Health inspection·July 6, 2023

F 0561 Level of Harm - Minimal harm or potential for actual harm On 07/26/23 at 9:50 A.M., an interview with Registered Nurse (RN) #142 revealed the residents' bathing preferences were assessed upon their admission to the facility and put on a baseline care plan. The employees who were responsible for following up on those preferences after a resident's admission were not working that week and were unavailable for any interviews. She was not sure how the resident's bathing preferences were being documented, after their initial admission assessment was completed. Residents Affected - Few On 07/06/23 at 10:15 A.M., a follow up interview with Resident #10 revealed she did not recall anyone asking her what her preference was on the frequency in which she wanted to receive showers. They (facility) just put them down for two a week. She again indicated it would be her preference to be showered every other day. She did not feel the two a week she was getting was enough to keep her hair from becoming greasy in between her shower days. On 07/06/23 at 10:19 A.M., an interview with State Tested Nursing Assistant (STNA) #102 revealed they did showers on residents every three days (two times a week) for everybody. She denied she had heard the resident was wanting more than the two showers a week as she was receiving. She denied she had asked the resident what her preference was on the number of showers she wanted each week. She just followed the shower schedule on the days the resident was scheduled to receive them. On 07/06/23 at 10:20 A.M., an interview with Social Service Designee (SSD) #155 revealed she did not ask the residents what their preferences were regarding bathing activities. She thought maybe the activity department or the nursing department was asking that. It was done upon admission, but acknowledged a resident's preference could change throughout their stay. On 07/06/23 at 10:21 A.M., an interview with Activity Director #141 revealed she was not assessing the residents preferences in regards to their bathing activities. She was not sure who was responsible for that, but it was not part of her assessments she completed. On 07/06/23 at 10:40 A.M., an interview with LPN #101 revealed she thought the STNA's were asking residents what their preferences were in regards to the frequency in which they wanted bathed. She then indicated the nurse who admitted the resident would ask them about their bathing preferences. She was not sure how they were assessed after that. They based the shower schedule off the residents' preferences and they were scheduled by room numbers. The residents also picked the time of day that they wanted their showers. She had not heard the resident verbalize wanting more showers but also denied she had ever asked her. A review of the facility's policy on Preferences for Everyday Living Inventory (PELI) undated revealed it was the policy of the facility that a PELI would be completed with the resident in the nursing facility. Utilizing PELI was completed by conducting MDS assessments that included the PELI derived questions, along with any follow up assessment, in accordance with the Resident Assessment Instrument (RAI) manual. Special attention was paid to the section (F.) questions when care planning. In addition to that section, the facility also utilized a Plan of Care for Choices form that was completed upon admission. The facility utilized that information to assist staff in understanding the resident's true preferences and in utilizing those preferences in the creation of a plan of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366250 If continuation sheet Page 2 of 19 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 366250 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kimes Nursing & Rehab Ctr 75 Kimes Lane Athens, OH 45701 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, self-reported incident (SRI) review, interview and facility policy review, the facility failed to ensure a thorough investigation was competed for an alleged allegation of abuse. This had the potential to affect all 47 residents residing in the facility and specifically affected Resident #39. Residents Affected - Few Findings Included: Review of the SRI dated 04/01/23 revealed Resident #39 reported Licensed Practical Nurse (LPN) #210, the agency nurse who worked through the night threw something and hit her in the nose with it and woke her up. The SRI indicated the resident was alert and oriented and was emotionally distressed at the moment, but no physical injuries were present. The Administrator immediately reported LPN #210 to the agency and banned the nurse from returning to the facility in any role. The SRI indicated residents were interviewed and statements were being collected from witnesses. Review of the medical record for Resident #39 revealed an initial admission date of 01/30/23 with the diagnoses including Alzheimer's disease, paranoid personality disorder, delusional disorder, cognitive communication deficit, mood disorder, major depressive disorder, congestive heart failure, obstructive sleep apnea, anxiety disorder, hypothyroidism and hypertension. Review of the resident's quarterly assessment dated [DATE] revealed the resident had a moderate cognitive deficit. The resident required supervision with bed mobility and was independent with transfers and ambulation. Review of the plan of care dated 05/11/23 revealed the resident had paranoid thoughts and ideation. Interventions included consults per orders, encourage resident to talk about her concerns, medication as ordered, monitor for false beliefs that cannot be shaken with logical argument, monitor for statement of hearing, seeing, feeling or smelling things that are not there, monitor for auditory and visual hallucinations and reassure resident that she is welcome at the facility and staff do not want her to leave. Review of the plan of care dated 02/02/23 revealed the resident utilized CPAP/BIPAP therapy related to obstructive sleep apnea. Interventions included CPAP cleaning and care per orders, educate resident/representative on the importance of CPAP/BIPAP therapy and encourage resident to use the CPAP/BIPAP. Review of the monthly physician orders for July 2023 identified an order dated 02/01/23 C-Pap at bedtime with home settings and 06/19/23 Seroquel 25 milligrams (mg) by mouth twice daily for paranoia and hallucinations. The SRI was substantiated indicating the abuse was verified by evidence. On 07/06/23 at 11:02 A.M., interview with the Administrator revealed she substantiated the allegation of abuse based on the interview with the alert and oriented resident. She said the perpetrator's agency interviewed the nurse and stated, if you want a copy of the interview, I can get one. Review of the email provided by the facility to the Administrator from Admissions Coordinator (AC) #105 revealed LPN #210 phoned the facility and requested to speak with the Administrator. The LPN was notified the Administrator was not in the building. AC #105 texted the Administrator the number the LPN was calling from and he requested to speak with her, the LPN was notified the Administrator (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366250 If continuation sheet Page 3 of 19 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 366250 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kimes Nursing & Rehab Ctr 75 Kimes Lane Athens, OH 45701 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 0610 would return his call. Level of Harm - Minimal harm or potential for actual harm On 07/06/23 at 11:50 A.M., interview with the Administrator verified she failed to return the call to LPN #210 and felt it was the agencies responsibility to obtain a statement. She stated, I don't know when asked how she would know if all pertinent questions would be covered. The Administrator verified the investigation was not thorough. Residents Affected - Few Review of the facility policy titled, Abuse, Neglect, Mistreatment, Misappropriation of Personal Property Prevention Policy and Procedure, dated 10/01/02 revealed the facility strictly prohibits resident abuse, neglect, mistreatment, non-therapeutic involuntary seclusion and/or misappropriation of resident property by employees, privileged physicians, consultants, volunteers and/or visitors. The facility will complete a thorough and comprehensive investigation of all incidents (Refer to the Incident and Accident Policy and Procedure). Review of the facility policy titled, Incident/Accident Reporting Policy and Procedure, dated 10/01/02 revealed written/verbal statements from all actual or potential witnesses with information related to the occurrence as warranted. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366250 If continuation sheet Page 4 of 19 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 366250 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kimes Nursing & Rehab Ctr 75 Kimes Lane Athens, OH 45701 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** Based on record review ,staff interview, policy and procedure review the facility failed to issue a bed hold notification letter to one resident (#47) out of one resident reviewed for hospitalizations. The census was 47. Findings Include: Review of Resident #47's medical record revealed an admission date of 4/28/23 with no cognitive deficits. Diagnoses include atherosclerosis, muscle weakness, surgical aftercare following surgery on the circulatory system, and atherosclerotic heart disease of natives coronary artery without angina pector. Resident #47 was discharged on 05/18/23 to the hospital. Review of Resident #47's medical record nurses progress notes from 05/01/23 to 05/18/23 confirmed resident was discharged to the hospital on [DATE] with no bed hold notification given. Interview on 07/05/23 at 4:09 P.M. with the Administrator verified Resident #47 or the designated resident representative was not issued a Bed Hold Notification Letter when transferred to the hospital . Review of the facility Hold Bed policy (no date) revealed the facility informs the resident of facility bed-hold policy upon admission and prior to a transfer to hospital or therapeutic leave. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366250 If continuation sheet Page 5 of 19 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 366250 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kimes Nursing & Rehab Ctr 75 Kimes Lane Athens, OH 45701 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 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the medical record for Resident #40 revealed an initial admission date of 02/22/23 with the admitting diagnoses including Alzheimer's disease, anxiety disorder, restlessness and agitation, chronic obstructive pulmonary disease, diabetes mellitus, anemia, insomnia, peripheral vascular disease, chronic kidney disease, hyperlipidemia and depression. . Review of the resident's Minimum Data Set (MDS) list revealed a quarterly MDS assessment with assessment reference date (ARD) date of 05/31/23 in progress. On 07/05/23 at 8:38 A.M., interview with Registered Nurse (RN) #142 verified the MDS assessment was not completed in the required 14 day timeframe. Based on medical record review and staff interview, the facility failed to complete comprehensive assessments as required. This affected three (Residents #9, #250, and #40) of 17 resident assessments reviewed. The census was 47. Findings Include: 1. Record review revealed Resident #9 was admitted to the facility on [DATE]. Her diagnoses were atrial fibrillation, Alzheimer's disease, repeated falls, cognitive communication deficit, muscle weakness, heart failure, generalized anxiety disorder, congestive heart failure, osteoporosis, cerebrovascular disease, kyphosis, anemia, osteoarthritis, atherosclerosis, anemia, chronic kidney disease, major depressive disorder, dermatitis, insomnia, disorder of thyroid, hypertension, delirium, atrial fibrillation, hyperlipidemia, dysphagia. Review of her Minimum Data Set (MDS) assessment, dated 02/22/23, revealed she was cognitively intact. Review of Resident #9 MDS assessments revealed her most recent completed assessment was on 02/22/23. Review of her MDS assessments in the electronic medical records revealed she had an assessment started on 05/25/23, but it was still in progress; it was not completed. 2. Record review revealed Resident #250 was admitted to the facility on [DATE]. Her diagnoses were Alzheimer's disease, nontraumatic subarachnoid hemorrhage, hyperlipidemia, and atrial fibrillation. Review of her MDS assessment, dated 05/29/23, revealed her cognitive assessment had not been completed. Review of Resident #250's MDS assessments revealed an entry assessment completed on 05/23/23, which only had the identifying and financial sections completed. Then, an MDS assessment was started on 05/29/23, but it had not been completed by the assessment reference date (ARD) of 06/05/23. Interview with Registered Nurse (RN) #200 on 07/03/23 at 3:50 P.M. confirmed both Resident #9 and #250 MDS assessments were not completed by the required ARD date set by the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366250 If continuation sheet Page 6 of 19 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 366250 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kimes Nursing & Rehab Ctr 75 Kimes Lane Athens, OH 45701 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure all resident Pre-admission Screening and Resident Review (PASRR) documents were accurate to resident current conditions and diagnoses. This affected one (Resident #1) of two residents reviewed for PASRR documents. The census was 47. Findings Include: Record review revealed Resident #1 was admitted to the facility on [DATE]. His diagnoses were encephalopathy, type II diabetes, schizoaffective disorder, dementia, acute kidney disease, cognitive communication deficit, peripheral vascular disease, hematuria, depression, edema, hypothyroidism, dysphagia, atrial fibrillation, hydronephrosis, hypo-osmolality and hyponatremia, anxiety disorder, hypertension, hypokalemia, difficulty walking, and hyperlipidemia. Review of his Minimum Data Set (MDS) assessment, dated 05/18/23, revealed he had a severe cognitive impairment. Review of Resident #1's PASRR document, dated 09/17/18, revealed under Section C, the facility indicated he did not have a diagnosis of dementia or Alzheimer's disease. Also, under Section D, the facility indicated he had no severe mental health diagnoses. But review of his diagnoses list, he had the following diagnoses that should have been indicated/updated on his PASRR document: schizoaffective disorder, which was added on 03/31/21, unspecified dementia, which was added on 10/01/22, depression, which was added on 11/19/21, and anxiety disorder, which was added on 09/17/18. Interview with Admissions Director #105 on 07/05/23 at 12:37 P.M. confirmed the PASRR documents provided were the most up to date. She confirmed Resident #1 had diagnoses that were not listed on PASRR documents and should have been. She confirmed they are to update the PASRR documents when there is a significant change that would potentially affect the outcome of the PASRR document. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366250 If continuation sheet Page 7 of 19 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 366250 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kimes Nursing & Rehab Ctr 75 Kimes Lane Athens, OH 45701 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 0646 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure all significant mental health changes were communicated to the state mental health agency. This affected one (Resident #1) of two residents reviewed for PASRR documents. The census was 47. Findings Include: Resident #1 was admitted to the facility on [DATE]. His diagnoses were encephalopathy, type II diabetes, schizoaffective disorder, dementia, acute kidney disease, cognitive communication deficit, peripheral vascular disease, hematuria, depression, edema, hypothyroidism, dysphagia, atrial fibrillation, hydronephrosis, hypo-osmolality and hyponatremia, anxiety disorder, hypertension, hypokalemia, difficulty walking, and hyperlipidemia. Review of his Minimum Data Set (MDS) assessment, dated 05/18/23, revealed he had a severe cognitive impairment. Review of Resident #1 PASRR document, dated 09/17/18, revealed under Section C, the facility indicated he did not have a diagnosis of dementia or Alzheimer's disease. Also, under Section D, the facility indicated he had no severe mental health diagnoses. But review of his diagnoses list, he had the following diagnoses that should have been indicated/updated on his PASRR document: schizoaffective disorder, which was added on 03/31/21, unspecified dementia, which was added on 10/01/22, depression, which was added on 11/19/21, and anxiety disorder, which was added on 09/17/18. There was no documentation to support these significant mental health changes were communicated to the state mental health agency. Interview with Admissions Director #105 on 07/05/23 at 12:37 P.M. confirmed the PASRR documents provided were the most up to date. She confirmed Resident #1 had diagnoses that were not listed on PASRR documents and should have been. She confirmed they are to update the PASRR documents when there is a significant change that would potentially affect the outcome of the PASRR document. She also confirmed she did not notify the state mental health agency when the significant mental health changes were identified. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366250 If continuation sheet Page 8 of 19 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 366250 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kimes Nursing & Rehab Ctr 75 Kimes Lane Athens, OH 45701 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure one resident's (#40) hospice continuity of care. This affected one of one resident reviewed for hospice. Residents Affected - Few Findings Included: Review of the medical record for Resident #40 revealed an initial admission date of 02/22/23 with the admitting diagnoses including Alzheimer's disease, anxiety disorder, restlessness and agitation, chronic obstructive pulmonary disease, diabetes mellitus, anemia, insomnia, peripheral vascular disease, chronic kidney disease, hyperlipidemia and depression. Review of the resident's clinical admission assessment dated [DATE] indicated the resident was admitted to the facility with hospice services. Review of the resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit. The assessment indicated the resident received hospice services. Review of the plan of care revealed the resident had no care plan addressing the resident's hospice status. Review of the monthly physician orders for July 2023 identified an order dated 04/11/23 indicating the resident was under hospice care for the diagnoses of Alzheimer's Dementia. Review of the resident's medical record revealed evidence of hospice notes and no evidence of continuity of care. On 07/06/23 at 12:14 P.M., interview with Registered Nurse (RN) #142 verified the resident's hospice notes were not available at the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366250 If continuation sheet Page 9 of 19 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 366250 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kimes Nursing & Rehab Ctr 75 Kimes Lane Athens, OH 45701 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to implement the physician ordered off-loading to one resident's (#15) Stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough or bruising. Residents Affected - Few May also present as an intact or open/ ruptured blister.) pressure ulcer. This affected one of one resident reviewed for pressure ulcers. Findings Included: Review of the medical record for Resident #15 revealed an initial admission date of 08/12/21 with the diagnoses including dementia, altered mental status, adult failure to thrive, nonrheumatic aortic valve insufficiency, cardiac murmur, generalized muscle weakness, schizoaffective disorder, metabolic encephalopathy, dysphagia, hypertension, disorder of kidney and ureter, gastro-esophageal reflux disease, insomnia and presence of cardiac pacemaker. Review of the plan of care dated 09/07/21 revealed the resident was at risk for skin integrity related to diagnoses of dementia with lack of safety awareness, failure to thrive, chronic confusion, schizoaffective disorder, requires extensive assist with bed mobility and repositioning tasks, incontinent of bowel and bladder, resistive with care, thin fragile skin with loose subcutaneous tissue, poor nutritional intake, frequently moves arms about reaching for items not there, will reach for staff when providing care, puts hands to mouth when not eating or drinking and wound to left lateral malleolus. Interventions included one to two assist with all transfers due to resistive with care, bilateral assist rails to enable resident to turn and reposition self, consult per order when indicated, creams per order, encourage and assist to turn and reposition side to side every one hour and as needed, diet per order, encourage to float heels, encourage to leave attends off while in bed, encourage to wear long sleeves, ensure socks or footwear in place before transfers, medication per order, monitor and replace pillow under feet and ankles as needed, nurse to monitor skin every week, padding to bilateral assist rails, pressure reducing cushion to chair, STNA to monitor skin with morning/bedtime care and showers, treatments per order, use turn/lift sheet in bed for repositioning to assist prevention of shearing, attempt total relief of pressure by no positioning directly on affected area and keep heels off bed and recliner chair. Review of the Braden scale dated 11/03/22 revealed a score of 14 indicating the resident was at risk for skin breakdown. Review of the nurses note dated 01/11/23 at 8:40 P.M. revealed during evening care State Tested Nursing Assistant (STNA) notified the nurse of a skin issue. Upon assessment a red, non-blanchable area was noted to the left lateral malleolus. No tenderness or signs/symptoms of infection were noted. The physician was notified and a new order for skin prep and increase turns to every hour was obtained. Review of the weekly pressure skin grid dated 01/11/23 revealed a Stage I pressure ulcer was identified to the resident's left lateral malleolus measuring 1.5 centimeters (cm) by 1.5 cm. The wound was described as being red and non-blanchable. Review of the weekly pressure skin grid dated 01/18/23 revealed the Stage I pressure ulcer measured (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366250 If continuation sheet Page 10 of 19 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 366250 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kimes Nursing & Rehab Ctr 75 Kimes Lane Athens, OH 45701 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 1.5 cm by 1.3 cm. The wound was described as being red with a pinpoint brownish colored scab to the center of the area. Review of the weekly pressure skin grid dated 01/25/23 revealed the Stage I pressure ulcer measured 1.2 cm by 0.9 cm. The wound was described as being red with a pinpoint brownish colored scab to the center of the area. Review of the weekly pressure skin grid dated 02/01/23 revealed the pressure ulcer was now classified as a suspected deep tissue injury (SDTI) measuring 1.5 cm by 1.4 cm. The wound was described as being red surrounding a brownish black area with a pinpoint scab. Review of the weekly pressure skin grid dated 02/03/23 revealed the SDTI measured 0.7 cm by 0.7 cm with intact skin. The wound was described as a SDTI versus Stage I. The wound was dark red/maroon/purple in color. Review of the weekly pressure skin grid dated 02/08/23 revealed the SDTI measured 1.0 cm by 1.0 cm and was a brown scab over the area. Review of the weekly pressure skin grid dated 02/15/23 revealed the SDTI measured 1.0 cm by 1.0 cm and was brown in color. Review of the weekly pressure skin grid dated 02/22/23 revealed the SDTI measured 1.0 cm by 1.0 cm and was black in color with the surrounding tissue red. Review of the weekly pressure skin grid dated 03/01/23 revealed the SDTI measured 1.0 cm by 1.0 cm and was black in color with the surrounding tissue red. Review of the weekly pressure skin grid dated 03/08/23 revealed the SDTI measured 1.5 cm by 1.5 cm and was described as being brown callous like skin. Review of the weekly pressure skin grid dated 03/015/23 revealed the SDTI measured 1.0 cm by 1.3 cm and described as pink with brown at the very bottom. Review of the weekly pressure skin grid dated 03/22/23 revealed the SDTI measured 1.0 cm by 1.3 cm and described as being brownish-red. Review of the weekly pressure skin grid dated 04/05/23 revealed the SDTI was now a Stage I pressure ulcer measuring 0.2 cm by 0.2 cm that was pink in color and almost healed. Review of the weekly pressure skin grid dated 04/12/23 revealed the SDTI was now a Stage I pressure ulcer measuring 2.0 cm by 2.0 cm that was pink in color. Review of the weekly pressure skin grid dated 04/19/23 revealed the wound was now a Stage II pressure ulcer measuring 1.5 cm by 1.4 cm by 0.1 cm that was pink in color with a yellow center. The wound had a small amount of clear drainage. Review of the weekly pressure skin grid dated 04/26/23 revealed the wound was now a Stage II pressure ulcer measuring 1.5 cm by 1.3 cm by 0.1 cm that was pink in color with a yellow center. The wound had no drainage. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366250 If continuation sheet Page 11 of 19 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 366250 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kimes Nursing & Rehab Ctr 75 Kimes Lane Athens, OH 45701 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the weekly pressure skin grid dated 05/03/23 revealed the wound was now a Stage II pressure ulcer measuring 1.4 cm by 1.2 cm by 0.1 cm that was pink in color with a yellow center. The wound had no drainage. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit. Review of the mood and behavior revealed the resident rejected care. The resident required extensive assistance of two staff for bed mobility, transfers and toilet use. The assessment indicated the resident was non-ambulatory. The assessment indicated the resident was always incontinent of both bowel and bladder. The resident was assessed as being at risk for skin breakdown and had one Stage II pressure ulcer. The facility implemented the interventions pressure reducing devices to bed/chair, nutrition or hydration intervention to manage skin problems, pressure ulcer/injury care, applications of nonsurgical dressings and applications of ointments/medications other than to feet. Review of the weekly pressure skin grid dated 05/10/23 revealed the wound was now a Stage II pressure ulcer measuring 1.4 cm by 1.2 cm by 0.1 cm that was pink in color. Review of the weekly pressure skin grid dated 05/17/23 revealed the wound was now a Stage II pressure ulcer measuring 1.4 cm by 1.2 cm by 0.1 cm that with no description of the wound. Review of the weekly pressure skin grid dated 05/24/23 revealed the wound was now a Stage II pressure ulcer measuring 1.3 cm by 0.9 cm by 0.1 cm with no description of the wound. Review of the weekly pressure skin grid dated 05/31/23 revealed the wound was now a Stage II pressure ulcer measuring 1.1 cm by 0.8 cm by 0.1 cm with no description of the wound. Review of the weekly pressure skin grid dated 06/01/23 revealed the wound was now a Stage II pressure ulcer measuring 2.0 cm by 2.0 cm by 0.1 cm with the wound being described as being red, superficially open and surrounded by non-blanchable skin. Review of the weekly pressure skin grid dated 06/07/23 revealed the wound was now a Stage II pressure ulcer measuring 1.9 cm by 0.8 cm by 0.1 cm with the wound was described as being pink with a yellow center. Review of the weekly pressure skin grid dated 06/14/23 revealed the wound was now a Stage II pressure ulcer measuring 1.9 cm by 0.7 cm by 0.1 cm with the wound was described as being pink with a yellow center. Review of the weekly pressure skin grid dated 06/21/23 revealed the wound was now a Stage II pressure ulcer measuring 1.9 cm by 0.8 cm by 0.1 cm with the wound was described as being pink with a yellow center. Review of the weekly pressure skin grid dated 06/14/23 revealed the wound was now a Stage II pressure ulcer measuring 0.9 cm by 0.9 cm by 0.1 cm with the wound was described as being pink with a yellow center. Review of the monthly physician orders for July 2023 identified orders dated 11/22/21 pressure reducing mattress to bed, 02/04/22 pressure reducing cushion to wheelchair, house barrier cream every shift for preventative, encourage to keep heels elevated off surface of bed, 05/04/22 weekly vital (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366250 If continuation sheet Page 12 of 19 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 366250 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kimes Nursing & Rehab Ctr 75 Kimes Lane Athens, OH 45701 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few signs with skin check, 01/12/23 encourage side to side turns every hour, 01/17/23 complete skin grid located in skin binder weekly with skin check, 02/02/23 cleanse area to left malleolus with wound wash, pat dry and cover with bordered foam dressing daily until resolved and 04/27/23 encourage resident to wear geri-sleeves to bilateral upper extremities at all times. On 07/03/23 at 1:48 P.M., observation of the resident revealed she was positioned on her left side with a pillow between her knees and one under both feet. The Stage II pressure ulcer to the left ankle was resting on the pillow. On 07/05/23 at 12:50 P.M., observation of the physician ordered treatment to the Stage II pressure ulcer by Licensed Practical Nurse (LPN) #101 and #151 revealed the LPN's washed their hands and donned their gloves. LPN #101 set up the required supplies on the bedside table on a barrier. The resident was positioned on her left side with her knees bent up towards her body. The resident had a pillow between her knees and one under her feet. No off-loading to the left ankle was noted. LPN #151 positioned the resident on her right side, removed the non-skid sock. LPN #101 removed the soiled dressing with no drainage noted. She cleansed the wound with wound cleanser and a 4X4. She sanitized her hands and donned a clean pair of gloves. She placed a bordered foam dressing on the wound. No breaks in infection control were noted. LPN #101 placed a pillow between the resident's knees and one under her ankles. No off-loading was noted to the left outer ankle. On 07/05/23 at 4:00 P.M., interview with Registered Nurse (RN) #142 verified the resident had no off-loading to the Stage II pressure ulcer to the left ankle. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366250 If continuation sheet Page 13 of 19 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 366250 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kimes Nursing & Rehab Ctr 75 Kimes Lane Athens, OH 45701 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, staff interview, and policy review, the facility failed to ensure fall prevention interventions were implemented for a resident with a known history of falls and considered to be at risk for falls. This affected one (Resident #2) of two residents reviewed for accidents. Findings include: A review of Resident #2's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included a fracture of the distal end of her right femur following a fall on 06/09/23, repeated falls, difficulty walking, age related osteoporosis, muscle weakness, muscle wasting and atrophy, need for assistance with personal care, osteoarthritis, hypertension, memory deficit following stroke, and unspecified dementia. A review of Resident #2's fall risk assessment completed on 04/14/23 revealed the resident was assessed to be a moderate risk for falls. Her risk factors included having a history of one to two falls during the past six months, medications that increase the risk for falls, memory and recall issues, being frequently incontinent of her bowel and bladder, agitated behaviors, being confined to a chair, and diagnoses that increased the risk for falls. A review of Resident #2's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had clear speech and adequate hearing. She sometimes was able to make herself understood and sometimes was able to understand others. Her cognition was moderately impaired. The resident required an extensive assist of two for bed mobility, transfers, locomotion on the unit, and toilet use. She was an extensive assist of one for locomotion off the unit. Ambulation did not occur. She was frequently incontinent of her bowel and bladder. No falls were indicated to have occurred since her prior MDS assessment. A review of Resident #2's care plans revealed she was at risk for falls and fall related injuries related to her diagnoses of dementia, a history of falls, history of a stroke, major depression, and a history of a right hip fracture. She was indicated to have had a fall with a right femur fracture requiring surgical repair. She was known to have balance and gait deficits and required an extensive assist with transfer and mobility tasks. She had a cognitive deficit with decreased safety awareness and over-estimated her abilities. The care plan was initiated on 06/20/22. The goal was to have decreased opportunities for falls and significant injuries through the next review. Her fall prevention interventions included the use of Dycem (a tacky pad that is placed on seating surfaces to prevent a resident from sliding out of the chair) to her wheelchair and for the use of a visual cue in her room to remind the resident to use her call light for assistance. A review of Resident #2's physician's orders revealed the use of Dycem to her wheelchair to prevent sliding was also included in her physician's orders. That order originated on 06/30/22. On 07/05/23 at 8:55 A.M., an observation of Resident #2 noted her to be sitting in her wheelchair in the lounge area across from the nurses' station. State tested Nursing Assistant (STNA #102) was asked to assist the resident to a standing position to verify if she had the Dycem in place under her while sitting in her wheelchair. She and another aide stood the resident up and Dycem was not noted to be in her wheelchair as per her plan of care. Her room was then checked and was not noted to have (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366250 If continuation sheet Page 14 of 19 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 366250 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kimes Nursing & Rehab Ctr 75 Kimes Lane Athens, OH 45701 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few any visual cues in her room to remind the resident to use her call light for assistance. Findings were verified by licensed practical nurse (LPN) #101. On 07/05/23 at 8:58 A.M., an interview with LPN #101 confirmed Resident #2 had an order for the use of Dycem to be placed under the resident when up in her chair to prevent sliding. She also confirmed by reviewing her plan of care that the resident was also to have visual cues in her room to remind her to use her call light for assistance. They were not able to find evidence of a Dycem pad being in her room nor was she able to explain why the visual cues were not in her room. She acknowledged both were still fall prevention interventions that were to be in place for the resident who had a history of falls. A review of the facility's policy on Falls Management undated revealed it was the policy of the facility to ensure residents received adequate supervision and appropriate assistive devices based on their individual risk factors to reduce and/ or prevent falls. The purpose of the policy included developing and implementing appropriate interventions to reduce or prevent falls based on the resident's individual risk factors. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366250 If continuation sheet Page 15 of 19 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 366250 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kimes Nursing & Rehab Ctr 75 Kimes Lane Athens, OH 45701 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 serve food in a safe and sanitary manner. This affected 46 of 46 residents who utilized the kitchen for meals (Resident #249 received nothing by mouth). The census was 47. Findings Include: Observation on 07/06/23 at 12:36 P.M. revealed [NAME] #163 touching the cornbread from the pan three times with gloves and placed them on the meal plates. Also, she touched one breaded pork chop with the same gloved hand and placed it on the meal plate. In between touching the cornbread and pork chop with the same gloved hands, she touched the counter top, drawer handle for utensils, three different food utensils, multiple plates, and the plate warmer lid to lift it up. Observation on 07/06/23 at 12:44 P.M. revealed [NAME] #163 touching four pork chops with her gloved hand. After touching the pork chops, she took the gloves off, did not wash her hands, and then put a new pair of gloves on. Observation on 07/06/23 at 12:45 P.M. revealed [NAME] #163 touching stuffing after it was served onto the resident's plate. She touched it with her gloved hand that had touched utensils, plate warmer lid handle, counter, and multiple plates without changing her glove. Observation on 07/06/23 at 12:46 P.M. revealed [NAME] #163 used the same gloved hand from above and multiple pork chops while they were on the steam table, on the way to grab the utensil to serve the spinach. She did not change her gloves. Observation on 07/06/23 at 12:48 P.M. revealed [NAME] #163 used the same gloved hand to move the cornbread that was on the resident's plate, to make room for another food item. She did not change her gloves. Interview with [NAME] #163 and Food Services Director #144 on 07/06/23 at 12:50 P.M. confirmed that gloves need to be changed after handling food and prior to touching something else with the same gloved hand. They confirmed that hands are to be washed after each time gloves are changed. [NAME] #163 stated she didn't remember touching the food items, but stated, if you say I did, then I must have. Review of facility Dietary Department Infection Control Responsibilities procedures, undated, revealed foods and liquids provide an ideal environment for the growth of bacteria. It is therefore the responsibility of all dietary personnel to know and practice the procedures specific to their department. Handwashing between activities in the dietary department and between handling different foods is very important. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366250 If continuation sheet Page 16 of 19 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 366250 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kimes Nursing & Rehab Ctr 75 Kimes Lane Athens, OH 45701 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on review of infection control records and infection control policies and procedures review the facility failed to appropriately monitor resident infections as per infection control policy and procedures for the month of July, August and September of 2022. In addition the facility failed to implement and perform their Legionella Precautionary Maintenance and Inspections per their Legionella Water Management Program. This affected all residents in the facility. The census was 47. Residents Affected - Many Findings Include: 1. Review of the the facility monthly infection control logs from 07/2022 to 07/2023 revealed for the months of 07/2022, 08/2022 and 09/2022 the monthly infection control log form did not include the resident symptoms, indicate if the resident had a chest x-ray or culture done with results , any type of necessary treatments and if the resident required Isolation. Interview on 07/06/23 11:48 AM with Registered Nurse (RN) #142 confirmed the Monthly Infection Log for 07/2022, 08/2022 and 09/2022 was incomplete and did not include the necessary documentation needed to track the residents who had an infection. Review of the Infection Prevention and Control Program (October 2018) revealed process surveillance (adherence to infection prevention and control practices) and outcomes surveillance (incidence and prevalence of healthcare acquired infections) are used as measures of the IPCP effectiveness. Surveillance tools are used for recognizing the occurrence of infections, recording their number and frequency, detecting outbreaks and epidemics, monitoring employee infection, monitoring adherence to infection prevention and control practices, and detecting unusual pathogens with infection control implications. 2. Review of the facility Legionella Water Management Program (dated 07/2017) revealed the facility maintenance and inspection frequency is as follows: Domestic Hot Water Storage tanks: check monthly Hot and Cold Water outlets: check monthly Incoming Cold Water Supply: check monthly Sinks and Showers: check monthly Air Conditioning & Air Handling Units: check bi-annually Circulating Pumps: check annually External Hose Bibs: check annually Tempering Valves: check monthly Ice Machine: check Bi-annually All water outlets in vacant rooms: check monthly (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366250 If continuation sheet Page 17 of 19 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 366250 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kimes Nursing & Rehab Ctr 75 Kimes Lane Athens, OH 45701 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Auditing Frequency check : bi-annually Level of Harm - Minimal harm or potential for actual harm Risk Assessment of Water System: check annually Chiller: check monthly Residents Affected - Many Review of the Legionella Tracking Logs from 07/2022 to 07/2023 revealed records indicating the resident in room sinks water temperatures were taken one time a month. There was no additional information of maintenance tracking for any other part of the facility. Interview on 07/05/23 at 1:10 P.M. with the Administrator verified the only documentation they track is the residents' sink water temperatures monthly. Interview on 07/06/2023 at 2:32 P.M. with Maintenance Director #105 revealed he is unaware of the Legionella policy and what maintenance and inspections he is responsible to track. Review of the Water Management Program (dated 07/2017) revealed their facility is susceptible to Legionella growth in its incoming water supply, hot water heater and storage tanks,all hot and cold water outlets, including sinks and showers, even if not in use. Air conditioning and air handling units, circulating pumps, external hose bibs, tempering valves, ice machine , water fountain and patient care machines, including C-pap and Bi-pap machines and Oxygen concentrators. The purpose of the Water Management Program is to identify areas of the water system where Legionella bacteria can grow and spread and reduce the risk of Legionella disease. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366250 If continuation sheet Page 18 of 19 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 366250 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kimes Nursing & Rehab Ctr 75 Kimes Lane Athens, OH 45701 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 0921 Level of Harm - Minimal harm or potential for actual harm Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation and interview the facility failed to maintain a clean, sanitary homelike environment. This affected one (#40) of 15 sampled residents. Residents Affected - Few Findings Included: On 07/03/23 at 9:57 A.M., observation of Resident #40's room revealed a strong odor of urine. The resident's bed side chair had peeling leather and a rip in the cushion. The resident's wall behind the headboard was also marred. On 07/05/23 at 1:20 P.M., observation of Resident #40 revealed the resident was quiet at bedrest with eyes closed. No signs of incontinence noted, however the resident's room continued to have a strong odor of urine. On 07/05/23 at 10:45 A.M., interview with Registered Nurse (RN) #142 verified the resident's room had a persistent strong odor of urine and the disrepair of the chair and wall. 07/06/23 at 8:00 A.M., observation of Resident #40's room revealed the room continued to have a strong odor of urine. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366250 If continuation sheet Page 19 of 19