Inspection·October 4, 2023

F 0880 Provide and implement an infection prevention and control program. 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 and resident interviews, policy review, and review of the Centers for Disease Control (CDC) guidelines, the facility failed to conduct Coronavirus Disease 2019 (COVID-19) testing as per facility policy and CDC guidelines. This affected one (#54) resident out of the five residents reviewed for infection control. The facility census was 78. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #54 revealed an admission date of 08/12/23 with medical diagnoses of Parkinson's disease, hypertensive heart disease, and chronic kidney disease Stage III. Review of the medical record for Resident #54 revealed an admission minimum data set (MDS) assessment, dated 08/19/23, which indicated Resident #54 had moderate cognitive impairment and required extensive staff assistance for bed mobility, transfers, dressing and toileting. Further review of the medical record revealed documentation to support Resident #54 was up to date on COVID-19 vaccinations. Review of the medical record for Resident #54 revealed Resident #54 shared a room with Resident #168, who his/her spouse. The medical record did not contain documentation to support Resident #54 had COVID-19 testing completed since admission to the facility. Interview on 10/04/23 at 11:10 A.M. with Resident #54 confirmed Resident #168 was his/her spouse and the two residents shared a room. Resident #54 confirmed Resident #168 was transferred to the hospital where he/she tested positive for COVID-19. Resident #54 also confirmed he/she had not been tested for COVID-19 since admission to the facility. Resident #54 confirmed he/she had close contact with Resident #168. 2. Review of the medical record for Resident #168 revealed an admission date of 07/28/23 with medical diagnoses of pneumonia, congestive heart failure, hypertensive heart disease, and atrial fibrillation. Further review of the medical record revealed Resident #168 discharged to the hospital on [DATE] and that Resident #168 shared a room with his/her spouse (Resident #54). Review of the medical record for Resident #168 revealed an admission MDS, dated [DATE], which indicated Resident #168 was cognitively intact and required extensive staff assistance with bed mobility, toileting, dressing and was dependent for transfers. Review of the medical record for Resident #168 revealed a nurses note, dated 09/29/23 at 7:09 A.M., which stated resident complained of shortness of breath and oxygen saturation was 68% on high flow (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 10/04/2023 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)