Inspection·August 2, 2023

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. Based on observation, interview, record review, and policy review the facility failed to maintain a clean and sanitary environment. This affected nine residents (#9, #10, #15, #20, #21, #23, #27, #32 and #33) and had the potential to affect all 46 residents residing in the facility. Findings include: Observation on 08/01/23 at 9:10 A.M. revealed a strong odor of urine from the center of the 200-hallway while walking toward the end of the hallway. There were a few black gnats flying within the hallway. Resident #32 was observed in the assigned room with the window partially open, sitting up in a wheelchair and spraying air freshener toward the center of the room. There were several small black gnats flying around the room. Interview at the time of the observation with Resident #32 stated the staff assisted when needed but was able to toilet independently except when urinating in the toilet it also got onto the floor but could not be prevented. Resident #32 indicated housekeeping cleaned no more than every other day because they were shorthanded, and the staff knew about how urine would get onto the floor. Resident #32's bathroom door was opened. There was a pungent odor of ammonia like urine which radiated from the bathroom which caused coughing when first smelled. There were numerous black gnats flying inside the bathroom and crawling around on the sink, toilet, walls, floor, and door. It was necessary to cover the mouth and nose to prevent breathing the gnats in and difficult to enter the bathroom due to the odor causing difficulty with breathing. There was a large puddle on the floor in front of the toilet of yellow liquid which appeared to be urine which had a shallow depth. The edges of the entire puddle were a dark dried brown ring. Along the edges of the floor from the door around the bathroom wall in front of and adjacent to the toilet had dark dried brown areas. Interview at the time of the observation with Resident #32 stated doing the best with it as possible and left the window partially open due to the odor. Interview on 08/01/23 at 9:16 A.M. with the Administrator verified the above observation and stated being aware of Resident #32 urinating on the floor but had never gone into Resident #32's bathroom. The Administrator indicated the facility had a housekeeping problem for the past two months. There were only two housekeepers, and the housekeeping director was off on leave. There was a struggle to staff the department so at times there was only one housekeeper which caused cleaning to not get completed as often as needed. After leaving Resident #32's bathroom, Resident #9's bathroom was observed with dirt and debris on the floor and a cobweb in the bottom corner of the floor in front of the toilet. The Administrator verified the observation. Interview on 08/01/23 at 9:33 A.M. with the Administrator confirmed being aware of the gnats in the building for at least the past two weeks and was working on a transition with pest control. The facility was sold, and the new company had not worked out contract agreements with the new owners so (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 7 Event ID: 365713 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 08/02/2023 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)