Health inspection·July 1, 2025

F 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few eyeglass dispensing. 360 Care form stated any service not covered by insurance can be covered through the offset process. Review of Resident #69's record revealed an order dated 05/23/25 ordered by the facility medical director that stated Resident #69 was ok to use the facility ancillary services such as psychiatrist, psychologist, social service, ophthalmologist, dentist, vision, hearing, podiatrist, certified nurse practitioner, and wound services. Review of Resident #69's record including progress notes, uploaded documents, and orders revealed no documentation the facility had reached out to 360 Care to provide services for Resident #69 regarding his broken eye lens to his prescription glasses. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365770 If continuation sheet Page 2 of 11 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 365770 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Cambridge 1471 Wills Creek Valley Drive Cambridge, OH 43725 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 review of the medical record and interview, the facility failed to provide care without causing a skin tear for Resident #67. This affected one resident (#67) of three residents reviewed for skin conditions. The facility census was 70. Residents Affected - Few Findings include: Record review revealed Resident #67 was admitted to the facility on [DATE] with diagnoses including morbid obesity and muscle weakness. Review of an MDS dated [DATE] revealed Resident #67's cognition remained intact, he had no behaviors, and had moisture associated skin damage (MASD). Review of a care plan dated 04/02/25 revealed Resident #67 was at risk for potential alteration to skin integrity and required protective/preventative skin care maintenance related to bladder and bowel incontinence and decreased mobility with a goal to have no new skin issues through the next review. Review of a nursing note dated 04/09/25 at 11:19 A.M. by Registered Nurse (RN) #115 revealed the wound nurse practitioner visited Resident #67 due to an open area to left side abdominal fold area. Resident #67's wife was present and stated it occurred during care when a staff member pulled up resident's pants too quickly/far. A new treatment was ordered. Review of a Skin Grid Non-Pressure assessment dated [DATE] revealed Resident #67 had a new skin area related to trauma in left side fold which was acquired on 04/08/25. The area was 0.2 centimeters (cm) by 0.8 cm by 0.1 cm with scant drainage. Interview on 06/29/25 at 3:26 P.M. with Resident #67 revealed his skin had been growing back under his abdominal fold after having yeast and an aide came in to clean him up, lifted his stomach too quickly and tore the skin. Interview on 07/01/25 at 9:48 A.M. with Certified Nursing Assistant (CNA) #132 revealed Resident #67 had reported to her another aide was cleaning him up and tore his new skin on his stomach fold so she reported it to the nurse. She could not recall which nurse. Interview on 07/01/25 at 2:39 P.M. with DON confirmed nursing note stated a skin tear was caused by an aide lifting Resident #67's stomach too fast/far. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365770 If continuation sheet Page 3 of 11 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 365770 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Cambridge 1471 Wills Creek Valley Drive Cambridge, OH 43725 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 - Some 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** 4. Review of Resident #69's medical record revealed he was admitted to the facility 05/23/25 with diagnoses including malignant neoplasm of lower third ossiphageous, severe protein calorie malnutrition, malignant neoplasm of the brain, cardiomyopathy, heart failure, depression, constipation, gastroesophageal reflux, chronic pain, cardiac defibrillator, and hypertension. Review of Resident #69's minimum data set (MDS) completed 05/28/25 revealed a brief interview for mental status score of 15 indicating no cognitive impairment. Review of Resident #69's smoking assessment completed on 5/23/25 and revealed the resident was a smoker, had no cognitive loss impairing their ability to smoke safely, the resident had no visual deficit, the resident smokes two to five times per day during the morning, afternoon, evenings, and nights. Question of can the resident light his own cigarette not applicable (N/A) was marked on the smoking assessment. Findings of the smoking assessment completed 05/23/25 for Resident #69 revealed he required adaptive equipment while smoking such as supervision. Resident smoking status determined by smoking assessment and facility assessment revealed he requires supervised smoking. Review of Resident #69's record revealed a progress note completed 06/01/25 stating Resident just came in from smoking, daughter states she lives down the street and doesn't mind coming up with him out to smoke. Ambulatory with one assist, medicated with morphine. Review of Resident #69's care plan completed 05/23/25 revealed the resident was at risk for alteration in skin integrity due to prolonged sun exposure while smoking. Review of Resident #69's care plan completed 05/23/25 revealed Resident #69 has potential for safety hazard or injury related to smoking. Resident #69 is able to smoke with supervision by staff or family. Goals include the resident will continue to follow facility smoking policy. Interventions include while smoking resident will have direct supervision by staff or family members. Interview on 07/01/25 at 8:11 A.M. with certified nurses' aide (CNA) #112 confirmed Resident #69 is a smoker. They state he smoked daily; about every three hours Resident #69 goes out to smoke. Observation on 06/30/25 at 12:50 P.M. revealed Resident #69 down the street at a nearby apartment complex under no supervision smoking a cigarette. Interview with Director of Nursing (DON), Administrator, and Regional Director #214 on 07/01/25 at 9:43 A.M. and 2:00 P.M. confirmed Residents #21 and #53 have lost their independent smoking privileges because of violations of the smoking policy by keeping smoking materials in their rooms. She also confirmed Resident #66 has been a supervised smoker since admission and Resident #69 is a supervised smoker because he was admitted to the facility after the new smoking policy was enacted that required all residents to be supervised smoking. They confirmed they keep resident smoking materials, who are supervised smokers, at the nurses desk, and they can retrieve them when it's smoking time. They confirmed if a resident is deemed safe to go on a leave of absence independently, they are able to take their smoking materials and go to the front of the facility property to smoke by themselves. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365770 If continuation sheet Page 4 of 11 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 365770 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Cambridge 1471 Wills Creek Valley Drive Cambridge, OH 43725 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 - Some They confirmed the smoking assessment doesn't differentiate between the smoking abilities/safety of the resident smoking, and the resident's refusal of not following the rules regarding keeping smoking materials in their room. Their policy is they do not want a resident who does not follow the rules of smoking or that is not safe to be a smoker, to smoke on property and potentially harm other residents. But, when asked why the above residents are permitted to leave property independently and smoke, if they are deemed supervised smokers. There was no adequate answer provided, other than they are trying to keep all the residents in the facility safe. Review of facility Smoking Policy, (undated), revealed the employee responsible at the time of the supervised smoke time is the only one to have smoking materials. There was nothing within the policy to dictate the procedures or responsibilities for those residents deemed to be supervised smokers, but choose to go on a leave of absence off facility property to independently smoke. Based on observations, medical record review, resident interview, staff interview, and facility policy review, the facility failed to ensure a safe smoking environment. This affected four residents (#21, #53, #66, and #69) of four residents reviewed for smoking safety. The census was 70. Findings Include: 1. Observations on 06/30/25 at approximately 9:30 A.M. revealed Resident #21 was given his smoking materials by facility nursing staff, and he went to the front of the building to smoke independently. He had his lighter and smoking materials in his hands with no staff going with him to the front of the building, and to the sidewalk, which is considered off property for smoking. Record review revealed Resident #21 was admitted to the facility on [DATE]. His diagnoses were chronic obstructive pulmonary disorder (COPD), idiopathic progressive neuropathy, alcoholic liver disease, type II diabetes, anemia, morbid obesity, and hypertension. Review of his minimum data set (MDS) assessment, dates 06/12/25, revealed he was cognitively intact. Review of Resident #21's smoking assessment, dated 03/11/25, revealed he was deemed to be an independent smoker. Review of Resident #21's smoking assessment, dated 05/23/25, revealed he was deemed to need supervision for smoking. The justification for making him a supervised smoker was he did not follow the facility policy of not keeping smoking materials in his room. Review of Resident #21's care plan, dated 06/29/23, revealed he was able to smoke without supervision of staff or family. Review of Resident #21 care plan, dated 06/29/25, revealed he was deemed to be a supervised smoker. But, according to his smoking assessment, he was deemed to be a supervised smoker on 05/23/25. Interview with Resident #21 on 06/30/25 at 8:45 A.M. revealed he was very upset and disappointed he was not deemed to be an independent smoker any more, simply because he had loose tobacco and rolling papers in his room. He confirmed he was able to get his smoking materials from nursing staff, and then wheel himself out to the sidewalk to smoke by himself. He didn't understand how he was allowed to do that by himself, but not smoke in the facility designated smoking area independently. 2. Observation on 06/30/25 at 2:15 P.M. revealed Resident #53 receiving her smoking materials from (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365770 If continuation sheet Page 5 of 11 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 365770 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Cambridge 1471 Wills Creek Valley Drive Cambridge, OH 43725 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 - Some nursing staff, and going outside independently to smoke. She had her smoking materials in her hands with no staff going with her to the front of the building, and to the sidewalk, which was considered off property for smoking. Record review revealed Resident #53 was admitted to the facility on [DATE]. Her diagnoses were radiculopathy, dysphagia, hemiplegia, type 1 diabetes, spinal stenosis, congestive heart failure, vitamin D deficiency, dorsalgia, depression, post traumatic stress disorder, hypertension, sleep apnea, polyneuropathy, hyperlipidemia, osteoarthritis, panic disorder, obesity, and allergic rhinitis. Review of her MDS assessment, dated 04/20/25, revealed she was cognitively intact. Review of Resident #53's smoking assessment, dated 04/17/25, revealed she was deemed to be an independent smoker. Review of Resident #53's smoking assessment, dated 05/23/25, revealed she was deemed to need supervision for smoking. The justification for making her a supervised smoker was she was not following the facility policy of not keeping smoking materials in her room. Review of Resident #53's care plan, dated 05/27/24, revealed she was deemed to be an independent smoker. Review of Resident #53's care plan, dated 06/30/25, revealed she was deemed to be a supervised smoker. But, according to her smoking assessment, she was deemed to be a supervised smoker on 05/23/25. Interview with Resident #53 on 06/29/25 at 11:25 A.M. revealed she went from unsupervised smoking to supervised smoking because the facility found a vape in her room. She doesn't feel it's fair to be deemed a supervised smoker for only having a vape in her room. She stated she can get her smoking materials and go to the front sidewalk by herself, but she has to sign out at the nurse's desk. She doesn't understand why she has to go to the front side walk, where there is no shade from the sun, by herself, but she can't do that in the facility's designated smoking area. 3. Observation on 07/01/25 at 12:20 P.M. revealed Resident #66 getting his smoking materials from nursing staff, and going independently to the front side walk to smoke. He had no staff or supervision with him. Record review revealed Resident #66 was admitted to the facility on [DATE]. His diagnoses were quadriplegia, type II diabetes, muscle weakness, need for assistance with personal care, intraspinal abscess and granuloma, hypokalemia, constipation, peripheral vascular disease, bipolar disorder, hyperlipidemia, and long QT syndrome. Review of his MDS assessment, dated 06/12/25, revealed he was cognitively intact. Review of Resident #66 smoking assessment, dated 03/07/25, revealed he was deemed to need supervision for smoking. Review of Resident #66 care plan, dated 06/30/25, revealed he was deemed to be a supervised smoker. Prior to 06/30/25, he did not have a care plan related to smoking. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365770 If continuation sheet Page 6 of 11 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 365770 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Cambridge 1471 Wills Creek Valley Drive Cambridge, OH 43725 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview the facility failed to acquire post dialysis vital signs as ordered for one resident(#55). This had the potential to affect one resident (#55) of one resident on dialysis in the facility. The census was 70. Residents Affected - Few Findings include: Record review revealed Resident #55 was admitted to the facility 9/13/23 with diagnoses including Stage 4 chronic kidney disease (CKD), kidney transplant, convulsions, hypothyroidism, hyperlipidemia, dependence on renal, benign prostatic hyperplasia, intellectual disabilities, polycystic kidneys, cardiomyopathy, hypertension, iron deficiency, cardiac arrhythmia, arthritis, mitral valve prolapse, and gastro esophageal reflux disease. Review of Resident #55's Minimum Data Set (MDS) completed 03/25/25 revealed a brief interview for mental status (BIMS) score of 10. The MDS revealed Resident 55 was receiving dialysis. Review of Resident #55 care plan revealed Resident #55 was at risk for impaired fluid volume and electrolyte imbalance related to impaired renal function, end stage renal disease (ESRD), and renal failure. Interventions included taking vital signs as ordered. Record review revealed an order for Resident #55 to go to dialysis every Monday, Wednesday, and Friday. Record review revealed an order placed 05/23/25 at 6:00 A.M. to obtain vital signs (VS) after returning from dialysis one time a day every Monday, Wednesday, and Friday. Review of medication administration records (MAR), treatment administration records (TAR), and vital sign flow sheet revealed the resident had no documentation of vital signs being completed after returning from dialysis on 05/23/25, 05/28/25, 06/20/25, and 06/27/25 as ordered. Interview on 07/01/25 at 4:15 P.M. with the Director of Nursing (DON) confirmed VS should be completed on Resident #55 after return from dialysis and on the dates of 05/23/25, 05/28/25, 06/20/25, and 06/27/25 VS were not completed post-dialysis. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365770 If continuation sheet Page 7 of 11 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 365770 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Cambridge 1471 Wills Creek Valley Drive Cambridge, OH 43725 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record and interview, the facility failed to ensure a resident had a thorough medication regimen review completed by the pharmacist. This affected one resident (#39) of five residents reviewed for medication review. The facility census was 70. Findings include: 1. Record review revealed Resident #39 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, depression and anxiety disorder. Review of a care plan dated 10/13/24 revealed Resident #39 was at risk for potential adverse side effects of psychotropic drug use with a goal to use the lowest therapeutic dose for control of symptoms through the review period. Review of a minimum data set (MDS) assessment dated [DATE] revealed Resident #39's cognition was severely impaired and she had no behaviors. Review of a nursing note dated 06/17/25 at 9:20 A.M. by Licensed Practical Nurse (LPN) #210 revealed a new order was received from hospice to increase Xanax from 0.5 milligrams (mg) to 1 mg twice a day scheduled, then every 4 hours as needed. Hospice had contacted and updated Resident #39's husband. Review of an order dated 06/17/25 revealed Resident #39 was to receive Xanax oral tablet 0.5 mg give 1 mg by mouth every four hours as needed for anxiety for 90 days per hospice. An additional order dated 06/17/25 revealed Resident #39 would receive Xanax 0.5 mg tablet give 1 mg by mouth one time a day for anxiety/aggression. An order dated 06/17/25 for Xanax 0.5 mg tablet give 1 mg by mouth at bedtime for anxiety and an order dated 06/17/25 for Alprazolam (Xanax) tablet 1 mg give 1 tablet by mouth in the evening for anxiety with dinner. Review of a controlled drug log dated 06/18/25 revealed Resident #39 received Lorazepam 1 mg from the pharmacy with instructions to administer 1 tablet by mouth two times a day (morning and bedtime) and 1 tablet by mouth every four hours as needed for anxiety. Resident #39 received one dose of unordered Lorazepam on 06/18/25, two doses on 06/19/25, one dose on 06/20/25, one dose on 06/21/25, one dose on 06/22/25, two doses on 06/23/25, and one dose on 06/24/25. Review of a pharmacy packing slip dated 06/17/25 revealed Resident #39 received a prescription containing 60 Lorazepam tablets 1 mg dose. Review of a Pharmacist Medication Regimen Review assessment dated [DATE] revealed the pharmacist completed a medication review for Resident #39 and had no recommendations. Review of Resident #39's medication administration record (MAR) for June 2025 revealed there was no documentation of Resident #39 receiving Lorazepam. Interview on 06/30/25 at 1:07 P.M. with Director of Nursing (DON) revealed hospice had updated Resident #39's Xanax order because her family was concerned she was not getting enough sleep so they (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365770 If continuation sheet Page 8 of 11 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 365770 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Cambridge 1471 Wills Creek Valley Drive Cambridge, OH 43725 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 0756 were trying to accommodate the family. Level of Harm - Minimal harm or potential for actual harm Interview on 07/01/25 at 8:15 A.M. with DON confirmed the controlled substance log shows medications were not given as ordered and she had additional information regarding this time period due to a medication error that occurred when hospice mistakenly sent a script for Ativan (Lorazepam) instead of Xanax. Residents Affected - Few Interview on 07/01/25 at 9:57 A.M. with Hospice Representative #313 revealed she works in the office and pushes orders from the physician to the nurses out in the field. HR #313 stated Resident #39's orders have always been for Xanax and the current order was for Xanax 1 mg scheduled three times daily dated 06/24/25. HR #313 revealed Resident #39 has never had an order for Ativan, but it was possible the physician sent the wrong medication for her due to a lot of medication changes. HR #313 stated if the facility received orders from hospice to adjust the Xanax but received a shipment of Ativan it would be their responsibility to identify the issue and contact hospice for clarification. Interview on 07/01/25 at 11:56 A.M. with Pharmacist #322 revealed when she completes the medication regimen review, she goes into the electronic system to review orders and most of the time she looks at them. Pharmacist #322 stated she assumes the medication sent to the facility is what is on the orders. Pharmacist #322 stated she does narcotic count audits, but she looks at the sheets to make sure the count is correct, and they are filling out the log correctly and numbers match. Pharmacist #322 stated it would have been hard for her to catch the medication error. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365770 If continuation sheet Page 9 of 11 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 365770 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Cambridge 1471 Wills Creek Valley Drive Cambridge, OH 43725 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 0759 Ensure medication error rates are not 5 percent or greater. 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 medication error rate was less than five percent. There were a total of 36 medication opportunities observed with two medication errors resulting in a 5.55% medication error rate. This affected one resident (#4) of three residents observed for medication administration. The census was 70. Residents Affected - Few Findings include: Record review revealed Resident #4 was admitted to the facility on [DATE] with diagnoses including hypertension, chronic kidney disease stage four, schizoaffective disorder, diastolic congestive heart failure, epilepsy, congenital absence of extremities, hyperlipidemia, hypothyroidism, chronic obstructive pulmonary disease, convulsions, drug induced dyskinesia, gastroesophageal reflux disease, arteriosclerotic heart disease, constipation, insomnia, failure to thrive, anemia. Record review of Resident #4's minimum data set (MDS) assessment completed 06/03/25 revealed a brief mental status (BIMS) score of 14. Observation of medication pass on 06/29/25 at 9:30 A.M. with Licensed Practical Nurse (LPN) #173 of medication administration to Resident #4 revealed LPN #173 prepared Rufinamide 400 milligrams (mg) 4 tablets for 1600 mg, Folic Acid 1 mg, Cimetidine 400 mg, Loratadine 10 mg, Multivitamin 1 tablet, Metoprolol 25 mg half a pill , Aspirin 81 mg, Lasix 20 mg, Levetiracetam 1000 mg, Levothyroxine 125 micrograms (mcg), Lisinopril 10 mg, Epidiolex 6.6 milliliters (ML) to be administered. Observation revealed Valbenazine 40 mg and Albuterol inhalation were marked as completed on the medication administration record (MAR). LPN #173 signed the MAR prior to medications being administered. LPN #173 verified observation of medication cup contained 14.5 pills, LPN #173 closed the computer screen out and grabbed the medication cup and began walking to Resident #4's room. Interview on 06/29/25 at 9:37 A.M. with LPN #173 revealed that when asked where the Valbenazine tablet was, LPN #173 stated it wasn't in the pre- packed pill package. When asked where the Albuterol was, LPN #173 stated it was in the cup, LPN #173 stated the Albuterol was a pill in the cup. LPN #173 proceeded to look at Resident #4's record and read that Albuterol was to be given as inhalation through inhaler, LPN #173 confirmed the Valbenazine was in its own medication bottle and not in the prepacked pill pack. LPN #173 confirmed she had not administered Albuterol and Valbenazine at that time. Review of Resident #4's orders revealed Resident #4 was to receive Ipratropium-Albuterol solution 0.5-2.5 (3) mg/3 ml 3 ML inhale orally, Rufinamide 400 milligrams (mg) 4 tablets for 1600 mg, Folic Acid 1 mg, Cimetidine 400 mg, Loratadine 10 mg, Multivitamin 1 tablet, Metoprolol 25 mg half a pill , Aspirin 81 mg, Lasix 20 mg, Levetiracetam 1000 mg, Levothyroxine 125 micrograms (mcg), Lisinopril 10 mg, Epidiolex 6.6 milliliters (ML) at the time of medication administration. Review of facility policy Medication Administration dated and revised 08/22/22 revealed review of the MAR to identify medication to be administered, administered medication as ordered in accordance with manufactures recommendations, and sign MAR after administration of medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365770 If continuation sheet Page 10 of 11 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 365770 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Cambridge 1471 Wills Creek Valley Drive Cambridge, OH 43725 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on record review and interview, the facility failed to ensure accurate documentation in the medical record for treatments for a resident. This affected one resident (#1) of 25 residents reviewed for documentation. The facility census was 70. Findings include: Review of the medical record for Resident #1 revealed an admission date of 10/11/17 with diagnoses including diabetes mellitus, heart failure and dementia. Review of the physician's orders for Resident #1 revealed she had orders for [NAME] hose, on in the morning and off at night dated 01/15/25; Miconazole Powder (antifungal), apply under breasts and abdominal folds topically every shift for redness/excoriation, apply to the crease of the buttocks and groin dated 05/13/22; Lac Hydrin External Cream 12%, apply to bilateral lower extremities/feet topically every night shift for diabetes mellitus dated 05/23/25; and Voltaren Arthritis Pain External Gel 1%, apply to shoulders topically one time a day for pain use 2 grams to the upper extremities and 4 grams to the lower extremities dated 06/11/25. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for June 2025 for Resident #1 revealed treatments were not documented completed as ordered for the [NAME] hose on 06/06/25 and 06/08/25; Miconazole Powder on dayshift on 06/02/25, 06/05/25, 06/13/25, 06/20/25, 06/25/25, 06/27/25 and 06/29/25 and at night on 06/06/25 and 06/08/25; Lac Hydrin on 06/06/25 and 06/08/25; and Voltaren on 06/13/25, 06/19/25, 06/20/25, 06/25/25, 06/27/25 and 06/29/25. Interview on 07/01/25 at 12:37 P.M. with the Director of Nursing (DON) verified the missing documentation on the TAR on the dates listed above for Resident #1. Review of the facility policy titled, Medication Administration, dated 08/22/22, revealed staff were to sign the MAR after medications were administered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365770 If continuation sheet Page 11 of 11