Inspection·May 18, 2023

F 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the appropriate documentation was contained in the medical record for residents who were discharged . This affected one (#281) of five residents reviewed for hospitalization. The facility census was 79. Findings include: Review of Resident #281's medical record revealed an admission date of 04/20/23. The resident was discharged from the facility while in the hospital on [DATE]. Diagnoses included acute pyelonephritis, type II diabetes mellitus, chronic obstructive pulmonary disease, chronic kidney disease, end-stage renal disease, and heart failure Review of Resident #281's five-day Medicare Minimum Data Set (MDS) 3.0 assessment, dated 04/27/23, revealed the resident was cognitively intact and required extensive assistance of one staff for a majority of the activities of daily living. The resident received oxygen, dialysis, and intravenous medications. Review of Resident #281's respiratory progress notes dated 04/27/23 and timed 8:25 A.M. revealed the resident was seen by respiratory therapy and was not responding. Resident #281 was sent out to the hospital. Review of Resident #281's nursing progress notes dated 04/27/23 and timed 3:21 P.M. revealed Resident #281's husband called and reported Resident #281 was being admitted to the hospital for a urinary tract infection, was non-responsive, and was concerned the resident had tested positive for the narcotic pain medication Fentanyl. The unidentified nurse who received the telephone call assured Resident #281's husband the resident had not received Fentanyl, as Resident #281 had a prescription for Fentanyl upon admission but Resident #281 and her husband reported Resident #281 had a negative experience with Fentanyl, and was subsequently never entered into her orders. Review of Resident #281's nursing progress notes dated 04/27/23 and timed 6:30 P.M. revealed Resident #281 was admitted to the hospital for acute delirium and urinary tract infection. The nurse at the hospital reported the drug screen only indicated a positive versus negative as opposed to giving an actual blood level of Fentanyl. Emergency department physicians indicated they had no explanation for Fentanyl being in the resident's system. Review of Resident #281's nursing progress notes dated 04/28/23 and timed 2:58 P.M. revealed the nurse practitioner spoke with the hospital social worker to discuss positive Fentanyl results. Resident #281 did not receive Fentanyl while in the facility and positive results indicated use within one day. Review of Resident #281's social service progress notes dated 05/01/23 and timed 9:41 A.M. revealed the resident discharged to the hospital on [DATE]. Review of Resident #281's social service progress notes dated 05/04/23 and timed 10:19 A.M. revealed social services contacted Resident #281's spouse per his request. Resident #281's spouse inquired about why the facility did not accept the resident back after her hospital stay. Rationale regarding (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365646 If continuation sheet Page 2 of 11 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 365646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kingston of Ashland 20 Amberwood Pkwy Ashland, OH 44805 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 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few declination of readmission was discussed. Resident #281's husband had further nursing questions and would follow up with the nurse practitioner. Resident #281's spouse requested the resident's medical records at this time. Review of Resident #281's paper and electronic medical records revealed no documentation from a physician regarding the resident's discharge. Interview on 05/17/23 at 2:05 P.M. with Social Worker #563 revealed Resident #281 was ultimately discharged due to a controlled substance being found in her system upon admission to the hospital. Interview on 05/17/23 at approximately 4:00 P.M. with the Director of Nursing (DON) verified Resident #281 was discharged from the facility and not accepted back due to Fentanyl being found in her system. The facility had suspicion the resident's husband brought Fentanyl in for the resident and felt the resident was a danger to herself and others. The DON verified there was no physician documentation in the medical record pertaining to this. Review of the facility policy titled, Bed Hold, Transfer, and Discharge Notice, dated September 2018, revealed the facility would provide notice to residents who were transferred or discharged from the facility per applicable federal and state regulations. The policy also stated when a resident was involuntarily discharged , the medical record would contain the basis for transfer or discharge and documentation by a physician when transfer or discharge was necessary for safety reasons. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365646 If continuation sheet Page 3 of 11 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 365646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kingston of Ashland 20 Amberwood Pkwy Ashland, OH 44805 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 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 medical record review, staff interview, and policy review, the facility failed to ensure residents and resident resident representatives received notice of transfer as soon as practicable upon discharge to the hospital. This affected one (#281) of five residents reviewed for hospitalization. The facility census was 79. Findings include: Review of Resident #281's medical record revealed an admission date of 04/20/23. The resident was discharged from the facility while in the hospital on [DATE]. Diagnoses included acute pyelonephritis, type II diabetes mellitus, chronic obstructive pulmonary disease, chronic kidney disease, end-stage renal disease, and heart failure Review of the census records for Resident #281 revealed the resident was transferred to a local hospital on [DATE] and then discharged . Review of both the electronic and paper charts revealed no evidence Resident #281 or the resident representative was provided with a notice of transfer or discharge. A discharge notice was issued when lack of notice was identified and requested during the survey on 05/17/23. Interviews on 05/17/23 at approximately 4:00 P.M. with Regional Manager #734 and the Director of Nursing (DON) verified no notice of discharge was issued for Resident #281 or the resident representative until requested during the survey on 05/17/23. Review of the facility policy titled, Bed Hold, Transfer, and Discharge Notice, dated September 2018, revealed the facility would provide notice to residents who were transferred or discharged from the facility per applicable federal and state regulations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365646 If continuation sheet Page 4 of 11 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 365646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kingston of Ashland 20 Amberwood Pkwy Ashland, OH 44805 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #10 revealed an admission date of 10/09/22. Diagnoses included chronic obstructive pulmonary disease, diabetes mellitus, heart failure and chronic kidney disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 was moderately impaired cognitively. Resident #10 required extensive assistance of two staff for bed mobility, dressing, and personal hygiene. Resident #10 required total assistance with two staff for transfer and toileting. Further review of Resident #10's medical record revealed Resident #10 was transferred to the hospital on [DATE] at 2:43 A.M. related to chest pain and returned to the facility on [DATE] at 1:35 P.M. Resident #10 was transferred to the hospital on [DATE] at 9:40 A.M. related to respiratory distress and returned to the facility on [DATE] at 6:45 P.M. Resident #10 was transferred to the hospital on [DATE] at 5:44 P.M. related to unresponsiveness and returned to the facility on [DATE] at 6:39 P.M. Review of the most recent Bed Hold Notice dated and signed on 05/04/23 at 1:50 P.M. revealed Resident #10 had 30 days left of bed holds. Interview on 05/17/23 at 2:38 P.M. with Regional Quality Assurance Nurse #801 stated Resident #10 already used 18 bed hold days since 01/01/23 and the bed hold notice dated 05/04/23 should have reflected that Resident #10 had twelve bed hold days left. Interview on 05/18/23 at 7:30 A.M. with Receptionist #546 stated a pre-populated form was printed out and given to Resident #10, and she never changed the amount of bed hold days because there was no way of changing the number of days. Review of the facility policy titled, Bed Hold, Transfer and Discharge Notice, dated September 2018, revealed it was the policy of the facility to provide a notice to residents that are transferred or discharged from the facility per applicable federal and state regulations. The policy also revealed a resident and their representative would be issued the appropriate bed hold notice and bed hold policy within 24 hours of hospitalization. Based on medical record review, staff interview, and facility policy review, the facility failed to provide a resident with the option to hold a bed at the facility following a transfer and failed to ensure an accurate amount of bed hold days were conveyed to a resident. This affected two (#10 and #281) of five residents reviewed for hospitalization. The facility census was 79. Findings include: 1. Review of Resident #281's medical record revealed an admission date of 04/20/23. The resident was discharged from the facility while in the hospital on [DATE]. Diagnoses included acute pyelonephritis, type II diabetes mellitus, chronic obstructive pulmonary disease, chronic kidney disease, end-stage renal disease, and heart failure Review of the census records for Resident #281 revealed the resident was transferred to a local hospital on [DATE] and then discharged . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365646 If continuation sheet Page 5 of 11 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 365646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kingston of Ashland 20 Amberwood Pkwy Ashland, OH 44805 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Review of both the electronic and hard charts revealed no evidence Resident #281 or their representative was given a bed hold notice for their discharge to the hospital. A bed hold notice was issued when it was identified and requested during the survey on 05/17/23. Interviews on 05/17/23 at approximately 4:00 P.M. with Regional Manager #734 and the Director of Nursing (DON) verified no bed hold notice was issued for Resident #281 until requested during the survey on 05/17/23. Event ID: Facility ID: 365646 If continuation sheet Page 6 of 11 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 365646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kingston of Ashland 20 Amberwood Pkwy Ashland, OH 44805 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 0626 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and facility policy review, the facility failed to allow a resident to return to the facility following hospitalization. This affected one (#281) of five residents reviewed for hospitalization. The facility census was 79. Findings include: Review of Resident #281's medical record revealed an admission date of 04/20/23. The resident was discharged from the facility while in the hospital on [DATE]. Diagnoses included acute pyelonephritis, type II diabetes mellitus, chronic obstructive pulmonary disease, chronic kidney disease, end-stage renal disease, and heart failure Review of Resident #281's five-day Medicare Minimum Data Set (MDS) 3.0 assessment, dated 04/27/23, revealed the resident was cognitively intact and required extensive assistance of one staff for a majority of the activities of daily living. The resident received oxygen, dialysis, and intravenous medications. Review of Resident #281's respiratory progress notes dated 04/27/23 and timed 8:25 A.M. revealed the resident was seen by respiratory therapy and was not responding. Resident #281 was sent out to the hospital. Review of Resident #281's nursing progress notes dated 04/27/23 and timed 3:21 P.M. revealed Resident #281's husband called and reported Resident #281 was being admitted to the hospital for a urinary tract infection, was non-responsive, and was concerned the resident had tested positive for the narcotic pain medication Fentanyl. The unidentified nurse who received the call assured Resident #281's husband the resident had not received Fentanyl, as Resident #281 had a prescription for Fentanyl upon admission but Resident #281 and her husband reported Resident #281 had a negative experience with Fentanyl, and was subsequently never entered into her orders. Review of Resident #281's nursing progress notes dated 04/27/23 and timed 6:30 P.M. revealed Resident #281 was admitted to the hospital for acute delirium and urinary tract infection. The nurse at the hospital reported the drug screen only indicated a positive versus a negative as opposed to giving an actual blood level of Fentanyl. Emergency department physicians indicated they had no explanation for Fentanyl being in the resident's system. Review of Resident #281's nursing progress notes dated 04/28/23 and timed 2:58 P.M. revealed the nurse practitioner spoke with the hospital social worker to discuss positive Fentanyl results. Resident #281 did not receive Fentanyl while in the facility and positive results indicated use within one day. Review of Resident #281's social service progress notes dated 05/04/23 and timed 10:19 A.M. revealed social services contacted Resident #281's spouse per his request. Resident #281's spouse inquired about why the facility did not accept the resident back after her hospital stay. Rationale regarding declination of readmission was discussed. Resident #281's husband had further nursing questions and would follow up with the nurse practitioner. Resident #281's spouse requested the resident's medical records at this time. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365646 If continuation sheet Page 7 of 11 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 365646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kingston of Ashland 20 Amberwood Pkwy Ashland, OH 44805 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 0626 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 05/17/23 at 2:05 P.M. with Social Worker #563 verified residents were normally able to return to their previous bed or the first available bed following hospitalization, but Resident #281 was not allowed to return due to a controlled substance being found in her system upon admission to the hospital. Interview on 05/17/23 at approximately 4:00 P.M. with the Director of Nursing (DON) verified Resident #281 went to the hospital and was not accepted back or allowed to return to the facility due to Fentanyl being found in her system. Review of the facility policy titled, Bed Hold, Transfer, and Discharge Notice, dated September 2018, revealed the facility would provide notice to residents who were transferred or discharged from the facility per applicable federal and state regulations. The policy also stated when a resident was involuntarily discharged , the medical record would contain the basis for transfer or discharge and documentation by a physician when transfer or discharge was necessary for safety reasons. This deficiency represents non-compliance investigated under Master Complaint Number OH00142631 and Complaint Number OH00142457. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365646 If continuation sheet Page 8 of 11 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 365646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kingston of Ashland 20 Amberwood Pkwy Ashland, OH 44805 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical records review, resident and staff interview, and facility policy review, the facility failed to ensure residents were not administered antibiotics without an appropriate indication for use or a stop date per facility policy. This affected three (#17, #18 and #31) of seven sampled residents reviewed for antibiotic use. The facility identified 16 residents were currently receiving antibiotics. The facility census was 79. Residents Affected - Some Findings include: 1. Review of Resident #18's medical record revealed an admission date to the facility occurred on 06/15/22 with medical diagnoses including chronic kidney disease, urinary tract infection, anxiety, and chronic respiratory failure. Further review of the medical record revealed Resident #18 was in the hospital from [DATE] through 04/19/23 with urosepsis related to an indwelling Foley catheter. The hospital discharge orders included removal of the urinary catheter. Review of the physician orders for Resident #18 revealed an order written by Certified Nurse Practitioner (CNP) #276 dated 04/22/23 for Resident #18 to receive the antibiotic Macrobid 50 milligrams (mg) by mouth daily for recurrent urinary tract infections. The medication order did not have a stop date and continued to be administered daily as of 05/16/23. Interview with CNP #276 on 05/17/23 at 11:04 A.M. confirmed Resident #18's urinary catheter was removed while she was in the hospital on [DATE]. CNP #276 stated the hospital notes identified the urosepesis was believed to be caused by the catheter. The interview additionally confirmed Resident #18's antibiotic had no current stop date and Resident #18's previous urinary tract infection occurred on 09/17/22 at which time she also had a urinary catheter in place. 2. Review of Resident #31's medical record revealed admission to the facility occurred on 04/01/21 with medical diagnoses including diabetes, congestive heart failure, major depression, and stroke. Review of Resident #31's most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact and walked with supervision. The assessment identified Resident #31 had no ulcers. Resident #31 received hospice services since her admission. Review of Resident #31's physician orders revealed on 07/22/21 an order for the antibiotic Cephalexin 500 mg by mouth to give daily for prophylaxis for recurrent cellulitis. Review of Resident #31's medication administration records revealed as of 05/17/23 Resident #31 continued to receive the antibiotic daily. The medication administration records revealed no evidence of any attempt to reduce the dose or stop the antibiotic. Interview on 05/16/23 at 12:50 P.M. with Resident #31 stated she had no idea why she received a daily antibiotic. Review of Resident #31's pharmacist medication reviews and recommendations completed on 06/28/22 and 03/27/23 revealed a pharmacist requested a stop date for Resident #31's antibiotic. Further review of the pharmacist medication reviews revealed CNP #276 disagreed with the recommendation with rationale that Resident #31 was a hospice resident and received end of life care. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365646 If continuation sheet Page 9 of 11 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 365646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kingston of Ashland 20 Amberwood Pkwy Ashland, OH 44805 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 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview with CNP #276 on 05/17/23 at 11:22 A.M. confirmed there were no attempts to stop Resident #31's antibiotic since it started on 07/22/21. 3. Review of Resident #17's medical record revealed an admission date of 07/30/19. Diagnoses included urinary tract infection, type II diabetes mellitus, heart failure, depression, retention of urine, and dehydration. Review of Resident #17's plan of care, dated 04/28/23, revealed the resident had recurring urinary tract infections. Interventions included administering antibiotics per physician order and reporting signs or symptoms of urinary tract infections. Review of Resident #17's physician orders revealed a current order dated 04/27/23 for the antibiotic Bactrim oral tablet 400-80 mg, 0.5 tablets via percutaneous endoscopic gastrostomy (PEG) tube. The medication order did not have a stop date and was continuing to be administered daily as of 05/16/23. Interview on 05/16/23 at 1:07 P.M. with Infection Preventionist #274 revealed Resident #17 had been on several prophylactic antibiotics due to a previous history of recurring urinary tract infections. Infection Preventionist #274 reported Resident #17's last urinary tract infection was in 2021. Infection Preventionist #274 verified Resident #17's antibiotic ordered by the physician had no stop date. Review of the facility policy titled, Antibiotic Stewardship Program, dated 10/13/21, revealed prescribing clinicians would be encouraged to utilize the antibiotic time out as a component of the organization's Antimicrobial stewardship program. The policy further revealed a specific end date for the antibiotic should be included in the medication order. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365646 If continuation sheet Page 10 of 11 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 365646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kingston of Ashland 20 Amberwood Pkwy Ashland, OH 44805 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, staff interview, and facility policy review, the facility failed to ensure the kitchen was clean and sanitary. This had the potential to affect all 76 residents who received food from the kitchen. The facility identified three (#17, #21 and #284) residents who received nothing by mouth. The facility census was 79. Findings include: Observation during the initial tour of the kitchen on 05/15/23 from 8:02 A.M. through 8:15 A.M. revealed the ceiling and wall were peeling in the dry storage area, the exhaust fan above the dish machine had grease and dust covered on the louvers on the exhaust fan, and the tabletop mixer had dried food on the top where the attachments are inserted and on the bowl holder. Observation in the walk-in refrigerator revealed precooked French toast outside of its original container and sausage patties with no label or date on it. Observation of the reach-in refrigerator revealed standing water inside the refrigerator and there was dried food on the interior walls. Interview with Dietary Manager #298 verified the findings at time of observation of 05/15/23 between 8:02 A.M. and 8:15 A.M. Review of the facility policy titled, Food Storage, dated May 2018, revealed food is stored, prepared, and transported to prevent contamination and all foods should be labeled and dated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365646 If continuation sheet Page 11 of 11