Health inspection·March 5, 2024

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility failed to ensure urinary catheter drainage bags were covered for privacy and did not eminate a strong odor of urine that could be smelled in the room and into the hallway and therefore traced to Resident #2's room. This affected one resident (#2) of one resident reviewed for urinary catheters. Findings include: Review of the medical record for Resident #2 revealed he was admitted to the facility on [DATE] with diagnoses including pneumonia, functional quadriplegia, and dementia. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed Resident #2 had a Brief Mental Status (BIMS) score of 9 indicating cognitive impairment, and Resident #2 was dependent on staff for activities of daily living (ADLs), was incontinent of urine and bowel, and had an indwelling catheter in place. Review of the physician orders dated 02/07/24 revealed Resident #2 had orders in place for foley catheter care every shift, foley catheter bag cover every shift, and catheter to remain covered every shift for privacy. Review of the care plan dated 11/07/23 revealed no documented acknowledgement of foley catheter care. Review of the care plan history revealed Resident #2 had an updated care plan put in place on 02/29/24 which was twenty-three days after the order for an indwelling catheter was put in place. Observation and interview on 03/04/24 at 5:45 A.M. revealed Employee #806 was seen exiting Resident #2's room. Resident #2 was sleeping in bed and his urinary catheter bag was uncovered (no privacy cover) exposing a view from anyone entering the doorway of the room that the bag was full of urine, as it sat on the floor under his bed. The room had a strong odor of urine that could be smelled from the hallway. Interview with employee #905, who was seen entering and exiting the room at the time of the observation, confirmed and verified the above findings. Review of the facility document titled Routine Resident Checks revised July 2013, revealed the facility had a policy in place to complete routine checks that included entering the resident's room, determine if needs were being met, and if toileting assistance was needed. Review of the document revealed the facility did not implement the policy. This deficiency represents noncompliance identified during the investigation of Complaint Number Page 1 of 17 366114 366114 03/05/2024 Embassy of Lyndhurst 1575 Brainard Rd Lyndhurst, OH 44124

F 0557 OH00151352. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 366114 Page 2 of 17 366114 03/05/2024 Embassy of Lyndhurst 1575 Brainard Rd Lyndhurst, OH 44124

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. Based on observation, resident interviews, staff interviews, and facility policy review, the facility failed to maintain a safe, clean, comfortable and sanitary environment in resident rooms affecting 17 Residents (#16, #39, #55, #25, #44, #51, #21, #3, #4, #6, #8, #9, #49, #58, #17, #57 and #56), and failed to maintain the second floor shower room in a safe, clean and sanitary manner which had the potential to affect an additional 21 residents living on the second floor (#1, #2, #5, #7, #10, #11, #13, #14, #18, #19, #22, #23, #24, #27, #28, #29, #30, #33, #38, #40, and #48.). The facility census was 61. Findings include: Interview and observation on 02/27/24 at 10:24 A.M. with Resident #16 revealed she felt her room was dirty and it needed to be painted. Resident #16 revealed she was embarrassed to have visitors due to the uncleanliness of her room. Observation revealed the door to her bathroom had various spots with missing paint, the floors appeared dirty and not mopped, and all four walls of her room had multiple scruffs, smears, and unidentified drip spots. Observation on 02/27/24 at 10:50 A.M. of Residents #39 and #55 rooms revealed chipped paint and dirty walls. Observation and confidential interview on 02/27/24 at 11:03 A.M. with Employee #822 of Resident #25's room revealed a massive brown stain on the ceiling presenting as a prior water leak that had dried and stained the ceiling. Employee #822 revealed the stain had been there for a long time and there were no current water leaks. Interview and observation on 02/27/24 at 11:05 A.M. with Resident #44 revealed her room, shared with Resident #51, walls needed painted, and the carpet needed cleaning. Observation revealed the carpet located on the left and right side of Resident #51's bed had large, yellow crusted residue stains dried into the carpet. Observation revealed Resident #51 had an enteral tube feeding pump and intravenous pole positioned next to her bed. Interview and observation on 02/27/24 at 11:23 A.M. with Resident #21 revealed she was placed in her current room due to bed bugs in a prior room. Resident #21 revealed her previous room was being treated by an exterminator. Resident #21 revealed her current room, shared with Resident #45, television was dirty and dusty, and the floors and walls were dirty. Observation revealed the wall behind Resident #21 headboard had multiple dried stains of various colors, the baseboards around the room appeared dirty and stained and the floors appeared to have not been swept or mopped. Observation on 02/27/24 from 11:22 A.M. to 11:53 A.M. of Resident's #3, #4, #6, #8, #9, #49, #57, and #58 rooms revealed dirty floors with various dried spills that appeared to have not been swept or mopped. Tour of the facility on 02/27/24 from 12:26 P.M. to 12:45 P.M. with the Director of Nursing (DON) and Maintenance Director (MD) #604 confirmed and verified the above findings. Additionally, the following observations were confirmed by both the DON and MD #604 while on tour of the facility: Resident #17's room door was split with a large crack at the bottom and was separated at the base. Resident #57 and #58's room door had various scratches across the bottom. Resident #12 and subsequent rooms, 366114 Page 3 of 17 366114 03/05/2024 Embassy of Lyndhurst 1575 Brainard Rd Lyndhurst, OH 44124

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some placard display of room numbers revealed peeled and exposed paint. Resident #56's room walls and door were dirty. Observation and interview on 03/04/24 at 6:15 A.M. of the 2nd floor shower room adjacent to the common area revealed a door with multiple scratches and exposed paint blotches, a broken handle that was loose and unable to be locked. Employee #806 confirmed and verified the findings at the time of the observation. Review of the facility document titled Cleaning and Disinfection of Environmental Surfaces revised August 2019, revealed the facility had a policy in place that environmental surfaces would be cleaned and disinfected according to current the Center for Disease Control (CDC) recommendations for disinfection of healthcare facilities and the Occupational Safety and Health Administration (OSHA) bloodborne pathogens standard. Review of the policy revealed housekeeping surfaces (e.g., floors, tabletops) would be cleaned on a regular basis, when spills occurred, and when these surfaces were visibly soiled, environmental surfaces would be disinfected (or cleaned) on a regular basis (e.g., daily, three times per week) and when surfaces were visibly soiled, and walls, blinds, and window curtains in resident rooms would be cleaned when these surfaces were visibly contaminated or soiled. Review of the document revealed the facility did not implement the policy in regard to the allegation. This deficiency represents noncompliance investigated under Master Complaint Number OH00151352. 366114 Page 4 of 17 366114 03/05/2024 Embassy of Lyndhurst 1575 Brainard Rd Lyndhurst, OH 44124

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on review of personnel files, review of facility policy and interviews with staff, the facility did not ensure all employees were checked against the nurse aide registry (NAR) and had evidence of Bureau of Criminal Investigation (BCI) checks. This had the potential to affect all 61 residents residing in the facility. The facility census was 61. Residents Affected - Many Findings Include: Review of employee personnel files revealed the following: Review of the personnel file for Dietary Manager (DM) #601, hire date of 01/02/24, revealed no evidence of a check against the nurse aide registry (NAR). Review of the online Ohio NAR for DM #601 revealed no findings for DM #601. Review of the personnel file for Employee #834, hired in December 2023 into the position of nurse, revealed no evidence of a criminal background check. Review of the facility Bureau of Criminal Investigation and Identification Log dated 02/02/24 through 02/29/24 revealed Employee #834 was not listed on the log. Interview on 03/04/24 at 2:15 P.M. with the Regional Director of Operations (RDO) #600 revealed the current company took over in January 2024 and at that time the facility had no Human Resources Director (HRD). RDO #600 revealed since the last HRD separated, there had been a big mess to fix regarding employee personnel files and the current HRD #701 was great at her job and was trying to fix concerns. RDO #600 confirmed and verified the above findings at the time of the interview. Review of the facility document titled Abuse, neglect, Exploitation and Misappropriation Prevention Program revised April 2021, revealed the facility had a policy in place to conduct employee background checks including but not limited to, the NAR. Review of the facility document revealed the facility did not implement the policy. This deficiency represents non-compliance investigated under Master Complaint Number OH00151352. 366114 Page 5 of 17 366114 03/05/2024 Embassy of Lyndhurst 1575 Brainard Rd Lyndhurst, OH 44124

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the facility policy and staff interview, the facility failed to ensure Resident #17's care plan was revised to reflect accurate advanced directives ordered by the physician as decided by the resident representatives. This affected one resident (#17) of three residents reviewed for accurate care plans. The facility census was 61. Findings include: Review of the medical record for Resident #17 revealed an admission date of [DATE] with diagnoses including dementia, atherosclerotic heart disease, and gout. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 had cognition impairment. Review of the physician order dated [DATE] revealed an order to have a hospice consultation. Review of the physician order dated [DATE] revealed an order for Do-Not-Resuscitate Comfort Care (DNRCC). Review of the Do-Not-Resuscitate (DNR) order form dated [DATE] revealed Resident #17 had a DNRCC order in place to be effective immediately. Review of the progress note dated [DATE] at 3:17 P.M. revealed a care conference was held with Resident #17's family in regard to his decline. Review of the progress note revealed hospice was discussed and Resident #17's family opted for DNRCC. Review of the care plan dated [DATE] revealed Resident #17 had an advance directive of full code with interventions that included cardiopulmonary resuscitation (CPR) to be attempted during a cardiac arrest. A confidential interview on [DATE] at 5:45 P.M. with Employee #924 confirmed and verified Resident #17 designated advance directives were not accurately documented in the medical record. Review of the facility document titled Advance Directives revised [DATE], revealed the facility had a policy in place that the interdisciplinary team would be informed of changes and/or revocations so that appropriate changes could be made in the resident medical record and care plan. Review of the document revealed the facility did not implement the policy. This deficiency represents noncompliance identified during the investigation of Complaint Number OH00151352 and OH00150809. 366114 Page 6 of 17 366114 03/05/2024 Embassy of Lyndhurst 1575 Brainard Rd Lyndhurst, OH 44124

F 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm Based on observations, resident interviews, staff interviews, review of the activity calendars and facility policy, the facility failed to ensure an adequate number and variety of therapeutic activities were being provided to meet the needs and preferences of the residents. This had the potential to affect all 61 residents residing in the facility. The facility census was 61. Residents Affected - Many Findings include: Observation on 02/27/24 at 9:39 A.M. of the first floor activities bulletin board revealed an empty display with no activity calendar posted. A confidential interview on 02/27/24 at 9:39 A.M. with Employee #813 revealed activities were offered, but there were no activities in the evenings or on the weekends. Interview on 02/27/24 at 9:49 A.M. with Resident #55 revealed the facility only offered bingo and painting. Resident #55 revealed there were no other activities offered. Interview on 02/27/24 at 10:01 A.M. with Resident #15 revealed she did not go to activities because all that facility offered was bingo and she did not like bingo. A confidential interview on 02/27/24 at 10:13 A.M. with Employee #823 revealed there was only one activity staff member, and they couldn't handle the load on their own. Employee #823 revealed the activity staff member tried to offer a variety of activities and switch it up, but there was nothing for the residents to do once the activity staff person left for the day. Interview and observation on 02/27/24 at 10:24 A.M. with Resident #16 revealed she was not sure what activities were offered and she was not provided with an activity calendar. Observation of Resident #16's room revealed no activity calendar in her room. Observation on 02/27/24 at 10:49 A.M. of the Reflections unit, revealed an empty display with no activities posted. Observation on 02/27/24 at 10:53 A.M. of the second floor unit revealed an empty display with no activities posted. A confidential interview on 02/27/24 at 10:53 A.M. with Employee #810 revealed there were no activities except keeping the television on all day. A confidential interview on 02/27/24 at 11:03 A.M. with Employee #822 revealed during the holidays, the activity department went big, but after that, no other activities had taken place, except bingo. Interview on 02/27/24 at 11:05 A.M. with Resident #44 revealed there were no activities offered that she enjoyed. A confidential interview on 02/27/24 at 11:15 A.M. with Employee #834 revealed there were no activities that she was aware of. Employee #834 revealed she had never seen any activities taking place. 366114 Page 7 of 17 366114 03/05/2024 Embassy of Lyndhurst 1575 Brainard Rd Lyndhurst, OH 44124

F 0679 Level of Harm - Minimal harm or potential for actual harm Interview on 02/27/24 at 11:54 A.M. with the Director of Nursing (DON) revealed the facility no longer had an activity director in place. The DON revealed the previous activity director recently put in her notice of separation and subsequently went on medical leave shortly after. The DON revealed there was one activity employee who worked whenever they needed her to, including on her off days. The DON revealed the activity employee worked five days a week, full time. Residents Affected - Many A confidential interview on 02/27/24 at 12:12 P.M. with Employee #915 revealed she had not observed any activities taking place. Interview and observation on 02/27/24 at 12:26 P.M., during tour of the facility with the DON, revealed the facility did not post activity calendars. The DON revealed the activity department completed rounds and gave each resident activity calendars. Observation of the first and second floor activities bulletin boards revealed an empty display with no activities posted. The DON confirmed and verified the findings at the time of the observation. A confidential interview on 02/27/24 at 3:53 P.M. with Employee #816 revealed there was only one activity person, and no activities took place in the evenings. Employee #816 revealed the activity person only offered activities for the Reflection unit, which was a locked memory care unit. Interview on 02/28/24 at 4:13 P.M. with the DON revealed the previous activity director stopped working at the facility in January 2024 and no other person had been hired to fill that vacancy as of 02/28/24. The DON revealed there were no evening activities in place and that there would be some added to the March 2024 calendar. Review of the facility activity calendars, during interview with the DON on 02/28/24 at 4:13 P.M., revealed the December 2023 calendar had no activities in place after 2:00 P.M. on some days, and no activities in place after 4:00 P.M. on some days. The January 2024 calendar had daily activities listed with no times to indicate when they took place for residents to participate, and the February 2024 calendar had no activities in place after 2:00 P.M. Review of the calendar for February, dated 02/27/24 revealed a 10:00 A.M. movie, 11:00 A.M. color purple, and 2:00 P.M. Bingo. Observations from 2:00 P.M. to 3:30 P.M. revealed no Bingo taking place in the facility. The DON confirmed and verified the above at the time of the findings. Review of the facility document titled Activity Programs revised June 2018, revealed the facility had a policy in place to meet the interests of and support the physical, mental, and psychosocial well-being of each resident and scheduled activities would be posted on the resident bulletin board. Review of the document revealed the facility did not implement the policy in regard to the allegation. This deficiency represents non-compliance investigated under Complaint Number OH00150809. 366114 Page 8 of 17 366114 03/05/2024 Embassy of Lyndhurst 1575 Brainard Rd Lyndhurst, OH 44124

F 0680 Ensure the activities program is directed by a qualified professional. Level of Harm - Minimal harm or potential for actual harm Based on personnel record review, staff interview and review of the facility activity director job description, the facility failed to ensure a qualified professional was in place to act as the activity director and direct the facility's activity program. This had the potential to affect all 61 residents residing in the facility. The facility census was 61. Residents Affected - Many Findings include: Review of the personnel file for Activity Director (AD) #603 revealed a date of hire of 09/15/22 with no date of separation listed. Interview on 02/27/24 at 11:54 A.M. with the Director of Nursing (DON) revealed the facility no longer had an activity director in place. The DON revealed AD #603 recently put in her notice of separation and subsequently went on medical leave shortly after. The DON revealed there was one activity employee who worked whenever they needed her to, including on her off days. The DON revealed the activity employee worked five days a week, full time. Follow-up interview on 02/27/24 at 3:25 P.M. with the DON revealed AD #603's last day worked was approximately in December of 2023. A confidential interview on 02/27/24 at 3:53 P.M. with Employee #816 verified there was only one activity person, and no other persons had been hired for the position of Activity Director. Employee #816 revealed in order to qualify for the director position a college degree, class, and certification was required, and the one activity staff member working in the facility did not meet the qualifications. Email correspondence on 03/05/24 at 3:52 P.M. with the DON, Administrator, and the Regional Director of Operations (RDO) #600 revealed AD #603 date of separation was 12/27/23. Review of the facility document titled Job Description for an activity director, effective 05/22/17, revealed the facility would employ a qualified person who held a minimum two year degree, licensed by the state and eligible for certification as an activity professional, two years' experience within the last five years, with one year being in a health care setting, and a training course completed by the state. Review of the document revealed the facility failed to employ a qualified activity director. This deficiency represents noncompliance identified during the investigation of Complaint Number OH00151352. 366114 Page 9 of 17 366114 03/05/2024 Embassy of Lyndhurst 1575 Brainard Rd Lyndhurst, OH 44124

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 record review, observation and interview, the facility did not ensure Resident #14 was appropriately supervised by two staff while being transferred using a mechanical lift. This affected one resident (#14) of three residents reviewed for hazard risks. The facility census was 61. Findings include: Review of the medical record for Resident #14 revealed an admission date of 10/21/22 with diagnoses including paraplegia, bipolar disorder, and morbid obesity. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #14 had intact cognition and was dependent on staff for activities of daily living (ADLs). Review of the care plan dated 11/09/23 revealed Resident #14 had a self-care performance deficit related to paraplegia and was at risk for falls with interventions including assist with transfers as needed and assist of two for transferring via hoyer lift (mechanical lift). Interview on 03/04/24 at 5:25 A.M. with Employee #703 revealed there was one nurse and two aides to assist on night shift. Employee #703 revealed one aide was in the room assisting Resident #14 with a mechanical lift transfer. Observation and interview on 03/04/24 at 5:30 A.M. with State Tested Nursing Assistant (STNA) #806 revealed she exited Resident #14's room with the hoyer lift and placed it against the wall outside of the room. Resident #14 was seen exiting the room via an electronic wheelchair heading towards the nursing station and was alert with no signs of injury. Observation of Resident #14's room revealed no other staff member was present in the room. STNA #806 revealed she utilized the hoyer lift alone due to Resident #14 needing to be up for her appointment, and two staff were to be present and assist with the hoyer lift transfer for Resident #14. STNA #806 confirmed and verified the above findings at the time of the observation. Review of the facility document titled Using a Mechanical Lifting Machine revised July 2017, revealed the facility had a policy in place for safe lifting using a mechanical lifting device. Review of the policy revealed at least two nursing assistants were needed to safely move a resident with a mechanical lift. Review of the facility document revealed the facility did not implement the policy. This deficiency was issued due to noncompliance identified during the investigation of Complaint Number OH00151352. 366114 Page 10 of 17 366114 03/05/2024 Embassy of Lyndhurst 1575 Brainard Rd Lyndhurst, OH 44124

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation of a test meal tray, resident interviews, staff interviews and facility policy review, the facility failed to serve hot, palatable, and visibly pleasing foods. This had the potential to affect all residents, except Residents #2, #8, #11, #49, and #60, who were identified by the facility a consuming nothing by mouth (NPO). The facility census was 61. Residents Affected - Many Findings include: Interview on 02/27/24 at 9:49 A.M. with Resident #55 revealed the facility's food was nasty with no alternatives, and the chicken patties were nasty. Interview on 02/27/24 at 10:01 A.M. with Resident #15 revealed the facility's food was nasty, can't eat it or stomach it. My brother orders food for me and has it delivered. The kitchen doesn't follow my preferences Interview on 02/27/24 at 10:24 A.M. with Resident #16 revealed the facility's food was nasty and she was not provided a menu to order alternatives. Interview on 02/27/24 at 11:05 A.M. with Resident #44 revealed the facility's food was served cold. A confidential interview on 02/27/24 at 11:15 A.M. with Employee #834 revealed residents complained about the facility's food being nasty all day. Interview on 02/27/24 at 11:23 A.M. with Resident #45 revealed the facility's food needed to be better. A confidential interview on 02/28/24 at 5:45 P.M. with Employee #924 revealed some residents reported nasty food on their meal trays. Interview on 02/29/24 at 8:40 A.M. with Resident #40 revealed the facility's food was institutionalized. Review of the concern logs dated from December 2023 to February 2024 revealed on 02/11/24 Resident #4 stated her food was always cold when she received it. Review of the facility menu for the week of 02/25/24 to 03/02/24 revealed the lunch meal for 02/29/24 consisted of tropical pork, white rice, oriental vegetable blend, dinner roll, and a cookie. Observation and interview on 02/29/24 at 12:57 P.M. revealed the last meal cart exited the kitchen. Observation revealed Resident #7 and Resident #19's meal trays and the test tray did not fit into the enclosed meal cart. Resident #7 and #19's meal trays were sat on top of the meal cart and the test tray was carried by hand by Dietary Manager (DM) #601. DM #601 revealed there was no more space on the meal cart for the trays. DM #601 confirmed and verified the above findings. Review of the test tray with DM #601 and Dietary Technician (DT) #605 on 02/29/24 at 1:20 P.M. revealed the tray consisted of a slice of tropical pork, oriental vegetables, and white rice. The pork measured an internal temperature of 109 degrees Fahrenheit (F), and the vegetables measured an internal temperature of 115 degrees F, and both did feel warm when taste tested by the surveyor. The rice 366114 Page 11 of 17 366114 03/05/2024 Embassy of Lyndhurst 1575 Brainard Rd Lyndhurst, OH 44124

F 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many measured an internal temperature of 135 degrees F and was warm. The pork was hard to cut and tough to chew and the rice grains were mashed together and formed a ball on the plate (similar to mashed potatoes). The pork, vegetables, and rice had little to no seasonings, was bland, and without flavor. DM #601 and DT #605 verified the findings of the test tray at the time of observation. Review of the facility document titled Food and Nutrition Services revised October 2017, revealed the facility had a policy in place to ensure the food appeared palatable and attractive, and served at a safe and appetizing temperature. Review of the documents revealed the facility did not implement the policy in regard to the allegation. This deficiency represents non-compliance investigated under Complaint Number OH00150809. 366114 Page 12 of 17 366114 03/05/2024 Embassy of Lyndhurst 1575 Brainard Rd Lyndhurst, OH 44124

F 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident record review, family interview, staff interviews, and review of the facility hospice contract, the facility failed to ensure hospice services were implemented in a timely manner. This affected one resident (#43) of three residents reviewed for hospice services. The facility census was 61. Findings include: Review of the medical record for Resident #43 revealed an admission date of 02/02/24 with diagnoses including sepsis, urinary tract infection, severe protein-calorie malnutrition, and chronic kidney disease. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #43 had a Brief Interview for Mental Status (BIMS) score of 6 indicating severe cognitive impairment, and Resident #43 required assistance from staff for activities of daily living (ADLs). Review of the progress note dated 02/07/24 at 1:51 P.M. revealed Resident #43 had a care conference that included the interdisciplinary team and family. Review of the progress note revealed Resident #43 required 24-hour care due to her ongoing medical needs, could not discharge home alone, and recommended her code status be changed due to her health and age. Review of the physician orders dated 02/14/24 revealed Resident #43 had an order in place to have a hospice consult. Further review of the medical record for Resident #43 revealed as of 02/28/24, hospice services had not been implemented, which was approximately 15 days after the initial consultation was ordered by the physician. A confidential interview on 02/27/24 at 10:45 A.M. with Employee #809 revealed Resident #43's family wanted hospice services to start due to her decline, but they had not been started yet. Employee #809 revealed the facility wanted to give her therapy, but the family did not want it to continue. Interview on 02/28/24 at 2:45 P.M. with Resident #43's family member revealed the facility, specifically the Director of Nursing (DON), was holding up the process in regard to Traditions Hospice services beginning. The family member revealed Resident #43, the family, and Traditions Hospice were on board, but the DON was prolonging her therapy instead of getting the hospice services started for Resident #43. The family member revealed Resident #43 was ninety-five years old, was in need of comfort care and was ready to move forward with hospice services after living a full life. A confidential interview on 03/01/24 at 8:59 A.M. with Employee #915 revealed Resident #43 family wanted hospice services to start but the process was prolonged. Review of the facility document titled Nursing Facility, Inpatient Respite, and General Inpatient Combined Contract revised November 2020, revealed the facility had an active and current contract and/or agreement in place with Traditions Hospice of [NAME] Heights as of 09/13/22. Review of the contract revealed the facility would be willing to make hospice services available to residents and implement the provisions of the agreement. Review of the contract revealed the facility did not implement 366114 Page 13 of 17 366114 03/05/2024 Embassy of Lyndhurst 1575 Brainard Rd Lyndhurst, OH 44124

F 0849 the contract in regard to the allegation. Level of Harm - Minimal harm or potential for actual harm Review of the facility document titled Hospice Program, revised July 2017, revealed the facility had a policy in place that hospice services were available to residents at the end of life. Review of the policy revealed the facility had an agreement in place with at least one Medicare-certified hospice to ensure residents who wished to participate in a hospice program may do so. Review of the document revealed the facility did not implement the policy in regard to the allegation. Residents Affected - Few This deficiency represents non-compliance investigated under Master Complaint Number OH00151352. 366114 Page 14 of 17 366114 03/05/2024 Embassy of Lyndhurst 1575 Brainard Rd Lyndhurst, OH 44124

F 0850 Hire a qualified full-time social worker in a facility with more than 120 beds. Level of Harm - Minimal harm or potential for actual harm Based on personnel record review, review of the job description for social services director and staff interview the facility failed to employ a full-time Licensed Social Worker (LSW). This had the potential to affect all residents residing in the facility. The facility census was 61. Residents Affected - Many Findings include: Review of the personnel file for LSW #602 revealed a date of hire of 09/19/22 with no date of separation listed. Review of an email correspondence on 03/05/24 at 3:52 P.M. with the Director of Nursing (DON), Administrator, and Regional Director of Operations (RDO) #600 revealed LSW #602's date of separation was 02/15/24. Interview on 02/27/24 at 11:54 A.M. with the DON revealed the facility no longer had an LSW in place. The DON revealed LSW #602 was no longer employed at the facility and no other LSW was hired in her place. Interview on 02/28/24 at 3:16 P.M. with Human Resources Director (HRD) #701 revealed her date of hire was 02/05/24 and at that time the facility employed an LSW. HRD #701 revealed she was unsure of LSW #602 exact date of separation. Review of the facility document titled Job Description for a social services director, effective 05/22/17, revealed the facility would employ a qualified LSW by the state of Ohio. Review of the document revealed the facility failed to employ a qualified LSW. This deficiency represents noncompliance identified during the investigation of Complaint Number OH00150809. 366114 Page 15 of 17 366114 03/05/2024 Embassy of Lyndhurst 1575 Brainard Rd Lyndhurst, OH 44124

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility failed to ensure the urinary cathetar drainage bag for Resident #2 was not sitting uncovered and directly on the floor exposing the bag to a source of contamination and potential infection. This affected one resident (#2) of one resident reviewed for urinary catheters. The facility census was 61. Residents Affected - Few Findings include: Review of the medical record for Resident #2 revealed he was admitted to the facility on [DATE] with diagnoses that included pneumonia, functional quadriplegia, and dementia. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed Resident #2 had a Brief Mental Status (BIMS) score of 9 indicating cognitive impairment, and Resident #2 was dependent on staff for activities of daily living (ADLs), was incontinent of urine and bowel, and had an indwelling catheter in place. Review of the physician orders dated 02/07/24 revealed Resident #2 had orders in place for foley catheter care every shift, foley catheter bag cover every shift, and catheter to remain covered every shift for privacy. Observation and interview on 03/04/24 at 5:45 A.M. revealed Employee #806 was seen exiting Resident #2's room. Resident #2 was sleeping in bed and his urinary catheter bag was full of urine and on the floor under his bed. Resident #2's urinary catheter bag was not covered with a privacy bag. The room had a strong odor of urine that could be smelled from the hallway. Interview with employee #905, who was seen entering and exiting the room at the time of the observation, confirmed and verified the above findings. Review of the facility document titled Routine Resident Checks revised July 2013, revealed the facility had a policy in place to complete routine checks that included entering the resident's room, determine if needs were being met, and if toileting assistance was needed. Review of the document revealed the facility did not implement the policy. This deficiency represents noncompliance identified during the investigation of Complaint Number OH00151352. 366114 Page 16 of 17 366114 03/05/2024 Embassy of Lyndhurst 1575 Brainard Rd Lyndhurst, OH 44124

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, staff interviews, and review of a police report, the facility failed to ensure all door locks in the facility kitchen properly worked to maintain a safe and secure environment at all times. This affected all 61 residents residing in the facility. The facility census was 61. Findings include: Review of a document titled City of Lyndhurst Police Department (CLPD) Call Summary Report, printed on 02/27/24, revealed on 01/26/24 at 6:57 P.M. the CLPD received a call regarding a suspicious person. Review of the report revealed several supervisors, who were not at the scene, had made calls and reported a suspicious person was running around with a mask and had exited the building prior to the officer's arrival. The officer checked the interior of the facility and left without further incident. Confidential interviews on 02/27/24 from 10:53 A.M. to 12:12 P.M. with Employee #810, #822, #834 and #915 revealed a door in the facility kitchen did not securely lock. Employee #915 revealed the facility was searched by police recently due to an incident involving an unknown, masked perpetrator who gained entry to the facility through a kitchen door and was seen running around the facility while wearing a face mask to conceal identity. No negative affects to the residents were reported at the time of the interviews. An observation and interview was conducted on 02/27/24 at 12:45 P.M. with Dietary Manager (DM) #601 and Maintenance Director (MD) #604 who revealed there were three doors to enter the kitchen from the outside. Observation of first door adjacent to office revealed if the door was kicked hard enough, it would open from the inside. Observation of a second door revealed it locked via a latch from the top and was utilized as a delivery door. The third door (trash door) locked from the inside. DM #601 revealed an unknown person entered the facility through the trash door around 6:00 P.M., ran through building and out the other kitchen door. DM #601 revealed none of the doors were locked at 6:00 P.M. when the unknown person entered then exited through the kitchen door. DM #601 revealed someone stuffed a plastic bag in the opening of the strike plate of the trash door lock which prevented it from locking and subsequently allowed entry by the unknown person. Observation of the trash door revealed a strike plate with a large opening with space to accommodate items placed inside, such as a plastic bag. Demonstration of the trash door revealed if an item was placed in the door lock, the door would not lock. DM #601 verified the above findings. Interview on 02/27/24 at 2:08 P.M. with the Director of Nursing (DON) revealed a man with a mask enter the facility through the kitchen door around the beginning of February and exited back through the back door in the kitchen. The DON revealed it happened while she was at home and she and the former Administrator #907 called the police. No negative affects to the residents were reported at the time of the interview with the DON. This deficiency represents non-compliance investigated under Complaint Number OH00150809. 366114 Page 17 of 17