Inspection·August 31, 2023

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Based on observation, record review, and interviews, the facility failed to honor one residents (#72) preference for rising hour. This affected one of one resident reviewed for choices. The facility census was 67. Findings Include: Review of the medical record for Resident #72 revealed an initial admission date of 05/18/23 with diagnoses including Guillain-Barre syndrome, adult failure to thrive, congestive heart failure, hypertension, gastro-esophageal reflux disease, atrial fibrillation, obesity, urine retention, sleep apnea, quadriplegia, dysphagia, unstageable pressure ulcer to right heel. Review of the plan of care dated 05/18/23 revealed the resident was at risk for decline in activities of daily living (ADL) participation as evidenced by need for assistance with ADL, transfers, ambulation and toileting related to impaired mobility related to quadriplegia, Guillain barre, failure to thrive, congestive heart failure, depression and atrial fibrillation. Interventions included one half laptray to left side while in tilt and space wheelchair, offer resident to be up in chair daily in A.M./lunch meal. Review of the resident's task list for the State Tested Nursing Assistants (STNA) identified an entry to offer the resident to be up in chair daily for A.M./lunch meal. On 08/28/23 at 10:40 A.M. interview with Resident #72 revealed she preferred time to be assisted up for the day was at 11:00 AM., however, many days she is not assisted out of bed and into her wheelchair. On 08/29/23 at 10:59 A.M., observation of Resident #72 revealed she was quiet at bedrest. On 08/29/23 at 1:00 P.M., Resident #72 was at bedrest visiting with her husband. She revealed the staff had not gotten her up as desired. On 08/29/23 at 1:03 P.M., interview with STNA #160 and STNA #120, who were assigned to the resident for care revealed the resident's preferred rising time was 11:00 A.M. STNA #120 verified the resident was not assisted up in her wheelchair at her preferred time. STNA #120 revealed the resident would remain in bed for the day. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365393 If continuation sheet Page 2 of 12 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 08/31/2023 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Based on record review, and staff interview the facility failed to have accurate advance directives in the electronic and medical record. This affected one resident (#5) of one resident reviewed for advanced directives. The facility census was 67. Findings include: Record review of Resident #5 revealed an admission date of 02/17/23 with pertinent diagnoses of: benign neoplasm of adrenal gland, chronic obstructive pulmonary disease, morbid obesity, vitamin D deficiency, hyperlipidemia, and obesity. Review of the 07/15/23 significant change Minimum Data Set (MDS) assessment revealed the resident was cognitively intact and required extensive assistance for bed mobility, transfer, locomotion on unit, and toilet use. The resident used a walker to aid in mobility and was occasionally incontinent of bladder and always continent of bowel. Review of the electronic medical record on 08/29/23 at 9:35 A.M. revealed the resident had a Physician's Order dated 02/18/23 for an advanced directive to be a do not resuscitate comfort care arrest (DNRCC-A) code status. Review of the paper medical record on 08/29/23 at 9:40 A.M. revealed a DNR Comfort Care Form dated 02/24/23 for the resident to be a do not resuscitate comfort care (DNRCC). Interview with the Director of Nursing (DON) on 08/29/23 at 2:09 P.M. verified Resident #5's electronic medical record and paper DNR code status did not match. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365393 If continuation sheet Page 3 of 12 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 08/31/2023 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 0602 Protect each resident from the wrongful use of the resident's belongings or money. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, and facility policy review, the facility failed to ensure one resident's (#72) tilt and space wheelchair was not misappropriated. This affected one of two residents reviewed for abuse. The facility census was 67. Residents Affected - Few Findings include: Review of the medical record for Resident #72 revealed an initial admission date of 05/18/23 with diagnoses including Guillain-Barre syndrome, adult failure to thrive, congestive heart failure, hypertension, gastro-esophageal reflux disease, atrial fibrillation, obesity, urine retention, sleep apnea, quadriplegia, dysphagia, unstageable pressure ulcer to right heel. Review of the plan of care dated 05/18/23 revealed the resident was at risk for decline in activities of daily living (ADL) participation as evidenced by need for assistance with ADL, transfers, ambulation and toileting related to impaired mobility related to quadriplegia, Guillain Barre, failure to thrive, congestive heart failure, depression and atrial fibrillation. Interventions included one half laptray to left side while in tilt and space wheelchair, offer resident to be up on chair daily in A.M./lunch meal. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. The resident required extensive assistance of two with ADL. Review of the resident's task list for the State Tested Nursing Assistants (STNA) identified an entry to offer the resident to be up in chair daily for A.M./lunch meal. Review of the August 2023 facility activity calendar revealed the happy hour/monthly birthday party was scheduled on 08/24/23 at 2:00 P.M. Review of the resident's August 2023 activity participation record revealed the resident had not attended the scheduled happy hour/monthly birthday party. On 08/28/23 at 10:42 A.M., interview with Resident #72 revealed the facility took her wheelchair to transport another resident to an appointment outside of the facility. She revealed she wanted to attend the scheduled birthday party for the August birthdays and was unable to attend due to the facility taking her wheelchair. She revealed she remained in bed that day. 08/29/23 1:03 P.M. interview with State Tested Nurse Aide (STNA) #120 verified the facility had taken Resident #72's wheelchair to transport Resident #46 to an appointment outside of the facility. STNA #120 revealed she was unsure if the resident was assisted into the her wheelchair that day. Review of the facility policy titled, Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, dated 10/06/22 revealed residents had the right to be free from abuse, neglect, exploitation and misappropriation of resident property. The facility defined misappropriation of resident property as the deliberate misplacement, exploitation or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365393 If continuation sheet Page 4 of 12 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 08/31/2023 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. A review of Resident #15's medical record revealed she was admitted to the facility on [DATE]. Her admitting diagnoses included the diagnosis of major depressive disorder and hallucinations. A review of Resident #15's preadmission screening/ resident review (PASARR) identification screen dated 06/12/20 revealed the screen was completed for an Ohio resident seeking nursing facility admission. Section (D.) of the screen documented indications of serious mental illness. There were seven diagnoses listed that the assessor was to mark the box by the diagnosis to indicate if the resident had that particular diagnosis. There was another box for the assessor to mark the presence of another mental disorder other than mental retardation that may lead to a chronic disability. The resident's screen was not marked to reflect her having any of those mental illness diagnoses, despite her being known to have major depressive disorder at the time of the screen was completed. A review of Resident #15's diagnoses list revealed the resident was given additional mental illness diagnoses, after her admission to the facility. A diagnosis of schizo-affective disorder was added to her diagnoses on 10/23/20. The diagnoses of anxiety disorder and dementia with a psychotic disturbance were added to her diagnoses on 02/28/23. Further review of Resident #15's medical record revealed it was absent for evidence of a new PASARR screen being completed, after the resident had additional diagnoses of a mental illness added to her diagnoses list. Findings were verified by Social Service Assistant #118. On 08/30/23 at 2:55 P.M., an interview with Social Service Assistant #118 revealed she was not the facility's social worker when Resident #15 was admitted to the facility on [DATE]. She confirmed the resident's initial PASARR screen was not completed accurately as her diagnosis of major depressive disorder was not included with the initial PASARR screen. She indicated the resident's diagnosis of major depressive disorder should have been marked under mood disorder, which was included as one of the diagnoses on the screen. She also confirmed the resident should have had a new PASARR screen completed, after she had a diagnosis of schizo-affective disorder added on 10/23/20. She verified she was working as the facility's social worker in September 2022, when the resident had the diagnosis of schizo-affective disorder of the depressive type added on 09/29/22. She was also working at the facility on 02/28/23 when dementia with psychotic features and anxiety disorder was added to her diagnoses. She stated she did not know she was required to submit a new PASARR, when a resident had a new mental illness diagnosis added, after their initial PASARR screen was completed upon admission. 4. Review of the medical record for Resident #44 revealed an initial admission date of 03/15/19 with the latest readmission of 10/06/20 with diagnoses including diabetes mellitus, insomnia, urinary incontinence, peripheral vascular disease, congestive heart failure, angina pectoris, mood disorder, post-traumatic stress disorder, hyperlipidemia, hypertension, dermatitis, dysphagia, gastro-esophageal reflux disease, hallucinations and left below the knee amputation. Review of the plan of care dated 08/11/23 revealed the resident had bipolar disorder and schizoaffective disorder. Interventions included administer medications as ordered, monitor closely during acute episodes of behaviors and psych consult as needed. Review of the medical record revealed on 04/18/23 the resident was given the diagnoses of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365393 If continuation sheet Page 5 of 12 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 08/31/2023 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 0644 schizoaffective disorder, bipolar type. Level of Harm - Minimal harm or potential for actual harm Review of the medical record failed to identify a change in condition PASARR when the diagnoses of schizoaffective disorder, bipolar was added. Residents Affected - Some On 08/29/23 at 2:39 P.M., interview with the Director of Nursing (DON) verified the facility had not completed a change in condition PASARR when the diagnoses of schizoaffective disorder, bipolar type was added. Based on record review and interview, the facility failed to ensure Level I PASSARs (Preadmission Assessment and Resident Review) were correct and reflected the need for a Level II review for mental health diagnoses for Residents #15, #16, #43,and #44. This affected four (Residents #15, #16, #43, and #44) of four residents reviewed for PASSARs. The facility census was 67. Findings included: 1. Record review revealed Resident #16 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, aphasia following cerebrovascular disease, peripheral vascular disease, major depressive disorder with psychotic features, anxiety disorder, hypertension, and dysphagia. Review of a minimum data set (MDS) completed on 07/19/23 revealed Resident #16 has a brief status for mental status (BIMS) of 14 indicating intact cognition and a depression scale of 17 indicating moderately severe depression. Record review revealed Resident #16 received a diagnosis of psychosis on 03/03/21 and schizophrenia on 10/15/21. Review of Resident #16's PASSAR revealed the diagnoses of depression, anxiety, schizophrenia, and psychosis had not been added to a resident review for a level II mental health screening. Interview on 08/29/23 at 2:31 P.M. with Social Worker (SW) #118 revealed an updated PASSAR had not been completed for Resident #16 because she was unaware mental health diagnoses had to be added for a Level II screening. SW #118 stated she reviews PASSARs when a resident admits to the facility to see if they need updated. 2. Record review revealed Resident #43 was admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia, COPD, anxiety disorder, major depressive disorder, chronic kidney disease, and insomnia. Review of a MDS completed on 07/01/23 revealed Resident #43 had a BIMS of 11 indicating mildly impaired cognition and a depression score of 8 indicating mild depression. Review of a PASSAR completed on 11/18/18 revealed Resident #43 had a diagnosis of schizophrenia but did not list anxiety disorder or major depressive disorder, and a resident review had not been completed to add the diagnoses for a Level II review for mental health. Interview on 08/29/23 at 2:31 P.M. with Social Worker (SW) #118 revealed an updated PASSAR had not been completed for Resident #43 because she was unaware mental health diagnoses had to be added for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365393 If continuation sheet Page 6 of 12 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 08/31/2023 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 0644 a Level II screening. SW #118 stated she reviews PASSARs when a resident admits to the facility to see if they need updated. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365393 If continuation sheet Page 7 of 12 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 08/31/2023 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 - 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 observation, record review, interview, and facility policy review, the facility failed to develop a comprehensive plan of care in the area of indwelling urinary catheter and pain for two residents (#63 and #64). This affected two of 22 sampled residents. The facility census was 67. Findings Include: 1. Review of the medical record for Resident #64 revealed an initial admission date of 05/08/23 with diagnoses including diabetes mellitus, pressure ulcer sacral region, personal history of malignant neoplasm, malaise, non-Hodgkin lymphoma, lymph nodes of inguinal region and lower limb, carcinoma in bladder, lymphedema, generalized muscle weakness, hypertension, histoplasmosis, hyperlipidemia, morbid obesity, benign prostatic hyperplasia, gastro-esophageal reflux disease and neuromuscular dysfunction of bladder. Review of the admission nursing observation dated 05/08/23 revealed the resident was admitted to the facility with an indwelling urinary catheter. Review of the bowel and bladder assessment dated [DATE] revealed the resident had a size 16 FR indwelling urinary catheter for neurogenic bladder. Review of the plan of care dated 05/08/23 revealed the resident had an indwelling urinary catheter related to neurogenic bladder, history of bladder cancer and 16 FR Foley with 20 ml balloon. Interventions included monitor for pain/discomfort due to catheter and monitor/record/report to physician signs/symptoms of urinary tract infection. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. Review of the mood and behavior revealed the resident displayed verbal behaviors towards others. The resident required extensive assistance of one with bed mobility, transfers, toilet use and supervision with ambulation. The assessment indicated the resident has an indwelling urinary catheter and was always continent of bowel. Review of the monthly physician orders for August 2023 identified orders dated 05/08/23 to change Foley catheter bag weekly, maintain dignity cover over indwelling urinary catheter collection bag, and 08/24/23 Foley #16 FR with 20 ml balloon due to bladder cancer, change every month, Foley catheter every shift. On 08/28/23 at 3:30 P.M., observation of Resident #64 revealed had an indwelling urinary catheter to a straight drain collection bag. On 08/31/23 at 9:44 A.M., interview with the Director of Nursing (DON) verified the resident's indwelling urinary catheter plan of care was not comprehensive. 2. Record review revealed Resident #63 was admitted to the facility on [DATE] and has diagnoses including lower back pain, chest pain, spinal stenosis, spondylosis with myelopathy in the cervical region, neuropathy, intervertebral disc in the lumbar region, bilateral sciatica, and anemia. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365393 If continuation sheet Page 8 of 12 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 08/31/2023 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 - Few Review of a MDS completed on 07/09/23 revealed Resident #63 has a BIMS of 15 indicating intact cognition and a depression scale of 5 indicating minimal depression. Review of a care plan updated on 07/22/23 revealed a pain care plan which stated Resident #63 may experience discomfort related to low back pain, chest pain, and lumbar fusion, but did not list resident specific pain goals. Care plan did not indicate the potential for pain affecting his activities of daily living and psychosocial well-being. Interview on 08/31/23 at 11:09 A.M. with Director of Nursing confirmed the pain care plan for Resident #63 was not comprehensive or resident specific. Review of a policy titled Care Plans, Comprehensive Person-Centered revealed comprehensive care plans should be completed within 21 days of admission to the facility or within seven days of the completion of an MDS. The comprehensive, person-centered care plan should measurable objectives and timeframes, describe services attained to maintain residents highest practicable physical, mental, and psychosocial well-being, include resident stated goals, build on the resident's strengths, and recognizes current standards of practice for problem areas. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365393 If continuation sheet Page 9 of 12 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 08/31/2023 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 - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, staff interview, and policy review, the facility failed to ensure a resident's pressure ulcer was accurately assessed to identify the proper staging of the pressure ulcer. This affected one resident (#39) of four residents reviewed for pressure ulcers. Residents Affected - Few Findings include: A review of Resident #39's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included vascular dementia, age-related physical debility, peripheral vascular disease, chronic kidney disease, diabetes mellitus, congestive heart failure, difficulty walking, and muscle weakness. A review of Resident #39's admission nursing assessment dated [DATE] revealed the resident was admitted to the facility with an unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer was covered by slough and/ or eschar in the wound bed) to her coccyx that measured 9 centimeters (cm) by 7 cm. A review of Resident #39's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was identified as being at risk for pressure ulcers and had an unhealed pressure ulcer at the time the assessment was completed. The MDS indicated the resident had an unstageable pressure ulcer that was present upon admission. A review of Resident #39's care plans revealed the resident had a pressure ulcer to her coccyx related to pressure points, debility, moisture, friction, impaired mobility, dementia, diabetes mellitus, a history of skin breakdown, and being non-compliant with preventative measures. The interventions indicated the staff would monitor for changes and would notify the physician as needed. A review of Resident #39's physician's orders revealed she had a treatment in place for the pressure ulcer to her coccyx. The treatment ordered was to cleanse the pressure ulcer with Dakin's solution, apply Medi-honey and a foam dressing daily until resolved. That order had been in place since 07/11/23. A review of Resident #39's pressure ulcer assessments for the pressure ulcer to her coccyx revealed the area was determined to be an unstageable pressure ulcer on 06/23/23, when the resident was admitted to the facility. Pressure ulcer assessments had been completed weekly. The weekly wound assessment dated [DATE] indicated the resident's pressure ulcer continued to be classified as an unstageable pressure ulcer. The assessment indicated the pressure ulcer had a depth of 1.2 cm and the wound bed was described as being moist, red with 100% granulation tissue. The weekly wound assessment dated [DATE] revealed the nurse assessing the pressure ulcer continued to classify it as an unstageable pressure ulcer with a depth recorded as 1 cm. The description of the wound continued to indicate the wound bed was moist, red, and presented as a healing stage II pressure ulcer. The last wound assessment completed on 08/23/23 revealed the pressure ulcer continued to be classified as an unstageable pressure ulcer with a depth recorded as 0.5 cm. The wound bed was moist, red, and presented as a healing stage II pressure ulcer. On 08/30/23 at 1:21 P.M., an observation of Resident #39's dressing change to the pressure ulcer she had to her coccyx revealed she had a small open area to her coccyx that was approximately the size (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365393 If continuation sheet Page 10 of 12 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 08/31/2023 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 Level of Harm - Minimal harm or potential for actual harm of a BB. The treatment was performed by Licensed Practical Nurse (LPN) #167 and she was assisted by LPN #191. LPN #191 assessed and measured the wound, after LPN #167 had removed the old dressing and cleansed the wound. LPN #191 indicated the pressure ulcer to the resident's coccyx measured 0.6 cm x 0.4 cm x 0.4 cm. She described the wound as being open with the wound bed having pink granulated tissue. The peri-wound area was indicated to be macerated with some white tissue surrounding the wound. Residents Affected - Few On 08/30/23 at 3:20 P.M., an interview with LPN #191 revealed LPN #167 was the facility's treatment nurse, but she was the one who usually assessed and measured the facility's pressure ulcers weekly. She denied she was wound certified, nor was the facility's treatment nurse. They had a nurse practitioner that frequently visited the facility, who was wound certified, and oversaw their wound treatments. She was asked what she was using to help her stage pressure ulcers and reported they had a guide they followed on staging pressure ulcers. She was asked to review the weekly pressure ulcer assessments for 08/09/23, 08/16/23, and 08/23/23 that had documentation that did not support the staging of the resident's pressure ulcer on her coccyx. She confirmed the pressure ulcer assessment completed on 08/09/23 did classify the pressure ulcer as an unstageable pressure ulcer, despite the wound bed having moist, red tissue present and a depth of 1.2 cm. She also confirmed the wound bed had 100% granulated tissue, which would not make it an unstageable pressure ulcer by definition. She agreed the pressure ulcer should have been classified as a stage III pressure ulcer (full thickness tissue loss, subcutaneous fat may be visible but bone, tendon, or muscle were not exposed and slough may be present but did not obscure the depth of tissue loss). She did not know that she could reclassify an unstageable pressure ulcer as a stage III or stage IV pressure ulcer, whenever the slough or the eschar was removed exposing the wound bed and amount of tissue loss that was present. She also confirmed the pressure ulcer assessments completed on 08/16/23 and 08/23/23, which had the pressure ulcer classified as an unstageable pressure ulcer that presented as a healing stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red, pink wound bed), were not accurate assessments either. Based on the wound characteristics and the depth of the wound recorded on the assessments as being 0.5 cm to 1 cm, it could not be a stage II pressure ulcer as it was not a shallow crater or had just the top layer of the dermis removed. She acknowledged the pressure ulcer remained a healing stage III pressure ulcer at that time and should have been assessed as such. A review of the facility's Pressure Injury Management Guidelines (copyrighted in 2019) revealed the definition of an unstageable pressure ulcer was a full-thickness skin and tissue loss, in which the extent of tissue damage within the ulcer could not be confirmed because it was obscured by slough or eschar. A stage III pressure ulcer was defined as a full-thickness loss of skin, in which adipose (fat) was visible in the ulcer and granulation tissue and rolled wound edges were often present. Slough and/ or eschar may be visible. A stage II pressure ulcer was defined as partial-thickness loss of skin with exposed dermis. The wound bed was viable, pink or red, moist and may also present as an intact or ruptured serum-filled blister. Adipose and deeper tissues were not visible. Granulation tissue, slough, and eschar were not present. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365393 If continuation sheet Page 11 of 12 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 08/31/2023 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 Based on observation, record review, interview and facility policy review, the facility failed to ensure nebulizer medication delivery system was stored properly. This affected one of one resident (#58) reviewed for respiratory. The facility census was 67. Residents Affected - Few Findings Include: Review of the medical record for Resident #58 revealed an initial admission date of 05/27/22 with the latest readmission of 07/15/23 with diagnoses including noninfective gastroenteritis and colitis, disorder of bone density, bacteremia, vascular dementia, chronic obstructive pulmonary disease (COPD), gastro-esophageal reflux disease, obstructive and uropathy, depression, anxiety disorder, epilepsy, osteoarthritis, spinal stenosis lumbar region, alcohol abuse, hypertension, neoplasm of unspecified behavior of endocrine glands and parts of nervous system, hyperlipidemia, bipolar disorder and hypothyroidism. Review of the plan of care dated 06/02/23 revealed the resident had an altered respiratory status/difficulty breathing related to COPD. Interventions included administer medications/puffers as ordered, monitor for effectiveness and side effects, encourage resident to elevate head of bed to help reduce shortness of breath, encourage sustained deep breaths, monitor for signs/symptoms of respiratory distress, monitor/document/report abnormal breathing patterns to physician, provide oxygen as ordered and provide relation training as appropriate to help normalize breathing patterns. Review of the monthly physician orders for August 2023 identified orders dated 08/24/23 for oxygen at two liters/minute via nasal cannula as needed for dyspnea, oxygen pulse oximetry every shift, change tubing every week and Ipratropium-Albuterol Inhalation Solution 0.5-2.5 milligrams (mg)/3 milliliter (ml) with the special instructions to inhale orally every six hours as needed for shortness of breath or dyspnea. On 08/28/23 at 3:15 P.M., observation of the resident's nebulizer medication dispenser revealed the tubing was wrapped around the acorn and laying on top of the machine without any bag. On 08/29/23 at 1:12 P.M., observation of the nebulizer medication dispenser revealed the tubing remained wrapped around the acorn and laying on top of the machine without any bag. Interview with Licensed Practical Nurse (LPN) #167 verified at the time of the observation the nebulizer medication dispenser was not stored properly. Review of the facility policy titled, Nebulizer Mist Therapy, (not dated) revealed the dried nebulizer, t-piece, mouth piece or mask in separate labeled plastic bag. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365393 If continuation sheet Page 12 of 12