Inspection·May 10, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview with Registered Nurse (RN) #255 at the time of the observation of Resident #62's right forearm on 05/09/23 at 10:30 A.M. verified the resident had an area of bruising and swelling to the right forearm, and also verified staff were not sure how Resident #62 obtained the bruise and swelling. Interview with the Director of Nursing (DON) on 05/09/23 at 2:15 P.M. verified a hospice staff member reported the area of bruising and swelling to Resident #62's right forearm, and staff were not sure how the bruising and swelling occurred. to that area. The DON verified a self-reported incident (SRI) had not been filed with the State Survey Agency. Review of an undated facility policy titled, Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, revealed it was the facility's policy to investigate all alleged violations involving abuse, neglect, misappropriation of resident property, exploitation or mistreatment, including injuries of unknown source in accordance with the policy. An injury was classified as an injury of unknown source when the source of the injury was not observed by any person, the source of the injury could not be explained by the resident, and the injury was suspicious because of the extent of the injury, the location of the injury (example, the injury is located in an area not generally vulnerable to trauma), the number of injuries observed at one particular point in time, or the incidence of injuries over time. All other allegations involving injuries of unknown source will be reported to the Ohio Department of Health (ODH) immediately, but in no event later than 24 hours after staff became aware of the incident or allegation. This deficiency represents non-compliance investigated under Master Complaint Number OH00142684. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365738 If continuation sheet Page 2 of 7 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 05/10/2023 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)

F 0610 Respond appropriately to all alleged violations. 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, interviews, review of an incident report, and review of a facility policy, the facility failed to complete an investigation involving an injury of unknown source. This affected one (#62) of three residents reviewed for abuse. The facility census was 65. Residents Affected - Few Findings include: Record review for Resident #62 revealed the resident was admitted to the facility on [DATE] and had diagnoses including chronic obstructive pulmonary disease, muscle weakness, unsteadiness on feet, anemia, major depressive disorder, and glaucoma. Review of an annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #62 had severely impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 07. The resident was assessed to require extensive assistance from two staff members for bed mobility, transfers, and toileting, and to require limited assistance from one staff member for eating. Review of the progress notes dated 04/09/23 through 04/30/23 revealed no documentation Resident #62 had any falls, injuries, or other incidents which could result in bruising or swelling. Review of a nursing progress note dated 05/01/23 revealed a hospice state tested nurse aide (STNA) noted a large bruise and swelling to Resident #62's right forearm while bathing him. Resident #62 was confused and uncertain of when and how he obtained the bruise. The physician and Director of Nursing (DON) were notified and new orders were obtained to perform an x-radiation (x-ray) on the area. Review of a facility incident report dated 05/01/23 revealed a hospice STNA noted a large bruise and to Resident #62's right forearm. Resident #62 was confused and uncertain when and how he obtained the bruise. A nurse spoke with Resident #62's son and elaborated on Resident #62's behaviors and increased agitation at night. Review of a progress note dated 05/03/23 revealed Resident #62's x-ray results on the right forearm were negative for fractures. Observation and interview on 05/09/23 at 10:30 A.M. revealed Resident #62 was laying in bed. There was a large bruise and swelling visible on the resident's right outer arm extending from just below the elbow to halfway between the elbow and the wrist. When Resident #62 was interviewed he was pleasantly confused and was unable to provide information related to the area of bruising and swelling. Interview with the Director of Nursing (DON) on 05/09/23 at 2:15 P.M. verified a hospice staff member reported the area of bruising and swelling to Resident #62's right forearm, and staff were not sure how the bruising and swelling occurred. to that area. The DON verified a formal investigation of the bruise and swelling of unknown source was conducted. Review of an undated facility policy titled, Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, revealed it was the facility's policy to investigate all alleged violations involving abuse, neglect, misappropriation of resident property, exploitation or mistreatment, including injuries of unknown source in accordance with the policy. An injury was classified as an injury of unknown source when the source of the injury was not observed by any person, the source (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365738 If continuation sheet Page 3 of 7 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 05/10/2023 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)

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few of the injury could not be explained by the resident, and the injury was suspicious because of the extent of the injury, the location of the injury (example, the injury is located in an area not generally vulnerable to trauma), the number of injuries observed at one particular point in time, or the incidence of injuries over time. All other allegations involving injuries of unknown source will be reported to the Ohio Department of Health (ODH) immediately, but in no event later than 24 hours after staff became aware of the incident or allegation. This deficiency represents non-compliance investigated under Master Complaint Number OH00142684. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365738 If continuation sheet Page 4 of 7 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 05/10/2023 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)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 and interviews, the facility failed to ensure transportation for a scheduled appointment was arranged timely resulting in a missed appointment. This affected one (#54) of three residents reviewed for medical appointments. The facility census was 65. Residents Affected - Few Findings include: Record review for Resident #54 revealed the resident was admitted to the facility on [DATE] and had diagnoses including bacterial meningitis, cognitive communication deficit, muscle weakness, cerebral infarction, tracheostomy status, hydrocephalus, retention of urine, and hyperlipidemia. This resident was discharged from the facility on 03/30/23, readmitted to the facility on [DATE], and transferred out to the hospital on [DATE]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #54 had mildly impaired cognition. The resident was assessed to require extensive assistance from two staff members for bed mobility, transfers, and toileting, and to require extensive assistance from one staff member for eating. Review of the hospital Discharge summary dated [DATE] revealed Resident #54 had an appointment for testing scheduled for 04/18/23 at 9:30 A.M., and a follow-up appointment scheduled with the surgeon on 04/21/23 at 10:00 A.M. Review of a physician order dated 04/09/23 revealed Resident #54 had an appointment for a computed tomography (CT) scan of the abdomen and pelvis scheduled for 04/18/23 at 9:30 A.M. with instructions to arrive one hour prior to the appointment, and to not eat or drink anything for four hours prior to the appointment. Further review of Resident #54's medical record revealed the appointment for the CT of the abdomen and pelvis was re-scheduled for 05/11/23. Telephone interview with Hospital Radiology Employee #599 on 05/09/23 at 1:49 P.M. stated Resident #54 was documented to have missed the appointment scheduled for 04/18/23 at 9:30 A.M. Hospital Radiology Employee #599 stated there was a note indicating a staff member from Resident #54's facility called on 04/18/23 between 12:30 P.M. and 12:45 P.M. to reschedule the resident's appointment noting there was a transportation issued. Telephone interview with Licensed Practical Nurse (LPN) #235 on 05/09/23 at 3:22 P.M. verified Resident #54 missed his scheduled appointment on 04/18/23 due to not having transportation set up. LPN #235 stated the facility transportation scheduler came to her at the end of business hours on 04/17/23 and informed her she was not able to set up transportation for Resident #54's appointment as she did not know which forms to fill out to get payment for the approved transport. LPN #235 stated on 04/18/23 she obtained the form to fill out to get Resident #54's transportation approved, sent it out, and called the hospital to reschedule the resident's appointment. This deficiency represents non-compliance investigated under Complaint Number OH00142293. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365738 If continuation sheet Page 5 of 7 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 05/10/2023 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)

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 observation, interviews, medical record review, and review of a facility policy, the facility failed to ensure fall interventions were in place per the plan of care. This affected one (#62) of one residents reviewed for falls. The facility census was 65. Findings include: Record review for Resident #62 revealed the resident was admitted to the facility on [DATE] and had diagnoses including chronic obstructive pulmonary disease, muscle weakness, unsteadiness on feet, anemia, major depressive disorder, and glaucoma. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #62 had severely impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 07. The resident was assessed to require extensive assistance from two staff members for bed mobility, transfers, and toileting, and to require limited assistance from one staff member for eating. The resident was assessed to have one fall since the prior assessment without injury. Review of the care plan dated 07/27/20 revealed Resident #62 was at risk for falls. Interventions included for the bed to be in low position, a handheld reacher at the bedside, and re-arrange the bed in the room to be against the wall. Observation on 05/09/23 at 10:30 A.M. revealed Resident #62 was lying in bed. The head of the bed was against the wall under the call light, the two sides of the bed were not observed to be against the wall, the bed was elevated from the floor and was not in low position, and there was not a handheld reacher visible in the room. Observation and interview on 05/09/23 at 1:05 P.M. with the Director of Nursing (DON) verified Resident #62's bed was not in low position, the bed was not arranged to be against the wall, and a handheld reacher was not located at bedside for the resident to utilize. Review of the facility policy titled, Falls and Fall Risk, Managing, reviewed 08/2022, revealed based on previous evaluations and current data, staff will identify interventions related to the residents risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365738 If continuation sheet Page 6 of 7 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 05/10/2023 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)

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 observation and staff interviews, the facility failed to maintain a clean and sanitary environment. This affected two (#205 and #210) of eight resident rooms in the facility. The facility census was 65. Findings include: 1. Observation of room [ROOM NUMBER] on 05/08/23 at 11:15 A.M. revealed the wall behind the bed headboard was caved in, and there were chunks of drywall debris observed on the floor below the headboard. The floor along the baseboard and under the bed had a thin layer of dirt and debris covering them. The bathroom floor had a layer of dirt and debris including dried toilet paper and toilet paper rolls on it. A wheeled walker in the bathroom was covered with dried white and black substances. Observation and interview with State Tested Nurse Aide (STNA) #199 on 05/08/23 at 3:20 P.M. verified the bathroom floor in room [ROOM NUMBER] was dirty and had dried toilet paper stuck to the floor. STNA #199 also verified the wheeled walker located in the bathroom was filthy. 2. Observation of room [ROOM NUMBER] on 05/09/23 at 10:30 A.M. revealed the floor and fall mats located by the bed were covered with dirt and food debris and were in need of being cleaned. There was a dried, brown substance located on the right wall inside the doorway to the room, on the two night stands located inside the room, and on the night stand by the right side of the bed. The privacy curtain hanging in the center of the room had a large amount of a dried, brown substance which appeared to be feces on it. Observations were verified with Registered Nurse (RN) #255 at the time of the observation. Observation and interview with the Director of Nursing (DON) on 05/09/23 at 1:05 P.M. verified there was a dried, brown substance on the floor under the bed's headboard in room [ROOM NUMBER]. The DON also verified there was a dried brown substance on the end tables and wall of the room. The DON verified the bathroom floor in room [ROOM NUMBER] was sticky and there was a strong urine odor present. The DON verified the room was in need of being adequately cleaned. This deficiency represents non-compliance investigated under Complaint Number OH00142293. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365738 If continuation sheet Page 7 of 7