Health inspection·May 30, 2024

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on record review, observation, and staff interviews, the facility failed to have emergency supplies on hand for a resident with a tracheostomy. This affected one resident (#10) of one resident reviewed for tracheostomy care. The facility census was 47. Residents Affected - Few Findings include: Review of Resident #10's medical record revealed an admission date of 02/25/22, with the following medical diagnoses: unspecified dementia, laryngeal cancer, tracheostomy, seizures, adult failure to thrive, hemiplegia, peripheral vascular disease, depression, chronic pain, aphonia, COVID-19, anxiety, sexual dysfunction, schizoaffective disorder, and traumatic brain injury. Review of the Minimum Data Set (MDS) assessment completed on 03/19/24 revealed this resident is severely impaired with cognition. Review of all physician orders for the month of May revealed no information prior to 05/29/24 for maintaining emergency equipment for a resident with a tracheostomy. Review of a physician order dated 05/29/24 revealed orders for interventions related to ambubag and emergency equipment. Observation on 05/28/24 at 1:23 P.M., of Resident #10 revealed the resident had a tracheostomy. There was no emergency equipment observed on hand or at bedside for this resident with a tracheostomy. No evidence of a resuscitation bag, oxygen supply, suction device, or tracheostomy mask being available. Observation on 05/28/24 at 4:16 P.M., of Resident #10 revealed no Ambubag or portable oxygen tank in room. Unplugged oxygen concentrator in closet at the back of the room. No suction observed in room as well. Interview, at the time of the observation, with Registered Nurse #50 verified there was no emergency equipment on hand for this resident with a tracheostomy. Review of a physician order dated 05/29/24 revealed orders for interventions related to ambubag and emergency equipment. Observation on 05/29/24 at 8:20 A.M., of Resident #10 revealed all required emergency equipment was available at bedside for this resident with a tracheostomy. Observation on 05/30/24 at 9:50 A.M., of Resident #10's surroundings revealed all emergency equipment on hand in the room of Resident #10. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366075 If continuation sheet Page 2 of 7 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 05/30/2024 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of Resident #10's medical record revealed an admission on [DATE], with diagnoses: unspecified dementia, laryngeal cancer, tracheostomy, seizures, adult failure to thrive, hemiplegia, peripheral vascular disease, depression, chronic pain, aphonia, COVID-19, anxiety, sexual dysfunction, schizoaffective disorder, and traumatic brain injury. Review of the Minimum Data Set (MDS) assessment completed on 03/19/24 revealed this resident is severely impaired with cognition. Review of the monthly physician orders for May 2024 revealed an order for Risperdal 3 milligram (mg) 1 tablet by mouth daily for unspecified dementia and Venlafaxine 75 mg 1 tablet by mouth daily for unspecified dementia . Review of the undated Black Box warning for both medications revealed increased mortality in elderly patients with dementia-related psychosis. Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Risperidone is not approved for the treatment of patients with dementia-related psychosis. Interview with the Director of Nursing on 05/30/24 at 10:00 A.M., verified unspecified dementia is an unacceptable diagnosis for the use of Risperidone and Venlafaxine. Review of the policy titled Consulting Pharmacist Monthly Drug Review, dated 2016, revealed an unnecessary drug was defined as any drug when used without adequate indication for its use. Based on record reviews, staff interview, review of the Food and Drug Administration (FDA) Black Box Warning, review of the Highlights of Prescribing Information, review of [NAME] Pocket Drug Guide for Nurses, and review of facility policy, the facility failed to ensure adequate indications for the use of antipsychotic medications. This affected four (#9, #10, #34, and #35) of five residents reviewed for unnecessary medications during the annual survey. The facility census was 47. Findings include: 1. Review Resident #9's medical record revealed an admission date of 04/12/24 , with diagnoses including severe dementia with psychotic disturbance, hallucinations, and restlessness and agitation. Review of the admission Minimum Data Set (MDS) assessment, dated 04/22/24, revealed the resident had severely impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 00. The resident was assessed to have received antipsychotic medication on a routine and as needed basis while residing in the facility. Review of the active physicians order, dated 05/04/24, revealed the resident was to be administered 2.5 milliliters (ml) of Haloperidol Lactate Oral Concentration (an antipsychotic medication) every six hours for severe dementia with psychotic disturbances and hallucinations. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366075 If continuation sheet Page 3 of 7 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 05/30/2024 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the undated Food and Drug Administration (FDA) Black Box Warning for the medication Haloperidol Lactate Oral Concentration, not dated, revealed elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Haloperidol is not approved for the treatment of patients with dementia-related psychosis. Interview on 05/30/24 at 11:20 A.M., with the Director of Nursing (DON) confirmed Resident #9 was receiving the antipsychotic medication Haloperidol Lactate Oral Concentration to treat the resident for severe dementia with psychotic disturbances and hallucinations. 3. Review of Resident #34's medical record revealed an admission date of 02/09/22, with diagnoses of unspecified dementia, cerebrovascular disease, anorexia, hypertension, unspecified psychosis, insomnia, anxiety disorder, restlessness, and agitation, wandering, and depression. Review of the quarterly MDS assessment dated [DATE] for Resident #34 revealed severe cognitive impairment and frequent incontinence of bowel and bladder. Resident #34 has no impairment in range of motion of upper and lower extremities and requires set up assistance for eating, moderate assistance for oral and personal hygiene, dressing, toileting, bed mobility and transfers, and maximal assistance for bathing. Review of physician orders for Resident #34 revealed an order dated 03/24/24 for Secuado (Asenapine) Transdermal Patch 24 Hour 5.7 Milligram (mg)/24 hour (hr). Apply 5.7 mg patch transdermally one time a day related to unspecified psychosis not due to a substance or known physiological condition. Review of Black Box Warning (BBW) issued from the facility's pharmacy associated with this Secuado (Asenapine) order for Resident #34 revealed an increased mortality in elderly patients with dementia-related psychosis. Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Secuado (Asenapine) is not approved for the treatment of patients with dementia-related psychosis. Review of [NAME] Pocket Drug Guide for Nurses, dated 2021, revealed Secuado (Asenapine) is classified as an Atypical antipsychotic indicated for the treatment of schizophrenia, acute treatment of manic or mixed episodes associated with bi-polar I disorder, or adjunct treatment with Lithium or Valproate for acute treatment of manic or mixed episodes associated with bipolar I disorder, and has a Black Box Warning (BBW) of elderly patients with dementia-related psychosis have increased risk of death if given Atypical antipsychotics and is not approved for this use. Interview on 05/30/24 at 11:16 A.M., with Director of Nursing, confirmed Resident #34 is being administered Secuado (Asenapine) for a diagnosis of unspecified psychosis not due to a substance or known physiological condition which is not an indicated diagnosis for this medication. 2. Review of Resident #35's medical record revealed an admission date of 03/18/24, with diagnoses of unspecified dementia, delusional disorder, hyperlipidemia, essential hypertension, benign prostatic hyperplasia, anxiety disorder, orthostatic hypotension, psychotic disorder with hallucinations, hallucinations unspecified, restlessness, agitation, and depression unspecified. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #35 was reported to have delusions and hallucinations on one to three days for the MDS assessment period. Resident #35 was reported to have disorganized thinking continually present during the MDS assessment period. Resident #35 was reported to receive antipsychotic medication during the MDS assessment period. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366075 If continuation sheet Page 4 of 7 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 05/30/2024 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of physician orders for Resident #35 revealed a prescription for Geodon (Ziprasidone HCl) Capsule 40 mg 1 capsule by mouth two times daily related to psychotic disorder with hallucinations due to known psychological condition. Interview on 05/30/24 at 11:25 A.M., with the Director of Nursing #71 confirmed that Resident #35 is being administered Geodon (Ziprasidone HCl) 40 mg 1 capsule BID for a diagnosis related to psychotic disorder with hallucinations. Review of the undated Highlights of Prescribing Information revealed that Geodon (Ziprasidone HCL) is an atypical antipsychotic. Indications and usages are for the treatment of schizophrenia and maintenance treatment of bipolar I disorder as an adjunct to lithium or valproate. There is a warning of increased mortality in elderly Patients with dementia Related Psychosis. Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death compared to placebo treatment. Review of the undated Black Box Warning from the pharmacy associated with Geodon (Ziprasidone HCl) capsule 40 mg order for Resident #35 revealed an increased mortality in elderly patients with dementia-related psychosis. Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Ziprasidone is not approved for the treatment of patients with dementia-related psychosis. Review of CMS.gov website page titled Atypical Antipsychotic Adult Dosing Chart dated October 29 2015 revealed that Geodon (Ziprasidone HCl) indications are for Bipolar I Disorder (mixed or manic episodes), and schizophrenia. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366075 If continuation sheet Page 5 of 7 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 05/30/2024 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 review of the facility Water Management Program, review of the Centers for Disease Control Prevention(CDC) guidance for Legionella prevention, staff interview, and review of facility policy, the facility failed to ensure an effective Water Management Program was in place to prevent and/or detect the presence of Legionella in the water supply. This had the potential to affect all 47 residents residing in the facility. The facility census was 47. Residents Affected - Many Findings include: Review of the undated facility diagram titled How to Monitor Your Control Measures, revealed disinfectant levels were to be checked where the pipe from the intersection of the road entered facility property and at sink, shower, and tub faucets used by residents. Review of facility water testing logs from 01/01/24 through 05/29/24 revealed no disinfectant levels were tested and no Legionella testing was conducted. All water temperatures obtained has results between 105 degrees Fahrenheit and 120 degrees Fahrenheit. Review of the online CDC guidance for controlling Legionella titled Monitoring Building Water(https://www.cdc.gov/control-Legionella/php/guidance/monitor-water-guidance.html), dated 03/15/24, revealed Legionella grows best in water temperatures between 77 degrees Fahrenheit and 113 degrees Fahrenheit. It's important to monitor the temperature, disinfectant residuals, and pH of building water. Interview on 05/29/24 at 3:24 P.M.,with Maintenance Director #70 confirmed no other facility staff members were part of the facility Water Management Program. Maintenance Director #70 additionally confirmed the only testing performed on the facility water supply were temperatures obtained weekly from the sink, shower, and tub faucets with all results between 105 degrees Fahrenheit and 120 degrees Fahrenheit. Maintenance Director #70 confirmed no testing for disinfectant residual levels, pH levels, or presence of Legionella bacteria were conducted on facility water samples. Review of the policy titled Infection Control/Water Systems, revised September 2018, revealed Legionella is a bacteria found naturally in fresh water. Legionella can colonize in water distribution lines throughout a water system, contaminating water supplies. Risk factors are water flow, disinfection, and water temperatures. Chemical testing will be conducted where necessary. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366075 If continuation sheet Page 6 of 7 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 05/30/2024 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 0947 Level of Harm - Potential for minimal harm Residents Affected - Many Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Based on review of eight employee files, staff interviews, and policy review, the facility failed to provide the 12 required annual in-service hours for two State Tested Nursing Assistants (STNAs). This had the potential to affected all 47 residents. The census was 47. Findings include: Review of the employee file for State Tested Nursing Assistant (STNA) #88 she was hired on 03/15/17 and had seven in-service training hours since 03/15/23. Review of STNA #85's employee file revealed she was hired 05/19/21 and had three in-service training hours since 05/19/23. Interview on 05/29/24 at 1:49 P.M., with Business Office Manager #69 verified STNA #88 had seven hours training since 03/15/23 and STNA #85 had three training hours since 05/19/23. Review of the policy titled Nurses Aide Training Program, dated 10/01/22, revealed each STNA was provided at least 12 hours of in-service training annually, based on their employment date. It was the STNA's responsibility to complete the in-service training to maintain employment status with the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366075 If continuation sheet Page 7 of 7