Inspection·October 24, 2019

F 0686 Level of Harm - Actual harm Residents Affected - Few Review of the resident's nursing notes dated 07/08/19 revealed a new pressure ulcer was noted to the coccyx, stage two open area 1.0 cm x 0.4 cm x less than 0.1 cm. No drainage was noted and no signs of infection. The wound bed was pink with surrounding skin reddened. New treatment order was obtained. Review of physician's orders dated 07/08/19 revealed an order to update the skin grid pressure form every Tuesday. Continued review of the physician's orders revealed an order dated 07/08/19 and renewed on 07/29/19 to cleanse wound to coccyx with normal saline, apply skin prep to surrounding areas and cover with adhesive foam every three days, and as needed. House barrier cream apply topically to affected areas after each incontinent episode. Review of the weekly pressure skin grid dated 07/09/19 revealed an area to the coccyx with original date of wound documented as 07/09/19. There were no measurements. The wound was described as having a pink wound bed with reddened surrounding skin. The physician was notified on 07/09/19. Review of the weekly pressure skin grids revealed no further grids were completed until 07/23/19. The description was a coccyx pressure wound originated on 07/09/19. The wound bed was pink with reddened surrounding skin, no drainage, no tunneling, and unchanged. No measurements were documented. Review of the weekly pressure skin grids revealed no further grids were completed until 08/07/19. The original date of the coccyx pressure area was 08/07/19 and the wound was described as pink wound bed with reddened surrounding skin. No drainage and no tunneling were noted and the wound was improved. No measurements were documented. Review of the resident's Braden scale (a tool to assess a resident's risk of developing a pressure ulcer) dated 09/05/19 revealed she was at moderate risk for a pressure ulcer. Review of the weekly pressure skin grids revealed no further grids were completed until 09/10/19. The original date of the pressure ulcer to the coccyx was 09/10/19. The wound was described as slight pink wound bed. Measurements were 0.5 cm x 0.5 cm x 0 cm. The stage was marked not applicable, and the wound was documented as healed. Review of the resident's weekly skin assessments revealed an assessment was completed on 09/21/19 and indicated the resident had no pressure ulcers. Review of the weekly pressure skin grids revealed on 09/24/19 the resident had a coccyx pressure ulcer that was healed and slightly pink. Review of the resident's shower sheets revealed one completed on 09/24/19 with no open areas. One was also completed on 09/27/19 with the sacrum area circled and open area written in. No further shower sheets after 09/27/19 were provided. Review of the resident's weekly skin assessments revealed an assessment was completed on 09/28/19 and indicated the resident had no pressure ulcers. Review of the resident's nursing notes revealed no nursing notes regarding the resident's coccyx pressure ulcer after 07/08/19 until 10/15/19. On 10/15/19, Licensed Practical Nurse (LPN) #224 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365615 If continuation sheet Page 2 of 11 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 365615 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Belle Springs. 221 North School Street Bellefontaine, OH 43311 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 0686 Level of Harm - Actual harm Residents Affected - Few documented the resident was seen by the wound physician for an unstageable deep tissue injury to the sacrum. Pressure reducing mattress noted on resident's bed, along with pressure reducing pad in wheelchair. The unstageable deep tissue injury was noted to be 3.5 cm x 3.5 cm with light serous drainage noted, with 70% viable tissue and 30% skin. New wound order obtained. The resident was recommended to be off-loaded as tolerated, obtain consent for debridement of wound, and add multivitamin. Review of the resident's October Treatment Administration Record (TAR) revealed weekly skin audits were not signed off as completed on 10/05/19 or 10/12/19. Updated skin grids weekly were not signed off on 10/01/19 or 10/08/19. Nurses continued to sign off on the treatment to cleanse the wound to coccyx with normal saline, apply skin prep to surrounding areas and cover with adhesive foam every three days, and as needed, until 10/13/19. The last nurse to sign off the order as completed was LPN #242 on 10/13/19. Review of the weekly pressure skin grids revealed on 10/15/19 the resident had an unstageable deep tissue injury to the coccyx with an original date of 10/15/19. Measurements were 3.5 cm x 3.5 cm, no depth was noted. Wound was noted to be dark purple in color with light serous drainage. Review of Wound Physician #267's note dated 10/15/19 revealed the resident had an unstageable deep tissue injury sacrum wound with light serous exudate. She had no pain. The wound measured 3.5 cm x 3.5 cm x not measurable. The etiology was pressure. The physician ordered Leptospermum honey apply once daily, cover with foam with border, skin prep to peri-wound daily. Off-load wound, reposition per facility protocol, and obtain consent for debridement. Follow up in seven days. Review of the weekly pressure skin grids revealed on 10/22/19, the wound was described as an unstageable pressure ulcer with measurements of 3.5 cm x 3.5 cm. The wound was described as a deep tissue injury with light serous drainage and dark purple in color. Wound status was marked as declined with the physician aware. Review of physician order dated 10/22/19, revealed the order was changed to cleanse the wound with in house wound cleanser, pat dry and apply desitin to wound, cover with foam border dressing change daily. Review of Wound Physician #267's note dated 10/22/19 revealed the resident continued with an unstageable deep tissue injury to the sacrum measuring 3.5 cm x 5.5 cm x 0.1 cm with light serous exudate. The wound was noted to contain 20% slough, 50% other viable tissues (subcutaneous fat, dermis, muscle), and 30% skin. The wound was debrided to remove necrotic tissue and establish the margins of viable tissue. Surface area was documented as 19.25 square cm of devitalized tissue including slough, biofilm and non-viable subcutaneous fat and surrounding connective tissues were removed to a depth of 0.2 cm and healthy bleeding tissue was observed. MDS post debridement stage of pressure ulcer was stage four. A new treatment was ordered for zinc ointment covered with foam with border, and apply skin prep to peri-wound area once daily. Off load wound, reposition per facility protocol, low air loss mattress. Follow up in seven days. On 10/22/19 at 7:28 P.M., LPN #224 documented Resident #39 was seen by the wound physician during rounds to follow up on wound to sacrum. She was noted to have a fair appetite. The resident's unstageable deep tissue injury wound was noted to deteriorate. Measurements were 3.5 cm x 5.5 cm x 0.1 cm. The physician completed surgical excisional debridement to remove necrotic tissue and establish margins of viable tissue. Procedure surgically excised tissue including slough, bio-film, and non-viable tissue. Hemostasis was achieved and a clean dressing was placed. Wound noted to have light serous (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365615 If continuation sheet Page 3 of 11 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 365615 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Belle Springs. 221 North School Street Bellefontaine, OH 43311 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 0686 Level of Harm - Actual harm Residents Affected - Few drainage and was 20% slough, 50% viable tissue, 30% skin. Physician also noted the resident had moisture associated dermatitis. New orders were obtained. Recommendation from the physician was for the resident to be on a low loss air mattress. Observation of Resident #39's wound care on 10/23/19 at 2:30 P.M. revealed the resident was lying in bed on a pressure relieving mattress (not low air loss). An open area to the resident's sacrum measured 2.0 cm x 2.5 cm with tunneling of unknown depth noted. Surrounding skin was red and macerated. Interview with LPN #224 and the Director of Nursing (DON) on 10/23/19 at 5:55 P.M. revealed Wound Physician #267 came to the facility on [DATE] around 9:30 A.M. until 11:30 A.M. LPN #224 stated she did not get time to put the orders in until approximately 7:45 P.M. and this was after Maintenance Director #258 had left for the day. She stated she told Maintenance Director #258 about the resident's order for a low air loss mattress the morning of 10/23/19 verbally. LPN #224 and the DON verified the resident did not have a low air loss mattress at this time. The facility had low air loss mattresses in house. The DON stated the resident had a pressure relieving mattress for management of pressure ulcers up to stage two. Interview with Maintenance Director #258 on 10/24/19 at 8:27 A.M. revealed he was not informed the resident needed a low air loss mattress until the evening of 10/23/19, after he had already left the building. He stated he received a text message. Telephone interview with LPN #242 on 10/24/19 at 10:10 A.M. revealed she changed the resident's dressing on 10/13/19. She stated the resident's coccyx wound was healed. She stated there was no open area and the skin was blanchable. When asked what open area she cleansed per the order, she stated the resident had a bowel movement and she cleaned her up. She stated she did not question why the order was to cleanse wound to coccyx. She verified she did not document an assessment of the wound or attempt to clarify the order. Interview with Wound Physician #267 via telephone on 10/24/19 at 11:37 A.M. revealed he did not want to speculate as to how the resident's pressure ulcer deteriorated. He stated it was possible the wound had not completely healed as documented on 09/24/19. He stated he saw the wound on 10/15/19 and it appeared as an unstageable deep tissue injury with light drainage. He stated when he debrided the wound on 10/22/19, he saw muscle fibers, so he staged it as a stage four pressure ulcer. Further interview with the DON on 10/24/19 at 3:20 P.M. revealed she asked the wound physician to look at the resident's wound on 10/15/19 as she thought they were still padding and protecting the resident's intact sacrum as a preventative measure. She did not realize the resident's order was for an open area to the coccyx. She stated she wanted the wound physician to observe the wound to see if the foam dressing was still appropriate. She verified the wound physician found an unstageable deep tissue injury on the resident's sacrum on 10/15/19 that was debrided on 10/22/19 and classified as a stage four pressure ulcer. She verified the facility did not document weekly on the resident's coccyx pressure ulcer in the skin grids or nursing notes. She stated they did not have any additional assessments. She verified the nurses were signing off for an open wound dressing, which would indicate a need for a weekly assessment. She verified the sacrum wound was first identified on 07/08/19 as a stage two pressure ulcer, with no further documentation until 07/23/19 with no assessment or measurement of the wound. She verified there was no further documentation until 08/07/19 with no measurement of the wound, then 09/10/19 with measurements of 0.5 x 0.5 x 0 depth slightly pink wound bed, improved, healed. She verified there was no further documentation on the resident's coccyx wound except (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365615 If continuation sheet Page 4 of 11 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 365615 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Belle Springs. 221 North School Street Bellefontaine, OH 43311 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 0686 the nurses continued to sign off every three days on a dressing to an open area on the coccyx until 10/13/19. Level of Harm - Actual harm Residents Affected - Few Review of the NPUAP website revealed an unstageable deep tissue injury was defined as intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. Continued review of the NPUAP website revealed, a stage four pressure ulcer was defined as a full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. Review of a facility policy titled Skin Assessment & Documentation Policy & Procedure dated 12/01/18 revealed a weekly skin assessment must be completed by the nurse and documentation of completion of the assessment is required by initialing the TAR. Document any findings in the nurse's notes or on the weekly skin assessment form. Once a new pressure area is identified, take the following steps: (including) Measure each area once a week and as needed for any changes in the wound. Record the measurements and description on the skin grid pressure form for the appropriate wound. Any changes in skin condition should be reported to the nurse and physician for follow-up. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365615 If continuation sheet Page 5 of 11 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 365615 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Belle Springs. 221 North School Street Bellefontaine, OH 43311 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #3 revealed an admission dated of 04/19/19. Diagnoses included acute and chronic respiratory failure with hypoxia, unspecified voice and resonance disorder, diabetes type two, hyperlipidemia, hypertension, non traumatic intracranial hemorrhage, dysphagia, chronic obstructive pulmonary disease, gastro-esophageal reflux disease, muscle weakness, cognitive communication deficit and gastrostomy status. Review of admission MDS assessment completed 04/23/19 documented Resident #3 had moderately cognitively impaired. Further review documented she required an extensive two person assist for extensive assistance for dressing. She was also assessed as having impairment to one side of her body. The MDS did documented occupational therapy (OT)minutes of therapy given to the resident. Review of comprehensive care plan documented Resident #3 had an ADL self care deficit related to her cardiovascular accident (CVA), and respiratory failure. Further review documented an intervention to wear cervical collar five hours daily which included to monitor the skin prior to application and when removed and to report any areas to the nurse/physician. Review of the STNA's visual/bedside Kardex report undated documented intervention to wear cervical collar five hours daily which included to monitor the skin prior to application and when removed and to report any areas to the nurse/physician. Review of OT evaluation and plan of treatment dated 04/15/19 lacked any documentation of Resident #3 having a contracture to her neck. Further review of an assessment documented she had normal tone to her upper extremities and was dependent of staff for all her ADL care. Review of OT Discharge summary dated [DATE] documented Resident #3 had a discharge goal to tolerate neck brace six hours per day with no irritation to prevent neck left lateral neck contracture and preserve skin integrity. Further review documented a discharge recommendation for 24 hour nursing care and splint and brace (Cervical/Miami J collar). Review of physician order dated 07/02/19 documented patient was to wear cervical collar as tolerated up to five hours per day. Review of physician orders from 09/01/19 through 10/22/19 lacked any documented order to to discontinue Resident #3 cervical J collar. Review of nursing notes from 09/01/19 through 10/04/19 lacked any documentation of Resident #3 refusing to wear the brace or documentation of the brace being applied when and for how long it was tolerated. Review of the TAR for September 2019 documented an order for patient to wear cervical collar as tolerated up to five hours per day. Further review lacked any documentation of the task being completed with for your information written to the side of the order. Review of TAR for October 2019 documented an order for patient to wear cervical collar as tolerated up to five hours per day. Further review lacked any documentation of the task being completed with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365615 If continuation sheet Page 6 of 11 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 365615 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Belle Springs. 221 North School Street Bellefontaine, OH 43311 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 0688 Level of Harm - Minimal harm or potential for actual harm for your information written to the side of the order. The order was also crossed out like it was discontinued but lacked any initials or date of discontinuation. On 10/21/19 1:49 P.M. an observation was made of Resident #3. Her neck appeared to have a contracture leaning towards her left shoulder while laying on her back in bed. There was no splint device observed. Residents Affected - Few On 10/21/19 at 4:00 P.M. an observation was made of Resident #3, her neck was leaning towards her left should with no splint device in place. On 10/22/19 at 3:20 P.M. interview with STNA #204 verified she worked with Resident #3 on a regular basis and was not aware of her having a cervical J collar neck brace. She stated she had never put a neck brace on and it had not been in place as far as she knew. She also verified usually an order for a brace would be on the STNA's Kardex (care plan) when they were to apply the braces for a resident. On 10/22/19 at 3:22 P.M. interview with LPN #236 verified she thought the order for Resident #3 cervical J collar brace had been discontinued sometime this month due to non compliance. She revealed she took care of Resident #3 frequently. She also revealed the order was for up to five hours a day as tolerated. She verified there was no documentation for how long Resident #3 was able to tolerate the brace or documentation of her refusing to wear the brace. She also revealed there was no schedule or specific directions on when and who was to apply the brace for the five hours a day as tolerated. She then verified the cervical J collar had not been in place on 10/21/19 and 10/22/19. On 10/22/19 at 3:23 P.M. interview with Certified Occupational Therapy Assistant (COTA) #265 verified the J collar was recommended for Resident #3 when she was discharged from therapy. He stated this would have been communicated to nursing. He verified if it was recommended it should be kept in place until an evaluation was done again or a physician discontinued it because of non use. He further verified per the original assessment from the therapist the resident did not have a neck contracture documented with a degree of contracture. He verified a therapist would need to evaluate her to assess her neck for a contracture and prescribed need therapy for them to make determination on what she would need now before they could provide her any therapy care. On 10/22/19 at 3:27 P.M. interview with DON verified Resident #3 did have a care plan in place for nursing and on the STNA's Kardex (care plan) to wear the cervical J collar as tolerated for five hours a day. She further verified there was no specific instruction of when this was to be done and/or by whom. She verified typically the STNA's put the splint devices in place and the nurses ensure the devices are in place. The nurses should document in the nursing notes if a resident refused. She verified they there was no documentation of refusal in the nursing notes. She also verified there was a current physician order for the cervical J collar and it should have been in place as ordered. She also verified it was crossed out on the treatment record for October 2019 and she did not know why. On 10/24/19 at 10:22 A.M. during an interview OT #266 verified Resident #3 did not have any contracture to her neck when she was evaluated for OT. She further revealed upon her discharge from OT the cervical J collar was in place to prevent a contracture to her neck from occurring as documented per the resident goal. On 10/24/19 at 10:51 A.M. an observation of an OT assessment completed per OT #266 revealed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365615 If continuation sheet Page 7 of 11 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 365615 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Belle Springs. 221 North School Street Bellefontaine, OH 43311 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #3 did not have a contracture to her neck. She revealed the muscles were tight and with massage and stretching of Resident #3 neck, she was able to complete full passive range of motion of Resident #3's neck. Review of policy and procedure for Splint/Brace device dated June 2014 documented splint/braces are removable devices used to prevent or control the progression of contractures, and the stabilization of muscles and joints. Further review documented to review the splint order and follow all specifications related to the physician order of the splint device. It also revealed to document the application and removal of the splint device, condition of the site, range of motion and resident tolerance. Based on medical record review, observations, staff interviews, and review of facility policy, the facility failed to ensure treatments were in place to prevent a reduction in range of motion (ROM). This affected two (Resident #3 and #7) of three residents reviewed for limited range of motion. The facility identified nine residents with contractures. The facility census was 60. Findings include: 1. Review of Resident #7's medical record revealed an admission date of 10/12/18. Medical diagnoses included malignant neoplasm of recto-sigmoid junction, aphasia following cerebrovascular disease, colostomy status, neuromuscular dysfunction of bladder, and secondary malignant neoplasm of liver and intrahepatic bile duct. The resident was receiving hospice services since 02/13/19. Review of the resident's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had short and long term memory problems. He was able to recall staff names and faces and able to recall that he was in a nursing home. His cognition was severely impaired. He had no behaviors and no rejection of care. He required extensive assistance with one staff for bed mobility, locomotion, dressing, toilet use, and hygiene. He had impairment on both sides of the upper and lower extremities. He had not received any range of motion or splint/brace assistance. Review of the resident's physician's orders revealed an order dated 11/02/18 for resident to wear left hand splint up to six hours per day as tolerated, preferably at night, and to wear carrot orthotic when not wearing splint as tolerated. Continued review of the physician's order revealed no order to discontinue orthotic use to the resident's left hand until 10/23/19. Review of the resident's rehabilitation screening dated 12/15/18, revealed the resident was referred from nursing. The resident was recently discharged from occupational and physical therapy on 11/02/18, with restorative ROM recommended for upper and lower extremities. Recommendation was to continue use of the carrot in left hand at all times as tolerated except when using left hand wrist hand finger orthotic (WHFO) six hours per day as tolerated, as per orders written 11/02/18. No changes since that date. Review of the resident's care plan revealed a care plan revised on 02/12/19 for activities of daily living (ADLs) self care deficit as evidenced by needs assist with bathing, dressing, mobility, toileting, hygiene related to hydrocephalus. The goal was to receive assistance necessary to meet ADL needs. Interventions included left hand splint was to be on six hours per day and hand carrot to be in place when splint is not on as tolerated (11/05/18). Review of the resident's Treatment Administration Records (TARs) revealed no documentation of WHFO (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365615 If continuation sheet Page 8 of 11 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 365615 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Belle Springs. 221 North School Street Bellefontaine, OH 43311 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 0688 orthotic or carrot orthotic since 04/07/19. Level of Harm - Minimal harm or potential for actual harm Review of the resident's nursing notes from 04/07/19 through 10/24/19 revealed no documentation of the resident refusing to wear a splint or carrot device. Residents Affected - Few Observation of Resident #7 on 10/21/19 at 10:25 A.M. and on 10/23/19 at 9:08 A.M., 10:30 A.M., 11:12 A.M., and 2:50 P.M. revealed his left hand had limited range of motion. He had no type of splint device in place and none was noted in his room. Review of the resident's document titled Bedside Kardex Report dated 10/23/19 revealed a mobility section with interventions of left hand splint was to be on six hours per day and hand carrot to be in place when splint was not on as tolerated. Interview with State Tested Nursing Assistant (STNA) #206 on 10/23/19 at 11:12 A.M. stated she had not seen a carrot or splint for the resident for at least a month or so. STNA #206 looked through the resident's room and could not find carrot or splint device. She looked on the STNA computerized care card and verified the resident was to have a left hand splint six hours per day and a hand carrot to left hand when splint not tolerated. Interview with Licensed Practical Nurse (LPN) #232 on 10/23/19 at 11:34 A.M. revealed she was not sure what the resident's splint schedule was. She stated she had been at the facility for a few months and had not seen a splint device for the resident. She verified there was no documentation on the current TAR for a carrot or splint orthotic. LPN #232 looked in the resident's room and could not find a carrot or splint. Interview with STNA #254 on 10/23/19 at 2:50 P.M. revealed she had placed a carrot device in the resident's left hand at times, but she had not seen the carrot device lately. She was able to locate the resident's carrot device in his drawer. She asked him if she could put it in his left hand and he shook his head yes. The device fit in the resident's left hand with no indication of pain. She was not able to locate the WHFO device. Interview with the Director of Nursing (DON) on 10/23/19 at 3:31 P.M. verified the resident's splint and carrot device had not been on the TAR or current physician's orders since April 2019. She stated the orders for the splint devices did not show up on May orders. She did not know why the orders fell off. She verified there was no discontinuation order (until 10/23/19) and the resident was still care planned to receive a splint and carrot device for his left hand. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365615 If continuation sheet Page 9 of 11 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 365615 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Belle Springs. 221 North School Street Bellefontaine, OH 43311 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 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Minimal harm or potential for actual harm Based on review of employee files and staff interview the facility failed to provide documentation of State Tested Nursing Assistants (STNA) having completed 12 hours annual in-service training. This affected two STNAs (#206 and #229) of two reviewed for annual in-service training. This had the potential to effect all 60 residents residing in the facility. Residents Affected - Many Findings include: Review of the employee file of STNA #206 revealed a hire date of 07/09/08. The file did not contain the required 12 hour annual in-service training. Review of the employee file of STNA #229 revealed a hire date of 05/30/84. The file did not contain the required 12 hour annual in-service training. Interview on 10/24/19 at 2:40 P.M. the Administrator verified the facility was unable to provide documentation confirming any STNA had completed the required 12 hour annual in-service training. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365615 If continuation sheet Page 10 of 11 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 365615 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Belle Springs. 221 North School Street Bellefontaine, OH 43311 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on medical record review and staff interview the facility failed to ensure physicians responded timely to pharmacy recommendations. This effected two (Residents #6 and #19 ) of five residents reviewed for unnecessary medications. The facility census was 60. Findings include: 1. Review of the medical record of Resident #6 revealed an admission date of 09/27/14. Diagnoses included essential hypertension, abnormal posture, hypothyroidism, dysphagia, muscle weakness, mixed receptive-expressive disorder, generalized anxiety disorder, Alzheimer's dementia with combative features, and depression. Review of the physician recommendation form dated 06/14/19 revealed the pharmacist recommended laboratory (lab) tests of basic or complete metabolic panel (to evaluate kidneys, blood glucose level, and electrolyte and acid/base balance), a hemoglobin A1C (tells average level of blood sugar over the past two to three months), a liver function test or lipid panel (to evaluate functioning of the liver) and a complete blood count (to evaluate overall health) every six months related to Resident #6 receiving an anti-psychotic medication. The form remained absent for any response from the physician. A second physician recommendation form dated 08/09/19 revealed the antipsychotic medication, quetiapine, was due to be reviewed for possible gradual dose reduction. The physician indicated The benefits outweigh the risks. The physician signed the form on 10/15/19. 2. Review of the medical record of Resident #19 revealed an admission date of 10/29/15. Diagnoses included type 2 diabetes mellitus with unspecified complications, acquired absence of right leg below knee, abnormal findings on diagnostic imaging of other parts of musculoskeletal system, abnormal posture, other obstructive an reflux uropathy, bladder-neck obstruction, polyneuropathy unspecified, iron deficiency anemia unspecified, left bundle-branch block unspecified, gastro-esophageal reflux disease without esophagitis, Barrett's esophagus with dysplasia unspecified, muscle weakness generalized, diabetic neuropathy unspecified, hyperlipidemia unspecified, paranoid schizophrenia, bipolar disorder, unspecified, essential hypertension, unspecified atrial fibrillation, constipation, other congenital malformations of vas deferens, epididymis, seminal vesicles and prostate, iron insufficiency anemia, and lower obstructive reflux uropathy. Review of the physician recommendation form dated 05/15/19 for Resident #19 revealed the pharmacist recommended a thyroid stimulating hormone test related to Resident #19 receiving levothryroxine and a lipid panel and liver function test related to the resident receiving atorvastatin. The form remained absent of any response from the physician. Interview on 10/22/19 at 3:15 P.M. with the Administrator and Corporate Nurse (CN) #264 provided verification of the three month lapse in the physician acting upon a pharmacy recommendation for Resident #6. Interview on 10/24/19 at 2:00 P.M. with Licensed Practical Nurse (LPN) #224 provided verification the facility failed to ensure the physician responded to a recommendation from the pharmacy regarding Residents #6 and #19's suggested lab tests. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365615 If continuation sheet Page 11 of 11