Health inspection·March 7, 2022

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observations on 03/03/22 at 10:02 A.M. revealed resident lying in bed with the call light hanging down from wall and button placed around the trash can. Interview on 03/03/22 at 10:05 A.M., with the Registered Nurse (RN) supervisor #139 confirmed the call light was out of reach and moved the call light from the trash can and placed in Resident #235's purse pocket which was sitting on resident's bed. She confirmed the call light had no clip or a way for it to fasten it to residents pillow or bedding as resident revealed she moves it and does not like rolling over it on when laying in bed. Interview on 03/03/22 at 10:11 A.M. with RN supervisor #139, the DON and RN #117 revealed Resident 3235 was independent and able to get up without assistance and could have gotten up and accessed her call light if it was not in reach from her bed. The DON confirmed the call light had no clip on it to fasten it. Observation on 03/03/22 at 10:18 A.M. revealed RN supervisor #139 went to Resident #235's room and moved resident's call light from the resident's purse to the side of the bed and with direction and assistance from the RN supervisor #139, Resident #235 was able to grab hold of her call light cord and pull the button up to her hand. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366075 If continuation sheet Page 2 of 18 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 366075 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Valley View 3363 Ragged Ridge Road Frankfort, OH 45628 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 0569 Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. Level of Harm - Minimal harm or potential for actual harm Based on record review, interview and policy, the facility failed to notify residents of Medicaid account balances. This affected two residents (#08 and #11) out of two residents reviewed for notification of Medicaid account balances. The facility census was 41. Residents Affected - Few Findings include: 1. Record review for Resident #08 revealed an admission date of 01/17/17. Diagnoses included paranoid schizophrenia, insomnia, and personal history of Coronavirus (COVID)-19. Review of the Resident #08's quarterly minimum data set (MDS) assessment, dated 01/02/22, revealed resident was cognitively intact. Further review of the MDS assessment revealed he required supervision from staff with bed mobility, transfers, walking, eating, toilet use and limited assistance from staff with dressing. Review of Resident #08's nursing progress notes did not reveal any conversation from staff to his resident representative regarding his Medicaid spend down. 2. Record review of Resident #11 revealed an admission date of 03/16/05. Diagnoses included dementia without behavior disturbance, hypokalemia, diabetes mellitus 2, anorexia, major depressive disorder, history of Covid-19, insomnia, and edema. Review of the quarterly MDS assessment, dated 01/07/22, revealed Resident #11 had impaired cognition. Resident #11 required assistance with bed mobility and transfer. Review of the social service notes for Resident #11 revealed a phone call was made to Resident #11's legal guardian regarding the need to spend Resident #11 balance down for Medicaid. Further review of the social service notes for Resident #11 revealed her guardian ask the facility to purchase a recliner chair for Resident #11. Review of the social service notes for Resident #11 revealed a note from the SSD #132. The notes read; this writer spoke with Resident #11 guardian. Discussed residents financial's. Guardian requested this SNF purchase a leather recliner for the resident from resident trust account. BOM notified. Interview on 03/03/22 at 09:07 A.M., with the Business Office Manager (BOM) #170 confirmed a letter of notification of requirement for spend down for Medicaid related to the resident fund balance for Resident #08 and Resident #11 was required. However, BOM #179 revealed she had no way of verifying the notification was sent to the resident representative for Resident #08 or Resident #11. The BOM #170 stated she was upset with herself for not copying the letter mailed to the resident representative for Resident #08 and Resident #11. The BOM #170 stated she was mailing the money to Medicaid on 03/04/22 for Resident #08, #11. Interview on 03/03/22 at 09:37 A.M. with the Administrator confirmed the facility had no verification of a spend down notice being mailed to Resident #08 or Resident #11's resident representative. The Administrator confirmed there were no calls and no written documentation of reaching out to either family. Interview on 03/03/22 at 10:18 A.M. with BOM #170 confirmed there was not a receipt for purchase of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366075 If continuation sheet Page 3 of 18 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 366075 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Valley View 3363 Ragged Ridge Road Frankfort, OH 45628 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 0569 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few a recliner for Resident #11. BOM #170 stated she was not notified by SSD #132 of Resident's 11's Power of Attorney (POA) request for purchase of recliner. Interview on 03/03/22 at 10:37 A.M. interview with SSD #132 stated the family purchased a chair for Resident #11 the previous year. SSD #132 stated the family requested the facility contact the funeral home. However, SSD #132 confirmed the facility does not have any record of this conversation with Resident #11 family. Review of the facility policy titled, Resident Trust Funds, undated stated, A provider shall give written notification to each resident who receives Medicaid and whose funds are managed by the provider, when the amount in the resident's PNA account reaches two hundred dollars ($200) less then the resource limit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366075 If continuation sheet Page 4 of 18 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 366075 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Valley View 3363 Ragged Ridge Road Frankfort, OH 45628 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure accurate code status in the resident's electronic medical record and the resident's paper charts. This affected one resident (#235) of one reviewed for advanced directives. The facility census was 41. Findings include: Review of the medical record for the Resident #235 revealed an admission date of 11/21/20. Diagnoses included other fracture of the head and neck of right femur fracture, covid-19, dementia without behaviors, diabetes type two, kidney disease stage three, anxiety, depression, cognitive impairment, needs for assistance, need for continuous supervision, and hypertension. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #235 was cognitively intact and required extensive assistance of two staff members for transfers, bed mobility, and toilet use and extensive assist of one staff for ambulation. Review of the plan of care dated 01/17/22 revealed Resident #235 had an advanced directive with interventions to discuss with the family and implement and treat per the physician order. Review of physician orders in the electronic medical record dated 11/25/20 identified orders for code status of Do Not Resuscitate Comfort Care-Arrest (DNRCC-A). After surveyor intervention, an updated code status was Do Not Resuscitate Comfort Care (DNRCC) was entered on 03/01/22. Review of the signed order form in the paper medical record dated 10/22/20 revealed a physician signed the form making Resident #235's code status DNRCC. Interview on 03/01/22 at 11:24 A.M. with Registered Nurse (RN) Supervisor #139 confirmed the code status in Resident #235's paper chart and electronic medical record did not match. Interview on 03/01/22 at 11:50 A.M. with Licensed Practical Nurse (LPN) #119 revealed staff would look in either the paper chart or in the electronic medical record when they needed to look for a resident's code status. Review of facility policy titled Advanced Directives, dated 12/2016, revealed the facility failed to implement the policy in regards to the allegation. The policy revealed the interdisciplinary team will review annually the resident advanced directives. The DON will inform the Physician for changes in orders related to resident wishes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366075 If continuation sheet Page 5 of 18 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 366075 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Valley View 3363 Ragged Ridge Road Frankfort, OH 45628 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 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) notice when therapy services were cut. This affected two residents (# 17 and #18) out of three residents reviewed for SNFABN notice. The facility census was 41. Residents Affected - Few Findings Include 1. Record review for Resident #17 revealed she was admitted to the facility on [DATE]. Diagnoses included Alzheimer' disease, Parkinson's disease, delusional disorder, major depressive disorder, chronic pain syndrome, hypokalemia, and anorexia. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #17 had impaired cognition. Resident #17 required extensive assistance from staff with bed mobility, transfers, dressing, personal hygiene, and toilet use. Resident #17 required supervision from staff with eating. Review of the nurse's progress notes for Resident #17 revealed a note to continue occupational and speech therapy as ordered. Needed extensive assist with Activities of Daily Living (ADL)s due to poor inability to anticipate needs or follow commands. Review of the Medicare Cut letter issued to Resident #17 revealed a discharge date from physical therapy on 10/02/21. The letter was issued on 09/27/21. However, the facility failed to issue a SNFABN notice for Resident #17. 2. Record review for Resident #18 revealed an admission dated of 12/04/2020. Diagnoses included dementia with behavioral disturbance, chronic kidney disease, essential primary hypertension, Coronavirus 2019 (Covid 19), insomnia, and hyperlipidemia. Review of the quarterly MDS assessment for Resident #18 dated 01/12/22 revealed Resident #18 had impaired cognition. Resident #18 required extensive assistance from staff with bed mobility, transfers, dressing toilet use, and personal hygiene. Resident #18 required supervision from staff with meals. Review of the Medicare cut letter stated services to end on 11/25/21 and was issued on 11/22/21 for Resident #17. However, the facility failed to issue a SNFABN notice for Resident #17. Interview 03/02/22 04:01 P.M., with the Administrator confirmed the facility failed to issue SNFABN letters correctly. The administrator stated she thought her plan of correction she put in place was effective however did agree the facility continues to have issues because of the confusion regarding part b services and who should be on the worksheet. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366075 If continuation sheet Page 6 of 18 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 366075 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Valley View 3363 Ragged Ridge Road Frankfort, OH 45628 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 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility failed to maintain privacy curtains. This affected one resident (#03) of two reviewed for privacy. The facility census was 41. Residents Affected - Few Findings include: Review of the medical record for the Resident #03 revealed an admission date of 04/06/21. Diagnoses included Alzheimer's disease, type two diabetes, chronic kidney disease, hypertension, psychosis, mood disorder, obsessive compulsive disorder, dementia with behaviors, and chronic pain. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #03 had moderate cognitive impairment and required supervision assistance of one staff member for bed mobility and transfers. Resident #03 was always continent of bladder and bowels. Observation on 02/28/22 at 8:10 A.M., 11:56 A.M., and 4:03 P.M., and on 03/01/22 at 8:21 A.M. and 11:45 A.M. revealed Resident #03's privacy curtain was tied in a knot chest high and was not able to provide full privacy for the resident. Interview on 03/01/22 at 11:50 A.M. with Licensed Practical Nurse (LPN) #119 revealed being unaware of the resident's curtain being tied up and was unaware of the reasoning for this. Observation on 03/01/22 at 11:52 A.M. revealed after the interview with LPN #119, LPN went to residents room and untied the curtain, confirming it was tied up and should not have been. Review of the facility policy titled Privacy, dated 05/2014, revealed no mention of privacy curtains and how they should be maintained. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366075 If continuation sheet Page 7 of 18 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 366075 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Valley View 3363 Ragged Ridge Road Frankfort, OH 45628 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and policy reviews, the facility failed to maintain sanitary resident bathrooms and failed to maintain safe water temperatures. This potentially affected 22 (#1, #2, #3, #4, #5, #7, #8, #9, #12, #15, #19, #20, #21, #26, #27, #28, #29, #183, #186, #233, #234, #235) of 22 residents that could independently use the bathroom independently. Facility census was 41. Findings include 1. Observation on 02/28/22 at 2:04 P.M., revealed the common space bathroom for resident's located across from gathering room had a pervasive odor of feces noted upon entering bathroom, a brown substance smeared on toilet seat, a large trash can to right of door with lid that does not close with a tight seal and several small clear bags full of trash noted in trash can. Observation on 02/28/22 at 2:10 P.M., revealed a male resident entered and used the common space bathroom for resident's located across from gathering room. Observation on 02/28/22 at 2:14 P.M., revealed a staff member and Safety and Health Consultant (SHC) surveyor entered the common space bathroom for resident's located across from gathering room for life safety code inspection. Observation on 02/28/22 at 2:21 P.M., revealed a female resident opened the door to the common space bathroom for resident's located across from gathering room and quickly closed the door shrugged her shoulders and walked away without using the bathroom. Observation on 02/28/22 at 2:23 P.M., revealed the bathroom across from room [ROOM NUMBER] which is a common space bathroom for residents, had a brown substance splattered inside the toilet and two large trash cans in bathroom. Observation on 02/28/22 at 2:29 P.M., revealed the front hall common bathroom for resident's had a brown substance smeared on the toilet seat, two large trash cans in bathroom and observed a staff member place tied trash bag from a resident room in the large trash can in bathroom. Observation on 02/28/22 at 3:48 P.M., revealed the toilet in front hall common bathroom has not been cleaned since 2:29 P.M. observation. Observation on 02/28/22 at 3:53 P.M., of the common space bathroom across from room [ROOM NUMBER] revealed the toilet in the bathroom has not been cleaned since 2:23 P.M. observation. Observation on 02/28/22 at 3:54 P.M., revealed the common space bathroom across form the gathering room had not been cleaned since the 2:04 P.M. observation. Observation on 03/01/22 from 8:05 A.M. to 8:12 A.M., revealed the three common area resident bathrooms had been cleaned. Interview on 03/03/33 at 9:44 A.M., with Housekeeping #149 revealed he works 7:00 A.M. to 3:00 P.M. and is responsible for the halls, restrooms, and dining/common area. He revealed he cleans the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366075 If continuation sheet Page 8 of 18 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 366075 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Valley View 3363 Ragged Ridge Road Frankfort, OH 45628 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 0584 Level of Harm - Minimal harm or potential for actual harm restrooms at least twice a day and spot cleans when necessary, cleans the dining/common area after each meal, mops the area at least once a day and spot mops when needed. He revealed he is the only housekeeper today. Housekeeping #149 stated there are usually three to four housekeepers working during day shift. One is assigned laundry, one is assigned resident rooms, and one is assigned to the common areas. States there is a housekeeper on evening shift, but not on night shift. Residents Affected - Some 2. Observation on 02/28/22 at 12:04 P.M., revealed a State Tested Nurse Aide washing her hands in the dining room sink turned the water on and placed hands in the water and quickly removed her hands stating, oww that's hot. Observation on 02/28/22 at 2:23 P.M., revealed the bathroom across from the room [ROOM NUMBER] which is a common space bathroom for residents has a water temperature of 124 degrees. Observation on 02/28/22 at 2:26 P.M., revealed Resident #3 and #5 in room bathroom had water temperature of 124 degrees. Observation on 02/28/22 at 2:29 P.M., revealed the front hall common bathroom for resident's had water temperature of 126 degrees. Observation and interview on 02/28/22 at 3:48 P.M., revealed the bathroom water temperature checks confirmed with Housekeeping #137 in front hall common bathroom of 125 degrees. Observation and interview on 02/28/22 at 3:50 P.M., revealed Resident #3 and #5 bathroom had a temperature of 123 degrees. Observation and interview on 02/28/22 at 3:53 P.M. revealed the bathroom water temperature checks confirmed with Housekeeper #137 in the common space bathroom across from resident room [ROOM NUMBER] of 126 degrees. Interview on 02/28/22 at 3:54 P.M., with Housekeeping #137 revealed she checks the water temperatures once weekly and stated she does not think her thermometer requires calibration. Housekeeper revealed half of the resident rooms share a water heater with the kitchen and laundry room. Observation on 02/28/22 at 12:04 P.M., revealed a State Tested Nurse Aide washing her hands in the dining room sink turned the water on and placed hands in the water and quickly removed her hands stating, oww that's hot. Interview on 03/01/22 at 1:50 P.M., with Housekeeping #137 revealed the water heater was turned to 125 with the goal to keep temperatures between 120 to 125 degrees. She revealed the building was split between two water heaters. She revealed no knowledge of burn risk with water temperatures over 120 degrees. She revealed she will turn the water heater down. Review of policy titled Water Temperatures, dated 12/2009, revealed water temperature should be set no higher than 120 degrees. Review of policy titled Routine Cleaning and Disinfecting, dated 2021, revealed consistent cleaning will be done to high touch surfaces including toilet seats, sink and faucets. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366075 If continuation sheet Page 9 of 18 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 366075 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Valley View 3363 Ragged Ridge Road Frankfort, OH 45628 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure residents with newly evident or possible serious mental disorders were referred for level II resident review upon a significant change in status assessment. This affected one (Resident #9) of two residents reviewed for pre-admission screening and resident review (PASARR). The facility census was 41. Findings include: Review of the medical record for the Resident #9 revealed an admission date of 04/19/19. Diagnoses included alcohol dependence induced dementia, alcohol use with psychotic disorder, anxiety disorder, delusion disorder, mood disorder due to known physiological condition with depressive features, obsessive compulsive behavior, opioid dependence in remission. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 had significant cognitive impairment and required supervision assistance of staff members. Review of the plan of care dated 01/03/22 revealed Resident #9 was prescribed anti-anxiety and anti-depressant medication due to anxiety, restlessness, agitation, and frustration. Review of the physician orders dated 12/29/21 revealed an order for Trazadone HCl tab (anti-depressant) 50 milligrams (mg) with instructions to give two tablets at night for restlessness. On 12/09/21, an order for Ativan (anti-anxiety) tab 0.5 mg with instructions to give one tablet twice daily for restlessness and agitation. On 08/10/21, an order for Zoloft 100 mg with instructions to give one tablet once daily for obsessive compulsive disorder. Review of Resident #9's PASARR assessment revealed the last assessment completed was in 04/2019. Interview on 03/01/22 at 2:05 P.M. with Social Worker (SW) #132 revealed if residents have a change in diagnosis a new PASARR will be completed. SW revealed Resident #9's most recent PASARR was completed on 04/2019. Resident had diagnosis of delusional disorder dated 08/27/19, mood disorder due to known physiological condition with depressive features dated 06/03/20, anxiety dated 10/05/20, obsessive compulsive disorder dated 08/09/21. Social worker revealed a new diagnosis would have required a new PASARR. Subsequent interview on 03/03/22 at 10:00 A.M. with SW #132 verified Resident #9 should have had an updated PASARR. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366075 If continuation sheet Page 10 of 18 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 366075 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Valley View 3363 Ragged Ridge Road Frankfort, OH 45628 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 0727 Level of Harm - Minimal harm or potential for actual harm Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on employee time sheet review and staff interview, the facility failed to have a Registered Nurse on duty for eight consecutive hours. This affected 41 of 41 residents in the building. The facility census was 41. Residents Affected - Many Findings include: Review of the facility employee time sheet on 03/02/22 revealed on 02/12/22, Registered Nurse (RN) #105 was the only RN on duty and worked from 7:00 A.M. to 2:45 P.M. for 7.75 hours that day. Review of the facility employee time sheet on 03/02/22 revealed on 02/13/22, Registered Nurse (RN) #105 was the only RN on duty and worked from 7:00 A.M. to 2:45 P.M. for 7.75 hours that day. Review of the facility employee time sheet on 03/02/22 revealed on 02/19/22, Registered Nurse (RN) #120 was the only RN on duty and worked from 7:00 A.M. to 12:00 P.M. and 12:30 P.M. to 3:00 P.M. for 7.50 hours that day. Interview with the Director of Nursing (DON) on 03/02/22 at 4:20 P.M. verified the facility did not have eight hours of Registered Nurse coverage on 02/12/22, 02/13/22, and 02/19/22. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366075 If continuation sheet Page 11 of 18 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 366075 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Valley View 3363 Ragged Ridge Road Frankfort, OH 45628 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 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation and staff interview, the facility failed to have nurse staff information posted that included the facility census, the total number of staff and the actual hours worked for Registered Nurses, Licensed Practical Nurses, and State Tested Nurse Aides. This had the potential to affect 41 of 41 residents in the building. The facility census was 41. Residents Affected - Many Findings include: Observation on 03/01/22 at 1:10 P.M., revealed the nurse staff information was posted on the window of the nursing station and did not included the total number of staff or the hours worked for Registered Nurses, Licensed Practical Nurses, and State Tested Nurse Aides. Observation on 03/02/22 at 2:20 P.M., revealed the nurse staff information was posted on the window of the nursing station and did not included the daily census, the total number of staff or the hours worked for Registered Nurses, Licensed Practical Nurses, and State Tested Nurse Aides. Interview on 03/02/22 at 2:24 P.M., with Licensed Practical Nurses (LPN) #160 verified the nurse staffing information posting did not included the daily census, the total number of staff, or the hours worked for Registered Nurses, Licensed Practical Nurses, and State Tested Nurse Aides. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366075 If continuation sheet Page 12 of 18 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 366075 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Valley View 3363 Ragged Ridge Road Frankfort, OH 45628 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 0772 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided. Based on medical record review and staff interview, the facility failed to complete laboratory services timely as ordered. This affected one (#16) of five reviewed for unnecessary medications. The facility census was 41. Findings include: Record review of Resident #16 revealed an admission date of 04/02/21, with diagnoses of: dementia with behaviors, shortness of breath, visual hallucinations, hypertension, elevated prostate specific antigen, gout, hypokalemia, dysphagia oral phase, post traumatic stress disorder, history of malignant neoplasm of the bladder, and psychosis. Review of a physician order dated 04/06/21 and discontinued on 01/11/22, revealed to draw valproic acid level, uric acid level, complete blood count, and basic metabolic panel, one time a day every three months starting on the 6th for one day related to dementia with behavioral disturbance, hypertension, and gout. Review of the medical record on 03/02/22 revealed the valproic acid level, uric acid level, complete blood count, and basic metabolic panel were drawn on 04/06/21 and 06/24/21 there was no laboratory test drawn on 10/06/21. Review of the treatment administration record for 10/01/21 to 10/31/21 revealed the valproic acid level, uric acid level, complete blood count, and basic metabolic panel were suppose to be drawn on 10/06/21 and the space to initial that it was completed was blank. Interview with Registered Nurse #117 on 03/03/21 at 8:50 A.M., verified there was not labs drawn for valproic acid level, uric acid level, complete blood count, and basic metabolic panel by the facility for 10/06/21. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366075 If continuation sheet Page 13 of 18 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 366075 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Valley View 3363 Ragged Ridge Road Frankfort, OH 45628 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, review of the facility's policy, and record review, the facility failed to provide meals according to the resident's physician's order for a mechanically altered diet. This affected one (Resident #5) of four reviewed for nutrition. The facility census was 41. Findings include Review of the medical record for Resident #5 revealed an admission date of 01/13/21. Diagnoses included dementia with behaviors, spasmodic torticollis, anxiety, chronic pain, gastric reflux, dysphagia, muscle weakness, and tremors. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had significant cognitive impairment. Review of the plan of care dated 12/28/21 revealed Resident #5 had nutritional problems or potential for nutritional problems with interventions to provide and serve meals or ordered Review of the physician orders dated 03/24/21 revealed an order for a regular diet with mechanical soft texture, regular thin consistency, no bread, and add extra gravy/sauces to meats. Review of the progress notes dated 03/24/21 revealed resident's diet was downgraded to mechanical soft due to oral pocketing of food during meals. Review of the diet ticket for Resident #5 revealed her order was written as mechanical soft, regular with thin liquids, and has a note for no bread. Observation on 02/28/22 at 12:05 P.M. revealed Resident #5 was served her plate of food. Resident was given a plate of chopped hot dog meat in a hot dog bun with ketchup and a side of french fries. Resident started eating her french fries and pudding for dessert. Interview on 02/28/21 at 12:07 P.M. with Resident #5 revealed the food tasted good, but stated she was not supposed to have bread and could not eat the rest of her meal. Resident #5 stated the doctor informed her not to eat bread. Observation on 02/28/21 at 12:09 P.M. revealed staff informed Dietician #169 of Resident #5's comment and the dietician went to the kitchen and got Resident #5 a new tray. The new tray had a bowl of chili and a side of french fries. Interview on 02/28/21 at 12:12 P.M. with Dietician #169 revealed she brought Resident #5 a new tray due to having orders for no bread and was given a hot dog bun. Dietician #169 verified Resident #5 was given the hotdog first and thought residents was ordered a finger foods diet. Interview on 03/02/22 10:00 A.M. with Dietary Manager (DM) #155 confirmed Resident #5 received the incorrect diet order on 02/28/22 and after eating half her side dishes, the meal was corrected and the chili was brought out. DM stated the incorrect meal was given and resident should have had the chili to start with as she does not have a finger food diet. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366075 If continuation sheet Page 14 of 18 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 366075 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Valley View 3363 Ragged Ridge Road Frankfort, OH 45628 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 03/02/22 at 1:00 P.M. with Speech Therapist (ST) #163 revealed Resident #5 had episodes of difficulty swallowing and completed a Barium swallow evaluation. The results led to a modified diet of mechanical soft and indicated no bread to be given. ST #163 stated the issue was with white bread, once it interacts with saliva can clump up and be difficult to swallow. ST #163 also indicated the residents issues with swallowing and possible aspiration history occurred when she was eating sandwiches with bread. Resident also has a history of pocketing. Review of the facility's undated policy titled Therapeutic Diets revealed the facility will provide therapeutic diets in accordance with resident choices, preference, medical status, and treatment. The therapeutic diet was a physician order. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366075 If continuation sheet Page 15 of 18 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 366075 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Valley View 3363 Ragged Ridge Road Frankfort, OH 45628 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 observations, staff interview, policy review, temperature log review, infection control log review, manufacture's recommendation review, the facility failed to ensure sanitation was provided when cleaning dishes and food was stored properly. This affected 41 of 41 residents that receive food from the kitchen. Facility census was 41. Findings include: Observation on 02/28/22 at 9:03 A.M., revealed an unopened can of fruit cocktail with multiple dents on the rim of the can, a box of 10-15 zucchini which had become moldy; a bag of mozzarella shredded cheese open to air and unsealed in the refrigerator; and a bag of frozen french fries was open to air and undated in the freezer, with french fries falling out of the bag onto other items. Interview on 02/28/22 at 9:03 A.M., with Dietary Manager (DM) #155 confirmed kitchen storage findings. DM #155 revealed cans are reviewed for dents and are returned to the send for refund. DM #155 confirmed the can of fruit cocktail had been missed. DM #155 confirmed and threw out the box of moldy vegetables, opened cheese and opened french fries. DM #155 revealed food gets delivered every other Tuesday, and Monday's are typically her day to clean out the kitchen. Interview on 02/28/22 at 9:03 A.M., with Dietary Manager (DM) #155 revealed the dishwasher was a low temperature washer with chemicals. Interview and observation on 03/02/22 at 10:00 A.M., revealed the dishwasher was running at 103 to 105 degrees. DM #155 revealed they are unable to get the dishwasher to temperature when the laundry runs. Interview and observation on 03/02/22 at 11:10 A.M., with DM #155 revealed the dishwasher was run with temperature ranging from 114 to 116. DM #155 revealed the minimum temperature was 120 degrees and revealed the facility documents temperatures of the dishwasher daily. DM #155 revealed the dishwasher does not have a booster on it. DM #155 revealed staff will need to wash dishes by hand until the dishwasher can get to temperature. Observation on 03/03/22 at 11:59 A.M., revealed the dishwasher had an out of order taped on it. Interview on 03/03/22 at 12:00 P.M. with DM #155 revealed she was trained to take test strips for the chemicals in the dishwasher and as long as the temperatures were close to 120 not to worry if they are below the 120 minimum. DM #155 revealed the dishwasher logs dated 01/22/22 to 01/26/22 were marked boil water did not use dish machine. DM #155 revealed the water heater had broken down and was out of order. In order to wash dishes in the sink the had to boil water. Review of the dishwasher manufacturers guidelines revealed the recommended temperature was 140 degrees, but the required minimum temperature was 120 degrees. Review of the facility temperature logs from 12/01/21 to 03/01/22 revealed temperature below 120 degrees on 12/01/21, 12/02/21, 12/03/21, 12/04/21, 12/06/21, 12/07/21, 12/09/21, 12/10/21, 12/11/21, 12/12/21, 12/13/21, 12/14/21, 12/15/21, 12/16/21, 12/17/21, 12/18/21, 12/20/21, 12/21/21, 12/22/21, 12/23/21, 12/24/21, 12/25/21, 12/27/21, 12/28/21, 12/29/21, 12/30/21, 12/31/21, 01/01/22, 01/04/22, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366075 If continuation sheet Page 16 of 18 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 366075 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Valley View 3363 Ragged Ridge Road Frankfort, OH 45628 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 01/05/22, 01/06/22, 01/07/22, 01/09/22, 01/10/22, 01/11/22, 01/14/22, 01/15/22, 01/16/22, 01/17/22, 01/18/22, 01/19/22, 01/21/22, 01/30/22, 01/31/22, 02/01/22, 02/02/22, 02/03/22, 02/04/22, 02/05/22, 02/06/22, 02/07/22, 02/08/22, 02/09/22, 02/10/22, 02/11/22, 02/12/22, 02/13/22, 02/14/22, 02/15/22, 02/16/22, 02/19/22, 02/20/22, 02/21/22, 02/22/22, 02/23/22, 02/25/22, 02/26/22, 02/28/22, 03/01/22. Of the 91 days reviewed, 69 days had temperatures below the minimum of 120 degrees. The temperatures ranged from 116 to 119 degrees. Review of the infection control revealed no food borne illness or gastrointestinal outbreaks with residents. Review of policy titled Refrigerated storage, Frozen storage, dry storage and supplies, undated, revealed the facility failed to implement the policy in regards to the allegation. The policy revealed food should be stored in a manner that optimizes food and safety and quality. The policy states food once opened should be sealed, labeled and rotated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366075 If continuation sheet Page 17 of 18 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 366075 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Valley View 3363 Ragged Ridge Road Frankfort, OH 45628 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 observations, staff interviews, and policy review, the facility failed to ensure clean laundry was protected from crossed contamination with soiled laundry. This had the potential to affect 41 of 41 residents at the facility. The facility census was 41. Residents Affected - Many Findings include: Observation on 03/01/22 at 11:32 A.M., of the facility laundry room revealed two doors side by side when entering the laundry room, however, the facility utilized one of the doors when entering the laundry room (the other door was blocked by a table and soiled laundry). The single washer was located inside upon entry into the laundry room facing the door. A few inches to the left of the washer were two-32 gallon which contained soiled laundry. The clean laundry container containing clean laundry was touching one of the soiled laundry containers. The single dryer was located behind the washer and the soiled laundry area. The room did not have a separated clean and soiled area. The room did not have an exit door beyond the dryer. The laundry area did not have a sink. Once the laundry was clean and folded, the pathway to return to the clean laundry to the facility was through the soiled laundry area. Interview on 03/01/22 at 11:32 A.M., with Housekeeping/Laundry aide (LA) #145 confirmed the only access to the facility laundry areas was through the single door because the other door to the laundry area was blocked. LA #145 confirmed the room was very small and the soiled linen container was pushed up against the clean laundry container. LA #145 confirmed the soiled laundry and the clean laundry are in the same area and it very hard to keep from cross contaminating due to the small location. Observation on 03/02/22 at 07:20 A.M., of the laundry room revealed three 32-gallon containers containing soiled laundry pushed to the side of the laundry next to the clean laundry. Interview on 03/02/22 at 7:50 A.M., with LA #145 confirmed the laundry room had three 32- gallon containers of soiled linen. LA #145 confirmed the staff try to keep the soiled laundry containers from touching the clean laundry containers, however, it is impossible due to the limited space. LA #145 stated the soiled laundry containers are brought to the laundry room from the shower rooms. LA #145 confirmed the only path to remove the clean laundry is through the soiled laundry area for it to be delivered to the residents in the facility. Interview on 03/02/22 at 10:06 A.M., with the Infection Control Prevention nurse (ICP) #102 confirmed the laundry room cross contamination of soiled and clean laundry is an infection control concern. Review of the facility policy titled, Laundry and Bedding Soiled, dated July 2009, stated, Soiled laundry/bedding shall be handled in a manner that prevents gross microbial contamination of the air and the persons handling the linens FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366075 If continuation sheet Page 18 of 18