Inspection·April 3, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interviews, staff interviews, Long-Term Care Ombudsman (LTCO) interview, review of the facility's Self-Reported Incidents (SRIs), and review of the facility's abuse policy, the facility failed to timely report an allegation of staff to resident verbal/emotional abuse to the State Agency. This affected one (Resident #58) of three residents reviewed for abuse. The facility's census was 63. Findings include: Record review for Resident #58 revealed the resident was readmitted to the facility from the hospital on [DATE]. Diagnoses included congestive heart failure, bipolar disorder, essential primary hypertension, schizophrenia, hyperlipidemia, Alzheimer's disease, type II diabetes mellitus, Parkinson's disease, Dementia, and anxiety. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #58 was cognitively intact and required supervision from staff with all activities of daily living. Interview on 03/27/23 at 11:55 A.M. Resident #58 reported he was concerned about the facility, Kicking him out, if he reported how staff treated him, and stated he had to sign a, Behavior contract. Resident #58 further reported when he admitted to the facility, a nurse pulled down her pants, exposed her bottom, and said he could, Kiss her ass. Resident #58 pointed across the hall and stated, Resident #57 witnessed the alleged incident. Resident #58 confirmed he told management about the incident and the Administrator met with him. Interview on 03/27/23 at 1:03 P.M. with the Administrator confirmed he became aware of the incident between Resident #58 and Licensed Practical Nurse (LPN) #341 on 03/09/23. The Administrator verified he did not report the incident to the State Agency and complete a SRI until 03/22/23, because he did not feel this incident was abuse. The Administrator felt the LPNs behavior was inappropriate but not abuse. Interview on 03/28/23 at 4:34 P.M. with Long-Term Care Ombudsman (LTCO) #500 revealed he spoke with both Resident #58 and Resident #57. Both residents reported on 03/08/23, LPN #341 pulled down her pants, exposed her bottom, and told Resident #58, You can kiss my ass. LTCO #500 verified he reported this incident to the Administrator and advised this was a reportable incident. LTCO #500 followed up with the Administrator and questioned why he never reported the incident in which the Administrator replied, I forgot. (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 4 Event ID: 365738 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 365738 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Fairfield 3801 Woodridge Boulevard Fairfield, OH 45014 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)