Inspection·June 23, 2025

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 observation, resident interview, and staff interview, the facility failed to provide a home-like environment in regards to facility's shower rooms being in good repair. This affected two residents (#1 and #4) with the potential to affect all residents residing in the facility. The current census is 87. Findings include: 1. Record review for Resident #1 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #1 include infective bursitis right elbow, diabetes type two, neuromuscular dysfunction of bladder. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition and was an extensive assist with Activities of Daily Living (ADLs). Review of Resident #1's care plans dated 05/2024 revealed a focus for ADL assistance. Interventions include mechanical lift for transfers, and staff assist with bathing. Interview on 06/23/25 at 12:55 P.M. with Resident #1 revealed the resident stated his main complaint with his care involved use of the shower room on the hall. Resident #1 stated every time he is being transported back to his room after his shower the shower chair wheels get stuck in the holes in the floor of the bathrooms causing the aides to have to push and pull his chair. Resident #1 stated it is uncomfortable and not homelike, and it upsets him the condition of the flooring in the bathrooms in the facility. Resident #1 stated he knows all the bathrooms in the facility are missing tiles in the floors as other residents have complained about the flooring. 2. Record review for Resident #4 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #4 include hypertension, heart failure, and chronic kidney disease. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition and required staff assist with ADLs including bathing. Review of Resident #4's care plans dated 05/2025 revealed a focus for ADL self-care deficit. Interventions include mechanical lift for transfers, staff to assist with ADLs, and sponge bath if residents declines a shower. Interview on 06/23/25 at 3:34 P.M. with Resident #4 revealed the resident stated she is getting her showers in the main bathroom on the 300-hall per the schedule. Resident #4 stated she did not like (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 06/23/2025 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)