Inspection·August 18, 2021

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review the facility failed to notify the ombudsman when residents were admitted to the hospital. This affected one (Resident #9) of three reviewed for hospitalization. The facility census was 84. Findings include: Record review of Resident #9 revealed an admission date of 06/27/18 with pertinent diagnoses of: chronic respiratory failure, chronic obstructive pulmonary disease, dementia, cerebrovascular disease, seizures, hypertension, arteriosclerotic heart disease, type two diabetes mellitus, major depressive disorder, dysphagia, hemiplegia and hemiparesis following non-traumatic intracerebral hemorrhage, benign prostatic hyperplasia, glaucoma, chronic kidney disease, and insomnia. Review of the 07/23/21 quarterly Minimum Data Set (MDS) assessment revealed Resident #9 was moderately cognitively impaired and required total dependence for bed mobility, eating, bathing, and toilet use. The Resident was always incontinent of bowel and bladder. Record review of Progress Notes dated 07/15/21 at 8:08 A.M. revealed Resident admitted to hospital on [DATE] with admitting diagnoses of sepsis, colitis, and pneumonia. Review of the medical record revealed no mention or documentation the Ombudsman was notified of Resident #9's admission to the hospital on [DATE]. Interview with the Administrator on 08/12/21 at 4:10 P.M. verified the Ombudsman was not notified of Resident #9's hospital admission. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365584 If continuation sheet Page 2 of 28 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 365584 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Rosemount Pavilion 20 Easter Drive Portsmouth, OH 45662 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** 3. Review of Resident #279's medical record revealed he was admitted on [DATE] with diagnoses that included: chronic obstructive pulmonary disease chronic pain, diabetes mellitus, Charcot's joint right ankle and foot, essential hypertension, anxiety disorder, hypothyroidism, and hyperlipoidemia. Residents Affected - Few Review of Resident #279's admission Minimum Data Set (MDS) dated [DATE] revealed the following. Resident #279 's speech was clear, he was understood, he understands others, and his cognition was intact. Resident #279 had severe depression, no indicators of psychosis, no behaviors, and did not reject care. Resident #279 received pain management, on scheduled pain medication, as needed pain medication, received non-medication intervention for pain, and had pain with a level of five out of 10 and did not use tobacco. Resident #279 received no opioid medication in the assessment period. Review of Resident #279's physician orders revealed an order for an opioid containing pain medication (Norco 7.5-325) every six hours for pain and a nicotine patch daily. Interview of the Director of Nursing (DON) on 08/16/21 at 12:39 P.M. confirmed Resident #279 smoked during the assessment period and used Norco (opiod). The DON confirmed the MDS was inaccurate. Based on medical record review, staff interview, and review of the Resident Assessment Instrument (RAI) the facility failed to ensure resident assessments were completed accurately in the areas of nutrition, skin integrity, and opiod use. This affected three (Residents #40, #41, and #279) of 22 residents reviewed for assessments. The facility census was 84. Findings Include: 1. Review of the medical record for Resident #40 revealed an admission date of 12/16/20. Diagnoses included unspecified displaced fracture of surgical neck of left humerus, 4-part fracture of surgical neck of left humerus, non-displaced fracture of right tibial spine, essential hypertension, unspecified dementia, and hypokalemia. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed the resident had severely impaired cognition. Resident #40 weighed 99 pounds. Review of Resident #40's weights revealed, on 07/08/21, Resident #40 weighed 100.4 pounds. On 06/01/21, Resident #40 weighed 98.8 pounds. On 05/04/21, Resident #40 weighed 101.8 pounds. On 04/12/21, Resident #40 weighed 99 pounds. On 03/04/21, Resident #40 weighed 106.8 pounds. On 02/22/21, Resident #40 weighed 108.2 pounds. On 02/08/21, Resident #40 weighed 120 pounds. On 02/01/21, Resident #40 weighed 118.2 pounds. On 01/25/21, Resident #40 weighed 119.4 pounds. On 01/11/21, Resident #40 weighed 121.2 pounds. On 12/17/20, Resident #40 weighed 123.7 pounds. Review of the CMS RAI Version 3.0 Manual dated 10/2019 revealed the base weight should be the most recent measure in the last 30 days. If the last recorded weigh was taken more than 30 days prior to the ARD of the assessment, weigh the resident again. If the resident cannot be weighed, use the standard no-information code (-) and document rationale on the resident's medical record. Interview on 08/12/21 at 3:53 P.M. LPN #345 verified the weight should have been coded with the standard no-information code (-). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365584 If continuation sheet Page 3 of 28 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 365584 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Rosemount Pavilion 20 Easter Drive Portsmouth, OH 45662 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. Review of the medical record for Resident #41 revealed an admission date of 07/01/21. Diagnoses included heart failure, chronic obstructive pulmonary disease, type 2 diabetes mellitus without complications, unspecified cirrhosis of liver, anxiety disorder, major depressive disorder, chronic atrial fibrillation, and end stage renal disease. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The resident required extensive assistance of two staff for bed mobility, transfers, and toileting. The resident had four Stage 2 pressure areas and no other pressure areas or injuries. Review of the comprehensive minimum data set (MDS) assessment dated [DATE] revealed the resident had four Stage 2 pressure areas and no other pressure areas or injuries. Review of the skin grid pressure assessments dated 07/02/21 and 07/07/21 revealed Resident #41 had three Stage 2 pressure areas to the right buttock and a Stage 2 pressure area to the left buttock. Review of the Nurse Practitioner's progress note dated 07/07/21 revealed Resident #41 had a Stage 3 pressure area to the right coccyx, two satellite lesions to the right coccyx, and an area to the left coccyx, which did not specify a type or stage. Review of the Nurse Practitioner's progress note dated 07/14/21 revealed Resident #41 had a Stage 3 pressure area to the right coccyx, two satellite lesions to the right coccyx, and an irregular Stage 2 pressure area to the left coccyx. Review of the RAI revealed ulcer staging should be based on review of the history of each pressure ulcer in the medical record. If the pressure ulcer has ever been classified at a higher numerical stage than what is currently observed, it should continue to be classified at the higher numerical stage. Interview on 08/16/21 at 3:35 P.M., RN/ADON #325 verified the MDS coding did not match the nurse practitioner's notes. Follow-up interview on 08/16/21 at 3:44 P.M RN/ADON #325 verified the nurse practitioner's assessment was to be used for MDS coding. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365584 If continuation sheet Page 4 of 28 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 365584 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Rosemount Pavilion 20 Easter Drive Portsmouth, OH 45662 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #63's medical record revealed she was admitted on [DATE] with diagnoses that included: dementia with behavioral disturbance, generalized anxiety, schizoaffective disorder, and bipolar disorder. Residents Affected - Few Review of Resident #63's admission Minimum Data Set (MDS) dated [DATE] revealed Resident #63 did not have a serious mental illness and/or intellectual disability. Review of Resident #63's PASRR identification screen dated 07/08/2021 did not indicate the Resident #63's diagnoses of serious mental illness and no level two PASRR was conducted. Interview of Licensed Social Worker (LSW) #370 on 08/11/21 at 8:51 A.M. confirmed Resident #63's PASSR should have indicated the resident had diagnoses of serious mental illness and no level two PASRR was conducted. Based on medical record review, and staff interview, the facility failed to complete a Preadmission Screening and Resident Review (PASRR) (a screen to check for a serious mental illness prior to admission into a facility) for residents with a qualifying diagnosis of bipolar disorder and failed to include a qualifying diagnosis when completing a level one PASRR for a resident. This affected two (Residents #59 and #63) of the two residents reviewed for PASRRs. The facility census was 84. Findings include: 1. Review of the medical record for Resident #59 revealed an admission date of 06/08/21. Diagnosis included bipolar disorder with current episode depression, heart failure, and hypertension. Review of Resident #59's quarterly Minimum Data Set (MDS) 3.0 assessment completed on 07/09/21 revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating an intact cognition for daily decision making ability. Resident #59 was noted to express feeling down, depressed or hopeless, have trouble falling asleep, or staying asleep, or sleeping too much. Resident #59 was noted to have the diagnoses of depression and bipolar disorder and receive antidepressants. Review of Resident #59's physician orders for August 2021 revealed: -Sertraline Hydrochloride (HCL), 50 milligram (mg) tablet, give one tablet every day for recurrent major depressive disorder -Topiramate, 100 mg tablet, give one tablet, twice a day for bipolar disorder Review of Resident #59's plan of care dated 06/09/21, revealed the resident uses antidepressant medication related to depression. Interventions include to administer medication as ordered, monitor and document side effects and effectiveness every shift. Review of Resident #59's miscellaneous documents revealed a document titled, PASRR, dated 05/19/21, which revealed a PASRR was not completed and the document was noted Not Applicable. Interview on 08/12/21 at 2:00 P.M. with Social Services Director #370 revealed a PASRR is completed when a resident has a qualifying diagnosis. Social Services Director #370 confirmed Resident #59 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365584 If continuation sheet Page 5 of 28 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 365584 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Rosemount Pavilion 20 Easter Drive Portsmouth, OH 45662 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 0645 Level of Harm - Minimal harm or potential for actual harm had a diagnosis of bipolar disorder, which would be a qualifying diagnosis to have a level one PASRR completed. Interview on 08/12/21 at 2:30 P.M. with the Administrator revealed the facility could not locate a level one PASRR for this resident. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365584 If continuation sheet Page 6 of 28 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 365584 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Rosemount Pavilion 20 Easter Drive Portsmouth, OH 45662 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and medical record review the facility failed develop comprehensive care plans for residents in the areas of refusal of treatment, smoking, and activities. This affected two (Resident #71 and #279) of 22 sampled resident's whose care plans were reviewed. Findings include: 1. Review of Resident #71's medical record revealed she was admitted on [DATE] with diagnoses that included: hypertensive urgency, asthma, chronic pain, osteoarthritis, pleural effusion, insomnia, dementia without behaviors, gastro-esophageal reflux disease, constipation, and cognitive communication deficit. Review of Resident #71's admission Minimum Data Set (MDS) dated [DATE] revealed the following. Resident #71's speech was clear, she made herself understood, she understands others, and her cognition was moderately impaired. Resident #71 had moderately severe depression, she had no psychosis, did not refuse care, and had no behaviors. It was somewhat important for Resident #71 to have reading material, to listen to music she liked, not very important to be around pets, somewhat important to do things in groups, very important to do her favorite activities, very important to get fresh air when the weather was good, and not very important to participate in religious activities. Resident #71 required extensive assistance of two staff for bed mobility, did not transfer, walk, or use locomotion. Review of Resident #71's quarterly MDS dated [DATE] revealed the following changes: verbal behaviors and other behaviors not directed towards others that occurred 1-3 days, limited assist of one person to transfer, supervision with one staff assistance to walk in her room, limited assistance of one staff to walk in corridor, supervision of two staff for locomotion on the unit, and extensive assistance of two staff for locomotion off the unit. Review of Resident #71's care plan for activities revealed it did not address the resident's desire to go outside. Resident #71's plan of care stated she would be encouraged/assisted,/invited to any scheduled activities of interest. Interview of Resident #71 on 08/12/21 at 1:57 P.M. stated she does not like to be in groups of people. Resident #71 stated she would like to go outside, but the facility had to approve to escort for her to go outside. Resident #71 stated there was not enough staff for her to go outside and she was a low on the priority to go outside. Interview of Activity Director (AD) #360 on 08/16/21 at 3:00 P.M. confirmed Resident #71's plan of care did not address her desire to go outside. 2. Review of Resident #279's medical record revealed he was admitted on [DATE] with diagnoses that included: chronic obstructive pulmonary disease chronic pain, diabetes mellitus, Charcot's joint right ankle and foot, essential hypertension, anxiety disorder, hypothyroidism, and hyperlipoidemia. Review of Resident #279's admission Minimum Data Set (MDS) dated [DATE] revealed the following. Resident #279 's speech was clear, he was understood, he understands others, and his cognition was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365584 If continuation sheet Page 7 of 28 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 365584 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Rosemount Pavilion 20 Easter Drive Portsmouth, OH 45662 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 intact. Resident #279 had severe depression, no indicators of psychosis, no behaviors, and did not reject care. Resident #279 required extensive assistance of one staff for bed mobility, supervision with set up help to transfer, to walk, and for mobility. Interview and observation of Resident #279 on 08/11/2021 at 12:51 P.M. revealed he smoked multiple times a day. Resident #279 stated he signs himself out and leaves the property to smoke. He also stated he did not use the nicotine patch. Review of Resident #279's plan of care was silent to the resident smoking and refusing to use the nicotine patch. Interview of the Director of Nursing (DON) on 08/16/21 at 12:39 P.M. confirmed Resident #279's plan care did not address his smoking and refusal of the nicotine patch. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365584 If continuation sheet Page 8 of 28 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 365584 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Rosemount Pavilion 20 Easter Drive Portsmouth, OH 45662 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 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. 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, resident interview, staff interview, and observation, the facility failed to identify a resident's need for an audiology consult who was experiencing signs of being hard of hearing. This affected one (Resident #27) of one resident reviewed for vision/hearing needs. The facility census is 84. Residents Affected - Few Findings included: Review of the medical record for Resident #27 revealed an initial admission date of 12/28/20 and a re-entry date of 03/29/21. Diagnoses included acquired absence of the left leg below the knee, hypothyroidism, and anxiety disorder. Review of Resident #27's quarterly Minimum Date Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating a moderately impaired cognition for daily decision making ability. Resident #27 was noted to require extensive assistance from one staff member for bed mobility, transfers, dressing, toilet use, and personal hygiene. Resident #27 was noted to have adequate hearing with no assistive devices. Review of Resident #27's plan of care dated 05/18/21 revealed the resident has a communication problem related to minimal difficulty hearing at times. Interventions include to anticipate and meet resident needs, monitor for a decline, and refer to audiology for a hearing consult as ordered and/or needed. Observation on 08/09/21 at 10:44 A.M. of Resident #27 revealed the resident in own room watching the television. The television volume was noted to be turned up very loud. Interview on 08/09/21 at 10:45 A.M. with Resident #27 revealed she turns her television up so loud because she has trouble hearing it. During interview, Resident #27 would ask this surveyor to repeat the question or was noted to turn her head to the right, allowing her left ear to face towards this surveyor during interview. Resident #27 also revealed she needs hearing aids and doesn't have any at this time. Interview on 08/16/21 at 3:09 P.M. with Social Service Director (SSD) #370 revealed she knew the resident listens to her television loudly. The SSD #370 revealed the audiologist was new and was only permitted to see a limited amount of residents. The Audiologist was last in the facility on 06/01/21 and Resident #27 was not on that referral list to be seen. The Social Service Director #370 revealed a resident would be put on the referral list if they personally complained or if it was noted the resident had a hearing issues. The Social Service Director #370 verified listing to the television, speaking loudly, and asking others to repeat questions would be a sign or symptoms of a resident being hard of hearing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365584 If continuation sheet Page 9 of 28 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 365584 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Rosemount Pavilion 20 Easter Drive Portsmouth, OH 45662 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 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, medical record review, resident interview, and observation the facility failed to provide an ongoing activities program that was of interest to the resident. This affected one (Resident #71) two sampled residents reviewed for activities. Residents Affected - Few Findings include: Review of Resident #71's medical record revealed she was admitted on [DATE] with diagnoses that included: hypertensive urgency, asthma, chronic pain, osteoarthritis, pleural effusion, insomnia, dementia without behaviors, gastro-esophageal reflux disease, constipation, and cognitive communication deficit. Review of Resident #71's admission Minimum Data Set (MDS) dated [DATE] revealed the following. Resident #71's speech was clear, she made herself understood, she understands others, and her cognition was moderately impaired. Resident #71 had moderately severe depression, she had no psychosis, did not refuse care, and had no behaviors. It was somewhat important for Resident #71 to have reading material, to listen to music she liked, not very important to be around pets, somewhat important to do things in groups, very important to do her favorite activities, very important to get fresh air when the weather was good, and not very important to participate in religious activities. Resident #71 required extensive assistance of two staff for bed mobility, did not transfer, walk, or use locomotion. Review of Resident #71's quarterly MDS dated [DATE] revealed the following changes: verbal behaviors and other behaviors not directed towards others that occurred 1-3 days, limited assist of one person to transfer, supervision with one staff assistance to walk in her room limited assistance of one staff to walk in corridor, supervision of two staff for locomotion on the unit, and extensive assistance of two staff for locomotion off the unit. Review of Resident #71's activities evaluation dated 01/13/2021 revealed Resident #71's activities included movies/television, music/talk radio, reading and writing. It did not state what type of movies/television and music/talk radio. The evaluation did not identify what reading material she liked or what writing she engaged in. The evaluation did not identify Resident #71's desire to participate in outdoor activities. Review of Resident #71's activity participation review dated 01/19/2021 stated she enjoyed activities such as music (classical/piano music), identified it was very important to go outside when the weather was good, Review of Resident #71's care plan for activities revealed it did not address the residents her desire to go outside. Resident #71's plan of care stated she would be encouraged/assisted,/invited to and scheduled activities of interest. Review of Resident #71's daily recreation/activity participation documentation for July and August 2021 revealed reading/writing, socializing, and television were marked daily with an I. Interview of Resident #71 on 08/12/21 at 1:57 P.M. stated she does not like to be in groups of people. Resident #71 stated she would like to go outside, but the facility had to approve to escort for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365584 If continuation sheet Page 10 of 28 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 365584 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Rosemount Pavilion 20 Easter Drive Portsmouth, OH 45662 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete her to go outside. Resident #71 stated there was not enough staff for her to go outside and she was low on the priority to go outside. Resident #71 stated she does not like watching television and almost never watches it and she does not listen to music very often. She stated she likes to do things in her room and she really likes to read. She stated there were books available, but they were not well organized. Interview of Activity Director (AD) #360 on 08/16/21 at 3:00 P.M. revealed she was not aware Resident #71 like to go outside and she did not think when there was an outside activity Resident #71 was invited to attend. AD #360 confirmed the activity evaluation identified it was very important for Resident #71 to go outside. AD #360 also confirmed the activity assessment did not identify what television shows, music, and radio programs Resident #71 liked. AD #360 stated the participation logs that identified Resident # 71 was marked I for socialization and television meant she could pursue the activity independently, not that she participated in those activity. Event ID: Facility ID: 365584 If continuation sheet Page 11 of 28 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 365584 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Rosemount Pavilion 20 Easter Drive Portsmouth, OH 45662 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, resident interview, and observation the facility failed to ensure residents received necessary care and treatment for application of hand protectors and hospice services. This affected two of 22 sampled residents (Residents #56 and #66). Residents Affected - Some Findings include: 1. Review of Resident #66's medical record revealed she was admitted on [DATE] with diagnoses that included: dysphagia, muscle weakness, abnormal posture, essential hypertension, hemiplegia right side, cerebrovascular disease, and cerebral edema. Review of Resident # 66's admission Minimum Data Set (MDS) dated [DATE] revealed the following. Resident #66's speech was clear, she makes herself understood, she understands others, her cognition was intact, and she had minimal depression. Resident #66 had verbal and other behavioral symptoms not directed toward others one to three days during the assessment period, that did not impact the resident or other residents, and she did not reject care. Resident #66 required extensive assistance of two staff for bed mobility, to transfer, to walk, for locomotion, to dress, extensive assistance of one staff to eat, extensive assistance of two staff for toilet use, personal hygiene, had range of motion limitations on one side upper and lower extremity, and used no mobility devices. Resident #66 had no alterations to her skin; she received occupational (OT) and physical therapy (PT). Review of Resident #66's quarterly MDS dated [DATE] revealed the following changes: she had no behaviors, she did not walk, required supervision of one staff to eat. Review of Resident # 66's physician orders revealed a palm protector as tolerated and to continue occupational therapy. Review of Resident #66's OT notes dated 08/05/2021 revealed staff were educated on the use of the palm protector. Interview and observation of Resident #66 on 08/11/21 at 10:23 A.M. revealed OT did not offer any devices for the contracted right hand if they had she would have accepted it. Resident #66 stated she used to crochet and she cannot now and she did not refuse therapy. Resident #66 stated her right hand had worsened since admission and her fingers are more contracted, and her right wrist had turned more inward. Resident #66 stated she had a stroke and that is why she was at the facility. Resident #66 and her spouse stated she did not have a palm protector and had not seen it for a while. Interview of Certified Occupational Therapist Assistant (COTA) #840 on 08/12/21 at 8:16 A.M. revealed Resident #66 had hemiparesis, spasticity, and passive range of motion (PROM) to her right hand. COTA #840 stated sometimes the resident refused therapy, was hesitant about therapy, and other times she fully participated in therapy. COTA #840 stated Resident #66 in the last few weeks a palm protector was to be applied during night and removed in the morning, Resident #66 had the palm protector She stated that Resident #66 had a palm protector in her room. COTA #840 stated the staff was educated on the use of the palm protector. Interview of State Tested Nursing Assistant (STNA) #330 on 08/12/21 at 10:07 A.M. revealed Resident #66 did not like to wear the palm protector. STNA #330 was not aware when Resident #66 was supposed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365584 If continuation sheet Page 12 of 28 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 365584 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Rosemount Pavilion 20 Easter Drive Portsmouth, OH 45662 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 to wear the palm protector. Level of Harm - Minimal harm or potential for actual harm Interview of Registered Nurse (RN) #365 on 08/12/21 at 10:20 A.M. revealed the only device she was aware of Resident #66 using was a tray table when she was in the wheel chair to elevate her right arm. RN #365 stated Resident #66 did not use a palm protector. Residents Affected - Some 2. Review of Resident #56's medical record revealed she was admitted on [DATE] with diagnoses that included: schizoaffective disorder, vascular dementia with behavioral, hypothyroidism, essential hypertension, stiffness of left hip, atrial fibrillation, dementia without behavioral, anxiety disorder, bipolar disorder, and Alzheimer's disease. Review of Resident #56's significant change Minimum Data Set (MDS) dated [DATE] revealed her speech was clear, she made herself understood, she usually understands others, and her cognition was severely impaired. She was on hospice. Review of Resident #56's physician orders revealed she was on hospice. Review of the resident's medical record revealed there was no evidence of communication regarding the resident's care and treatment as it relates to the hospice services she receives. Interview of Licensed Practical Nurse (LPN) #408 on 08/16/21 at 1:27 P.M. revealed hospice came in and saw Resident #56, but they did not leave any notes and there were no notes available at the nurses station. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365584 If continuation sheet Page 13 of 28 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 365584 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Rosemount Pavilion 20 Easter Drive Portsmouth, OH 45662 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 observation, staff interview, resident interview, and medical record review the facility failed to ensure residents received the nutritional interventions to maintain body weight and to ensure nutritionally adequate diets were provided. This affected two of four sampled residents reviewed for nutrition (Resident #71 and #41). Residents Affected - Few Findings include: 1. Review of Resident #71's medical record revealed she was admitted on [DATE] with diagnoses that included: hypertensive urgency, asthma, chronic pain, osteoarthritis, pleural effusion, insomnia, dementia without behaviors, gastro-esophageal reflux disease, constipation, and cognitive communication deficit. Review of Resident #71's admission Minimum Data Set (MDS) dated [DATE] revealed the following. Resident # 71's speech was clear, she made herself understood, she understands others, and her cognition was moderately impaired. Resident #71 had moderately severe depression, she had no psychosis, did not refuse care, and had no behaviors. Resident #71 required extensive assistance of two staff for bed mobility, did not transfer, walk, or use locomotion, supervision of one staff to eat. Resident #71 had no swallowing problems, was 69 inches and 110 pounds, had no unplanned weight changes, and received a mechanically altered diet. Review of Resident #71's quarterly MDS dated [DATE] revealed the following changes: verbal behaviors and other behaviors not directed towards others that occurred one to three days, supervision with setup help to eat, weighed 98 pounds, had unplanned weight gain and weight loss, and her diet not mechanically altered. Review of Resident #71's physician orders revealed a regular diet and house shakes three times a day. Review of Resident #71's weights revealed: On 01/07/2021 she weighed 110 pounds, On 03/5/21 she weighed 87 pounds (had an unplanned severe weight loss of 23 pound, she lost 20 percent of her weight in one month), On 03/10/2021 she weighed 84.5 pounds, On 04/05/2021 she weighed 91.3 pounds, On 05/04/2021 she weighed 90.4 pounds, On 06/01/2021 she weighed 88.5 pounds, and On 07/08/2021 she weighed 98.4 pounds. Review of Resident #71's admission nutritional assessment dated [DATE] revealed she was vegetarian (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365584 If continuation sheet Page 14 of 28 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 365584 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Rosemount Pavilion 20 Easter Drive Portsmouth, OH 45662 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 by choice. Level of Harm - Minimal harm or potential for actual harm Review of Resident #71's nutrition note date 03/12/2021 revealed her March 2021 weight was 87 pounds, it was a significant weight loss of 19.6 percent in 30 days. A re-weigh was requested to verify weight loss. The re-weigh was obtained on 03/10/2021 and Resident #71 weighed 84.5 pounds. Resident #71 received a mechanical soft, vegetarian diet per her preference with intakes ranging between 25-100% at meals. Resident #71 received health shakes twice daily for additional support that was started back in January. The recommendation was to increase health shake to three times a week. Residents Affected - Few Review of the nutrition note dated 04/12/2021 revealed Resident #71's weight was 91.3 pounds and her body mass index (BMI) was 15.2 indicating she was under weight for her height. No dietary changes were recommended. Review of Resident #71's nutrition notes dated 05/24/2021 and 07/20/21 revealed she had weight changes and no dietary changes were recommended. Review of the facility's menus revealed no vegetarian menus or recommendations for the replacement of animal proteins. Observation on 08/12/21 at 7:45 A.M. of Resident #71's breakfast meal revealed she received orange juice, two pancakes, oatmeal, 2% milk , syrup, and asked for butter. Her tray card said no meat. Review of the menu revealed in addition to what Resident #71 received what the menu called for with the exception of sausage. The resident did not receive a protein source to replace the sausage. Interview of Resident #71 on 08/12/21 at 1:57 P.M. revealed she was a vegetarian. Resident #71 stated she ate animal based proteins such as eggs and dairy. Interview of Dietary Manager (DM) #857 on 08/12/21 at 2:56 P.M. revealed when meat was on the menu Resident #71 should receive a dairy product. DM #857 confirmed there was no menu planned for a vegetarian diet. Interview of Registered Dietitian Nutritionist (RND) #335 on 08/16/21 at 2:36 P.M. revealed she was not aware Resident #71 was a vegetarian and there was no planned vegetarian diet. 2. Review of the medical record for Resident #41 revealed an admission date of 07/01/21. Diagnoses included heart failure, chronic obstructive pulmonary disease, type 2 diabetes mellitus without complications, unspecified cirrhosis of liver, anxiety disorder, major depressive disorder, chronic atrial fibrillation, and end stage renal disease. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The resident required extensive assistance of two staff for bed mobility, transfers, and toileting. Review of Resident #41's weights revealed, on 07/01/21, Resident #41 weighed 290.6 pounds. On 07/06/21, Resident #41 weighed 290.8 pounds. On 07/13/21, Resident # 41 weighed 283.8 pounds. On 07/27/21, Resident # 41 weighed 279 pounds. On 08/02/21, Resident #41 weighed 255.2 pounds. On 08/09/21, Resident #41 weighed 246 pounds. Review of nursing progress notes dated 07/01/21 through 08/15/21 revealed no evidence of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365584 If continuation sheet Page 15 of 28 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 365584 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Rosemount Pavilion 20 Easter Drive Portsmouth, OH 45662 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 facility notifying RND #335 of significant weight changes which occurred on 08/02/21 and 08/09/21. Level of Harm - Minimal harm or potential for actual harm Review of the nutrition/weight note dated 08/08/21 revealed a reweight was requested. Residents Affected - Few Interview on 08/12/21 at 11:33 A.M., Registered Nutrition Dietitian (RND) #335 stated the facility does not notify her of weight changes. RND #335 stated she lets the facility know who needs to be weighed and then follows up the next time she is at the facility. RND #335 further verified the facility had not notified her of Resident #41's weight on 08/02/21 nor 08/09/21. RND #335 stated she became aware of Resident #41's 08/02/21 weight on 08/08/21 when she followed up on the weekly weight. Interview on 08/12/21 at 11:52 A.M., the Director Of Nursing (DON) stated the unit manager provides a weight list for the unit and checks to make sure they are complete. The DON further stated the aides are asked to reweigh the resident if they notice a change and the nurse supervisor is notified of the weight once verified. Interview on 08/12/21 at 12:05 P.M., RN/Assistant Director Of Nursing (ADON) #325 stated, once a weight is entered into the medical record, it will generate an alert if there is a significant weight change. The alert is left for the dietitian to review during the next visit. RN/ADON #325 stated nursing supervisor's review of the weights does not always happen as it should because it is sometimes difficult to get weights. RN/ADON #325 further stated any notifications, including the dietitian, should be documented in the medical record. Review of the facility policy titled, Weight Assessment and Intervention, undated, revealed any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the Dietitian in writing. Verbal notification must be confirmed in writing. Further, the Dietitian will respond within reasonable time frame of receipt of written notification. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365584 If continuation sheet Page 16 of 28 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 365584 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Rosemount Pavilion 20 Easter Drive Portsmouth, OH 45662 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to ensure oxygen tubing was changed per the physician's order. This affected one (Resident #41) of one residents reviewed for respiratory care. The facility identified nine residents who receive respiratory treatments. The facility census was 84. Residents Affected - Few Findings include: Review of the medical record for Resident #41 revealed an admission date of 07/01/21. Diagnoses included heart failure, chronic obstructive pulmonary disease (COPD), type 2 diabetes mellitus without complications, unspecified cirrhosis of liver, anxiety disorder, major depressive disorder, chronic atrial fibrillation, and end stage renal disease. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The resident required extensive assistance of two staff for bed mobility, transfers, and toileting. Review of the physician orders revealed orders dated 07/02/21 for oxygen via nasal cannula at 3 liters per minute (LPM), 07/04/21 to change oxygen tubing weekly on Sunday, and 07/06/21 for BiPAP at bedtime and daytime napping for sleep apnea. Observation on 08/09/21 at 3:27 P.M. revealed Resident #41 wearing the BiPAP mask and had an oxygen concentrator at the bedside. The BiPAP and oxygen tubing were dated 07/26/21. Interview on 08/09/21 at 3:56 P.M., licensed practical nurse (LPN) #300 verified the dates on the oxygen and BiPAP tubing were dated 07/26/21. LPN #300 further stated oxygen tubing was to be changed weekly on Sunday nights. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365584 If continuation sheet Page 17 of 28 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 365584 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Rosemount Pavilion 20 Easter Drive Portsmouth, OH 45662 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 medical record review and staff interview the facility failed to ensure residents who received antipsychotic medication had an adequate indication for use and had target behaviors identified. This affected one of five sampled residents and one resident reviewed for hospice (Resident #56 and #63). Findings include: 1. Review of Resident #63's medical record revealed she was admitted on [DATE] with osteoarthritis of knee, dementia with behavioral disturbance, generalized anxiety, and schizoaffective disorder bipolar disorder. Review of Resident #63's admission Minimum Data Set (MDS) dated [DATE] revealed the following. Resident #63 did not have a serious mental illness and/or intellectual disability. Resident #63 received an antipsychotic medication. Review of Resident #63's physician orders revealed an antidepressant medication (Zoloft) 50 milligrams (mg) daily, an antianxiety medication (Ativan) 0.5 mg once daily at bed time, and antipsychotic medication (Seroquel) 25 mg twice daily. Review of Resident #63's plan of care revealed the psychoactive medications were listed; however no target behaviors were identified. There were no target behaviors identified in Resident #63's medical record. Interview of Licensed Practical Nurse (LPN) #40 on 08/16/2021 at 11:10 AM revealed Resident #63 did not have any behaviors. Interview of the Director of DON) on 08/16/2021 at 3:27 P.M. confirmed no target behaviors were identified for Resident #63. 2. Review of Resident #56's medical record revealed she was admitted on [DATE] with diagnoses that included: schizoaffective disorder, vascular dementia with behavioral, hypothyroidism, essential hypertension, stiffness of left hip, atrial fibrillation, dementia without behavioral, anxiety disorder, bipolar disorder, and Alzheimer's disease. Review of Resident #56's significant change Minimum Data Set (MDS) dated [DATE] revealed her speech was clear, she made herself understood, she usually understands others, and her cognition was severely impaired. Resident #56 received an antipsychotic medication, antidepressant medication, and antidepressant medication daily. Review of Resident #56's physician orders revealed she was on hospice; she received an antipsychotic medication (Risperdal) 1 mg at bed time for irritability. Interview of the Corporate Registered Nurse #900 on 08/16/2021 at 3:22 P.M. confirmed irritability was not a reason to give an antipsychotic medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365584 If continuation sheet Page 18 of 28 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 365584 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Rosemount Pavilion 20 Easter Drive Portsmouth, OH 45662 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on staff interview, observation and record review the facility failed to ensure medications error rates were less than 5% when they administered the wrong medication and wrong dosage amount for Resident #47. The facility had 29 medication administration opportunities with two errors for a medication error rate of 6.9%. The facility census was 84. Residents Affected - Few Findings include: Record review of Resident #47 revealed an admission date of 09/11/15 with pertinent diagnoses of: type two diabetes mellitus, hypothyroidism, schizoaffective disorder, dementia, vitamin D deficiency, and gastro-esophageal reflux disease. Review of Resident #47's Physician Orders on 08/11/21 revealed an order dated 02/09/21 for heartburn relief 10 mg tablet give two tablets orally one time a day for gastro-esophageal reflux disease. Review of Resident #47's Physician Orders on 08/11/21 revealed an order dated 01/26/21 for Vitamin D3 2000 unit tablet give one tablet orally one time a day for supplement. Observation of a medication pass on 08/11/21 at 9:15 A.M. with Registered Nurse (RN) #835 revealed she administered one tab of Vitamin D3 1000 unit tablet. Observation of a medication pass on 08/11/21 at 9:15 A.M. with Registered Nurse (RN) #835 revealed she administered two tablets of calcium carbonate 500 milligrams (mgs) to Resident #47. Resident #47 did not have an order for calcium carbonate 500 mgs. Interview on 08/11/21 at 9:59 A.M. with RN #835 verified she gave one tablet of Vitamin D3 1000 units tablet and it should have been Vitamin D3 one tablet of 2000 units. Interview on 08/11/21 at 9:59 A.M. with RN #835 verified she gave calcium carbonate 500 mgs to Resident #47 and that she should of administered famotidine (heartburn relief) two tabs of 10 mgs instead. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365584 If continuation sheet Page 19 of 28 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 365584 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Rosemount Pavilion 20 Easter Drive Portsmouth, OH 45662 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 - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of facility policy for administering medication, the facility failed to ensure residents were free from significant medication errors when physician orders for a blood pressure medication were not followed and the medication was not administered to a resident. This affected one (Resident #281) of three residents reviewed for hospitalization. The facility census was 84. Residents Affected - Few Actual harm occurred when Resident #281 was admitted to the facility from the hospital on [DATE] with orders for a blood pressure medication that was not administered resulting in elevated blood pressure and requiring the resident's treatment at the hospital. Findings include: Review of the medical record of Resident #281 revealed the resident admitted to the facility on [DATE]. Diagnoses included cerebral infarction, paroxysmal atrial fibrillation, essential hypertension, type 2 diabetes mellitus, and insomnia. Review of the comprehensive Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed the resident had intact cognition. Review of the physician's orders revealed an order dated 07/31/21 at 12:21 A.M. to administer hydralazine hcl (antihypertensive) 10 milligrams (mg) by mouth every 6 hours. Review of the medication administration record (MAR) revealed the resident did not receive hydralazine hcl 10 mg as ordered on 07/31/21 at 6:00 A.M., 12:00 P.M., and 6:00 P.M. Review of a nursing progress note dated 07/31/21 at 6:56 P.M. revealed the resident complained of chest pain and shortness of breath and requested to go to the hospital. Resident #281's blood pressure was 209/53. Review of emergency department (ED) Note dated 07/31/21 revealed the resident stated he had not received his medications at the nursing home and the nurse practitioner spoke with nursing home staff, who stated they will work on getting all meds ordered at least by Monday. Review of the ED Report dated 07/31/21 revealed the resident was seen for generalized weakness, chronic pain, debility, acute urinary tract infection, and hypertension. Resident #281 received one dose of hydralazine hcl 10 mg during ED visit on 07/31/21 at 11:48 P.M. Additional instructions included to get all medications filled ASAP. Interview on 08/11/21 at 5:00 P.M. with Registered Nurse (RN) #320 stated hydralazine hcl 10 mg is not available in the e-box. RN #320 stated, if a medication is not available upon admission, she calls the pharmacy and asks for a drop ship and notifies the physician and responsible party of the medication being unavailable. RN #320 further stated these actions would be documented in the resident's medical record. Interview on 08/12/21 at 10:38 A.M., RN/Assistant Director Of Nursing (ADON) #325 stated Resident #281 admitted to the facility from the hospital on [DATE] at approximately 10:00 P.M. RN/ADON #325 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365584 If continuation sheet Page 20 of 28 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 365584 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Rosemount Pavilion 20 Easter Drive Portsmouth, OH 45662 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 - Actual harm Residents Affected - Few stated pharmacy deliveries usually arrive daily between 1:00 and 2:00 P.M. and between 9:00 P.M. and 10:00 P.M. RN/ADON #325 stated Resident #281 arrived after the evening pharmacy delivery and the expectation would have been to have the meds sent STAT, which would have the meds delivered within 4 hours. RN/ADON #325 further verified Resident #281's MAR and progress notes lacked evidence of the hydralazine being administered on 07/31/21 at 6:00 A.M., 12:00 P.M. and 6:00 P.M. Review of the facility policy titled, Administration and Documentation of Medications, undated, revealed every resident should receive medications as prescribed by a licensed physician safely, properly, and in a timely manner, and all medications shall be accurately and completely documented. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365584 If continuation sheet Page 21 of 28 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 365584 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Rosemount Pavilion 20 Easter Drive Portsmouth, OH 45662 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, policy review, and staff interview the facility failed to ensure medications were stored appropriately when the facility had numerous expired medications and undated insulin. This affected three Residents (#8, #59, and #67) and affected two of four medication carts observed for med storage. The facility census was 84. Findings include: Observation on 08/12/21 at 10:43 A.M. of the 100 hall medication cart revealed the following expired over the counter medications: cetrizine 10 milligrams (mgs) expired 07/21, Vitamin B-12 100 micrograms expired 07/21, and multi vitamin with iron expired 12/20. Interview with Licensed Practical Nurse (LPN) #408 on 08/12/21 at 10:43 A.M. verified the medications were all expired and should have been discarded and not used. Observation on 08/12/21 at 10:54 A.M. of the 400 hall medication cart revealed Resident #67 insulin Lispro vial was not marked when opened and was received from pharmacy on 03/01/21. Resident #8 Lantus insulin vial was not marked when opened and was received from pharmacy on 05/25/21. Resident #59 had a Basaglar insulin pen dated open on 06/14/21. There was a Humalog pen that was undated and no Resident name was on the pen. There was a colace bottle 100 mgs that expired 06/21, and a calcium 600 mgs bottle that the expiration date looked like 06/21 but was not completely legible. There was a Vitamin C 500 mgs bottle that expired 06/21, and a sodium bicarbonate bottle that did not have an expiration date on it. Interview with Registered Nurse (RN) #320 on 08/12/21 at 10:54 A.M. verified the medications were all expired and should have been discarded and not used. Review of the Basaglar Insulin Kwikpen Use website on 08/12/21 revealed to throw away the pen after using it for 28 days. Review of the facility Storage of Medications policy dated 04/01/19 revealed discontinued, outdated drugs or biologicals are returned to the dispensing pharmacy or destroyed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365584 If continuation sheet Page 22 of 28 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 365584 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Rosemount Pavilion 20 Easter Drive Portsmouth, OH 45662 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on menu review, resident interview, staff interview, and medical record review the facility failed to have a vegetarian menu prepared in advance. This affected one of four sampled residents reviewed for nutrition (Resident #71). Findings include: Review of Resident #71's medical record revealed she was admitted on [DATE] with diagnoses that included: hypertensive urgency, asthma, chronic pain, osteoarthritis, pleural effusion, insomnia, dementia without behaviors, gastro-esophageal reflux disease, constipation, and cognitive communication deficit. Review of Resident #71's admission Minimum Data Set (MDS) dated [DATE] revealed the following. Resident #71's speech was clear, she made herself understood, she understands others, and her cognition was moderately impaired. Resident #71 had moderately severe depression, she had no psychosis, did not refuse care, and had no behaviors. Resident #71 required extensive assistance of two staff for bed mobility, did not transfer, walk, or use locomotion, supervision of one staff to eat. Resident #71 had no swallowing problems, was 69 inches and 110 pounds, had no unplanned weight changes, and received a mechanically altered diet. Review of Resident #71's quarterly MDS dated [DATE] revealed the following changes: verbal behaviors and other behaviors not directed towards others that occurred one to three days, supervision with setup help to eat, weighted 98 pounds, had unplanned weight gain and weight loss, and her diet not mechanically altered. Review of Resident #71's physician orders revealed a regular diet and house shakes three times a day. Review of Resident #71's admission nutritional assessment dated [DATE] revealed she was vegetarian by choice. Review of the facility's menus revealed no vegetarian menus or recommendations for the replacement of animal proteins. Observation on 08/12/21 at 7:45 A.M. of Resident #71's breakfast meal revealed she received orange juice, two pancakes, oatmeal, 2% milk , syrup, and asked for butter. Her tray card said no meat. Review of the menu revealed in addition to what Resident #71 received the menu called for with the exception of sausage. The resident did not receive a protein source to replace the sausage. Interview of Resident #71 on 08/12/21 at 1:57 P.M. revealed she was a vegetarian. Resident #71 stated she ate animal based proteins such as eggs and dairy. Interview of Dietary Manager (DM) #857 on 08/12/21 at 2:56 P.M. confirmed there was no menu planned for a vegetarian diet. Interview of Registered Dietitian Nutritionist (RND) #335 on 08/16/21 at 2:36 P.M. revealed she was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365584 If continuation sheet Page 23 of 28 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 365584 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Rosemount Pavilion 20 Easter Drive Portsmouth, OH 45662 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 0803 not aware Resident #71 was a vegetarian and there was no planned vegetarian diet. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365584 If continuation sheet Page 24 of 28 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 365584 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Rosemount Pavilion 20 Easter Drive Portsmouth, OH 45662 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm 5. Record review of Resident #9 revealed an admission date of 06/27/18 with pertinent diagnoses of: chronic respiratory failure, chronic obstructive pulmonary disease, dementia, cardiovascular disease, seizures, hypertension, arteriosclerotic heart disease, type two diabetes mellitus, major depressive disorder, dysphasia, hemiplegia and hemiparesis following non-traumatic intracerebral hemorrhage, benign prostatic hyperplasia, glaucoma, chronic kidney disease, and insomnia. Residents Affected - Some Review of the 07/23/21 quarterly Minimum Data Set (MDS) assessment revealed Resident #9 was moderately cognitively impaired and required total dependence for bed mobility, eating, bathing, and toilet use. The Resident was always incontinent of bowel and bladder. Review of a Physician Order dated 07/20/21 revealed clostridium difficile precautions for Resident #9. Observation on 08/09/21 at 10:40 A.M. revealed Resident #9's room had a plastic tub of personal protective equipment outside the door. There was not a sign indicating to see nurse prior to entrance to the room or what kind of isolation precautions the Resident was on. Interview with Licensed Practical Nurse (LPN) #506 on 08/09/21 at 10:43 A.M. verified Resident #9 is on contact precautions for clostridium difficile and there was not a sign telling staff or visitors to see nurse or what kind of isolation precautions to use. Review of a facility Isolation- Notices of Transmission Based Precautions policy undated revealed when transmission based precautions are implemented, the Infection Preventionist determines the appropriate notification to be placed on the room entrance door and on the front of the Residents chart so that personnel and visitors are aware of the need for and type of precautions. Based on medical record review, observation, staff interview, review of facility policy for Notices of Transmission Based Precautions, Wound Care, and review of the Center for Disease Center guidance on Respirators on/Respirators off, the facility failed to ensure infection control safety measures were followed for residents who were in quarantine for COVID-19 and being an unvaccinated new admission, resident on contact isolation, and for residents during a wound dressing change. This affected five residents (Resident #9, #19, #274, #275, and #285) of the 22 residents reviewed during this annual survey. The facility census was 84. Findings include: 1. Review of the medical record for Resident #19 revealed an admission date of 12/26/18. Diagnoses included pressure ulcer to the coccyx, muscle weakness, and hemiplegia affecting unspecified side. Review of Resident #19's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/17/21, revealed the resident's cognition was not assessed. No behaviors were noted. Resident #19 was noted to require extensive assistance from two staff members for bed mobility, and dressing and extensive assistance from one staff member for eating, toilet use, and personal hygiene. Resident #19 was noted to have no impairment to her bilateral upper extremity but did have impairment to her bilateral lower extremities. Resident was noted to always be incontinent of bowel and bladder functions. Resident #19 was noted to have one Stage III pressure ulcer which was not present upon admission. Interventions for this included a pressure reducing device to be applied to the resident's chair and bed, and to turn (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365584 If continuation sheet Page 25 of 28 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 365584 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Rosemount Pavilion 20 Easter Drive Portsmouth, OH 45662 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 0880 and reposition the resident, and to complete pressure ulcer injury care. Level of Harm - Minimal harm or potential for actual harm Review of Resident #19's plan of care dated 01/10/19 and revised on 05/17/21, revealed the resident has impairment to skin integrity related to incontinence, fragile skin, limited mobility, and declining health as evidenced by a Stage III ulcer located on the coccyx, and a vascular ulcer to the left foot 5th metatarsal. Interventions include to provide antibiotics as ordered, wound treatments as ordered, encourage good nutrition, keep skin clean and dry, speciality mattress to bed, turn and reposition every two hours. Residents Affected - Some Review of Resident #19's physician orders for 08/2021 revealed: - Cleanse area to coccyx with wound cleanser, pat dry, pack with lodofoam (a single cotton gauze strip impregnated with formulated Iodofoam solution used for sterile drainage of open and/or infected wounds) and cover with a clean, dry, dressing, every day and as needed if loose or soiled. Complete every day shift for wound care. Observation of the coccyx wound dressing change for Resident #19 completed on 08/11/21 at 10:33 A.M. by Nurse Practitioner (NP) #100 revealed the NP #100 placed the needed supplies to complete Resident #19's wound treatment on the resident's bedside table without cleaning the bedside tablet prior nor placing a clean barrier between the bedside table and wound treatment supplies. NP #100 then proceeded to apply a pair of gloves and completed the dressing change which included removing the old dressing, removing the soiled wound packing, cleansing the wound, measuring the size of the wound, repacking the wound with the ordered Iodofoam gauze, and applying a clean dry dressing, all while wearing the same pair of gloves for the entire procedure. After removing the old dressing, NP #100 placed the old dressing, including the soiled Iodofoam that was placed in the residents wound, onto the resident's bedside table. After completing Resident #19's wound dressing change, NP #100 proceeded to reposition the resident in her bed to ensure comfort and raise the head of her bed up and lower the bed to a safe level all while still wearing the same soiled gloved that were used to complete the dressing change. NP #100 then removed the soiled, old dressing from the residents bedside table and placed it into the trash can followed by removing the soiled gloves and placing them in the trash can as well. Resident #19's bedside table was then placed at the bedside for easy reach without being cleaned. Interview on 08/12/21 at 2:30 P.M. with the Director of Nursing (DON) confirmed infection control had not been maintained during the coccyx wound dressing change for Resident #19 when NP #100 had not cleaned the bedside tablet and placed a barrier between the table and dressing supple's, changed gloved or completed hand hygiene during the resident's dressing change as well as placing the soiled dressing on the resident's bedside table and not cleaning the table after removing the soiled dressing. Review of the facility policy titled Wound Care, revised on 09/2018, revealed, Use disposable cloth to establish a clean field on resident's over bed tablet. Place all items to be used during the procedure on the clean field. Put on exam gloves, loosen tape and remove old dressing, Pull gloves over dressing and discard into appropriate receptacle. Wash and dry you hands thoroughly. Put on a new pair of gloves. After wound cleansing, remove and discard gloves and perform hand hygiene, apply new clean gloves. After dressing change is completed, remove disposable gloves and discard into designated container. Wash and dry you hands. Reposition the bed covers. Make the resident comfortable. Clean over bed table with the facility's cleansing wipes or alcohol wipes. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365584 If continuation sheet Page 26 of 28 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 365584 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Rosemount Pavilion 20 Easter Drive Portsmouth, OH 45662 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2. Review of the medical record of Resident #275 revealed an admission date of 07/29/21. Diagnoses included aftercare following joint replacement surgery, chronic pain, type 2 diabetes mellitus, gastro-esophageal reflux disease, essential hypertension, and bipolar disorder. Review of Resident #275's immunization record revealed no evidence Resident #275 was vaccinated for COVID-19 as of 08/12/21. Observation on 08/09/21 at 12:30 P.M., State Tested Nurse Aide (STNA) #305 donned a gown, gloves, and face shield and entered the room of Resident #275 to deliver a meal tray. STNA #305 was not observed to don an N-95 mask prior to entering the room of Resident #275. The door to Resident #275's room contained signs indicating the resident was under observation for COVID-19 and the need to wear an N-95 mask when entering the room. 3. Review of the medical record of Resident #274 revealed an admission date of 08/05/21. Diagnoses included acute respiratory failure with hypoxia, chronic diastolic (congestive) heart failure, paroxysmal atrial fibrillation, gastro-esophageal reflux disease, and essential hypertension. Review of the resident's immunization record revealed the resident was not vaccinated for COVID-19 as of 08/16/21. Observation on 08/09/21 at 12:33 P.M., STNA #305 donned a gown, gloves, and face shield and entered the room of Resident #274 to deliver a meal tray. STNA #305 was not observed to don an N-95 mask prior to entering the room of Resident #274. The door to Resident #274's room contained signs indicating the resident was under observation for COVID-19 and the need to wear an N-95 mask when entering the room. Interview on 08/09/21 at 12:35 P.M., STNA #305 verified she did not wear an N-95 into the rooms of Residents #274 and #275 when delivering their meal trays. STNA #305 further affirmed she should have worn an N-95 mask into the rooms of Residents #274 and #275, and stated she did not because there were not any N-95 masks available in the bins outside of the rooms. 4. Review of the medical record of Resident #285 revealed an admission date of 08/09/21. Diagnoses included atherosclerotic heart disease of native coronary artery without angina pectoris, major depressive disorder, gastro-esophageal reflux disease without esophagitis, paroxysmal atrial fibrillation, type 2 diabetes mellitus, stage 4 chronic kidney disease, and anxiety. Review of Resident #285's immunization record as of 08/16/21 revealed Resident #285 was not vaccinated for COVID-19. Observation on 08/11/21 at 12:24 P.M., revealed Physical Therapy Assistant (PTA) #310 and STNA #315 in the hallway outside of the room of Resident #285 each donned gowns and gloves and placed an N-95 mask directly over their surgical mask. PTA #310 and STNA #315 then entered the room of Resident #285. The door to Resident #285's room contained signs indicating the resident was under observation for COVID-19 and the need to wear an N-95 mask when entering the room. Interview on 08/11/21 at 12:37 P.M., upon exiting the room of Resident #285, STNA #315 verified she and PTA #310 placed N-95 masks directly over the surgical masks and wore the masks into the room of Resident #285 in that manner. STNA #315 stated this was the way she was instructed to wear the N-95 mask. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365584 If continuation sheet Page 27 of 28 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 365584 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Rosemount Pavilion 20 Easter Drive Portsmouth, OH 45662 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 08/12/21 at 10:49 A.M., Registered Nurse (RN)/Assistant Director Of Nursing (ADON) #325 stated, when entering a COVID-19 quarantine room, staff should don an N-95 mask, goggles, gloves, and a gown. Upon further questioning, the RN/ADON #325 stated staff should remove their surgical mask before donning the N-95 mask. Interview on 08/16/21 at 1:29 P.M., RN/ADON #325 stated new admissions who have not been fully vaccinated for COVID-19 are placed in a COVID-19 quarantine room for 14 days. Review of the CDC Respirator On/Respirator Off guidance, dated 06/09/20 (https://www.cdc.gov/coronavirus/2019-ncov/downloads/hcp/fs-respirator-on-off.pdf) revealed, to ensure proper placement, nothing should come between the face and the respirator. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365584 If continuation sheet Page 28 of 28