Inspection·June 14, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, staff interviews, and review of Resident Assessment Instrument (RAI) manual 3.0, the facility failed to develop a comprehensive care plan for one (Resident #51) of three residents reviewed for care plan development. The facility census was 73. Findings included: 1. Review of the medical record for Resident #51 revealed an admission date of 02/25/23 with medical diagnoses of chronic obstructive pulmonary disease (COPD), diabetes mellitus, congestive heart failure (CHF), major Depression, and chronic pain syndrome. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #51 was cognitively intact and required extensive assistance with bed mobility, transfers, dressing, toileting, and bathing. Further review revealed under the section, Care Area Assessment (CAA), revealed the facility would proceed with a care plan for Activities of Daily Living (ADLs), vision, communication, urinary incontinence, psychosocial well-being, and mood. Further review of the medical record revealed no documentation to support a person-centered care plan was developed to address Resident #51's ADLs, vision, communication, urinary incontinence, psychosocial well-being, and mood. Interview on 06/13/23 at 11:25 A.M. with Licensed Practical Nurse (LPN) #94 confirmed Resident #51 did not have person-centered comprehensive care plan to address ADLs, vision, communication, urinary incontinence, psychosocial well-being, and mood as indicated in the MDS. Interview on 06/13/23 at 11:49 A.M. with Director of Nursing (DON) stated the facility utilizes the RAI manual as their policy for comprehensive care plan development and implementation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365532 If continuation sheet Page 2 of 7 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 365532 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Greenville 243 Marion Drive Greenville, OH 45331 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 record review, resident and staff interviews, and policy review, the facility failed to provide showers/baths as scheduled. This affected one (Resident #6) of one resident reviewed for showers/bathing. The facility census was 73. Residents Affected - Few Findings included: Review of the medical record for Resident #6 revealed an admission date of 03/13/15 with medical diagnoses of hypertension, arthritis, and transient ischemic attack (TIA). Review of the quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #6 was cognitively intact and required extensive assistance with bed mobility, transfers, toileting and was dependent upon staff for bathing. Review of Resident #6's care plan revealed the resident had an ADL deficit related to physical limitations and arthritis. Interventions included assisting Resident #6 with bath/showers as needed. Further review of the medical record revealed Resident #6 was scheduled for bath/showers on Tuesdays and Fridays each week. Review of the physician progress note dated 01/30/23 at 10:10 P.M. revealed Resident #6 had a complaint related to missing her baths. Resident #6 reported she would get a rash underneath her breasts, which caused discomfort if she did not get her baths as scheduled. Review of shower sheets revealed Resident #6 received a bed bath on 05/11/23, 05/16/23, 05/25/23, 05/30/23, and 06/07/23, indicating the resident was not receiving a bath and/or shower twice a week as scheduled. Interview on 06/11/23 at 3:03 P.M. with Resident #6 revealed she was scheduled for bed bathes on Tuesdays and Fridays each week but did not receive them as scheduled. Interview on 06/13/23 at 2:10 P.M. the Director of Nursing (DON) confirmed Resident #6 did not receive her bed baths as scheduled. Review of the facilities activities of daily living policy revised March 2018, stated residents will be provided care, treatment and services as appropriate to maintain or improve their ability to carry out the ADLs. Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Services include assistance with bathing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365532 If continuation sheet Page 3 of 7 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 365532 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Greenville 243 Marion Drive Greenville, OH 45331 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 - Minimal harm or potential for actual harm Based on observations and staff interview, the facility failed to post daily staffing information as required. This had the potential to affect at 73 residents residing in the facility. The facility census was 73. Residents Affected - Many Findings included: Observations on 06/12/23 at 8:30 A.M., 06/13/23 at 7:30 A.M. and 06/14/23 at 7:50 A.M. revealed no evidence of daily staffing information posted in a prominent area visible to residents and visitors. Observation on 06/14/23 at 7:55 A.M. revealed a staffing schedule form posted on the back wall at the main nurse's station. The form was behind a four-foot-tall medical record chart rack, which was filled with resident charts. The form was not visible from the nurse's station counter. The form included the names of the nurses and aides working that day on each shift but did not have documentation to support the census or the total number of actual hours worked per shirt for licensed and unlicensed staff responsible for care. Interview on 06/14/23 at 7:59 A.M. with the Director of Nursing (DON) confirmed the facility did not have daily staffing information posted, which included the census, the total number of actual hours worked per shift for licensed and unlicensed staff responsible for care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365532 If continuation sheet Page 4 of 7 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 365532 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Greenville 243 Marion Drive Greenville, OH 45331 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed ensure the physican addressed pharmacy recommendations in a timely manner. This affected two (Residents #20 and #57) of five residents reviewed for phamacy recommendations. The facility census was 73. Findings: 1. Medical record review for Resident #20 revealed an admission date of 08/01/22. Diagnoses included chronic obstructive pulmonary disease, type II diabetes, moderate protein-calorie malnutrition, osteoarthritis, hyperlipidemia, occlusion and stenosis of carotid artery, peripheral vascular disease, gastroenteritis and colitis, major depressive disorder, anxiety disorder, and hypertension. Review of Resident #20's Minimum Data Set (MDS) assessment dated [DATE] revealed her Brief Interview for Mental Status (BIMS) score was 15, indicating she was cognitively intact. Resident #20 required supervision with eating and dressing, limited assistance with personal hygiene, and extensive assistance with toileting, bed mobility and transfers. Review of Resident #20's physician's orders revealed orders for Prozac (Selective Serotonin Reuptake Inhibitor [SSRI]) 30 milligrams, Zoloft (SSRI) 50 milligram and Mirtazapine (antidepressant) 7.5 milligrams, all prescribed for a diagnosis of depression. Review of Resident #20's pharmacy recommendations dated 08/22/22 revealed an irregularity with duplicate therapy of Zoloft and Prozac with a recommendation to discontinue one of the SSRIs immediately, to decrease risk of serotonin syndrome. There was no evidence the recommendation being reviewed, signed or addressed by the physician. There was an additional recommendation dated 01/24/23 recommending a trial reduction of Mirtazapine 7.5 milligrams, which also had no evidence of being reviewed, signed or addressed by the physician. Interview on 06/14/23 at 10:05 A.M. with the Director of Nursing (DON) verified Resident #20 had a pharmacy recommendation on 08/22/22 regarding duplicate therapy with two medications for depression and another recommendation 01/24/23 for a trial reduction of Mirtazapine, with neither recommendation addressed by the physician. The DON reported she asked the physician specifically about the recommendation for duplicate therapy and was told he would review the recommendation at the next visit, however he never reviewed the recommendation. 2. Medical record review for Resident #57 revealed he was initially admitted initially on 05/13/21 with re-entry 07/06/21. Diagnoses included encephalopathy, hypokalemia, hematuria, bipolar disorder, gastro-eosphgeal reflux disease, acute kidney failure, hyperosmolality and hypernatremia, major depressive disorder, hypertension, dementia, mild cognitive impairment and generalized anxiety disorder. Review of Resident #57's Minimum Data Set (MDS) assessment dated [DATE] revealed his Brief Interview for Mental Status (BIMS) score was not assessed as he was rarely understood. He required extensive assistance for eating and toileting and was totally dependent for dressing, personal care, bed mobility and transfers. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365532 If continuation sheet Page 5 of 7 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 365532 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Greenville 243 Marion Drive Greenville, OH 45331 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the Resident #57's physician's orders revealed an order for Ativan (medication used to treat anxiety) 0.5 miligrams. Give one tablet by mouth every four hours as needed for anxiety with a start date of 12/30/21. Review Resident #57's pharmacy reviews revealed a pharmacy recommendation dated 08/22/22 requesting a time frame for the as needed Ativan. There was no evidence the physician reviewed, signed, or addressed the recommendation. On 09/29/22, the pharmacy recommended a 14-day limit on the as needed Ativan. The physician reviewed the order on 10/03/23 and extended the medication and would re-evaluate in two months. Further review revealed on 10/27/22, the pharmacy recommended a 14-day limit on the as needed Ativan. There was no evidence the physician reviewed, signed, or addressed this recommendation. On 11/27/22, the pharmacist recommended discontinuing the as needed Ativan and the physician recommended no changes on 12/01/22. On 01/24/23, the pharmacy recommended either to discontinue the as needed Ativan or set a 14-day limit. There was no evidence the physician reviewed, signed, or addressed the recommendation. On 02/24/23, the pharmacy recommended discontinuing the as needed Ativan as it should be limited to 14-days. The physician did not review the recommendation until 04/13/23 at which time he chose to continue the order as written with no stop date. Interview on 06/14/23 at 10:05 A.M. with the Director of Nursing (DON) verified the physician had not timely addressed pharmacy recommendations related to Ativan and the 14-day limit on the as needed medications. Review of the policy for 'Tapering Medications and Gradual Drug Dose Reduction' revised April 2007 revealed after medications were ordered for a resident, the staff and practitioner should seek an appropriate dose and duration for each medication that minimizes the risk of the adverse consequences. All medications should be considered for possible tapering. Residents who used anti psychotic drugs should receive gradual does reductions. Tapering should be considered when the residents clinical condition had improved, target symptoms resolved, non-pharmacological interventions had been effective or the resident had not responded to the treatment. A Physician should review periodically whether current medications were still necessary in their current dose and order appropriate tapering of medications as indicated. Within the first year after a resident was admitted on an anti psychotic medication or after starting on an anti-psychotic medication a gradual dose reduction shall be attempted in two separate quarters unless clinically contraindicated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365532 If continuation sheet Page 6 of 7 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 365532 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Greenville 243 Marion Drive Greenville, OH 45331 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, staff interview, and policy review, the facility failed to ensure residents were offered the pneumococcal vaccine. This affected two (Residents #4 and #51) of the five reviewed for vaccinations. The facility census was 73. Residents Affected - Few Findings included: 1. Review of the medical record for Resident #4 revealed an admission date of 11/02/21 with medical diagnoses of Alzheimer's disease, hyperlipidemia, hypothyroidism, and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #4 had severe cognitive impairment and required extensive staff assistance with bed mobility, transfers, toileting, dressing, and was dependent upon staff for bathing. Further review of the medical record revealed no documentation to support Resident #4 received the pneumococcal vaccine. The medical record did not contain documentation to support the facility provided Resident #4 or the resident's representative with education regarding the pneumococcal vaccine or offered the pneumococcal vaccine. 2. Review of the medical record for Resident #51 revealed an admission date of 02/25/23 with medical diagnoses of chronic obstructive pulmonary disease, diabetes mellitus, convulsions, depression, hypertension, and chronic pain syndrome. Review of the quarterly MDS assessment dated [DATE] indicated Resident #51 was cognitively intact and required extensive staff assistance with bed mobility, transfers, dressing toileting and bathing. Further review of the medical record revealed no documentation to support Resident #51 received the pneumococcal vaccine. The medical record did not contain documentation to support the facility provided Resident #51 with education regarding the pneumococcal vaccine or offered the pneumococcal vaccine. Interview on 06/14/23 at 9:13 A.M. with Director of Nursing (DON) confirmed the medical records for Residents #4 and #51 did not contain documentation to support the facility offered education about or offered the pneumococcal vaccine to either resident. Review of the policy titled, Pneumococcal Vaccine, revised October 2019 stated all residents would be offered the pneumococcal vaccine to aid in preventing pneumonia/pneumococcal infections. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365532 If continuation sheet Page 7 of 7