Inspection visit
Inspection
9 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 9 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0580
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room,
etc.) that affect the resident.
Based on medical record review, interview and facility policy review, the facility failed to ensure one
resident's (#35) primary care physician was notified of blood glucose levels above physician ordered
parameters. This affected one resident (#35) of five residents reviewed for unnecessary medications. The
facility census was 71.
Findings Include:
Review of the medical record for Resident #35 revealed an initial admission date of 03/15/19 with the latest
readmission of 02/23/24 with the diagnoses including but not limited to diabetes mellitus with diabetic
neuropathy, obstructive sleep apnea, chronic obstructive pulmonary disease, protein calorie malnutrition,
vitamin D deficiency, hyperlipidemia, schizoaffective disorder bipolar type, congestive heart failure,
hypertension, anxiety disorder, major depressive disorder, chronic kidney disease, insomnia due to mental
disorder, post traumatic stress disorder, mood disorder and acquired absence of left leg below knee.
Review of the plan of care dated 03/25/19 revealed the resident had diabetes mellitus and neuropathy.
Interventions included but not limited to medication as ordered, monitor/document for side effects and
effectiveness, educate resident/family/caregivers as to the correct protocol for glucose monitoring.
Review of the plan of care dated 04/22/25 revealed the resident had no cognitive deficit. The assessment
indicated the resident received hypoglycemic medications.
Review of the resident's monthly physician orders for May 2025 identified orders dated 04/10/25 Insulin
Aspart FlexPen 100 units/milliliter (ml) subcutaneously per sliding scale before meals and at bedtime as
follows, 151 to 200 two units, 201 to 250 give four units, 251 to 300 give six units, 301 to 350 give eight
units 351 to 400 give 10 units, 401 to 500 give 12 units, blood sugar greater than 400 give 12 units and
notify physician and blood sugars less than 60 notify the physician.
Review of the resident's April 2025 Medication Administration Record (MAR) revealed on 04/13/25 at 6:30
A.M. the resident's blood glucose level was 413, on 04/20/25 at 4:00 P.M. the resident's blood glucose level
was 435, on 04/22/25 at 7:00 P.M. the resident's blood glucose level was 425 and on 04/28/25 at 7:00 P.M.
the resident's blood glucose level was 459.
Review of the resident's May 2025 MAR revealed on 05/01/25 at 7:00 P.M. the resident's blood glucose
level was 483, on 05/03/25 at 11:00 A.M. the resident's blood glucose level was 416, on 05/09/25 at 11:00
A.M. the resident's blood glucose level was 400 and on 05/12/25 at 6:30 A.M. the resident's
(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 10
Event ID:
365393
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
365393
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/29/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Ayden Healthcare of Jackson
8668 State Route 93
Jackson, OH 45640
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 0580
blood glucose level was 481.
Level of Harm - Minimal harm
or potential for actual harm
Review of the resident's medical record revealed no documented evidence the physician was notified of the
blood glucose levels above 400 in April 2025 and May 2025.
Residents Affected - Few
05/28/25 01:31 PM interview with the Director of Nursing (DON) #324 verified the physician was not notified
of the blood glucose levels above 400 as physician ordered in April 2025 and May 2025.
Review of the facility policy titled, Notification of Change, not dated revealed the facility must immediately
inform the resident, consult with the resident's physician and if known, notify the resident's legal
representative or an interested family member when there is a need to alter treatment. All change in
conditions and physician and family notifications need to be placed in the medical record.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365393
If continuation sheet
Page 2 of 10
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
365393
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/29/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Ayden Healthcare of Jackson
8668 State Route 93
Jackson, OH 45640
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 0641
Ensure each resident receives an accurate assessment.
Level of Harm - Minimal harm
or potential for actual harm
Based on interview and record review the facility failed to accurately code antipsychotic medication on the
Minimum Data Set (MDS) for Resident #7. This affected one resident (Resident #7) of 22 whose MDS was
reviewed. The facility census was 71.
Residents Affected - Few
Findings include:
Review of the medical record review for Resident #7 revealed an admission date of 10/30/06 with
diagnoses including schizophrenia, dementia, anxiety, moderate intellectual disability, major depressive
disorder, bipolar disorder type two, and delusional disorder.
Review of the physicians orders dated 05/25 revealed Resident #7 was prescribed and received zyprexa
(antipsychotic medication) 2.5 milligrams by mouth daily related to schizophrenia.
Review of the most recent MDS, a quarterly, dated 04/03/25 revealed Resident #7 had moderate cognitive
impairment with physical and verbal behaviors. Resident #7 diagnoses included schizophrenia, dementia,
anxiety, depression, bipolar disorder, and psychotic disorder. Resident #7 received antianxiety medication
and antidepressant medication. The MDS did not include the antipsychotic medication zyprexa.
Interview on 05/29/25 at 2:25 P.M. with the Director of Nursing confirmed the MDS was not coded
accurately to include the antipsychotic medication. The facility did not have a policy regarding completion of
the MDS. However, followed the Resident Assessment Instrument (RAI) manual.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365393
If continuation sheet
Page 3 of 10
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
365393
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/29/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Ayden Healthcare of Jackson
8668 State Route 93
Jackson, OH 45640
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 - Few
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
interview and record review the facility failed to complete the 48 hour baseline care plan to reflect the
trauma Resident #72 received from a recent motor vehicle accident. This affected one resident (Resident
#72) of nine reviewed for 48 hour baseline care plan. The facility census was 71.
Finding include:
Review of the medical record for Resident #72 revealed an admission date of 04/23/25 with diagnoses
including unspecified fracture of lower end of right radius (long bone of the forearm that runs along the side
of thumb and wrist), displaced trimalleolar fracture of right lower leg (ankle), unspecified fracture of right
patella (knee), depression, mood disorder, and anxiety.
Review of the physician orders dated 05/25 revealed Resident #72 was ordered and received ativan
(antianxiety medication) 0.5 milligrams (mg) by mouth every eight hours for anxiety, duloxetine
hydrochloride (antidepressant medication) 30 mg by mouth two times daily for depression and Amitriptyline
hydrochloride 25 mg by mouth at bedtime for depression.
Review of the most recent Minimum Data Set (MDS) Medicare five day admission revealed Resident #72
was cognitively intact with social isolation, verbal and physical behaviors. The diagnoses included on the
MDS included other fractures, depression and bipolar disorder. The assessment did not include post
traumatic stress disorder or trauma.
Review of the admission nursing assessment dated [DATE] revealed the trauma informed care section was
blank and not completed.
Review of the 48 hour baseline care plan dated 04/24/25 for Resident #72 revealed no plan of care
addressing trauma, triggers or interventions.
An interview on 05/29/25 at 11:00 A.M. revealed Resident #72 stated she was in a motor vehicle accident
and shattered her right leg, foot, hip and wrist. Resident #72 stated she had multiple screws and plates in
her leg and arm. Resident #72 stated she had residual emotions related to the accident. Resident #72
stated she was depressed, anxious and felt scared or fear inside of herself all the time. Resident #72 stated
loud noise would make it worse because she would think of the the other motor vehicle slamming in to hers.
An interview on 05/29/25 at 1:35 P.M. with Social Services Assistant (SSA) #465 confirmed she would not
complete a thorough trauma informed care assessment unless it was triggered by the nursing admission
assessment. SSA #465 also confirmed that a resident involved in a motor vehicle accident with serious
injuries, and resulting in nursing home placement, would need a trauma informed care assessment and
plan of care.
An interview on 05/29/25 at 1:44 P.M. with the Assistant Director of Nursing (ADON) #301 confirmed the
trauma informed care assessment was not completed on admission and did not trigger a plan of care.
The facility did not have a policy related to trauma informed care.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365393
If continuation sheet
Page 4 of 10
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
365393
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/29/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Ayden Healthcare of Jackson
8668 State Route 93
Jackson, OH 45640
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 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
interview and record review the facility failed to complete a comprehensive plan of care to reflect the trauma
Resident #72 received from a recent motor vehicle accident or identify the triggers. This affected one
(Resident #72) of 22 reviewed for plan of care. The facility census was 71.
Review of the medical record for Resident #72 revealed an admission date of 04/23/25 with diagnoses
including unspecified fracture of lower end of right radius (long bone of the forearm that runs along the side
of thumb and wrist), displaced trimalleolar fracture of right lower leg (ankle), unspecified fracture of right
patella (knee), depression, mood disorder and anxiety.
Review of the physician orders dated 05/25 revealed Resident #72 was ordered and received ativan
(antianxiety medication) 0.5 milligrams (mg) by mouth every eight hours for anxiety, duloxetine
hydrochloride (antidepressant medication) 30 mg by mouth two times daily for depression and Amitriptyline
hydrochloride 25 mg by mouth at bedtime for depression.
Review of the most recent Minimum Data Set (MDS) Medicare five day admission revealed Resident #72
was cognitively intact with social isolation, verbal and physical behaviors. The diagnoses included on the
MDS included other fractures, depression and bipolar disorder. The assessment did not include post
traumatic stress disorder or trauma.
Review of the admission nursing assessment dated [DATE] revealed the trauma informed care section was
blank and not completed.
Review of the plan of care for Resident #72 revealed no plan of care with causes of trauma, triggers or
interventions for treatment of trauma informed care related to motor vehicle accident causing Resident #72
admission to the nursing facility.
An interview on 05/29/25 at 11:00 A.M. revealed Resident #72 stated she was in a motor vehicle accident
and shattered her right leg, foot, hip and wrist. Resident #72 stated she had multiple screws and plates in
her leg and arm. Resident #72 stated she had residual emotions related to the accident. Resident #72
stated she was depressed, anxious and felt scared or fear inside of herself all the time. Resident #72 stated
loud noise would make it worse because she would think of the the other motor vehicle slamming in to hers.
An interview on 05/29/25 at 1:35 P.M. with Social Services Assistant (SSA) #465 confirmed that a resident
involved in a motor vehicle accident with serious injuries, and resulting in nursing home placement, would
need a trauma informed care assessment and plan of care.
An interview on 05/29/25 at 1:44 P.M. with the Assistant Director of Nursing (ADON) #301 confirmed the
trauma informed care plan of care was not completed for Resident #72.
The facility did not have a policy related to the development of the plan of care.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365393
If continuation sheet
Page 5 of 10
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
365393
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/29/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Ayden Healthcare of Jackson
8668 State Route 93
Jackson, OH 45640
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
medical record review, interview, and facility policy review, the facility failed to ensure quarterly care
conferences were conducted and the required departments were present at care conferences. This affected
six residents (#12, #14, #27, #31,#37 and #64) of eight residents reviewed for care planning. The facility
census was 71.
Findings Include:
1. Review of the medical record for Resident #12 revealed an initial admission date of 04/16/18 with the
latest readmission date of 12/10/24 with the diagnoses including but not limited to COPD, vitamin
deficiency, allergic rhinitis, protein calorie malnutrition, squamous cell carcinoma of skin of right upper limb
including shoulder, neoplasm of unspecified behavior of bone, soft tissue and skin, congestive heart failure,
peripheral vascular disease, diabetes mellitus, hypothyroidism, hyperlipidemia, dementia, hypertension,
chronic kidney disease and arthritis.
Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the
resident had a severe cognitive deficit.
Review of the medical record revealed the last care conference held was on 12/11/24. Further review of the
care conference revealed the only staff member who attended was the Assistant Director of Nursing
(ADON) #301.
On 05/27/25 at 4:27 P.M., interview with the resident's family member revealed the facility does not hold
quarterly care conferences.
2. Review of the medical record for Resident #14 revealed an initial admission date of 12/29/23 with the
latest readmission of 11/21/24 with the diagnoses including but not limited to chronic obstructive pulmonary
disease (COPD), insomnia, peripheral vertigo, constipation, major depressive disorder, diabetes mellitus
with diabetic neuropathy, hypertension, chronic pain, retention of urine, anxiety disorder, hyperlipidemia,
peripheral vascular disease, severe morbid obesity, asthma, lymphedema, dysphagia, sleep apnea, atrial
fibrillation and arthritis.
Review of the resident's quarterly MDS assessment dated [DATE] revealed the resident had no cognitive
deficit.
Review of the medical record revealed the last documented care conference was held on 01/24/24.
On 05/27/25 at 11:08 A.M., interview with the resident revealed he had not had a care conference in quite
some time.
3. Review of the medical record for Resident #64 revealed an initial admission date of 02/22/24 with the
latest readmission of 12/01/24 with the diagnoses including but not limited to metabolic encephalopathy,
dementia with agitation, Parkinsonism, chronic respirator failure, COPD, diabetes mellitus, obesity,
osteoarthritis, anxiety disorder, atypical atrial flutter, anemia, atrial fibrillation, fatty liver, degenerative
disorders of nervous system, depression, sleep apnea, hypertension, chronic kidney disease, congestive
heart failure and Parkinson's disease.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365393
If continuation sheet
Page 6 of 10
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
365393
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/29/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Ayden Healthcare of Jackson
8668 State Route 93
Jackson, OH 45640
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 resident's significant change MDS assessment dated [DATE] revealed the resident had no
cognitive deficit.
Review of the medical record revealed the last care conference the facility held was on 07/01/24 and all
required disciplines were not present during the care conference.
Residents Affected - Some
4. Review of the medical record for Resident #31 revealed an admission date of 02/23/23 and readmission
date of 06/23/23 with diagnoses including vascular dementia, peripheral vascular disease, chronic kidney
disease stage three, depression, diabetes mellitus type two, hypertension and anxiety.
Review of the most recent annual Minimum Data Set (MDS) dated [DATE] revealed Resident #31 had
moderate cognitive impairment with no behaviors.
The nursing progress notes were silent related to care conference meetings with resident, staff and or
representative on a quarterly basis.
An interview on 05/27/25 at 3:11 P.M. with Resident #31 revealed she did not recall any discussion about
her care or a care conference meeting with the staff and herself.
5. Review of the medical record for Resident #37 revealed an admission date of 07/29/19 with diagnoses
including paraplegia, sleep apneas, Parkinson's disease, hypothyroidism, morbid obesity and diabetes
mellitus type two.
Review of the most recent annual MDS dated [DATE] revealed Resident #37 was cognitively intact with
rejection of care behaviors.
The nursing progress notes were silent related to care conference meetings with resident, staff and or
representative on a quarterly basis.
An interview on 05/27/25 at 3:11 P.M. with Resident #37 revealed she did not recall any discussion about
her care or a care conference meeting with the staff and herself.
6. Review of the medical record for Resident #27 reveals an admission date of 01/31/25 with diagnoses
including severe protein-calorie malnutrition and adult failure to thrive.
Review of the quarterly MDS assessment for Resident #27 dated 04/25/25 revealed the resident had intact
cognition.
Review of the electronic medical record for Resident #27 revealed no documentation of care conferences.
Interview on 05/27/25 at 2:00 P.M. reveals Resident #27 does not recall ever having a meeting with social
services and care providers about care plan.
Interview with Social Services Director #465 on 05/29/25 at 08:36 AM revealed she does an annual care
conference and then documents in the progress notes if she had spoke to the family or residents about
anything. She said she was not aware they needed to be completed quarterly. She verified all required
disciplines were not present during the care conference.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365393
If continuation sheet
Page 7 of 10
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
365393
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/29/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Ayden Healthcare of Jackson
8668 State Route 93
Jackson, OH 45640
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 facility policy titled, Care Conferences, last revised 01/2020 revealed care conferences will be
scheduled to include the resident, resident representative, and interdisciplinary team (IDT) as soon as
possible after admission, routinely and with a change in condition.
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365393
If continuation sheet
Page 8 of 10
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
365393
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/29/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Ayden Healthcare of Jackson
8668 State Route 93
Jackson, OH 45640
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
Based on observation, medical record review and interviews, the facility failed to ensure one resident (#62)
skin interventions were in place as physician ordered. This affected one (Resident #62) of one resident
reviewed for skin conditions. The facility census was 71.
Residents Affected - Few
Findings Include:
Review of the medical record for Resident #62 revealed an initial admission date of 04/27/24 with the
diagnoses including but not limited to nontraumatic intracranial hemorrhage, Parkinsonism, protein calorie
malnutrition, vitamin D deficiency, insomnia, depression, constipation, hyperlipidemia, cerebral infarction,
hypertension, malaise, chronic obstructive pulmonary disease (COPD), anemia and asthma.
Review of the plan of care dated 04/26/24 revealed the resident had the potential impairment to skin
integrity related to debility, anemia,intracranial hemorrhage, impaired mobility and COPD. Interventions
included avoid scratching and keep hands and body parts from excessive moisture, keep fingernails short,
monitor for side effects of the antibiotics and over-the-counter pain medications: gastric distress, rash, or
allergic reactions which could exacerbate skin injury, monitor/document location, size and treatment of skin
injury, report abnormalities, failure to heal, signs/symptoms of infection, maceration to physician and weekly
treatment documentation to include measurement of each area of skin breakdown's width, length, depth,
type of tissue and exudate and any other notable changes or observations.
Review of the resident's monthly physician orders for May 2025 identified an order dated 10/03/24 tubigrip
(provides continuous support for the management of strains, sprains, and swelling) to right hand/arm daily
for comfort on in am and off in pm.
Review of the resident's May 2025 Treatment Administration Record (TAR) revealed on 05/28/25 the TAR
was initialed by Licensed Practical Nurse (LPN) #344 the tubigrip was in place.
On 05/27/25 at 3:18 P.M., observation of Resident #62 revealed the resident did not have the physician
ordered tubigrip in place to his right arm.
On 05/28/25 at 12:36 P.M., interview and observation of the resident revealed he did not have the tubigrip
to his right arm in place and the facility had not provided the tubigrib for him to utilize.
On 05/28/25 at 12:39 P.M., interview with Certified Nursing Assistant (CNA) #501 and #545 revealed the
CNA had never seen the resident with a tubigrip to his right arm and was unsure when it was supposed to
be in place.
On 05/28/25 at 12:46 P.M., interview and observation with Licensed Practical Nurse (LPN) #344 verified the
tubigrip was not in place to the resident's right arm and the tubigrip could not be located in his room to be
placed on.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365393
If continuation sheet
Page 9 of 10
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
365393
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/29/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Ayden Healthcare of Jackson
8668 State Route 93
Jackson, OH 45640
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 0699
Provide care or services that was trauma informed and/or culturally competent.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review revealed the facility failed to ensure trauma was identified and assessed for
causes and potential triggers. This affected one (Resident #72) of two residents reviewed for trauma
informed care. The facility census was 71.
Residents Affected - Few
Findings include:
Review of the medical record for Resident #72 revealed an admission date of 04/23/25 with diagnoses
including unspecified fracture of lower end of right radius (long bone of the forearm that runs along the side
of thumb and wrist), displaced trimalleolar fracture of right lower leg (ankle), unspecified fracture of right
patella (knee), depression, mood disorder and anxiety.
Review of the physician orders dated 05/25 revealed Resident #72 was ordered and received ativan
(antianxiety medication) 0.5 milligrams (mg) by mouth every eight hours for anxiety, duloxetine
hydrochloride (antidepressant medication) 30 mg by mouth two times daily for depression and Amitriptyline
hydrochloride 25 mg by mouth at bedtime for depression.
Review of the most recent Minimum Data Set (MDS) Medicare five day admission revealed Resident #72
was cognitively intact with social isolation, verbal and physical behaviors. Resident #72 required assistance
to complete activities of daily living. The diagnoses included on the MDS included other fractures,
depression and bipolar disorder. The assessment did not include post traumatic stress disorder or trauma.
Review of the admission nursing assessment dated [DATE] revealed the trauma informed care section was
blank and not completed.
Review of the plan of care for Resident #72 revealed no plan of care with causes of trauma, triggers or
interventions for treatment of trauma informed care related to motor vehicle accident causing Resident #72
admission to the nursing facility.
An interview on 05/29/25 at 11:00 A.M. revealed Resident #72 stated she was in a motor vehicle accident
and shattered her right leg, foot, hip and wrist. Resident #72 stated she had multiple screws and plates in
her leg and arm. Resident #72 stated she had residual emotions related to the accident. Resident #72
stated she was depressed, anxious and felt scared or fear inside of herself all the time. Resident #72 stated
loud noise would make it worse because she would think of the the other motor vehicle slamming in to hers.
An interview on 05/29/25 at 1:35 P.M. with Social Services Assistant (SSA) #465 confirmed that a resident
involved in a motor vehicle accident with serious injuries, and resulting in nursing home placement, would
need a trauma informed care assessment and plan of care. SSA #465 also confirmed Resident #72 was
not assessed for trauma informed care.
An interview on 05/29/25 at 1:44 P.M. with the Assistant Director of Nursing (ADON) #301 confirmed the
trauma informed care plan of care was not completed for Resident #72.
The facility did not have a policy related to trauma informed care.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365393
If continuation sheet
Page 10 of 10
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Back to topCitations
9 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0351GeneralS&S Epotential for harm
Install an approved automatic sprinkler system.
F655 - Comprehensive Person-Centered Care Planning
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
- 0039GeneralS&S Fpotential for harm
Conduct testing and exercise requirements.
F580 - Notification of Changes
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F699 - Trauma-informed care
Provide care or services that was trauma informed and/or culturally competent.
FAQ · About this visit
Common questions about this visit
What happened during the May 29, 2025 survey of AYDEN HEALTHCARE OF JACKSON?
This was a inspection survey of AYDEN HEALTHCARE OF JACKSON on May 29, 2025. The surveyor cited 9 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at AYDEN HEALTHCARE OF JACKSON on May 29, 2025?
Yes, 9 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Install an approved automatic sprinkler system."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.