Health inspection·January 29, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Interview on 01/17/24 at 3:36 P.M. with the Director of Nursing (DON) confirmed Resident #78's representative was not notified of the resident's significant weight loss. Review of the facility policy titled Notification of Changes dated 09/22/22 revealed the facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. Event ID: Facility ID: 365446 If continuation sheet Page 2 of 25 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 01/29/2024 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 0641 Ensure each resident receives an accurate assessment. 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 the accuracy of resident assessments. This affected two (Residents #15 and #60) of 22 sampled residents. The facility census was 84. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #60 revealed an admission date of 01/19/22 with diagnoses including quadriplegia, acute respiratory failure, aphasia, dysphagia, and severe protein calorie malnutrition Review of the care plan for Resident #60 dated 09/08/23 revealed the resident had an order for hospice care due to terminal diagnoses of intracranial hemorrhage. Interventions included the following: allow resident time and the opportunity to discuss his situation as needed, check with resident to see if he/she would like clergy visits, hospice care to be provided by hospice agency of resident's or family's choice, refer family to grieving support groups as needed, resident to be kept comfortable and as pain free as medically possible. Review of the quarterly MDS assessment for Resident #60 dated 12/14/23 revealed the resident had a moderate cognitive deficit. The assessment was coded negatively for the resident receiving hospice services. Review of the monthly physician orders for January 2024 for Resident #60 revealed the resident was admitted to hospice services with a diagnosis of intracranial hemorrhage. Interview on 01/22/24 9:37 A.M. with the Administrator confirmed the quarterly MDS for Resident #60 dated 12/14/23 was inaccurate related to the resident's enrollment with hospice services. The Administrator confirmed the resident had been receiving hospice services since admission to the facility. 2. Review of the medical record for Resident #15 revealed an admission date of 09/07/23 with diagnoses including bipolar disorder, dementia with other behavioral disturbances, and history of falling. Review of the nurse progress note for Resident #15 dated 11/10/23 revealed the resident was found lying on the right side on the floor in the dining area with no injuries noted. Review of the discharge return anticipated MDS assessment for Resident #15 dated 11/11/23 revealed the resident was coded to have had no falls since the prior assessment. Interview on 01/18/24 at 9:35 A.M. with MDS Nurse #199 confirmed Resident #15 had fallen while in the facility on 11/10/23, and the MDS assessment dated [DATE] had not been accurately coded to reflect the fall. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365446 If continuation sheet Page 3 of 25 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 01/29/2024 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. 2. Review of the medical record for Resident #25 revealed an initial admission date of 02/07/23 with the latest readmission date of 02/27/23 with diagnoses including polyneuropathy, diabetes mellitus, protein calorie malnutrition, anxiety disorder, Down's Syndrome, hypercalcemia, unstageable pressure ulcer to left hip, dislocation of left shoulder, gastro-esophageal reflux disease, anemia and psoriasis. Review of the PASARR for Resident #25 dated 05/09/23 revealed it was good for 180 days. Review of the quarterly MDS assessment for Resident #25 dated 11/28/23 revealed the resident had a severe cognitive deficit. Review of the medical record for Resident #25 revealed it did not include an updated PASARR for the resident. The only PASARR on file for Resident #25 was the one dated 05/09/23. Interview on 01/18/24 at 9:59 A.M. with the Administrator confirmed the facility had not completed a PASARR for resident since the one dated 05/09/23. Based on medical record review and staff interview, the facility failed to ensure resident Pre-admission Screening and Resident Review (PASARR) documents were accurate regarding resident current conditions and diagnoses and were completed when appropriate. This affected two (Residents #25 and #59) of four residents reviewed for PASARR documents. The census was 84. Findings include: 1.Review of the medical record for Resident #59 revealed an admission date of 08/07/21 with diagnoses including diabetes mellitus type II, drug induced subacute dyskinesia, depression, seizures, hypertension, and anxiety. Further review of the medical record revealed a diagnosis of unspecified psychosis was added for Resident #59 on 05/23/22. Review of the Minimum Data Set (MDS) assessment for Resident #59 dated 01/13/23 revealed the resident was severely impaired for cognition. Review of the PASARR document for Resident #59 dated 07/31/21 revealed it did not include any psychiatric diagnoses for the resident. Interview on 01/22/24 at 2:28 P.M. with the Administrator confirmed the facility should have completed a new PASARR for Resident #59 upon the addition of a new psychiatric diagnosis on 05/23/22. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365446 If continuation sheet Page 4 of 25 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 01/29/2024 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 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. Based on medical record review and staff interview, the facility failed to ensure comprehensive care plans were developed and implemented to reflect the need for care in the area of Post Traumatic Stress Disorder (PTSD) and Preadmission Screening and Resident Review (PASARR) recommendations. This affected one (Residents #76) of 22 residents reviewed for care planning. The facility census was 84. Findings include: Review of the medical record for Resident #76 revealed an admission date of 11/01/23 with diagnoses including schizophrenia, bipolar disorder, anxiety, and PTSD. Review of the admission Minimum Data Set (MDS) assessment for Resident #76 dated 11/07/23 revealed the resident was cognitively intact. Review of the Notice of Level II PASARR Outcome for Resident #76 dated 10/16/23 revealed based on the information provided in the Level II assessment and current records, Resident #76 met inclusion criteria for serious mental illness with diagnoses of schizophrenia, bipolar disorder, nicotine dependence, anxiety disorder, and PTSD. Specialized services and support nursing facility staff were required to provide included supportive counseling from nursing facility staff, skills training, ongoing evaluation of the effectiveness of current psychotropic medications on target symptoms, mental health counseling, behaviorally based treatment plan, and structured therapeutic activities. Review of the active care plans for Resident #76 initiated 11/01/23 revealed there was not a plan of care in place that addressed the specialized services and support detailed in the residents Level II PASARR assessment nor a care plan that addressed the resident's needs related to PTSD. Interview on 01/22/24 at 9:20 A.M. with the Director of Nursing (DON) confirmed there were no care plans in place addressing the care of Resident #76 related to the Level II PASARR assessment or the resident's PTSD diagnosis. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365446 If continuation sheet Page 5 of 25 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 01/29/2024 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 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 Based on medical record review, observation, staff interview, and facility policy review, the facility failed to ensure staff provided assistance with nail care and routine shaving for dependent residents. This affected two (Residents #38 and #78) of four residents reviewed for activities of daily living (ADLs). The facility census was 84. Residents Affected - Few Findings Include: 1. Review of the medical record for Resident #38 revealed an admission date of 10/12/23 with diagnoses including fracture of lumbar vertebra, cardiac arrest, chronic respiratory failure, chronic obstructive pulmonary disease (COPD), diabetes mellitus, morbid obesity, hypertension, constipation, gastro-esophageal reflux disease, hyperlipidemia, chronic kidney disease, atrial fibrillation, congestive heart failure, osteoarthritis, anemia, anxiety disorder, and major depressive disorder. Review of the plan of care for Resident #38 dated 10/26/23 revealed the resident had a self-care deficit related to COPD. Interventions included the following: therapy evaluation and treat as needed, refuses care/risk and benefits with encouragement given, set-up bath items and put out clothes as needed, toileting with one assist, transfers with one assist and shave daily as needed. Review of the Minimum Data Set (MDS) assessment for Resident #38 dated 11/06/23 revealed the resident was cognitively intact. Review of the mood and behavior section of the MDS revealed the resident displayed verbal behaviors directed towards others, behaviors not directed towards others and rejection of care. Review of the progress notes for Resident #38 dated 10/12/23 to 01/17/24 revealed there was no documentation regarding refusal of care. Observation on 01/16/24 at 12:34 P.M. of Resident #38 revealed the resident was holding her hands in fists and her long and jagged fingernails were cutting into the palm of her hands. The resident was unable to open her hands completely on request. Observation on 01/17/24 at 9:30 A.M. of Resident #38 revealed the resident's fingernails were long and jagged with visible debris underneath and she had untrimmed hairs to her chin. Observation on 01/17/24 at 1:45 P.M. of Resident #38 revealed the resident's fingernails were long and jagged with visible debris underneath and she had untrimmed hairs to her chin. Interview on 01/17/24 at 1:47 P.M. with State Tested Nursing Assistant (STNA) #163 confirmed Resident #38's fingernails were long and jagged with visible debris underneath and should be trimmed and cleaned. STNA #163 further confirmed Resident #38's chin hair was long and needed to be trimmed. Review of the facility policy titled Grooming a Resident's Facial Hair dated 2017 revealed it was the practice of the facility to assist residents with grooming facial hair to help maintain proper hygiene as per current standards of practice. 2. Review of the medical record for Resident #78 revealed an admission date of 08/02/23 with diagnoses including cerebrovascular accident (CVA) with right sided hemiplegia, osteoarthritis, nontraumatic subarachnoid hemorrhage, frontal lobe and executive function deficit following CVA, major (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365446 If continuation sheet Page 6 of 25 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 01/29/2024 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few depressive disorder, anxiety disorder, migraine, nicotine dependence, obstructive sleep apnea, hypertension, and hyperlipidemia. Review of the plan of care for Resident #78 dated 08/15/23 revealed the resident had a self-care deficit related to CVA, history of fracture, hemiplegia, impaired mobility, incontinence, pain, poor health management, weakness and osteoarthritis. Interventions included staff to assist with grooming and hygiene and to provide nail care weekly and as needed. Review of the MDS assessment for Resident #78 dated 11/06/23 revealed the resident had a severe cognitive deficit. Observations on 01/17/24 at 8:19 A.M. and 10:45 A.M. of Resident #78 revealed the resident's fingernails were long with visible debris underneath. Interview on 01/17/24 at 12:45 P.M. with the Administrator confirmed Resident #78's fingernails were long with visible debris underneath and staff should clean and trim the resident's nails. Review of the facility policy titled Nail Care dated 2023 revealed routine cleaning and inspection of nails would be provided during ADL care on an ongoing basis. Routine nail care included trimming and filing on a regular schedule. Nail care should be provided between scheduled occasions as the need arises. This deficiency represents non-compliance investigated under Complaint Number OH00149963. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365446 If continuation sheet Page 7 of 25 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 01/29/2024 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, observation, staff interview, facility policy review, and review of guidelines from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to ensure pressure ulcers were thoroughly assessed and failed to ensure treatments for pressure ulcers were completed as ordered. This affected one (Resident #57) of five residents reviewed for pressure ulcers. The facility census was 84. Residents Affected - Few Findings include: Review of the medical record for Resident #57 revealed an initial admission date of 06/19/23 with the latest readmission of 11/07/23 with diagnoses including severe protein calorie malnutrition, chronic respiratory failure, severe morbid obesity, diabetes mellitus, chronic obstructive pulmonary disease (COPD), stage IV pressure ulcer sacral region, chronic kidney disease, hypertension, hyperlipidemia, and congestive heart failure. Review of the admission assessment for Resident #57 dated 06/20/23 revealed the resident was admitted to the facility with an unstageable pressure ulcer to the sacrum measuring 1.5 centimeters (cm) by 1.0 in length by 0.5 cm in width. The assessment did not include any additional description of the wound. Review of the readmission assessment for Resident #57 dated 09/06/23 revealed the resident was readmitted to the facility with a stage IV pressure ulcer to the sacrum measuring 8.0 cm in length by 6.0 cm in width by 0.5 cm in depth, a suspected deep tissue issues (SDTI) to the left lateral foot measuring 1.0 cm, and an unstageable pressure ulcer to the right heel measuring 4.5 cm in length by 4.6 cm in width. The assessment did not include any additional description of the wounds. Review of the plan of care for Resident #57 dated 09/12/23 revealed the resident was at risk for skin breakdown related to impaired mobility, stage IV pressure ulcer wound to the sacrum and stage IV pressure ulcer to the right heel. Interventions included the following: low air loss mattress with lateral supports, observe skin for redness or open areas, notify the nurse, observe skin with showers/care, notify nurse of any new areas of skin breakdown, off-loading boots, may remove for hygiene and skin checks, pressure reducing/relieving cushion to chair, supplements per order, treat left distal lateral foot as ordered, weekly head to toe skin assessment, document and report abnormal findings to physician. Review of the readmission assessment for Resident #57 dated 11/07/23 revealed the resident was readmitted with wounds and to see the full description. The area on the assessment for detailed wound documentation was blank. Further review of the medical record revealed it did not include an assessment of Resident #57's wounds upon readmission to the facility. Review of the pressure ulcer risk assessment for Resident #57 dated 11/08/23 revealed the resident was at risk for skin breakdown. Review of the weekly pressure ulcer assessment for Resident #57 dated 11/14/23 revealed the resident had a stage IV pressure ulcer to the sacrum which measured 1.4 cm in length by 0.6 cm in width by 0.1 cm in depth. The resident had an area to the right heel which measured 3.8 cm in length by 4.1 cm in width. The assessment included a description which indicated the wound bed was granulation tissue with serous exudate and maceration to the peri-wound, but it did not indicate to which wound this (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365446 If continuation sheet Page 8 of 25 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 01/29/2024 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few description applied. The assessment did not indicate what stage and/or type of wound was present to the resident's right heel. The assessment did not indicate if the wounds had improved, declined or were unchanged. Review of the weekly pressure ulcer assessment for Resident #57 dated 11/21/23 revealed the stage IV pressure ulcer to the resident's sacrum measured 2.6 cm in length by 2.3 cm in width by 0.3 cm in depth. The resident had an area to the right heel which measured 2.4 cm in length by 2.2 cm in width. The assessment included a description which indicated the wound bed was granulation tissue with serous exudate and maceration to the peri-wound, but it did not indicate to which wound this description applied. The assessment did not indicate what stage and/or type of wound was present to the resident's right heel. The assessment did not indicate if the wounds had improved, declined or were unchanged. Review of the weekly pressure ulcer assessment for Resident #57 dated 11/28/23 revealed the stage IV pressure ulcer to the resident's sacrum measured 2.2 cm in length by 1.8 cm in width by 0.2 cm in depth with no description of the wound. The wound to the resident's right heel measured 4.5 cm in length by 4.8 cm in width. The assessment included a description which indicated the wound bed was granulation tissue with serous exudate and maceration to the peri-wound, but it did not indicate to which wound this description applied. The assessment did not indicate what stage and/or type of wound was present to the resident's right heel. The assessment did not indicate if the wounds had improved, declined or were unchanged. Review of the weekly pressure ulcer assessment for Resident #57 dated 12/05/23 revealed the stage IV pressure ulcer to the resident's sacrum measured 2.1 cm in length by 1.7 cm in width by 0.1 cm in depth with no description of the wound. The right heel wound measured 6.0 cm in length by 5.2 cm in width. The assessment included a description which indicated the wound bed was granulation tissue with serous exudate and maceration to the peri-wound, but it did not indicate to which wound this description applied. The assessment did not indicate what stage and/or type of wound was present to the resident's right heel. The assessment did not indicate if the wounds had improved, declined or were unchanged. Review of the weekly pressure ulcer assessment for Resident #57 dated 12/19/23 revealed the stage IV pressure ulcer to the sacrum measured 2.3 cm in length by 1.4 cm in width by 0.2 cm in depth with no description of the wound. The right heel wound measured 4.2 cm in length by 4.3 cm in width by 0.4 cm in depth. The assessment included a description which indicated the wound bed was granulation tissue with serous exudate and maceration to the peri-wound, but it did not indicate to which wound this description applied. The assessment did not indicate what stage and/or type of wound was present to the resident's right heel. The assessment did not indicate if the wounds had improved, declined or were unchanged. Review of the weekly pressure ulcer assessment for Resident #57 dated 12/26/23 revealed the stage IV pressure ulcer to the sacrum measured 1.8 cm in length by 1.0 cm in width by 0.2 cm in depth with no description of the wound. The right heel wound measured 4.4 cm in length by 4.2 cm in width by 0.4 cm in depth. The assessment included a description which indicated the wound bed was granulation tissue with serous exudate and maceration to the peri-wound, but it did not indicate to which wound this description applied. The assessment did not indicate what stage and/or type of wound was present to the resident's right heel. The assessment did not indicate if the wounds had improved, declined or were unchanged. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365446 If continuation sheet Page 9 of 25 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 01/29/2024 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the weekly pressure ulcer assessment for Resident #57 dated 01/02/24 revealed the stage IV pressure ulcer to the sacrum measured 3.4 cm in length by 1.6 cm in width by 0.3 cm in depth with no description of the wound. The right heel wound measured 4.5 cm in length by 4.3 cm in width by 0.4 cm in depth. The assessment included a description which indicated the wound bed was granulation tissue with serous exudate and maceration to the peri-wound, but it did not indicate to which wound this description applied. The assessment did not indicate what stage and/or type of wound was present to the resident's right heel. The assessment did not indicate if the wounds had improved, declined or were unchanged. Review of the weekly pressure ulcer assessment for Resident #57 dated 01/09/24 revealed the stage IV pressure ulcer to the sacrum measured 1.2 cm in length by 1.3 cm in width by 0.3 cm in depth with no description of the wound. The right heel wound measured 4.8 cm in length by 4.6 cm in width by 0.4 cm in depth. The assessment included a description which indicated the wound bed was granulation tissue with serous exudate and maceration to the peri-wound, but it did not indicate to which wound this description applied. The assessment did not indicate what stage and/or type of wound was present to the resident's right heel. The assessment did not indicate if the wounds had improved, declined or were unchanged. Review of the weekly pressure ulcer assessment for Resident #57 dated 01/16/24 revealed the stage IV pressure ulcer to the sacrum measured 1.8 cm in length by 0.6 cm in width by 0.2 cm in depth with no description of the wound. The right heel wound measured 3.6 cm in length by 3.4 cm in width by 0.4 cm in depth. The assessment included a description which indicated the wound bed was granulation tissue with serous exudate and maceration to the peri-wound, but it did not indicate to which wound this description applied. The assessment did not indicate what stage and/or type of wound was present to the resident's right heel. The assessment did not indicate if the wounds had improved, declined or were unchanged. Review of the Treatment Administration Record (TAR) for Resident #57 dated December 2023 revealed the physician ordered treatment to the stage IV pressure ulcer to the sacrum (cleanse wound to sacrum with soap and water and pat dry, apply calcium alginate and Alleyn border foam dressing and change once daily) was not signed off as completed on the following dates: 12/03/23, 12/07/23, 12/11/23 and 12/12/23. The physician ordered treatment to the stage IV pressure ulcer to the heel (cleanse wound to right heel with soap and water, pat dry, apply calcium alginate and cover with border gauze once daily) was not signed off as completed on 12/12/23, 12/13/23 and 12/27/23. Review of the monthly physician's orders for Resident #57 for January 2024 revealed orders dated 01/17/24 to cleanse the stage IV pressure wound to the sacrum with wound wash or normal saline (NS), apply calcium alginate with silver and cover with border gauze daily and to cleanse the stage IV pressure wound to right heel with wound wash or NS, and to apply calcium with silver and border gauze daily. Observation on 01/17/24 at 1:10 P.M. of wound care for Resident #57 per Licensed Practical Nurse (LPN) #190 and State Tested Nursing Assistant (STNA) #219 revealed the staff completed the treatment to the pressure ulcers to the resident's sacrum and the resident's right heel. The resident had a dime-sized pressure ulcer to the sacrum which had visible necrotic tissue to the wound bed and a pressure ulcer to the right heel which was the size of a fifty-cent coin with visible slough to the wound bed. Interview on 01/18/24 at 8:25 A.M. with the Director of Nursing (DON) confirmed the facility staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365446 If continuation sheet Page 10 of 25 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 01/29/2024 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few did not conduct thorough wound assessments of Resident #57's stage IV pressure ulcer to the sacrum and the unstageable pressure ulcer to the right heel. The DON confirmed the facility measured the wounds weekly, but the assessments did not include a specific description of each wound and did not indicate whether or not the condition of the wound was improving or deteriorating and/or if the wound treatment needed to be changed. Further interview with the DON confirmed Resident #57 did not receive wound care as ordered to the right sacrum on 12/03/23, 12/07/23, 12/11/23 and 12/12/23 and did not receive wound care as ordered to the right heel on 12/12/23, 12/13/23 and 12/27/23. Review of the facility policy titled Wound Treatment Management dated 09/22/22 revealed wound treatments would be provided in accordance with physician orders, including the cleansing method, type of dressing and frequency of dressing change. Review of the NPUAP guidelines dated 2014 at (https://npiap.com/general/custom.asp?page=2014Guidelines) pages 151 and 152 revealed pressure ulcers should be assessed initially and the re-assessed at least weekly. The nurse should document the results of all wound assessments. The assessment and documentation of the physical characteristics of the wound should include the following: location, category/stage, size, tissue type(s), color, peri wound condition, wound edges, sinus tracts, undermining, tunneling, exudate, odor. The staff should use the findings of the pressure ulcer assessment to plan and document interventions that will best promote wound healing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365446 If continuation sheet Page 11 of 25 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 01/29/2024 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 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. Level of Harm - Actual harm Residents Affected - Few Based on medical record review, observation, staff interview, and facility policy review, the facility failed to develop and implement comprehensive and individualized interventions to prevent the onset of joint contractures for Resident #38. Actual harm occurred on 01/10/24 when Resident #38, who was admitted to the facility without contractures was assessed to have developed contractures to the third and fourth fingers on the left and right hands which caused pain upon range of motion for the resident due to a lack of interventions to prevent the contractures from occurring. This affected one (Resident #38) of one resident reviewed for range of motion. The facility census was 84. Findings include: Review of the medical record for Resident #38 revealed an admission date of 10/12/23 with diagnoses including fracture of lumbar vertebra, chronic respiratory failure, chronic obstructive pulmonary disease (COPD), diabetes mellitus, morbid obesity, hypertension, hyperlipidemia, chronic kidney disease, atrial fibrillation, congestive heart failure, encephalopathy, osteoarthritis, anemia, anxiety disorder, major depressive disorder. Review of the care plan for Resident #38 initiated 10/12/23 revealed the plan did not include the resident's risk for development of contractures and/or an individualized range of motion program for the resident. Review of the occupational therapy (OT) evaluation for Resident #38 dated 10/13/23 revealed the resident's range of motion to the right upper extremity was within normal limits, and the left upper extremity range of motion was within normal limits. A goal of therapy was for Resident #38 to tolerate passive range of motion to bilateral upper extremities to prevent the development of contractures. Review of the Minimum Data Set (MDS) for Resident #38 dated 11/06/23 revealed the resident was cognitively intact and had no functional limitations in range of motion. Review of the OT treatment note for Resident #38 dated 01/10/24 revealed therapy staff were providing manual joint mobilization to the resident's hands to increase joint mobility and/or range of motion. Review of the OT treatment note for Resident #38 dated 01/15/24 revealed OT was providing manual joint mobilization to increase joint mobility and/or range of motion in bilateral upper extremities to aid in contracture control. Further review revealed the treatment note was edited on 01/17/24 at 1:10 P.M. by OT Aide #174 to reflect the addition of the range of motion exercises. Review of the care plan for Resident #38 dated 01/17/24 revealed the resident had an alteration in musculoskeletal status related to contractures to the fingers of her right and left hand. Interventions included continue therapy as ordered, monitor for pain, give analgesics as ordered, monitor for side effects and effectiveness, monitor skin to right and left hand for skin breakdown. Observation on 01/16/24 at 12:34 P.M. revealed Resident #38 was holding her hands in fists, and her long and jagged nails were cutting into the palm of her hands. The resident was unable to open her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365446 If continuation sheet Page 12 of 25 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 01/29/2024 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 hands completely on request. Level of Harm - Actual harm Observation on 01/16/24 at 1:35 P.M. with Registered Nurse (RN) #203 revealed Resident #38's hands were clenched tightly. RN #203 attempted to provide range of motion to the resident's fingers and the resident began screaming out in pain. Residents Affected - Few Interview on 01/16/24 at 1:35 P.M. with RN #203 confirmed Resident #38's fingers were stiff and contracted and the resident verbalized pain when the nurse attempted to provide passive range of motion to the resident's hands. Interview on 01/17/24 at 12:05 P.M. with Occupational Therapist (OT) #178 confirmed Resident #38 was placed on therapy caseload upon admission and they had continued to work with the resident approximately three times weekly since admission. OT #178 confirmed Resident #38 had entered the facility without contractures, but the resident had developed contractures to both hands which were first identified on 01/10/24. OT #178 confirmed therapy had provided range of motion exercises three days per week. Interview on 01/22/24 at 10:51 A.M. with Nurse Practitioner (NP) #500 confirmed Resident #38 had developed contractures to the third and fourth fingers to her hands since the resident's admission to the facility. Interview on 01/22/24/ at 2:28 P.M. with the Director of Nursing (DON) confirmed the Resident #38 was admitted to the facility without contractures and the resident had developed contractures to both hands which were first identified on 01/10/24. The DON further confirmed the facility had not developed an individualized range of motion program or implemented other interventions to prevent contracture formation. Review of the facility policy titled Prevention of Decline in Range of Motion dated 09/29/22 revealed the facility in collaboration with the medical director, DON and OT consultant should establish and utilize a systemic approach for prevention of decline in range of motion, including assessment, appropriate care planning and preventative care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365446 If continuation sheet Page 13 of 25 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 01/29/2024 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 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview, review of hospital progress notes, review of the facility policy, and review of manufacturer's guidelines, the facility failed to ensure Resident #70 was provided adequate and necessary interventions to prevent falls including a fall with injury and failed to ensure post-fall investigations were completed for Resident #69. This affected two residents (Resident #69 and #70) of four residents reviewed for falls. The facility census was 84. Actual harm occurred on 11/29/23 when Resident #70, who was moderately cognitively impaired, at risk for falls and care planned to require the use of hipsters (a type of garment worn to help reduce the risk of injuries from a fall, such as hip fractures, through impact-absorbing foam pads over the critical fracture area) sustained a fall with increased pain and subsequent left hip fracture when not wearing the hipsters as care planned. As a result of the fall, the resident was hospitalized and required surgical intervention to repair the hip fracture. Findings include: 1. Review of the medical record for Resident #70 revealed an admission date of 01/10/23 with diagnoses including history of displaced intertrochanteric fracture of the right femur, dementia, muscle weakness, and repeated falls. Review of the Minimum Data Set (MDS) assessment for Resident #70 dated 11/30/23 revealed the resident was moderately cognitively impaired. Review of the care plan for Resident #70 dated 02/03/23 revealed the resident was at risk for falls related to history of falls and history of fracture. Interventions included the resident should wear hipsters at all times. Review of the nursing progress note for Resident #70 dated 11/29/23 timed at 11:11 P.M. revealed the resident was sitting in a chair in the common area and got up and fell in front of the chair. After the fall, Resident #70 was complaining of left hip pain and was unable to stand. Review of the nursing progress note for Resident #70 dated 11/30/23 timed at 12:31 A.M. revealed the resident was sent to the hospital via ambulance for a post-fall evaluation. Review of the facility fall investigation for Resident #70 dated 11/30/23 revealed the investigation did not indicate whether or not the resident was wearing hipsters per the plan of care at the time of the fall. Review of the hospital discharge summary for Resident #70 dated 12/03/23 revealed the resident was admitted to the hospital on [DATE] with a left hip fracture after sustaining a mechanical fall. The resident underwent surgical repair of the fracture on 12/01/23. Observation on 01/22/24 at 1:08 P.M. revealed Resident #70 was resting in bed and was not wearing hipsters. There were no hipsters visible in the resident's room. Interview on 01/22/24 at 1:08 P.M. with State Tested Nursing Assistant (STNA) #125 confirmed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365446 If continuation sheet Page 14 of 25 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 01/29/2024 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 Resident #70 was not wearing hipsters and did not have hipsters visible in his room. STNA #125 further confirmed she was not aware of the need for Resident #70 to wear hipsters. Level of Harm - Actual harm Residents Affected - Few Interview on 01/22/24 at 2:05 P.M. with the Director of Nursing (DON) confirmed Resident #70 was at risk for falls with injury and his care plan included the intervention of wearing hipsters at all times to prevent risk of hip fractures if the resident fell. The DON further confirmed that the intervention of wearing hipsters at all times remained a current intervention on the resident's care plan. Telephone interview on 01/22/24 at 2:54 P.M. with Licensed Practical Nurse (LPN) #169 confirmed she was working the night Resident #70 fell and fractured his hip. LPN #169 confirmed Resident #70 was supposed to wear hip protectors at all times, but stated he was not wearing them at the time of his fall on 11/29/23. Review of the undated manufacturer's recommendations for hip protectors revealed the garment was worn to protect against hip injuries from falls. The hip protectors had sewn-in foam pads which sat over the hip bones to help absorb energy from falls. Review of the facility policy titled Fall Interventions Program dated 09/29/22 revealed each resident would be assessed for fall risk and would receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. 2. Review of the medical record for Resident #69 revealed an admission date of 07/14/23 with diagnoses including end stage renal disease, seizure disorder, type two diabetes mellitus, and acute respiratory failure with hypoxia. Review of the MDS assessment for Resident #69 dated 10/27/23 revealed the resident was moderately cognitively impaired and used a wheelchair for mobility. Review of the progress notes for Resident #69 revealed the resident sustained falls on 10/31/23 and 11/02/23. Review of the medical record for Resident #69 revealed the record did not include any type of investigations regarding the resident's falls on 10/31/23 and 11/02/23. Interview on 01/22/24 at 1:35 P.M. with the DON confirmed the facility had not completed a post-fall investigations regarding Resident #69's falls on 10/31/23 and 11/02/23. Review of the facility policy titled Fall Prevention Program dated 09/29/2022 revealed when a resident falls the facility would complete a post-fall investigation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365446 If continuation sheet Page 15 of 25 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 01/29/2024 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 Based on medical record review, observation, and staff interview the facility failed to ensure accurate monitoring regarding resident consumption of physician ordered snacks. This affected one (Resident #54) of the three residents reviewed for nutrition. The facility census was 84. Residents Affected - Few Findings include: Review of the medical record for Resident #54 revealed an admission date of 12/06/21 with diagnoses including dementia, aphasia, psychosis, aphasia, vitamin B12 deficiency, and altered mental status. Review of the annual Minimum Data Set (MDS) assessment for Resident #54 dated 12/06/23 revealed the resident was cognitively impaired, was coded negative for significant weight loss, and received a mechanically altered diet. Review of the care plan for Resident #54 revised 01/12/24 revealed the resident was at risk for impaired nutritional status. Interventions included staff should provide snacks three times a day. Review of the physician orders for Resident #54 revealed an order dated 08/16/23 for the resident to receive three snacks a day. Review of the Medication Administration Record (MAR) for Resident #54 for January 2024 revealed on 01/16/24 the resident was documented as having consumed 100 percent of the morning snack and 100 percent of the lunch snack. On 01/17/24 Resident #54 was documented as having consumed 50 percent of morning snack and 100 percent of the lunch time snack. On 01/18/24 Resident #54 was documented as having consumed 50 percent of the morning snack. Review of the nutritional risk assessment for Resident #54 dated 12/12/23 revealed the resident received peanut butter sandwiches for snacks because they provided increased protein. Observation on 01/16/23 at 4:15 P.M. revealed Resident #54 was lying in bed sleeping. There was half of a peanut butter sandwich lying on the resident bedside table in plastic bag which had not been opened or consumed. The bag was labeled with the resident's name and a date of 01/16/24. Observation on 01/17/24 at 8:45 A.M. revealed Resident #54 was lying in bed sleeping. There was half of a peanut butter sandwich on the residents bedside table in a plastic bag which had not been opened. The bag was labeled with the resident's name and was dated 01/17/24. Interview on 01/17/24 at 8:51 A.M. with State Tested Nursing Assistant (STNA) #126 confirmed the morning snack for Resident #54 was unopened and had not been consumed. STNA #126 stated Resident #54 frequently refused her snacks. Observation on 01/17/24 at 2:10 P.M. revealed Resident #54 was up ambulating in the room. There was half of a peanut butter sandwich on the residents bedside table in a plastic bag which had not been opened. The bag was labeled with the resident's name and was dated 01/17/24. Interview on 01/17/24 at 2:15 P.M with STNA #126 confirmed the snack for Resident #54 was unopened and had not been consumed. STNA #126 stated the resident had again refused the snack. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365446 If continuation sheet Page 16 of 25 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 01/29/2024 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 Observation on 01/18/24 at 10:23 A.M. revealed Resident #54 was lying in bed sleeping. There was half of a peanut butter sandwich on the residents bedside table in a plastic bag which had not been opened. The bag was labeled with the resident's name and was dated 01/18/24. Interview 01/18/24 at 10:39 A.M. with STNA #126 confirmed the morning snack for Resident #54 was unopened and had not been consumed and the resident had refused the snack. STNA #126 further stated the nurse on duty documented the percentage of the residents' snacks consumed. Interview on 01/18/24 at 10:34 A.M with Dietary Supervisor (DS) #120 on 01/18/24 at 10:34 A.M. confirmed the kitchen provided Resident #54 with a snack of half of a peanut butter sandwich in the morning, at lunch time, and in the evening to fulfill the physician's order of a snack three times a day. Interview on 01/18/24 at 10:42 A.M. with Licensed Practical Nurse (LPN) #102 confirmed nurses documented the percentage of snacks consumed by residents in the MAR and relied on the STNAs to tell the nurses the percentage of the snacks consumed by the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365446 If continuation sheet Page 17 of 25 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 01/29/2024 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure oxygen saturation levels and respiratory rates were monitored as ordered by the physician for residents with impaired respiratory status. This affected one (Resident #21) of two residents reviewed for respiratory care. The facility census was 84. Residents Affected - Few Findings include: Review of the medical record for Resident #21 revealed an admission date of 07/16/23 with diagnoses including vascular dementia, shortness of breath, chronic obstructive pulmonary disease (COPD), and nicotine dependence. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #21 dated 10/20/23 revealed the resident was mildly cognitively impaired. Review of the care plan for Resident #21 dated 07/28/23 revealed the resident was at risk for impaired gas exchange related to shortness of breath and COPD. Interventions included monitor oxygen saturation as ordered and as needed. Review of the physician's orders for Resident #21 revealed an order dated 08/29/23 to obtain vital signs every Wednesday on night shift. Review of the vital sign records for Resident #21 from October 2023 to January 2024 revealed the last recorded oxygen saturation levels for the resident was done on 10/25/23 and the resident's record did not include any subsequent assessments of oxygen saturation. Review of the vital sign records for Resident #21 from November 2023 to January 2023 revealed the last documented respiration rate for the resident was done on 11/17/23 and the resident's record did not include any subsequent assessments of respiratory rates. Interview on 01/18/24 at 8:28 A.M. with Licensed Practical Nurse (LPN) #190 confirmed Resident #21 had a physician's order for vital signs to be obtained every week on Wednesday on night shift. LPN #190 further confirmed the last recorded oxygen saturation level for Resident #21 was done on 10/25/23 and the last recorded respiratory rate for Resident #21 was done on 11/17/23. Review of the facility policy titled Vital Signs undated revealed vital signs were indicators of health status and included temperature, pulse, respiratory rate, blood pressure, oxygen saturation level, and pain level. Licensed nurses were responsible for knowing the usual range of a resident's vital signs, analyzing and interpreting routine vital signs, and notifying the physician of abnormal findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365446 If continuation sheet Page 18 of 25 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 01/29/2024 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 0699 Provide care or services that was trauma informed and/or culturally competent. Level of Harm - Minimal harm or potential for actual harm Based on medical record review and staff interviews the facility failed to ensure residents with post-traumatic stress disorder (PTSD) were appropriately assessed with care plans implemented to minimize triggers and/or re-traumatization. This affected one (Resident #76) of two facility-identified residents with PTSD/history of trauma. The facility census was 84. Residents Affected - Few Findings include: Review of the medical record for Resident #76 revealed an admission date of 11/01/23 with diagnoses including PTSD, schizophrenia, bipolar disorder, and anxiety. Review of the admission Minimum Data Set (MDS) assessment for Resident #76 dated 11/07/23 revealed the resident was cognitively intact and was coded for an active and current diagnosis of PTSD. Review of the care plan for Resident #76 initiated 11/01/23 revealed the plan did not identify the cause of the resident's PTSD, triggers which could cause re-traumatization and/or interventions to reduce the risk of re-traumatization and provide care for PTSD symptoms. Interview on 01/22/24 at 9:20 A.M. with the Director of Nursing (DON) confirmed the facility had not conducted an assessment regarding the source of Resident #76's PTSD and the possible triggers which could cause re-traumatization for the resident. The DON further confirmed the facility had not implemented a care plan for Resident #76 to minimize the risk of re-traumatization and care for PTSD symptoms. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365446 If continuation sheet Page 19 of 25 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 01/29/2024 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 - Some 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. Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure target behaviors were identified and monitored in conjunction with the use of anti-psychotic medications. This affected four (Residents #15, #54, #59, and #76) of 22 facility-identified residents with orders for anti-psychotic medications. The facility census was 84. Findings include: 1. Review of the medical record for Resident #15 revealed an admission date of 09/07/23 with diagnoses including bipolar disorder, dementia with other behavioral disturbances, and hallucinations. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #15 dated 12/20/23, revealed the resident was mildly cognitively impaired and received anti-psychotic medication on a routine basis. Review of the physician's orders for Resident #15 revealed an order dated 11/30/23 for Seroquel (an anti-psychotic medication) 300 milligrams (mg) once a day in the evening related to bipolar disorder. Review of the care plan for Resident #15 initiated 09/07/23 revealed the care plan did not include documentation regarding target behaviors being treated by use of the anti-psychotic medication. Interview on 01/18/24 at 8:00 A.M with the Director of Nursing (DON) confirmed the facility had not identified target behaviors or monitored behaviors related to the use of anti-psychotic medication for Resident #15. 2. Review of the medical record for Resident #54 revealed an admission date of 12/06/21 with diagnoses including dementia with other behavioral disturbances, psychosis, and anxiety disorder. Review of the annual MDS assessment for Resident #54 dated 12/06/23 revealed the resident was cognitively impaired and received anti-psychotic medication on a routine basis. Review of the physician's orders for Resident #54 revealed an order dated 07/26/23 for the Zyprexa 7.5 mg once daily for unspecified psychosis. Review of the care plan for Resident #54 initiated 12/06/21 revealed the care plan did not include documentation regarding target behaviors being treated by use of the anti-psychotic medication. Interview on 01/18/24 at 8:00 A.M with the DON confirmed the facility had not identified target behaviors or monitored behaviors related to the use of anti-psychotic medication for Resident #54. 3. Review of the medical record for Resident #76 revealed an admission date of 11/01/23 with diagnoses including schizophrenia, bipolar disorder, and post-traumatic stress disorder (PTSD). Review of the admission MDS assessment for Resident #76 dated 11/07/23 revealed the resident was cognitively intact and received anti-psychotic medication on a routine basis. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365446 If continuation sheet Page 20 of 25 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 01/29/2024 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 Review of the physician's orders for Resident #76 revealed an order dated 11/07/23 for loxapine succinate 55 mg twice daily for schizophrenia. Review of the care plan for Resident #76 initiated 11/01/23 revealed the care plan did not include documentation regarding target behaviors being treated by use of the anti-psychotic medication. Residents Affected - Some Interview on 01/18/24 at 8:00 A.M with the DON confirmed the facility had not identified target behaviors or monitored behaviors related to the use of anti-psychotic medication for Resident #76. 4. Review of the medical record for Resident #59 revealed an admission date of 08/07/21 with diagnoses including dementia with behavioral disturbance, diabetes mellitus, drug induced subacute dyskinesia, psychosis, major depressive disorder, insomnia, and anxiety disorder. Review of the physician's orders for Resident #59 revealed an order dated 07/25/23 for Risperdal 0.25 mg and 0.5 mg once daily for psychosis. Review of the care plan for Resident #59 initiated 08/07/21 revealed the care plan did not include documentation regarding target behaviors being treated by use of the anti-psychotic medication. Interview on 01/22/24 at 2:35 P.M with the DON confirmed the facility had not identified target behaviors or monitored behaviors related to the use of anti-psychotic medication for Resident #59 Review of the facility policy titled Unnecessary Drugs-Without Adequate Indications for Use undated revealed the facility would manage each residents' drug regimen and would monitor the medications to promote or maintain the residents highest practicable mental, physical and psychosocial well-being free from unnecessary drugs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365446 If continuation sheet Page 21 of 25 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 01/29/2024 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure residents were free of significant medication errors. This affected one (Resident (#54) out of the five residents reviewed for unnecessary medications. The facility census was 84. Residents Affected - Few Findings include: Review of the medical record for Resident #54 revealed an admission date of 12/06/21 with diagnoses including dementia, psychosis, and hypothyroidism. Review of the physician's orders for Resident #54 revealed an order dated 07/28/23 for 100 micrograms (mcg) of levothyroxine sodium (a thyroid hormone) once a day for hypothyroidism. Review of the laboratory results for Resident #54 dated 11/27/23 revealed the resident had a thyroid stimulating hormone (TSH) level of 0.139 milliunits per liter (mU/L) which was a below normal result indicating the need for decreased thyroid hormone. The normal range was 0.4 to 4.0 mU/L. Further review revealed Nurse Practitioner (NP) #500 reviewed the laboratory result on 11/29/23 and documented an order at the bottom of the page to decrease the dose of levothyroxine sodium for Resident #54 to 50 mcg per day and to recheck the resident's TSH level in eight weeks. Review of the physician's orders for Resident #54 revealed an order dated 11/29/23 to administer 50 mcg of levothyroxine sodium once a day for hypothyroidism. Review of the consultant pharmacist's Medication Regimen Review (MRR) recommendation for Resident #54 dated 12/05/23 revealed on 11/29/23 a new order for levothyroxine 50 mcg was added and the order for levothyroxine 100 mcg was still active. Further review revealed there were no progress notes or lab work related to the new order and it was unclear if the new order reflected an increased or decreased dose of levothyroxine. The Director of Nursing (DON) had written on the bottom of the MRR recommendation form that the time of administration had been updated. Review of the annual Minimum Data Set (MDS) assessment for Resident #54 dated 12/06/23 revealed the resident was cognitively impaired. Review of the December 2023 and January 2024 Medication Administration Records (MARs) for Resident #54 revealed the resident was administered a 100-mcg dose and a 50-mcg dose of levothyroxine sodium daily from 12/06/23 to 01/17/24 for a total of 150 mcg per day. Review of the TSH results for Resident #54 dated 01/19/24 revealed the resident had a low TSH level of 0.030 mU/L. Interview with the DON on 01/22/24 at 9:05 A.M. confirmed Resident #54's TSH level on 11/27/23 was low. The DON confirmed NP #500 gave an order on 11/29/23 to decrease the dose of levothyroxine from 100 mcg per day to 50 mcg per day. The DON further confirmed the facility staff did not discontinue the 100-mcg dose of levothyroxine, and the nurses had administered 150 mcg per day of levothyroxine to Resident #54 rather than the reduced dose of 50 mcg per day ordered by NP #500. DON further confirmed this was a medication error identified by the surveyor. Interview with NP #500 on 01/22/24 at 10:49 A.M. confirmed she wrote an order on 11/29/23 to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365446 If continuation sheet Page 22 of 25 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 01/29/2024 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 0760 Level of Harm - Minimal harm or potential for actual harm decrease Resident #54's levothyroxine sodium from 100 mcg per day to 50 mcg per because the resident's TSH level was low on 11/27/23 which indicated a need for a decreased dose of the medication. NP #500 confirmed the surveyor identified a medication error which resulted in the resident receiving an increased dose of levothyroxine sodium. NP #500 further confirmed the increased dose of levothyroxine could result in increased confusion and lethargy for the resident. Residents Affected - Few Review of the facility policy titled Medication Errors dated 09/29/23 revealed significant medication errors included errors which caused the resident discomfort or jeopardized his/her safety. The facility should ensure residents were free from significant medication errors. This deficiency represents non-compliance investigated under Complaint Number OH00149963. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365446 If continuation sheet Page 23 of 25 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 01/29/2024 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility failed to ensure physician visit notes were accurately documented in the resident medical record. This affected one (Resident #15) of 22 resident records sampled. The facility census was 84. Findings include: Record of the medical record for Resident #15 revealed an admission date of 09/07/23 with diagnoses including bipolar disorder, dementia with behavioral disturbance, and history of falling. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #15 dated 12/20/23 revealed the resident had mildly impaired cognition. Review of the nurse progress notes for Resident #15 revealed the resident was sent to the emergency room and was admitted to hospital on [DATE]. The resident was readmitted to the facility on [DATE]. Review of the physician progress note for Resident #15 dated 11/16/23 revealed the physician examined the resident in the facility for a 60-day regulatory visit. Interview on 01/18/24 at 8:00 A.M with the Director of Nursing (DON) confirmed Resident #15 was admitted to the hospital on [DATE] and did not return to the facility until 11/29/23. The DON further confirmed Physician #400 would not have been able to conduct a visit with Resident #15 in the facility on 11/16/23 as the resident was admitted to the hospital at that time. Telephone interview with Physician #400 on 01/22/24 at 4:00 P.M. confirmed the physician progress note for Resident #15 dated 11/16/23 had been documented in error. Physician #400 confirmed he had not examined the resident on that date. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365446 If continuation sheet Page 24 of 25 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 01/29/2024 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation and staff interview the facility failed to maintain a clean and functional environment with evidence of poor repair to five rooms that required wall repairs, room heater repairs, and painting. This affected five residents in rooms numbered B-1, B-5, B-8, B-12, and F-64. The facility census was 84. Findings include: Observation on 01/17/24 at 2:30 P.M. of Room B-12 with the Administrator revealed a large hole in the wall between the outside window and the wall heater. Cold air from outside was blowing into the room through the hole. Areas behind both beds had exposed dry wall and other exposed areas from missing paint with large holes in the drywall observed. The vent screen on the heating unit was visibly rusty and unpainted. Observation on 01/17/24 at 2:35 P.M. of Room B-8 with the Administrator revealed there were large, unrepaired holes in the drywall behind both resident beds and holes under the clock and across the room in the middle of the wall. There were some areas of exposed dry wall between the beds. Observation on 01/17/24 at 2:40 P.M. of Room B-5 with the Administrator revealed there were two large water stains on the ceiling above the sink. The vent screen on the heating unit was visibly rusty and unpainted. Observation on 01/17/24 at 2:45 P.M. of Room B-1 with the Administrator revealed there was a large area of stained flooring under the resident's bed. The vent screen on the heating unit was visibly rusty and unpainted. Observation on 01/17/24 at 2:52 P.M. of Room #F-64 with the Administrator revealed the metal cover on the heating unit was not properly installed and was leaning against the wall. Dry wall was exposed in multiple areas where the paint was peeling away. Interview on 01/17/24 at 3:00 P.M. with the Administrator confirmed the area identified during the observations of Rooms B-1, B-5, B-8, B12, and F-64 needed to be repaired. This deficiency represents non-compliance investigated under Complaint Number OH00149963. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365446 If continuation sheet Page 25 of 25