Inspection·September 29, 2023

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few facility on [DATE]. The Manifest was signed it was received on 04/11/23 but the delivery time was not documented. The medical record did not indicate the time the medication was delivered. Review of Resident #20's Medication Administration Audit Report revealed Resident #20's Augmentin oral suspension was administered for the first time on 04/12/23 at 9:09 AM. This was approximately 19 hours after it was ordered. The medical record did not contain evidence the physician was notified Resident #20's medication arrived on 04/11/23 but was not administered until 04/12/23 at 9:09 A.M. Review of Resident #20's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status and Mood Interview were not completed due to Resident #20 was rarely or never understood. Resident #20 required extensive assistance of two staff members for bed mobility, was total dependence of two staff for transfers and toilet use. Resident #20 was always incontinent of urine and bowel. Review of Resident #20's care plan revised 07/25/23 included Resident #20 had a urinary tract infection which resolved with treatment after his admission. On 05/12/23 Resident #20's indwelling catheter remained in place and antibiotics were started for a urinary tract infection. Resident #20 had an appointment with a urologist, his catheter was removed on 05/22/23 and Resident #20 voided without difficulty. On 07/2023 Resident #20 continued to void without difficulty, had incontinence of bladder, and was dependent for hygiene and toileting. Resident #20's urinary tract infection would resolve without complications by the review date. Interventions included to give antibiotic therapy as ordered, monitor and document for side effects and effectiveness. Interview on 09/27/23 at 11:44 A.M. of Wife #252 revealed Resident #20 was unable to speak and while he resided on another nursing unit in the facility he did not get the care he needed. Wife #252 stated a couple weeks before Resident #20 was moved to the secured nursing unit she could tell he was in pain and she insisted a nurse evaluate him. It took 20 minutes for the aide to tell a nurse Resident #20 needed looked at, and the nurse said she could not call the physician because it was night time. Wife #252 started crying and stated she went home, knowing Resident #20 was in pain and she was so upset. Wife #252 stated she came in the next morning at 6:00 A.M. and waited for the physician to arrive and insisted he evaluate Resident #20 before he saw any other resident. Wife #252 stated the physician diagnosed Resident #20 with a urinary tract infection and muscle spasms, and he was given something for pain and antibiotics. Wife #252 stated she felt like no one cared and Resident #20 was just a number. Wife #252 stated Resident #20 had an indwelling catheter when this happened, but the catheter was since discontinued. Interview on 09/28/23 at 8:29 A.M. of Physician #251 revealed antibiotics for a urinary tract infection should be started as soon as the urine culture was reported. Physician #251 stated if the bacteria count was greater than 100,000 a urine culture and sensitivity would be completed. As soon as the culture report was received the antibiotics would be initiated. Observation on 09/28/23 at 8:41 A.M. of Resident #20 revealed he was sitting in a wheelchair in his room and was yelling out loudly and continuously. Resident #20 was unable to be interviewed. Interview on 09/28/23 at 10:29 A.M. of Licensed Practical Nurse (LPN) #254 revealed she took care of Resident #20 when he resided on the nursing unit she was assigned to. LPN #254 stated Resident #20 had a catheter, it often needed flushed, and she remembered he had a urinary tract infection. Interview on 09/28/23 at 11:12 A.M. with the Director of Nursing (DON) and Regional Nurse #266 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365783 If continuation sheet Page 2 of 12 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 365783 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aventura at Assumption Village 9800 Market Street North Lima, OH 44452 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few revealed Resident #20 had a PEG tube. Regional Nurse #266 stated when the urine culture and sensitivity results came back on 04/11/23 the physician was notified, an antibiotic order was placed for Augmentin, and it was administered the next morning (04/12/23) when it arrived from pharmacy. Regional Nurse #266 indicated she could not answer the question as to why the Augmentin was not started earlier. Interview on 09/28/23 at 1:13 P.M. with Pharmacist #255 revealed Resident #20's order for Augmentin suspension was ordered on 04/11/23 at 2:00 P.M. Pharmacist #255 stated Resident #20's Augmentin suspension left the pharmacy on the second delivery of the day, the facility was the second stop and Resident #20's Augmentin arrived to the facility on [DATE] between 8:00 P.M. and 9:00 P.M. Interview on 09/29/23 at 1:04 P.M. with DON and Regional Nurse #266, Director of Assisted Living, and Administrator present, confirmed Resident #20 was ordered Augmentin on the 04/11/23 and revealed the facility received the medication at 9:58 P.M. on 04/11/23 as pharmacy entered the building at 9:58 A.M. on 04/11/23. The medication was not given at this time because it would have been a medication error. Facility staff confirmed Augmentin was not started until 04/12/23 at 9:09 A.M. Facility staff revealed unless ordered as an emergency medication or a specified as a stat medication by the physician or available in the contingency starter supply all orders are presumed to be administered on the first scheduled medication time following the normal delivery of the pharmacy. Augmentin suspension was not available in the starter kit. Review of the facility policy titled Administering Medications revised 08/2022 included medications were administered in a safe and timely manner, and as prescribed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365783 If continuation sheet Page 3 of 12 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 365783 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aventura at Assumption Village 9800 Market Street North Lima, OH 44452 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 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident must receive and the facility must provide necessary behavioral health care and services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure Resident #20's behavior, including frequent episodes of loud and continuous yelling out was monitored and addressed timely. This affected one resident (#20) of three residents reviewed for behavioral health treatment. Findings include: Review of Resident #20's medical record revealed an admission date of 04/04/23 and diagnoses included monoplegia (paralysis restricted to one limb) of upper limb following cerebral infarction affecting right dominant side, aphasia following unspecified cerebrovascular disease, and dementia. Review of Resident #20's physician orders dated 05/23/23 revealed orders to monitor behaviors: 1 equaled no behavior, 2 equaled aggressive; 3 equaled verbally abusive, 4 equaled physically aggressive, 5 equaled withdrawn, 6 equaled tearful, 7 equaled accusatory, 8 equaled wandering, 9 equaled resisted care. Interventions included 1 equaled one to one supervision, 2 equaled redirection, 3 equaled engage in activities, 4 equaled give time to calm, 5 equaled talk with resident. Outcome: S equaled same, I equaled improved, W equaled worse, three times a day. If behaviors were noted, non-pharmacological interventions must be attempted prior to medication use. Yelling out was not identified as a behavior to track. Review of Resident #20's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status and Mood Interview were not completed due to Resident #20 was rarely or never understood. Resident #20 required extensive assistance of two staff members for bed mobility, was total dependence of two staff for transfers and toilet use. Resident #20 was always incontinent of urine and bowel. Resident #20 was total dependence of one staff member for locomotion on the unit. Review of Resident #20's care plan revised 07/25/23 included Resident #20 had a mood problem related to disease process CVA (cerebrovascular accident), need for adjustment to placement. Resident #20 would have improved mood state, calmer appearance, no signs and symptoms of depression, anxiety, or sadness through the review dated. Resident #20 would have improved sleep pattern by reporting, displaying adequate rest or documented episodes of insomnia less than weekly through the review date. Interventions included to administer medications as ordered and monitor, document for side effects and effectiveness; behavioral health consults as needed; monitor, record, report to the physician as needed mood patterns, signs and symptoms of depression, mood as per facility behavior monitoring protocols. Further review included Resident #20 had a problematic manner in which Resident #20's acts were characterized by ineffective coping. Resident #20 had agitation, yelled out during care or when alone in his room. Resident #20 was aphasic (a language disorder that affected a person's ability to communicate) and unable to communicate his needs. Resident #20 at times had muscle spasms and medication ordered. Resident #20 would continue to be monitored, received pain treatment and per the physician might be behavioral or pain related. On 06/28/23 Resident #20's pain management was made routine and would monitor for effectiveness. Resident #20 would still at times be agitated frustrated if unable to voice needs. Resident #20 would have reduced incidents of agitated behavior through next review. Interventions included to be careful of not invading residents' personal space; elicit family input for best approach to Resident #20; give medication as prescribed by the physician and monitor effectiveness; initiate a behavior management consult; keep schedules routine and predictable. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365783 If continuation sheet Page 4 of 12 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 365783 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aventura at Assumption Village 9800 Market Street North Lima, OH 44452 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 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #20's nursing progress notes dated 07/29/23 through 09/27/23 revealed documentation on 07/31/23, 08/01/23, 08/02/23 (three times), 08/04/23, 08/07/23, 08/10/23, 08/17/23, 09/08/23, and 09/19/23 which stated yes to was a behavior observed for Resident #20. Further review revealed no evidence of the behavior exhibited or what interventions were provided related to the behaviors. Review of Resident #20's psychiatric progress notes dated 09/06/23 included Resident #20 was seen for a psychiatric follow up. The notes included no issues were reported by the nursing staff. Resident #20 had non existent eye contact, had appropriate affective expression, sensorium and cognition was unable to be assessed. Resident #20 had unspecified dementia without behavioral disturbance. There was no documentation regarding Resident #20 often loudly and continuously yelling out. Review of Resident #20's physician progress note dated 09/08/23 and written by Physician #251 did not reveal documentation addressing Resident #20 often loudly and continuously yelling out. Review of Resident #20's Medication Administration Record (MAR) dated 09/02/23, 09/18/23 and 09/20/23 from 5:00 A.M. to 6:00 A.M. revealed Resident #20 had one behavior documented on each of those days. Further review revealed not applicable was documented for behaviors, interventions and no was documented for behavior outcomes. Not applicable was documented for same, improved, worse and not applicable was documented for medication administration and effectiveness. Review of Resident #20's MAR dated 09/08/23 from 5:00 A.M. to 6:00 A.M. revealed two behaviors were documented. Resident #20 was tearful, and interventions included redirection and talking with resident. Yes, was documented for behavior outcomes and Resident #20 was the same for same, improved, worse. No medications were administered and not applicable to medication effectiveness. Review of Resident #20's MAR dated 09/19/23 from 5:00 A.M. to 6:00 A.M. revealed four behaviors were documented. Resident #20 was tearful, and interventions were redirection, give time to calm and talk with resident. Behavior outcomes were documented as yes and Resident #20 was same for same, improved, worse. Resident #20 was not administered medications and not applicable for medication effectiveness. Review of Resident #20's MAR dated 09/06/23 and 09/07/23 from 5:00 A.M. to 6:00 A.M did not reveal documentation related to Resident #20's behavior charting. Review of Resident #20's MAR dated 09/05/23 from 1:00 P.M. to 2:00 P.M. revealed two behaviors were documented. Resident #20 was tearful, and interventions were one to one supervision and give time to calm. No, was documented for behavior outcomes and same was documented for same, improved, worse. No medications were administered, and a one was coded for medication effectiveness, but the key asked for yes or no. On 09/07/23 from 1:00 P.M. to 2:00 P.M. one behavior was documented. Not applicable was marked for behaviors, but an intervention of one-to-one supervision was initiated. No, was documented for behavior outcomes, not applicable was documented for same, improved, worse and for medications administered and medication effectiveness. Review of Resident #20's MAR on 09/01/23, 09/03/23, 09/05/23 and 09/17/23 from 8:00 P.M. to 9:00 P.M. revealed one behavior was documented. Not applicable was marked for behaviors and interventions, no to behavior outcomes, not applicable to same, improved, worse and not applicable for medications administered and effectiveness. On 09/07/23 from 8:00 P.M. to 9:00 P.M. two behaviors were documented. Resident #20 was tearful and interventions were redirection and talk with resident. No was documented for behavior outcomes, same was documented for same, improved, worse. No was documented for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365783 If continuation sheet Page 5 of 12 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 365783 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aventura at Assumption Village 9800 Market Street North Lima, OH 44452 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 0740 medications administered and not applicable for medication effectiveness. Level of Harm - Minimal harm or potential for actual harm Review of Resident #20's MAR on 09/19/23 from 8:00 P.M. to 9:00 P.M. revealed no documentation related to behavior charting. Residents Affected - Few Observation on 09/27/23 at 11:20 A.M. of Resident #20 revealed he was sitting in a padded wheelchair in the common area of the secured nursing unit and Wife #252 was standing next to the wheelchair. Resident #20 was yelling out continuously. Interview on 09/27/23 at 11:24 A.M. with State Tested Nursing Assistant (STNA) #253 and Licensed Practical Nurse (LPN) #273 confirmed Resident #20 was yelling out continuously. STNA #253 stated Resident #20 called out like that often. LPN #273 stated Resident #20 did not like to be alone, and would stop yelling if someone was in his room or nearby in the common area. LPN #273 stated Resident #20 used to be on Tramadol (pain), but it was discontinued. LPN #273 stated Resident #20 received Tylenol (acetaminophen) three times a day. Interview on 09/27/23 at 11:44 A.M. with Wife #252 revealed Resident #20 used his middle name and not his first name which the staff used to address him. Wife #252 stated she repeatedly told the nurses he used his middle name, but the nurses continued to call him by his first name and that confused him. Wife #252 stated Resident #20 had a feeding tube (PEG percutaneous gastrostomy tube) and he could not swallow or talk and would get frustrated due to his inability to speak. Wife #252 stated Resident #20 yelled out due to his frustration. Wife #252 stated Resident #20 was not in pain and she could tell when he was in pain. Wife #252 stated some days Resident #20 was quieter than others. Interview on 09/27/23 at 12:10 P.M. with STNA #239 revealed when Resident #20 was screaming, if she did not think he was in pain she would turn one light off in his room and leave the other light on and that seemed to calm him. STNA #239 stated adjusting the lights worked about fifty percent of the time. STNA #239 stated if Resident #20 was in his room yelling she would go in the room and talk to him. STNA #239 indicated when Resident #20's wife visited he was quiet about seventy five percent of the time. STNA #239 revealed at one point Resident #20 was receiving Tramadol for pain, but it was discontinued and she did not know why. STNA #239 stated Resident #20 had muscle spasms on his bad side. Interview on 09/27/23 at 1:23 P.M. of Speech Therapist (ST) #240 revealed Resident #20 was discharged from Speech Therapy on 08/21/23. ST #240 stated Resident #20 was initially evaluated because he had a PEG tube, was not making progress, was at risk for aspiration. ST #240 stated Resident #20 was not safe to trial eating. ST #240 indicated Resident #20 could answer yes and no questions, they tried strategies to help him communicate his wants and needs, and had twenty five percent accuracy with one step commands. ST #240 stated she was hopeful Resident #20 could have a communication board, but he was not able to make a choice between two items. ST #240 revealed she tried so hard to help him communicate either verbal or non verbal but was not successful. Interview on 09/27/23 at 2:42 P.M. with the Director of Nursing (DON) revealed she did not consider Resident #20's yelling out a behavior, and he always yelled out. The DON stated Resident #20's wife told her Resident #20 yelled out even before he was admitted to the facility. Interview on 09/28/23 at 7:37 P.M. with Physician #251 and Licensed Practical Nurse/Unit Manager (LPN/UM) #313 revealed Physician #251 stated it was not reported to him that Resident #20 yelled out a lot. Physician #251 revealed if Resident #20 was in discomfort he should be aware. LPN/UM #313 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365783 If continuation sheet Page 6 of 12 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 365783 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aventura at Assumption Village 9800 Market Street North Lima, OH 44452 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 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated it was very common for Resident #20 to call out, and he received Tylenol three times a day. Physician #251 stated Resident #20 could be evaluated by psychiatry services, and he did not see any indications to put him on anything. LPN/UM #313 stated Resident #20 yelling out was not reported to Physician #251 because he always called out. Observation on 09/28/23 at 8:41 A.M. of Resident #20 revealed he was sitting in a padded wheelchair in his room facing away from the door. Resident #20's television was turned on, and Resident #20 was continuously and loudly yelling out. Interview on 09/28/23 at 8:41 A.M. with LPN #254 confirmed Resident #20 was loudly yelling out and stated sometimes she would go in his room and talk to him to calm him down. Interview on 09/28/23 at 10:29 A.M. with LPN #254 revealed Resident #20 used to reside on the nursing unit she usually was assigned to. LPN #254 stated Resident #20 had a stroke and all Resident #20 did was scream. LPN #254 stated Resident #20 was non verbal. Interview on 09/28/23 at 11:34 A.M. with LPN #273 revealed she did not always write yes to the question did Resident #20 have behaviors when completing the behavior monitoring tool located in Resident #20's Medication Administration Record (MAR). LPN #273 stated she marked no frequently because she did not consider Resident #20's yelling a behavior, and he yelled out a lot from frustration due to inability to speak. LPN #273 stated sometimes she tried redirection, and sometimes she felt like Resident #20 was in pain and documented a reason his pain medication was administered. LPN #273 would yell out when he needed his incontinence brief changed. LPN #273 stated she asked Physician #251 about Resident #20's yelling, but nothing was done. Observation on 09/28/23 at 2:50 P.M. of Resident #20 revealed the door to his room was closed and Resident #20 could be heard loudly yelling in his room even with the door to his room closed. When Resident #20's door to his room was opened Resident #20 was observed sitting in his wheelchair facing away from the door, music was playing and the television was on. STNA #239 confirmed Resident #20's door to his room was closed, he was in his room loudly yelling, and the yelling could be heard in the hall even though the door to his room was closed. STNA #239 stated Resident #42 did not like to hear Resident #20 yelling and closed the door to his room. Observation on 09/28/23 at 3:46 P.M. of Resident #20 revealed the door to his room was open, and he was sitting in a padded wheelchair, facing away from the door, the television was on and Resident #20 was loudly and continuously yelling. This deficiency represents non-compliance investigated under Master Complaint Number OH00146420. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365783 If continuation sheet Page 7 of 12 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 365783 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aventura at Assumption Village 9800 Market Street North Lima, OH 44452 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. 4. Review of the medical record for Resident #32 revealed an admission date of 02/26/22. Diagnoses included vascular dementia with behavioral disturbance, type two diabetes, major depressive disorder, chronic obstructive pulmonary disease, anxiety disorder, and severe chronic kidney disorder, stage four. Review of the care plan, dated 02/27/22, revealed Resident #32 received psychoactive medications including antipsychotics and antidepressants to manage mood and behaviors related to anxiety disorder, depression, and vascular dementia with behaviors. Interventions included administer medications per orders, monitor for adverse effects of medications, monitor for changes in levels of behavior and mood, monthly medication review completed monthly by physician and pharmacy, and monitor for orthostatic hypotension, change in level of care, increased confusion, lethargy, slurred speech, chewing and swallowing problems, and change in cognition. Review of the quarterly Minimum Data Set (MDS) Assessment, dated 07/17/23, revealed Resident #32 had moderate cognitive impairment. Resident #32 had no behaviors or indicators of psychosis during the look back period. The assessment indicated Resident #32 did not have a diagnosis of bipolar disorder, psychotic disorder, schizophrenia, or post-traumatic stress disorder. The assessment indicated Resident #32 received antipsychotic medications for seven days during the look back period. Review of the assessment titled CHP-Psychopharmacologic Medication Review 3, dated 03/23/23, revealed Resident #32 received Seroquel (classified as an antipsychotic), and Zoloft (classified as an antidepressant). The assessment indicated the medications were appropriate to treat the specific conditions. Review of the physician's orders for September 2023 for Resident #32 identified orders for Seroquel (an antipsychotic medication) 75 milligrams (mg) orally one time daily for major depressive disorder and Zoloft (an antidepressant ) 50 mg by mouth one time daily for depression. Review of the black box warnings for Seroquel revealed it was not approved for the treatment of patients with dementia-related psychosis or major depressive disorder. On 09/28/23 at 1:15 P.M., an interview with the Director of Nursing (DON) verified dementia or major depression were not an appropriate diagnosis for the use of antipsychotic medications. Review of facility policy titled Psychotropic Drug Use, dated 03/2020, revealed antipsychotic drugs should not be used unless the clinical record documented that the resident had one or more of the following specific conditions: schizophrenia, schizo-affective disorder, delusional disorder, psychotic mood disorder, acute psychotic episodes, brief reactive psychosis, schizophreniform disorder, atypical psychosis, Tourette's disorder, Huntington's disease, or organic mental syndromes with associated psychotic behaviors which have been quantitatively and objectively documented. Antipsychotics should not be used if one or more of the following were the only indication: wandering, poor self-care, restlessness, impaired memory, anxiety, depression without psychotic features, insomnia, unsociability, indifference to surroundings, fidgeting, nervousness, uncooperativeness, or agitated behaviors which did not represent a danger to the resident or others. Based on medical record review, review of facility policy and interview, the facility failed to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365783 If continuation sheet Page 8 of 12 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 365783 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aventura at Assumption Village 9800 Market Street North Lima, OH 44452 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 ensure antipsychotic medications were only used to treat appropriate diagnoses with clinical rationale. This affected four residents (#24, #32, #78, and #341) of five residents reviewed for unnecessary medications. The census was 96. Findings include: Residents Affected - Some 1. Review of the medical record for Resident #24 revealed an admission date of 05/23/21. Diagnoses included dementia with behavioral disturbance, cerebrovascular disease, recurrent depressive disorders, neonatal cerebral leukomalacia, anxiety disorder, and altered mental status. Review of the care plan, dated 05/24/21, revealed Resident #24 received psychoactive medications including antipsychotics and antidepressants to manage mood and behaviors related to anxiety disorder, depression, cerebral leukomalacia, and vascular dementia with behaviors. Interventions included administer medications per orders, monitor for adverse effects of medications, monitor for changes in levels of behavior and mood, monthly medication review completed monthly by physician and pharmacy, and monitor for orthostatic hypotension, change in level of care, increased confusion, lethargy, sensitivity to light, slurred speech, chewing and swallowing problems, and change in cognition. Review of the quarterly Minimum Data Set (MDS) Assessment, dated 08/04/23, revealed Resident #24 had moderate cognitive impairment. Resident #24 had no behaviors or indicators of psychosis during the look back period. The assessment indicated Resident #24 did not have a diagnosis of bipolar disorder, psychotic disorder (other than schizophrenia), schizophrenia, or post-traumatic stress disorder. The assessment indicated Resident #24 received antipsychotic medications for seven days during the look back period. Review of the assessment titled CHP-Psychopharmacologic Medication Review 3, dated 08/17/23, revealed Resident #24 received Zyprexa (classified as an antipsychotic), Seroquel (classified as an antipsychotic), and Cymbalta (classified as an antidepressant). The diagnoses indicated for use of the medications were vascular dementia with behaviors, altered mental status, depression, anxiety, and cerebral leukomalacia. The assessment indicated the medications were appropriate to treat the specific conditions. Review of the physician's orders for September 2023 for Resident #24 identified orders for Zyprexa (an antipsychotic medication) 5 milligrams (mg) orally at bedtime for dementia with behavioral disturbance, and Seroquel (an antipsychotic medication) 12.5 mg by mouth one time daily for dementia with behavioral disturbance. Review of the black box warnings for both Zyprexa and Seroquel revealed they were not approved for the treatment of patients with dementia-related psychosis. On 09/28/23 at 1:15 P.M., interview with the Director of Nursing (DON) verified dementia was not an appropriate diagnosis for the use of antipsychotic medications. On 09/29/23 at 4:40 P.M., interview with the DON verified Resident #24 received antipsychotic medications for the treatment of dementia with behaviors. She stated the physician was aware and had signed off on the medication orders, which indicated approval for use. Review of facility policy titled Psychotropic Drug Use, dated 03/2020, revealed antipsychotic drugs should not be used unless the clinical record documented that the resident had one or more of the following specific conditions: schizophrenia, schizo-affective disorder, delusional disorder, psychotic mood disorder, acute psychotic episodes, brief reactive psychosis, schizophreniform disorder, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365783 If continuation sheet Page 9 of 12 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 365783 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aventura at Assumption Village 9800 Market Street North Lima, OH 44452 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some atypical psychosis, Tourette's disorder, Huntington's disease, or organic mental syndromes with associated psychotic behaviors which have been quantitatively and objectively documented. Antipsychotics should not be used if one or more of the following were the only indication: wandering, poor self-care, restlessness, impaired memory, anxiety, depression without psychotic features, insomnia, unsociability, indifference to surroundings, fidgeting, nervousness, uncooperativeness, or agitated behaviors which did not represent a danger to the resident or others. 2. Review of the medical record for Resident #78 revealed an admission date of 06/09/23. Diagnoses included Alzheimer's disease, dementia with behavioral disturbance, major depressive disorder, and anxiety disorder. Review of the physician's note dated 06/20/23 revealed Resident #78 suffered from behavioral disturbance secondary to dementia, which was treated with Risperdal (an antipsychotic medication). Review of the physician's orders for September 2023 for Resident #78 identified orders for Risperdal 0.25 milligrams (mg) two times daily for dementia with behavioral disturbances. Review of the black box warning for Risperdal revealed it was not approved for the treatment of patients with dementia-related psychosis. Review of the quarterly Minimum Data Set (MDS) Assessment, dated 09/14/23, revealed Resident #78 had severe cognitive impairment. Resident #78 had no behaviors or indicators of psychosis during the look back period. The assessment indicated Resident #78 did not have a diagnosis of bipolar disorder, psychotic disorder (other than schizophrenia), schizophrenia, or post-traumatic stress disorder. The assessment indicated Resident #78 received antipsychotic medications for seven days during the look back period. Review of the care plan, dated 09/17/23, revealed Resident #78 used drugs having an altering effect on the mind related to depression, anxiety, and dementia with behaviors. Interventions included monitor resident's mood and behaviors, monitor resident's mental status, observe for movement side effects of antipsychotic medications (stooped posture, muscle spasms, stiffness, motor restlessness, tremors, involuntary movements, gait, increased agitation, and loss of balance), observe for non-movement side effects of antipsychotic medications (sore throat, upper respiratory infection, color change of skin, dry mouth, nasal congestion, constipation, blurred vision, weight gain, confusion, difficult urination, dark urine, hypotension, drooling, loss of muscle, and nausea or vomiting), and psychiatry to follow up as needed. Review of the assessment titled CHP-Psychopharmacologic Medication Review 3, dated 09/27/23, revealed Resident #78 received Risperdal (classified as an antipsychotic), Zoloft (classified as an antidepressant), Ativan (classified as an antianxiety), Depakote (an anticonvulsant), and Vistaril (an antihistamine). The diagnoses indicated for use of the medications were depression, dementia with behaviors, Alzheimer's disease, and anxiety. The assessment indicated the medications were appropriate to treat the specific conditions. On 09/28/23 at 1:15 P.M., interview with the DON verified Resident #78 received antipsychotic medications for the treatment of dementia. She also verified dementia was not an appropriate diagnosis for the use of antipsychotic medications. On 09/28/23 at 1:53 P.M., interview with the DON stated Resident #78 admitted with the orders for Risperdal to treat dementia. She stated Resident #78 had behavioral disturbances related to dementia (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365783 If continuation sheet Page 10 of 12 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 365783 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aventura at Assumption Village 9800 Market Street North Lima, OH 44452 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 and that was the reason for the use of Risperdal. Level of Harm - Minimal harm or potential for actual harm Review of facility policy titled Psychotropic Drug Use, dated 03/2020, revealed antipsychotic drugs should not be used unless the clinical record documented that the resident had one or more of the following specific conditions: schizophrenia, schizo-affective disorder, delusional disorder, psychotic mood disorder, acute psychotic episodes, brief reactive psychosis, schizophreniform disorder, atypical psychosis, Tourette's disorder, Huntington's disease, or organic mental syndromes with associated psychotic behaviors which have been quantitatively and objectively documented. Antipsychotics should not be used if one or more of the following were the only indication: wandering, poor self-care, restlessness, impaired memory, anxiety, depression without psychotic features, insomnia, unsociability, indifference to surroundings, fidgeting, nervousness, uncooperativeness, or agitated behaviors which did not represent a danger to the resident or others. Residents Affected - Some 3. Review of the medical record for Resident #341 revealed an admission date of 09/13/23. Diagnoses included dementia without behavioral disturbance/psychotic disturbance/mood disturbance, major depressive disorder, and muscle weakness. Review of the physician's orders for September 2023 for Resident #341 identified orders for Seroquel (an antipsychotic medication) 25 milligrams (mg) by mouth one time daily for mental/mood conditions. Review of the black box warning for Seroquel revealed it was not approved for the treatment of patients with dementia-related psychosis. Review of the admission Minimum Data Set (MDS) Assessment, dated 09/18/23, revealed Resident #341 had severe cognitive impairment. Resident #341 had no behaviors or indicators of psychosis during the look back period. The assessment indicated Resident #341 did not have a diagnosis of bipolar disorder, psychotic disorder (other than schizophrenia), schizophrenia, or post-traumatic stress disorder. The assessment indicated Resident #341 received antipsychotic medications for five days during look back period. Review of the care plan, dated 09/20/23, revealed Resident #341 was at-risk for adverse effects due to the use of psychotropic medications to manage mood and behavior related to agitation, anxiety disorder, and dementia. Interventions included administer medications per orders, attempt non-pharmacological interventions prior to administration of as needed (PRN) medications, inform the resident and family of risks and benefits of medications, monitor for adverse effects of antipsychotic medications (unsteady gait, weight loss, loss of appetite, fatigue, nausea or vomiting, tardive dyskinesia, shuffling gait, shaking, rigidity, inability to sit still, and pill rolling of thumb and finger), notify the physician promptly of adverse effects, pharmacist to review the medications per facility protocol, physician to review use of medications per facility protocol, and psychiatry consult as needed. Review of the assessment titled CHP-Psychopharmacologic Medication Review 3, dated 09/26/23, revealed Resident #341 received Seroquel (classified as an antipsychotic) and Buspar (classified as an antianxiety). The diagnoses indicated for use of the medications were dementia with behaviors and depression. The assessment indicated the medications were appropriate to treat the specific conditions. On 09/28/23 at 1:15 P.M., interview with DON verified dementia was not an appropriate diagnosis for the use of antipsychotic medications. On 09/28/23 at 4:30 P.M., interview with the DON verified Resident #341 received antipsychotic (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365783 If continuation sheet Page 11 of 12 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 365783 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aventura at Assumption Village 9800 Market Street North Lima, OH 44452 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete medications for the treatment of dementia. She stated Resident #341 admitted with the orders for Seroquel to treat dementia with behaviors. Review of facility policy titled Psychotropic Drug Use, dated 03/2020, revealed antipsychotic drugs should not be used unless the clinical record documented that the resident had one or more of the following specific conditions: schizophrenia, schizo-affective disorder, delusional disorder, psychotic mood disorder, acute psychotic episodes, brief reactive psychosis, schizophreniform disorder, atypical psychosis, Tourette's disorder, Huntington's disease, or organic mental syndromes with associated psychotic behaviors which have been quantitatively and objectively documented. Antipsychotics should not be used if one or more of the following were the only indication: wandering, poor self-care, restlessness, impaired memory, anxiety, depression without psychotic features, insomnia, unsociability, indifference to surroundings, fidgeting, nervousness, uncooperativeness, or agitated behaviors which did not represent a danger to the resident or others. Event ID: Facility ID: 365783 If continuation sheet Page 12 of 12