Inspection·June 26, 2025

F 0641 Review of the Long-Term Care Facility RAI 3.0 User's Manual dated October 2024 page L-1 to L-2 revealed to code a resident edentulous the resident would lack all natural teeth or parts of teeth. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365607 If continuation sheet Page 2 of 15 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 06/26/2025 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Based on medical record review and staff interview, the facility failed to ensure a resident Preadmission Screening and Resident Review (PASARR) evaluations were accurate and updated. This affected one (Resident #2) of the two residents reviewed for PASARR evaluations. The facility census was 76 residents. Findings include: Review of the medical record for Resident #2 revealed an admission date of 03/11/21 with diagnoses including anxiety disorder, post-traumatic stress disorder (PTSD), psychotic disorder with delusions, bipolar disorder, major depressive disorder, and type two diabetes mellitus. Review of the Minimum Data Set (MDS) assessment for Resident #2 dated 05/07/25 revealed the resident was moderately cognitively impaired. Review of the PASARR for Resident #2 dated 03/11/21 revealed the resident had no diagnoses of mental disorders listed in section-D (indication of serious mental Illness). A box was checked no for having any of the mental disorders listed which included schizophrenia, mood disorder, delusional (paranoid) disorder, panic or other severe anxiety disorder, somatoform disorder, personality disorder, other psychotic disorder, and another mental disorder other than mental retardation that may lead to a chronic disability. Further review of Resident #2's medical record revealed no documentation of an updated PASARR being completed. The diagnosis of PTSD was added 02/21/21, the diagnosis of bipolar disorder was added 03/11/21, and the diagnosis of psychotic disorder with delusions was added 05/01/25. Interview on 06/24/25 at 3:20 P.M. with Social Services Director (SSD) #215 confirmed Resident #2's PASARR dated 03/11/22 was not accurate, and the facility had not completed an update PASARR to include the mental health diagnoses which were added for the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365607 If continuation sheet Page 3 of 15 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 06/26/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to develop accurate person-centered comprehensive care plans. This affected one (Resident #54) of two residents reviewed for dental/oral status. The facility census was 76 residents. Findings include: Review of the medical record for Resident #54 revealed an admission date of 11/01/23 with diagnoses including right hemiparesis, dysphagia, hypertension, seizures, and diabetes mellitus. Review of the person-centered comprehensive care plan for Resident #54 dated 11/13/23 revealed the resident was at risk for oral/dental problems related to being edentulous. Review of the annual Minimum Data Set (MDS) assessment for Resident #54 dated 11/07/24 revealed the resident was edentulous. Review of a dental assessment for Resident #54 dated 02/05/25 revealed the resident had some teeth in all four quadrants. Review of the MDS assessment for Resident #54 dated 04/20/25 revealed the resident had severely impaired cognition, required supervision with eating, required substantial/maximum staff assistance with oral hygiene, and no oral or dental issues. Observation on 06/25/25 at 7:14 A.M. of Resident #54 with Director of Nursing (DON) revealed the resident had several teeth to upper and lower jaw. Interview on 06/25/25 at 7:15 A.M with the DON confirmed Resident #54 had several teeth to the upper and lower jaw Interview on 06/25/25 at 7:42 A.M. with MDS Nurse #205 confirmed Resident #54's annual MDS dated [DATE] and person-centered comprehensive care plan indicated Resident #54 was edentulous. MDS Nurse #205 also confirmed the facility dental assessment dated [DATE] indicated Resident #54 had teeth and was not edentulous. MDS Nurse #205 confirmed the facility had not developed a comprehensive care plan regarding the resident's dental needs. Review of the policy titled Care Planning dated 04/28/22 revealed the facility's care planning/interdisciplinary team was responsible for the development of an individualized comprehensive care plan for each resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365607 If continuation sheet Page 4 of 15 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 06/26/2025 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure members of the Interdisciplinary Team (IDT) were present at care conferences and failed to conduct care conferences as required. This affected five (Residents 16, #24, #28, #38, and #70) of five residents reviewed for care conferences. The facility census was 76 residents. Findings include: 1. Review of the medical record for Resident #24 revealed an admission date of 03/17/25 with diagnoses including acute kidney failure, hypertension, dehydration, morbid obesity, and congestive heart failure. Review of the care conference summary for Resident #24 dated 03/20/25 revealed the participants included the resident and Social Service Director (SSD) #215. There were no other IDT members present. Interview on 06/24/25 03:20 P.M with SSD #215 confirmed she was the only IDT member present at Resident #24's admission care conference on 03/20/25. 5. Review of the medical record for Resident #16 revealed an admission date of 05/14/25 with diagnoses including cellulitis to left lower limb, acute thrombosis of left popliteal vein, and diabetes mellitus with a discharge date of 06/06/25. Review of a care conference summary for Resident #16 dated 05/19/25 revealed the resident and SSD #215 attended the care conference. Review of the summary revealed it did not include documentation of SSD #215's review of medications, therapies, or treatments with Resident #16. Interview on 06/25/25 at 8:32 A.M. with SSD #215 confirmed an initial care conference was conducted with Resident #16 on 05/19/25. SSD #215 confirmed the attendees to care conference included the SSD and the resident with no other members of the IDT in attendance. SSD #215 stated she discussed discharge plans with Resident #16 at the care conference on 05/19/25, but she did not review medications, treatments, or therapy services provided with the resident. Review of the facility policy titled Care Conferences revised January 2020 revealed the facility's Care Planning/IDT was responsible for the development of an individualized comprehensive plan for each resident. The policy stated care conferences would be scheduled to include the resident, resident's representative and IDT as soon as possible after admission, routinely, and with a change in condition. Members of the IDT included Registered Nurse (RN), Dietary Manager, Social Service, therapists, nursing assistants, and others as appropriate or necessary to meet the needs of the resident. 2. Review of the medical record for Resident #28 revealed an admission date of 01/14/23 with diagnoses including hemiplegia and hemiparesis following cerebral infraction, major depressive disorder, and type two diabetes mellitus. Review of the medical record for Resident #28 revealed care conferences were completed on 08/30/24 and 03/28/25. Interview on 06/25/25 at 12:15 P.M. with SSD #215 confirmed care conferences should be completed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365607 If continuation sheet Page 5 of 15 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 06/26/2025 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 0657 Level of Harm - Minimal harm or potential for actual harm quarterly and the facility only completed two care conference in the prior year for Resident #28 on 08/30/24 and 03/28/25. 3. Review of the medical record for Resident #38 revealed an admission date of 03/22/22 with diagnoses including Huntington's disease, major depressive disorder, and anxiety disorder. Residents Affected - Some Review of the medical record for Resident #38 revealed care conferences were completed on 09/06/24 and 12/13/24. Interview on 06/25/25 at 12:14 P.M. with SSD #215 confirmed only two care conferences had been completed for Resident #38 in the past year on 09/06/24 and 12/13/24. 4. Review of the medical record for Resident #70 revealed an admission date of 11/25/24 with diagnoses including metabolic encephalopathy, type two diabetes mellitus, Alzheimer's disease, and depression. Review of the medical record for Resident #70 revealed care conferences were completed on 11/29/24 and 12/10/24. Interview on 06/25/25 at 9:57 A.M. with SSD #215 confirmed only two care conferences had been completed for Resident #70 in the past year on 11/29/24 and 12/10/24. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365607 If continuation sheet Page 6 of 15 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 06/26/2025 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, observation, resident interview, staff interview, and review of the facility policy, the facility failed to provide cares/services to dependent residents to maintain adequate personal hygiene. This affected one (Resident #6) of the three residents reviewed for activities of daily living (ADLs). The facility census was 76 residents. Residents Affected - Few Findings include: Review of the medical record for Resident #6 revealed an admission date of 01/11/19 with diagnoses including chronic obstructive pulmonary disease, schizoaffective disorder-bipolar type, and depression. Review of the Minimum Data Set (MDS) assessment for Resident #6 dated 05/12/25 for the resident had severely impaired cognition and required moderate staff assistance with personal hygiene. Observation on 06/23/25 at 1:46 P.M. of Resident #6 revealed the resident had gray facial hair on her chin. Interview on 06/23/25 at 1:47 P.M. with Resident #6 confirmed she had gray facial hair on her chin and sometimes staff removed her facial hair, but they had not done so in a long time. Observation on 06/24/25 at 11:43 A.M. revealed Resident #6 had gray facial hair on her chin Interview on 06/24/25 at 11:47 A.M with Certified Nursing Assistant (CNA) #335 confirmed Resident #6 had gray facial hair on her chin. CNA #335 stated staff were expected to trim the facial hair for both men and women on shower days and as needed. Interview on 06/25/25 at 1:27 P.M. with the Director of Nursing (DON) confirmed staff were expected to provide residents with assistance with facial hair removal as needed even if the resident refused showers. Review of the facility policy titled Activities of Daily Living dated 04/28/25 revealed appropriate care and services would be provided for residents who were unable to carry out ADLs independently with the consent of the resident and in accordance with the care plan to include assistance with hygiene. Residents who were unable to carry out ADLs independently would receive services necessary to maintain good personal hygiene. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365607 If continuation sheet Page 7 of 15 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 06/26/2025 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 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm Based on medical record review and staff interview, the facility failed to schedule timely ophthalmology appointments for residents. This affected one (Resident #28) of 21 residents sampled. The facility census was 76 residents. Residents Affected - Few Findings include: Review of the medical record review for Resident #28 revealed an admission date of 01/14/23 with diagnoses including hemiplegia and hemiparesis following cerebral infraction, major depressive disorder, and type two diabetes mellitus. Review of the Minimum Data Set (MDS) assessment for Resident #28 dated 05/22/25 revealed the resident was cognitively intact. Review of the progress note for Resident #28 dated 06/04/25 revealed the resident was examined by the facility eye doctor who gave a referral to an ophthalmologist for cataract surgery. Review of the medical record for Resident #28 dated 06/04/25 to 06/25/25 revealed it did not include documentation regarding scheduling the resident for a consultation with an ophthalmologist. Interview on 06/25/25 at 11:55 A.M. with Certified Nursing Assistant (CNA) #326 confirmed she was responsible for scheduling outside doctor appointments and transportation. CNA #326 further confirmed she was aware of Resident #28's referral for ophthalmology, but she had not contacted the ophthalmology office and had not scheduled an appointment for Resident #28. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365607 If continuation sheet Page 8 of 15 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 06/26/2025 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, review of the facility policy, and review of online resources per the Centers for Disease Control and Prevention (CDC), the facility failed to administer antibiotic medications with appropriate indication for use. This affected one (Resident #13) of seven residents reviewed for medications. The facility census was 76 residents. Residents Affected - Few Findings include: Review of the medical record for Resident #13 revealed an admission date of 09/26/24 with diagnoses including Alzheimer's disease, hypertension, chronic kidney disease, type two diabetes, and major depressive disorder. Review of the Minimum Data Set (MDS) assessment for Resident #13 dated 04/03/25 revealed the resident was severely cognitively impaired. Review of physician's orders for Resident #13 revealed an order dated 09/27/24 for an antibiotic, nitrofurantoin oral capsule 50 milligrams (mg), give one capsule by mouth with meals one time a day for urinary tract infection (UTI) prevention. Review of a pharmacy recommendation for Resident #13 dated 06/18/25 revealed the resident #13 was receiving nitrofurantoin for prophylaxis of UTIs. The pharmacy report suggested there was a higher proportion of spontaneous pulmonary reactions, including fatalities, in elderly patients receiving this medication for six months or longer. The pharmacy reports also suggested an increased proportion of severe hepatic reactions, including fatalities, in elderly patients and there was a potential for renal impairment with nitrofurantoin and was also considered a high-risk medication for elderly patients according to Centers for Medicare and Medicaid Services (CMS) since safer alternatives existed. The pharmacist requested the physician to consider changing or discontinuing this medication if it was appropriate. The pharmacy recommendation was signed on 06/24/25 by the physician who agreed to discontinue the nitrofurantoin. Review of Resident #13's medical record revealed it did not include documentation per the physician regarding the rationale for the long-term use of nitrofurantoin. Interview on 06/24/25 at 3:04 P.M. with Assistant Director of Nursing (ADON) #203 confirmed Resident #13 had been on nitrofurantoin since admission on [DATE] for UTI prophylaxis, and the antibiotic order did not have an end date. ADON #203 stated nitrofurantoin was discontinued for Resident #13 per a pharmacy recommendation on 06/24/25. Interview on 06/25/25 at 9:01 A.M with ADON #203 confirmed Resident #13's record did not include documentation per the resident's physician outlining the rationale for the long-term use of nitrofurantoin. Review of the facility policy titled Antibiotic Stewardship dated August 2025 revealed the purpose of the antibiotic stewardship program was to monitor the use of antibiotics. If an antibiotic was indicated, prescribers would provide complete antibiotic orders including the following elements: drug name, dose, frequency of administration, duration of treatment with start and stop date or number of days of therapy, route of administration, indications for use. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365607 If continuation sheet Page 9 of 15 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 06/26/2025 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 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Review of online guidance per the CDC titled The Core Elements of Antibiotic Stewardship for Nursing Homes Appendix A: Policy and Practice Actions to Improve Antibiotic Use page 7 retrieved online on 07/08/25 at https://www.cdc.gov/antibiotic-use/hcp/core-elements/nursing-homes-antibiotic-stewardship.html revealed surveys of antibiotic use in nursing homes had shown UTI prophylaxis accounted for a significant proportion of antibiotic prescriptions, but very few studies supported antibiotic use for UTI prophylaxis, especially in older adults, and many studies had shown this antibiotic exposure increased the risk of side effects and resistant organisms. Therefore, efforts to educate providers on the potential harm of antibiotics for UTI prophylaxis could reduce unnecessary antibiotic exposure and improve resident outcomes. Event ID: Facility ID: 365607 If continuation sheet Page 10 of 15 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 06/26/2025 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, observation, staff interview, and review of manufacturer guidelines, the facility failed to ensure staff primed insulin pen devices prior to insulin administration resulting in significant medication errors. This affected one (Resident #46) of the three residents observed for medication administration. The facility census was 76 residents. Residents Affected - Few Findings include: Review of the medical record for Resident #46 revealed an admission date of 07/13/21 with diagnoses including type two diabetes mellitus, major depressive disorder, hypertension, obstructive sleep apnea, and morbid obesity. Review of the physician's orders for Resident #46 revealed an order dated 12/11/24 for insulin lispro with meals an order dated 02/06/25 for Lantus insulin in the morning. Observation on 06/25/25 at 7:55 A.M. of medication administration for Resident #46 per Licensed Practical Nurse (LPN) #345 revealed the nurse attached a new needle to a Lantus insulin pen and dialed the dose to 52 units and administered the injection to the resident. LPN #345 then attached a new needle to a lispro insulin pen and the dialed the dose to 18 units and administered the injection to the resident. LPN #345 did not prime the pens prior to administration of Lantus insulin and lispro insulin to Resident #46. Interview on 06/25/25 at 7:57 A.M. with LPN #345 confirmed she did not prime the insulin pens prior to administration to Resident #46. Review of manufacturer instructions for the Lantus insulin pen undated revealed to always perform a safety test before each injection to insure an accurate dose. To ensure the pen and needle worked properly and the pen was free of air bubbles, the nurse should take the following steps: select a dose of two units, take off the outer needle cap and keep it to remove the used needle after injection, take off the inner needle cap and discard it, hold the pen with the needle pointing upwards, tap the insulin reservoir so that any air bubbles rise up towards the needle, press the injection button all the way in, check to see if insulin comes out of the needle tip. The nurse may have to perform the safety test several times before insulin is seen. Review of manufacturer instructions for the Lispro insulin pen undated revealed the nurse should prime the pen before each injection. Priming your pen means removing the air from the needle and cartridge that may collect during normal use and ensure that the insulin pen is working correctly. If the nurse did not prime before each injection it could result in the resident getting too much or too little insulin. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365607 If continuation sheet Page 11 of 15 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 06/26/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on medical record review, observation, staff interview and review of the facility policy, the facility failed to ensure medications were stored properly. This affected one (Resident #37) of the five residents observed for medication storage. The facility census was 76 residents. Findings include: Review of the medical record for Resident #37 revealed admission date of 10/24/24 with diagnoses including systemic lupus erythematosus, major depressive disorder, chronic respiratory failure with hypoxia and rheumatoid arthritis. Review of the Minimum Data Set (MDS) assessment for Resident #37 dated 03/31/25 revealed the resident was cognitively intact and required staff set-up with activities of daily living (ADLs.) Observation on 06/25/25 at 3:20 P.M. of Resident #37's room revealed the resident was seated in her chair with the bedside table directly in front of her. On the bedside table there was a bottle of over the counter (OTC) vitamins with a letter M written in black marker on the lid. Interview on 06/25/25 at 3:22 P.M. with Licensed Practical Nurse (LPN) #207 confirmed there was a bottle of OTC vitamins on the resident's bedside table which had been brought in per the resident's daughter. LPN #207 removed the medication from the bedside table and confirmed the vitamins should be stored in an area accessible only to staff. Review of the facility policy titled Medication Storage undated revealed medications should be stored in a manner that was only accessible to authorized personnel. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365607 If continuation sheet Page 12 of 15 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 06/26/2025 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 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, observation, resident representative interview, staff interview, and review of the facility policy, the facility failed to provide routine dental services. This affected one (Resident #54) of two residents reviewed for dental services. The facility census was 76 residents. Residents Affected - Few Findings include: Review of the medical record for Resident #54 revealed an admission date of 11/01/23 with diagnoses including right hemiparesis, dysphagia, hypertension, seizure disorder, and diabetes mellitus. Review of the dental note for Resident #54 dated 03/20/24 revealed the resident was seen by the dentist and had 10 teeth extracted. Further review revealed Resident #54's remaining teeth would need to be extracted, and physician clearance was left at the facility. Review of the dental note for Resident #54 dated 09/30/24 revealed the dentist was in the facility but the resident was not seen because the planned services were unable to be completed in the resident's room. Review of the dental assessment for Resident #54 dated 02/05/25 revealed the resident had some teeth in all four quadrants. Review of the Minimum Data Set (MDS) assessment for Resident #54 dated 04/20/25 revealed the resident had severely impaired cognition, required supervision with eating, and required substantial/maximum staff assistance with oral hygiene. Interview on 06/23/25 at 9:52 A.M. with Resident #54's representative confirmed the resident was supposed to have his remaining teeth pulled a long time ago so the resident could get dentures. Resident #54's Representative stated they did not know when Resident #54 was last seen by the dentist. Observation on 06/25/25 at 7:14 A.M. of Resident #54 with the Director of Nursing (DON) revealed the resident had several teeth to upper and lower jaw. Interview on 06/25/25 at 7:20 A.M. with the DON confirmed Resident #54 had some teeth pulled in 03/20/24 and was supposed to have his remaining teeth pulled after physician clearance. The DON confirmed Resident #54 had not been seen by the dentist since 03/20/24. Review of the facility policy titled Dental Services revealed the facility would arrange for routine and emergency dental services to meet the resident's oral health services in accordance with the resident's assessment and plan of care. Routine and 24-hour emergency dental services were provided to the residents through a contract agreement with a licensed dentist that came to the facility monthly, a referral to a personal dentist, a referral to community dentist, or a referral to other health care organizations that provide dental services. A social service representative would assist residents with appointments, transportation arrangements, and reimbursement of dental services under the state plan, if eligible. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365607 If continuation sheet Page 13 of 15 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 06/26/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, staff interview, and review of the facility policy, the facility failed to ensure food was stored and prepared in a sanitary manner. This had the potential to affect all of the residents residing in the facility with the exception of one facility-identified resident (#79) who had a diet order for nothing by mouth. The facility census was 76 residents. Findings include: 1. Observation on 06/23/25 at 8:03 A.M. revealed employee drinks were stored on dry stock shelves and on top of a box of straws. Interview 06/23/25 at 8:03 A.M. with Dietary Supervisor (DS) #208 confirmed employee personal items should be stored in a way to prevent contamination and should not be stored with the residents' food items or supplies. 2. Observation on 06/23/25 at 8:04 A.M. of the dish machine revealed that it reached 155 degrees Fahrenheit (F) for the wash cycle and 174 degrees F for the final rinse. Interview with DS #208 on 06/23/25 at 8:06 A.M. confirmed the temperature for the wash cycle was 155 degrees F and the temperature for the final rinse was 174 degrees. Review of the dish machine temperature log for June 2025 revealed that the dish machine final rinse cycle reached 180 degrees only once on 06/05/25. All other final rinse temperatures were recorded as being from 170 degrees F to 179 degrees F. There were no water temperatures recorded for the following dates: 06/08/25, 06/19/25, 06/20/25, 06/21/25, and 06/22/25. Interview on 06/23/25 at 8:07 A.M. with DS #208 confirmed the majority of final rinse temperatures recorded for June 2025 did not reach 180 degrees F as required and there were missing water temperatures on the following dates: 06/08/25, 06/19/25, 06/20/25, 06/21/25, and 06/22/25. Review of the facility policy titled Cleaning Dishes/Dish Machine dated 2021 revealed for high temperature dish machines the wash temperature must be between 150 degrees F to 165 degrees F with the final rinse temperature at 180 degrees F. 3. Observation on 06/23/25 at 8:08 A.M. revealed there was an empty soda bottle stored on the clean dish rack with clean bowls stored on the bottom. Interview on 06/23/25 at 8:08 A.M. with DS#208 verified that the soda bottle belonged to an employee, and the dishes underneath were clean. 4. Observation on 06/23/25 at 8:12 A.M. of the walk-in cooler revealed it contained an unlabeled and undated peanut butter cake Interview on 06/23/25 at 8:12 A.M. with DS #208 confirmed the cake was made the day before and did not have a label or a date. Review of the facility policy titled Food Storage dated 2021 revealed all refrigerated foods should (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365607 If continuation sheet Page 14 of 15 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 06/26/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm be covered, labeled, and dated and routinely monitored to assure that foods would be consumed by their safe use by dates or discarded. 5. Observation on 06/23/25 at 8:15 A.M. revealed the guard inside the ice machine had scratches in the plastic with a black residue. Residents Affected - Many Interview on 06/23/25 at 8:15 A.M. with DS #208 confirmed the guard to the ice machine was scratched and had a black residue. Observation on 06/24/25 at 2:48 P.M. revealed DS #208 scrubbed the ice machine guard in the areas that had the black residue with a white cloth. Observation of the cloth revealed dark spots where it was used to clean the guard. Interview on 06/24/25 at 2:49 P.M. with DS #208 confirmed the black residue transferred onto the cloth, but she was unable to completely remove the residue from the guard to the ice machine. 6. Observation on 06/23/25 at 11:35 A.M. revealed [NAME] #377 used her gloved hands to move the lunch tray cart and then began preparing plates for the residents. [NAME] #377 touched and placed biscuits on residents' plates with the same gloved hands. Interview on 06/23/25 at 11:45 A.M. with [NAME] #377 confirmed she touched the cart with her gloved hands and did not change her gloves afterwards. [NAME] #377 confirmed she touched the biscuits with her gloved hands and that she normally used a utensil when handling food. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365607 If continuation sheet Page 15 of 15