the uninflated mattress on a steel bed frame. STNA #412 confirmed the low air loss mattress was not on, stated Resident #5 was recently moved from another room to the current room and the staff must have forgot to turn the mattress back on when they moved her. STNA #412 pressed the power button to turn the mattress on. Nurse #416 walked into the room and stated Resident #5 was recently moved and the staff must have forgotten to turn the mattress back on once the move was complete. STNA #412 stated she did not notice the mattress was not turned on and it was off all day since she arrived at 7:00 A.M. During interview on 05/11/23 at 2:30 P.M., the Director of Nursing (DON) stated she did not know what time Resident #5 was moved from her room but checking the electronic record indicated it was on 05/10/23 at 4:43 P.M. The DON confirmed Resident #5's low air loss mattress was not turned on and functioning appropriately for about 19 hours. During interview on 05/17/23 at 11:06 A.M., Wound Physician (WP) #464 and the Assistant Director of Nursing, Wound Nurse (WN) #430 stated if Resident #5's low air loss mattress was not turned on and inflated it could cause a pressure injury. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365713 If continuation sheet Page 4 of 5 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 365713 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Painesville 70 Normandy Dr Painesville, OH 44077 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 During observation on 05/17/23 at 11:06 A.M., WP #464 and WN #430 revealed Resident #5 was lying in bed and her heels were resting directly on the low air loss mattress and were not offloaded. Observation of Resident #5's left heel revealed a known pressure injury found when Resident #5 was readmitted to the facility from the hospital and a new area, dark red in color and about the size of a dime. WP #464 stated the new area of the left heel was a blood blister deep tissue pressure injury and length was 1.5 cm, width 3.0 cm and depth unable to be determined. WP #464 stated heels should be offloaded and an offloading boot should be used. Observation revealed an offloading boot was in Resident #5's room and WP #464 placed it on her left foot after treatment was completed. Review of the facility policy titled Pressure Injury Prevention and Management revised 08/22/22 included the facility was committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal pressure ulcer, injury, prevent infection and the development of additional pressure ulcers, injuries. Evidence-based interventions for prevention would be implemented for all residents who were at risk or who had a pressure injury present. Basic or routine care interventions could include, but were not limited to redistribute pressure, provide appropriate, pressure-redistributing support surfaces. Review of Owners Manual for PressureGuard APM2 and PressureGuard APM2 Safety Supreme air therapy support surface undated, included the PressureGuard APM2 models were powered, flotation therapy mattresses providing a pressure management surface for the prevention and treatment of pressure ulcers. The inflation system consists of four urethane air cylinders in standard models that run head to foot underneath the body and the foam topper. These cylinders perform the alternating pressure therapy and the lateral rotation therapy. Cylinders inflate and deflate in a fixed ten minute cycle. The cycles and inflation levels were designed to provide and maintain low interface pressures throughout the mattress, and to redistribute peak interface pressure points during the alternating cycle. Comfort level selection allowed selection of air cylinder firmness within a relatively small range. Press softer or firmer button to achieve desired setting. Begin in the softest setting, then adjust for comfort as desired. This is an incidental deficiency discovered during the course of this complaint investigation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365713 If continuation sheet Page 5 of 5