Inspection·May 4, 2023

F 0837 Level of Harm - Potential for minimal harm Residents Affected - Many Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. Based on record review and interview, the facility failed to ensure the Administrator's license was active. This has the potential to affect all residents residing in the facility. Current census is 83. Findings include: Review of the Administrator's employee file revealed the Administrator was placed in the position of Administrator on 08/03/21. The employee file revealed a letter from the Bureau of Executives of Long-Term Services and Supports, (BELTSS) dated 07/02/21 informing the Administrator her current license would be inactive as of 07/02/22 if renewal, including 20 hours of education, and renewal payment of the licensure fee was not completed prior to 07/01/22. Review of the BELTSS website, https://beltss.age.ohio.gov/license, revealed the Administrator's license was inactive as of 07/01/22. Review of a printed email from the Director of Nursing (DON) revealed the Administrator had paid the license renewal fee. The screen shot did list the Administrator's renewal status for 06/30/22 as late-missed deadline and there was no Licensed Nursing Home Administrator (LNHA) Continuing Education (CE) marked as satisfied. There was no date on the document identifying when it was sent or received. Review of the Board of Executives of Long-Term Services and Supports website titled Continuing Educations Requirement revealed the license will marked as inactive if more than 10 CE's are completed online, but as long as you have more than 20 CE's completed submit the information with the renewal payment and the license will be renewed. During interview on 05/04/23 at 8:31 A.M., BELTSS board member #1 stated as of 07/01/22 the Administrator's license was considered inactive due to the requirements of the renewal not being completed. The board member stated the BELTSS website was updated daily and at the time of the survey the Administrator's license was not active. During interview on 05/04/23 at 2:20 P.M. with the Administrator via conference call, revealed the Administrator stated she contacted BELTSS office in 2021, and was informed due to the pandemic she would not have to complete the 20 hours of education and her license was to remain inactive, however it would not affect her working at the facility. The Administrator stated she no longer possessed the email notification from BELTSS stating she did not have to complete the education in person due to (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 365615 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 05/04/2023 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)