Health inspection·October 12, 2022

F 0584 Level of Harm - Minimal harm or potential for actual harm Interview on 10/04/22 at 3:40 P.M. Maintenance Assistant (MA) #69 verified in Resident #12's the wall surface could not be sanitized. MA #69 stated the facility had no fulltime Maintenance Director or maintenance staff and there was no ongoing plan to repair walls, or a painting schedule. MA #69 had no work orders to show previous repair work. MA #69 verified there were renovation projects in resident rooms, including window coverings, which had not been completed. Residents Affected - Few Interview on 10/03/22 at 4:55 P.M., the Administrator verified there was no Maintenance Director at the facility and there were no prioritized plans for wall repair. This deficiency substantiates Complaint Number OH00136380. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365920 If continuation sheet Page 2 of 12 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 365920 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Lebanon 700 Monroe Road Lebanon, OH 45036 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 medical record review and staff and resident interview, the facility failed to ensure residents received timely assistance to transfer out of bed. This affected one (#33) of five residents sampled for activities of daily living (ADL) assistance. The facility census was 58. Residents Affected - Few Findings include: Review of the medical record for the Resident #33 revealed an admission date of 09/01/2021. Diagnoses included but were not limited acute and chronic respiratory failure with hypoxia, type II diabetes, unspecified systolic heart failure, morbid obesity, unspecified bipolar disorder, irritable bowel syndrome, and unspecified schizoaffective disorder. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact, had no behaviors, did not reject care, and did not wander. Resident #33 was a one to two-person physical assist, required limited assistance for bed mobility, total assistance for transfers, extensive assistance for dressing, toileting, and personal hygiene, supervision eating, and locomotion did not occur. Resident #33 was frequently incontinent of bowel and bladder and was not on a toileting program. Review of the care plan dated revealed Resident #33 needed assistance with ADL's related to weight, weakness, chronic obstructive pulmonary disease (COPD), bipolar anxiety, heart failure, irritable bowel syndrome, schizophrenia, depression, and morbid obesity. Interventions included moisture barrier cream after each incontinence episode, encourage to complete self-care as possible, keep call light within reach, two-person care for all needs, two-person assist for transferring with additional assist as needed, one person total assist for locomotion on the unit, and therapy as ordered. Review of task documentation dated 09/08/2022 to 10/05/2022 revealed Resident #33 received assistance out of bed four (09/15/2022, 09/16/2022, 09/19/2022, and 10/01/2022) out of twenty-seven days. Review of the medical record revealed Resident #33 last received occupational and physical therapy services from 05/04/2022 to 05/20/2022 and was cut by insurance despite therapy recommendations. Discharge recommendations included continue hover transfer mat with staff time two assist to chair daily. During an interview on 10/03/2022 at 12:51 P.M. Resident #33 stated she made repeated requests to get out of bed and did not get the help she needed. Resident #33 stated she felt she was discriminated against because of her weight. Resident #33 stated she used an inflatable pad to transfer from bed to chair and back. The pad took about 20 seconds to inflate, and it allowed her to slide into her chair. It took a lot of time to align the bed and chair together, and it took three to five staff members to safely assist her. During an interview on 10/05/22 at 2:33 P.M. the Director of Nursing (DON) stated Resident #33 was up in her chair at least twice a week as the resident prefers. The DON stated it takes two to four staff to do it and is usually done by the Assistant Director of Nursing (ADON) #9 and Unit manager #10. There is a lift machine that is kept in the bathroom and it belongs to the resident. During an interview on 10/06/22 at 9:09 A.M. the ADON #9 stated to get Resident #33 out of bed, the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365920 If continuation sheet Page 3 of 12 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 365920 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Lebanon 700 Monroe Road Lebanon, OH 45036 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 facility used a pneumatic device that forces air into the mattress, and it floated her. ADON #9 stated the set up took a lot of time getting Resident #33 onto the air pod and then getting the bed and wheelchair aligned. Resident #33 was unable to use the Hoyer because it did not fit under the bed frame. ADON #9 confirmed Resident #33 was not assisted out of bed as often as the resident would like. Residents Affected - Few This deficiency substantiates Complaint Number OH00136060. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365920 If continuation sheet Page 4 of 12 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 365920 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Lebanon 700 Monroe Road Lebanon, OH 45036 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 - Immediate jeopardy to resident health or safety 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** THIS IS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Residents Affected - Few Based on medical record review, staff interview, resident interview, and review of the facility ' s smoking policy, the facility failed to ensure Resident #34 did not smoke while wearing oxygen. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm and/or injuries when agency State Tested Nursing Assistant (STNA) #10 took Resident #34 outside for a smoke break and lit the resident ' s cigarette while Resident #34 was wearing oxygen per nasal cannula. The oxygen ignited, resulting in burns to both nostrils and singed the nose hairs. This affected one (Resident #34) of four residents reviewed for smoking. The facility identified 16 residents (#01, #02, #05, #06, #09, #17, #19, #20, #22, #34, #39, #44, #45, #48, #52, and #156) who smoke and six residents (#05, #17, #19, #20, #34, and #45) who use oxygen and smoke. The facility census was 58. On 10/05/2022 at 11:51 A.M., the Administrator, Director of Nursing (DON), and Regional Clinical Director #125 were notified Immediate Jeopardy began on 09/04/22 at 9:30 A.M. when Resident #34, who utilized oxygen therapy via nasal cannula, was assisted by STNA #10 to smoke while wearing oxygen. STNA #10 took Resident #34 outside for a smoke break and lit the resident ' s cigarette resulting in the oxygen igniting. Consequently, the resident sustained burns to both nostrils and singed nose hairs. The Immediate Jeopardy was removed on 09/05/22 and the deficient practice was corrected on 10/02/22 when the facility implemented the following corrective actions: • On 09/04/22 at 9:35 A.M., Licensed Practical Nurse (LPN) #23, LPN #38, and Respiratory Therapist (RT) #73 assessed Resident #34 and had no concerns. Resident #34 refused to go to the hospital for evaluation and treatment. Medical Director #150 was notified and instructed staff to continue monitoring and call if Resident #34 had a change of condition. • On 09/04/22 at 9:45 A.M., the DON verified safety devices (smoking blanket and fire extinguisher) were present in the designated smoking area. • On 09/04/22 at 11:30 A.M., RT Manager #20 assessed Resident #34. Vital signs were stable and there was no acute distress noted. The DON assessed Resident #34 and noted a blister to the resident s nose and cheek near the right nostril. • On 09/04/22 at 1:19 P.M., the DON educated all staff regarding the smoking policy and oxygen use. The DON sent education via email to all staffing agencies the facility used, posted the smoking policy at each nurse ' s station, and placed the smoking policy in the agency staff orientation binder. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365920 If continuation sheet Page 5 of 12 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 365920 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Lebanon 700 Monroe Road Lebanon, OH 45036 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 - Immediate jeopardy to resident health or safety On 09/04/22 at 1:30 P.M., the DON posted signs stating Absolutely no oxygen beyond this point on smoke doors and verified safety devices were present in the designated smoking area. • Residents Affected - Few On 09/04/22, audits of current resident smokers were completed to ensure care plans for smoking were in place and smokers who used oxygen had physician orders for oxygen to be removed prior to smoking. • On 09/04/22 at 1:15 P.M., the DON conducted audits for supervised smoke breaks to include every scheduled smoke break through 09/06/2022, then random audits of supervised smoke breaks twice weekly for six weeks to ensure compliance with oxygen removal before smoking. Audits will be completed by the DON/designee. • On 09/06/22, the Quality Assurance and Performance Improvement (QAPI) committee met to review all measures implemented to ensure ongoing compliance, and the QAPI committee will review audits to determine the need for continuation. • Review of audits revealed the facility audited all supervised smoke breaks from 09/04/22 at 1:15 P.M. to 09/06/22 at 10:00 P.M. to ensure that all breaks were supervised by staff and oxygen was removed prior to smoking. Additional audits of random smoke breaks were conducted twice weekly starting on 09/07/22 with no concerns noted for smoking safety. • Observation on 10/04/22 at 3:45 P.M. of the scheduled smoke break revealed staff were outside supervising the residents. Resident #34 was not present, and there were no oxygen tanks or unsafe smoking practices observed. • During staff interviews conducted 10/03/22 from 12:03 P.M. to 12:05 P.M., STNA #24, STNA #32, and STNA #54 stated they had been educated on the smoking policy after the incident took place with Resident #34. Residents had to remove oxygen prior to smoking and there was no oxygen allowed in the designated smoking area. During an interview on 10/06/2022 at 2:05 P.M., STNA #15 stated she had read the smoking policy in the agency orientation binder and acknowledged she had understood the policy before beginning her assignment at the facility. Findings include: Review of the medical record revealed Resident #34 was admitted to the facility on [DATE] with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365920 If continuation sheet Page 6 of 12 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 365920 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Lebanon 700 Monroe Road Lebanon, OH 45036 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 - Immediate jeopardy to resident health or safety Residents Affected - Few diagnoses including acute respiratory failure with hypoxia, Chronic Obstructive Pulmonary Disease (COPD), unspecified schizophrenia, unspecified anxiety disorder, and mild intellectual disabilities. Review of the care plan dated 08/04/22 identified Resident #34 had potential for safety hazard or injury related to smoking. Resident was able to smoke with supervision by staff or family. Interventions included resident must remove oxygen while smoking, smoking in designated areas only, notify management if resident was observed being unsafe during smoking, observe for burn holes, educate to smoking policy, smoking assessment completed on admission and quarterly, and direct supervision by family or staff when smoking. Review of the most recent Minimum Data Set (MDS) assessment, dated 08/11/22, revealed Resident #34 had moderately impaired cognition, had verbal and self-directed behaviors, did not wander, and rejected care one to three out of seven days per week. Resident #34 was a one-person assist, required limited assistance with personal hygiene, and required supervision with all remaining Activities of Daily Living (ADL). Resident #34 was a current tobacco user. Resident #34 had physician orders dated 08/13/22 for oxygen to be removed while smoking and an order dated 09/09/22 for oxygen via nasal cannula, titrate to maintain stats greater than 90 percent. Review of the smoking assessment completed on 09/04/22 revealed Resident #34 had cognitive loss which impaired his ability to smoke safely. Resident #34 smoked five to ten times daily, used oxygen, and was able to light his own cigarettes. Resident #34 was a supervised smoker and required continuous education to remove oxygen before smoking. Review of the nursing progress notes revealed on 09/04/22, Resident #34 was wearing oxygen while smoking which resulted in singed nose hairs and burns to tip of the nose and right cheek. Resident #34 refused to go to the hospital for evaluation and treatment. Resident #34 was assessed by respiratory therapy, nursing applied a hydrogel dressing, and the resident was educated about wearing oxygen while smoking. Resident #34 had no emergency contacts listed for notification. Review of a witness statement dated 09/04/22 indicated Agency STNA #10 stated she took Resident #34 outside for a smoke break and was outside for approximately 10 minutes when Resident #34 ' s Nose tube set flame. Resident #34 was immediately assessed by LPN's #23, #28 and RT #73. The resident kept stating he was okay. During an interview on 10/05/22 at 9:02 A.M. the DON stated the resident was outside with an agency aide. He was having increased behaviors. She took him out for an unscheduled smoke break, and she was so flustered she did not think about what she was doing. STNA #10 lit his cigarette, and he was wearing his oxygen. They were out there for about 10 minutes before the injury occurred. As soon as she saw the flames, she removed the oxygen, grabbed the cannula, threw it on the ground, and brought the resident in. RT #73 assessed the resident, and the doctor was called. The resident originally refused to go out, agreed on re-approach, and within minutes stated he felt fine and refused to go. The Medical Director (#150) was aware and said to monitor. Medical Director (#150) came in the next day and assessed the resident. Wound NP #140 followed the resident until the blisters healed. He was just taken off wound rounds last week. The DON further stated she came straight into the facility and educated all staff immediately, sent education to the agencies they used, placed signs on the doors to remove oxygen before residents went out, and put a copy of the smoking policy in the agency binder and at every nurse ' s station. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365920 If continuation sheet Page 7 of 12 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 365920 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Lebanon 700 Monroe Road Lebanon, OH 45036 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 - Immediate jeopardy to resident health or safety The DON met one on one with STNA #10, assessed the designated smoking area to ensure it had a fire blanket and extinguisher and completed assessments of all smokers for orders to remove oxygen prior to smoking and ensured care plans were up to date. The DON completed audits of every smoke break for a few days and then two random smoke breaks per week. The QAPI committee met to review the incident and interventions placed to prevent further incidents and would continue to review audits monthly and as needed to ensure compliance. Residents Affected - Few Review of policy titled Resident Smoking, no date, revealed safety measures for designated smoking included prohibition of oxygen use in the smoking area. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365920 If continuation sheet Page 8 of 12 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 365920 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Lebanon 700 Monroe Road Lebanon, OH 45036 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations and staff interview, the facility failed to ensure a residents indwelling urinary (Foley) catheter bag was timely emptied and not being stored on the floor. This affected one (#12) of five residents reviewed for urinary catheter care. The facility census was 58. Findings Include: Record review of Resident #12 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #12 included osteomyelitis left ankle and foot, diabetes, and neuromuscular dysfunction of bladder. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed the resident had moderately impaired cognition and was receiving medications insulin, Aquaphor, Zofran, and mirtazapine. The resident was currently receiving Macrobid antibiotic for urinary tract infection and had an order for a urinary catheter. Further review of Resident #12's medical record revealed the resident had an physician orders for an indwelling urinary (Foley) catheter. Observation on 10/03/22 at 10:05 A.M. revealed Resident #12 was in bed with his indwelling urinary (Foley) catheter bag full of urine. Further observations revealed Resident #12's indwelling urinary (Foley) catheter bag was lying to the right side of him on the floor. Interview on 10/03/22 at 10:06 A.M. with Licensed Practical Nurse (LPN) #23 verified Resident #12's indwelling urinary (Foley) catheter bag was full of urine and needed emptied and the residents catheter bag should not be lying on the on floor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365920 If continuation sheet Page 9 of 12 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 365920 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Lebanon 700 Monroe Road Lebanon, OH 45036 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff and resident interviews and policy review, the facility failed to ensure residents had mediations available as ordered. This affected one (#33) of five residents reviewed for medication administration. The facility census was 58. Findings include: Review of the medical record for the Resident #33 revealed an admission date of 09/01/2021. Diagnoses included but were not limited acute and chronic respiratory failure with hypoxia, type II diabetes, unspecified systolic heart failure, morbid obesity, unspecified bipolar disorder, irritable bowel syndrome, and unspecified schizoaffective disorder. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact, had no behaviors, did not reject care, and did not wander. Resident #33 was a one to two-person physical assist, required limited assistance for bed mobility, total assistance for transfers, extensive assistance for dressing, toileting, and personal hygiene, supervision eating, and locomotion did not occur. Review of the medical record revealed Resident #33 had physician orders dated 08/31/2022 for pseudoephedrine HCL ER tablet Extended Release 12-hour 120 mg, one tablet by mouth every 12 hours as needed (PRN) for sinus congestion. Observation on 10/06/22 at 9:41 A.M. revealed the Assistant Director of Nursing (ADON) #9 administered routine morning medications including insulin's and performed blood glucose monitoring with no concerns. ADON #9 administered PRN Fiorcet as requested and informed Resident #33 she did not have an active order for the Sudafed she requested. Resident #33 stated she was confused because she had received on 10/05/22. ADON #9 stated he did not know why the orders for Sudafed kept falling off the MAR and he would have to call the doctor for a new prescription. Observation on and interview on 10/06/2022 at 9:56 A.M. revealed ADON #9 reviewed Resident #33's physician orders in the computerized medical record system and confirmed the resident had an active PRN order for pseudoephedrine HCL ER 12-hour 120 mg tablet every 12 hours as needed for sinus congestion. ADON #9 searched the medication cart and confirmed the medication was not available. ADON #9 stated this had happened before, dates not specified, and he or other nursing staff went to local pharmacy #1 to buy the medication. Review of policy titled Medication Administration last revised 03/01/2022 revealed medication carts were kept stocked with adequate supplies and medications were administered within 60 minutes of their scheduled times as ordered. This deficiency substantiates Complaint Number OH00136060. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365920 If continuation sheet Page 10 of 12 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 365920 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Lebanon 700 Monroe Road Lebanon, OH 45036 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, staff interview and policy review, the facility failed to ensure foods were labeled and dated and failed to ensure expired foods were discarded in resident refrigerators. Additionally, the facility failed to ensure kitchen equipment was maintained in sanitary condition. This had the potential to affect 56 out of 58 residents who received food from the kitchen, the facility identified two (#3 and #53) residents who do not receive their food/meals from the kitchen. The facility census was 58. Findings include: Observation on 10/05/22 at 10:00 A.M. revealed the kitchen hood screens above the cooking surfaces of the stove and grill had a coating of heavy grease and dusty debris. The hood cleaning sticker on the side of the hood revealed the next scheduled cleaning was to be on 09/20/22. Observation on 10/05/22 at 12:23 P.M. revealed a sign on the refrigerator stating label and date each item before putting in the fridge. After three days throw away. The following concerns were identified in the resident [NAME] Unit refrigerator: 1. Three open containers of juice dated 04/02/22, 04/29/22 and 04/29/22. 2. Open bag of bread dated 07/29/22. 3. There was no freezer thermometer and no freezer temperature log. 4. Bag of cheese undated and unlabeled. Observation on 10/05/22 at 12:23 P.M. revealed a sign on the refrigerator stating label and date each item before putting in the fridge. After three days throw away. The following concerns were identified in the resident East Unit refrigerator: 1. Bag of unidentifiable food with no date and no label. 2. Container of meat with no name or date. 3. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365920 If continuation sheet Page 11 of 12 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 365920 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Lebanon 700 Monroe Road Lebanon, OH 45036 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 0812 Opened container of yogurt dated 07/27/22. Level of Harm - Minimal harm or potential for actual harm 4. Open container of juice dated 06/27/22. Residents Affected - Some 5. There was no freezer thermometer and no freezer temperature log. Interview on 10/05/22 at 12:23 P.M. with Dietary Manager, (DM) #63 verified the foods in the resident unit refrigerators were undated and unlabeled, and the foods were not safe for residents to consume after seven days. DM #63 stated it was nursing staff responsibility to monitor and remove expired and undated foods from the resident refrigerators and housekeeping to maintain freezer thermometers and record freezer temperatures. DM #63 verified the hood cleaning was past due and the screens over the cooking surfaces were exposed to dust falling from the screens. The facility confirmed the identified concerns had the potential to affect 56 out of 58 residents who received food from the kitchen, the facility identified two (#3 and #53) residents who do not receive their food/meals from the kitchen. Review of the facility policy Date Marking undated, revealed foods will be date marked and shall be used within seven days after prepared or opened. Review of the facility policy Sanitary Conditions, undated, revealed all equipment will be maintained in a clean and sanitary fashion. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365920 If continuation sheet Page 12 of 12