Inspection visit

InspectionMarch 13, 2025

AYDEN HEALTHCARE OF BELLE SPRINGS.CMS #36561511 citations on this visit

11 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 11 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, family interview, staff interview and policy review, the facility failed to ensure a resident's room was maintain in good repair. This affected for one (#22) of two residents reviewed for physical environment. The facility census was 77. Findings include: Review of medical record for Resident #22 revealed an admission date of 01/31/22. The resident was admitted with diagnoses of hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side, cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery, and epilepsy. Review of quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #22 had severe cognitive impairment. Resident #22 required setup or clean up assistance for eating. Supervision or touching assistance was required for oral hygiene. Substantial/maximal assistance was required for toilet hygiene, shower/bathe self, upper body dressing, lower body dressing, and personal hygiene. Resident #22 is dependent for putting on/taking off footwear. Review of the care plan revealed Resident #22's dignity and autonomy will be maintained at the highest level with interventions including keeping the environment quiet and calm and keeping lighting low and familiar objects near. Observation on 03/12/25 at 4:29 P.M., revealed when entering Resident #22's room, the wall is damaged, the wall next to window is damaged with a large hole next to it, and the restroom wall is damaged. Interview on 03/12/25 at 4:31 P.M. with Certified Nurse Aide (CNA) #178 confirmed the walls are damaged. CNA #178 revealed the walls have been that way since she started working here one year ago. Observation and interview on 03/12/25 at 5:42 P.M., with the Director of Nursing (DON) confirmed the walls are damaged. The DON stated the large, damaged spot on the wall by the window is from the footboard of the bed that used to be in this room. The DON thinks the bed was moved months ago. Interview on 03/13/25 at 8:30 A.M., with the DON stated Resident #22's bed was moved on 02/27/25. Interview on 03/13/25 at 9:18 A.M., with Resident #22's daughter confirmed the walls are damaged. Resident #22's daughter stated Resident #22 would have wanted the walls fixed. Resident #22's (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 13 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 03/13/2025 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 0584 daughter stated maintenance was notified but he said he had other projects to do first. Level of Harm - Minimal harm or potential for actual harm Observation on 03/13/25 at 10:25 A.M., with Maintenance Supervisor #163 confirmed the damage on the entrance wall measured 37 inches long by 5 inches wide, the hole in the wall by the window is 20 inches long by 10 inches wide, and the damaged wall in the bathroom is 37 inches long by 15 inches wide. Residents Affected - Few Review of the maintenance request log for the last 6 months revealed Resident #22's room is not listed on the log. Review of the policy titled, Resident Environmental Quality, dated August 2023 stated, It is the policy of this facility to be designed, constructed, equipped, and maintained to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365615 If continuation sheet Page 2 of 13 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 03/13/2025 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 0606 Not hire anyone with a finding of abuse, neglect, exploitation, or theft. Level of Harm - Potential for minimal harm Based on employee file review, staff interview, and policy review, the facility failed to implement the policy to ensure employees were checked against the Ohio Nurse Aide Registry. This affected five (Certified Nursing Assistant (CNA) #178, CNA #175, Licensed Practical Nurse (LPN) #162, Registered Nurse (RN) #171, and Activities Assistant (AA) #101 of six employee files reviewed. This had the potential to affect all residents who reside in the facility. The facility census was 77. Residents Affected - Many Findings include: Review of employee file for CNA #178 revealed no evidence of the employee being checked against the Nurse Aide Registry. CNA #178 was originally hired as a hospitality aide on 10/03/23. CNA #178 attended the CNA classes and passed the CNA testing on 04/20/24 which is when the employee was checked against the nurse aide registry. Review of employee file for CNA #175 revealed no evidence of the employee being checked against the Nurse Aide Registry. CNA #175 was hired on 12/22/24 as a CNA. CNA #175 attended the CNA classes on 11/26/24 and completed the course on 12/20/24. Review of employee file for LPN #162 with hire date of 02/14/25 revealed no evidence of the employee being checked against the Nurse Aide Registry. Review of employee file for RN #171 with hire date of 03/14/22 revealed no evidence of the employee being checked against the Nurse Aide Registry. Review of employee file for AA #101 with hire date of 07/15/24 revealed no evidence of the employee being checked against the Nurse Aide Registry. Interview on 03/13/25 at 2:45 P.M., with Human Resources Director (HRD #140) revealed the HRD did not run all employees against the Ohio Nurse Aide Registry. HRD #140 stated they run the employees against the abuse registry. HRD #140 verified the above employees were not ran against the nurse aide registry at the time of employment. The affected staff was checked during the survey for the nurse aide registry and no violations were found. Review of policy titled, Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, dated on October 2024, revealed the facility will do the following prior to hiring a new employee: check the Ohio Nurse Aide Registry (and attempt to check other state registries if the individual is known to have worked in another state) for all potential new employees (licensed and unlicensed) and new volunteers to determine if there is a finding of abuse, neglect, or misappropriation of property against the individual prior to the use of that individual. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365615 If continuation sheet Page 3 of 13 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 03/13/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interview, the facility failed to ensure care planned fall interventions were implemented. This affected one (#4) of three residents reviewed for falls. The facility census was 77. Findings include: Review of medical record for Resident #4 revealed an admission date of 10/17/20, with diagnoses including morbid obesity with alveolar hypoventilation, type two diabetes, chronic kidney disease stage four, atrial fibrillation, sleep apnea, bipolar disorder, unsteadiness on feet, major depressive disorder, and anxiety. Review of Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was cognitively intact. Resident #4 required supervision or touching assistance for oral hygiene, toileting, and bathing. Partial/moderate assistance for upper and lower body dressing and personal hygiene. Supervision or touching assistance for bed mobility and transfers. Review of care plan dated 02/17/25 revealed Resident #4 was at risk for accidental falls. Interventions included educate resident on wearing appropriate footwear, educate resident on sitting down when dressing, education on use of call light for assistance, encourage resident to utilize regular chairs while in the activity room instead of walker seat, encourage to wear proper fitting shoes in good repair, non-skid footwear at all times as tolerated, perimeter mattress, Reacher at bedside/recliner, remind to lock wheeled walker before attempting to sit on it, resident to use shower bench instead of shower chair during showers, keep bed in lowest position, provide rest periods, and low bed. Observation on 03/13/25 at 10:54 A.M., of Resident #4's room revealed the resident was sitting in the recliner with proper fitting shoes. The wheeled walker was located across the room in front of the bookshelf. No Reacher was in view on the bedside table, bed, dresser, or walker. No perimeter mattress was on the bed. Interview on 03/13/25 at 10:57 A.M., with Licensed Practical Nurse (LPN) #143 verified Resident #4 had a regular mattress with no perimeters. LPN #143 stated the resident does not sleep in the bed. LPN #143 stated the resident sleeps in her recliner. LPN #143 verified the resident's Reacher was not visible. LPN #143 asked Resident #4 where her Reacher was, and the resident shrugged her shoulders. Resident #4's roommate stated check under the mattress. LPN #143 checked under the mattress and located the Reacher. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365615 If continuation sheet Page 4 of 13 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 03/13/2025 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, and policy review, the facility failed to implement the policy on ensure oxygen tubing was changed weekly. This affected one (#36) of three residents reviewed for respiratory care. The facility census was 77. Residents Affected - Few Findings include: Review of medical record for Resident #36 revealed an admission date of 02/04/24, with diagnoses including chronic atrial fibrillation, ischemic cardiomyopathy, type 2 diabetes, anxiety, vascular dementia, repeated falls, insomnia, pressure ulcer of left heel stage 4, acquired absence of right leg above knee, obstructive and reflux uropathy, fall on same level, acute respiratory failure with hypoxia. Review of Annual Minimum Data Set assessment dated [DATE] revealed Resident #36 had severe cognitive impairment. Resident #36 received oxygen therapy. Review of current physician orders for Resident #36 revealed oxygen via nasal cannula at a rate of 2 liters as needed for saturations below 90%. Review of care plan dated 02/19/25 for Resident #36 revealed the resident at risk for cardiopulmonary disease/exacerbation related to atrial fibrillation, coronary artery disease, hypertension, and oxygen use. Interventions included monitor oxygen saturation, oxygen as ordered, and change tubing weekly. Observation on 03/10/25 at 9:23 A.M., of oxygen concentrator revealed the oxygen tubing was dated 02/16/25. Observation on 03/10/25 at 3:02 P.M., of oxygen concentrator revealed the oxygen tubing remained dated 02/16/25. Interview on 03/10/25 at 3:15 P.M. with Certified Nursing Assistant (CNA) #190 verified the oxygen tubing was dated 02/16/25 for Resident #36. Interview on 03/11/25 at 10:50 A.M., with Director of Nursing (DON) revealed oxygen tubing is to be changed weekly. DON stated the changing of the tubing should be on a physician order. Review of policy titled, Oxygen Administration, revised April 2023, revealed care and cleaning of equipment shall be in accordance with facility policies for each such equipment. Oxygen tubing and mask/cannula will be changed weekly and as needed if it becomes soiled or contaminated. The resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365615 If continuation sheet Page 5 of 13 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 03/13/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 observation, staff interview, review of medication package insert, review of manufacturer recommendations, and policy review, the facility failed to ensure medications and solutions were dated when opened and stored under recommended conditions. This had the potential to affect all new admissions and residents who have their blood sugars checked using the glucometer. The facility identified 10 (#5, #6, #7, #19, #21, #29, #36, #55, #60, and #73) residents who had their blood sugars checked using the glucometer. The facility census was 77. Findings include: Observation on 03/10/25 at 8:30 A.M., of the medication cart on 200 hallway revealed one bottle of Aplisol injection (tuberculin solution) 5/0.1 milliliter (ml) not refrigerated or dated when opened. Also observed a box of assure prism control solution 4 milliliters (ml) times two vials (control solution for glucometer) open and not dated. Interview on 03/10/25 at 8:31 A.M., with Licensed Practical Nurse (LPN) #147 revealed the nurse verified the Aplisol was not refrigerated or dated. LPN #147 verified the Aplisol should be refrigerated. LPN #147 verified the glucometer control solution was opened and not dated. LPN #147 stated the night shift runs the controls on all the glucometer's and the control solution is usually in the med room. Review of the undated manufacturer recommendation for the glucometer control solution revealed do not use beyond three months (90 days) after opening the vial. Record the discard date (three months from the day the vial was opened) on the vial label. Review of the medication package insert for APLISOL® (Tuberculin Purified Protein Derivative, Diluted [Stabilized Solution]), dated November 2013, revealed failure to store and handle Aplisol as recommended may result in a loss of potency and inaccurate test results. Storage: DO NOT FREEZE This product should be stored at 2°-8°C (36°-46°F) and protected from light. Vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency. Review of the undated policy titled, Medication Storage, revealed medications will be stored in a manner that maintains the integrity of the product, ensures the safety of the residents and is in accordance with Ohio Department of Health regulations. Medications requiring refrigeration will be stored in a refrigerator that is maintained between two to eight degrees Celsius (36-46 degrees Fahrenheit). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365615 If continuation sheet Page 6 of 13 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 03/13/2025 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observations, staff interview, and policy review, the facility failed to ensure pureed food was an appropriate smooth texture prior to serving residents on a pureed diet. The deficient practice had the potential to affect 10 (#6, #15, #32, #34, #41, #51, #53, #54, #63, and #184) of 10 residents on a prescribed pureed diet. The facility census was 77. Findings include: Interview on 03/12/25 at 10:34 A.M., with [NAME] #109 revealed the menu for lunch was pot roast, mashed potatoes, and Normandy vegetables. [NAME] #109 revealed she would be doing the purees. [NAME] #109 stated she is looking for a baby food consistency with her purees. [NAME] #109 stated a resident doesn't have to chew a puree. [NAME] #109 stated a puree food is completed when there are no chunks and no pieces of food. [NAME] #109 revealed she does not taste the purees. [NAME] #109 confirmed they have ten residents who required a puree lunch. Observation on 03/12/25 at 10:38 A.M., revealed [NAME] #109 started making the pot roast puree. On 03/12/25 at 10:41 A.M., [NAME] #109 stated the pot roast puree was done and ready to serve. Observation of the puree pot roast revealed it looked chunky. Observation on 03/12/25 at 10:43 A.M., revealed the puree pot roast looked chunky and not smooth. The puree pot roast was tasted and it was found to be very chunky and had to be chewed. Interview on 03/12/25 at 10:44 A.M., with Dietary Supervisor (DS) #122 and [NAME] #109 confirmed the puree was chunky. Observation on 03/12/25 at 10:52 A.M., revealed [NAME] #109 started to puree the pot roast again. On 03/12/25 at 10:54 A.M., [NAME] #109 revealed the puree was done. The puree was tasted and was found to still have chunks of meat in it. Interview on 03/12/25 at 10:54 A.M., with DS #122 confirmed the puree was still chunky. Observation on 03/12/25 at 10:54 A.M., revealed [NAME] #109 started to puree the pot roast again. On 03/12/25 at 10:56 A.M., [NAME] #109 revealed the puree was finished. The puree was tasted and it was now smooth. Review of the policy titled, Level One Puree Diet, dated 12/06/20 stated Individuals with severe chewing and/or swallowing problems may be prescribed a puree diet. All foods will be pureed to a moist mashed potato or smooth pudding like consistency that eliminates the need for chewing. Pureed foods are generally cohesive. Food is pureed in a food processor to achieve a consistent smooth and easy to swallow product. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365615 If continuation sheet Page 7 of 13 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 03/13/2025 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 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, review of cleaning schedules, staff interviews, and policy reviews, the facility failed to ensure food products were dated when opened, kitchen sanitation was being maintained, and the proper sanitizer test strips were used with the dish machine. This had the potential to affect all 77 residents who received food from the kitchen. The facility census was 77. Findings include: 1. Observation on 03/10/25 at 8:00 A.M., of the kitchen revealed one bag of breadsticks open and undated in the walk-in freezer, one bag of shredded lettuce open and undated, one container of what appears to be crushed pineapple not labeled or dated, one bag of pepperoni open not dated, and two stacks of sliced cheese wrapped in saran wrap not dated observed in the walk-in refrigerator. Interview on 03/10/25 8:15 A.M., with Dietary Supervisor (DS) #122 verified the open bag of breadsticks in the walk-in freezer was not dated. Also verified the undated and labeled items in the walk-in refrigerator. Observation on 03/12/25 at 11:53 A.M., in the walk in cooler revealed three bottles of holiday nog dated 02/03/25. A large bag of orange shredded cheese was dated 03/02. Interview on 03/12/25 at 11:59 A.M., with DS #122 confirmed the expiration date was 02/03/25 and the bottles of holiday nog should be thrown out. DS #122 revealed they keep food seven to ten days after opening and she learned that from her food safety class. Review of the policy titled, General HACCP Guidelines for Food Safety, dated 2021, revealed the dietary staff will label and date foods. Review of the policy titled, General Food Preparation and Handling, dated 2021, stated Use leftovers within 7 days per Food Code or discard. Check state regulations for more detail. 2. Observation on 03/12/25 at 11:39 A.M., revealed the kitchen utensil drawer had random debris inside the drawer with the kitchen utensils were sitting on. Review of the kitchen cleaning schedule revealed the prep area is cleaned and sanitized twice a day. Interview on 03/12/25 at 11:40 A.M., with DS #122 confirmed the drawer is dirty and it needed cleaned. Review of the policy titled, General Sanitation of Kitchen, dated 2021 stated Food and nutrition services staff will maintain the sanitation of the kitchen through compliance with a written, comprehensive cleaning schedule. 3. Interview on 03/12/25 at 11:48 A.M., with DS #122 revealed the dish machine is a low temperature chemical machine. DS #122 revealed it uses chlorine sanitizer and they ensure it reaches the proper chemical concentration by using test strips. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365615 If continuation sheet Page 8 of 13 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 03/13/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Observation on 03/12/25 at 11:48 A.M., with DS #122 revealed the facility is using quaternary ammonia (quat) test strips. DS #122 tested the dish machine with the quat test strips and confirmed there was no color change. Interview on 03/12/25 at 11:48 A.M., with DS #122 revealed she was not aware the test strips she was using were quat. DS #122 revealed their chemical company are changing everything out. DS #112 confirmed they were using quat test strips to check the chlorine sanitizer dish machine. Interview on 03/12/25 at 11:51 A.M., with DS #112 revealed she was asking if another kind of test strips were the correct test strips. Observation on 03/12/25 at 11:51 A.M., with DS #112 revealed the next test strips she brought were quat test strips as well. Interview on 03/12/25 at 12:36 P.M., with DS #112 revealed the dishwasher sanitizer is tested on ce every two weeks. DS #112 also revealed she is using quat test strips but probably shouldn't be using them. Interview on 03/13/25 at 1:32 P.M., with the Administrator revealed the facility currently does not have the correct test strips for the dishwasher machine. Review on 03/13/25 at 1:50 P.M., of the test strip log brought in by the Administrator revealed there are only two test strips on the sheet dated 07/05/24, 07/12/24, 07/22/24 and 08/30/24. Interview on 03/13/25 at 1:50 P.M., with the Administrator revealed those are the only two strips they have on their log. Interview on 03/13/25 at 2:49 P.M., with DS #122 confirmed there are only two strips on their test strip log and the test strips are quat test strips. Review of the policy titled, Cleaning Dishes/Dish Machine, dated 2021 ,stated The dish machines will be checked prior to meals to assure proper functioning and appropriate temperatures for cleaning and sanitizing. The policy also stated . Prior to use, proper temperatures and/or chemical concentrations and machine function should be verified. Confirm that soap and rinse dispensers are filled and have enough cleaning product for the shift. Review of the Sanitation of Dishes/Dish Machine policy dated 2021, revealed the low temperature dishwasher has wash temperature of 120°F and a sanitation of 50 PPM hypochlorite. 4. Observation on 03/12/25 at 11:01 A.M., revealed Dietary Aide (DA) #113 was in the kitchen at a long stainless steel table rolling silverware. DA #113 was not wearing a hairnet. Interview on 03/12/25 at 11:03 A.M., with Dietary Aide #113 revealed he only wears a hairnet if he is in a food area. Observation on 03/12/25 at 11:04 A.M, revealed DS #122 told Dietary Aide #113 that if he is wrapping silverware he has to wear a hairnet. Dietary Aide #113 put on a hairnet. Interview on 03/12/25 at 12:36 P.M., with DS #122 revealed the hairnet policy is everyone has to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365615 If continuation sheet Page 9 of 13 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 03/13/2025 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 0812 wear one. If you come into the kitchen you put a hairnet on. Level of Harm - Minimal harm or potential for actual harm Review of the policy titled, Employee Sanitary Practices, dated 2021, stated All employees will wear hair restraints (hairnet, hat, and/or beard restraint) to prevent hair from contacting exposed food. Note: This does not apply to employees who have a totally shaved or bald head; nor does it apply to employees such as counter staff who only serve beverages and wrapped or packaged foods, hostesses, and wait staff if they present a minimal risk of contaminating exposed food, clean equipment, utensils, and linens; and unwrapped single service and single-use articles. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365615 If continuation sheet Page 10 of 13 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 03/13/2025 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 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 review of medical records, staff interview, observation, and review of policies, the facility failed to ensure staff follow enhance barrier precautions (EBP). This affected one (#31) of four residents reviewed for transmission based precautions. The facility failed to ensure clean laundry was not exposed to dirty surfaces and items. This had the potential to affect all residents of the facility. The facility also failed to prepare medications in a sanitary manner. This affected one (#22) of six residents reviewed for medication administration. The facility census was 77. Residents Affected - Many Findings include: 1. Review of Resident #31's medical record revealed an admission date of 10/04/22. Diagnoses listed included cerebral infarction, hypertensive heart disease, aphasia, dysphagia, hyperlipidemia, hemiplegia, and hemiparesis. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 had severe cognitive impairment and an indwelling urinary catheter. Review of a care plan revealed Resident #31 was on EBP due to having an urinary catheter. Staff will use gown and gloves when providing high-contact resident care activities such as dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care/use/maintenance, and chronic wound care. Observation on 03/12/25 at 9:18 A.M., of Resident #31's suprapubic urinary catheter flushing revealed Licensed Practical Nurse (LPN) #204 was not wearing a gown. LPN #204 downed gloves, entered Resident #31's room, pulled back Resident #31's bed covering and flushed Resident #31's suprapubic catheter. LPN #204 held the catheter tubing in her gloved hands, separated the tubing , and then flushed the catheter. Interview on 03/12/25 at 9:24 A.M., with LPN #240 confirmed Resident #31 was in EBP and she should have worn a gown while flushing his suprapubic catheter. Review of the policy titled,Enhance Barrier Precautions (EBP), dated 04/01/24 revealed EBP are indicated for residents with an indwelling medical device. Devices listed include central line, peripheral inserted central catheter (PICC line), midline, urinary catheter, suprapubic catheters, central vascular lines, hemodialysis catheters, feeding tubes, tracheostomy, nephrostomy, chest tube, drain tubes, and ventilator if if the resident is not know to be infected or colonized with an multi-drug resistant organism (MDRO). 2. Observation on 03/12/25 at 12:22 P.M., of House Keeping Aide #137 pushing a cart in the hallway, with clean resident clothing hanging on hangers and folded in the bin not covered. Interview, at the time of the observation, with House Keeping Aide #137, verified the clean clothing was not covered. Interview and observation on 03/13/25 at 10:16 A.M. to 10: 35 A.M., with the Assistant Director of Laundry and Environmental Services #131 confirmed there are two designated laundry areas, one is a clean laundry room, and one is the dirty room. No clean laundry should be around any dirty laundry . Observation of the clean room area revealed several shelves of clean laundry neatly folded and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365615 If continuation sheet Page 11 of 13 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 03/13/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many hanging on racks not covered. One shelf along the wall revealed the folded laundry and a designated area for employee personal belongings. There were two coffee cups with lids sitting on the shelves of clean laundry items. The door in the clean laundry room leading to the washers/dryers revealed two coats belonging to staff hanging on the back of the doors. Observation of the clean area housing the two dryers revealed a large trash bin with no lid containing discarded dirty disposable laundry bags verified by the Assistant Director of Laundry and Environmental Services #131. Review of the policy titled,Laundry and Bedding, Soiled Policy, October 2018 revealed clean linen are protected from dust and soiling during transport and storage to ensure cleanliness. Clean linens are stored separately, away from soiled linens, at all times. 3. Observation on 03/10/25 at 8:50 A.M., of Licensed Practical Nurse (LPN) #153 revealed the nurse was preparing medications for Resident #22. LPN #153 was observed popping a pill out of the package from the narcotic drawer into her bare hands and placing the pill onto the top of the medication cart. Observation of the top of the medication cart revealed 5 loose pills on top of the cart and a medication cup with six pills. LPN #153 was observed picking up the 5 loose pills and putting them into a medication cup with her bare hands. Interview on 03/10/25 at 8:51 A.M., with LPN #153 verified she picked up the pills with her bare hands from the top of the medication cart and placed them in the medication cup. LPN #153 stated she normally pops the medications from the narcotic drawer into her hand and would place them on the medication cart prior to putting them into a medication cup. LPN #153 stated she should not do that and should place the medications in a medication cup without touching them. Review of policy titled, Administering Medications, revised April 2019, revealed staff follows established facility infection control procedures including handwashing, antiseptic technique, gloves, isolation precautions for the administration of medications as applicable. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365615 If continuation sheet Page 12 of 13 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 03/13/2025 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, staff interview, and policy review, the facility failed to maintain the kitchen microwave in a safe operating condition. This deficient practice had the potential to affect all 77 residents who received meals from the kitchen. The facility census was 77. Residents Affected - Many Findings include: Observation on 03/12/25 at 11:41 A.M., revealed the interior ceiling of the microwave had a large black/rusty color in the middle. Interview on 03/12/25 at 11:42 A.M., with Dietary Supervisor #122 revealed the microwave is used to warm up food such as waffles and pancakes. Dietary Supervisor #122 confirmed there is rust in the microwave. Review of the policy titled, Equipment Safety,dated 2021, stated Safety precautions will be followed when using electrical equipment. The policy also stated All equipment should be cleaned properly, following the instructions in the equipment manual. Review of the policy titled, Resident Environmental Quality, dated August 2023, stated The facility shall maintain all essential mechanical, electrical, and patient care equipment in safe operating condition. The policy also stated All facility personnel are responsible for reporting broken, defective or malfunctioning equipment or furnishings immediately upon identification of the issue. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365615 If continuation sheet Page 13 of 13

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Citations

11 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0324GeneralS&S Fpotential for harm
Provide properly protected cooking facilities.
0741GeneralS&S Epotential for harm
F741 - The facility must have sufficient staff who provide direct services to
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
0584GeneralS&S Dpotential for harm
F584 - Safe Environment
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
0606GeneralS&S Cno actual harm
F606 - The facility must—
Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
0689GeneralS&S Dpotential for harm
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
0695GeneralS&S Dpotential for harm
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
0805GeneralS&S Epotential for harm
F805 - Food and drink
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
0812GeneralS&S Fpotential for harm
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
0880GeneralS&S Fpotential for harm
F880 - Infection Control
Provide and implement an infection prevention and control program.
0908GeneralS&S Fpotential for harm
F908 - Maintain all mechanical, electrical, and patient care equipment in safe
Keep all essential equipment working safely.
0761GeneralS&S Epotential for harm
F761 - Labeling of Drugs and Biologicals
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.

FAQ · About this visit

Common questions about this visit

What happened during the March 13, 2025 survey of AYDEN HEALTHCARE OF BELLE SPRINGS.?

This was a inspection survey of AYDEN HEALTHCARE OF BELLE SPRINGS. on March 13, 2025. The surveyor cited 11 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at AYDEN HEALTHCARE OF BELLE SPRINGS. on March 13, 2025?

Yes, 11 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide properly protected cooking facilities."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

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Data from CMS Care Compare public records. Dataset last refreshed June 15, 2026. If you believe any information is inaccurate, report it here.

Inspection·March 13, 2025