Health inspection·December 26, 2024

F 0696 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #12's care plans with initiated date of 11/26/24 revealed a focus for amputation of left leg below the knee. Interventions included exercises per therapy, monitor and document signs of depression and changes in behaviors, and therapy evaluations as ordered. There is no mention of prosthetic leg. Observation and interview on 12/23/24 at 1:12 P.M., with Resident #12, revealed the resident was observed in his wheelchair ambulating towards his room. Resident #12's left leg appeared to be amputated below the knee with no prosthetic leg visible. Resident #12 stated to the surveyor, They took my leg. Resident #12 did not elaborate or answer any questions from the surveyor regarding his leg. Further attempts to interview Resident #12 were unsuccessful. Interview on 12/26/24 at 10:30 A.M., with Licensed Social Worker (LSW) #1, revealed when Resident #12 was admitted from the hospital on [DATE], he returned to the hospital and then re-admitted to the facility on [DATE]. Per LSW #1, the resident's personal belongings were bagged up and taken to a contained area outside of the facility. LSW #1 stated she was informed by the resident that the hospital had bagged up all his belongings when he first admitted to the emergency room due to him having bed bugs in his home. LSW #1 stated the resident's prosthetic leg was also bagged up at the hospital and placed with the belongings due to being infested with bed bugs. LSW #1 stated upon admission to the facility Resident #12 was assessed per protocol and there were no bugs found on his person. Resident #12 was then admitted to a semi-private room and placed in isolation per protocol. LSW #1 stated the resident's leg was still infested with bed bugs due to the facility not being able to hire an exterminator to come and treat the infested items. LSW #1 stated she attempted to spray an insecticide on the resident's prosthetic, but she was unable to rid the prosthetic leg of bed bugs. LSW #1 did state she was not trained in pest extermination and stated she did not know which chemicals were to be used to safely clean the prosthetic leg. LSW #1 stated she then attempted to get Resident #12 a new prosthetic and was able to schedule an appointment for a new prosthetic in October 2024. LSW #1 claimed the outside clinic refused to make a new prosthetic for the resident due to not being able to measure and use the infested prosthetic. LSW #1 stated as of 12/26/24, she did not know if the resident would receive a new prosthetic leg. Interview on 12/26/24 at 11:13 A.M., with Environmental Manager (EM) #500 revealed when Resident #12 was admitted he came to the facility with all his personal items having been bagged up and placed into a safe contained area outside of the facility due to an infestation of bed bugs. EM #500 stated no one had attempted to rid the items of the bed bugs per her knowledge. EM #500 stated the facility had not contacted the contracted exterminator due to having an unpaid balance and the exterminator refused to come to the facility. EM #500 stated at the time of the survey all of Resident #12's belongings remained isolated in the contained area, including his prosthetic leg, due to bed bugs still being visibly alive on all of the items. Interview on 12/26/24 at 2:00 P.M., with Administrator revealed Resident #12 did attend an appointment with the prosthetic clinic to receive a new prosthetic leg on 12/10/24. Per the Administrator the physician and facility are working with the clinic to have a new prosthetic available to the resident. Per the Administrator all other personal items have been replaced by the facility for Resident #12 as of 12/10/24, the day after the surveyor entered the facility for the investigation. Interview on 12/26/24 at 3:35 P.M., with the Administrator verified the extermination services had not been paid by the facility since August 2024. Per the Administrator the facility planned to pay the invoices and have the exterminator resume their contracted services. The Administrator verified (continued on next page) 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 12/26/2024 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)

F 0696 there had been no extermination services provided to the facility since August 2024. Level of Harm - Minimal harm or potential for actual harm Review of the undated protocol titled Bed Bug Protocol, revealed the staff will bag up and treat all personal items infested with bed bugs. Once treated all personal items are to be returned to the resident for use. Residents Affected - Few This deficiency represents non-compliance found during the complaint investigation for Complaint Number OH00159874. 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 12/26/2024 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)

F 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of contractor services invoices, interview with outside contractor service, and staff interview, the facility failed to remain solvent by paying all contractors for their services. This had the potential to affect all 67 residents residing in the facility. The current census is 67. Residents Affected - Many Findings include: Review of the facility's contract with the extermination services revealed the exterminators were scheduled to provide services for the facility monthly and treat for any infestations. The contract was for 12 months of service beginning February 2024. Further review revealed the facility had no invoices for the contractor after 08/20/24. Interview on 12/26/24 at 12:08 P.M., with the Receptionist #100, from the exterminator contracted service company, revealed as of August 2024, the facility had an unpaid balance and the extermination service were no longer providing any treatments to the facility due to nonpayment. Interview on 12/26/24 at 10:30 A.M., with Licensed Social Worker, (LSW) #1, revealed when Resident #12 was admitted from the hospital on [DATE], returned to the hospital and the re-admitted to the facility on [DATE]. Per LSW #1, the resident's personal belongings were bagged up and taken to a contained area outside of the facility. LSW #1 stated due to the facility owing money to the contracted exterminator there had been no extermination services provided to eradicate the bed bugs from Resident #12's personal items. Interview on 12/26/24 at 3:35 P.M., with the Administrator verified the extermination services had not been paid by the facility since August 2024. Per the Administrator the facility planned to pay the invoices and have the exterminator resume their contracted services. The Administrator verified there had been no extermination services provided to the facility since August 2024. This deficiency represents non-compliance discovered during the complaint investigation for Complaint Numbers OH00160209 and OH00159874. 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 12/26/2024 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)

F 0839 Employ staff that are licensed, certified, or registered in accordance with state laws. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY Residents Affected - Many Based on staff interview, review of resident records, review of employee files, review of license verification via the Ohio Board of Nursing database, review of facility corrective action, and review of staffing schedules the facility failed to ensure all nurses who were providing care to resident had active licenses. This had the potential to affect all residents residing in the facility. The current census is 67. Findings include: Review of Ohio Board of Nursing License Verification database revealed Licensed Practical Nurse (LPN) #150's the nurse's licensed had expired as of [DATE]. Review of the facility's daily nursing schedules dating from [DATE] to [DATE] revealed LPN #150 had been scheduled to work on [DATE]. Review of LPN #150's employee file revealed her license had not been renewed as of [DATE], no new license verification evidence was noted in the employee file. Interview on [DATE] at 10:00 A.M., with Human Resource Manager (HRM) #2 revealed LPN #150 did have an expired license on her last day of work, [DATE]. Per HRM #2, the nurse was terminated on [DATE] and had not returned back to the facility. Interview on [DATE] at 3:10 P.M., with Interim Director of Nursing (IDON) revealed all nurses licenses have been checked for validity and as of [DATE], all nurses currently employed and working the facility have licenses in good standing. IDON verified LPN #150 had worked after her nursing license expired. IDON stated the issue was discovered on [DATE] and immediately handled by the management. IDON stated they suspended LPN #150 and she was eventually terminated due to her license being expired. IDON stated they put a plan of correction in place at the time of the discovery. IDON stated she assessed all residents cared for by LPN #150 and found no issues or concerns with the nursing care. IDON stated she did an audit of all medications administered by LPN #150 and found no errors. IDON stated all nurses and HRM were educated on license verification and renewal on [DATE]. Review of the facility's corrective action revealed the following actions were implemented and the deficiency corrected as of [DATE]: • Beginning on [DATE], and completed on [DATE], the Director of Nursing verfiied all nurse's (licensed practical nurse and registered nurses) licenses were fully up to date and active in the Ohio Board of Nursing license verification database. • On [DATE], LPN #150 was sent home and suspended from the schedule until the nurse's license could be verified as renewed. LPN #150's employment was terminated as of [DATE] per the employee file. (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 12/26/2024 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)

F 0839 • Level of Harm - Minimal harm or potential for actual harm Beginning on [DATE] to [DATE], the Director of Nurses conducted a nursing assessment of all residents being cared for by LPN #150 from [DATE] to [DATE]. Per the DON, no issues were discovered during the assessments. Residents Affected - Many • Beginning [DATE] to [DATE], DON conducted license verifications on all new nurses applying to the facility. • Review of 11/2024 and 12/2024 audits for licensed staff revealed the audits were completed to ensure all nursing staff continued to have active licenses. • Review of three additional resident records (#4, #5, and #6) for residents treated by LPN #150 on [DATE], revealed no concern with the nursing care documented in the medical charts. • Review of the education dated [DATE] revealed all nursing staff were educated on the renewal requirement of their licenses. This deficiency represents non-compliance found during the complaint investigation for Complaint Numbers OH00160579 and OH00159874. 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 12/26/2024 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)

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of contractor services invoices, interview with outside contractor service, policy review, and staff interview, the facility failed to maintain a pest control program in accordance with policy. This had the potential to affect all 67 residents residing in the facility. The current census is 67. Residents Affected - Many Findings include: Review of the facility's contract with the extermination services revealed the exterminators were scheduled to provide services for the facility monthly and treat for any infestations. The contract was for 12 months of service beginning February 2024. Further review revealed the facility had no invoices for the contractor after 08/20/24. Interview on 12/26/24 at 12:08 P.M., with the Receptionist #100, from the exterminator contracted service company, revealed as of August 2024, the facility had an unpaid balance and the extermination service were no longer providing any treatments to the facility due to nonpayment. Interview on 12/26/24 at 10:30 A.M., with Licensed Social Worker (LSW) #1, revealed when Resident #12 was admitted from the hospital on [DATE], returned to the hospital and the re-admitted to the facility on [DATE]. Per LSW #1, the resident's personal belongings were bagged up and taken to a contained area outside of the facility. LSW #1 stated due to the facility owing money to the contracted exterminator there had been no extermination services provided to eradicate the bed bugs from Resident #12's personal items. Interview on 12/26/24 at 3:35 P.M., with the Administrator verified the extermination services had not been paid by the facility since August 2024. Per the Administrator the facility planned to pay the invoices and have the exterminator resume their contracted services. The Administrator verified there had been no extermination services provided to the facility since August 2024. Review of the policy titled, Pest Control, dated October 2019, revealed the facility will maintain an effective pest control program. The facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. Pest control services are provided on a routine basis by a contracted pest control services. This deficiency represents non-compliance discovered during the complaint investigation for Complaint Number OH00159874. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365532 If continuation sheet Page 7 of 7