Inspection·September 19, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, review of the facility policy, review of the Self-Reporting Incident (SRI) database, and staff interviews, the facility failed to report an injury of unknown origin to the State Agency. This affected one (#15) out of 11 residents reviewed for abuse allegations not being reported. The current census is 68. Findings include: Record review of Resident #15 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #15 include dementia, retrograde amnesia, falls, and asthma. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition and was a complete assist for Activities of Daily (ADL). Review of Resident #15's care plans dated 08/16/24 revealed no focus for behaviors. Further review of the care plans revised on 08/19/24 revealed a focus for actual skin impairment to skin integrity of right posterior calf. Interventions included follow protocols for treatments of injury, identify and document potential causative factors to eliminate or resolve where possible. Review of Resident #15's skin assessments dated 08/19/24 revealed the resident had a laceration to her right lower leg measuring 6 centimeters (cm) by 4.8 cm. On 08/27/24 the laceration to the right lower leg measured 3.5 cm by 2.6 cm and was noted as healing. On 09/16/24 the laceration to the lower right leg measured 2.5 cm by 1.2 cm. Review of Resident #15's vital signs on 08/18/24 at 5:00 A.M. Resident #15 complained of pain at a 7 out of 10 level. Per the vital signs the resident denied any pain during further assessments. Review of Resident #15's progress notes dated 08/18/24 at 5:39 A.M. the nurse documented the aide was conducting bed rounds and called for help to the resident's room. Resident #15 was noted to be on the side of the bed semi-curled up with a 'skin tear' to the posterior right calf. Per the note the resident was unable to verbalize how she got the wound. The nurse assessed the wound and applied a dressing. Per the note the nurse noted the wound was greater than 1 cm deep and was unable to be closed by the skin flap. The nurse then notified the physician and family. Per the note the resident was sent out to the hospital for treatment. Further review of the progress notes revealed on 08/18/24 at 12:04 A.M. the nurse had assessed the resident with no open wounds. Per the note dated 08/18/24 at 8:30 A.M. Resident #15 returned to the facility with a new order for antibiotics. On 08/18/24 at 9:51 A.M. Resident #15 was moved from her current room to a room across from the nurses' station. (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 4 Event ID: 365532 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 09/19/2024 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)