Inspection·September 18, 2024

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 record review and interview, the facility failed to ensure showers/bed baths were provided to Residents #18, #23, and #29 as scheduled. This affected three residents (#18, #23, and #29) of five residents reviewed for showers. The facility census was 52. Residents Affected - Some Findings include: 1. Review of the medical record for Resident #18 revealed an admission date of 07/19/24. Diagnoses included fracture of left pubis, dementia, Bell's palsy, chronic pain syndrome, and fracture of the fifth lumbar vertebra. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #18 was cognitively intact. Review of shower/bathing task report for Resident #18 for 30-days revealed the resident received bed baths on 08/23/24, 08/27/24, 09/13/24, and 09/14/24. Review of the shower/bathing sheets for Resident #18 for two months revealed none had been completed, Interview on 09/15/24 at 11:33 A.M. Resident #18 stated she rarely got a bed bath. Staff never mentioned them to her. 2. Review of the medical record for Resident #23 revealed an admission date of 10/05/23. Diagnoses included end stage renal disease, dependence on renal dialysis, diabetes, and acute and chronic respiratory status. Review of the Medicare - 5 Day MDS 3.0 assessment dated [DATE] revealed Resident #23 was cognitively intact. Review of the shower/bathing task report for Resident #23 for 30-days revealed the resident had received a shower or bed bath on 0 8/18/24, 08/22/24, 08/23/24, 08/26/24, 09/14/24, and 09/15/24. Review of the shower/bathing sheets for Resident #23 for two months revealed the resident had a bed bath on 08/01/24, on 08/12/24, and had refused on 08/26/24. Interview on 09/15/24 at 12:51 P.M. Resident #23 stated she didn't get her bed baths when she was supposed to. 3. Review of the medical record for Resident #29 revealed a readmission date of 08/13/24. Diagnoses included fracture of left humerus, fracture of pubis, repeated falls, orthopedic aftercare, and intervertebral disc displacement lumbar region. Review of the Medicare Five-Day MDS 3.0 assessment dated [DATE]revealed Resident #29 was cognitively intact. Review of the shower/bathing task report for Resident #29 for 30-days revealed on 08/23/24 and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365713 If continuation sheet Page 2 of 6 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 09/18/2024 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 08/27/24 the resident refused a shower/bath. The resident received a bed bath on 09/13/24 and 09/14/24. Level of Harm - Minimal harm or potential for actual harm Review of the shower/bathing sheets for Resident #29 for two months revealed on 09/08/24 the form was blank regarding a bath/shower and appeared to be a skin check only and on 09/10/24, the resident refused. Residents Affected - Some Interviews on 09/15/24 at 2:13 P.M. and on 09/17/24 at 5:31 P.M., Resident #29 stated she was not allowed showers at first, but now she was able to have them. She had not received a shower in a while. When one was offered, it was at night, and she preferred to go to bed early. She wanted her showers during the day. Interview on 09/18/24 at 11:33 A.M. with the Director of Nursing (DON) verified those were all the shower sheets available. The documentation in Point Click Care (PCC), the electronic medical record, was lacking. Very few showers/bed baths were documented. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365713 If continuation sheet Page 3 of 6 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 09/18/2024 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure Resident #39 received wound care according to physician's orders. This affected one resident (#39) of one resident reviewed for pressure ulcers. The facility census was 52. Residents Affected - Few Findings include: Record review of Resident #39 revealed he was admitted to the facility on [DATE] and had diagnoses including diabetes, atrial fibrillation, and end stage renal disease. He was admitted with unstageable pressure ulcers (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) to both heels as well as two pressure sores to his gluteus. The gluteus pressure sores had since healed, and the heel pressure sores progressed to stage III pressure ulcers (full thickness tissue loss, subcutaneous fat may be visible, but bone, tendon or muscle are not exposed, slough may be present but does not obscure the depth of tissue loss, may include undermining and tunneling). Review of wound assessments revealed the wounds had decreased in size since admission and the most recent assessment on 09/10/24 identified the right heel to measure 1.4 by 1.6 centimeters (cm) with a depth of 0.3 cm, and the left heel measured 1.5 by 2.0 centimeters with a depth of 0.3. Resident #39 had physician's orders dated 08/28/24 to have daily dressing changes to both heels. Review of his September treatment administration record (TAR) revealed the dressings were changed on 09/02/24, 09/03/24, 09/05/24, 09/08/24, and 09/12/24, 09/13/24, 09/14/24, and 09/15/24 with refusals documented on 09/06/24, 09/09/24, 09/10/24, 09/11/24, and 09/16/24. Interview with Resident #39 on 09/17/24 at 9:17 A.M. revealed he did not receive regular wound care, although his wounds have improved since his admission. Observation of a wound care procedure for Resident #39 by Assistant Director of Nursing (ADON) #202 and Wound Physician #901 on 09/17/24 at 11:31 A.M. revealed the pressure sore dressings on both of Resident #39's heels were dated 09/10/24. The dressing change revealed the wounds were stage III pressure sores with no clear evidence of infection. The left heel wound measured 1.4 cm by 1.8 cm with a depth of 0.4 cm, and the right heel wound measured 1.0 cm by 1.7 cm with a depth of 0.2 cm. Interview with ADON #202 on 09/17/24 at 12:09 P.M. confirmed the above observation. She confirmed the previous dressings were the same dressings she applied when doing her weekly wound rounds on 09/10/24. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365713 If continuation sheet Page 4 of 6 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 09/18/2024 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 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Potential for minimal harm Based on review of personnel files and interview, the facility did not ensure an annual evaluation was completed for stated tested nurse aide (STNA) #225. This affected one of the 12 personnel files reviewed and had the potential to affect all 52 residents residing in the facility. Residents Affected - Many Findings include: Review of the personnel file for STNA #225 revealed the most recent annual evaluation for STNA #225 was completed on 05/05/23. Interview on 09/18/24 at 12:54 P.M. with Human Resources/Payroll #205 confirmed the most recent evaluation was dated 05/05/23. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365713 If continuation sheet Page 5 of 6 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 09/18/2024 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on review of personnel files and interview, the facility did not ensure tuberculosis testing was completed on or prior to the date of hire for the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON) #202, Human Resources/Payroll #205, State Tested Nurse Aide (STNA) #212, Licensed Practical Nurse (LPN) #243, and LPN #238. This affected seven of the 12 personnel files reviewed and had the potential to affect all 52 residents residing in the facility. Residents Affected - Many Findings include: Review of the personnel file for the Administrator revealed the date of hire was 07/03/24, and the tuberculosis test was not administered until 07/16/24. Review of the personnel file for the DON revealed the date of hire was 04/23/24, and the tuberculosis test was not administered until 07/16/24. Review of the personnel file for the ADON #202 revealed the date of hire was 06/12/24, and the tuberculosis test was not administered until 07/16/24. Review of the personnel file for Human Resources/Payroll #205 revealed the date of hire was 04/29/24, and the tuberculosis test was not administered until 07/16/24. Review of the personnel file for the STNA #212 revealed the date of hire was 06/10/24, and the tuberculosis test was not administered until 07/17/24. Review of the personnel file for the LPN #238 revealed the date of hire was 06/09/24, and the tuberculosis test was not administered until 07/17/24. Review of the personnel file for the LPN #243 revealed the date of hire was 07/25/24, and the tuberculosis test was not administered until 07/29/24. Interview on 09/18/24 at 12:59 P.M. with the Human Resources #205 verified the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365713 If continuation sheet Page 6 of 6