Inspection·April 30, 2021

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few notified of the blood glucose level, the notification should be documented in the nursing progress notes. DON #1 verified Resident #8 had blood glucose levels above 400 mg/dL on 03/02/21 and 03/12/21 and there was no documentation in the medical record of the physician being notified as ordered. Review of the policy titled, Change in Condition or Status, updated 03/31/21, revealed a change in a resident's condition, treatment plan and/or status will be promptly reported to his/her attending physician. The charge nurse will notify the resident's attending physician including when there is a need to alter the resident's treatment or notification is deemed necessary or appropriate in the best interest of the resident. This deficiency is a recite from the survey dated 03/08/21. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366073 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 366073 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Swanton 214 S Munson Rd Swanton, OH 43558 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 Based on observations, medical record reviews, resident and staff interviews, and review of a facility policy, the facility failed to obtain resident blood glucose levels as ordered by the physician. This affected two (#8 and #52) of five residents reviewed for unnecessary medications. The facility identified 14 residents with physician orders for blood glucose monitoring. The census was 46. Residents Affected - Few Findings include: 1. Review of Resident #8's medical record revealed an admission date of 11/27/19. Diagnoses included diabetes mellitus type II, bradycardia, heart failure, bullous pemphigoid, mixed receptive-expressive language disorder, and hyperlipidemia. Review of a physician order dated 02/06/20 revealed Resident #8 was ordered sliding scale Novolog insulin before meals and at bedtime scheduled for 7:00 A.M., 11:00 A.M., 4:00 P.M., and 8:00 P.M., daily with instructions for blood glucose levels greater than 400 milligrams per deciliter (mg/dL) to call the physician. Review of Resident #8's diabetic administration record (DAR) for January 2021 revealed no documentation of blood glucose levels obtained on 01/02/21 at 7:00 A.M. and 11:00 A.M., on 01/10/21 and 01/11/21 at 8:00 P.M., on 01/12/21 at 11:00 A.M, and on 01/31/21 at 8:00 P.M. Review of Resident #8's DAR for February 2021 revealed no documentation of blood glucose levels obtained on 02/03/21 at 8:00 P.M., on 02/06/21 at 8:00 P.M., on 02/11/21 at 4:00 P.M. and 8:00 P.M., and on 02/20/21 at 8:00 P.M. Review of Resident #8's DAR for March 2021 revealed no documentation of blood glucose levels obtained on 03/09/21 at 11:00 A.M., on 03/14/21 at 8:00 P.M., on 03/19/21 at 11:00 A.M., on 03/21/21 at 8:00 P.M., on 03/23/21 and 03/24/21 at 11:00 A.M., on 03/28/21 at 4:00 P.M. and 8:00 P.M., on 03/29/21 at 8:00 P.M., and on 03/31/31 at 4:00 P.M. and 8:00 P.M Further review of Resident #8's January, February, and March 2021 DARs revealed blood glucose levels obtained after the missing dates were within range of the physician ordered sliding scale and did not require additional physician intervention. Review of Resident #8's nursing progress notes and vital signs between 01/01/21 and 03/31/21 revealed no documentation of blood glucose levels obtained for the missing dates before meals and at bedtime as ordered. Observations on 04/27/21 at 10:38 A.M., 12:20 P.M., and 3:26 P.M., revealed Resident #8 sitting in her wheelchair in the common area of the facility wearing a face mask. Resident #8 was free from distress and displayed no signs of elevated blood glucose levels. Interview on 04/28/21 at 2:05 P.M. with Director of Nursing (DON) #1 verified there was no documentation in the medical record of Resident #8's blood glucose levels being obtained before meals and at bedtime as ordered for the missing dates on the January, February, and March 2021 DARs. 2. Review of Resident #52's medical record revealed an admission date of 04/16/21. Diagnoses included Type II Diabetes Mellitus, malignant neoplasm of the lung, enterocolitis, diarrhea, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366073 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 366073 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Swanton 214 S Munson Rd Swanton, OH 43558 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 cardiomyopathy, and abnormal levels of serum enzymes. Level of Harm - Minimal harm or potential for actual harm Review of the physician order for Resident #52, dated 04/17/21 and discontinued on 04/22/21, revealed an order for Novolog Insulin (intermediate acting insulin), 100 units per milliliter (ml), inject subcutaneously before meals for blood sugar according to sliding scale. The sliding scale included the following: 8 to 150 give 5 units, 151 to 200 give 6 units, 201 to 250 give 7 units, 251 to 300 give 8 units, 301 to 350 give 9 units, 351 to 400 give 10 units. Residents Affected - Few Review of the Medication Administration Record (MAR) for Resident #52, dated 04/20/21, revealed the residents blood glucose level was scheduled to be checked at 6:00 A.M., 10:00 A.M., and 4:00 P.M. Further review revealed the resident's blood sugar was checked at 5:53 P.M. and found to be 600 mg/dl. The MAR section for 04/20/21 stated to see the progress notes for additional information. Further review of the MAR revealed no evidence of blood sugar checks or the administration of insulin before or after 5:53 P.M. Review of the meal intake records for Resident #52 dated 04/20/21 revealed the resident ate 75 percent of his first meal at 9:41 A.M., 75 percent of his second meal at 1:12 P.M., and 100 percent of his third meal at 6:32 P.M. Review of the recorded blood glucose levels for Resident #52 for 04/20/21 revealed the residents blood sugar was measured at 5:53 P.M. and found to be 600 milligrams (mg) per deciliter (dL). There were no additional documented blood sugars on 04/20/21 before or after the 5:53 P.M. measurement. Review of the untimed and undated diabetic report sheet for Resident #52 revealed a blood glucose value of 121 mg/dL, a comment stating the resident ate, a comment that the resident's blood sugar was high and the physician was called for orders. At the bottom of the report sheet a comment was written to administer 14 units and 10 units. Review of the nurse progress note for Resident #52 dated 04/20/21 and time stamped at 5:28 P.M. revealed the resident blood sugar was reading high on the glucometer, indicating the blood sugar was over 600. The resident's physician was contacted, and orders were obtained to give 14 units of Novolog and 10 units of Lantus. Interview on 04/27/21 at 3:43 P.M. with Resident #52 revealed he gets his blood sugars checked three times a day. Resident #52 stated that there was a day recently his blood sugar was over 600 mg/dL. Resident #52 stated his blood sugars had been sporadic and that he does not usually experience symptoms with fluctuating blood sugar. Resident #52 denied any side effects or adverse events that occurred on the day he had a blood sugar over 600 mg/dL. Interview on 04/29/21 at 9:12 A. M., with the Director of Nursing (DON) verified that the resident's blood sugar was not checked at his scheduled time on 04/20/21 at the scheduled 10:00 A.M. time. DON stated the nurse who was taking care of Resident #52 that day told her she did not obtain the blood sugar because the resident had already begun eating, and she thought it would skew the result. DON stated she educated the nurse that a resident's blood sugar should still be taken, and the physician contacted if there are concerns for the accuracy of a test. DON verified that the resident medical record did not include all of the blood glucose readings, but the morning blood glucose was measured before the resident ate breakfast by the nurse and found to be 121 mg/dL, which she recorded on the report sheet. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366073 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 366073 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Swanton 214 S Munson Rd Swanton, OH 43558 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Review of a facility policy titled, Obtaining a Fingerstick Glucose Level, revised October 2011, revealed the purpose of the procedure was to obtain a blood sample to determine the resident's blood glucose level. Staff should verify there is a physician's order for the procedure and review the resident's care plan and provide for any special needs of the resident. The person performing the procedure should record the date and the time the procedure was performed in the medication record, and follow facility policies and procedures for appropriate nursing interventions regarding blood glucose results results (if resident is on sliding scale coverage, and/or physician intervention is needed to adjust insulin or oral medication dosages. Staff should report results promptly to the supervisor and the Attending Physician. Event ID: Facility ID: 366073 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 366073 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Swanton 214 S Munson Rd Swanton, OH 43558 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 - Few 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** Based on observation, record review, staff interview, and facility policy, the facility failed to implement a care plan intervention for falls. This affected one (#44) of two residents review for falls. The facility census was 46. Findings include: Review of the medical record for Resident #44 revealed the resident was initially admitted to the facility on [DATE] with re-entry on 04/25/21. Diagnoses including pneumonitis due to inhalation of food and vomit, osteomyelitis of vertebra sacral and sacrococcygeal region, pressure ulcer of sacral region stage 4, acute on chronic systolic (congestive) heart failure, chronic respiratory failure with hypoxia, type two diabetes mellitus with diabetic chronic kidney disease, hypo-osmolality and hyponatremia, hypotension, paroxysmal atrial fibrillation, benign prostatic hyperplasia with urinary tract symptoms, anxiety disorder, pressure ulcer right heel unstageable, elevated white blood cell count, and unspecified call subsequent encounter. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was moderately impaired and had a fall prior to admission or reentry. Review of Resident #44 care plan revealed the resident is at risk of falls due to impulsiveness and previous falls on 02/11/21. One intervention included mat to floor beside bed. Observation on 04/26/21 at 11:44 A.M. revealed Resident #44 revealed in bed and no fall mat in place. Observation on 04/27/21 at 7:11 A.M. revealed Resident #44 in bed and no fall mat in place. Observation on 04/27/21 at 9:58 A.M. revealed Resident #44 in bed and no fall mat in place. Observation on 04/27/21 at 1:57 P.M. revealed Resident #44 in bed and no fall mat in place. Interview on 04/27/21 at 1:57 P.M. with State Tested Nursing Assistant (STNA) #250 verified Resident #44 was in bed and the fall mat was not in place. Observation on 04/28/21 at 5:30 P.M. revealed Resident #44 in bed and no fall mat in place. Interview on 04/28/21 at 5:31 P.M. with Activities Staff #251 verified Resident #44 was in bed and the fall mat was not in place. Review of the policy titled, Accident and Occurrence Policy, revised 04/01/21, indicated interventions will be initiated to prevent additional incidents. This deficiency is a recite from the survey dated 03/08/21. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366073 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 366073 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Swanton 214 S Munson Rd Swanton, OH 43558 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 - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, staff interviews, and review of facility policy, the facility failed to ensure hair restraints were worn in the kitchen, opened food was properly labeled and dated in the walk-in refrigerator, and proper kitchen sanitation was implemented during meal service. This had potential to affect 46 of 46 residents who receive food from the kitchen. The census was 46. Findings include: 1. Observation on 04/26/21 at 9:44 A.M., revealed Kitchen Staff #252 in the kitchen standing next to the steam table with no hairnet or hair restraint. Interview on 04/26/21 at 9:45 A.M., with Kitchen Staff #252 verified not wearing a hairnet in the kitchen. 2. Observation on 04/26/21 at 9:49 A.M., revealed the walk-in refrigerator contained a bag of fried fish unlabeled and undated, an unknown patty like product unlabeled and undated, a single hotdog in a open plastic bag unlabeled and undated, two uncovered pans of jello like product, an uncovered half ham undated and unlabeled, diced potatoes unlabeled and undated, cut cucumber in a five gallon bucket uncovered, and tomato sauce un labeled and undated. Interview on 04/26/21 at 9:56 A.M., with Kitchen Staff #253 verified the bag of fried fish unlabeled and undated, an unknown patty like product unlabeled and undated, a single hotdog in a open plastic bag unlabeled and undated, two uncovered pans of jello like product, an uncovered half ham undated and unlabeled, diced potatoes unlabeled and undated, cut cucumber in a five gallon bucket uncovered, and tomato sauce un labeled and undated. 3. Observation on 04/26/21 at 11:03 A.M., revealed Kitchen Manager #254 not washing his hands prior to donning gloves and temping the hot lunch meal. Observation on 04/26/21 at 11:10 A.M., revealed Kitchen Manager #254 take off gloves, leave the kitchen, re-enter the kitchen with product for a sandwich and don new gloves. Kitchen Manager #254 did not wash his hands prior to donning the gloves and preparing the sandwich. Observation on 04/26/21 at 11:12 A.M., revealed a order slip fall to the floor and Kitchen Manager #254 picked it up with the gloved hand. After placing the slip on the counter immediately handled lettuce for the burger topping. Kitchen Manager #254 did not wash his hands and re-glove after picking up the slip and touching the lettuce. Interview on 04/26/21 at 11:14 A.M., with Kitchen Manager #254 verified not washing his hands prior to donning gloves prior to taking temperatures and handling the food. Kitchen Manager #254 verified not doffing gloves, washing hands, and donning gloves after picking up an order slip from the floor then touching food. Review of the policy titled, Food Storage, dated 2013, verified all refrigerated foods should be covered, labeled, and dated. Review of the policy titled, Preventing Forborne Illness, revised July 2014, verified employees (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366073 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 366073 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Swanton 214 S Munson Rd Swanton, OH 43558 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 will demonstrate knowledge and competency in food handling practices prior to working with food or serving food to residents. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366073 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 366073 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Swanton 214 S Munson Rd Swanton, OH 43558 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, medical record review, review of the Centers for Medicare and Medicaid (CMS) webpage, review of the Centers for Disease Control and Prevention (CDC) webpage, and review of the facility policy, the facility failed to implement a COVID-19 quarantine for a resident who was readmitted to the facility following a hospitalization greater than 24 hours and was not fully vaccinated or had a confirmed COVID-19 infection in the previous three months, and failed maintain infection control measures during medication administration. This affected one (#50) of two residents reviewed for transmission based precautions and one (#33) of five residents observed during medication administration. The deficient practice had potential to affect all 46 residents residing in the facility. The census was 46. Residents Affected - Many Findings include: 1. Review of Resident #50's medical record revealed an admission date of 03/29/18 with diagnoses including Parkinson's disease, suicidal ideation, paranoid schizophrenia, major depression, and muscle weakness. Review of a Discharge return anticipated Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #50 had an unplanned transfer to a psychiatric hospital. Review of an entry MDS assessment dated [DATE] revealed Resident #50 returned to the facility. Review of a nursing progress notes dated 04/02/21 revealed Resident #50 was expressing suicidal ideation with a plan for staff to assist him and had delusions of the President trying to kill him and if Resident #50 went to the hospital the driver was going to kill him on the way. Review of a nursing progress note revealed Resident #50 was readmitted to the facility on [DATE] and was alert and oriented to person and place. Review of a readmission nursing assessment dated [DATE] revealed Resident #50 received a rapid COVID-19 test at 11:27 A.M. that was negative. Review of Resident #50's physician orders, progress notes, and care plan revealed no documentation of being placed on COVID-19 quarantine after being readmitted to the facility on [DATE]. Review of Resident #50's electronic health record revealed Resident #50 received his first dose of the COVID-19 vaccine on 03/23/21 and received his second dose on 04/20/21. Review of Resident #50's most recent COVID-19 test on 04/26/21 revealed he tested negative and review of the April 2020 medication administration record revealed Resident #50 displayed no signs and symptoms of COVID-19. Observation on 04/26/21 between 10:00 A.M. and 5:00 P.M., revealed Resident #50 in his room the entire day. Resident #50's room did not have any signs posted on or near his door indicating he was on any COVID-19 precautions, there was no personal protective equipment (PPE) available for staff or visitors to put on during resident care interactions, and no container for staff members to place used PPE in upon exiting the room. Staff members were observed providing care and services for Resident #50's wearing gloves, eye protection, and N95 face masks; however, no gown was worn for any care, the eye protection was not cleaned after care interactions and the N95 face masks were neither covered (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366073 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 366073 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Swanton 214 S Munson Rd Swanton, OH 43558 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many with surgical masks and removed after care or replaced with a new N95 face mask upon exiting Resident #50's room. Observation on 04/27/21 at 7:57 A.M., revealed Licensed Practical Nurse (LPN) #250 preparing Resident #50's medication for administration. Resident #50's room continued to have no signs posted and no PPE available for staff or visitors to maintain COVID-19 precautions. LPN #250 was wearing and N95 face mask and eye protection when she walked into Resident #50's bedroom to administer his medications at his bedside coming within a few feet of Resident #50. LPN #250 did not put on a gown or gloves. Resident #50 took his medications orally and when LPN #250 exited the room her face mask was not changes and her eye protection was not sanitized. Subsequent observations were made on 04/27/21 at 12:22 P.M. and 3:21 P.M. and on 04/28/21 at 8:42 A.M. and revealed Resident #50 remained without signs posted near his room and there was no PPE available for resident interactions. Resident #50 was not observed outside of his bedroom on any of these observations. Interview on 04/27/21 at 12:22 P.M., with Resident #50 stated felt okay and denied any cough, shortness of breath, or elevated temperatures. Resident #50 was not aware of the dates he received his COVID-19 vaccines and could not give a specified date when he returned to the facility from the hospital. Interview on 04/28/21 at 9:52 A.M., with State Tested Nurse Aide (STNA) #310 and at 10:18 A.M. with Registered Nurse (RN) #140 both stated Resident #50 was not on specific COVID-19 quarantine and had not been since he returned from the hospital on [DATE]. Both staff members stated they wore standard N95 face masks and eye protection during Resident #50's care just the same as they did for all other residents in the facility. Interview on 04/28/21 at 10:42 A.M., with RN Infection Preventionist (RNIP) #1 stated she was on vacation when Resident #50 was readmitted to the facility from the hospital and did not return to work until the week of the annual survey. RNIP #1 verified Resident #50's second dose of his COVID-19 vaccine was administered on 04/20/21 and he was still in his two week waiting period to be fully vaccinated. RNIP #1 also verified Resident #50 had not tested positive for COVID-19 in the last three months, but rather in 2020 when the facility had a COVID-19 outbreak. RNIP #1 reviewed the facility's COVID-19 re-admission policy and verified Resident #50 should have been placed in COVID-19 quarantine on readmission to the facility on [DATE]. RNIP#1 stated Resident #50 did not have any signs or symptoms of COVID-19 and not had any positive COVID-19 tests since he was readmitted . Review of a COVID-19 test collected on 09/24/20 and received on 09/26/20 revealed Resident #50 tested positive for COVID-19. Interview on 04/28/21 at 2:05 P.M., with Director of Nursing (DON) #1 stated Resident #50's COVID-19 quarantine was considered on his readmission but was not implemented as it may have caused him further behaviors and delusions such as were displayed prior to him being hospitalized on [DATE]. DON #1 cited the CDC guidance for residents who frequently leave the facility for medical appointments and who are gone for less than 24 hours as the basis for the facility not implementing a COVID-19 quarantine upon Resident #50's return to the facility on [DATE]. Interview on 04/29/21 at 11:40 A.M., with the Administrator verified the facility had no residents in the facility with suspected or confirmed COVID-19 infections. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366073 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 366073 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Swanton 214 S Munson Rd Swanton, OH 43558 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Review of the CDC website at, https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html, titled, Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes, last updated 03/29/21, under the heading, New Admissions and Residents who Leave the Facility,Create a Plan for Managing New Admissions and Readmissions, revealed residents with confirmed SARS-CoV-2 infection who have not met criteria for discontinuation of Transmission-Based Precautions should be placed in the designated COVID-19 care unit. In general, all other new admissions and readmissions should be placed in a 14-day quarantine, even if they have a negative test upon admission. Exceptions include residents within three months of a SARS-CoV-2 infection and fully vaccinated residents as described in CDC's Updated Healthcare Infection Prevention and Control Recommendations in Response to COVID-19 Vaccination. Facilities located in areas with minimal to no community transmission might elect to use a risk-based approach for determining which residents require quarantine upon admission. Decisions should be based on whether the resident had close contact with someone with SARS-CoV-2 infection while outside the facility and if there was consistent adherence to IPC practices in healthcare settings, during transportation, or in the community prior to admission. Further review of the CDC website under, Create a Plan for Residents who leave the Facility, revealed residents who leave the facility should be reminded to follow all recommended IPC practices including source control, physical distancing, and hand hygiene and to encourage those around them to do the same. Individuals accompanying residents (e.g., transport personnel, family members) should also be educated about these IPC practices and should assist the resident with adherence. For residents going to medical appointments, regular communication between the medical facility and the nursing home (in both directions) is essential to help identify residents with potential exposures or symptoms of COVID-19 before they enter the facility so that proper precautions can be implemented. In most circumstances, quarantine is not recommended for residents who leave the facility for less than 24 hours (e.g., for medical appointments, community outings with family or friends) and do not have close contact with someone with SARS-CoV-2 infection. Quarantining residents who regularly leave the facility for medical appointments (e.g., dialysis, chemotherapy) would result in indefinite isolation of the resident that likely outweighs any potential benefits of quarantine. Facilities might consider quarantining residents who leave the facility if, based on an assessment of risk, uncertainty exists about their adherence or the adherence of those around them to recommended IPC measures. Residents who leave the facility for 24 hours or longer should generally be managed as described in the New admission and readmission section. Review of the CDC website at, https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-after-vaccination.html, under the title, Updated Healthcare Infection Prevention and Control Recommendations in Response to COVID-19 Vaccination, last updated 04/27/21, revealed under the heading, Definitions, revealed fully vaccinated refers to a person who is greater than or equal to two weeks following receipt of the second dose in a two-dose series, or greater than or equal to two weeks following receipt of one dose of a single-dose vaccine; there is currently no post-vaccination time limit on fully vaccinated status. Review of county COVID-19 positivity rates obtained from the CMS webpage, https://data.cms.gov/stories/s/q5r5-gjyu, revealed the most recent data collected between 04/07/21 and 04/20/21 revealed the county positivity rate where the facility was located was 5.6% placing it in the yellow level. Counties with a yellow level distinction were counties with a test percent positivity greater than or equal to 5.0% to less than or equal to 10.0% or with less than 500 tests and less than 2,000 tests per 100,000 and less than 10% positivity over 14 days, indicating moderate community spread. Review of a facility policy titled, Policy and Procedure for COVID-19: Resident Returning To Facility Following A Community Or Hospital Visit, updated April (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366073 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 366073 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Swanton 214 S Munson Rd Swanton, OH 43558 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 2021, revealed all residents who returned to the facility following a medical appointment (was transported by anyone other than a medical transport services), originally would be placed in droplet and contact precautionary quarantine, for a minimum of 14 days. This will continue for any non-fully COVID-19 vaccinated residents. If a resident is taken to a medical appointment, dialysis or a hospital emergency department per a medical transportation service, a 14 day quarantine is required, unless the resident is full vaccinated with no known exposure. 2. Observation on 04/27/21 at 7:41 A.M., revealed Registered Nurse (RN) #120 administering medications to residents on the 200 Hall. RN #120 began preparing Resident #33's medications at the medication cart by first opening the medication cart drawer, removed an inhaler from the cart, and placed it on top of the medication cart. RN #120 then proceeded to remove Resident #33's buspirone 15 milligrams (mg) tablet from the medication card, placing the tablet in her bare hand, and then placing the tablet into the medication cup all without washing or sanitizer her hands. RN #120 continued to remove a Lasix 20 mg tablet, a Gabapentin 300 mg tablet, a hydroxyzine 25 mg tablet, a Lisinopril 5 mg tablet, a metformin 500 mg tablet, a Protonix 40 mg tablet, and a venlafaxine 75 mg tablet all from individual medication cards, dispensing the tablets from the medication cards into her bare hand, and then placing the tablets into the medication cup for administration. RN #120 was observed touching all of Resident #33's medication cards, pill bottles, and inhalers that were scheduled for the morning medication administration, touching the medication cart, and the computer mouse all without gloves and without washing or sanitizing her hands before placing the individual medications into her bare hands for administration. RN #120 proceeded to take the medication cup into Resident #33's bedroom and administered her medications. Interview on 04/27/21 at 7:53 A.M., with RN #120 verified she placed all of Resident #33's medications from the medication cards into her bare hand without washing or sanitizing her hands. RN #120 stated she sometimes placed the medications into her hand to avoid the medication coming out of the medication card and landing on top of the medication cart. This deficiency is a recite from the survey dated 03/08/21. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366073 If continuation sheet Page 12 of 12