Inspection·September 19, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility staff interviews and policy review the facility failed to develop a complete comprehensive care plan to include activities. This affected three (Resident #9, #13, and #45) out of four residents reviewed for activities. The facility census was 88. Findings include: 1. Record review of Resident #9 revealed an admission date of 07/10/23 with diagnoses of acute and chronic respiratory failure with hypoxia, major depressive disorder, and heart failure. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact, required set-up assistance with eating, and required supervision assistance with oral hygiene, toileting hygiene, bathing, dressing, personal hygiene, bed mobility, transfers, and ambulation. Review of the Activities Initial Review assessment dated [DATE] revealed the resident had interests / hobbies of arts and crafts. Unknown if resident wished to participate in activities while in the facility. Review of the current care plan revealed it was absent for activities. 2. Record review of Resident #13 revealed an admission date of 07/10/24 with diagnoses of osteoarthritis of the hip, type II diabetes mellitus without complications, and depression. Review of the quarterly MDS dated [DATE] revealed the resident was cognitively intact, required supervision assistance with eating, required substantial assistance with oral hygiene, toileting hygiene, bathing, dressing, personal hygiene, bed mobility, transfers, and wheelchair mobility. Review of the Activities Initial Review assessment dated [DATE] revealed the resident had interests / hobbies of word puzzles and watching television. Unknown if resident wishes to participate in activities while in the facility. Review of the current care plan revealed it was absent for activities. 3. Record review of Resident #45 revealed an admission date of 04/19/24 with diagnoses of acute osteomyelitis of right ankle and foot, acquired absence of left leg below knee, and type II diabetes mellitus with diabetic chronic kidney disease. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 365186 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 365186 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Madeira 5970 Kenwood Road Cincinnati, OH 45243 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)