Inspection·August 25, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few physician and family were notified regarding Resident #6's decreased oral intakes since 07/30/23, including the lack of nutrition and hydration from 08/07/23 through 08/10/23. Review of the monthly progress note dated 08/08/23 and timed 7:28 P.M., completed by Physician Assistant (PA) #326, revealed Resident #6 did not appear to be in any distress and there were no concerns from nursing staff other than increased incidents of falls. Interview on 08/17/23 at 4:25 A.M. with State Tested Nursing Assistant (STNA) #252 verified Resident #6 had not eaten lunch or dinner on 08/07/23 and did not consume any meals or drinks on 08/08/23 or 08/10/23. STNA #252 stated Resident #6 was offered finger foods and drinks but refused the alternatives. STNA #252 stated at each meal Resident #6 did not eat the nurse was notified. Interview with STNA #238 on 08/17/23 at 3:30 P.M. verified Resident #6 did not consume any food or drinks on 08/09/23. STNA #238 stated the nurse was notified of the resident's meal refusal and refusal of alternative food and drink choices. Interview on 08/17/23 at 4:32 P.M. with Licensed Practical Nurse (LPN) #239 verified working on 08/07/23 through 08/10/23 from 7:00 A.M. and 7:00 P.M. LPN #239 verified she was notified of Resident #6 refusing to eat or drink. LPN #239 stated alternatives were offered and the resident consumed very little. LPN #239 verified she did not notify the physician of Resident #6 not eating or drinking. Interview on 08/21/23 at 8:29 A.M. with PA #326 revealed no knowledge of Resident #6's refusal to eat for three days. PA #326 stated the nurses shared Resident #6 had a decreased appetite and the PA related the decreased appetite to medication changes. Interview 08/21/23 at 8:57 A.M. with Physician #315 revealed no knowledge of Resident #6 not eating or drinking. Review of the facility policy titled Change in a Resident's Condition or Status, dated May 2017, revealed the facility shall promptly notify the resident, his or her representative and the attending physician of changes in the residents medical or mental condition and or status. A significant change of condition is a major decline or improvement in the residents status that will not normally resolve itself without intervention, impacts more than one area of the resident health status, requires interdisciplinary review and revisions to the care plan. Interview 08/17/23 at 10:00 A.M. with the Director of Nursing (DON) verified communication did not occur with the family regarding Resident #6's refusals to eat and drink. This deficiency represents non-compliance investigated under Complaint Number OH00145553. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365617 If continuation sheet Page 2 of 14 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 365617 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Waterville 8885 Browning Drive Waterville, OH 43566 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of hospital records, review of a facility Self-Reported Incident (SRI), review of the facility abuse investigation, review of the coroner's report, staff interviews, review of the facility policy titled Freedom from Abuse Neglect, and Exploitation, review of facility policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, and review of facility policy titled Resident to Resident Altercations, the facility failed to ensure Resident #100 and Resident #101, were free from abuse. This resulted in Immediate Jeopardy and serious life-threating injuries and/or death for Resident #101 when after witnessing a verbal altercation between Resident #100 and Resident #101, during which time Resident #101 had exhibited physical aggression, State Tested Nursing Assistant (STNA) #230 was unable to obtain assistance from additional staff and left the two residents unsupervised in their room while she went to notify the nurses of the situation. Upon returning to the room after obtaining assistance, staff discovered Resident #100 and Resident #101 involved in a physical altercation in which Resident #100 had been struck in the head and Resident #101 had been repeatedly struck in the head and face. Resident #101 was bleeding from lacerations above the eye and to the mouth and was transported via emergency services to a local hospital where he was identified to have a subdural hematoma, subarachnoid hemorrhage, and an epidural hematoma. Consequently, Resident #101 expired nine hours and 20 minutes after the incident from the blunt force trauma injuries sustained in the altercation. This affected two (#100 and #101) of four (#6, #12, #100, and #101) residents reviewed for physical abuse. The facility census was 69. On [DATE] at 5:19 P.M., the facility Administrator, Director of Nursing (DON), and the [NAME] President of Clinical Operations #500 were notified Immediate Jeopardy began on [DATE] at 6:05 P.M., when STNA #230 witnessed a verbal altercation and per her statement, a lunging motion with a fist by Resident #101 toward Resident #100, which was occurring in their shared room. STNA #230 intervened and attempted to call for assistance by activating the call light with no other staff responding. STNA #230 left the residents unsupervised in the room, sitting on their beds after the arguing stopped, and went to the nurses' station to notify the nurse of the situation. STNA #230 returned to the room after notifying Licensed Practical Nurse (LPN) #297 and found Resident #100 holding Resident #101 in a headlock and yelling for help. Resident #101 was bleeding from a laceration to his eyebrow and his mouth. Resident #101 told staff he bopped Resident #100 on the head. Resident #100 told staff he hit Resident #101 about 20 times while demonstrating an upper cut motion. Resident #101 was transferred to a local emergency room for evaluation and treatment. Resident #101 had sustained head injuries of a subdural hematoma, subarachnoid hemorrhage, and an epidural hematoma. Resident #101 expired on [DATE] at 3:25 A.M. The coroner's report listed the manner of death as a homicide from blunt force trauma with subdural hematoma. The Immediate Jeopardy was removed on [DATE] when the facility educated all staff on the facility abuse policy and initiated the use of walkie talkies for staff communication on the dementia unit. The deficiency remained at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) until it was corrected on [DATE] when the facility implemented the following corrective actions: • (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365617 If continuation sheet Page 3 of 14 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 365617 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Waterville 8885 Browning Drive Waterville, OH 43566 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 0600 On [DATE] at 6:15 P.M., LPN #243 notified the DON of the altercation. An investigation was initiated, and the SRI was reported to the State Survey Agency. Level of Harm - Immediate jeopardy to resident health or safety • Residents Affected - Few On [DATE] at 6:15 P.M., the DON directed the nurses to stay on the dementia unit to document and not at the nurse's station. • On [DATE] at approximately 6:20 P.M., the police responded to the facility with the emergency medical services (EMS) and were notified of the incident. • On [DATE] at approximately 6:20 P.M., LPN #243 notified the families and physicians for Resident #100 and Resident #101 regarding the incident. • On [DATE], the DON started daily audits to identify any roommate conflicts. These occurred daily on the dementia unit for seven days, then three times a week for the rest of the facility through [DATE]. • On [DATE] at 10:00 P.M., LPN #296 completed skin sweeps for all the residents residing on the dementia unit to identify any injuries, with no injuries reported. • On [DATE], the Administrator, the DON, [NAME] President of Clinical Operations #500, and Medical Director #315 met via the telephone and developed a plan of correction. • On [DATE], Corporate Director of Clinical Education #520 provided education to all facility staff on the facility abuse and neglect, communication and behaviors, and behavior interventions via an online education program. The DON conducted post education competencies for all facility staff from [DATE] through [DATE]. • On [DATE], the facility purchased walkie talkies for use by all staff on the dementia unit with the use implemented at 4:00 P.M. LPN #243 educated staff on the dementia unit on the use of the walkie talkies. • (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365617 If continuation sheet Page 4 of 14 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 365617 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Waterville 8885 Browning Drive Waterville, OH 43566 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 0600 On [DATE], Maintenance Supervisor #289 changed the lock on the door that accessed the dementia unit from the nursing station from a keypad to a push button for quicker access to the unit. Level of Harm - Immediate jeopardy to resident health or safety • Residents Affected - Few On [DATE], the facility placed a new desk on the dementia unit for nursing staff to utilize when charting to enable the staff to remain on the unit at all times. • Interviews on [DATE] and [DATE] with LPN #239, LPN #243, LPN #297, LPN #305, Respiratory Therapist (RT) #302, STNA #230, and Registered Nurse (RN) #287 verified they were educated on the facility's abuse policy and the protection of residents during resident-to-resident altercations. • On [DATE], the medical records for Resident #6 and Resident #12 were reviewed for abuse. No concerns were identified. Findings include: Review of the SRI, dated [DATE], revealed the facility reported an allegation of physical abuse involving Resident #100 and Resident #101. The allegation concluded that Resident #100 and Resident #101 had a verbal altercation followed by a physical altercation. Resident #101 went over to Resident #100 and hit him on the head. Resident #100 put Resident #101 in a headlock and hit him in the face and head. Resident #101 was bleeding from the mouth and eyebrow. Both residents were sent to the local emergency room for evaluation and treatment. The responsible parties and the physician were notified of the incident on [DATE]. Local Law Enforcement was notified of the allegation on [DATE]. As a result of the investigation the facility unsubstantiated the allegation of abuse. Review of the medical record for Resident #101 revealed an admission date of [DATE] with diagnoses of atrial fibrillation, dementia, diabetes mellitus, high blood pressure, and heart failure. Review of Resident #101's quarterly Minimum Data Set (MDS) assessment, dated [DATE], revealed the resident had moderately impaired cognition and behaviors of rejection of care. Review of Resident #101 nurses' notes dated [DATE] at 7:21 P.M. revealed the resident was involved in an altercation with his roommate with the family and doctor notified. Review of hospital emergency department to admission discharge record dated [DATE] revealed Resident #101 was initially evaluated at a freestanding emergency room (ER) following an assault. At the initial evaluation the resident was found to have a large subdural hematoma, subarachnoid hemorrhage, and possibly an epidural hematoma with a mild midline shift by computerized tomography (CT) scan. A Glascow coma scale (GCS) (a way to measure consciousness after brain injury) was initially 14 (able to answer and respond appropriately) upon arrival to the freestanding ER. Then his mentation began declining with the resident requiring intubation (placement of breathing tube) prior to transfer to a second hospital for a higher level of care. Upon arrival to the hospital the GCS was three without sedation. The patient was on the blood thinner Eliquis and was given Kcentra (medication used to reverse blood thinning effects). A repeat CT scan of the head was obtained with results of significant (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365617 If continuation sheet Page 5 of 14 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 365617 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Waterville 8885 Browning Drive Waterville, OH 43566 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 0600 Level of Harm - Immediate jeopardy to resident health or safety progressive enlargement of the right subdural hematoma with the maximum thickness increased to three centimeters (cm) from 2.3 cm. There was compression to the right lateral ventricle and a dilated left ventricle with herniation. The neurosurgeon was consulted and discussed with family members the poor prognosis even with surgery. The family decided to change the code status to do not resuscitate comfort care. The patient was admitted to the neurological intensive care unit where he was passionately extubated (breathing tube removed). Resident #101 expired on [DATE] at 3:25 A.M. Residents Affected - Few Review of the coroner's report dated [DATE] revealed Resident #101's cause of death was from blunt head trauma with subdural hematoma that occurred in an altercation. The manner of death was identified as a homicide. Review of the medical record for Resident #100 revealed an admission date of [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD), anxiety, and dementia with agitation. Review of Resident #100's admission MDS assessment, dated [DATE], revealed moderately impaired cognition and rejection of care. Review of Resident #100's physician orders from [DATE] revealed hospice care, Ativan 1 milligram (mg) every six hours for anxiety and every four hours as needed for anxiety, and Buspar 30 mg three times daily for anxiety. Review of Resident #100's care plan, dated [DATE], revealed the resident was care planned for verbal aggression toward staff, and resisting medication and personal care. Interventions included allowing resident choices, analyze circumstances and triggers to care, and deescalate behaviors. Review of nurses' notes dated [DATE] at 7:18 P.M. revealed the resident was involved in an altercation with the roommate. The family and doctor were notified. Review of the facility investigation revealed a staff statement from STNA #230 which noted on [DATE] around 6:00 P.M. she witnessed Resident #101 lunge over to Resident #100 with a fist but did not hit Resident #100. She yelled for Resident #101 to stop. He then turned towards her and cussed at her stating You want some to? STNA #230 assisted the resident to his bed, and he was still cussing and yelling. STNA #230 asked Resident #101 to go with her to the nurse to report the incident and he refused. STNA #230 asked Resident #100 to go with her to report the incident to the nurse and he also refused. Resident #100 was on his bed and calm the whole time. STNA #230 yelled for a nurse and then ran to the nurses' station where she alerted LPN #297 of the situation, and that Resident #101 was yelling and threatening her. STNA #230 ran back to the room and found Resident #101 on Resident #100's bed in a headlock and Resident #101 was bleeding. Resident #100 was yelling Help during this time. STNA #230 stated the residents were alone for approximately 30 seconds. The nurses arrived and directed STNA #230 to get LPN #297. STNA #230 stated 911 was called and police arrived. Both residents were sent out for evaluation. STNA #230 stated Resident #100 had red knuckles. Review of an addendum statement dated [DATE] from STNA #230 revealed there was an argument between Resident #100 and Resident #101 about urine on the floor. STNA #230 felt comfortable with leaving the residents as they were not arguing, and both were safely sitting on their beds. STNA #230 stated she felt comfortable leaving them alone because these two residents didn't have any prior aggressive behaviors toward anyone, just verbal bickering and fighting. Review of the facility investigation revealed a staff statement dated [DATE] from LPN #239 which (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365617 If continuation sheet Page 6 of 14 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 365617 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Waterville 8885 Browning Drive Waterville, OH 43566 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few indicated she was at the nurses' station and STNA #230 advised Resident #100 and Resident #101 were arguing and might need to be separated. LPN #239, along with LPN #297, got up immediately and went to the residents' room. When the nurses got to the room both residents were in their beds already separated. Blood was observed on the curtain. Resident #101 stated he went over to Resident #100 and bopped him on the head. Resident #100 told the nurses he hit Resident #101 20 times and demonstrated using an upper cut motion. LPN #239 was not able to control Resident #101's bleeding, so LPN #297 took over and LPN #239 went to get help from LPN #243. Review of the facility investigation revealed a staff statement dated [DATE] from LPN #297 that documented LPN #297 and LPN #239 were at the nurses' station when STNA #230 reported Resident #100 and Resident #101 were arguing, had an altercation, and were bleeding. Both nurses went to the residents' room and found Resident #100 and Resident #101 both on their own beds. Resident #101 was bleeding from his mouth and eye and there was blood on the curtain. Resident #101 told the nurse he went over to Resident #100 and bopped him on the head once. Resident #100 told LPN #297 he hit Resident #101 20 times. Resident #100 had blood on his hand. LPN #297 called 911 for Resident #101. LPN #297 stated the police and emergency medical services both responded and spoke to both residents. LPN #297 stated Resident #101 was communicating prior to leaving the facility and appeared to be cognitively alright. LPN #297 stated the entire incident lasted approximately five minutes. Review of the facility investigation revealed a staff statement dated [DATE] from LPN #243 which noted she was alerted to an altercation between Resident #100 and Resident #101 that went from verbal to physical. Resident #101 had injuries that needed medical attention. LPN #243 instructed staff to separate the residents and call 911 for transportation. Police and emergency medical services arrived, and Resident #101 was transported by stretcher. Resident #101 was alert and talking when he was transported. Review of a staff statement dated [DATE] from LPN #243 revealed she notified that an altercation had occurred and Resident #101's mouth was bleeding. She then notified the DON of the situation who directed LPN #243 to notify the doctor and families and send the residents out for evaluation. Interview on [DATE] at 8:00 A.M., the DON stated she was notified of an altercation between Resident #100 and Resident #101 on [DATE] at approximately 6:15 P.M. She was informed Resident #101 was bleeding and staff could not get it to stop. The DON stated she directed the staff to send the resident out for evaluation. Resident #101 was sent to a local ER for evaluation and treatment. The DON stated the facility learned of the death of Resident #101 on [DATE] when Resident #101's son came to the facility to pick up the residents' personal belongings. Interview on [DATE] at 10:20 A.M., the Administrator stated neither of the residents had been involved in any previous altercations. Interview on [DATE] at 10:41 A.M., STNA #230 stated she was picking up dinner trays at approximately 6:00 P.M. on [DATE] when she heard a little commotion from the residents' room and went to see what was happening. STNA #230 found Resident #100 and #101 involved in a verbal argument about urinating on the floor. STNA #230 stated she was able to get the residents calmed down and both residents were sitting on their beds. STNA #230 stated she tried to get them as far away from each other in the room as possible. She did this by having Resident #101 sit on the side of the bed furthest away from the roommate and closest to the doorway. STNA #230 stated she tried to get each of the residents to go with her to alert the nurse about the argument but both residents refused. STNA #230 she stated she ran to the nurses' station and was away from the room about 10 seconds before returning. When (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365617 If continuation sheet Page 7 of 14 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 365617 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Waterville 8885 Browning Drive Waterville, OH 43566 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few STNA #230 returned to the room she found Resident #100 had Resident #101 in a headlock and Resident #101 was bleeding. STNA #230 stated she was able to get the residents separated and went to get the nurses. The nurses were already on the way to the room and STNA #230 told the nurses she found Resident #100 had Resident #101 in a headlock. STNA #230 stated the residents each told what happened and both residents told the same version of the incident. Resident #101 stated he went to Resident #100 and bopped him on the head. Resident #100 stated he hit him back about 20 times while holding him in a headlock. Resident #100 was demonstrating an uppercut hitting motion. Interview on [DATE] at 3:08 P.M., LPN #239 stated LPN #297 and LPN #239 were at the nurses' station documenting with their back toward the secured dementia unit. The nurses were notified of the arguing between the residents and went to the residents' room. When she arrived, she observed both residents were sitting in their beds and there was blood on the privacy curtain. LPN #239 stated the entire time Resident #101 was alert and telling the staff and the police officer the details of the incident. Resident #101 stated I bopped him on the head and then stated Resident #100 hit him on the head. During a follow up interview on [DATE] at 5:16 P.M., STNA #230 stated she yelled for assistance during the incident, and no one responded so she went to the nurse's desk. Interview on [DATE] at 9:28 A.M., LPN #297 stated she does not recall hearing anyone yell for help; however, she was training another nurse and other residents were at the half door near the nurses' station. It is possible she did not hear anyone. LPN #297 stated both nurses were sitting at the desk with backs toward the unit documenting. LPN #297 stated it was close to 6:05 P.M. when STNA #230 told the nurses about the residents having an argument. On the way to the room, STNA #230 met the nurse in the hall and was informed of the additional altercation between Resident #100 and Resident #101 with Resident #101 bleeding. LPN #297 stated she tended to Resident #101 first due to the bleeding, but she was unable to control the bleeding from his mouth. She called 911 for assistance for the uncontrolled bleeding. LPN #297 stated both residents were sent out to a local ER for evaluation and treatment. Follow up interview on [DATE] at 12:39 P.M., STNA #230 stated while picking up dinner trays she witnessed Resident #101 standing between the beds in his room cussing and yelling at Resident #100. STNA #230 stated she yelled at Resident #101 to stop. He then walked over to her with his fist raised, grabbed her by both wrists, shook her, and stated You want some of this too? STNA #230 stated she had Resident #101 sit down on his bed and he complied. She offered to take Resident #101 to the nurses' station to report the incident and he refused to leave. STNA #230 offered to Resident #100 to leave the room and he refused also. STNA #230 went to the nurses' station to report the verbal altercation and that he had grabbed and shook her. When she went back to the room, she heard Resident #100 yell Help me. She observed Resident #100 sitting on his bed with Resident #101 bent over being held in a headlock position by Resident #100. Resident #101 was bleeding. STNA #230 stated she did not witness any hits between the residents. STNA #230 stated she activated the call light after the verbal altercation but did not yell for help with the verbal altercation. STNA #230 stated she did not actually run to the nurses' station; it was just a figure of speech. Review of facility policy titled Freedom from Abuse Neglect, and Exploitation, revised 10/22, revealed it is the policy of this company that all residents have the right to be free from abuse, neglect, and exploitation. The facility must provide a safe resident environment and protect residents from abuse. Under the area of Protection lists the facility must have written procedures that ensures all residents are protected from physical and psychosocial harm during and after the investigation (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365617 If continuation sheet Page 8 of 14 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 365617 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Waterville 8885 Browning Drive Waterville, OH 43566 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 0600 including increased supervision of the alleged victim and residents. Level of Harm - Immediate jeopardy to resident health or safety Review of facility policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, revised 10/22, revealed residents have the right to be free from abuse, neglect, exploitation, and misappropriation of resident property. If a resident is accused or suspected, the facility will protect the resident and will ensure other residents are protected as determined by the circumstances, which may include but are not limited to increased supervision of the alleged perpetrator and/or other residents, room or staffing changes, and immediate transfer or discharge, if indicated. Residents Affected - Few Review of the facility policy titled Resident to Resident Altercations, revised [DATE], revealed if two residents are involved in an altercation the staff must separate the residents and institute measures to calm the situation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365617 If continuation sheet Page 9 of 14 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 365617 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Waterville 8885 Browning Drive Waterville, OH 43566 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 - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of emergency department medical records, review of hospital medical records, staff interviews, physician interview, physician assistant (PA) interview, review of the facility policy titled Food and Nutrition Services, and review of the facility policy titled Resident Hydration and Prevention of Dehydration, the facility failed to ensure adequate hydration was provided to a resident, failed to provide an assessment of a resident refusing food and fluids, and failed to notify the physician and Dietetic Technician, Registered (DTR)/Registered Dietitian (RD) of a resident's refusal of food and fluids for three days. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injuries, and/or death for Resident #6 who had refused foods and fluids on 08/07/23, 08/08/23, 08/09/23 and 08/10/23 with no assessment of the resident being completed and no notification to the facility DTR #320/RD or the resident's physician for additional interventions. Consequently, Resident #6 suffered an acute change in condition, was sent by emergency squad to the emergency department and then to a secondary hospital and was admitted to the hospital's critical care unit with diagnoses of acute kidney failure, dehydration and acute respiratory failure which required intubation. This affected one (#6) of four (#6, #23, #59, and #62) residents reviewed for nutrition and hydration needs. The facility census was 69. Residents Affected - Few On 08/21/23 at 1:12 P.M., the Administrator, [NAME] President of Clinical Operations #500 and the Director of Nursing (DON) were notified Immediate Jeopardy began on 08/10/23 when Resident #6, who had a recent history of acute kidney failure and had been having meal intakes of less than 25%, was transferred to the hospital with lethargy after refusing food and fluids since 08/07/23. Staff failed to ensure adequate fluids were provided to the resident, failed to provide an assessment of the resident's hydration status when ongoing refusals of meals and fluids occurred, and failed to notify Medical Director #315 and DTR #320 of the resident's refusal to eat and drink to allow for assessments of the resident and the potential implementation of additional interventions to prevent dehydration. Resident #6 was emergently transferred to the emergency department on 08/10/23 where laboratory (lab) tests revealed acute kidney injury and dehydration. Resident #6 was intubated, transferred to a secondary hospital, and admitted to a critical care unit with diagnoses of acute respiratory failure, acute renal failure, and dehydration. The Immediate Jeopardy was removed on 08/18/23 when the facility implemented the following corrective actions: • On 08/18/23, the Corporate Director of Clinical Education #520 changed the settings in the electronic medical records so a clinical alert would come up when a resident had a meal intake less than 25 percent. These alerts will be followed up on daily and discussed on business days in the facility morning meetings. If a trend is noted, the physician and DTR #320/RD will be notified for a follow-up assessment. • On 08/18/23, the DON or designee, began daily audits of the electronic record clinical alerts to ensure they were followed up on. The audits are to be done daily for one week, then three times a week for four weeks to ensure follow up with the physician. The results of the audits will be reviewed by the facility Quality Assurance Performance Improvement (QAPI) team. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365617 If continuation sheet Page 10 of 14 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 365617 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Waterville 8885 Browning Drive Waterville, OH 43566 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 - Immediate jeopardy to resident health or safety On 08/18/23, the DON and Medical Records Clerk #282 educated all nurses on the clinical alerts, reporting decreased meal intakes to the physician and to assess residents who are not taking adequate food and fluids. Residents Affected - Few • On 08/18/23, the Administrator, the DON, [NAME] President of Clinical Operations #500, and Medical Director #315 met via the telephone and developed a plan of correction.??? • On 08/21/23, the medical records for Resident #23, Resident #59, and Resident #62 were reviewed for nutrition and hydration. No concerns were noted. Although the Immediate Jeopardy was removed on 08/18/23, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of the medical record for Resident #6 revealed an admission date of 07/12/23. Admitting diagnoses for Resident #6 included cerebral infarct, vascular dementia, hypertension, acute kidney failure, insomnia, anxiety disorder, and hyperlipidemia. Resident #6 was discharged on 08/10/23 to the hospital. Review of the admission assessment dated [DATE] revealed Resident #6 was on a regular diet with thin liquids, had no difficulty swallowing, and had a pink coloration to the tongue, cheeks, and lips. Review of the admission physician orders dated 07/12/23, revealed the resident was ordered a regular diet. Review of the history and physical completed by Physician #321, dated 07/14/23, revealed Resident #6 was admitted to the facility from the hospital on [DATE] with a history of vascular dementia. Resident #6 had a creatinine of 1.16 milligram/deciliter (mg/dl) which was down from 1.72 mg/dl upon admission (normal 0.7 - 1.2 mg/dl). Review of the comprehensive Minimum Data Set (MDS) assessment, dated 07/19/23, revealed Resident #6 had moderate cognitive impairment and had disorganized thinking. The resident required supervision after setup for eating. Review of the care plan initiated on 07/20/23, revealed Resident #6 was noted with potential for altered nutrition and hydration status related to unplanned weight loss related to inadequate oral intakes as evidenced by less than seventy-five percent intake of some meals. Interventions included the administration of medication as ordered, assistance with meals as needed, honor food preferences as able, obtain weights as ordered, offer meal substitutions as needed, provide diet as ordered and provide snacks per facility policy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365617 If continuation sheet Page 11 of 14 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 365617 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Waterville 8885 Browning Drive Waterville, OH 43566 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 - Immediate jeopardy to resident health or safety Residents Affected - Few Review of the nutritional assessment completed by DTR #320 on 07/20/23 revealed the resident was on a regular diet with thin liquids. The average meal intake was fifty to seventy-five percent. The resident's weight upon admission was 138.4 pounds and on 07/19/23 the resident had a weight of 134.4 pounds but was still within his body mass index (BMI). Daily nutritional needs were 1520 to 1840 kilocalories and 1530 to 1840 milliliters (ml) of fluid. Resident #6 was assessed with a potential for malnutrition. Review of the physician orders dated 07/21/23 revealed an order for a comprehensive metabolic panel (CMP) and complete blood count (CBC) weekly on Fridays. Review of the laboratory testing results for the CMP collected on 07/21/23 revealed a normal creatinine level of 1.1 mg/dl and an elevated blood urea nitrogen (BUN) level of 25 mg/dl (normal 8-23 mg/dl). The physician was notified, and no additional orders were received. Review of the laboratory testing results for the CMP collected on 07/28/23 revealed a creatinine level of 1.25 mg/dl and an elevated BUN level of 28 mg/dl. The sodium level was 138 milliequivalant/liter (meq/l) (normal 133-146) and the chloride level was 106 meq/l (normal 95-117). The physician was notified, and no new orders were received. Review of the laboratory testing results for the CMP collected on 08/04/23 revealed an elevated creatinine level of 2.05 mg/dl, an elevated BUN of 59 mg/dl, and elevated sodium level of 152 meq/l, and an elevated chloride level of 114 meq/l. The physician was notified with no new orders written. Review of the meal intakes revealed on 07/30/23, 07/31/23, and 08/01/23, Resident #6 consumed 0-25% of all meals. On 08/02/23, Resident #6 refused breakfast and lunch and consumed only 0-25% of the dinner meal. On 08/03/23, Resident #6 consumed 0-25% of all meals. On 08/05/23, Resident #6 consumed 0-25% of two meals and refused the third meal. On 08/06/23, Resident #6 only consumed 0-25% of all three meals. On 08/07/23, Resident #6 consumed 0-25% of the breakfast meal and refused lunch and dinner. On 08/08/23, 08/09/23, and 08/10/23, the meal intakes document Resident #6 refused all meals. Review of the snack acceptance logs for 08/07/23 through 08/10/23 revealed Resident #6 accepted a snack twice a day; however, the log does not indicate what was offered or how much was consumed. Review of the nursing progress notes from 07/30/23 through 08/10/23 revealed no documentation of Resident #6's meal intakes of less than 25%. The nursing progress notes of 08/07/23 through 08/10/23 did not have any documentation of an assessment of Resident #6 when he had refused all meals. The medical record had no evidence the DTR #320, or the physician were notified of the resident's refusal of meals. Review of the monthly progress note dated 08/08/23 and timed 7:28 P.M., completed by Physician Assistant (PA) #326, revealed Resident #6 did not appear to be in any distress and there were no concerns from nursing staff other than increased incidents of falls. Review of the nursing progress note dated 08/10/23 at 8:58 P.M., revealed Resident #6 was sent to the hospital. The nursing progress note dated 08/11/23 at 8:55 A.M. documented Per charge nurse from shift who sent resident out he went for labored breathing and irregular pulse going from 33 to over 100 and lethargy. Review of the emergency department record for Resident #6, dated 08/10/23, revealed the resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365617 If continuation sheet Page 12 of 14 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 365617 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Waterville 8885 Browning Drive Waterville, OH 43566 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 - Immediate jeopardy to resident health or safety Residents Affected - Few was seen for altered mental status. Lab work revealed the resident had a critically high BUN of 97 mg/dl, an elevated creatinine level of 2.6 mg/dl, a critically high sodium level of 165 meq/l, and a critically high chloride level of 131 meq/l. A chest x-ray revealed no cardiopulmonary disease. Diagnoses in the emergency department were acute respiratory failure, acute renal failure, and dehydration. The emergency department transferred Resident #6 to a secondary hospital for critical care. Review of the emergency department record from the second hospital, dated 08/11/23 at 3:37 A.M. revealed Resident #6 was minimally responsive to verbal and painful stimuli with pinpoint pupils. The resident was hypoxemic and was intubated for airway protection. The resident's labs revealed acute kidney injury. He was given two boluses of normal saline intravenous (IV) for a total of 1500 ml, then started on normal saline IV 150 ml per hour. The computerized tomography (CT) scan of the head and chest were negative for an acute problem. The resident's weight was 115 pounds 15.4 ounces. The resident was transferred to the hospital for intensive care unit level care. Resident #6 remains hospitalized . Interview on 08/17/23 at 4:25 A.M. with State Tested Nursing Assistant (STNA) #252 verified Resident #6 had not eaten lunch or dinner on 08/07/23 and did not consume any meals or drinks on 08/08/23 or 08/10/23. STNA #252 stated Resident #6 was offered finger foods and drinks but refused the alternatives. STNA #252 stated at each meal Resident #6 did not eat the nurse was notified. Interview with STNA #238 on 08/17/23 at 3:30 P.M. verified Resident #6 did not consume any food or drinks on 08/09/23. STNA #238 stated the nurse was notified of the resident's meal refusal and refusal of alternative food and drink choices. Interview on 08/17/23 at 4:32 P.M. with Licensed Practical Nurse (LPN) #239 verified working on 08/07/23 through 08/10/23 from 7:00 A.M. and 7:00 P.M. LPN #239 verified she was notified of Resident #6 refusing to eat or drink. LPN #239 stated alternatives were offered, and the resident consumed very little. LPN #239 stated Resident #6 spent time sleeping. LPN #239 verified she did not notify the physician or dietary of Resident #6 not eating or drinking. Interview on 08/17/23 at 3:46 P.M., DTR #320 revealed no knowledge of Resident #6's refusal to eat and drink and denied knowledge of abnormal lab results. DTR #320 stated there had been no communication from nursing regarding Resident #6's meal refusals. DTR #320 verified with awareness of the situation there could have been an assessment and possible interventions put into place to encourage Resident #6 to eat and drink. Interview on 08/21/23 at 8:29 A.M. with PA #326 revealed no knowledge of Resident #6's refusal to eat for three days. PA #326 stated the nurses shared Resident #6 had a decreased appetite and the PA related the decreased appetite to the psychiatric medication changes. Interview 08/21/23 at 8:57 A.M. with Physician #315 revealed no knowledge of Resident #6 not eating or drinking and further stated fluids were to be encouraged due to the resident's abnormal kidney function. Physician #315 stated had he been notified of Resident #6 not eating and drinking there would have been other interventions that could have been implemented to prevent hospitalization. Physician #315 verified the cumulative of not eating and drinking adequately for three and half days caught up with Resident #6 and hospitalization was required. Interview with the DON on 08/21/23 at 11:15 A.M. verified the physician had recommended for staff to encourage fluids for Resident #6 and further verified no order existed related to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365617 If continuation sheet Page 13 of 14 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 365617 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Waterville 8885 Browning Drive Waterville, OH 43566 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 recommendation. Level of Harm - Immediate jeopardy to resident health or safety Review of the facility policy titled Food and Nutrition Services, revised October 2017, revealed the multidisciplinary staff, including nursing staff, the attending physician, and the dietician will assess each resident's nutrition needs, food likes, dislikes and eating habits, as well as physical, functional, and psychosocial factors that affect eating and nutritional intake. Nursing personnel, with the assistance of the food and nutrition services staff, will evaluate and document as indicated, food and fluid intake of resident with, or at risk for, significant nutritional problems. Variations of unusual eating or intake patterns will be recorded in the resident medical record and brought to the attention of the nurse. The nurse will evaluate the significance of such information and report it, as indicated, to the attending physician and dietician. Residents Affected - Few Review of the facility policy titled Resident Hydration and Prevention of Dehydration, dated October 2017, revealed nurses will assess for signs of dehydration during daily care. If the potential inadequate intake or signs and symptoms of dehydration are observed, intake and output monitoring will be initiated and incorporated into the care plan and the physician will be notified. Orders may be written for extra fluids to be encouraged in between meals and or with medication passes. The dietician, nursing staff and the physician will assess all factors that may be contributing to inadequate fluid intake with orders for medications that may exacerbate dehydration reviewed and held, if appropriate, and laboratory tests ordered to assess actual hydration. Additionally, the physician may initiate intravenous hydration and hospitalization if necessary. This deficiency demonstrates non-compliance related to the allegations in Master Complaint OH00145553. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365617 If continuation sheet Page 14 of 14