Inspection·November 4, 2022

F 0638 Assure that each resident’s assessment is updated at least once every 3 months. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews , record reviews, and policy and procedure review, the facility failed to update one resident's elopement assessment quarterly. This had the potential to affect one Resident ( #09) out of one resident reviewed for elopement. The facility census was 83. Residents Affected - Few Findings include: Review of medical record for Resident #09 revealed resident was admitted on [DATE] with diagnoses including but not limited to dementia with behavioral disturbance, repeated falls, muscle weakness, schizoaffective disorder, seizures, anxiety, schizophrenia, depression, suicidal ideation's, insomnia, auditory hallucinations, visual hallucinations, and wandering. Review of Minimum Data Set (MDS) dated [DATE] revealed resident had moderately impaired cognition. Resident #09 had inattention and disorganized thinking that fluctuated. Resident #09 required extensive assist of one staff member for Activities of Daily Living (ADL's). Review of Care Plan dated 08/01/22 revealed Resident #09 was at risk for elopement/wandering related to dementia, impaired cognition, and schizophrenia. Interventions included but not limited to administer medications as ordered, monitor and report changes in behavior, monitor side effects of medications, provide one on one visits as needed, provide diversional activities of interest as needed, redirection as needed, wander guard to be worn at all times check placement and function, and monitor skin under wander guard. Review of Elopement Risk Assessments dated 10/27/21, 02/27/22, 06/27/22, and 10/27/22 revealed assessments were completed every four months. Interview on 11/03/22 at 11:58 A.M. with Director of Nursing (DON) verified elopement risk assessments were completed every four months. DON verified that it was not completed quarterly. DON verified assessment should be done every three months for quarterly. Review of policy titled Wandering and Elopements not dated revealed residents are assessed upon admission, quarterly, and with change of status. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365615 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 365615 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/04/2022 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 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. Based on interviews and record reviews the facility failed to update a Residents Comprehensive Care Plan . This had the potential to affect one Resident (#42) out of four residents reviewed for care plan's. The facility census was 83. Findings include: Review of medical record for Resident #42 revealed admission date of 10/17/20 with moderate cognitive deficits. The resident was admitted with Type 2 diabetes mellitus , bipolar disorder, anemia, depression, anxiety, and chronic kidney disease. Review of the dentist progress notes on 02/11/22 revealed patient received her dentures for the first time. She has no history of dentures in the past. Patient was having a hard time by herself seating the dentures on her gums for a complete seal. Patient would benefit from denture adhesive until she can completely seat them on her own. Review of Resident #42 Minimum Data Set (10/17/22) did not indicate the resident was edentulous. Review of Resident #42 Plan of Care last updated 10/17/22 revealed no indication resident had dentures. On 11/01/22 at 9:25 A.M. observation and interview with Resident #42 revealed her to be tooth less and not wearing dentures. She requested to have her dentures. On 11/03/22 at 9:50 A.M., the Director of Nursing confirmed Resident #42's plan of care was updated on 11/03/22 to include denture care and wear after surveyor intervention. On 11/03/22 at 11:30 A.M., Resident #42 was observed eating lunch without her dentures. When asked where her dentures were , she stated I need my bottom teeth. On 11/03/22 at 11:57 A.M., interview with State Tested Nursing Assistant (STNA) # 403 revealed she was aware Resident #42 has dentures. She confirmed Resident #42 was not wearing her dentures. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365615 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 365615 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/04/2022 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, interview, and review of facility policy, the facility failed to provide documentation to support Foley catheter care was provided and Foley catheter outputs were monitored for Resident #30. This affected one (Resident #30) of one resident reviewed for urinary tract infection. The facility census was 83. Findings include: Review of the medical record for Resident #30 revealed admission date of 08/09/22. Diagnoses included sepsis, urinary tract infection, multiple myeloma, lymphedema, Klebsiella Pneumoniae, hypothyroidism, syncope and collapse, morbid obesity, atrial fibrillation (A Fib), sick sinus syndrome, intra-abdominal and pelvic swelling, mass and lump, and peripheral vascular disease. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #30 had impaired cognition. The resident required extensive assistance of two plus persons for bed mobility, transfers, toilet use, and personal hygiene. The resident had in indwelling Foley catheter. Review of the Care Plan dated 08/10/22 revealed the resident had urosepsis infection with goal infection will resolve without complications. Interventions include administer antibiotics as ordered, assess for pain per facility policy and medication as ordered, assess for signs of infection and report to physician: redness, swelling, increased pain, purulent drainage, elevated temperature, change in color of sections, cough, congestion, abnormal lung sound, diarrhea, vomiting, monitor for signs of urinary tract infection (UTI): foul smelling urine, cloudy urine, sediment, decreased output, and vital signs as ordered. Resident is at risk for alteration in elimination. Resident will be free of complications related to appliance use. Interventions included change Foley catheter as ordered and as needed, empty Foley catheter bag every shift and as needed, Foley catheter to straight drain, keep Foley bag below level of bladder, and intake and output, record results. Review of physician orders dated 08/16/22 revealed Foley catheter output every shift, every day and night shift for monitoring. Review of physician orders dated 08/22/22 revealed Foley catheter care routinely and as needed, every shift for Foley catheter care. Review of the Treatment Administration Record (TAR) for August 2022 revealed documentation for Foley catheter care routinely and as needed, every shift for Foley catheter care, was silent from 08/09/22 to 08/22/22. Documentation post catheter care order dated 08/22/22 was silent on 08/25/22 for day and night. Documentation for Foley catheter output every shift, every day and night shift for monitoring, was silent on 08/17/22 day and night shift, 08/18/22, 08/19/22, 08/21/22, 08/22/22, and 08/23/22 day shift, 08/24/22 and 08/25/22 day and night shift. The Foley catheter was discontinued on 08/26/22. Interview on 11/03/22 at 12:58 P.M. the Director of Nursing (DON) stated the resident was admitted with a Foley catheter related to severe lymphedema. She stated he had a compromised immune system because of chemotherapy treatments. She stated he had a cystoscopy last week related to chronic UTI and was followed by urology. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365615 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 365615 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/04/2022 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 0690 Level of Harm - Minimal harm or potential for actual harm Interview on 11/03/22 at 1:30 P.M. the DON verified no documentation for Foley care and outputs. She stated State Tested Nurse Aid (STNA) may have documented in Point of Care (POC) and she would check nursing notes for additional documentation. She verified Foley care would be routine practice for any resident with an indwelling Foley catheter. At 3:00 P.M., the DON stated she was unable to locate additional documentation for Foley catheter care or catheter output. Residents Affected - Few Interview on 11/03/22 at 3:03 P.M. Resident #30 stated staff were emptying his Foley bag twice a day, but he could not be sure they provided catheter care every shift. The facility had no current residents with indwelling Foley catheters. Review of facility policy titled Catheter Care, Urinary, revised date September 2014, revealed the purpose of this procedure is to prevent catheter-associated urinary tract infections. Maintain an accurate record of the resident's daily output, per facility policy and procedures. Empty collection bag at least every eight hours. Changing the indwelling catheters or drainage bags at routine, fixed intervals is not recommended. Rather, it is suggested to change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised. Wash the resident's genitalia and perineum thoroughly with soap and water. Rinse the area well and towel dry. The following information should be recorded in the resident's medical record: the date and time the catheter care was given. The name of the individual(s) giving catheter care. All assessment data obtained when giving catheter care. Character of urine such as color, clarity, and odor. Any problems noted at the catheter-urethral junction during perineal care such as drainage, redness, bleeding, irritation, crusting, or pain. How the resident tolerated the procedure. If the resident refused the procedure, the reason(s) why and intervention taken. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365615 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 365615 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/04/2022 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 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 record review, interview, and policy review, the facility failed to ensure medications were stopped per prescription which led to resident receiving prednisone for an extended period of time. This affected one (Resident #28) of five residents reviewed for unnecessary medications. Facility census was 83. Residents Affected - Few Findings include: Review of medical record for Resident #28 revealed resident was admitted on [DATE] with diagnoses including but not limited to encephalopathy, sleep apnea, non-pressure chronic ulcer of left calf limited to breakdown of skin, occlusion and stenosis of unspecified carotid artery, anxiety, non-pressure chronic ulcer of left heel and midfoot, protein-calorie malnutrition, type two diabetes, hyperlipidemia, major depressive disorder, heart failure, chronic venous hypertension with ulcer of bilateral lower extremity, typical atrial flutter, hypertension, and rheumatoid arthritis. Review of Minimum Data Set (MDS) dated [DATE] for Resident #28 revealed resident had moderately impaired cognition. Resident #28 required extensive assist of two for bed mobility, transfers, and toileting. Review of Care Plan dated 09/26/22 for Resident #28 revealed resident exhibits non compliance related to refusal of preventative care, BiPap, wearing foam boots while in bed, medications, wound care, mask, blood sugar testing, incontinence care, and breakfast. Interventions include document educational attempts made with resident and family related to non compliance, educate resident, family or responsible party on negative outcomes related to non compliance, and notify physician of non compliance. Review of discharge orders from hospital dated 03/15/22 for Resident #28 revealed prescription for Prednisone (steroid) 20 milligrams (mg) give 40 mg orally daily with breakfast. Dispense 10 tablets. Review of Medical Practitioner Note for Resident #28 dated 03/20/22 revealed date of service 03/18/22 stated for chronic obstructive pulmonary disease (COPD) complete prednisone and albuterol. Review of Medication Administration Record (MAR) dated March 2022 through June 2022 for Resident #28 revealed resident received Prednisone 20 mg- 2 tablets in the morning every day starting on 03/16/22 through 06/04/22. Review of General Progress note dated 06/04/22 at 5:07 P.M. for Resident #28 revealed new order received from Nurse Practitioner to start titrating Prednisone. New order consisted of Prednisone 30 mg for one week then Prednisone 10 mg for one week then discontinue. Review of MAR for June 2022 for Resident #28 revealed Prednisone 30 mg given 06/05/22 through 06/11/22. Prednisone 10 mg given 06/12/22 through 06/18/22 then discontinued. Review of Medical Practitioner Note dated 06/06/22 for Resident #28 revealed tapering Prednisone, COPD controlled. Resident #28 followed wound clinic. Resident #28's legs remained bright red, non-tender, no drainage, and mild swelling compared to baseline. Consider drug reaction to doxycycline (antibiotic) or prolonged use of prednisone. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365615 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 365615 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/04/2022 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 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 11/03/22 at 9:38 A.M. with Director of Nursing (DON) verified Prednisone 40 mg was taken daily from 03/16/22 through 06/04/22 when NP titrated the dose for Resident #28. DON verified discharge order stated 10 tablets. Review of policy titled Administering Medication revised April 2019 revealed medications are administered in accordance with prescribed orders, including any required time frame. This deficiency substantiates complaint number OH00135112. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365615 If continuation sheet Page 7 of 7