Inspection·May 10, 2023

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and review of the Residents Rights, the facility failed to maintain a clean living environment for the residents. This had the potential to affect all 74 residents in the facility. The facility census was 74. Findings include: Observations on 05/09/23 from 9:15 A.M. through 10:00 A.M. of the 300 hall revealed rooms 313, 314, 316 to have black grime on the floors, chipped paint on the door frames and the bathrooms with strong urine odors. The shower room on 300 hall had black substance in the corners and along the wall of the residents shower stall. Observations on the 400 hall revealed rooms 409, 411 and 413 had black grime on the floor and along the base board of the room, and the walls were dirty. room [ROOM NUMBER] bathroom looked dirty and had strong urine smell. The ice cart used for 300 and 400 hall had dust, grime, food particles and rust on the tray where the ice chest sat. The ice machine in the dining room was dusty and had grime on it. The 200 hall floors had black grime and stains along the base boards, and resident door ways/thresholds needed painted. The 200 hall shower room had strong odor of sewer, the resident shower stall had black substance in corners and on the floor. The privacy curtain for the shower stall was soiled and frayed at the bottom. An interview on 05/09/23 at 10:00 A.M. with Certified Nursing Assistant (CNA) #102 and #41 confirmed the strong sewer smell and the black mold in the residents shower stall on 200 hall. An interview on 05/09/23 along with observations from 10:30 A.M. through 10:50 A.M. with the Administrator and the Director of Nursing (DON) confirmed the mold in the shower rooms on 200 and 300 halls, the black grime and dirt on the floors throughout the facility and the need for paint. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 365584 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 05/10/2023 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)