Inspection·February 18, 2022

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Interview on 02/17/22 at 9:08 A.M., with STNA #67 verified she was standing while feeding Resident #11. STNA #11 verified they are to be sitting by the resident to assist with eating. Review of the policy titled Dignity, revised 02/2020, revealed each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, feeling of self-worth and self-esteem. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents. For example: Helping the resident to keep urinary catheter bags covered. Event ID: Facility ID: 365330 If continuation sheet Page 2 of 22 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 365330 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Wauseon 303 W Leggett St Wauseon, OH 43567 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 0570 Assure the security of all personal funds of residents deposited with the facility. Level of Harm - Potential for minimal harm Based on review of resident funds, review of surety bond, and staff interviews, the facility failed to ensure the amount of the surety bond was equal to or greater than the total amount of resident funds. This affected affect 12 (#4, #7, #8, #13, #18, #19, #20, #24, #29, #31, #32, #33) residents with current accounts and had the potential to affect all residents. Facility census was 39. Residents Affected - Many Findings include: Review of resident funds on 02/14/22 at 4:15 P.M., revealed a total account balance of $28,460.30 for twelve residents (#4, #7, #8, #13, #18, #19, #20, #24, #29, #31, #32, #33). Review of the surety bond on 02/14/22 at 4:25 P.M., revealed a surety bond in the amount of $25,000.00. Interview on 02/14/22 at 4:26 P.M., with the Business Office Manager #4 verified the current total amount of resident funds was $28,460.30 with a surety bond amount of $25,000.00. The Business Office Manager #4 further added she knew the surety bond must be greater than the current total amount of resident funds. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365330 If continuation sheet Page 3 of 22 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 365330 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Wauseon 303 W Leggett St Wauseon, OH 43567 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident record review, resident interview, resident family interview, staff interview, and policy review; the facility failed to provide the resident/resident representative a written summary of the baseline care plan. This affected two (#338 and #36) of four residents reviewed for baseline care planning. The census was 39. Findings include: 1. Review of the medical record for Resident #338 revealed the resident was admitted to the facility on [DATE]. Diagnoses include respiratory failure, diabetes mellitus type two, and hypertension. Review of the medical record for Resident #338 revealed a baseline care plan dated 01/26/22. The medical record contained no evidence of Resident #338 or of the resident's representative being provided a written summary of the baseline care plan. Review of an admission minimum data set (MDS) assessment target date 02/02/22, revealed Resident #338 had intact cognition. Interview on 02/14/22 at 9:53 A.M., with Resident #338 revealed the resident was not given a copy of the baseline care plan. Interview on 02/15/22 at 12:24 P.M., with the Assistant Director of Nursing (ADON) #61 verified the medical record for Resident #338 contained no evidence of the resident or representative being provided a written summary of the baseline care plan. 2. Review of the medical record for Resident #36 revealed an admission date of 01/20/22 and medical diagnoses of cerebral infarction, type 2 Diabetes Mellitus, dysphagia, persistent vegetative state, and cognitive communication deficit. Review of the comprehensive Minimum Data Set (MDS) dated [DATE] revealed Resident #36 was in a persistent vegetative state, required extensive assistance of two staff for bed mobility, toileting, and personal hygiene, and was totally dependent for eating. Interview on 02/15/22 at 8:42 A.M., with the daughter of Resident #36 (Emergency Contact #1), revealed she was not involved in the care planning process. Interview on 02/15/22 at 2:24 P.M., revealed the Director of Nursing could not provide documentation the baseline care plan for Resident #36 was provided to his daughter. Review of a policy titled, Care Plans - Baseline, dated 12/16 revealed the resident and their representative will be provided a summary of the baseline care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365330 If continuation sheet Page 4 of 22 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 365330 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Wauseon 303 W Leggett St Wauseon, OH 43567 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records, staff interview, family interviews, resident interviews and review of policy, the facility failed to revise care plans and failed to ensure residents/resident representatives were given the opportunity to participate in the care planning process. This affected five (#7, #32, #338, #36, #9) of 12 residents reviewed for care planning. The facility census was 39. Findings include: 1. Review of the medical record revealed Resident #7 had an admission date of 06/29/20. Diagnosis included multiple sclerosis, chronic pain syndrome and type two diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. Review of the care plan conference notes revealed the resident's last care conference meeting was completed 04/13/21. Interview on 02/17/22 at 9:11 A.M., Resident #7 revealed she had not been to a care plan meeting in a long time. Resident #7 revealed it was important to have the meeting to find out what is going on and be able to ask questions. Interview on 02/17/22 at 9:24 A.M., Social Service Director (SSD) #40 verified Resident #7 had not had a care plan conference meeting since 04/13/21. 2. Medical record review revealed Resident #32 had an admission date of 08/13/20. Diagnosis included chronic respiratory failure, bipolar disorder and pulmonary fibrosis. Review of the quarterly MDS assessment dated [DATE] revealed the resident had intact cognition. Review of a care conference summary revealed Resident #32 had not participated in a care meeting since 04/13/21. Interview on 02/17/22 at 9:14 A.M., Resident #32 stated she had not been invited to a care plan meeting recently and would like to attend a care plan meeting. Interview on 02/17/22 at 9:24 A.M., SSD #40: verified Resident #32 had not had a care conference meeting since 04/13/21. SSD #40 revealed she just started working in the facility in 12/2021. SSD #40 revealed initial care plan meetings were completed but not quarterly care plan meetings. SSD #40 stated she had not been trained to complete quarterly care plan conferences. 3. Review of the medical record for Resident #338 revealed the resident was admitted to the facility on [DATE]. Diagnoses include respiratory failure, diabetes mellitus type two, and hypertension. Review of an admission MDS assessment completed 02/08/22, revealed Resident #338 had intact cognition. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365330 If continuation sheet Page 5 of 22 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 365330 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Wauseon 303 W Leggett St Wauseon, OH 43567 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 0657 Level of Harm - Minimal harm or potential for actual harm Review of the medical record for Resident #338 revealed no evidence of Resident #338 being included in the care planning process. Interview on 02/14/22 9:53 A.M., with Resident #338 revealed the resident had not been invited to or attended a care planning conference. Residents Affected - Some Interview on 02/15/22 at 12:25 P.M., with Social Service Director (SSD) #40 verified there was no care conference scheduled or conducted for Resident #338. SSD #40 reported a care conference would be scheduled for Resident #338 soon, because the resident was scheduled to be discharging home at the end of February. 4. Review of the medical record for Resident #36 revealed an admission date of 01/20/22 and medical diagnoses of cerebral infarction, type 2 Diabetes Mellitus, dysphagia, persistent vegetative state, and cognitive communication deficit. Review of the comprehensive Minimum Data Set (MDS) dated [DATE] revealed Resident #36 was in a persistent vegetative state, required extensive assistance of two staff for bed mobility, toileting, and personal hygiene, and was totally dependent for eating. Review of the physician orders revealed an order dated 02/14/22 for enteral feed formula Glucerna 1.2 and an order dated 02/11/22 for enteral feed every shift for nutrition 80 milliliters (mL) per hour continuous infusion. Review of the current care plan dated 02/02/22 revealed Resident #36 required tube feeding due to dysphagia and a persist vegetative state. Interventions included tube feeding formula Diabetisource AC at 70 milliliters (mL) an hour continuous infusion, and water flushes via percutaneous gastrostomy tube (a tube into the stomach) 200 mL every six hours. Interview on 02/16/22 at 2:58 P.M., with Dietetic Technician, Registered #75 confirmed the care plan for Resident #36 was not updated with the current tube feeding order. 5. Review of the medical record for Resident #9 revealed an admission date of 06/29/20 and medical diagnoses of end stage renal disease, type 2 Diabetes Mellitus, and dependence on renal dialysis. Review of the quarterly MDS dated [DATE] revealed Resident #9 had intact cognition. Resident #9 required supervision with setup help only for transfers, walking, eating, toileting and hygiene. Review of the physician orders for Resident #9 revealed a discontinued order from 01/19/21 to 03/04/21 for a 1500 mL daily fluid restriction. Review of the current care plan dated 07/06/20 to 03/02/22 revealed Resident #9 had a potential for altered nutrition and hydration, a potential for unplanned weight gain, and a potential for altered lab values. Interventions included fluid restriction as ordered. Further review of the care plan revealed Resident #9 had fluid overload or potential fluid overload. Interventions included a fluid restriction of 1500 mL daily, distributed between nursing shifts (300 ml 7 A.M.-3 P.M., 200 ml 3 P.M. -11 P.M., and 160 ml 11 P.M.-7 A.M.) and meals (360 ml at breakfast, 240 ml at lunch and supper). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365330 If continuation sheet Page 6 of 22 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 365330 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Wauseon 303 W Leggett St Wauseon, OH 43567 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the Care Conference Summary revealed Resident #9 had not had a care conference since 03/23/21. Interview on 02/14/22 at 2:17 P.M., with Resident #9 revealed he had not been included in care planning. Interview on 02/15/22 at 2:27 P.M., with the Director of Nursing (DON) revealed the record for Resident #9 contained no documentation of a care conference occurring since 03/23/21. Interview on 02/15/22 at 2:29 P.M., with the Social Services Director #40 revealed care conferences should be held within 72 hours of admission and then quarterly. The care conferences should include the resident and/or representative. Further interview confirmed Resident #9 did not have a care conference since 03/23/21. Interview on 02/16/22 at 4:07 P.M., with the Assistant Director of Nursing (ADON) #61 confirmed Resident #9's care plans were not updated regarding a fluid restriction, and further confirmed the fluid restriction was discontinued on 03/04/21. Review of the facility policy titled, Resident Participation - Assessment/Care Plans, revised 12/16 revealed no guidance regarding the timing of care conferences or the revision of care plans. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365330 If continuation sheet Page 7 of 22 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 365330 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Wauseon 303 W Leggett St Wauseon, OH 43567 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record resident and staff interviews, and policy review, the facility failed to ensure a resident was provided assistance with shaving. This affected one (#5) of three residents reviewed for assistance with activities of daily living (ADL). The census was 39. Residents Affected - Few Findings include: Review of the medical record for Resident #5 revealed the resident was admitted to the facility on [DATE]. Diagnoses include arthropathy, disturbances of skin sensation, muscle weakness, hypertension. osteoarthritis, and lesion of the median nerve. Review of a care plan dated 02/21/20 revealed Resident #5 had an ADL self care deficit as evidenced by need for assistance related to inability to stand for any length of time secondary to bilateral leg weakness, decreased endurance, decreased activity tolerance, and limited range of motion in hands related to arthritis. Interventions include assist with daily hygiene, grooming, dressing, oral care, and eating as needed. Review of a quarterly minimum data set (MDS) assessment dated [DATE], revealed Resident #5 had intact cognition. The resident required extensive assistance of one person for personal hygiene. Observation on 02/14/22 at 10:22 A.M., of Resident #5 revealed the resident was observed with dark gray coarse hairs located on the residents chin and above the top lip. Observation on 02/15/22 at approximately 3:00 P.M., revealed the resident continued to have dark gray coarse hairs located above the top lip and on the chin. Observation on 02/16/22 at 8:15 A.M., of Resident #5 revealed the resident continued to have dark gray coarse hairs located above the top lip and on the chin. Interview on 02/16/22 at 9:11 A.M., with Resident #5 revealed the resident does not like having facial hair. The resident reported being provided assistance with showers on Tuesdays and Fridays. The resident further reported the staff member who assists the resident with showers would shave the resident's facial hair on shower days and as needed throughout the week. Resident #5 revealed the resident asked the State Tested Nurse Aide (STNA) to shave facial hair on 02/15/22, but there was no razor in the shower room. Resident #5 reported the STNA must have forgotten to find a razor and assist with shaving. Interview on 02/16/22 at 1:23 P.M., with STNA #560 revealed the STNA assisted Resident #5 with a shower on 02/15/22. STNA #560 verified Resident #5 was not provided assistance with removal of facial hair. Review of a policy titled, Activities of Daily Living (ADL), Supporting dated 03/18, revealed appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care, including support and assistance with hygiene (bathing, dressing, grooming, and oral care). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365330 If continuation sheet Page 8 of 22 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 365330 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Wauseon 303 W Leggett St Wauseon, OH 43567 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 - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, medical record review, policy review, and review of information from the National Pressure Injury Advisory Panel (NPIAP), the facility failed to assess and monitor pressure ulcers to prevent the deterioration of wounds. This resulted in Actual Harm when Resident #36 was admitted to the facility with a Stage 2 pressure ulcers (partial thickness skin loss into but no deeper than the dermis) to the coccyx and a Stage 2 pressure ulcer to the ankle that were not assessed and monitored regularly. Subsequently, both pressure ulcers declined and was assessed as Unstageable (full thickness tissue loss but is either covered by extensive necrotic tissue or by eschar) 15 days after admission. This affected one (#36) of two residents reviewed for pressure ulcers. The facility identified two residents in the facility with pressure ulcers. The facility census was 39. Residents Affected - Few Findings include: Review of the medical record for Resident #36 revealed an admission date of 01/20/22 and re-admitted [DATE], with diagnoses of cerebral infarction, type 2 Diabetes Mellitus, dysphagia, persistent vegetative state, and cognitive communication deficit. During the admission, Resident #36 was hospitalized from [DATE] to 02/11/22. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #36 was in a persistent vegetative state, required extensive assistance of two staff for bed mobility, toileting, and personal hygiene, and was totally dependent for eating. Further review revealed Resident #36 was admitted with two stage 2 pressure ulcers. Review of the admission Nursing Observation dated 01/20/22 revealed Resident #36 was admitted with a Stage 2 pressure ulcer to his coccyx measuring 5.0 centimeters (cm) in length, 5.0 cm in width, and no depth was documented. Resident #36 also admitted with a Stage 2 pressure ulcer to his left ankle measuring 5.0 cm width, 4.0 cm length and 1.0 cm depth. Review of the physician's orders revealed a consult dated 01/21/22 for wound care to evaluate and treat, and an order dated 01/25/22 for body audits to be completed every Tuesday for skin observation. Further review of the physician's orders for Resident #36 revealed an order dated 01/21/22 to 02/06/22 to cleanse his left ankle with normal saline, pat dry, and apply foam dressing daily. Review of the physician's orders dated 01/21/22-01/22/22 revealed an order to cleanse coccyx wound with normal saline, pat dry, and apply clean dry foam dressing daily. An order dated 01/22/22 to 01/23/22, to cleanse coccyx wound with normal saline, pat dry apply clean dry foam dressing, change every 72 hours, and as needed if dressing soiled, loose, or off. An order dated 01/23/22 to 02/06/22, to cleanse coccyx wound with normal saline, pat dry, apply adhesive foam dressing daily, dressing is to be changed twice daily due to incontinence and as needed if dressing is soiled or dislodged. Review of the treatment administration record (TAR) for January 2022 revealed Resident #36 had a body audit completed, no review or measurements of the coccyx or left ankle pressure ulcers were documented. Review of the medical record revealed no evidence of weekly skin grid assessments including (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365330 If continuation sheet Page 9 of 22 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 365330 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Wauseon 303 W Leggett St Wauseon, OH 43567 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 measurements and staging of pressure sores between 01/20/22 and 02/03/22. Level of Harm - Actual harm Review of the Weekly Skin assessment dated [DATE] revealed no measurements of the coccyx or left ankle pressure ulcers. Residents Affected - Few Review of the Skin Grid Pressure assessment for Resident #36 dated 02/04/22 revealed his coccyx pressure ulcer increased, measured 7 cm length, 10 cm width, the depth was unable to be determined, and the wound had declined and was Unstageable. Review of the Skin Grid Pressure assessment for Resident #36 dated 02/04/22 revealed his left ankle pressure ulcer measured 2.5 cm length, 1.5 cm width, the depth was unable to be determined, and the wound had declined and was Unstageable. Interview on 02/16/22 at 11:44 A.M., with the Assistant Director of Nursing (ADON) #61, revealed Skin Grid assessments were expected to be completed once weekly by staff nurses, and verified no Skin Grid assessments were completed for Resident #36 between 01/20/22 and 02/03/22. Further interview revealed the physician was notified regarding the worsened pressure ulcers on 02/04/22, and no orders were received from the physician before Resident #36 discharged to the hospital on [DATE]. ADON #61 stated the Wound Care Nurse visited the facility once every two weeks and was unable to visit the resident on her scheduled day due to inclement weather. Observation and staff interview on 02/16/22 at 2:46 P.M., of wound care to Resident #36 by Licensed Practical Nurse (LPN) #38 revealed a coccyx wound that was uncovered due to staff removing during incontinence care due to soilage. The wound had no odor, and the pressure ulcer was about the size of a peach that was last measured at 7 cm length, 10 cm width, and the depth was unable to be determined. The wound bed was pink around the edges and had a moderate amount of tan/gray slough in the center. The wound was cleansed with wound cleanser and patted dry and then covered with a foam dressing and was dated and initialed. LPN #38 was assisted by State Tested Nurse Aide (STNA) #39. Resident #36 remained comfortable throughout the procedure and had a low air loss mattress to the bed. Review of the policy titled, Prevention of Pressure Injuries, revised April 2020, revealed the facility would perform risk skin assessments weekly for existing pressure injury risk factors. Further review of the policy revealed the facility would evaluate, report and document potential changes in the skin, and review the interventions and strategies for effectiveness on an ongoing basis. Review of the National Pressure Injury Advisory Panel Stages revealed a Stage 2 Pressure Injury was described as: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink, or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). An Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) on the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365330 If continuation sheet Page 10 of 22 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 365330 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Wauseon 303 W Leggett St Wauseon, OH 43567 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 heel or ischemic limb should not be softened or removed. Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365330 If continuation sheet Page 11 of 22 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 365330 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Wauseon 303 W Leggett St Wauseon, OH 43567 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and policy review, the facility failed to ensure a resident received hydration per physician orders for tube feeding flushes. This affected one (#36) of one resident reviewed for hydration. The facility census was 39. Residents Affected - Few Findings include: Review of the medical record for Resident #36 revealed an admission date of 01/20/22 and medical diagnoses of cerebral infarction, type 2 Diabetes Mellitus, dysphagia, persistent vegetative state, and cognitive communication deficit. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #36 was in a persistent vegetative state, required extensive assistance of two staff for bed mobility, toileting, and personal hygiene, and was totally dependent for eating. Review of the physician orders for Resident #36 revealed an order dated 02/11/22 for enteral feed every shift for nutrition 80 milliliters (mL) per hour continuous infusion, flush with 40 mL per hour. Further review revealed a diet order dated 02/11/22 for nothing by mouth (NPO). Review of the care plan revealed Resident #36 had a potential for altered nutrition and hydration, a potential for unplanned weight loss and increased needs for wounds. Interventions included flushes as ordered. Observations on 02/14/22 at 6:24 P.M., 02/15/22 at 6:44 A.M. and 9:28 A.M., and 1:20 P.M. revealed Resident #36's tube feeding pump display read flush 40 milliliters (mL) every zero hours. Observations on 02/15/22 at 6:44 A.M. and 9:28 A.M., and 1:20 P.M., revealed Resident #36's flush bag contained 950 mL, and was dated 02/15/22 at 12:00 A.M. Interview on 02/15/22 at 1:50 P.M., with Licensed Practical Nurse (LPN) #6 revealed the flush bags were filled once daily with water during night shift. Further interview revealed Resident #36 had orders to receive flushes of 40 mL per hour. Observation at that time confirmed Resident #36's flush bag contained 950 mL, and the tube feeding pump display read flush 40 mL every zero hours. Continued interview with LPN #6 revealed Resident #36 should have received approximately 500 mL between 12:00 A.M. and 1:50 P.M. and his flush bag contained 950 mL. Review of the facility policy titled Resident Hydration and Prevention of Dehydration, revised October 2017, revealed nursing would monitor fluid intake. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365330 If continuation sheet Page 12 of 22 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 365330 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Wauseon 303 W Leggett St Wauseon, OH 43567 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and review of the dialysis agreement, the facility failed to ensure communication to correlate care was provided by the dialysis clinic for residents receiving hemodialysis. This affected one (#9) of one resident reviewed for hemodialysis. The facility identified two residents on hemodialysis. The facility census was 39. Residents Affected - Few Findings include: Review of the medical record for Resident #9 revealed an admission date of 06/29/20 and medical diagnoses of end stage renal disease, type 2 Diabetes Mellitus, and dependence on renal dialysis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 had intact cognition. Resident #9 required supervision with setup help only for transfers, walking, eating, toileting and hygiene. Review of the progress notes revealed no documentation the facility received updates from the dialysis clinic. Review of the hemodialysis communication book for Resident #9 revealed no communication sheets from the dialysis clinic. Interview on 02/16/22 at 10:21 A.M., with the Director of Nursing (DON) revealed the dialysis center does not consistently send a return communication. Interview on 02/17/22 at 8:45 A.M., with the DON confirmed the progress notes for Resident #9 contained no documentation of communication from the dialysis clinic regarding his treatment. Review of the agreement titled Nursing Home Dialysis Transfer Agreement, signed 08/12/19, revealed the dialysis center shall provide the facility information on aspects of the management of a designated resident's care related to the provision of dialysis services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365330 If continuation sheet Page 13 of 22 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 365330 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Wauseon 303 W Leggett St Wauseon, OH 43567 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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on review of staff schedules, staff on duty hours daily postings, staff timecards and staff interviews, the facility failed to ensure a Registered Nurse (RN) was on duty for eight hours a day seven days a week. This has the potential to affect 39 of 39 residents in the facility. The census is 39. Findings include: Review on 02/15/22 at 9:00 A.M., of the staff schedules for 02/12/22 revealed no RN was scheduled to work. Registered Nurse (RN) #56 was scheduled from 2:30 A.M. until 6:30 A.M. on 02/13/22. Further review of staff schedules for Sunday, 02/13/22 revealed one (RN) #39 scheduled from 6:30 A.M. until 12:30 P.M. Review of staff on duty hour postings on 02/15/22 at 9:05 A.M., revealed zero registered nurse hours on Saturday, 02/12/22 and six register nurse hours on Sunday, 02/13/22. Review of timecard on 02/16/22 at 8:48 A.M., for RN #56 revealed a clocked in at 2:58 A.M. on 02/13/22 and clocked out at 7:09 A.M. on 02/13/22 for a total of 4.08 hours. Review of timecard on 02/16/22 at 8:50 A.M., for RN #39 revealed a clocked in on 02/13/22 at 6:29 A.M. and clocked out at 11:59 A.M. for a total of 6.53 hours. Interview on 02/15/22 at 4:25 P.M., with the Director of Nursing #13 confirmed there was not a RN on duty for Saturday, 02/12/22 for eight hours. Interview on 02/15/22 at 4:28 P.M., with Administrator #48 verified there was not a RN on duty for Saturday, 02/12/22. Interview with Business Office Manager #4 verified staffing schedules are for a twenty-four-hour period, 6:30 A.M. through 6:30 A.M. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365330 If continuation sheet Page 14 of 22 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 365330 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Wauseon 303 W Leggett St Wauseon, OH 43567 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 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on review of staff schedules, staff on duty hours daily postings, staff timecards and staff interviews, the facility failed to ensure the staffing information posted on the staff on duty hours was accurately reported. This has the potential to affect 39 of 39 residents in the facility. The census is 39. Residents Affected - Many Findings include: Review on 02/15/22 at 9:00 A.M., of the staff schedules for 02/12/22 revealed no Registered Nurse (RN) was scheduled to work. (RN) #56 was scheduled from 2:30 A.M. until 6:30 A.M. on 02/13/22. Further review of staff schedules for Sunday, 02/13/22 revealed one (RN) #39 scheduled from 6:30 A.M. until 12:30 P.M. Review of staff on duty hour postings on 02/15/22 at 9:05 A.M., revealed zero registered nurse hours on Saturday, 02/12/22 and six register nurse hours on Sunday, 02/13/22. Review of timecard on 02/16/22 at 8:48 A.M., for RN #56 revealed a clocked in at 2:58 A.M. on 02/13/22 and clocked out at 7:09 A.M. on 02/13/22 for a total of 4.08 hours. Review of timecard on 02/16/22 at 8:50 A.M., for RN #39 revealed a clocked in on 02/13/22 at 6:29 A.M. and clocked out at 11:59 A.M. for a total of 6.53 hours. Interview on 02/15/22 at 4:25 P.M., with the Director of Nursing #13 confirmed there was not a RN on duty for Saturday, 02/12/22 for eight hours. Interview with the Administrator on 02/15/22 at 4:28 P.M., verified there was no RN hours for Saturday, 02/12/22 and only six RN hours for Sunday, 02/13/22 posted. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365330 If continuation sheet Page 15 of 22 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 365330 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Wauseon 303 W Leggett St Wauseon, OH 43567 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident record review and staff interview, the facility failed ensure medication was timely administer as ordered by the physician. This affected one (#338) of six residents reviewed for unnecessary medication. The census was 39. Findings include: Review of the medical record for Resident #338 revealed the resident was admitted to the facility on [DATE]. Diagnoses include respiratory failure, Diabetes Mellitus type two, and hypertension. Review of the hospital discharge instructions dated 01/26/22, revealed the Resident #338 was admitted to the facility with orders to receive the following medication on 01/26/22: famotidine 20 milligram (mg) tablet at 9:00 P.M. and insulin glargine 35 units subcutaneous as directed. Review of the medical record for Resident #338 revealed the resident was admitted to the facility on [DATE] at approximately 4:20 P.M. Review of the medication administration record (MAR) dated January 2022, revealed an order for famotidine table 20 mg give one tablet by mouth every morning and at bedtime for indigestion and lantus solution (insulin glargine) 100 units per milliliter (ml) inject 35 units subcutaneously every morning and at bedtime for Diabetes Mellitus. Review of the MAR revealed no evidence of famotidine and lantus being administered on 01/26/22 at bedtime. Review of the facility's medication inventory on hand supply list revealed the medication lantus was available in the medication supply for resident use. The medication famotidine was not on the emergency medication supply list. Interview on 02/17/22 at 8:35 A.M., with the Director of Nursing (DON) revealed it was the facility's expectation, if a medication was ordered and not yet delivered from the pharmacy, the medication would be obtained from the medication inventory on hand supply. The DON verified the medication famotidine and lantus were ordered to be administered to Resident #338 on 01/26/22 at bedtime. The DON verified the medication was not administered as ordered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365330 If continuation sheet Page 16 of 22 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 365330 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Wauseon 303 W Leggett St Wauseon, OH 43567 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 - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and policy review, the facility failed to ensure as needed (PRN) psychotropic medications had a stop date after 14 days of use. This affected one (#13) of five sampled residents reviewed for unnecessary medications. The facility identified 18 residents that receive psychotropic medications. The facility census was 39. Findings include: Review of the medical record revealed an admission date of 12/09/20. Diagnoses included chronic obstructive pulmonary disease with acute exacerbation, emphysema, essential hypertension, anxiety disorder, major depressive disorder, recurrent, urinary incontinence, and gastro-esophageal reflux disease without esophagitis. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 had moderate cognitive impairment. No behaviors were exhibited during the assessment period. Resident received antipsychotic, antianxiety, and opioids seven days during the assessment period and diuretics three days during the assessment period. Antipsychotics were received on a routine basis only. A gradual dose reduction has been attempted with the date of last attempt: 07/16/21. Review of the care plan dated 12/10/22 revealed Resident #13 had impaired cognitive function/altered thought process related to low oxygen saturation due to end stage chronic obstructive pulmonary disease and emphysema. Interventions included: administer medications as ordered. Monitor/document for side effects and effectiveness. Ask yes/no questions in order to determine the resident's needs. Communicate with the resident/family/caregivers regarding residents capabilities and needs. Use the resident preferred name, identify yourself at each interaction. Face the resident when speaking and make eye contact. Reduce any distractions. Cue, reorient and supervise as needed. Discuss concerns about confusion, disease process, Nursing Home placement with resident/family/caregiver. Present just one thought, idea, question or command at a time. Provide a program of activities that accommodates the resident's abilities. I am at risk of psychotropic medication side effects because I take PRN and routine anxiolytic for anxiety, have depression with risk of antidepressant administration/initiation, routine use of antipsychotic medication. Administer psychotropic medications as ordered by physician. Monitor for side effects. Review of the physician orders revealed an order dated 10/21/21-11/11/21 for ativan one milligram (mg) every four hours as needed; 11/11/21 ativan one mg tablet every six hours and every two hours as needed and on 12/14/21-02/15/22 ativan one mg one tablet every two hours PRN. Interview on 02/17/22 at 8:25 A.M., with the Director of Nursing verified the resident did not have a stop date for PRN ativan and was not evaluated by the physician to see if the medication needed continued. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365330 If continuation sheet Page 17 of 22 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 365330 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Wauseon 303 W Leggett St Wauseon, OH 43567 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 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. Based on observation, staff interviews, review of dietary spreadsheets, and review of facility policies, the facility failed to prepare and serve pureed foods in a manner to maintain nutritional value. This affected five (#3, #4, #20, #28, and #287) of five residents on a pureed diet. The facility census was 39. Findings include: Observation on 02/15/22 at 11:04 A.M., revealed the [NAME] #60 placed five Salisbury steaks in a food processor and used an unknown amount of water to make pureed meat. Interview at that time of the observation, with the [NAME] #60, revealed there were six residents on a pureed diet, and he confirmed he used five Salisbury steaks, not one for each resident. Observation on 02/15/22 at approximately 11:35 A.M., revealed one resident on a pureed diet received double protein portions, and the [NAME] #60 provided two scoops of a two-ounce scoop of pureed Salisbury steak on the tray. Two additional residents were served one two-ounce scoop of pureed meat. Interview on 02/15/22 at 11:40 A.M., with the [NAME] #60 revealed he used a two-ounce scoop for the pureed meat portion. Interview on 02/16/22 at 3:44 P.M., with the Regional Culinary Services Manager #76 revealed nutritive liquids (broth, gravy, or milk) should be used to thin pureed foods. Further interview revealed using water to thin foods would decrease the nutritive value. Review of the Diet Spreadsheet revealed a single serving of the Salisbury steak puree portion should be four to five-ounces. Interview on 02/17/22 at 8:40 A.M.,with the [NAME] #60 confirmed the portion size listed in the Diet Spreadsheet for pureed Salisbury steak on 02/15/22, was four to five ounces. Review of the policy titled, Portion Control, updated 03/07/21, revealed individuals will receive the appropriate portions of food as outlined on the menu spreadsheets. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365330 If continuation sheet Page 18 of 22 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 365330 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Wauseon 303 W Leggett St Wauseon, OH 43567 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 observations, staff interviews, infection control log reviews and review of policies, the facility failed to store, prepare, and distribute foods in a safe, sanitary manner. This affected 38 of 38 residents who received food from the kitchen. The facility identified one (#36) resident had an order for nothing by mouth. The facility census was 39. Findings include: Observation on 02/14/22 at 9:26 A.M., revealed the reach-in refrigerator contained a container of chili dated 01/27/22, and a container of chili with meat dated 01/30/22, and an undated Styrofoam container of cupcakes. Interview at the time of the observation, with the [NAME] #60, confirmed the chili was beyond its use-by date and the cupcakes were undated. Observation on 02/14/22 at 9:31 A.M., revealed a box of sprouting and rotted red skinned potatoes in the dry storage area. Interview at the time of the observation, with the [NAME] #29, confirmed the potatoes were sprouting and rotted. Observation on 02/14/22 at approximately 9:34 A.M. revealed four and a half gallons of chocolate milk labeled best if used by 02/11/22. Interview at the time of the observation, with [NAME] #29, confirmed the chocolate milk was past its best if used by date. Observation on 02/15/22 at 11:03 A.M., revealed [NAME] #60 used a thermometer to check the temperature of Salisbury steak, zucchini, and mashed potatoes without sanitizing it between food items. Observation on 02/15/22 at 11:10 A.M., revealed [NAME] #60 pureed Salisbury steak in the food processor. After removing the pureed Salisbury steak, the [NAME] #60 rinsed the food processor container and blade off with water using a spray nozzle. The [NAME] #60 then filled the food processor with zucchini. Interview at the time of the observation, with [NAME] #60 confirmed he used only water to rinse the food processor and confirmed remnants of Salisbury steak remained in the food processor with the zucchini. Further observation revealed the [NAME] #60 proceeded to use the contaminated food processor to puree the zucchini, then placed the contaminated pureed zucchini on the steam table in preparation for food service. Interview on 02/15/22 at 11:22 A.M., with [NAME] #60 confirmed he did not sanitize the thermometer between uses, and revealed no sanitizer wipes were available in the kitchen. Observation on 02/15/22 at 11:40 A.M., revealed [NAME] #60 served the contaminated zucchini to residents on a pureed diet. Observation on 02/16/22 at approximately 9:25 A.M., revealed [NAME] #29 using the three compartment sink to wash containers used for food distribution. The wash compartment contained soapy water, the rinse compartment contained clear water, and the sanitizer compartment was empty. [NAME] #29 washed, rinsed, and placed the dishes in the empty sanitizer compartment to dry. Observation on 02/16/22 at 9:30 A.M., revealed [NAME] #29 collected wet dishes from the empty (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365330 If continuation sheet Page 19 of 22 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 365330 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Wauseon 303 W Leggett St Wauseon, OH 43567 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 sanitizer compartment and put them away on a shelf. Interview at the time of the observation, with [NAME] #29 revealed the sanitizer compartment of the sink did not hold water due to a defect with the drain. Further interview with [NAME] #29 confirmed she did not sanitize the dishes before putting them away while they were still wet. Interview on 02/16/22 at approximately 9:33 A.M., with [NAME] #60 revealed the sanitizer sink would hold water, the drain had to be manually held open to drain the sink. Interview on 02/17/22 at 7:45 A.M., with the Maintenance Supervisor #68 revealed he was aware of the problem with the three compartment sink in the kitchen. He verified the sanitizer compartment will hold water, though it must be manually drained. Review of the infection control logs reveled there have been no food born related illness in the facility. Review of the policy titled, Taking Accurate Temperatures, updated 03/07/21, revealed a clean, rinsed, sanitized, and air-dried thermometer is needed to take temperatures. Review of the policy titled, General Food Preparation and Handling, updated 03/07/21, revealed all food service equipment should be cleaned, sanitized, air-dried, and reassembled after each use. Review of the policy titled, Food Storage, updated 03/07/21, revealed date marking will be visible on all high-risk food to indicate the date by which a ready-to-eat food should be consumed or discarded, and leftover food shall be dated and used within three days or discarded. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365330 If continuation sheet Page 20 of 22 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 365330 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Wauseon 303 W Leggett St Wauseon, OH 43567 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 0838 Level of Harm - Potential for minimal harm Residents Affected - Many Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Based on record review and staff interview, the facility failed to annually review and update the facility assessment to determine what resources are necessary to care for its residents. This had the potential to affect 39 of 39 residents in the facility. The facility census was 39. Findings include: Review of the facility assessment revealed it had not been reviewed or updated since 10/29/18. Interview on 02/17/22 at 11:35 A.M., with the Administrator verified the facility had not conducted a review or update of the facility assessment since 10/29/18. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365330 If continuation sheet Page 21 of 22 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 365330 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Wauseon 303 W Leggett St Wauseon, OH 43567 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 the facility Legionella Control Risk Management Plan, staff interview and review of facility policy, the facility failed to monitor and implement control measures to prevent Legionella growth. This had the potential to affect 39 of 39 residents in the facility. The facility census was 39. Residents Affected - Many Findings include: Review of the facility risk management plan for Legionella Control, updated 11/2021, revealed thee facility identified pipe work with low flow in several areas and would flush the areas weekly. Also, the facility would monitor the hot water system, measure the temperature weekly and make adjustments if the temperature was below 140 degrees Fahrenheit. Additionally sink basin and shower heads would be cleaned monthly of scale and lime build up to ensure proper water flow. Furthermore the facility would test the water system for colony forming units (CFUs) of Legionella per milliliter of water. Interview on 02/16/22 at 2:51 P.M., with the Administrator verified the facility had not been flushing water in low flow areas, and had not monitored water temperatures of the hot water system. The Administrator also verified there was no documentation the facility had cleaned sink basin and shower heads to ensure proper water flow. The Administrator revealed the facility had not completed testing of the water system for Legionella. Review of the facility policy titled Legionella Water Management Program, dated 07/2017, revealed the purpose of the water management program was to identify areas in the water system where Legionella bacteria could grow and spread, and to reduce the risk of Legionnaire's disease. Further review of the policy revealed the facility would implement specific measures to control the introduction and/or spread of Legionella and monitor the effectiveness of the control measures. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365330 If continuation sheet Page 22 of 22