Inspection·January 29, 2024

F 0559 [DATE] to 12/20/23 the facility moved her stuff to a different room without notifying her. Level of Harm - Minimal harm or potential for actual harm Interview on 01/29/24 at 3:30 P.M. with DON confirmed the medical record for Resident #49 did not contain documentation to support the facility notified Resident #49 of her room change on 12/12/23 while she was hospitalized from [DATE] to 12/20/23. Residents Affected - Few Review of the facility policy titled, Transfer, Room to Room, revised December 2016, stated the facility was to orient the resident to the transfer in a form and manner that the resident can understand and included location of room, who is the new roommate, if any, who would be providing the resident's care, that visitors would be information and why the transfer is taking place. The policy stated the information should be recorded in the resident's medical record include date/time room transfer was made, names and titles of staff who assisted with the move, how the resident tolerated the move, any assessment data obtained during the room move, if the resident refused, the resident why and the intervention taken, and the signature and title of person recording the data. This deficiency represents non-compliance investigated under Complaint Number OH00149671. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365607 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 365607 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/29/2024 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interviews, review of the facility Self-Reported Incidents (SRI), and policy review, the facility failed to ensure residents were free from resident-to-resident sexual abuse. This affected two (#11 and #62) out of the three residents reviewed for abuse. The facility census was 71. Findings included: 1. Review of the medical record for Resident #62 revealed an admission date of 01/07/22 with medical diagnoses of Alzheimer's disease, legal blindness, hypertension, and adult failure to thrive. Review of the medical record for Resident #62 revealed a quarterly Minimum Data Set (MDS), dated [DATE], which indicated Resident #62 had moderate cognitive impairment and required supervision with eating and substantial staff assistance with toilet hygiene, bed mobility, transfers, and bathing. Review of the medical record for Resident #62 revealed a Social Service note dated 01/11/24 at 2:07 P.M. which stated an attempt was made to contact the resident's power of attorney (POA) to notify him of an incident that occurred today with a male resident. The note stated there was no answer and a message was left requesting a return call. Review of the medical record revealed no further documentation related to an incident on 01/11/24. 2. Review of the medical record for Resident #11 revealed an admission date of 03/22/22 with medical diagnoses of Huntington's disease, mild Intellectual Disabilities, anxiety, and dysphagia. Review of the medical record for Resident #11 revealed a quarterly MDS, dated [DATE], which indicated Resident #11 is sometimes understood, able to understand information, and per staff interview alert and oriented to person, place, and time. Review of the MDS revealed Resident #11 required supervision with eating, transfers, and bed mobility and substantial staff assistance with toilet hygiene and bathing. Review of the medical record for Resident #11 revealed a nurse's note dated 01/15/24 at 8:00 P.M. which stated a staff member notified the nurse that a male resident was observed with his hands on her chest. The note stated Resident #11 was removed from the situation, assessed head to toe, and the Director of Nursing (DON) was notified. Review of the medical record for Resident #11 revealed no documentation related to the incident investigated for the SRI dated 01/11/24. 3. Review of the medical record for Resident #35 revealed an admission date of 03/01/23 with medical diagnoses of Coal worker's pneumonoconiosis, Parkinson's disease, atherosclerotic heart disease (ASHD), and atrial fibrillation. Review of the medical record for Resident #35 revealed a quarterly MDS, dated [DATE], which indicated Resident #35 had moderate cognitive impairment and required substantial/maximum staff assistance with toileting hygiene, bathing, and bed mobility and was dependent for transfers. Review of the medical record for Resident #35 revealed a nurse's note dated 01/11/24 at 12:13 P.M. which stated the nurse was notified that Resident #35 was observed being inappropriate with other female residents. The note stated Resident #35 was observed grabbing at female resident breasts and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365607 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 365607 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/29/2024 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 0600 genital area. Level of Harm - Minimal harm or potential for actual harm Review of the medical record revealed a Social Service note dated 01/11/24 at 1:47 P.M. that Resident #35 was observed by care staff in the dining room grabbing at the breasts of two female residents. The note stated Resident #35 was questioned regarding his behavior and he admitted to touching Resident #11 and Resident #62's breasts but could not state why he did it. Residents Affected - Few Review of the medical record for Resident #35 revealed a physician order dated 01/11/24 for resident to be always visible by staff when not in bed and to document on behaviors every shift. The medical record revealed an order dated 01/12/24 for medroxyprogesterone acetate 10 milligrams one tablet by mouth daily for sexual behaviors. Review of the medical record for Resident #35 revealed a behavior care plan dated 01/12/24 which stated Resident #35 had the potential to be physically aggressive related to history of harm to others and poor impulse control. The interventions included medications as ordered and to document behaviors. 4. Review of the medical record for Resident #75 revealed an admission date of 10/15/20 with medical diagnoses of cerebral infarction with right hemiparesis, chronic obstructive pulmonary disease, depression, and hyperlipidemia. Review of the medical record revealed Resident #75 discharged from the facility on 01/21/24. Review of the medical record for Resident #75 revealed a quarterly MDS, 01/10/24, which indicated Resident #75 was cognitively intact and was independent with eating, bed mobility, transfers, and toilet hygiene. No behaviors were noted on the MDS. Review of the medical record for Resident #75 revealed a nurse's note dated 01/15/24 at 10:30 P.M. which stated Resident #75 was observed touching another female resident inappropriately in the dining room which was witnessed by the dietary staff. Further review of the note stated the DON and Administrator were notified and the police department was contacted. Review of the medical record revealed a nurse's note dated 01/17/24 at 10:34 A.M. which stated a police officer came to the facility to notify Resident #75 he was being charged with a crime related to the incident on 01/15/24. Review of the medical record for Resident #75 revealed a physician order dated 01/15/24 which stated if the resident must be supervised at all times by a staff member when he comes out of his room. Review of the SRI dated 01/11/24 stated Resident #35 was observed by staff to be touching Resident #11 and Resident #62's breasts over the top of their shirts while sitting in the dining room. Review of the SRI revealed an investigation was completed which included resident and staff interviews, resident assessments, and staff education. The SRI stated neither resident had any adverse effects from the incident. The SRI indicated the facility substantiated the allegation of abuse. Review of the SRI dated 01/15/24 stated Resident #75 was observed by staff with his hands down the front of Resident #11's shirt and was touching her breasts. The SRI stated an investigation was completed which included resident and staff interviews, resident assessments, police notification, and staff education on abuse. The SRI indicated the facility substantiated the allegation of abuse. Interview on 01/29/24 at 4:00 P.M. with DON confirmed the facility substantiated the allegation of sexual abuse by Resident #35 to Resident #11 and Resident #62 on 01/11/24 after a thorough (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365607 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 365607 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/29/2024 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few investigation. DON also confirmed the facility substantiated the allegation of sexual abuse by Resident #75 to Resident #11 on 01/15/24 after a thorough investigation. Review of the facility policy titled, Abuse and Neglect, revised March 2018, stated sexual abuse was defined as non-consensual sexual contact of any type with a resident. The policy stated the residents would be assessed, the physician would be notified, and the facility management and staff would institute measures to address the needs of residents and minimize the possibility of abuse and neglect. This deficiency represents non-compliance investigated under Complaint Number OH00150359. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365607 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 365607 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/29/2024 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 0742 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, and staff interviews, the facility failed to provide adequate behavioral supervision for Resident #35, in accordance with the residents physician orders. This affected one (#35) out of three reviewed for sexual behaviors. The facility census was 71. Findings included: Review of the medical record for Resident #35 revealed an admission date of 03/01/23 with medical diagnoses of Coal worker's pneumonoconiosis, Parkinson's disease, atherosclerotic heart disease (ASHD), and atrial fibrillation. Review of the medical record for Resident #35 revealed a quarterly Minimum Data Set (MDS), dated [DATE], which indicated Resident #35 had moderate cognitive impairment and required substantial/maximum staff assistance with toileting hygiene, bathing, and bed mobility and was dependent for transfers. Review of the medical record for Resident #35 revealed a nurse's note dated 01/11/24 at 12:13 P.M. which stated the nurse was notified that Resident #35 was observed being inappropriate with other female residents. The note stated Resident #35 was observed grabbing at female resident breasts and genital area. Review of the medical record revealed a Social Service note dated 01/11/24 at 1:47 P.M. that resident was observed by care staff in the dining room grabbing at the breasts of two female residents. The note stated Resident #35 was questioned regarding his behavior and he admitted to touching Resident #11 and Resident #62's breasts but could not state why he did it. Review of the medical record for Resident #35 revealed a physician order dated 01/11/24 for resident to be always visible by staff when not in bed and to document on behaviors every shift. The medical record revealed an order dated 01/12/24 for medroxyprogesterone acetate 10 milligrams one tablet by mouth daily for sexual behaviors. Review of the medical record for Resident #35 revealed a behavior care plan dated 01/12/24 which stated Resident #35 had the potential to be physically aggressive related to history of harm to others and poor impulse control. The interventions included medications as ordered and to document behaviors. Observation on 01/29/24 at 11:48 A.M. revealed Resident #35 sitting in the dining room with other female residents, identified as Resident #11 and Resident #62. The observation revealed no staff were present to supervise Resident #35 while he was in the dining room with the other female residents. Observation with interview on 01/29/24 at 11:52 A.M. with State Tested Nursing Assistant (STNA) #217 confirmed Resident #35 was sitting in the dining room alone with Resident #11 and Resident #62 and there was not any staff present to supervise Resident #35. Interview on 01/29/24 at 4:00 P.M. with Director of Nursing (DON) confirmed Resident #35 was not to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365607 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 365607 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/29/2024 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 0742 be left unsupervised when out of his room. Level of Harm - Minimal harm or potential for actual harm This deficiency is based on incidental findings discovered during the course of this complaint investigation. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365607 If continuation sheet Page 7 of 7