Inspection·June 1, 2023

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 resident and staff interview, observations, review of the medical record, and review of the facility policy, the facility failed to ensure fall prevention interventions were in place for a resident who was at a high risk for falls and with two recent falls in the facility. This affected one (Resident #165) of two residents reviewed for falls. The facility census was 64. Findings include: Review of the medical record for Resident #165 revealed an admission date of 05/01/23 with diagnoses of acute respiratory failure, chronic obstructive pulmonary disease, and muscle weakness. Review of the five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #165's cognition was not assessed. Resident #165 required extensive assistance of two people for bed mobility, transfers, toileting, and personal hygiene. Review of the incomplete MDS assessment dated [DATE] revealed Resident #165 had intact cognition. Review of the fall investigation dated 05/19/23 revealed Resident #165 attempted to transfer from her wheelchair to bed when she began to slip. Staff were present and attempted to reposition Resident #165 with the use of a gait belt but the staff were unsuccessful and lowered Resident #165 to the floor. Resident #165 was assessed for injuries with none identified. The intervention was for maintenance to place non-skid strips to bedside. Review of a physician order dated 05/22/23 revealed Resident #165 should have non-skid strips to bedside. Review of the fall investigation dated 05/26/23 revealed Resident #165 was observed on the floor by staff walking by the room. Resident #165 was assessed for injuries and assisted off the floor. Resident #165 was educated on the use of call light for assistance. Review of the Fall Risk Evaluation completed 05/26/23 revealed Resident #165 was at a high risk for falls. Review of the current care plan for Resident #165 revealed she was at risk for falls due to decreased physical function. Interventions included ensuring the call light was within reach at all times and non-skid strips to the floor as ordered. Interview and observation with Resident #165 on 05/30/23 at 9:10 A.M. revealed she was lying in bed, had a tracheostomy (a tube from in her throat to assist with breathing) and was connected to a mechanical ventilator. Resident #165 was able to communicate by mouthing words but was unable to speak audibly. Observation at that time revealed Resident #165's call light was on the floor, out of reach. When asked how she called for help when she was nonverbal and could not reach her call light, Resident #165 indicated she had to wait for someone to come and check on her. There were no non-skid strips on the floor near the resident's bedside. Interview and observation on 05/30/23 at 9:14 A.M. with State Tested Nurse Aide (STNA) #529 confirmed Resident #165's call light was not in reach. STNA #529 tied the call light to the right mobility (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366073 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 366073 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/01/2023 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 bar attached to Resident #165's bed and asked Resident #165 if she could reach the call light. Resident #165 indicated she could reach the call light at that time. Observation and interview on 05/30/23 at 3:59 P.M. with STNA #517 confirmed no non-skid strips were on the floor around Resident #165's bed. Residents Affected - Few Observation on 05/31/23 at 3:55 P.M. revealed Resident #165's call light was out of reach on the floor behind her bed. Interview at that time with Resident #165 revealed she had a passy muir valve (a cap on the tracheostomy tube allowing speech) in her tracheostomy and was able to verbalize. Further observation revealed the non-skid strips were on the floor next to Resident #165's bed. Interview on 06/01/23 at 8:16 A.M. with Maintenance Director #546 confirmed he installed non-skid strips in Resident #165's room this week, a couple of days ago. Maintenance Director #546 stated it had been on his list of maintenance tasks to complete, but he just had not had time to install them until this week. Review of the facility policy titled Fall Prevention and Management Policy, dated 04/01/22, revealed preventative measures would be put in place for residents at risk for falls. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366073 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 366073 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/01/2023 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and record review, the facility failed to ensure a resident was administered tube feeding per physician orders and complications of the tube feeding was timely reflected in the medical record. This affected one (#166) of one resident reviewed for tube feeding (TF). The facility identified 13 residents receiving TF. The facility census was 64. Findings include: Review of the medical record for Resident #166 revealed an admission date of 05/18/23. Diagnoses included type II diabetes mellitus, seizures, gastrostomy status (having a tube for feeding into the stomach), tracheostomy status (having a tube into the throat for breathing), and pneumonitis due to inhalation of food and vomit. Review of the admission Assessment with Baseline Care Plan dated 05/19/23 revealed Resident #166 was alert and oriented to person and situation, had unclear verbal communication, and had impaired cognition or decision making skills. Review of a physician order dated 05/18/23 revealed Resident #166 received Jevity 1.2 (tube feeding formula) at 50 milliliters per hour (ml/hour) via pump per gastrostomy tube (g-tube) (a tube into the stomach) and flush g-tube with 30 ml water every hour via pump. Review of a Late Entry progress note, entered on 05/31/23 at 10:36 A.M. by Licensed Practical Nurse (LPN) #567 and dated 05/29/23 at 4:00 P.M. revealed Resident #166 vomited in bed and the TF was held. A Certified Nurse Practitioner (CNP) was notified and orders were given to start TF slowly as tolerated. Observation on 05/30/23 at 8:58 A.M. revealed Resident #166 lying in bed on a ventilator with TF running through his g-tube. Observation of the TF pump at that time revealed Jevity 1.2 was running at 10 ml/hour with water flushes as 30 ml/hour. Observation on 05/30/23 at 2:52 P.M. revealed Resident #166 lying in bed on a ventilator and the TF pump was turned off. Observation on 05/31/23 at 7:00 A.M. revealed Resident #166 lying in bed on a ventilator with the TF pump running Jevity 1.2 at 50 ml/hour with water flushes at 30 ml/hour. Interview on 05/31/23 at 7:05 A.M. with LPN #551 confirmed she worked on 05/30/23 and Resident #166's TF pump was running Jevity 1.2 at 10 ml/hour when she came to work on 05/30/23 at approximately 7:00 A.M. LPN #551 stated she checked Resident #166's orders and saw the TF order was for 50 ml/hour. LPN #551 stated she asked another nurse if there was a reason for the low rate and was told Resident #166 had vomited, the TF was held for an unknown period of time, then restarted at a low rate, with the expectation the TF rate would increase slowly while staff monitored Resident #166 for tolerance until he reached the ordered rate of 50 ml/hour. Follow-up interview on 05/31/23 at 7:36 A.M. with LPN #551 verified the medical record for Resident #166 did not reflect a change in the TF orders, nor was a progress note in the electronic medical record (EMR) to document the emesis or adjustment of the TF rate for Resident #166. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366073 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 366073 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/01/2023 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 05/31/23 at 8:25 A.M. with LPN #561 revealed he worked the night shift (approximately 7:00 P.M. to 7:00 A.M.) on 05/29/23 and 05/30/23 and was assigned to the hall where Resident #166 resided. LPN #561 was not aware Resident #166 had vomited recently, and was not aware Resident #166's TF was running at a rate lower than what was ordered by the physician. Interview on 05/31/23 at 2:12 P.M. with LPN #551 revealed she spoke with LPN #567 (who worked day shift on 05/29/23) on 05/30/23 at approximately 3:00 P.M. regarding Resident #166's TF running at only 10 ml/hour. LPN #551 stated LPN #567 worked day shift on 05/29/23 during which time Resident #166 vomited and his tube feeding was turned off, then resumed at a low rate with plans to increase the TF rate slowly and monitor tolerance. LPN #551 stated LPN #567 told LPN #561 to increase the TF overnight on 05/29/23. LPN #551 verified Resident #166's TF did not increase from 10 ml/hour until after approximately 3:00 P.M. on 05/30/23. Interview on 06/01/23 at 7:43 A.M. with LPN #567 revealed she worked day shift on 05/29/23 and was assigned to care for Resident #166. LPN #567 confirmed Resident #166 was on the ventilator and the TF was at his goal rate when he vomited three times during her shift. LPN #567 stated Resident #166 vomited in the morning when she was providing morning medications. LPN #567 stated Resident #166's head of bed was elevated. LPN #567 turned off the TF at that time for a short period of time, then resumed the TF. LPN #567 stated Resident #166 vomited around 12:00 P.M. on 05/29/23 and LPN #567 turned off the TF and called the CNP at that time for guidance. LPN #567 stated the CNP advised her to stop the TF for Resident #166, then resume the TF later in the day at 10 ml/hour and increase slowly back to goal to monitor his tolerance. LPN #567 stated the standard protocol was to increase the TF rate by 10 ml every hour and monitor for tolerance until the resident reached their TF goal rate. LPN #567 confirmed she did not enter the orders from the CNP into the EMR and did not write a progress note at that time. LPN #567 stated she advised LPN #561 in shift report on 05/29/23 to increase the TF as tolerated for Resident #166. LPN #567 stated Resident #166's TF was at 10 ml/hour when she left the faciity on [DATE] at approximately 7:00 P.M. with the expectation Resident #166's TF would be increased overnight. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366073 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 366073 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/01/2023 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 - 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 interviews, and review of the facility policy, the facility failed to ensure the food was prepared and served in a sanitary manner. This had the potential to affect all residents in the facility except 12 residents (#25, #42, #51, #52, #54, #55, #57, #59, #60, #61, #110, and #166) identified to receive no food from the kitchen. The facility census was 64. Findings include: 1. Observation during noon meal service in the dining room on 05/30/23 beginning at 11:55 A.M. revealed staff assisting residents with cutting their meals and providing condiments. Observation at approximately 12:16 P.M. revealed State Tested Nurse Aide (STNA) #516 cutting spaghetti for Resident #8. Further observation revealed STNA #516 wore a white bracelet with long cloth ties, and the ties dragged through the spaghetti as STNA #516 cut Resident #8's spaghetti. Interview on 05/30/23 at 12:18 P.M. with STNA #516 confirmed her bracelet ties dragged through Resident #8's spaghetti and confirmed the end of the white string on her bracelet was colored red. 2. Observation on 05/31/23 at approximately 10:55 A.M. revealed [NAME] #569 chopping cucumbers while wearing gloves. [NAME] #569 picked up a box of aluminum foil to hand to another staff member with her gloved right hand, then proceeded to chop cucumbers without changing gloves and performing hand hygiene. [NAME] #569 then picked up the chopped cucumbers with both gloved hands and placed them in a mixing bowl. Interview on 05/31/23 at 11:00 A.M. with [NAME] #569 revealed the cucumbers would be used for a fresh cucumber and onion salad. [NAME] #569 confirmed she touched the aluminum foil box with her gloved hand and proceeded to prepare ready-to-eat food without performing hand hygiene and changing her gloves. [NAME] #569 stated she was knowledgeable about performing hand hygiene when touching non-food items while preparing ready-to-eat items but did not follow the proper protocol. 3. Observations on 05/31/23 beginning at 11:55 A.M. revealed [NAME] #518 wore gloves and worked throughout the kitchen. [NAME] #518 opened ovens, took food temperatures, wrote down food temperatures, used cloth towels to remove pans from the steam table and place pans in the oven, used serving utensils for chicken casserole, green beans, breadsticks, mashed potatoes, and handled paper meal tickets. Continued observation on 05/31/23 at approximately 12:20 P.M. revealed [NAME] #518 proceeded to use tongs to place a chicken breast on a plate for Resident #7. [NAME] #518 then picked up a knife and cut the chicken into bite-sized pieces while holding the chicken in place with her other gloved hand. Once cut, [NAME] #518 used both gloved hands to move the chicken into one area of the plate. [NAME] #518 served mashed potatoes and green beans on the plate and handed the plate to the dietary aide to serve to Resident #7, and the plate left the kitchen. [NAME] #518 did not change gloves during the continuous observation. Interview on 05/31/23 at 12:23 P.M. with [NAME] #518 confirmed she had not performed hand hygiene or changed her gloves prior to touching Resident #7's chicken. [NAME] #518 confirmed she was wearing the same gloves that had touched the oven doors, the steam table pans, the thermometer, the pen, the serving utensils, and the paper meal tickets before touching Resident #7's chicken. [NAME] #518 confirmed she should have performed hand hygiene and changed her gloves prior to touching ready-to-serve food for Resident #7. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366073 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 366073 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/01/2023 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 Review of the facility policy titled Maintaining a Sanitary Tray Line, reviewed 03/01/23, revealed staff should change gloves when activities are changed, or when the type of food being handled is changed. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366073 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 366073 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/01/2023 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 Based on medical record review, observations, resident interview, staff interview, and review of the facility policy, the facility failed to ensure soiled linen for a resident on transmission-based precautions was handled per facility policy to potentially prevent the spread of a contagious infection. This had the potential to affect all residents, except Resident #21, who was identified by the facility as being on contact precautions. The facility census was 64. Residents Affected - Many Findings include: Review of Resident #21's medical record revealed an admission date of 05/17/21. Diagnoses included Parkinson's disease, dementia, and fibromyalgia. Review of the annual Minimum Data Set Assessment (MDS) assessment, dated 04/02/23, revealed Resident #21 was cognitively intact. Review of a plan of care focus area initiated 05/28/23 revealed Resident #21 required isolation/quarantine related to shingles. Interventions included isolation/quarantine maintained by staff during the acute infection period. Review of the current physician orders for 05/30/23 revealed Resident #21 was on contact isolation for possible shingles. In addition, Resident #21 was prescribed zirgan ophthalmic gel 0.15%, instill one application in the left eye three times daily for ophthalmic shingles for 14 days and valacyclovir HCI one gram, one tablet by mouth three times a day for infection until 05/31/23. Observation on 05/30/23 at 10:34 A.M. revealed a personal protective equipment (PPE) cart located outside of Resident #21's room. A sign posted on the wall above the cart revealed the resident was on contact based precautions and all staff were required to don gloves and a gown when providing care. Interview on 05/30/23 at 10:35 A.M. with Licensed Practical Nurse (LPN) #526 confirmed Resident #21 was on contact precautions due to shingles and staff needed to don gloves and a gown when providing care to the resident or touching objects in the residents room. Observation and interview on 05/30/23 at 10:36 A.M. with Resident #21 revealed the resident had a weeping rash covering her left eye, extending up the forehead to the hairline. Resident #21 stated she had shingles, which was painful and caused a burning sensation. Interview on 05/31/22 at 7:40 A.M. with Housekeeping Aide (HA) #576 revealed she worked in laundry at the facility and was unaware of the process to launder soiled linen for residents who were on transmission-based precautions (TBP). Interview on 05/31/23 at 7:45 A.M. with Registered Nurse (RN) #532 confirmed Resident #21 had shingles and was on contact precautions, which required staff to don gloves and a gown when providing direct resident care. In addition, RN #532 stated a box, lined with a red bag, was kept in the resident's room for soiled linen to be placed in for transportation to the laundry room. Observation on 05/31/23 at 7:49 A.M. of Resident #21's room revealed no box lined with a red bag for soiled linen. Interview on 05/31/23 at 7:53 A.M. with Housekeeping Supervisor (HS) #575, with HA #576 present, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366073 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 366073 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/01/2023 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 revealed she supervised laundry staff. HS #575 stated soiled linen for residents on TBP was placed in a gray bag and brought to the laundry room separate from all other resident laundry, placed on the floor in front of the small washer to keep it separate from all other linen, and washed and dried separate from all other resident and facility linen. HS #575 stated shingles just happened with Resident #21. HS #575 confirmed contact precautions was ordered for Resident #21 on 05/24/23. HA #576 verified she worked on 05/28/23, was unaware Resident #21 was on contact precautions, and no precautions were in place for the handling for Resident #21's laundry. Interview on 05/31/23 08:01 A.M. with Stated Tested Nurse Aide (STNA) #540 revealed Resident #21's soiled laundry was placed in a yellow isolation bag and then the laundry was washed separate from all other resident laundry. STNA #540 stated the bags for the soiled linen were kept in the PPE cart. Observation, with STNA #540, of the PPE cart located outside of Resident #21's room revealed the cart contained no bags for soiled linen. STNA #540 stated the place she used to work at used yellow bags and maybe someone used the last bag and did not put anymore in the cart. STNA #540 was unable to articulate where to get soiled linen bags or how Resident #21's soiled linen was transported to the laundry room. Interview on 05/31/23 08:53 A.M. with STNA #537 revealed residents on TBP had soiled linen placed in a clear plastic bag, tied, and placed in the soiled linen cart to be transported to the laundry room. STNA #537 was unaware of any special precautions for laundering soiled linen for a resident on TBP. Interview on 05/31/23 at 3:02 P.M. with the Director of Nursing revealed the facility had no special precautions for the handling of soiled linen for a resident on TBP. Review of the facility policy titled Handling Soiled Linen, reviewed 10/01/22, revealed all used linen should be handled using standard precautions and treated as potentially contaminated. Examples of linen that may require special handling include, but are not limited to: residents with contagious conditions such as chicken pox (same virus that causes shingles), herpes zoster, or other skin lesions and residents with infections transmitted by contact. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366073 If continuation sheet Page 9 of 9