Inspection·October 27, 2023

F 0692 Level of Harm - Actual harm Residents Affected - Few interventions were to start nutritional ice cream supplements three times daily at meals and the liquid supplements discontinued due to poor acceptance by Resident #05. The nutrition assessment did not mention the abnormal comprehensive metabolic panel dated 08/14/23. Review of the weekly body audit dated 09/09/23 revealed Resident #05 developed two new pressure areas on the sacrum and distal buttocks that were both unstageable wounds. The previous weekly body audit dated 08/28/23 revealed Resident #05's skin was intact. Review of the nutrition assessment by RD #90 completed on 09/29/23 revealed this was first time Resident #05 was nutritionally assessed after Resident #05 developed two unstageable pressure ulcers on 09/09/23. The resident's weight was 149 pounds on 09/01/23 with no weight loss and Body Mass Index (BMI) of 27.2. There was no additional weight recorded for Resident #05 from 09/02/23 to 09/29/23. The resident was dependent on one staff assistance for feeding mechanical soft diet, nectar thickened liquids with nutritional ice cream cups at all meals, with intakes varying from 26 to 100 percent. Resident #05's unstageable pressure ulcers to the sacrum and coccyx were declining. Liquid protein supplements at 30 ml twice daily were recommended for wound support. The resident continued to receive 800 ml of water daily via the gastrostomy tube. The nutrition assessment did not include the calculations of the resident's increased calorie and protein nutritional needs due to the unstageable pressure ulcers, did not accurately reflect the resident's meal intake, and did not mention the abnormal comprehensive metabolic panel dated 08/14/23. Review of Resident #05's weight record revealed the admission weight was 146 pounds on 07/27/23, 148 pounds on 08/10/23, 149 pounds on 09/01/23, and 142 pounds on 10/03/23. On 10/03/23, Resident #05 lost seven pounds (4.6 percent) in one month. Review of the wound documentation dated 10/03/23 revealed Resident #05's two unstageable wounds were combined and Resident #05 now had one unstageable pressure ulcer. The wound measured 7.0 centimeter (cm) in length by 6.8 cm in width and unable to determine depth and the wound had declined. Review of the meal intake records, from the time the two unstageable areas were identified on 09/09/23 until 10/03/23 when Resident #05's pressure areas were deteriorating and the seven pounds weight loss to 142 pounds, revealed Resident #05 was consuming less than half of his meals for 63 of the 80 opportunities which was equivalent to 78.5 percent, 51 to 75 percent of his meal consumed for 14 of the 80 opportunities equivalent to 17.5 percent of his meals and consumed more than 75 percent of his meals only three of the 80 opportunities equivalent to about four percent of his meals. Resident #05's daily estimated nutritional needs during this period were 2,010 kcals based on 30 calories per kilogram body weight, 100 to 134 grams of protein based on 1.5 to 2.0 gram per kilogram of body weight with unstageable pressure areas, and 2,010 ml of fluid based on 30 ml per kilogram of body weight. Based on the meal intake records including meals, nutritional supplements, and snacks, the resident's average daily intake during this period provided approximately 1,200 kilocalories (kcals) (60% of his estimated energy needs) and 42 grams of protein (31 to 42 percent of his estimated protein needs) daily. Review of the nursing progress note dated 10/10/23 revealed the resident's responsible family member contacted the Director of Nursing and expressed concerns Resident #05 was not eating well and he would like the tube feeding restarted. A physician's order for Jevity 1.5 at 60 ml for 12 hours nocturnally with 200 ml water flushes every six hours was initiated on 10/10/23. On 10/10/23, Dietary Technician (Diet Tech) #84 noted the tube feeding provided 1080 calories, 46 grams of protein and a total of 1347 ml of fluid daily. On 10/12/23, Diet Tech #84 noted the resident was not tolerating (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365607 If continuation sheet Page 2 of 4 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 10/27/2023 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)

F 0692 Level of Harm - Actual harm Residents Affected - Few anything by mouth except nectar thickened liquids and requested the tube feeding be changed to continuous Isosource 1.5 ml at 60 ml plus the water flush. On 10/12/23, Resident #05 was found unresponsive and diagnosed with a urinary tract infection, acute encephalopathy, and hyperammonemia. Telephone interview with Physician #98 on 10/24/23 at 1:30 P.M. revealed Resident #05's pressure areas were not healing, and the resident continued to decline until he was hospitalized on [DATE]. Interview with Registered Nurse (RN) #80 on 10/24/23 at 2:28 P.M. verified Resident #05 received very little nutrition via the tube feeding during his entire stay. Telephone interview with Diet Tech #84 on 10/24/23 at 4:00 P.M. verified she was notified Resident #05 had two unstageable pressure ulcers via electronic mail on 09/13/23 which was communicated to RD #90 on a shared spreadsheet. Diet Tech #84 stated she was in the facility weekly to monitor the resident's nutritional status. Telephone interview with RD #90 on 10/24/23 at 5:08 P.M. revealed she coordinated with Diet Tech #84 and completed assessments for high-risk residents with pressure ulcers, tube feedings and receiving dialysis during her one-to-three-hour monthly visits. RD #90 verified her assessment on 09/29/23 had no new calculations for Resident #05's nutritional needs with the two unstageable pressure ulcers. She verified her recommendation for liquid protein 30 ml twice daily but did not specify the nutrition the supplement would provide to the resident. RD #90 verified her note did not specify calories, protein, and fluid provided to the resident from meals, nutrition supplements and snacks he consumed by mouth. RD #90 stated the resident's seven-pound weight loss from the previous month identified on 10/03/23 was not addressed because it was not considered significant until it was five percent or more weight change. Interview with [NAME] #92 on 10/25/23 at 8:50 A.M. revealed she was Resident #05's niece. The resident was eating well at home and received a nocturnal tube feeding for years every night prior to his admission. During his stay at the facility, he declined with the pressure ulcers and did not eat well especially the past month. The resident went home from the hospital on [DATE]. A second telephone interview with RD #90 on 10/26/23 at 9:30 A.M. confirmed she was not aware Resident #05 was consuming 50 percent or less at most meals from 09/09/23 through 0/03/23. RD #90 verified Resident #05 was not consuming enough nutrition to meet his estimated energy and protein needs. RD #90 verified she did not review and address the complete metabolic panel concerning the low glucose and low albumin on 08/14/23. Review of the facility policy titled Nutritional Assessment, revised 2017, revealed a nutritional assessment included the current nutritional status and risk factors for impaired nutrition was conducted for each resident by the multidisciplinary team as indicated by a change in condition that placed the resident at risk for impaired nutrition. The assessment was a process that included gathering and interpreting data, using the data to help define meaningful interventions for the resident at risk including a description of the resident's usual intake and appetite, any reduced appetite or weight loss, recent events that may have affected resident's nutritional status, laboratory results and general appearance of the resident. The need for enteral nutrition was periodically reassessed for appropriateness and effectiveness based on the resident's requirements for nutrient intake. Review of the facility policy titled Pressure Ulcers/Skin Breakdown, revised April 2018, revealed staff should attempt to maintain stable weight and provide 1.2 to 1.5 grams of protein per kilogram (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365607 If continuation sheet Page 3 of 4 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 10/27/2023 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)

F 0692 of body weight for residents with pressure ulcers. Level of Harm - Actual harm Review of the National Pressure Ulcer Advisor Panel (NPUAP) 2019 revealed nutrition screening should be conducted for those at risk of pressure injury and comprehensive nutrition assessments should be conducted for adults screened to be at risk for malnutrition and at risk of a pressure injury and for all adults with a pressure injury. If nutritional requirement cannot be achieved by normal dietary intake, offer calorie-and protein-fortified foods and/or nutritional supplements to the usual diets of adults at risk for pressure injury and are malnourished/at risk for malnutrition. Provide high-calorie, high protein, arginine, zinc, and antioxidant oral nutritional supplements or enteral formulas to adults with Stage II or greater pressure injury and are malnourished/at risk of malnutrition. Develop and implement individualized nutrition care plans for those with or at risk of a pressure injury and who are malnourished or at risk of malnutrition. Residents Affected - Few This deficiency represents non-compliance investigated under Master Complaint Number OH00147667 and Complaint Number OH00147570. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365607 If continuation sheet Page 4 of 4