Health inspection·May 19, 2022

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 05/18/22 at 10:20 A.M. interview with Resident #75 revealed she was often awakened by someone yelling at night. Resident #75 further revealed she was not for certain if it was a man or woman who yelled, but it did worry her when she heard it. On 05/18/22 at 12:00 P.M. interview with Occupational Therapist (OT) #420 revealed Resident #45 always wants to be picked up for occupational and physical therapy, but he couldn't do much. OT #420 revealed Resident #45 was a yeller. On 05/18/22 at 1:45 P.M. interview with Social Worker #430 revealed she was aware of multiple resident complaints including Resident #64 and Resident #2 about Resident #45's yelling. Social Worker #430 further stated she had made several attempts to make accommodations for residents who had complaints about the noise. Social Worker #430 stated she was frustrated because every time she tried to make a room change for Resident #64 and Resident #2, she was not able to. Social Worker #430 stated the Director of Nursing (DON) and Administrator would not allow her to move residents to other rooms. Social Worker #430 had suggested using an empty room or the empty hall in the facility but was told she could not because of staffing concerns. Social Worker #430 revealed multiple emails had been ignored when trying to advocate for residents with complaints about Resident #45. On 05/18/22 at 2:00 P.M. interview with the DON confirmed staff were aware of resident complaints about Resident #45 yelling. The facility failed to provide additional information related to how a comfortable and homelike environment was provided for Resident #2, #19, #329, #64 and #75 related to Resident #45 yelling at random and ongoing times throughout each day. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365446 If continuation sheet Page 2 of 13 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 365446 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Piketon 7143 Route 23 South Piketon, OH 45661 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy and procedure review and interview the facility failed to communicate with therapy about range of motion and assistive device recommendations for Resident #23 and failed to ensure restorative range of motion was provided as ordered and addressed in the plan of care for the resident. This affected one resident (#23) of five residents reviewed for range of motion. Findings Include: Review of the medical record for Resident #23 revealed an admission date of 06/02/16 with diagnoses including chronic pulmonary edema, aphasia, mixed hyperlipidemia, sequelae of protein-calorie malnutrition, Alzheimer's disease, dysphagia, contracture of right ankle and right hand, major depression disorder, anorexia, hemiplegia affecting right side, cognitive communication deficit and cerebral infarction. Review of the restorative plan of care, dated 03/15/21 revealed Resident #23 was at risk for a decline in functional range of motion related to limited mobility. A decline was expected due to diagnoses. Interventions included completing passive range of motion ten repetitions of three to bilateral lower extremities six to seven days a week for at least 15 minutes a day, completing passive range of motion to bilateral upper repetitions with ten repetitions for 15 minutes or more for six to seven days a week, the nurse was to be informed of any changes in Resident #23's ability to participate or of any pain, and if the resident refused it should be offered again at a later time. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 05/06/22 revealed Resident #23 had severely impaired cognition, required extensive assistance from one person for bed mobility and transfers, walking and locomotion did not occur during the look back period and the resident was totally dependent on one person for eating. The assessment revealed the resident had range of motion impairment of the bilateral upper and lower extremities on one side. Review of Resident #23's physician's orders revealed she had an order for restorative passive range of motion to her right lower extremity according to the plan of care starting 05/11/22. Further review revealed an order for active range of motion to left lower extremity according to the plan of care starting 05/11/22. Review of the restorative task documentation Passive range of motion to bilateral lower extremity six to seven days a week for at least 15 minutes per day from 04/19/22 to 05/17/22, revealed they were not done consistently. Documentation indicated range of motion was done on 04/22/22, 04/27/22, 04/28/22, 04/29/22, 05/02/22, 05/06/22 and 05/07/22. Range of motion was refused on 04/23/22 and 05/10/22 and listed as 'not applicable' on 05/14/22. Review of the restorative task documentation Passive range of motion to bilateral upper extremities. Staff to perform range of motion to bilateral upper extremities six to seven days per week for 10 repetitions for 15 minutes or more from 04/19/22 to 05/17/22, revealed they were not done consistently. Documentation indicated range of motion was done on 04/22/22, 04/27/22, 04/28/22, 04/29/22, 05/02/22, 05/06/22 and 05/07/22. Range of motion was refused on 04/23/22 and 05/10/22 and listed as 'not applicable' on 05/14/22. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365446 If continuation sheet Page 3 of 13 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 365446 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Piketon 7143 Route 23 South Piketon, OH 45661 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the physical therapy Discharge summary, dated [DATE] revealed Resident #23 received physical therapy from 03/01/22 to 05/06/22. The summary indicated a restorative program was not indicated at that time. Review of the occupational therapy Discharge summary, dated [DATE] revealed Resident #23 received occupational therapy from 02/28/22 to 05/06/22. The summary indicated a restorative program was not indicated at that time; she had a good prognosis with consistent staff follow-through. On 05/16/22 at 11:50 A.M., 12:38 P.M. and 1:22 P.M. and on 05/17/22 at 9:06 A.M. and 4:05 P.M. Resident #23's right hand was observed to be tightly contracted and her fingers were not visible. At each observation a soft palm protector was observed on the resident's bedside table. On 05/18/22 at 12:08 P.M. Resident #23's right hand was observed to be tightly contracted. A soft palm protector was resting on her chest above her hand. Agency Certified Nurse Aide (CNA) #77 attempted to unclench Resident #23's hand to view it. At that time, she was unable to open it enough to view the palm as Resident #23 was using her left hand to attempt to get her to stop opening her right hand. However, Resident #23's nails were observed to extend around half a centimeter past her fingertips. All nails on her right hand were black from the tip to halfway down her fingernail. On 05/18/22 at 12:08 P.M. interview with Agency CNA #77 confirmed Resident #23's nails were black and needed clipped and the hand protector had not been on. Agency CNA #77 reported completing restorative programs were hit or miss. She reported she made sure Resident #23 was wearing the palm protector but declined to comment on other aides. On 05/18/22 at 11:58 A.M. interview with Occupational Therapist (OT) #420 revealed Resident #23's contractures were not going to get better. She previously had a splint for her right hand, however, it no longer worked for her. She reported they then switched to the palm protectors, which she should wear a majority of the time. She revealed she had not gotten an order for the protector. OT #420 reported she made an error in the discharge summary and stated she had recommended the passive range of motion restorative program continue for Resident #23. On 05/19/22 at 9:30 A.M. interview with Physical Therapy (PT) Aide #210 revealed they had recommended no splints or restorative program for Resident #23's bilateral lower extremities upon discharge from therapy. On 05/19/22 at 10:00 A.M. interview with the Director of Nursing (DON) confirmed the remaining orders for range of motion to lower extremities, the plan of care interventions for bilateral upper and lower extremities, and the missing documentation for the restorative program as listed in the plan of care. She reported there seemed to be a communication problem. Review of the undated policy titled Restorative Nursing Documentation revealed treatment provided as part of a restorative nursing program was to be documented on a daily basis by the restorative aide or other trained individual. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365446 If continuation sheet Page 4 of 13 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 365446 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Piketon 7143 Route 23 South Piketon, OH 45661 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, record review and interview the facility failed to ensure fall interventions were in place for Resident #50 to prevent falls. This affected one resident (#50) of three residents reviewed for falls. Findings include: Review of the medical record for Resident #50 revealed the resident was admitted to the facility on [DATE] with diagnoses including hyperlipidemia, type two diabetes mellitus, dysphagia, chronic obstructive pulmonary disease, hemiplegia and hemiparesis affecting right dominant side, mood disorder, aphasia, cerebral infarction, cognitive communication deficit and major depression. Review of the plan of care, initiated 08/31/20 revealed Resident #50 was at risk for falls related to impaired balance, impaired mobility, hemiplegia, incontinence, pain, seizures, dizziness, and history of falls. Resident #50 had been educated and encouraged related to safety needs however, she continued to self-transfer and self-ambulate without asking for assistance. Interventions included anti-roll backs to wheelchair, perimeter mattress, extensive assistance of two staff members for transfers, encourage the resident to wear non-skid footwear, keep bed in lowest position, nonskid strips in front of the toilet, starting 09/16/20 Dycem to cushion in wheelchair, starting 11/18/21 Dycem to wheelchair, and starting 05/06/22 there was an intervention check the wheelchair had Dycem when getting the resident out of bed. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/15/22, revealed Resident #50 had intact cognition, functional limitation in range of motion on one side to both upper and lower extremities, required extensive assist of one person for bed mobility and dressing and extensive assistance of two persons for transfers. Resident #50 had one fall since prior assessment without injury. Review of the progress note, dated 05/06/22 revealed Resident #50 was observed laying on her left side on the floor in front of her wheelchair. She stated she had slid out on her butt and fell over. The resident denied hitting her head, denied any pain or discomfort and no injuries were noted. Resident #50 was helped up by two staff without difficulty. There was no Dycem in wheelchair but there was a pillow on it. The new intervention was to check that the wheelchair had Dycem in it when getting the resident out of bed. Review of the fall investigation report, dated 05/06/22 revealed it repeated the information in Resident #50's progress note. Resident #50 was found on the floor, she stated she slid out of her wheelchair, and there was no Dycem noted in the wheelchair. The new intervention was to check that the wheelchair had Dycem in it when getting the resident out of bed. On 05/16/22 at 9:10 A.M. and on 05/18/22 at 12:08 P.M. observation revealed Resident #50 did not have a perimeter mattress in place. This was confirmed by Agency Certified Nurse Aide (CNA) #77 on 05/18/22 at 12:08 P.M. On 05/18/22 at 3:40 P.M. and 4:30 P.M. interview with the Director of Nursing (DON) confirmed the use of the Dycem was addressed multiple times in Resident #50's plan of care. She reported the first time the intervention was to put it in the wheelchair, the second time was to put the Dycem on the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365446 If continuation sheet Page 5 of 13 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 365446 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Piketon 7143 Route 23 South Piketon, OH 45661 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 cushion in the chair and the third time the Dycem had not been in place. She additionally confirmed Resident #50 had an order for a perimeter mattress and it was in her plan of care, however, it was not in place. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365446 If continuation sheet Page 6 of 13 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 365446 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Piketon 7143 Route 23 South Piketon, OH 45661 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy and procedure review and interview the facility failed to monitor meal and supplement intake for Resident #23 who had a significant weight loss. This affected one resident (#23) of seven residents reviewed for nutrition. Residents Affected - Few Findings Include: Review of the medical record for Resident #23 revealed the resident was admitted to the facility on [DATE] with diagnoses including chronic pulmonary edema, aphasia, mixed hyperlipidemia, sequelae of protein-calorie malnutrition, Alzheimer's disease, dysphagia, contracture right ankle and right hand, major depression disorder, anorexia, hemiplegia affecting right side, cognitive communication deficit and cerebral infarction. Review of the plan of care, dated 11/03/21 revealed Resident #23 was at nutritional risk related to diagnoses of depression, dementia, dysphagia, hyperlipidemia, hypertension, and malnutrition, and poor meal intakes, weight fluctuations related to variable meal intakes, refusing meals at times and history of significant weight loss. Interventions included providing the diet as ordered, weighing the resident as ordered, encouraging meal and fluid acceptance, give medication to stimulate appetite, give nutritional supplements as ordered and ice cream with lunch and supper. Review of Resident #23's physician's orders revealed Resident #23 had an order for facility nourishment with meals and snacks starting 05/11/21, fortified juice with meals starting 05/02/22, Med pass (supplement) 90 milliliters (ml) twice a day starting 05/05/22 and increased to 200 ml on 05/12/22. Review of Resident #23's weight records revealed on 11/04/21 the resident weighed 116 pounds, on 12/02/21 the resident weighed 112 pounds, on 01/06/22 the resident weighed 108.6 pounds, on 02/03/22 she weighed 105 pounds, on 03/03/22 she weighed 106 pounds, on 04/07/22 she weighed 103.2 pounds, on 04/14/22, she weighed 101.4 pounds, on 04/21/22 she weighed 104 pounds, on 04/28/22 she weighed 102 pounds, and on 05/05/22 she weighed 102.4 pounds. Residents weight of 102.4 pounds indicated a clinically significant weight loss of 11.7% since 11/04/21. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 05/06/22 revealed Resident #23 had severely impaired cognition and was totally dependent on one person for eating. Resident #23 was 59 inches tall and weighed 102 pounds, she had lost weight while not on a weight-loss regimen. Review of the nutritional risk assessment, dated 05/09/22 revealed Resident #23 weighed 102 pounds which was a significant weight loss of 12% over 180 days. The resident's usual weight was 120-130 pounds. The resident was assessed to have total calorie needs as 1202 to 1740 calories a day, 46 to 55 grams of protein a day, and 1202 to 1740 ml of fluids per day. The resident was on a mechanical soft diet, her supplements and snacks included facility nourishment, juice, Med pass and ice cream which she had varied intake of. The dietitian indicated the resident had poor solid food intake; she consumed from 25-50% of meals. Foods, fluids, and interventions were to be encouraged. The dietitian indicated the resident liked liquids better than solid foods but had varied intake. Review of Resident #23's documentation for meal intake from 04/19/22 to 05/18/22 revealed three intakes were documented on 04/20/22, 04/22/22, 04/27/22, 05/06/22 and 05/07/22. Only two intakes were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365446 If continuation sheet Page 7 of 13 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 365446 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Piketon 7143 Route 23 South Piketon, OH 45661 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few documented on 04/23/22, 04/28/22, 04/29/22, 05/02/22, 05/10/22, 05/14/22 and 05/17/22. Only one intake was documented on 05/11/22. No meal documentation was entered on 04/19/22, 04/21/22, 04/24/22, 04/25/22, 04/26/22, 04/30/22, 05/01/22, 05/03/22, 05/04/22, 05/08/22, 05/09/22, 05/12/22, 05/13/22, 05/15/22, 05/15/22 or 05/18/22. Review of Resident #23's documentation for intake of fortified juice with meals from 05/02/22 to 05/18/22 revealed there were no days where three intakes with meals were documented. Only two intakes were documented on 05/02/22, 05/06/22, 05/07/22, 05/10/22 and 05/14/22. Only one intake was documented on 05/05/22 and 05/11/22. No intakes were documented on 05/03/22, 05/04/22, 05/08/22, 05/09/22, 05/12/22, 05/13/22, 05/15/22, 05/16/22, 05/17/22 or 05/18/22. Review of Resident #23's documentation for intake of facility nourishment at all three meals from 04/19/22 to 05/18/22 revealed there were three intakes documented on 04/22/22 and 04/27/22. Only two intakes were documented on 04/23/22, 04/28/22, 04/29/22, 05/02/22, 05/06/22, 05/07/22, 05/10/22, and 05/14/22. Only one intake was documented on 04/20/22, 05/05/22, and 05/11/22. No intakes were documented on 04/19/22, 04/21/22, 04/24/22, 04/25/22, 04/26/22, 04/30/22, 05/01/22, 05/03/22, 05/04/22, 05/08/22, 05/09/22, 05/12/22, 05/13/22, 05/15/22, 05/16/22, 05/17/22 or 05/18/22. Review of Resident #23's documentation for facility nourishment with snacks three times a day from 04/19/22 to 05/18/22 revealed there were three intakes documented on 05/02/22. Two intakes were documented on 04/22/22, 04/23/22, 04/27/22, 04/28/22, 04/29/22, 05/06/22, 05/07/22, 05/10/22, and 05/14/22. One intake was documented on 04/20/22, 05/05/22, and 05/11/22. No intakes were documented on 04/19/22, 04/21/22, 04/24/22, 04/25/22, 04/26/22, 04/30/22, 05/01/22, 05/03/22, 05/04/22, 05/08/22, 05/09/22, 05/12/22, 05/13/22, 05/15/22, 05/16/22, 05/17/22 or 05/18/22. Interview on 05/19/22 at 10:34 A.M. with Registered Dietitian (RD) #95 revealed she had been following Resident #23 closely. She reported they had adjusted her Med pass supplement amount frequency due to changing intakes. RD #95 reported they had multiple interventions in place including juice and other liquid supplements. She confirmed documentation for meal and supplement intake outside of the Medication Administration Record was a problem. She reported she would have to ask multiple facility staff to determine her true intake. Interview on 05/19/22 at 1:20 P.M. with the Director of Nursing (DON) confirmed meal intake and supplement intake were not documented according to when they should have been given. She reported this was due to agency staff. The DON said they were aware of the problem but by the time they realized the documentation had not occurred the agency staff had left. Review of the undated facility policy titled Nutritional and Dietary Supplements revealed due to the possible interactions with some medications, the resident's intake should be documented in the clinical record. Review of the undated facility policy titled Weight Monitoring revealed nutrition interventions were to be identified, implemented, monitored and modified consistent with the resident's assessed needs and current professional standards. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365446 If continuation sheet Page 8 of 13 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 365446 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Piketon 7143 Route 23 South Piketon, OH 45661 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 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident must receive and the facility must provide necessary behavioral health care and services. Based on observation, record review and interview the facility failed to develop and implement a comprehensive and individualized behavior management plan to address the total care needs of Resident #45 and to decrease and/or eliminate yelling behaviors the resident was exhibiting. This affected one resident (#45) of one resident reviewed for accommodation of needs. Findings Include: A review of the medical record for Resident #45 revealed an admission date of 01/25/21 with diagnoses including paraplegia, hemiplegia to left hand, end stage renal disease, paralytic syndrome and chronic respiratory failure. A review of the resident's care plans revealed no plan of care related to or addressing behaviors or difficulty with range of motion to the resident's upper and lower extremities. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 04/04/22 revealed Resident #45 was alert and oriented, able to make decisions, was dependent on staff for mobility and had a pressure injury wound to his sacrum. The MDS assessment also revealed Resident #45 had impaired range of motion to both upper and both lower extremities and had a history of verbal behavior towards others but not enough to significantly intrude on others privacy. An occupational therapy evaluation, dated 05/10/22 revealed Resident #45 had a significant decline in functional mobility and generalized weakness after multiple recent hospital stays. Review of an occupational note for Resident #45, dated 05/13/22 revealed Resident #45 had impaired mobility in all four extremities including all fingers on his right and left hand. It also revealed he was dependent (on staff) for bed mobility, eating and transfers. On 05/16/22 at 9:35 A.M. interview with Resident #2 revealed he had a complaint about Resident #45 always yelling. Resident #2 stated Resident #45 was keeping him awake because he yells 12 hours per day. Resident #2 further stated he had told several staff about the noise, but nothing had changed. On 05/18/22 at 9:20 A.M. a follow up interview requested by Resident #2 was conducted. Resident #2 revealed he was concerned Resident #64 might hurt Resident #45 because the resident (#45) had been yelling all night again. Resident #2 did not state when or how Resident #64 would hurt Resident #45. On 05/18/22 from 9:24 A.M. through 9:30 A.M. an observation revealed Resident #45, who was in his room was yelling and could be heard up to four rooms away. The call light for Resident #45 was not ringing or lit up at the time. Resident #45 was repeatedly yelling out statements that included I am burning up, oh God, and Help. Resident #64 was heard yelling at Resident #45 to shut up, knock it off, and turn it down! Resident #64 also called Resident #45 an inconsiderate brat. On 05/18/22 at 9:30 A.M. interview with Resident #64 confirmed he was upset with Resident #45 and stated he (Resident #45) yells all night interrupting his sleep. Resident #64 stated he had no intention of hurting anyone but wanted his roommate to stop the nonsense. Resident #64 stated he had reported this to the social worker and thought they were working on a new room for him. Resident #64 further revealed the nurses had not done anything but call him (Resident #45) a screamer when he had reported his frustration to them. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365446 If continuation sheet Page 9 of 13 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 365446 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Piketon 7143 Route 23 South Piketon, OH 45661 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 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 05/18/22 at 9:35 A.M. an observation of Resident #45's call light revealed it was right next to his left hand. The call light was a flat pancake style. Resident #45 became visibly angry when he was asked to show he was unable to ring his call light. Resident #45 began yelling again and stated, How many hundreds of times do I have to tell you I CAN'T!!! Resident #45 then stated the wound on his bottom was burning and requested cream be placed on it. Resident #45 began crying and stated, Why do I have to keep telling people I can't do it? An interview with State Tested Nursing Assistant (STNA) #310 on 05/18/22 at 9:45 A.M. revealed STNA #310 stated she had always heard Resident #45 yelling and had never seen him use a call light. On 05/18/22 at 9:48 A.M. an observation between Resident #45 and Licensed Practical Nurse (LPN) #970 was conducted. When LPN #970 asked Resident #45 to use his left hand to press the call light, Resident #45 stated he couldn't. LPN #970 was observed rolling her eyes. When Resident #45 began yelling he stated he couldn't push the button because he was paralyzed, LPN #970 moved the call light to the right side and asked Resident #45 to try pressing the call light with his right hand. Resident #45 yelled again stating he couldn't. On 05/18/22 at 9:50 A.M. interview with LPN #970 confirmed Resident #45 always yelled and complained about his bottom hurting. LPN #970 revealed Resident #45's inability to press the call light was a behavior and he needed to see psychology services. LPN #970 revealed she was aware of the pressure ulcer on Resident #45's sacrum and that he had complained of it burning. LPN #970 revealed Resident #45 shouldn't be having much pain there because the wound was almost healed. LPN #970 further stated she had never seen the resident use his call light except one time maybe a few weeks ago. LPN #970 stated she did not know the process for evaluating the ability of resident's use of call lights. On 05/18/22 at 10:00 A.M. an interview with Resident #19 revealed she had sometimes heard someone yelling and pointed to the doorway. Resident #19 revealed the noise occurred at random times. On 05/18/22 at 10:05 A.M. an interview with Resident #329 revealed she always hears a gentleman yelling and it wakes her up at night. Resident #329 further revealed she had tried to ignore it but couldn't always help it. Resident #329 also stated she felt bad for whomever was yelling. On 05/18/22 at 10:20 A.M. interview with Resident #75 revealed she was often awakened by someone yelling at night. Resident #75 further revealed she was not for certain if it was a man or woman who yelled, but it did worry her when she heard it. On 05/18/22 at 12:00 P.M. interview with Occupational Therapist (OT) #420 revealed Resident #45 always wants to be picked up for occupational and physical therapy, but he couldn't do much. OT #420 revealed Resident #45 was a yeller and did not like when they tried stretching his hands in the past because it was painful for him. On 05/18/22 at 1:45 P.M. interview with Social Worker #430 revealed she was aware of multiple resident complaints including Resident #64 and Resident #2 about Resident #45's yelling. Social Worker #430 further stated she had made several attempts to make accommodations for residents who had complaints about the noise. Social Worker #430 stated she was frustrated because every time she tried to make a room change for Resident #64 and Resident #2, she was not able to. Social Worker #430 stated the Director of Nursing (DON) and Administrator would not allow her to move residents to other rooms. Social Worker #430 had suggested using an empty room or the empty hall in the facility but was told she could not because of staffing concerns. Social Worker #430 revealed multiple emails had been (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365446 If continuation sheet Page 10 of 13 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 365446 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Piketon 7143 Route 23 South Piketon, OH 45661 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 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete ignored when trying to advocate for residents with complaints about Resident #45. Social worker #430 also confirmed there was no plan of care for Resident #45 about his yelling behavior. On 05/18/22 at 2:00 P.M. interview with the DON confirmed staff were aware of resident complaints about Resident #45 yelling. The DON revealed she believed Resident #45 knew how to use a call light and had behaviors. There was no evidence the behaviors had been comprehensively assessed or addressed to manage, decrease or prevent. The DON revealed she was not aware there was no care plan for behaviors in Resident #45's medical record. Event ID: Facility ID: 365446 If continuation sheet Page 11 of 13 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 365446 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Piketon 7143 Route 23 South Piketon, OH 45661 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to provide an appropriate diagnosis for the use of antipsychotic medication for Resident #51. This affected one resident (#51) of five residents reviewed for unnecessary medication use. Findings Include: Record review for Resident #51 revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia, muscle weakness, depression, hypertension, anxiety, insomnia, Vitamin D deficiency, seizures, dementia, falls and diabetes mellitus type II. Review of the Minimum Data Set (MDS) 3.0 assessment, completed on 02/09/22 revealed the resident had severe cognitive impairment. Review of physician's orders revealed the resident had an order for the psychoactive medication, Seroquel 50 milligrams (mg) by mouth daily for unspecified dementia, anxiety and depression and Risperdone three mg by mouth daily at bedtime for unspecified dementia. Interview with the Director of Nursing on 05/18/22 at 02:35 P.M. verified unspecified dementia was not an acceptable diagnosis for the use of Seroquel or Risperdone. Also verified the resident received the medications on a daily basis. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365446 If continuation sheet Page 12 of 13 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 365446 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Piketon 7143 Route 23 South Piketon, OH 45661 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 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on record review and staff interview the facility failed to ensure quarterly Quality Assessment and Assurance (QAA) meetings were conducted. This had the potential to affect all 84 residents residing in the facility. Residents Affected - Many Findings Include: Review of the QAA sign in sheets from 2021 and 2022 revealed meetings were held on 07/29/21 and 11/19/21. The facility failed to provide any additional sign in sheets to reflect quarterly meetings being conducted. Interview with the Administrator on 05/19/22 at 1:50 P.M. verified no further meeting sign in sheets could be found or provided as the only records were from meetings held on 07/29/21 and 11/19/21. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365446 If continuation sheet Page 13 of 13