Inspection·October 7, 2021

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some and fell. A skin tear to left eyebrow measured 2 centimeters (cm) by 0.1 cm by 0.1 cm, skin tear to left elbow measured 0.5 cm by 0.5 cm by 0.1 cm. Review of the nursing progress notes dated 10/01/21 through 10/06/21 revealed no monitoring of the hematoma or the skin tears. Review of the Treatment Administration Record (TAR) revealed no documentation of monitoring the skin issues Review of the plan of care for falls dated 10/04/21 revealed a new intervention of Dycem (non skid mat) to wheelchair seat at all times. There was no care plan addressing the new skin issues from the fall. Review of the 10/21 physician orders did not reveal an order to monitor the bruise and skin tear above the left eye. Review of the care plan progress note dated 10/04/21 at 1:17 P.M. revealed the Interdisciplinary team (IDT) was aware of the resident's fall on 10/01/21. The resident was seated in the wheelchair in the hallway when last seen and was then found on the floor with a hematoma noted to left eyebrow and a skin tear noted to the center of the hematoma and left elbow. Resident #39 was sent to the emergency department for evaluation and treatment. Returned to the facility on [DATE] with no acute findings noted on Cat Scan of head. An interview with Licensed Practical Nurse (LPN) #162 on 10/07/21 at 8:15 A.M. revealed if a resident had a bruise or skin tear, the nurse would monitor and document findings in progress notes and TAR until area resolved. An interview with the Director of Nursing (DON) on 10/07/21 at 10:15 A.M. revealed the Assistant Director of Nursing (ADON) provided care and monitored pressure and non pressure wounds. The ADON had a form she documented the information on which was kept in the skin book. The ADON provided wound notes for Resident #39's skin tear to left eye brow and left elbow dated 10/01/21 and 10/06/21. The DON confirmed this was the only documentation. The DON confirmed there was no care plan addressing the hematoma, or skin tears to left eye or left elbow. 3. Record review for Resident #66 revealed the resident was admitted to the facility on [DATE] with diagnoses including malignant neoplasm of the bladder, bacteremia, acute kidney failure, anemia, abnormal serum enzyme level, hematuria, muscle weakness, and encounter for palliative care. The resident had allergies to Ketamine. Review of the admission Minimum Data Set (MDS) assessment, dated 09/15/21, revealed Resident #66 had slightly impaired cognition evidenced by a Brief Interview Mental Status (BIMS) score of 13. The resident was assessed to require limited assistance from one staff member for bed mobility, extensive assistance from two staff members for transfers, and extensive assistance from two staff members for toileting. Review of the physicians orders, dated 09/11/21, revealed Resident #66 had orders to admit to Hospice. Review of the active care plans for Resident #66 on 10/05/21 revealed the care plans did not include a hospice care plan. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365393 If continuation sheet Page 2 of 16 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 365393 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Jackson 8668 State Route 93 Jackson, OH 45640 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview with Registered Nurse (RN) #138 on 10/06/21 at 11:55 A.M. verified a hospice care plan had not been put into place for Resident #66 until 10/05/21 and stated the care plan should have been initiated immediately upon the resident's admission to the facility as he was admitted to the facility receiving hospice services. 4. Review of the medical record revealed Resident #21 had an admission date of 10/05/18 with diagnoses including chronic obstructive pulmonary disease, hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting left non-dominant side, malignant neoplasm of ascending colon, chronic kidney disease stage three, major depressive disorder, dysphagia, chronic respiratory failure with hypoxia. Review of the physician's orders for Resident #21 revealed an order for oxygen four liters per minute as needed for shortness of breath starting 01/29/21. Review of the plan of care dated 04/22/21 revealed Resident #21 had chronic obstructive pulmonary disease with a history of chronic respiratory failure. Interventions included offering support and encouragement, provide as needed medications for anxiety medications, monitor for any signs and symptoms of respiratory infection. A revision to the care plan dated 06/05/21 included the intervention of monitoring for signs and symptoms of acute respiratory failure included providing oxygen as ordered, additional revision on 10/06/21 included administering oxygen according to the physician's order. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed the resident had intact cognition. On 10/05/21 at 3:00 P.M. and on 10/06/21 at 10:05 A.M. interview with the Director of Nursing (DON) revealed the care plan had not included oxygen use until it had been revised on 10/05/21 and 10/06/21. It was additionally confirmed the care plan did not include care related to oxygen use including changing the tubing. Review of the policy titled Oxygen Administration dated October 2010, revealed before administering oxygen the resident's care plan should be assessed for any special needs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365393 If continuation sheet Page 3 of 16 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 365393 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Jackson 8668 State Route 93 Jackson, OH 45640 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and staff interview the facility failed to provide one resident (#52), who was dependent for activities of daily living (ADL) nail care. This affected one of three residents reviewed for ADL. Residents Affected - Few Findings include: Review of Resident #52's medical record revealed an original admission date 12/22/16 with the latest readmission of 12/29/18. Diagnoses included dementia with behavioral disturbances, major depressive disorder, history of falling, hypertension, psychotic disorder with delusions, contracture of unspecified joint and allergic rhinitis. Review of the resident's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had clear speech, rarely/never understood others, sometimes made herself understood, and had a severe cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of zero. The resident required extensive assist of two staff for personal hygiene, including nail care. Review of the plan of care dated 12/23/16 revealed the resident had a self-care deficit as evidence by need for assistance with activities of daily living, transfers, ambulation, and toileting as related to debility, dementia and contractures. Interventions included to assist to bathe/shower as needed, assist with daily hygiene, grooming, dressing, oral care and eating as needed, break ADL tasks into sub-task for easier patient performance, gentle range of motion (ROM) to all extremities daily during care as tolerated and provide oral care daily and as needed. On 10/04/21 at 10:51 A.M. observation of Resident #52 revealed her nails were long and jagged with chipped nail polish. Further observation revealed the resident had a brown substance under her nails. On 10/05/21 at 3:55 P.M. observation of Resident #52 revealed her nails remained long and jagged with chipped nail polish and a brown substance under the nails. On 10/06/21 at 12:36 P.M. interview with State Tested Nursing Assistant (STNA) #179 verified Resident #52's nails were long, jagged and dirty with pealing nail polish. The STNA said nail care was to be provided every Sunday and she would get the residents nails cleaned after she ate. She said the resident used her fingers to eat. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365393 If continuation sheet Page 4 of 16 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 365393 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Jackson 8668 State Route 93 Jackson, OH 45640 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of the facility policy related to falls, the facility failed to provide monitoring and care related to a hematoma and skin tears for Resident #39. This affected one of 16 residents reviewed. The facility census was 63. Residents Affected - Few Findings inlcude: An observation on 10/04/21 at 3:26 P.M. of Resident #39 found a purple and green bruise above left eyebrow with a small skin tear in the center and a skin tear to left elbow. Resident #39 was unaware how she obtained the bruise and the skin tears. Review of the medical record for Resident #39 revealed an admission date of 08/17/21 with diagnoses including fracture of left femur and sacrum, Parkinson's disease and dementia. Review of the five day admission Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was cognitively impaired, and required two person extensive physical assistance with transfers and mobility. The resident had a history of falls. Review of the fall investigation dated 10/01/21 revealed the resident ambulated without assistance and fell. The skin tear to left eyebrow measured 2 centimeters (cm) by 0.1 cm by 0.1 cm, skin tear to left elbow measured 0.5 cm by 0.5 cm by 0.1 cm. Review of the care plan progress note dated 10/04/21 at 1:17 P.M. revealed the Interdisciplinary team (IDT) was aware of the residents fall on 10/01/21. The resident was seated in the wheelchair in the hallway when last seen and was then found on the floor with a hematoma noted to left eyebrow and a skin tear noted to the center of the hematoma and left elbow. Resident #39 was sent to the emergency department for evaluation and treatment. The resident returned to the facility on [DATE] with no acute findings noted on Cat Scan of head. Review of the nursing progress notes dated 10/01/21 through 10/06/21 revealed no monitoring of the hematoma or the skin tears. Review of the Treatment Administration Record (TAR) revealed no documentation of monitoring or treatment of the skin tears. Review of the 10/21 physician orders did not reveal an order to monitor the bruise and skin tear above the left eye or the left elbow. Review of the facility policy titled Falls-clinical protocol dated 03/18 indicated the staff, with the physician's guidance, would follow up on any fall with associated injury until the resident was stable and delayed complications such as late fracture or subdural hematoma had been ruled out or resolved. Delayed complications such as late fractures or major bruising could occur hours or days after a fall. An interview with Licensed Practical Nurse (LPN) #162 on 10/07/21 at 8:15 A.M. revealed if a resident had a bruise or skin tear, the nurse would monitor, provide treatment and document findings in progress notes and on the TAR until area was resolved. An interview with the Director of Nursing (DON) on 10/07/21 at 10:15 A.M. revealed the Assistant Director of Nursing (ADON) provided care and monitored pressure and non pressure wounds. The ADON had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365393 If continuation sheet Page 5 of 16 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 365393 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Jackson 8668 State Route 93 Jackson, OH 45640 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 0684 a form she documented the information which was kept in the skin book. Level of Harm - Minimal harm or potential for actual harm The ADON provided wound notes for Resident #39's skin tear to left eye brow and left elbow dated 10/01/21 and 10/06/21. The ADON provided weekly care and documentation of all wounds. The DON confirmed this was the only documentation of care of the hematoma and two skin tears. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365393 If continuation sheet Page 6 of 16 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 365393 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Jackson 8668 State Route 93 Jackson, OH 45640 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to implement physician ordered pressure ulcer interventions. Actual harm occurred to Resident #7 when the facility failed to place pressure reducing heel boots on the resident as ordered by the physician and the resident subsequently developed a pressure ulcer to his right heel. This affected one resident (#7) of the three residents reviewed for pressure ulcers and injuries. Residents Affected - Few Findings include: Record review for Resident #7 revealed the resident was admitted to the facility on [DATE] with diagnoses including type two diabetes mellitus, abnormal weight loss, unspecified dementia with behavioral disturbance, restlessness, and agitation. The resident had no known allergies. Review of the significant change assessment, dated 9/20/21, revealed Resident #7 did not have any pressure ulcers and was at risk for pressure ulcer development. The resident required extensive assistance from two staff members with bed mobility, transfers, and toileting. Review of the care plan with a revision date of 09/30/21 revealed Resident #7 had potential/actual impairment to skin integrity related to fragile skin and history of skin ulcers. Interventions included air relieving mattress to bed, heel boots as resident would tolerate, and follow facility protocols for treatment of injury. Review of the physicians' order, dated 09/30/21, revealed Resident #7 an order for pressure relieving heel boots to feet as resident would tolerate. Review of facility progress notes, dated 09/30/21 through 10/05/21, revealed no documentation that Resident #7 refused or removed the heel boots. Observation of Resident #7 on 10/04/21 at 11:30 A.M. and 3:30 P.M. revealed he was lying in bed on his back. The resident was not wearing heel boots and his heels were lying directly on the surface of the bed. Observation of Resident #7 on 10/05/21 at 9:35 A.M. revealed he was lying in bed on his back. Resident #7 was not wearing heel boots and his heels were lying directly on the surface of the bed. Observation with Licensed Practical Nurse (LPN) #132 on 10/05/21 at 1:52 P.M. verified Resident #7 was lying on his back, he was not wearing the pressure relieving heel boots and his heels were lying directly on the surface of the bed. There was a bandage in place to the back of the resident's right heel. When the bandage was removed a round area of purple discoloration surrounded by reddened skin was observed. Further observation revealed there were no heel boots Resident #7's room. Interview with LPN #132 on 10/05/21 at 1:55 P.M. verified Resident #7 was not wearing heel boots and heel boots could not be located in his room. LPN #132 verified the area to the back of the resident's heel appeared to be a pressure ulcer and indicated the bandage had been applied to the area by the wound care nurse. Interview with LPN #189 on 10/05/21 at 2:32 P.M. revealed the area to the right heel of Resident #7 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365393 If continuation sheet Page 7 of 16 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 365393 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Jackson 8668 State Route 93 Jackson, OH 45640 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 0686 had been discovered the morning of 10/05/21 and the Nurse Practitioner (NP) was going to assess the area. Level of Harm - Actual harm Residents Affected - Few Observation of Resident #7's right heel with NP #199 on 10/05/21 at 2:34 P.M. revealed a round, purple area consistent with a deep tissue injury (DTI). A DTI is a persistent, non-blanchable deep red, purple or maroon area of intact skin or blood-filled blister caused by damage to the underlying soft tissue due to prolonged pressure over a period of time. Interview with NP #199 on 10/05/21 at 2:37 P.M. revealed she was notified of the area to the heel of Resident #7 a couple of days ago and had planned to assess the area on 10/05/21 while making rounds at the facility. NP #199 stated she could not recall what, if any, wound care orders she had provided for the area when notified. NP #199 verified the area to the back of the right heel of Resident #7 was a DTI. Interview with State Tested Nursing Assistant (STNA) #161 on 10/06/21 at 10:00 A.M. revealed she had provided care for Resident #7 and could not recall the resident wearing pressure relieving heel boots. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365393 If continuation sheet Page 8 of 16 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 365393 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Jackson 8668 State Route 93 Jackson, OH 45640 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 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 observation, interview, and record review, the facility failed to maintain fall interventions for Resident #4. This affected one (#4) of four residents reviewed for falls. Findings include: Review of the medical record for Resident #4 revealed the resident was admitted on [DATE] with diagnoses including anxiety disorder, cerebral palsy, major depressive disorder, foot drop, chronic pain syndrome, dysphagia, and gastro-esophageal reflux disease. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had moderately impaired cognition and limited range of motion in the upper extremities on both sides. Review of the plan of care dated 11/14/20 revealed the resident was at risk for falls and potential injury related to poor decision making skills, unsteady gait, foot drop, muscle weakness, lack of coordination, weakness, and impaired balance. Interventions included assisting with transfers as needed, leaving urinal at bedside, educating and reminding the resident to move his bedside table out of the way, encouraging him to allow staff to assist the resident when ambulating, non-slip strips to the floor in his room in area of high traffic, and therapy to screen and evaluate as needed. Review of the fall investigation dated 08/28/21, revealed the resident had a fall and the intervention to prevent further falls was non-slip strips to high traffic area of room on floor. Written on the fall investigation provided by the Director of Nursing (DON) was 10/02/21 floor stripped and waxed and 10/05/21 non skid strips replaced. On 10/04/21 from 10:25 A.M. to 5:40 P.M. and on 10/05/21 from 7:15 A.M. to 12:55 P.M. observation revealed no non-skid strips in Resident #4's room. This was confirmed by Licensed Practical Nurse (LPN) #132 on 10/05/21 at 12:55 P.M. She additionally confirmed non-skid strips were an intervention in the plan of care. On 10/05/21 at 2:39 P.M. interview with the Director of Nursing (DON) revealed the resident's floor had been stripped and waxed recently. She stated maintenance planned on putting the strips back down on the morning of 10/04/21 but this was delayed because surveyors from the Ohio Department of Health entered the building. On 10/05/21 at 4:25 P.M. interview with Maintenance Director #200 revealed he had learned the skid strips needed replaced that morning. He said the facility had an employee who came in to strip and wax the floors and he had recently done Resident #4's room. He reported this employee was fairly new and must not have known to reapply the strips afterwards. Further interview with the DON on 10/06/21 at 8:45 A.M. revealed the DON had made an error on the fall investigation when she reported the floor was stripped on 10/02/21 as it had been stripped on 10/01/21. Review of the monthly floor chart for October 2021 revealed Resident #4's floor was stripped and waxed on 10/01/21. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365393 If continuation sheet Page 9 of 16 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 365393 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Jackson 8668 State Route 93 Jackson, OH 45640 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 Review of the policy titled Managing Falls and Fall Risk dated March 2018, revealed the staff were to implement a resident-centered fall prevention plan to reduce the risk for falls. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365393 If continuation sheet Page 10 of 16 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 365393 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Jackson 8668 State Route 93 Jackson, OH 45640 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on observation, interview and facility policy review, the facility failed to ensure the enteral feeding bottle and tubing for Resident #36 was labeled with nurse initials, date and time initiated. This affected one resident receiving tube feeding. The facility census was 63. Findings include: An observation on 10/04/21 at 10:03 A.M. of Resident #36's enteral feeding bottle and tubing hanging from the administration pole and threaded through the pump, revealed no date and time the formula was initiated and the nurse did not initial. An interview on 10/04/21 at 10:15 A.M. with Licensed Practical Nurse (LPN) #13 confirmed the bottle of enteral feeding was not dated or initialed by the nurse along with the tubing. Review of the facility policy titled Enteral Tube feeding via Continuous Pump dated 11/18 revealed the facility did not follow the policy regarding labeling. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365393 If continuation sheet Page 11 of 16 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 365393 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Jackson 8668 State Route 93 Jackson, OH 45640 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to date and change oxygen tubing at appropriate intervals and document when 'as needed' oxygen was being used for Resident #21. This affected one resident (#21) of one reviewed for oxygen use. The facility identified 15 residents receiving oxygen. Residents Affected - Few Findings include: Review of the medical record revealed Resident #21 had an admission date of 10/05/18 with diagnoses including chronic obstructive pulmonary disease, hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting left non-dominant side, malignant neoplasm of ascending colon, chronic kidney disease stage three, major depressive disorder, dysphagia, chronic respiratory failure with hypoxia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed the resident had intact cognition. Review of the physician's orders for September and October 2021 revealed an order for oxygen four liters per minute as needed for shortness of breath. There were no orders to change oxygen tubing. Review of the Treatment Administration Record (TAR) for September and October 2021 revealed oxygen was documented as having been used on 09/08/21. On 10/04/21 at 12:25 P.M. observation revealed Resident #21 had oxygen in place. The oxygen tubing was undated. On 10/04/21 at 12:31 P.M. interview with Licensed Practical Nurse (LPN) #155 confirmed Resident #21's oxygen was in place and the tubing was undated. LPN #155 revealed she thought the respiratory therapist was responsible for changing the oxygen tubing. At 12:33 P.M., LPN #155 revealed their process had recently changed and it was nursing's responsibility to change the oxygen tubing. On 10/05/21 at 12:50 A.M. and 1:38 P.M. observation revealed Resident #21 was receiving oxygen. On 10/05/21 at 1:46 P.M. interview with LPN #132 confirmed Resident #21 was receiving oxygen. When reviewing the TAR's LPN #132 confirmed it was only documented the resident had used oxygen once since the beginning of September. LPN #132 confirmed the resident used oxygen more frequently than that, she said he used it most nights and on and off throughout the day. She was unsure why it was not documented in the TARs. Review of the policy titled Oxygen Administration dated October 2010, revealed before administering oxygen the resident's care plan should be assessed for any special needs. Oxygen tubing was to be changed at a minimum monthly and as needed. Following oxygen administration the nurse should document the reason for as needed oxygen administration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365393 If continuation sheet Page 12 of 16 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 365393 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Jackson 8668 State Route 93 Jackson, OH 45640 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to address one resident's (#24) pharmacy recommendation in a timely manner. Additionally the facility also failed to carry out one resident's (#52) pharmacy recommendation when addressed by the physician. This affected two of five residents reviewed for unnecessary medications. Findings Include: 1. Review of Resident #24's medical record revealed an original admission date of 04/03/17 with the latest readmission of 03/20/20. Diagnoses included chronic obstructive pulmonary disease (COPD), acute and chronic respiratory failure, chronic bronchitis, emphysema, bipolar disorder, paranoid personality disorder, dysphagia, low back pain, anxiety disorder, gastroesophageal reflux disease (GERD), chronic pain syndrome, insomnia, vitamin D deficiency, benign prostatic hyperplasia, constipation, hypertension, osteoarthritis, major depressive disorder and nontoxic goiter. Review of the plan of care dated 02/04/20 revealed the resident used anti-anxiety medications related to anxiety disorder. Interventions included to administer anti-anxiety medications as ordered by the physician and monitor/document/report as needed any adverse reactions to anti-anxiety medication. Review of the resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had clear speech, understood others, made himself understood and had a moderate cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of 12. Review of the mood and behavior indicated the resident had indicators of depression, but displayed no behaviors. The resident required extensive assistance of two staff for bed mobility, transfers and was non-ambulatory during the assessment period. The resident received antidepressant, antianxiety, diuretic and opioid. Review of the resident's monthly physician's orders for September 2021 identified orders dated 09/22/21 for Clonazepam 2 milligrams (mg) by mouth three times daily for bipolar disorder, major depressive disorder and anxiety disorder. Review of the pharmacy recommendation dated 10/28/20 revealed the pharmacist recommended a gradual dose reduction for the medication Buspar 5 mg by mouth three times a day. The physician addressed the recommendation on 12/02/21. On 10/06/21 at 3:45 P.M. interview with the Director of Nursing (DON) verified the pharmacy recommendation was not addressed in a timely manner. 2. Review of Resident #52's medical record revealed an original admission date 12/22/16 with the latest readmission of 12/29/18. Diagnoses included dementia with behavioral disturbances, major depressive disorder, history of falling, hypertension, psychotic disorder with delusions, contracture of unspecified joint and allergic rhinitis. Review of the resident's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had clear speech, rarely/never understood others, sometimes made herself understood and had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365393 If continuation sheet Page 13 of 16 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 365393 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Jackson 8668 State Route 93 Jackson, OH 45640 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 0756 a severe cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of zero. Level of Harm - Minimal harm or potential for actual harm Review of the pharmacy recommendation dated 06/26/20 revealed the pharmacist recommended the medication Claritin be changed from daily to as needed. The physician addressed the recommendation on 07/05/20 and ordered the medication to be on an as needed basis and if no use in 30 days to discontinue the medication. Residents Affected - Few Review of the pharmacy recommendation dated 12/29/20 revealed the pharmacist recommended the medication Claritin be changed to an as needed basis. The physician addressed the recommendation on 01/28/21 and ordered to discontinue the medication. Review of the resident's physician's telephone orders revealed a telephone order dated 02/09/21 to discontinue the medication Claritin. On 10/07/21 at 11:30 A.M. interview with the Director of Nursing (DON) verified the resident's Claritin was not discontinued as ordered on 07/05/21 and she received the medication until 02/09/21 when the physician wrote an additional order to discontinue the medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365393 If continuation sheet Page 14 of 16 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 365393 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Jackson 8668 State Route 93 Jackson, OH 45640 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure one resident's (#52) Claritin (an antihistamine medication) was discontinued as physician ordered. This affected one of five residents reviewed for unnecessary medications. Residents Affected - Few Findings include: Review of Resident #52's medical record revealed an original admission date 12/22/16 with the latest readmission of 12/29/18. Diagnoses included dementia with behavioral disturbances, major depressive disorder, history of falling, hypertension, psychotic disorder with delusions, contracture of unspecified joint and allergic rhinitis. Review of the resident's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had clear speech, rarely/never understood others, sometimes made herself understood and had a severe cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of zero. Review of the pharmacy recommendation dated 06/26/20 revealed the pharmacist recommended the medication Claritin be changed from daily to as needed. The physician addressed the recommendation on 07/05/20 and ordered the medication to be on an as needed basis and if no use in 30 days to discontinue the medication. Review of the pharmacy recommendation dated 12/29/20 revealed the pharmacist recommended the medication Claritin be changed to an as needed basis. The physician addressed the recommendation on 01/28/21 and ordered to discontinue the medication. Review of the medical record revealed no evidence the facility changed the medication to as needed or discontinued the medication as ordered until 02/09/21. On 10/07/21 11:30 A.M. interview with the Director of Nursing (DON) verified the resident's Claritin was not changed to as needed or discontinued as ordered on 07/05/21 and she received the medication until 02/09/21 when the physician wrote an additional order to discontinue the medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365393 If continuation sheet Page 15 of 16 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 365393 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Jackson 8668 State Route 93 Jackson, OH 45640 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 - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and interview the facility failed to serve food in a sanitary manner, when touching ready to eat food with soiled gloves for two residents (#13 and #43). The facility identified 62 residents who consumed food from the kitchen. The facility census was 63. Findings include: On 10/06/21 at 11:30 A.M. observation of the lunch service revealed Dietary Aide #121 was serving the meal. She was observed at 11:30 A.M. washing her hands and putting on a pair of gloves. At 11:43 A.M., 11:44, A.M., and 12:10 P.M. she was observed touching and adjusting her face mask and at 12:05 P.M. she was observed putting her right hand on her scrubs while wearing the same pair of gloves. Observation at 11:54 A.M. revealed Dietary Aide #121 grabbing a hot dog bun out of a bag for Resident #43 and at 12:30 P.M. she grabbed two hot dog buns for Resident #13. She did not change gloves or wash hands before touching the food. Interview at 12:40 A.M. with Dietary Aide #121 confirmed she had touched her face mask and touched food without removing her gloves and washing her hands. It was confirmed two residents received the hot dog buns she touched. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365393 If continuation sheet Page 16 of 16