Inspection·March 13, 2024

F 0554 Level of Harm - Minimal harm or potential for actual harm Review of the policy titled Administering Medications, revised April 2019, revealed residents may self-administer their own medications only if the attending physician in conjunction with the interdisciplinary care team, has determined the resident is able to safely administer medications. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365617 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 365617 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Waterville 8885 Browning Drive Waterville, OH 43566 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 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm Based on record review and staff interview, the facility failed to ensure proper and timely notice was given to residents when they were discharged from skilled service. This affected two (#63 and #79) of three sampled residents who were discharge from skilled services in the past six months. The facility census was 75. Residents Affected - Few Findings Include: Review of the Beneficiary Notification for Resident #63 revealed Resident #63 began Medicare Part A services on 09/20/23 and his last covered day was 10/19/23. A Notification of Medicare Non-Coverage (NOMNC) form CMS 10123 was documented as not provided. In addition, Resident #63 remained in the facility and a skilled nursing facility advanced beneficiary notice of non-coverage (ABN) form CMS-1005 was not provided. Review of the Beneficiary Notification for Resident #79 revealed Resident #79 began Medicare Part A services on 10/18/23 and his last covered day was 12/07/23. A Notification of Medicare Non-Coverage (NOMNC) form CMS 10123 was provided and signed on 12/06/23. In addition, Resident #79 remained in the facility and a skilled nursing facility advanced beneficiary notice of non-coverage (ABN) form CMS-1005 was not provided. Interview on 03/12/24 at 9:07 A.M., with the Administrator verified the correct beneficiary forms were not provided to Resident #63 and #79 when they discharged from Medicare Part A services and remained in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365617 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 365617 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Waterville 8885 Browning Drive Waterville, OH 43566 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and review of policy, the facility failed to ensure a resident's care plans were revised to include supports and interventions to address communication needs. This affected two (#6 and #46) of three residents reviewed for communication. The facility census was 75. Findings include: 1. Review of Resident #46's medical record revealed an admission date of 02/12/24. Diagnoses included cerebral palsy, contracture of multiple locations, epilepsy, developmental disorder, cognitive communication deficit, and schizophrenia. Review of Resident #46's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of zero indicating Resident #46 was rarely or never understood. A staff assessment for mental status was completed and indicated Resident #46 had short and long term memory problems. Resident #46 was severely cognitively impaired. Resident #46 was dependent on staff for all activities of daily living. Resident #46 displayed physical behavioral symptoms directed toward others four to six days during the review period. Resident #46 displayed verbal behavioral symptoms directed toward others, other behavioral symptoms not directed toward others, and rejection of care one to three days during the review period. Review of Resident #46's care plan revised 02/19/24 revealed supports and interventions for risk for alterations in comfort as evidenced by verbalization, facial expression, and body language, risk for impaired skin integrity, potential for alteration in nutrition, behavior problem related to inflicting self. No supports or interventions were found for communication. Observation and attempted interview on 03/10/24 at 11:23 A., with Resident #46 found her unable to verbally respond. Resident #46 gave eye contact and appeared to have some understanding when she was spoken to. Resident #46 responded by rocking happily in her bed when called by her name and hiding her face with her hand and smiling when she was complemented. Interview on 03/11/24 at 11:04 A.M., with State Tested Nursing Assistant (STNA) #507 revealed Resident #46 was not able to communicate verbally but was able to motion for yes and smack or push things away for no. Resident #46 would yell out when she wanted to be changed and would also yell if she was touched and it was not explained to her what was happening. Resident #46 was able to show she had understanding of what was being said to her. For example Resident #46 loved ranch dressing and she would typically refuse to eat until she was shown the bottle of ranch and could see it being put on her food. Resident #46 would then eat 100% of whatever had the ranch on it. STNA #507 reported she had not learned how to communicate with Resident #46 from the facility. STNA #507 reported having a number of years working with individuals with developmental disabilities and had been trained in that setting on how to communicate with residents who were nonverbal. Interview on 03/12/24 at 7:29 P.M., with STNA #457 revealed Resident #46 was nonverbal but was able to make some of her needs known. STNA #457 reported Resident #46 was combative with care at times but if you spoke with her and explained what was happening and played music she would typically calm down. STNA #457 reported she learned how to communicate with nonverbal residents from life experience and not from the facility or Resident #46's care plan. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365617 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 365617 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Waterville 8885 Browning Drive Waterville, OH 43566 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 Interview on 03/12/24 at 8:12 A.M., with the Director of Nursing (DON) verified Resident #46's care plan was not updated to include supports and interventions for communication. The DON reported Resident #46 was able to communicate by using nonverbal indicators and some sign language. This information was not in her care plan. 2. Review of Resident #6's medical record revealed an admission date of 01/15/24. Diagnoses included quadriplegia, protein calorie malnutrition, convulsions, severe sepsis with septic shock, dysphagia, and gastrostomy status. Review of Resident #6's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of zero indicating Resident #6 was rarely or never understood. Resident #6 was totally dependent on staff for all activities of daily living. Resident #6 displayed no behaviors during the review period. Review of Resident #6's care plan revised 01/16/24 revealed supports and interventions risk for alteration in comfort, self-care deficit, risk for falls, risk for alteration in mood, and seizures. No supports or interventions were found for communication. Interview on 03/10/24 at 10:59 A.M., with Resident #6 found him to be alert and aware. Resident #6 was able to communicate verbally when given time and he was listened to closely. Resident #6 was able to answer all the interview questions asked when given enough time. Interview on 03/11/24 at 9:30 A.M., with State Tested Nursing Assistant (STNA) #475 revealed Resident #6 was dependent on staff for all his care needs. STNA #475 reported Resident #6 was able to communicate verbally but was not able to let them know when he needed something so they would check on him every hour or two. STNA #475 revealed she was not aware of any communication techniques that worked with Resident #6 and was not sure if he was aware or not, but she didn't think he was. Interview on 03/12/24 at 8:12 A.M., with the Director of Nursing (DON) verified Resident #6's care plan was not updated to include supports and interventions for communication. The DON reported Resident #6 was able to verbally communicate if he was given time and he was listened to closely. Review of the facility titled, Care Plans, Comprehensive Person-Centered, revised October 2018 revealed the facility would develop and implement a comprehensive person centered care plan for each resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365617 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 365617 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Waterville 8885 Browning Drive Waterville, OH 43566 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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, resident interview, staff interview, and review of policy, the facility failed to ensure a resident who was dependent on staff for care received personal hygiene care as desired. This affected one (#6) of two resident's reviewed for activities of daily living. The facility census was 75. Residents Affected - Few Findings include: Review of Resident #6's medical record revealed an admission date of 01/15/24. Diagnoses included quadriplegia, protein calorie malnutrition, convulsions, severe sepsis with septic shock, dysphagia, and gastrostomy status. Review of Resident #6's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of zero indicating Resident #6 was rarely or never understood. Resident #6 was totally dependent on staff for all activities of daily living. Resident #6 displayed no behaviors during the review period. Review of Resident #6's care plan revised 01/16/24 revealed supports and interventions risk for alteration in comfort, self-care deficit, risk for falls, risk for alteration in mood, and seizures. Interview on 03/10/24 at 10:59 A.M., with Resident #6 found him to be alert and aware. Resident #6 was able to communicate verbally when given time and he was listened to closely. Resident #6 reported he was not getting cleaned up as often as he would like. He reported he was not getting cleaned up during the day as often as he would like. Review of Resident #6's State Tested Nursing Assistant (STNA) Tasks revealed Resident #6's was to be provided morning and evening care daily including personal hygiene and oral hygiene. Review of Resident #6's morning and evening care documentation revealed Resident #6 was to be provided care for the day shift: 6:30 A.M. to 6:30 P.M. and the night shift: 6:30 P.M. to 6:30 A.M., not documented as being provided care on the 6:30 A.M. to 6:30 P.M. shift on 02/01/24, 02/02/24, 02/03/24, 02/04/24, 02/05/24, 02/09/24, 02/10/24, 02/11/24, 02/13/24, 02/15/24, 02/16/24, 02/17/24, 02/20/24, 02/21/24, 02/27/24, 02/28/24, 02/29/24, 03/02/24, 03/03/24, 03/06/24, 03/07/24, 03/08/24, 03/09/24, or 03/10/24. Interview on 03/12/24 at 2:54 P.M., with the Director of Nursing (DON) revealed the staff documentation was completed at the end of the shift. So the 6:30 A.M. to 6:30 P.M. shift would be documented around 6:00 P.M. and the 6:30 P.M. to 6:30 A.M. care would be documented around 6:00 A.M. at the end of their shifts. The DON provided documentation reflecting the shifts Resident #6 had care provided. The DON verified there were a number of days in February 2024 and March 2024 where Resident #6 was not documented as having care provided. Review of the policy titled, Activities of Daily Living (ADLs), Supporting, revised March 2018 revealed residents who were unable to carry out activities of daily living independently would receive services to maintain good nutrition, grooming and personal and oral hygiene. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365617 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 365617 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Waterville 8885 Browning Drive Waterville, OH 43566 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 medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure fall interventions were in place and residents received post fall assessments as required. This affected two (#36 and #55) of three residents reviewed for falls. The facility census was 75. Findings include: 1. Review of the medical record revealed Resident #36 was admitted on [DATE]. Diagnoses included unspecified dementia with other behavioral disturbances, atherosclerotic heart disease of native coronary artery without angina pectoris, other hyperlipidemia, hypertensive chronic kidney disease, anxiety disorder due to known physiological condition, major depressive disorder recurrent, anxiety disorder due to known physiological condition, major depressive disorder, chronic kidney disease, fibromyalgia. Review of the Minimum Data Set (MDS) assessment, dated 01/24/24, revealed Resident #36 was moderately cognitively impaired. Review of the most recent care plan dated 05/24/19 revealed Resident #36 was at risk for injury due to falls and dementia. Intervention dated 10/28/19 revealed Resident #36's bed was to be kept in the lowest position while in use. The care plan was updated to reflect Resident #36 had an actual fall with minor injury due to poor balance, poor communication/comprehension, and unsteady gait. The new intervention dated 02/09/24 revealed to apply non-skid strips to the floor next to the bed. Review of the nursing notes, dated 02/09/24, revealed Resident #36 had an unwitnessed fall with minor injury. The immediate intervention post fall was to have a low bed and nightlight. The follow-up of the interdisciplinary team notes revealed the intervention was for the resident to had skid strips at the bedside. Observation on 03/10/24 at 4:28 P.M. revealed Resident #36 was lying in bed. The bed was not in the lowest position and no skid strips were at the bedside. Observation on 03/12/24 at 7:43 A.M. revealed Resident #36 was lying in bed. The bed was not in the lowest position. Interview on 03/12/24 at 7:50 A.M. with the Director of Nursing (DON) verified Resident #36's bed was not in the lowest position and there were no skid strips at the bedside. 2. Review of the medical record revealed Resident #55 was admitted on [DATE]. Diagnoses included dementia, type two diabetes mellitus without complications, malignant neoplasm endometrium, chronic kidney disease stage III, and schizoaffective disorder. Review of the Minimum Data Set (MDS) assessment, dated 03/07/24, revealed Resident #55's cognitive ability was unable to assessed. Resident #55 had two or more falls with no injury at the time of the assessment. Review of the care plan, last revised on 02/23/24, revealed Resident #55 had an actual fall with no (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365617 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 365617 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Waterville 8885 Browning Drive Waterville, OH 43566 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 injury. Interventions included to complete neuro-checks as ordered. Level of Harm - Minimal harm or potential for actual harm Review of the fall investigation, dated 02/22/24 at 12:00 P.M. revealed Resident #55 was found on the floor after an unwitnessed fall. No neurological checks were in the medical record. Residents Affected - Few Review of the fall investigation, dated 03/08/24 at 5:45 P.M. revealed Resident #55 was found on the floor after an unwitnessed fall and had a laceration to the forehead. One neurological assessment was completed on 03/08/24 at 6:03 P.M. The neurological evaluation stated to complete neurological evaluation post fall hourly for four hours. No additional neurological checks were in the medical record. Interview on 03/13/24 at 12:45 P.M. with the Director of Nursing (DON) verified neurological checks were not completed as required for Resident #55. Review of the facility policy titled Managing Falls and Fall Risk, revised March 2018, revealed the facility will implement a resident-centered fall prevention plan to reduce the specific risk factors of falls. Review of the facility policy titled Neurological Assessment, revised October 2010, revealed neurological assessments are indicated following a fall or other accident/injury involving head trauma. The documentation should be recorded in the resident's medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365617 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 365617 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Waterville 8885 Browning Drive Waterville, OH 43566 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, staff interview, and review of facility policy, the facility failed to ensure a resident received enteral feeding (delivery of nutrients through a feeding tube directly into the stomach, duodenum, or jejunum) per physicians orders. This affected one (Resident #31) of one resident reviewed for enteral feeding. The facility identified six residents that required total nutrition by enteral feeding. The facility census was 75. Findings include: Medical record review revealed Resident #31 was admitted on [DATE] with diagnoses of dysphagia and gastrostomy. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 had cognitive impairment. Resident #31 received total nutrition by enteral feeding and has not had any weight loss. Review of the current physician orders for 03/2024 for Resident #31 revealed an order enteral feeding of Vital AF 1.2 at 65 milliliters (ml) per hour for 22 hours, off from 3:00 A.M. to 5:00 A.M. for Synthroid medication (treats thyroid disease). Observation on 03/10/24 at 12:17 P.M. of Resident #31 revealed his empty enteral feeding bottle was hanging on the enteral feeding pole and the enteral feeding pump was turned off. Subsequent observations on 03/10/24 at 2:41 P.M. and 4:12 P.M. of Resident #31 revealed his empty enteral feeding bottle remained empty and hanging on the enteral feeding pole and the enteral feeding pump also remained in the off position. Interview on 03/10/24 at 4:30 P.M. with Licensed Practical Nurse (LPN) #411 verified the enteral feeding bottle was empty and enteral feeding pump was turned off. LPN #411 could not verify how long the enteral feeding had been empty and off for Resident #31. LPN #411 stated she administered medication for Resident #31, and it was running but could not give an estimated time of when she administered the medication. LPN #411 verified Resident #31 did not get prescribed feeding or water flushes per physician orders. Review of the facility policy titled Enteral Tube Medication Administration, dated 2022, revealed adequate nutritional support through enteral feeding will be provided to residents as ordered. This deficiency represents non-compliance investigated under Complaint Number OH00151000. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365617 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 365617 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Waterville 8885 Browning Drive Waterville, OH 43566 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 medical record review, observation, staff interview, and review of the facility policy, the facility failed to maintain appropriate emergency tracheostomy supplies at the bedside of a resident with a tracheostomy. This affected one (#53) of two residents reviewed for tracheostomy and ventilator. The facility identified six residents that required tracheostomy emergency supplies at the bedside. The facility census was 75. Residents Affected - Few Findings include: Medical record review revealed Resident #53 was admitted to the facility on [DATE]. Diagnoses included malignant neoplasm of the head, face, neck, glottis, and larynx, and tracheostomy. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #53 was cognitively intact and required suctioning and tracheostomy care. Review of the current monthly physician orders for Resident #53 revealed to verify emergency equipment in room to include ambu bad, oxygen, and suction canister, if tracheostomy becomes dislodged maintain patent airway, notify physician and respiratory therapy director, maintain tracheostomy size #6 flex, suction every shift and as needed. Observation on 03/10/24 at 4:51 P.M. revealed Resident #53 had a tracheostomy in place and the resident's room did not have an ambu bag in the room. Interview on 03/10/24 at 5:51 P.M. with Respiratory Therapist (RT) #478 verified there was no ambu bag at the bedside for Resident #53. RT #478 stated all residents with tracheostomy should have tracheostomy of current size and one size smaller at bedside in the event of decannulation, all ambu bags were to be hanging from the wall for emergency use. Review of the facility policy titled Tracheostomy Care, dated 06/2023, revealed that equipment that is required to be present at bedside during trach care should include ambu bag, oxygen, and back up trach in the event of an emergency. This deficiency represents non-compliance investigated under Complaint Number OH00151000. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365617 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 365617 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Waterville 8885 Browning Drive Waterville, OH 43566 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 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. 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 interview, and review of the facility policy, the facility failed to develop interventions for dementia care. This affected one (Resident #64) of one resident reviewed for dementia care. The facility census was 75. Residents Affected - Few Findings include: Review of the medical record revealed Resident #64 was admitted on [DATE]. Diagnoses included other specified disorders of brain, acute respiratory failure with hypoxia, diffuse traumatic brain injury with loss of consciousness status unknown, acute respiratory failure with hypercapnia, Parkinson's disease, depression, dementia with agitation, and adult failure to thrive. Review of the Minimum Data Set (MDS) assessment, dated 02/07/24, revealed Resident #64 was severely cognitively impaired. Resident #64 had verbal or other behavioral practices exhibited one to three of seven days. Review of the most recent care plan revealed the care plan did not include interventions for Resident #64's diagnoses of dementia. Interview on 03/13/24 at 11:10 A.M. with Licensed Practical Nurse (LPN) #445 revealed Resident #64 can be aggressive with staff such as twist their hands or has been known to walk out of his room with no pants on or his brief around his ankles. LPN #445 reports other times he can be really sweet. LPN #445 stated the resident does not understand if you try to educate him but the staff have put on music or his television that seems to help. Interview on 03/13/24 at approximately 11:30 P.M. with the Director of Nursing (DON) verified Resident #64's care plan did not identify or address Resident #64's needs for dementia care. Review of the facility policy titled Comprehensive Person-Centered Care Plans, dated October 2018, revealed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and function needs is developed and implemented for each resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365617 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 365617 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Waterville 8885 Browning Drive Waterville, OH 43566 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview, and policy review, the facility failed to ensure residents rooms were clean and provided with clean linen. This affected three (#28, #44, and #64) of three residents reviewed for physical environment. The facility census was 75. Findings include: 1. Review of the medical record revealed Resident #28 was admitted on [DATE]. Diagnoses included Alzheimer's disease with late onset, muscle weakness, paranoid personality disorder, restlessness and agitation, major depressive disorder recurrent, Parkinson's disease, and schizophrenia. Review of the Minimum Data Set (MDS) assessment, dated 01/11/24, revealed the resident was severely cognitively impaired. Resident #28 required partial/moderate assistance with chair to bed transfer, toilet transfer, and tub/shower transfer. Observation on 03/10/24 at 10:18 A.M., revealed Resident #28's floor had what appeared to be approximately 8 inch diameter of jelly smeared on the floor right next to the resident's bed. Interview on 03/10/24 at 5:57 P.M., with State Tested Nurse Aide (STNA) #420 revealed Resident #28 had spilled her breakfast plate on the floor today. STNA #420 stated she cleaned it up the best she could and verified it left a 8-9 inch round sticky stain of jelly. STNA #420 reported housekeeping rarely cleans the resident rooms in the hall. Observation on 03/11/24 at 8:35 A.M., revealed the jelly sticky stain on Resident #28's floor remained. Subsequent interview with STNA #504 verified the jelly was still on Resident #28's floor next to the bed from the morning before. 2. Review of the medical record revealed Resident #44 was admitted on [DATE]. Diagnoses included unspecified dementia, pneumonia, anxiety disorder, major depressive disorder, and muscle wasting and atrophy. Review of the MDS assessment, dated 02/15/24, revealed the resident was cognitively intact. Resident #44 required supervision or touching assistance with toileting and showering. Resident #44 was frequently incontinent of bladder and always incontinent of bowel. Observation on 03/10/24 at 4:02 P.M., revealed Resident #44 laying down in bed. The bed linens had dark brown colored smears on the sheets and blanket. The resident's floor next to the bed had a reddish brown colored liquid type smear and brown streaks. Interview on 03/10/24 at 5:57 P.M., with STNA #420 reported Resident #44's room is always a mess. STNA #420 could not identify the substances on Resident #44's bed and linens stating she hoped it was chocolate. 3. Review of the medical record revealed Resident #64 was admitted on [DATE]. Diagnoses included other specified disorders of brain, acute respiratory failure with hypoxia, diffuse traumatic brain injury with loss of consciousness status unknown, acute respiratory failure with hypercapnia, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365617 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 365617 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Waterville 8885 Browning Drive Waterville, OH 43566 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 0921 Level of Harm - Minimal harm or potential for actual harm parkinsonism, depression, unspecified dementia with agitation, adult failure to thrive, muscle wasting and atrophy, muscle weakness, and dysphagia oropharyngeal phase. Review of the MDS assessment, dated 02/07/24, revealed the resident was severely cognitively impaired. Resident #64 required substantial/maximal assistance with showering and toileting. Residents Affected - Few Observation on 03/10/24 at 3:34 P.M., revealed Resident #64 laying in bed with his eyes open. The bed linens near the torso area were observed to have dried liquid type rings. Observation on 03/10/24 at 6:03 P.M., revealed the state of Resident #64's linens had not changed. Interview on 03/10/25 at 6:06 P.M., with STNA #505 revealed they had just provided care to Resident #64 and had not noticed the sheets. STNA #505 verified the linens needed changed. Review of policy titled, Quality of Life- Homelike Environment, dated May 2017, verified residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. This includes a clean, sanitary and orderly environment in addition to clean bed and bath linens that are in good condition. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365617 If continuation sheet Page 13 of 13