Embassy Of Newark

Federal health inspectors cited EMBASSY OF NEWARK in NEWARK, OH for a deficiency under regulatory tag F-F0644 during a complaint investigation conducted on 2025-08-21.

Category: Resident Assessment and Care Planning Deficiencies

The facility was found deficient in the following area: Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 7 deficiencies cited during this inspection of EMBASSY OF NEWARK.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-17.

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review, the facility failed to ensure the care plan included comprehensive psychosocial interventions to address identified behaviors. This affected one resident (#64) out of thirty residents reviewed for care planning. The facility census was 105.Findings include:Review of the medical record for Resident #64 revealed an admission date of 05/30/25 with diagnoses including depression, anxiety disorder, hypertension, and insomnia.Review of the Minimum Data Set (MDS) 3.0 admission assessment dated [DATE REDACTED] revealed Resident #64 was cognitively intact and has no mood or behavioral concerns.Review of the care plan dated 07/14/25 revealed the resident was known to make inappropriate and sexual comments to staff. Interventions included one-on-one supervision, every 15-minute and 30-minute checks as needed for safety of both this resident and others, referral to psych as needed, and staff monitoring for any inappropriate behaviors.Interview on 08/18/25 at 3:52 P.M. with Resident #64 revealed he wanted to grow a relationship with a cognitively impaired resident located within the facility.

Resident #64 was unhappy the facility had forbidden him from seeing this resident in person and was forced to have supervised visits or visits behind glass walls.Interview on 08/19/25 at 8:19 A.M. with the Administrator confirmed Resident #64 voiced a desire to grow a relationship with a cognitively impaired resident, Resident #107. They informed Resident #107's Power of Attorney (POA) who requested the resident have no contact with Resident #64. The facility agreed, stating they wanted Resident #64 to cool off. The Administrator was unsure if Resident #64 was seeing psych services at this time but believed it could be beneficial. The Administrator reported that staff are well aware that Resident #64 was to stay away from Resident #107. The Administrator shared Resident #64 had become obsessed with Resident #107, and staff are diligent to ensure that during the entire friendship, interactions were only under supervised visits. The facility will continue to keep Resident #64 and Resident #107 separate until Resident #107's POA agreed otherwise, at which time the situation would be revisited. The Administrator confirmed these current concerns were not noted on the resident's care plan. This deficiency represents non-compliance investigated under Complaint number 2592657.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Embassy of Newark

75 McMillen Drive Newark, OH 43055

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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 medical record review, observations, and staff interview, the facility failed to ensure fall interventions were in place. This affected two residents (#1 and #43) of five residents reviewed for fall safety. The facility census was 105. Findings include:1.Review of the medical record for Resident #1 revealed an initial admission date of 10/06/21 and a re-entry date of 03/09/25. Diagnoses included peripheral vascular disease, embolism and thrombosis of deep veins of the lower extremities, and unsteadiness on feet. Review of the physician orders for Resident #1 dated 02/25/25 revealed an order for the resident's bed to be in the lowest position when occupied. Review of the care plan dated 03/10/25 for Resident #1 revealed this resident was at risk for falls related to medication use, decrease mobility, non-ambulatory, and obesity comorbidities. Fall interventions included to be sure the call light is in reach, bed in lower position when occupied, and to follow facility fall protocol. Review of Resident #1's Minimum Data Set (MDS) 3.0 assessment dated [DATE REDACTED] revealed a Brief

Interview for Mental Status (BIMS) score of 14 out of 15 indicating an intact cognition for daily decision-making abilities. Resident #1 was noted to experience impairment to both lower extremities and was dependent on staff for bed mobility. Observations made on 08/11/25 at 9:30 A.M, on 08/14/25 at 11:00 A.M., and 2:30 P.M., on 08/19/25 at 3:00 P.M., and again on 08/20/25 at 10:40 A.M., revealed Resident #1's

in bed at the time of each observation. During each observation, the bed was not in the lowest position.

Interview on 08/18/2025 at 3:19 P.M. with Licensed Practical Nurse (LPN) #403 confirmed Resident #1 had

an order for his bed to be in the lowest position when occupied and per current observation, Resident #1's bed was not in the lowest position. 2.Review of the medical record for Resident #43 revealed an initial admission date of 04/05/24 and a re-entry date of 07/27/24. Diagnoses included a pathological fracture of

the left femur, vascular dementia, muscle weakness, and difficulty walking. Review of Resident #43's quarterly MDS 3.0 assessment dated [DATE REDACTED] revealed a BIMS score of 09 out of 15 indicating a severely impaired cognition for daily decision-making abilities. Review of the undated care plan revealed Resident #43 was at risk for falls due to a cerebral vascular accident with hemiplegia to the left side, use of psychotropic medications, cognitive status, and vitamin d deficiency. Interventions include to place a reminder sign in the resident's room to remind him to call for assistance. Observations completed on 08/12/25 at 3:10 P.M. and again on 08/20/25 at 9:40 A.M. revealed no signs were posted in Resident #43's room to remind him to call for assistance. Interview on 08/20/25 at 10:00 A.M. with Registered Nurse (RN) #999 confirmed there was not a sign posted in Resident #43's room to remind him to call for assistance as per order and fall interventions. Review of the policy Managing Falls and Fall Risk, revised 03/2021 revealed the staff will implement a resident-centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with a history of a fall. This deficiency represents noncompliance investigated under Complaint Number 2582471.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Embassy of Newark

75 McMillen Drive Newark, OH 43055

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 0697

missed eight scheduled doses: 08/10/25 at 8:00 A.M., 12:00 P.M., 4:00 P.M., and 8:00 P.M., and 08/11/25 at 12:00 A.M., 4:00 A.M., 8:00 A.M., and 12:00 P.M.

Level of Harm - Actual harm Residents Affected - Few

During an interview on 08/18/25 at 10:33 A.M., LPN #400 confirmed she was working with Resident #46

during the day shift on 08/10/25 when the resident was without his narcotic pain medication. She was informed by the night shift nurse that the facility had run out of Oxycodone and was awaiting delivery of the medication from the pharmacy. LPN #400 had not contacted the pharmacy to verify the refill request and had not received a delivery during her shift.

During an interview on 08/21/25 at 11:38 A.M., Medical Director (MD) #900 confirmed an on-call physician was initially notified on 08/11/25 at approximately 12:00 A.M. via the facility’s non-urgent messaging system. As a result of the non-urgent alert, a voicemail was left, and the return call was not expected until

the morning from an on-call physician. MD #900 was notified again on 08/11/25 at approximately 12:30 P.M. and was informed that Resident #46 had been without his prescribed pain medication and was experiencing increased pain. By that time, staff had already begun coordinating with the on-call physician and pharmacy to obtain a new prescription and arrange for delivery. MD #900 acknowledged that Resident #46 should not have gone without scheduled pain medication for such an extended period. MD #900 confirmed nursing staff often wait until medications are completely depleted before requesting refills, which prevents physicians and pharmacies from acting proactively. MD #900 stated that, ideally, refill requests should be submitted several days in advance to avoid any lapse in medication availability.

Review of the facility policy titled, Pain-Clinical Protocol, dated March 2018 revealed, the physician and staff will identify individuals who have pain or who are at risk of having pain. The physician will order appropriate non-pharmacological and medication interventions to address the individual's pain.

This deficiency represents noncompliance investigated under Complaint Number 1263770 (OH00165823).

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Embassy of Newark

75 McMillen Drive Newark, OH 43055

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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

and reported to the administrator, additionally the nurse supervisor/charge nurse/supervisor shall promptly initiate and document investigation of the accident or incident.

Review of the policy Controlled Substances revealed access to controlled medications remain locked at all times, and access is recorded. Only authorized licensed nursing and/or pharmacy personnel have access to controlled drugs maintained on the premises. Upon administration, the nurse administering the medication is responsible for recording the name of the resident receiving the medication, the name, strength, and dose of the medication, time of administration, quantity remaining, and a signature of the nurse administering the medication.

This deficiency represents noncompliance investigated under Complaint Number 1263770 (OH00165823).

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Embassy of Newark

75 McMillen Drive Newark, OH 43055

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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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 medical record review, hospice records, staff interview, and facility policy review, the facility failed to ensure hospice records were available for review to allow for effective collaboration between the facility and the hospice provider. This affected one resident (#43) of one resident reviewed for hospice care. The facility census was 105. Findings include:Review of the medical record for Resident #43 revealed an initial admission date of 04/05/25 and a re-entry date of 07/27/24. Diagnoses included vascular dementia, cerebral atherosclerosis, disorders of the bone density and structure, and hypertension. Review of Resident #43's Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE REDACTED] revealed a Brief Interview for Mental Status (BIMS) score of 09 out of 15 indicating severely impaired cognition for daily decision-making abilities. Interview on 08/19/25 at 12:49 P.M. with a hospice staff member revealed Resident #43 was planned to received Certified Nursing Assistant (CNA) services three times per week, nursing care weekly, and a social services visit monthly. All staff who visit Resident #43 are to fill out a summary of the care provided after returning to the office and this will either be faxed or emailed over to the facility. Interview with 08/19/25 10:00 A.M. with Registered Nurse (RN) #243 revealed hospice notes are located at the nurse's station in a binder. Observation of the binder revealed only a sign in log was located in this binder. No hospice notes or care notes were available. RN #243 stated that she believed the unit manager may have Resident #43's hospice notes in her office. A request was made on 08/19/25 for Resident #43's hospice notes for review which was not provided until later that same day. Each received document was noted to be printed on 08/19/25, which was the day the notes were requested. Interview with Licensed Practical Nurse (LPN) #215 confirmed the documents were not available at the facility upon request and Hospice had to be contacted so the documents could be forwarded to the facility. Review of the facility policy titled, Hospice Program, dated 07/2017 revealed the facility would designate a staff member to ensure that the long-term care facility communicates with the hospice medical director, the residents attending physician and other practitioners participating in the provision of care to the resident as needed. This deficiency represents noncompliance investigated under Complaint Number 1263770 (OH00165823).

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Embassy of Newark

75 McMillen Drive Newark, OH 43055

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 0925

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

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 Resident #75's wound and living space were free from pests. This affected one resident (#75) of six residents sampled for wounds. The facility census was 105. Findings include: Review of Resident #75's medical record revealed an admission date of 01/31/05 and diagnoses including malignant neoplasm of head and face, squamous cell carcinoma, autistic disorder, diabetes, anxiety disorder, peripheral vascular disease, hypertension, acquired absence of right leg below the knee, and non-pressure chronic ulcer of other part of left lower leg with other specified severity. Review of Resident #75's Minimum Data Set (MDS) significant change in status assessment dated [DATE REDACTED] revealed a Brief Interview of Mental Status (BIMS) score of 13 indicating the resident was cognitively intact and had no recorded behaviors. Further review revealed Resident #75 required set up assistance for eating and was dependent on staff for all other activities of daily living. Resident #75 was assessed to be always incontinent of bladder, frequently incontinent of bowel, and was receiving hospice services. Resident #75 was recorded as having an unhealed diabetic ulcer. Review of Resident #75's progress notes revealed a note dated 07/17/25 at 11:33 P.M. written by Licensed Practical Nurse (LPN) Unit Manager #215 indicating she was notified of a new wound and upon assessment, debris was noted in the wound bed of the left foot.Observation on 08/11/25 at 10:40 A.M. revealed flies were observed in Resident #75's room and in the hallway outside of Resident #75's room. Observation on 08/14/25 at 11:00 A.M. revealed flies were observed in Resident #75's room on the bed. In an interview on 08/18/25 at 12:36 P.M., LPN Unit Manager #215 stated Resident #75 had chronic cellulitis of her lower left leg and foot and was being treated with an antibiotic (medication used to treat infection) and a diuretic (medication used to help decrease swelling) prior to the wound on her left foot opening on 07/17/25. A follow-up interview at 12:47 P.M. revealed LPN Unit Manager #215 stated there were also some maggots present in Resident #75's wound bed when she first observed the wound on 07/17/25. However, LPN Unit Manager #215 stated the next day Resident #75's wound bed was clean. In an interview on 08/18/25 at 2:43 P.M., Certified Nursing Assistant (CNA) #146 revealed Resident #75's wound was found on 07/17/25 when she and CNA #125 were providing care, and the wound was observed to have some maggots in it. CNA #146 and CNA #125 reported the new area immediately to the nurse. CNA #146 stated she had not seen any other wounds with maggots in them. In an interview on 08/18/25 at 3:17 P.M., LPN #403 stated that she completed a treatment to Resident #75's left lower leg on 7/17/25 on day shift and she did not see any new area on the foot at that time. LPN #403 stated that she changed the dressing while the resident was lying in bed, and had to pick up Resident #35's leg to do the dressing and had a good view of the bottom of her foot.In an interview on 08/19/25 at 9:00 A.M., CNA #125 stated that when the open area was found on Resident #75's left foot it had a few maggots in it. CNA #125 stated she had not seen any other wounds with maggots in them. CNA #125 stated Resident #75 often had flies in her room because she would hoard food and trash and the staff had to go in and clean her room. Observation on 08/19/25 at 12:12 P.M. revealed Resident #75's dressing change was completed by LPN Unit Managers #215 and #240. The dressing to Resident #75's plantar surface wound of the left foot was completed. The wound bed was observed and appeared clean with no debris present in the wound. However, flies were noted in the room during the dressing change and the presence of the flies were confirmed by LPN Unit Managers #215 and #240. This deficiency represents noncompliance investigated under Complaint Numbers 2582471 and 2568937.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet