Health inspection·August 23, 2023

F 0689 #17 clearly had burns sustained from the shower room on 07/21/23. From 07/21/23 to 08/10/23, the [NAME] shower room remained in use for the residents to receive showers in. Level of Harm - Immediate jeopardy to resident health or safety The Immediate Jeopardy was removed on 08/15/23 when the facility implemented the following corrective actions: Residents Affected - Some • On 07/21/23, the facility implemented a Quality Assurance Performance Improvement (QAPI) plan, and it was continually updated and monitored on 07/24/23, 07/25/23, 07/31/23, 08/02/23, 08/07/23, 08/09/23, and 08/10/23. The QAPI plan included water temperatures obtained in the [NAME] shower room, an incident report along with staff statements obtained, the shower room chemicals and supplies were audited, and education on Activities of Daily Living (ADL) care to the licensed nurses was completed. • On 08/05/23, the DON, Unit Manager #87, and Unit Manager #86 completed skin assessments on all 50 in-house residents and found no negative outcomes. • On 08/05/23, Resident #17 returned to the facility with a physician order for Resident #17 to see an outside wound clinic for the burns on her bilateral legs. The initial appointment was scheduled for 08/11/23 but the wound clinic had to reschedule the initial appointment. • On 08/06/23, Physician #203 assessed Resident #17's wounds as burns on the bilateral lower extremities. • On 08/10/23, the Administrator, DON, Regional Director of Operations #200, and RDCS #190 completed a root cause analysis involving the incident where Resident #17 sustained burns in the shower on 07/21/23. The identified root cause was determined to be a faulty mixing valve which did not allow the shower to maintain proper water temperatures resulting in Resident #17 sustaining burns on her bilateral legs. The root cause analysis identified the following two issues: maintenance staff did not know how to identify water temperature issues and how to fix appropriately and the facility staff did not know how to properly notify maintenance staff on maintenance issues. • On 08/10/23 at 10:22 A.M., Maintenance Supervisor #12 and Regional Maintenance Director #180 closed the [NAME] Shower room for no resident use and turned off the water supply to the [NAME] Shower room. On 08/10/23 at 5:00 P.M., Regional Maintenance Director #180 replaced the mixing valve to ensure proper temperatures are maintained for all residents. • (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365920 If continuation sheet Page 2 of 9 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 08/23/2023 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 - Some On 08/10/23, Maintenance Supervisor #12 and Regional Maintenance Director #180, audited all water temperatures throughout the building including the East and [NAME] shower rooms, all resident rooms, and common areas where water is accessible to the residents. There were no negative findings. • By 08/14/23, the Administrator will educate all 87 staff on how to notify management staff on equipment issues and specifically how to address these in a timely manner to ensure the safety of the residents. • On 08/14/23, the Administrator and DON implemented an Agency Binder for agency staff to utilize while working a shift at the facility. This binder includes education on how to report mechanical issues as well as other concerns and incidents to management staff in a timely manner. • On 08/14/23, the Administrator educated Maintenance Director #12 on how to fix a mixing valve. • On 08/14/23, the facility will conduct daily water temperature audits to ensure the water temperatures are accurate and within the appropriate guidelines. This will be completed by Maintenance Supervisor #12 and/or designee for two weeks and then three to five times per week for the next month with results being reported to the QAPI committee and interventions adjusted as indicated to maintain ongoing compliance. • On 08/14/23 at 7:35 A.M., observation of the [NAME] shower room revealed the [NAME] shower room was open for residents to receive showers, and the shower control knob mixing valve for the cold and hot water were operating properly and hot and cold water was being released at the temperature as indicated on the shower control knob. • On 08/14/23, staff interviews with LPN #04 and #87, State Tested Nursing Assistants (STNA) #32, and #50, Housekeeper #69, and Receptionist #14 revealed they were educated on how to timely report equipment issues. • On 08/15/23, the facility submitted a Self-Reported Incident (SRI) to the State Survey Agency. The SRI reported Resident #17 sustained an injury of unknown origin on 07/21/23. Although the Immediate Jeopardy was removed on 08/15/23, the facility remains out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365920 If continuation sheet Page 3 of 9 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 08/23/2023 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 monitoring to ensure on-going compliance. Level of Harm - Immediate jeopardy to resident health or safety Findings include: Residents Affected - Some Review of Resident #17's medical record revealed Resident #17 was admitted to the facility on [DATE]. Diagnoses included muscle weakness, repeated falls, dementia without behavioral disturbance, schizoaffective disorder, tremors, and history of encephalopathy. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) assessment score of seven. Resident #17 required extensive one-person assistance with bed mobility, dressing, and personal hygiene and was dependent on one-person for showering/bathing. Resident #17 had no pressure ulcers or venous and arterial ulcers present. Review of the care plan revised 08/24/21 revealed Resident #17 required assistance with activities of daily living (ADL) related to immobility, generalized weakness, repeated falls, confusion and memory loss, tremors, history of encephalopathy, dementia, anxiety, and schizophrenia. Resident #17 was able to make needs known. ADLs may vary over the course of the day, usually received extensive assistance with ADLs. Interventions included to provide additional assistance as needed and document accordingly. Report any significant changes to the charge nurse and physician. Further review of the resident's care plan revealed Resident #17 had the potential for alteration in skin integrity and required protective/preventive skin care maintenance related to bladder incontinence, impaired mobility, impaired cognition, and unable to recognize risk. Interventions included to inspect the skin condition daily during personal care and report any impaired areas to the charge nurse. Resident #17 required extensive assistance with weight bearing for bathing. Provide additional assistance as needed and document accordingly. Review of the skin assessment dated [DATE] revealed Resident #17 had no skin impairments and the resident's skin was intact. Review of the facility incident report titled Skin Alteration, dated 07/21/23 at 4:47 P.M., revealed Resident #17 was observed with an area of moisture between thighs and calves during routine ADL care by an STNA. Nursing was then alerted. Resident #17 was unable to give a description of the incident. The predisposing physiological factors included immobility, incontinence, and fragile skin. The Interdisciplinary Team (IDT) review on 07/25/23 documented by the DON revealed Resident #17 was observed with skin impairment to bilateral inner legs and left foot. Resident #17 was followed by Wound Nurse Practitioner (WNP) #400 and a treatment was in place. The physician and family were notified. The Regional Nurse (RDCS #190) instructions/direction carried out at time of event. Review of STNA #402's witness statement dated 07/21/23 revealed STNA #402 gave a shower to Resident #17 on 07/21/23. The resident did not have any redness noted to her bilateral legs prior to the shower. While in the shower, STNA #402 adjusted the water temperature to the residents' request. Resident #17 did have a large bowel movement in the shower. STNA #402 stated she did clean the resident after the bowel movement with the pink house body wash. No redness was noted at that time to her bilateral legs. Resident #17 had an episode of unresponsiveness while in the shower. Resident #17 was not left unattended and STNA #402 went to the shower room door and shouted for LPN #08. After LPN #08 took the resident's vital signs and finished her evaluation, STNAs #402 and #52 took Resident #17 back to her room and transferred the resident to bed. After transferring the resident to bed, redness was noted to her bilateral thighs. The resident denied the redness was painful. The resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365920 If continuation sheet Page 4 of 9 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 08/23/2023 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 - Some continued to have diarrhea throughout the shift. The resident had three more bowel movements during the shift. Review of STNA #52's witness statement dated 07/21/23 revealed she assisted STNA #402 to transfer Resident #17 to the shower chair and the resident was fine. The STNA revealed she went to the shower room to throw away trash and observed STNA #402 washing the resident's hair. The resident was okay. The STNA did not notice Resident #17's legs until Resident #17 was unresponsive and LPN #08 was in the shower room assessing Resident #17. Review of LPN #08's witness statement dated 07/21/23 at 2:30 P.M., revealed upon going into the shower room, she noticed Resident #17 was arousable to pain, blood pressure was 133/55 millimeters of mercury (mm/Hg), heart rate 80 beats per minute and unable to obtain an oxygen saturation, respirations were twelve breaths per minute, easy and unlabored. LPN #08 noted red marks on Resident #17's inner thighs. Resident #17 was covered up then taken back to her room and put in bed. Upon assessment, Resident #17's left leg from her thigh to her foot was red and the skin was peeling, and the right thigh was red. LPN #08 reported her assessment to the unit manager. Review of the skin assessment dated [DATE] at 4:47 P.M., after the resident received a shower, revealed Resident #17 had Moisture Associated Skin Damage (MASD) to her left thigh measuring 35 centimeters (cm) in length, 11 cm in width, and the depth could not be determined. The resident's left calf was assessed to have MASD that measured 20 cm in length, 14 cm in width and the depth could not be determined. The resident's left foot was assessed to have MASD and measured 15 cm in length, and 8.0 cm in width, the depth could not be determined. The resident's right thigh revealed the resident had MASD measuring 27 cm in length, 4.0 cm in width and the depth could not be determined. Review of the nursing progress note dated 07/21/23 at 4:55 P.M. revealed the wound nurse, LPN #87 documented Resident #17 was noted with an area of moisture between her thighs and calves during routine ADL care by an STNA. An STNA alerted nursing. The wound nurse assessed area and immediately initiated a treatment plan. All documentation completed. The responsible party, Resident #17's primary care physician, the DON, and WNP #400 were made aware. Review of WNP #400's progress note assessment, dated 07/25/23 at 8:30 A.M., revealed Resident #17 was seen for full thickness, non-pressure wounds to her bilateral legs with an onset date of 07/21/23. Wounds were currently being treated with Silvadene. Physician #203 started Resident #17 on a ten-day course of Vibramycin (oral antibiotic to treat and prevent infections). WNP #400's new orders on 07/25/23 were to clean the bilateral legs with facility wound cleanser. Apply silver wound gel (contains silver that inhibits the growth of microorganisms). Cover with oil emulsion dressing (non-adherent gauze mesh impregnated with white petrolatum that permits the flow of exudate without sticking to the wounds). Secure with ABD pad and kerlix. Change daily. Review of Resident #17's nursing progress notes revealed there was no documentation on 07/30/23 when the resident was sent to the hospital for evaluation. Review of the EMS report dated 07/30/23 at 5:23 P.M., revealed Resident #17 began to have pain in her legs about a week ago. The resident's family visited today (07/30/23) and urged the facility to have Resident #17 transported to the hospital for evaluation. The nurses stated they were told not to send Resident #17 out (to the hospital). The residents' son stated Resident #17 was not acting like her normal self and stated she was very sluggish and not talkative like she would be on a normal day. Facility staff stated they were breaking their procedures and called to have Resident #17 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365920 If continuation sheet Page 5 of 9 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 08/23/2023 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 - Some transported to the hospital. Resident #17 was complaining of pain in lower extremities. Resident #17 has what appeared to be burns running the medial side of her left leg from the thigh down to her left foot. Wounds on her ankle and foot were open and less healed than those proximal. Resident #17 had the beginnings of similar burn like wounds on the medial side of her right thigh trailing off to redness as they extended distal to the knee. Review of the hospital encounter report dated 07/30/23 revealed Resident #17 was diagnosed with burns to her left thigh, down her left leg from inner thigh to foot, black eschar, and an open blister at the bottom of her foot and intact blisters behind the knee. A burn on the right inner upper thigh eschar was present. Resident #17's wounds were debrided on 07/31/23. Resident #17 was diagnosed with MRSA on bilateral leg wounds and the left foot and ordered IV antibiotics consisting of Vancomycin 1,000 milligrams (mg/10 milliliters (ml) once daily in the evenings for ten days, and Cefepime two gram (gm)/100 ml to be administered every twelve hours for ten days. Resident #17 returned to the facility on [DATE] at 7:30 P.M. Review of the care plan revised on 08/01/23 revealed Resident #17 has an actual area of skin impairment related to open wounds to her bilateral legs and left foot. Interventions included to ask the resident about pain level prior to dressing change procedure, medicate if needed. Avoid tight clothing. Continue treatment as ordered by the physician or nurse practitioner (NP). Nursing to observe the wound dressing daily to ensure the dressing remains intact and there were no signs or symptoms of infection or increased drainage. Review of Resident #17's re-admission assessment to the facility dated 08/05/23 revealed the residents' wound measurements to the right thigh were 16 cm in length, 5.0 cm in width, and depth could not be determined. The left thigh wound from her left thigh to the left foot measured 78 cm in length, 13 cm in width, and depth could not be determined. The resident was diagnosed with MRSA of bilateral leg wounds and left foot and returned to the facility with orders from the hospital to continue IV antibiotics consisting of Vancomycin 1,000 mg/10 ml once daily in the evenings for ten days, and Cefepime 2.0 gm/100 ml to be administered every twelve hours for ten days. Additional orders included for Resident #17 to follow up with Wound Clinic #750 on 08/11/23 and schedule an appointment with infectious disease physician as soon as possible. Review of Resident #17's History and Physical dated 08/06/23 completed by Physician #203 revealed Resident #17 was admitted to the nursing home from the hospital. Resident #17 required admission to the hospital for treatment of burns on both legs that also had a secondary infection. She underwent debridement of the abnormal tissue. She was evaluated by an infectious disease physician. She was placed on IV cefepime and vancomycin. She was sent to the facility with orders for a ten-day course of antibiotic therapy. She had a peripherally inserted central catheter (PICC) line placed. Resident #17 stated she was not experiencing discomfort to the wounds on her legs. On 08/09/23 at 10:30 A.M., during an interview with Wound LPN #87 revealed on 07/21/23 at approximately 2:00 P.M., she was alerted by LPN #08, Resident #17's assigned nurse, Resident #17 had redness to her lower legs after receiving a shower. The wound nurse stated she questioned STNA #402 who gave the resident a shower earlier and the STNA insisted it could not have been the shower because the water was not that hot. The wound nurse stated she texted pictures of the wounds to RDCS #190, WNP #400, and the DON. The DON was on vacation on 07/21/23. The wound nurse stated the wounds appeared to her as burns. The wound nurse stated RDCS #190 responded to her and stated the wounds appeared as MASD because Resident #17 had just got out of the shower and it looked like to her skin stuck together and ripped off related to the shape and there were no other burns on her body. RDCS #190 instructed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365920 If continuation sheet Page 6 of 9 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 08/23/2023 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 - Some to classify the wounds as MASD. The wound nurse stated the DON responded to her and stated the wounds appeared to be burns and WNP #400 responded with a question, Did the resident spill something hot on her? The wound nurse stated she responded to WNP #400 that RDCS #190 instructed to classify the wounds as MASD because there were no other burns on the resident's body. The wound nurse asked WNP #400 if it was OK to label the wounds as MASD. The wound nurse stated WNP #400 responded, I guess if we can't explain a burn. During the interview, LPN #87 became tearful and stated she had been the wound nurse at the facility for approximately three weeks and did not feel the wounds to Resident #17's legs were MASD. LPN #87 stated she was following the instructions from RDCS #190, because she was an RN and had more experience with wounds. On 08/09/23 at 12:25 P.M., during a telephone interview with WNP #400 stated she was informed by Wound LPN #87 of Resident #17's wounds to her bilateral legs on 07/21/23 and she did not assess the residents' wounds until 07/25/23, when she does her weekly wound rounds in the facility on Tuesdays of every week. WNP #400 stated she classified the wounds as full thickness non-pressure wounds that had 100% yellow slough (necrotic tissue). WNP #400 stated she was notified by Wound LPN #87 on 07/21/23 that RDCS #190 had classified the wounds as MASD, and the skin peeled off when Resident #17 crossed/uncrossed her legs. WNP #400 stated she has known of patients who experience spontaneous blisters from Bullous pemphigoid (a rare skin condition causing large fluid-filled blisters). On 08/09/23 at 2:15 P.M., during an interview with STNA #52 revealed she worked on 07/21/23 and was not Resident #17's assigned STNA. STNA #52 stated she assisted the resident's assigned STNA #402 to transfer Resident #17 from the bed to the shower chair after breakfast but was not certain of the time. STNA #52 stated she could see the residents' arms and legs during the transfer and Resident #17 had no redness or blisters to her arms or legs. STNA #52 stated she heard STNA #402 yell for the nurse (LPN #08) because Resident #17 had become unresponsive in the shower room. STNA #52 stated she saw LPN #08 go into the shower room and the nurse came out of the shower room and asked both STNAs #402 and #52 to take Resident #17 back to her room and put her in bed. STNA #52 stated a blanket was on the resident, which was always done when transporting a resident from the shower to prevent the resident from getting cold. STNA #52 stated when she assisted STNA #402 to transfer Resident #17 from the shower chair to her bed she noticed Resident #17 had very reddened areas to both her legs that were not there prior to the resident's shower. STNA #52 stated she asked STNA #402 what happened, and she stated she didn't know. On 08/10/23 at 8:29 A.M., during a telephone interview with STNA #402 revealed on 07/21/23, she was Resident #17's assigned STNA. STNA #402 stated after breakfast, she was not certain of the time, she gave the resident a shower. STNA #402 stated Resident #17 had no redness to her skin prior to her shower. STNA #402 stated Resident #17 became unresponsive during the shower, and she yelled for LPN #08 and the LPN came into the shower room to assess Resident #17. Resident #17 became responsive, and LPN #08 instructed her to take the resident back to her room and put her back to bed. STNA #402 stated she wrapped Resident #17 in a blanket and with the assistance of STNA #52, they took the resident back to her room. When Resident #17 was in her room, STNA #402 removed the blanket, she saw Resident #17 had very reddened areas to both her legs and the left foot and reported it to LPN #08. STNA #402 stated the water was not too hot during the shower and she does not know what could have caused the very reddened areas to Resident #17's legs and foot. On 08/10/23 at 9:03 A.M., during a telephone interview with LPN #08 revealed she was Resident #17's assigned nurse on 07/21/23. LPN #08 stated after breakfast not certain of the time, STNA #402 came to her informing her Resident #17 did not want to take her scheduled shower. LPN #08 stated she spoke with Resident #17 and told her she would feel better after a shower and the resident agreed. LPN (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365920 If continuation sheet Page 7 of 9 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 08/23/2023 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 - Some #08 stated she observed both STNAs #52 and #402 transport the resident to the shower. LPN #08 stated she saw STNAs #52 and #402 standing in the hallway outside the [NAME] shower room door, which was approximately 15 feet from the nurse's station, discussing a comb and could not hear all the conversation. LPN #08 stated STNA #402 went back into the shower room and a few minutes later yelled out the shower room door that Resident #17 was not responding. LPN #08 stated she immediately assessed Resident #17 and did the sternal rub (a technique to test an unconscious person's responsiveness). LPN #08 stated Resident #17 became responsive, and her vital signs were within normal limits. LPN #08 stated she did notice some redness to the residents' legs, but nothing alarming, and instructed STNA #52 and STNA #402 to take Resident #17 back to her room and put her back into bed. LPN #08 stated after the resident was returned to bed and after lunch approximately 1:30 P.M., she assessed the resident again and found the resident's left leg and foot and right thigh were red and had what appeared to be blisters. LPN #08 immediately reported her findings to Wound LPN #87. LPN #08 stated she checked the [NAME] shower that day (07/21/23) and noted the shower control knob was backwards and in order to turn the shower off, the knob had to be positioned in the hot position to the left instead of to the right which was the cold position and also the off control. LPN #08 stated she immediately reported her findings to Maintenance Supervisor #12 verbally but did not complete a written notification. LPN #08 stated she was aware the residents' wounds were classified as MASD and in her experience she has never known MASD with a specific pattern on the legs and not include other areas such as the buttocks or perineal area. On 08/10/23 at 8:10 A.M., during an observation/interview with Maintenance Supervisor #12 confirmed the shower control in the west shower room was not functioning properly. Maintenance Supervisor #12 denied being aware of this prior to 08/10/23 and revealed he was just finding this out during the interview and observation at 8:10 A.M. Maintenance Supervisor #12 revealed if the shower control knob was functioning properly to receive hot water, the knob must be positioned to the left and to receive cold water and to turn the shower off the knob should be positioned to the right. During the observation with Maintenance Supervisor #12, he confirmed to turn off the water, the shower control knob had to be positioned to the far left in the hot position and when the shower control knob was positioned in the cold/off position cold water was received and the shower could not be turned off. Maintenance Supervisor #12 stated no one had reported shower control in the [NAME] shower was not functioning properly and he was not aware any resident sustained burns from the shower. Maintenance Supervisor #12 contacted the Regional Maintenance Director #180. On 08/10/23 at 10:22 A.M., during an observation/interview with Regional Maintenance Director #180 confirmed the [NAME] shower control knob was not functioning properly and to turn the water off, the shower control must be positioned in the opposite position to the left labeled hot and should be positioned to the right in the cold/off position. Regional Maintenance Director #180 revealed the shower control knob mixing valve for the cold and hot water was stripped and he would repair/replace the shower control mixing valve as soon as possible. Regional Maintenance Director #180 placed an out of order sign on the [NAME] shower room and turned the water to the shower room off. On 08/10/23 at 2:26 P.M., during an interview with RDCS #190 stated Resident #17's wounds were a result of MASD that developed into cellulitis and MRSA. RDCS #190 stated the reason Resident #17's Physician #203 classified the residents' wounds as burns was because of the information in the hospital report dated 07/30/23 and the EMS classified the wounds as burns because it was reported to them by LPN #50 prior to the resident being transported to the hospital on [DATE]. On 08/14/23 at 8:50 A.M., during an interview with the DON revealed she was on vacation on 07/21/23 and she received a text message with pictures of Resident #17's wounds to her bilateral lower legs, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365920 If continuation sheet Page 8 of 9 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 08/23/2023 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 - Some and they were discovered when the resident was put back to bed after receiving a shower. The DON stated she notified the Administrator and RDCS #190 to get staff statements, have Maintenance Supervisor #12 check the water temperatures in the facility and notify Physician #203 and the resident's family. The DON instructed Wound LPN #87 to take corrective actions as this could be an Immediate Jeopardy as Resident #17 sustained severe burns from the shower. The DON stated the corrective actions were not implemented on 07/21/23 because RDCS #190 said Resident #17's wounds were MASD, not burns. The DON stated she did not see the residents' wounds until she returned from vacation on 07/25/23 and there were no blisters, and the wounds had yellow slough on the base. The DON stated she has never seen MASD turn into blisters and the skin peel away especially in the pattern and location where the residents' wounds were. The DON stated Wound LPN #87 classified the wounds as MASD as RDCS #190 directed her to. The DON stated the family came in the facility to visit the resident on Sunday 07/30/23 and saw the wounds and wanted the resident sent to the hospital. The DON stated on 08/10/23 before 5:00 P.M., the Regional Maintenance Director #190 went to the local hardware store and purchased the mixing valve shower cartridge and repaired the shower on the west hall, the shower was functioning properly, and the water temperatures were calibrated at 110 degrees Fahrenheit (F). Maintenance Supervisor #12 was monitoring the water temperatures daily. On 08/14/23 at 8:55 A.M., during a telephone interview with Physician #203 stated he was not aware Resident #17 had burns to her bilateral lower legs until the hospital notified him. Physician #203 stated Resident #17 clearly had burns sustained from the shower room on 07/21/23 due to the pattern and location of the burns. Physician #203 stated you can't get MASD on the top of your foot during a shower. An attempt to interview LPN #50 during the investigation was unsuccessful. Review of the facility policy titled Abuse, Neglect and Exploitation, revised 10/01/22, revealed the policy of this facility is to provide protections for health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, and exploitation and misappropriation of resident property. Definitions: Serious Bodily Injury means an injury involving extreme physical pain; involving substantial risk of death; involving protracted loss or impairment of the function of a bodily member, organ, or mental faculty; requiring medical intervention such as surgery, hospitalization, or physical rehabilitation; or an injury resulting from criminal sexual abuse. This deficiency represents non-compliance investigated under Complaint Number OH00145032. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365920 If continuation sheet Page 9 of 9