Inspection·September 18, 2023

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 medical record review, resident and staff interview, self-reported incident review, and review of a facility policy, the facility failed to report all allegations of abuse to the administrator and other officials in a timely manner. This affected two (#3 and #4) of six residents reviewed for abuse. The census was 75. Findings include: 1. Record review of Resident #3 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #3 include chronic obstructive pulmonary disease, diabetes, anxiety, chronic respiratory failure, and heart failure. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition and required a two-person assist for activities of daily living (ADLs). Further review revealed the resident received hospice services and was on supplemental oxygen. Interview on 09/14/23 at 11:09 A.M., with Resident #2 stated she was not in the room on 07/13/23 when the alleged abuse from the Administrator towards Resident #3 occurred, but verified she witnessed Resident #3 report the allegations of abuse to the facility staff including the business office manager and the social worker the next day on 07/14/23. Interview on 09/18/23 at 2:20 P.M., with Resident #3 stated she reported the alleged abuse she experienced on 07/13/23 to Business Office Manager (BOM) #500 and Social Worker (SW) #400 after the incident the following day on 07/14/23, and then again at a later date. Resident #3 stated she reported to the staff she felt bullied and abused by the Administrator. Resident #3 verified she also reported her allegations to an investigator in the facility the week of 09/11/23. Resident #3 stated she was afraid of retribution, but felt she needed to report the alleged verbal abuse she experienced by the Administrator. Interview on 09/18/23 at 10:20 A.M., with BOM #500 stated on 07/13/23 her and the Administrator went into Resident #3's room and told her she had a balance due on her bill, and if she could not pay, she would receive a 30-discharge notice. BOM #500 stated it was an uncomfortable conversation for the resident and the staff, and stated the Administrator kept telling the resident she had to pay her bill or she would have to be discharged . BOM #500 stated it was an unprofessional conversation, but she could not determine if the Administrator was being verbally abusive or intimidating to Resident #3. BOM #500 verified she reported to the social worker on 07/14/23 after Resident #3 stated she felt verbally abused by the Administrator. BOM #500 stated she did not report any allegations of abuse to the Administrator or Director of Nursing (DON). (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: 365607 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 365607 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Piqua 275 Kienle Drive Piqua, OH 45356 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)