Inspection·December 21, 2023

F 0684 condition. Level of Harm - Immediate jeopardy to resident health or safety • Residents Affected - Few • On [DATE] at approximately 7:00 P.M., the DON notified MD #500 and reviewed the findings with him. On [DATE] at approximately 9:45 A.M., LPN #200 was suspended pending the completion of the investigation. • On [DATE] at approximately 10:00 A.M., the DON notified Director of Clinical Services (DCS) #550 and DCS #550 gave directives for auditing like residents, auditing notification of physician, education to be given to all licensed nurses and nurse aides, auditing change of condition of all residents, auditing that nurse assessments being completed and physician notification made as applicable. • On [DATE] at approximately 10:15 A.M., and continued [DATE], State Tested Nursing Assistants (STNA) and licensed nurses were verbally educated on nursing assessment, reporting of resident refusal of care and decline/change in condition, physician notification of resident decline/change in condition, and documentation standards by the DON. A group/formal in-service was scheduled to be conducted on [DATE] by the DON. • On [DATE] at approximately 11:15 A.M., DCS #550 arrived at the facility and assisted with the review of documentation, interviewing employees, and meeting with MD #500 via phone. Investigation ongoing; nurse in question (LPN #200) remains suspended pending conclusion of investigation. • On [DATE], the DON reviewed all residents on North Hall, to identify any resident that was acutely ill and could suffer serious outcome. Medical records were reviewed to validate that all residents had been assessed and to identify any resident that may have warranted the physician being notified. • On [DATE], an impromptu Quality Assurance and Performance Improvement (QAPI) meeting was held with the Administrator, MD #500, the DON, Human Resource Director (HRD) #350, and DCS #550 regarding Resident #75, and the lack of physician notification by LPN #200 on [DATE]. MD #500 did not have any further recommendations. • On [DATE] and ongoing daily, the DON and/or the Assistant DON (ADON) or designee, will continue to review the 24-hour shift change report as well as the 24-hour clinical report to identify residents (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365532 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 365532 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few that may have had a change in condition. For those residents identified as having a change in condition, the DON/ADON/designee will monitor that residents are being assessed and physician notified as appropriate. • Monitoring will occur five times a week for four weeks and then randomly thereafter, the DON/ADON/designee will conduct rounds on all units to identify residents that may have a change in condition. If any residents are identified as declining in condition, a review of the medical record documentation will be conducted to validate assessment by a nurse and the physician has been notified if appropriate. • Audit results will be submitted to the QAPI committee on an ongoing basis, as needed, for further recommendations. • On [DATE], an in-service was conducted by the DON on chain of command, walking rounds, reporting to nurse, vital signs, reporting any resident refusals of care and significant change, and documenting all incidents with all nursing staff including STNAs and all licensed nurses and was completed on [DATE]. • On [DATE], the medical records for three additional residents (#14, #59 and #85) were reviewed for changes in condition and/or death, with no concerns noted. • Interview on [DATE] at 3:20 P.M. with Residents # 09, #14 and #59, who had condition changes, revealed no concerns regarding the staff care and treatment pertaining to timely nurse assessments. • Observation on [DATE] at 2:48 P.M. revealed STNA #62 obtaining and reporting vitals of residents on the Main Unit to LPN #65. • On [DATE] at 8:30 A.M., from 1:38 P.M through 3:10 P.M., interviews with LPN #65, LPN #90, LPN #70, Registered Nurse (RN) #80, STNA #50, STNA #55, STNA #60, and STNA #62, stated they received education on notification of changes and re-assessing residents. Findings Include: Review of the closed medical record for Resident #75 revealed the resident was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. The resident expired at the hospital on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365532 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 365532 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few [DATE]. Diagnoses for Resident #75 include malignant neoplasm of rectum with colon resection surgery on [DATE], diabetes, morbid obesity, chronic kidney disease, and heart failure. The resident was a Full Code status. Review of the Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed the resident had intact cognition and required partial assistance for mobility, and extensive assistance for toileting and bathing. Review of handwritten nurses ' notes, listed as late entry for [DATE], former LPN #200 documented on [DATE] at 8:00 A.M. Resident #75 took all of her medication. At 11:30 A.M., therapy staff notified former LPN #200 that Resident #75 ' s blood pressure was low, respirations were 18 breaths per minute, and oxygen saturation was 91 percent (%) with the electronic vitals machine. Therapist #100 stated therapy would not be delivered due to the resident stating she did not feel good. At 11:45, the former LPN #200 documented blood pressure was completed with manual equipment and the value was 87/49 mmHg. The resident was sleeping at 12:30 P.M. and at 1:20 P.M. the resident was sleeping. Another late entry dated [DATE] at 1:55 P.M revealed former LPN #200 passed onto the second shift nurse, LPN #72, that Resident #75 was starting to decline due to her blood pressure measuring 87/49 mmHg and to keep an eye on her as Resident #75 wasn ' t feeling well. Review of nursing progress notes in the Electronic Medical Record (EMR), dated [DATE] at 9:53 P.M., revealed the second shift nurse, LPN #72, was called to Resident #75 ' s room when the resident refused incontinence care multiple times. Upon rolling the resident on her side, the resident vomited coffee ground emesis and had loose bloody stool. The resident ' s respirations were 28 breaths per minute and the pulse was 54 beats per minute (bpm). The resident refused medication. MD #500 was notified and ordered the resident sent to hospital via EMS. After the EMS call was completed, the resident was reassessed with respirations of 7 breaths per minute, with labored breathing. The EMS arrived, resumed care, and transported the resident to the hospital. There were no nursing notes in the EMR on [DATE] on the first shift by former LPN #200. Review of Resident #75 ' s clinical vital log documentation dated [DATE] at 10:36 P.M. by LPN #72, revealed Resident #75 ' s blood pressure was 88/54 mmHg, pulse 54 beats per minute, respirations 28 breaths per minute, blood sugar 95 milligrams per deciliter, and oxygen saturation 90 % on room air. Previous blood pressure included on admission dated [DATE] was 124/49 mmHg, on [DATE] was 116/63 mm/Hg, on [DATE] was 142/47 mmHg, on [DATE] was 115/44 mmHg, on [DATE] was 126/60 mmHg and on [DATE] was 129/51 mm/Hg. There were no vital signs recorded for Resident #75 by the first shift former LPN #200. Review of the EMS report dated [DATE] revealed the EMS was contacted at 4:39 P.M. on [DATE], arrived at 4:47 P.M., and transported Resident #75 to the hospital at 5:15 P.M. The report revealed, upon arrival at the facility, Resident #75 was unresponsive with a blood pressure of 65/32 mmHg with pulse of 36 beats per minute and oxygen saturation of 81 %. The resident had sinus bradycardia, was mottled and diaphoretic. The resident had rapid breathing and was unable to verbally respond. An attempt to insert a intravenous line was unsuccessful, and the resident was transported to the hospital. Resident #75 was taken to the emergency room, became pulseless and was intubated. The resident expired. Review of the hospital emergency room documents dated [DATE] at 6:20 P.M. revealed Resident #75 arrived at the emergency room on [DATE] at 5:17 P.M. and expired at 10:07 P.M. The resident arrived with a diagnosis of hypotension, cardiac dysthymia and full cardiac arrest. The resident was intubated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365532 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 365532 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 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 0684 Level of Harm - Immediate jeopardy to resident health or safety and had no cardiac activity. The resident was 12 days post-surgery for rectal cancer with decline in responsiveness over past several days. Review of an investigation statement dated [DATE] by first shift STNA #30 revealed on [DATE] she reported to former LPN #200 multiple times on the day shift that Resident #75 was refusing care, meals, and vitals. The former LPN #200 was not observed to check on Resident #75 during the shift. Residents Affected - Few Review of an investigation statement dated [DATE] by first shift LPN #70 revealed on [DATE] at 1:00 P.M. she heard STNA #30 report to former LPN #200 that Resident #75 was refusing care. LPN #70 suggested to former LPN #200 that Resident #75 needed assessed. Former LPN #200 continued sitting at the nurses station and was not noted to assess Resident #75. Review of an investigation statement dated [DATE] by STNA #40 revealed she took STNA #30 into Resident #75 ' s room to provide care and attempt to obtain vitals. The blood pressure was not reading, and former LPN #200 was notified. Former LPN #200 did not notably respond to two additional times during the shift of STNA #40 ' s concerns of Resident #75 ' s care refusals and pain. The second shift STNA #45 was notified of Resident #75 ' s refusals of care during shift change at 2:00 P.M. Review of an investigation statement dated [DATE] by second shift STNA #45 revealed on [DATE] she received shift report at 2:00 P.M. from STNA #30. STNA #30 reported Resident #75 refused care, meals and had reported the information to former LPN #200 throughout the day. STNA #30 had stated former LPN #200 had not checked on the resident after being notified several times of Resident #75 ' s refusals. At 2:30 P.M., STNA #45 told second shift LPN #72 of Resident #75 ' s refusals. LPN #72 stated she had not been notified by former LPN #200 of Resident #75 ' s refusals. At 4:15 P.M., LPN #72 assisted STNA #45 with incontinence care of Resident #75 when the resident began vomiting and had loose stools. The EMS was called, and the EMS transported Resident #75 to the hospital. Review of the written investigation statement dated [DATE] by former LPN #200 revealed she was called to Resident #75 ' s room by Therapist #100 due to the resident was short of breath and had low blood pressure. The resident stated she did not feel good. Therapist #100 reported she was unable to get a good blood pressure with the electronic vital machine. Former LPN #200 documented that she obtained vitals with manual equipment on a handwritten late entry nurse ' s note and could not recall the exact blood pressure value and respirations were 16. Former LPN #200 told Therapist #100 the therapy session could not be provided due to the resident stated she did not feel well and had low blood pressure. She documented the resident went to sleep and was resting comfortably the remainder of the shift with no nausea or vomiting. The resident had refused the lunch meal. Former LPN #200 reported vitals and the resident condition to second shift LPN #72 because former LPN #200 felt the resident was declining. Review of the investigation statement dated [DATE] and physical therapy documentation dated [DATE] at 1:56 P.M., Therapist #100 revealed the visit with Resident#75 on [DATE] noted Resident #75 ' s blood pressure was obtained of a value of 82/19 mmHg. Therapist #100 reported the low blood pressure to former LPN #200. Former LPN #200 responded she was going to finish her medication pass and would reassess the blood pressure with manual equipment. Therapist #100 noted former LPN #200 directed no therapy to be provided due to decline in medical status. Review of an investigation statement dated [DATE] by second shift LPN #72 verified the nurses' notes entered on [DATE] at 9:53 P.M., LPN #72 revealed upon arrival of the shift starting at 2:00 P.M. on [DATE], former LPN #200 reported Resident #75 had refused care and may be declining but thought (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365532 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 365532 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Resident #75 was doing OK. At 3:30 P.M., STNA #45 reported Resident #75 had been refusing incontinence care and needed care. Resident #75 resisted and then permitted LPN #72 and STNA #45 to provide incontinence care. The resident had coffee ground vomiting and loose bloody stool. Review of facilities SRI, submitted by the facility Administrator on [DATE], revealed LPN #72 reported former LPN #200 did not assess Resident #75. Former LPN #200 was terminated due to failure to maintain honest and accurate records of services as well as inefficiency, lack of productive effort or other unsatisfactory work performance. Review of the investigation statement of LPN #65 revealed on [DATE] on second shift report at 2:00 P.M, former LPN #200 reported to LPN #72, Resident #75 ' s blood pressure was 86/46 mmHg, and the resident was declining. At 4:20 P.M., LPN #72 reported to LPN #65, EMS had been called as Resident #75 was vomiting, and had diarrhea. LPN #65 called former LPN #200. Former LPN #200 reported Resident #75 had not vomited, had no diarrhea, and verified the blood pressure was 86/46 mmHg. Interview on [DATE] at 10:43 A.M, the DON verified the investigation of Resident #75 ' s change of condition, resulting in hospitalization and death, was not acted upon by former LPN #200. Former LPN #200 did not notify the physician during the first shift of [DATE] when blood pressure was verified at 86/46 mmHg at 11:45 A.M. The investigation revealed STNAs #30 and #40 notified former LPN #200 throughout first shift of Resident #75 ' s refusal of care, meals and general decline in condition. The DON verified Therapist #100 had notified former LPN #200 of the resident ' s low blood pressure and general weakness at 11:35 A.M. The DON verified former LPN #200 did not document progress notes of Resident #75 ' s conditional changes or vitals obtained during the first shift of [DATE]. The DON stated former LPN #200 documented, with inaccurate dates, and late entry documentation on [DATE] during the investigative interview. The handwritten late entry documentation was not contained in Resident #75 ' s medical record. The DON verified the former LPN #200 was suspended during the investigation and employment terminated on [DATE]. The DON verified former LPN #200 was terminated due to lack of documentation of Resident #75 ' s assessment, recording of blood pressure in the medical record, did not respond to notification from STNAs #30 and #40 of resident condition change, had inaccurate late entry documentation and did not use facility nurses reporting documentation on the second shift nursing report. The DON stated the nurse written shift report could not be located during the investigation to confirm or deny Resident #75 ' s blood pressure was communicated to the second shift nurse. The DON verified the second shift LPN #72, reporting to work at 2:00 P.M., did not assess Resident #75 until 3:30 P.M. Interview on [DATE] at 11:05 A.M. with MD #500 revealed discussion with Resident #75 ' s Emergency Physician on [DATE] that Resident #75 was most likely having a cardiac event during the day of [DATE]. MD #500 stated he was not notified until 4:35 P.M. by second shift LPN #72 of the low blood pressure, vomiting, loose stools and general change in condition. MD #500 stated the first shift nurse, former LPN #200, should have contacted him when the low blood pressure of 86/49 mmHg was first assessed at 11:45 A.M., in addition to refusal of meals and general not feeling well. Interview on [DATE] at 11:18 A.M., LPN #70 verified she had suggested to former LPN #200 to assess Resident #75 after STNA #30 had reported the resident ' s refusal of care. Former LPN #200 was not observed to act immediately to assess the resident. Interview on [DATE] at 11:40 A.M. with second shift LPN #65 verified she had heard former LPN #200 give shift report to second shift LPN #72 including blood pressure of 86/49 mmHg and a general decline in condition of Resident #75. LPN #65 verified the blood pressure value and decline in condition (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365532 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 365532 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few was sufficient assessment information to notify the physician immediately. LPN #65 verified LPN #72 did not report having contacted MD #500 and EMS until 4:20 P.M. Interview on [DATE] at 12:07 P.M. with second shift nurse LPN #72 verified she received written shift report from former LPN #200 which did not have blood pressure values and there was no vital or progress record in the EMR from former LPN #200. LPN #72 revealed former LPN #200 stated the resident was in decline but was stable. The verbal clinical report contained no blood pressure values. LPN #72 verified she started her medication pass and did not assess Resident #75 until STNA #45 reported Resident #75 needed assessment due to refusal of care and general decline. During incontinence care, Resident #75 started vomiting and had loose stool, with a blood pressure of 88/54 mmHg, pulse 54 beats per minute and respirations of 27 breaths per minute. EMS was contacted at about 4:15 P.M and the respirations had decreased to 6 breaths per minute. LPN #72 stated she should have made resident visual rounds at the start of her shift to ensure the residents on her assignment had been assessed accurately. Interview on [DATE] at 1:20 P.M., Therapist #100 verified she had obtained Resident #75 ' s blood pressure on [DATE] at about 12:30 P.M. and the blood pressure was 82/19 mmHg. Therapist #100 verified she reported immediately to former LPN #200 the low blood pressure value. Former LPN #200 directed no therapy be provided due to the condition change. Former LPN #200 stated she would obtain a blood pressure with manual equipment. Therapist #100 stated she did observe former LPN #200 taking Resident #75 ' s blood pressure with manual equipment about 15 minutes later. Interview on [DATE] at 1:30 P.M., former LPN #200 verified Resident #75 took her medications without difficulty at the 8:00 A.M. medication pass. Former LPN #200 denied STNAs #30 and #40 reported the resident had refused care, refused meals, refused vitals and had a general decline. She stated around 12:00 P.M. Therapist #100 notified her of Resident #75 ' s low blood pressure with the electronic vital machine of 80/19 mmHg and pulse of 70 beats per minute. The resident had reported not feeling well, wanted to be left alone and sleepy. Former LPN #200 stated she obtained a blood pressure 15 minutes later with manual equipment and the blood pressure was 86/49 mmHg at around 1:00 P.M. Former LPN #200 stated since the resident ' s admission on [DATE], the resident had been lowly motivated, and spent much time in bed. She stated she checked on Resident #75 at 1:50 P.M and the resident was sleeping so she did not obtain new vitals. Former LPN #200 stated the low blood pressure changes, refusal and general decline had not concerned her enough to contact MD #500. She stated she had reported, in written shift report and verbally, the blood pressure of 86/49 mmHg to second shift LPN #72. Since Resident #75 ' s blood pressure was assessed at approximately at 1:00 P.M., and former LPN #200 ' s shift ended at 2:00 P.M, former LPN #200 stated the second shift nurse, LPN #72, should have followed up on Resident #75 ' s decline. Review of former LPN #200 ' s personnel record revealed a date of hire of [DATE] and termination date of [DATE]. The termination was described by the DON as failure to maintain honest and accurate records of service provided, inefficiency, lack of proactive effort or other unsatisfactory work performance. Former LPN #200 was suspended on [DATE] during the investigation which ended on [DATE]. The disciplinary termination notice was signed by the DON on [DATE] and former LPN #200 refused to sign. Review of the facility policy titled Change in a Resident's Condition, dated February 2021 revealed the nurse supervisor/charge nurse will notify the resident's attending physician or on-call physician when there has been a change in resident condition. This includes a significant change in the resident ' s mental condition, refusal of treatment, or a major decline in the resident's status which (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365532 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 365532 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 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 0684 will not normally resolve itself without intervention by staff. Level of Harm - Immediate jeopardy to resident health or safety According to the American Heart Association at www.heart.org, titled Understanding Blood Pressure Readings, a blood pressure reading of systolic less than 90 and diastolic less than 60 is considered hypotensive and a clinical abnormal value. Residents Affected - Few This deficiency represents non-compliance investigated under Complaint Number OH00148885. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365532 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 365532 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and policy review, the facility failed to document in the resident record a medical change in condition and accurately document the care and services provided. This affected one (#75) of four resident records reviewed for accurate documentation. The facility census was 71. Findings include: Review of Resident #75's closed medical record revealed the resident was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. The resident expired at the hospital on [DATE]. Diagnoses for Resident #75 included malignant neoplasm of the rectum with colon resection surgery on [DATE], diabetes, morbid obesity, chronic kidney disease, and heart failure. Review of the comprehensive Minimum Data Set, (MDS) assessment dated [DATE], revealed the resident had intact cognition and required partial assistance for mobility, and extensive assistance for toileting and bathing. Review of a handwritten nurse notes, provided by the Director of Nursing, (DON), revealed the notes were listed as late entry documentation of [DATE], by Former Licensed Practical Nurse (LPN) #200. Former LPN #200 documented on [DATE] at 8:00 A.M., the resident (#75) took all of her medication. At 11:30 A.M., therapy staff notified Former LPN #200 of Resident #75's blood pressure was low, respiration of 18, and oxygen saturation at 91 percent with the electronic vital machine. Therapist #100 stated therapy would not be delivered due to the resident stating she did not feel good. At 11:45 A.M., Former LPN #200 documented blood pressure was completed with manual equipment and the value was 87/49 millimeters of mercury, (mmHg). The resident was sleeping at 12:30 P.M. At 1:20 P.M., the resident was sleeping. A late entry dated [DATE] at 1:55 P.M., revealed Former LPN #200 reported to the second shift nurse, LPN #72 that Resident #75 was starting to decline due to her blood pressure was 87/49 mmHg and to keep an eye on her, and wasn't feeling well. The late entry handwritten nurse notes were not located in any chart of Resident #75. There was no documentation of nursing progress notes, no assessments, and no documentation of the resident's vital values in the electronic resident chart or hard chart. Interview on [DATE] at 10:43 A.M., with the Director of Nursing, (DON) verified the investigation of Resident #75's change condition, resulting in hospitalization and death, was not acted upon by Former LPN #200. Former LPN #200 did not notify the physician during the first shift of [DATE] when blood pressure was verified at 86/46 mmHg at 11:45 A.M. The DON verified Former LPN #200 was terminated on [DATE] due to lack of accurate documentation of Resident #75's condition change assessment and did not record vital signs, including blood pressure in the medical record. The DON verified the handwritten late entry documentation provided by Former LPN #200 nurse was inaccurate and was not located in any medical chart. Interview on [DATE] at 1:30 P.M., with Former LPN #200 verified Resident #75 took her medications without difficulty at the 8:00A.M. medication pass. LPN #200 denied State Tested Nurse Aide (STNA) #30 and #40 reported the resident had refused care, refused meals, refused vital assessment, and had a general decline. LPN #200 stated around 12:00 P.M., the Therapist #100 notified her of Resident #75's low blood pressure with the electronic vital machine of 80/19 mmHg and pulse of 70. The resident had reported not feeling well, wanted to be left alone and sleepy. Former LPN #200 stated she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365532 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 365532 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few obtained a blood pressure 15 minutes later with manual equipment and the blood pressure was 86/49 mmHg at around 1:00 P.M. Former LPN #200 stated since the resident's admission on [DATE], the resident had been lowly motivated, and spent much time in bed. LPN #200 stated she checked on Resident #75 at 1:50 P.M and the resident was sleeping so she did not obtain new vitals. Former LPN #200 verified she did not document nursing progress notes, assessments and did not document of the resident's vital values in the electronic resident chart. Former LPN #200 stated she was directed by the DON on [DATE] to write out a handwritten late entry documentation of the events on [DATE] regarding Resident #75's clinical care and condition changes. Former LPN #200 stated she could not recall the complete blood pressure value or timelines, as the time had lapsed since [DATE]. She verified the date of [DATE] listed was inaccurate and the handwritten documentation was not in the chart. Review of the policy titled, Change in a Resident's Condition, dated February 2021, revealed the nurse will record in the resident's medical record information relative to changes in the resident's medical condition or status. This deficiency represents non-compliance investigated under Complaint Number OH00148885. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365532 If continuation sheet Page 10 of 10