Inspection·May 31, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm her room and eating lunch. Resident #31 was upset and stated she was agitated because the floor nurse just killed two roaches crawling across my floor in front of me. Resident #31 stated she was frustrated with the lack of pest control at the facility. Resident #31 said she did not think the facility had ever washed the privacy curtains hanging in the room. Resident #31 pointed at the curtains that were heavily soiled with an unknown brown smeared substance. Residents Affected - Few Interview on 05/30/23 at 12:45 P.M., with LPN # 209 confirmed the privacy curtains hanging on each side of Resident #31's bed were heavily soiled with black marks, dirt, and an unknown brown smeared substance all over both curtains. LPN #209 confirmed she killed the two roaches located in Resident #31's room while she was eating her lunch. Review of the facility policy titled Resident Rights, dated December 2016 revealed the facility stated all employees will treat Residents with dignity, kindness, and respect. Further review of the policy revealed, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a dignified existence. This deficiency represents noncompliance discovered in Complaint Number OH00142990. 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 05/31/2023 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 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, observation, staff and family interview, and policy review, the facility failed to ensure residents were provide timely nail care. This affected one Resident (#35) out of three residents reviewed for hygiene care and services. The facility census was 65. Residents Affected - Few Findings include: Review of the medical record for Resident #35 revealed an admission date of 08/20/21. Diagnoses included spinal stenosis, Coronavirus 2019 (Covid-2019), anemia, retina detachment, and diabetes. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35 had impaired cognition. The resident required extensive assistance from staff with bed mobility, transfers, dressing, toilet use and personal hygiene. Review of Resident # 35's plan of care revealed no behavioral or resistance to care listed. Interview on 05/30/23 at 9:22 A.M., with a family member of Resident #35 revealed the lack of personal care provided to Resident # 35, specifically mentioned nail care. Observation on 05/30/23 at 10:23 A.M. revealed Resident #35 was in his wheelchair in his room. Resident #35 had long nails with what appeared to be an unknown brown substance underneath the nails. Interview on 05/30/23 at 10:27 A.M., with stated tested nurse aide (STNA) #119 verified Resident #35 had very long fingernails containing an unknown brown substance under [NAME] them. STNA #119 stated Resident #35 needed to have his nails trimmed. Review of the facility policy titled Activities of Daily Living (ADLS), Supporting, dated March 2018 revealed appropriate care and services will be provided to residents who are unable to provide care for themselves. 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 05/31/2023 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 0692 Provide enough food/fluids to maintain a resident's health. 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 policy review, the facility failed to ensure nutritional weight loss interventions were in place to aid in the prevention of unplanned weight loss. This affected one resident (#35) out of three residents reviewed for weight loss. The facility census was 65. Residents Affected - Few Findings include, Review of the medical record for Resident #35 revealed an admission date of 08/20/21. Diagnoses included spinal stenosis, Coronavirus 2019 (Covid-2019), anemia, retina detachment, and diabetes. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35 had impaired cognition. The resident required extensive assistance from staff with bed mobility, transfers, dressing, toilet use and personal hygiene. The resident required supervision from staff with eating and weighed 145 pounds and was 59 inches tall. Review of Resident #35's weights for the past six months revealed the following weights on 12/09/23 he weighed 166.2 pounds, on 01/09/23 he weighed 162.9 pounds, on 02/10/23 he weighed 164.6 pounds, on 03/02/23 he weighed 147.5 pounds, on 04/14/23 he weighed 145 pounds, and on 05/08/23 he weighed 142.5 pounds. On 01/09/23 and 02/10/23 the resident was weighed in the wheelchair. On 03/02/23 and 04/14/23 the resident was not weighed in the wheelchair. Review of a physician visit note for Resident #35 dated 03/10/23 revealed no indication of a significant weight loss, Staff reported no other problems. Review of the physician notes revealed he was assessed on 05/03/23 and there was no information regarding concerns of weight loss. The progress notes revealed staff reported no other changes. Review of the physician orders for Resident #35 revealed he required a mechanical soft diet, with cut up food texture, regular thin consistency. There were no dietary supplements or shakes ordered. Review of the dietary progress notes for Resident #35 dated 03/03/23 revealed a weight warning and documented Resident #35's weight was 147.5 pounds with a weight loss of 17.1 pounds a 10.4 percent loss and a request was documented to confirm Resident #35's weight. A dietary note dated 05/12/23 revealed Resident #35 weighed 142.5 pounds which was 22.1 pound loss and 13.4 percent of weight loss over three months and a 25 pound weight loss and 14.9 percent of weight loss over six months. Resident #35 consumed 51-100 percent of meals. A recommendation of mighty shakes three ties a day was recommended. The resident remained at a healthy body mass index (BMI) of 21 which was considered normal. Review of the care plans for Resident #35 revealed he was care planned for poor cognition, nutrition/hydration risk, endocrine risk, and vision risk. The care plan for vision revealed he was at risk for impaired visual function related to his diagnosis of detached retina and diabetes. The intervention listed on the visual care plan included to tell the resident where you are placing their items and be consistent. Interview on 05/31/23 at 10:00 A.M., with the Diet Technician (DT) #500 revealed she couldn't believe Resident #35 had a 17.1 pound weight loss recorded on 03/02/23. The DT #500 stated she asked for a reweigh from nursing staff, however, never got one. The DT #500 confirmed she had not followed up to confirm if the facility verified the 17.1-pound weight loss in March. The DT #500 confirmed it (continued on next page) 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 05/31/2023 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few appeared the weight loss was correct because Resident #35's weight continued to decline. The DT #500 stated she recommended a weight loss supplement for Resident #35 in April 2023; however, she was unable to provide any documentation to verify the request. The DT #500 confirmed Resident #35 has had a 22 pound weight loss 15.51 percent in three months. The DT #500 confirmed the last documented weight for Resident #35 was on 05/08/23. The DT #500 stated she recommended mighty shakes three times a day (TID) on 05/12/23, however, confirmed this was never ordered and Resident #35 was not receiving the weight loss supplement. Interview on 05/30/23 at 12:49 P.M. with Medical Director (MD) # 502 revealed he did not recall being notified of a significant weight loss for Resident #35 for the month of March 2023 when Resident #35's weight dropped from 164.6 (02/10/23) to (03/02/23) 147.5 lbs. MD #502 was not aware of the continued weight loss through 05/08/23. MD #502 was not aware the DT #500 recommended supplemental shakes to be added to the Resident #35's diet on 05/12/23. Interview on 05/31/23 at 12:29 P.M. with the Minimum Data Set (MDS) Nurse #169 confirmed she overlooked the order request for supplements for Resident #35 requested on 05/12/23. MDS #169 stated she remembered the facility questioning if Resident #35's recorded weight was accurate in March 2023, however, she was not sure what was done regarding this. Interview on 05/30/23 at 3:05 P.M. the Director of Nursing (DON) confirmed she was not aware of Resident #35's significant weight loss during the month of March 2023 and the continued weight loss through 05/08/23. The DON stated she has meetings with the Diet Technician, Medical Director, and Assistant Director of Nursing to discuss Residents with weight loss. The DON stated at this meeting they will write the Residents name upon the board to monitor it and Resident #35 was not on her board. The DON stated she was unable to provide a reason why the order requested by DT #500 on 05/12/23 for mighty shakes three times a day was never ordered. Interview on 05/31/23 at 3:23 P.M. with the Registered Dietician (RD) #502 revealed she visits the facility once per month. RD #502 stated DT #500 was responsible for assessing residents and monitoring high risk residents. RD #502 stated if a resident had weight loss, they will often ask for a reweigh. RD #502 was unable to provide information regarding the possible reasons for Resident #35's significant weight loss over the past three months or why the facility has not taken any action to try and prevent the weight loss. Review of the facility policy titled Weight Assessment and Intervention, dated March 2022 revealed weights are monitored for undesirable weight or unintended weight loss or gain. Further review of the policy revealed, Any weight change of five percent or more since the last weight assessment is retaken the next day for confirmation. The threshold for unplanned weight loss will be based on the following criteria, one month-5 percent weight loss is significant; greater than five percent is severe, three months-7.5 percent weight loss is significant; greater than 7.5 percent is severe, six months-10 percent weight loss is significant, greater than 10.5 percent is severe. 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 05/31/2023 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 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 observation, review of the kitchen log, staff interview and policy review, the facility failed ensure food was stored safely and ensure kitchen sanitation was maintained. This had the potential to affect all 63 residents who received food from the facility kitchen. The facility identified two residents (#30 and #65) who did not eat from the kitchen. The facility census was 65. Findings include, Observation and interview during the initial tour of the kitchen on 05/30/23 at 10:00 A.M. with Dietary [NAME] (DC) #127 revealed the facility refrigerator contained 15 unlabeled and undated containers of what appeared to be sliced peaches. Two large metal pans on the shelf in the walk in cooler containing an orange solid substance. The DC #127 confirmed the orange substance was gelatin and he confirmed the large covered pans were unlabeled, undated and had no item name. There were also 12 uncovered, unlabeled, and unknown desserts which the [NAME] #127 verified he was unable to identify the type of dessert, when it was made, or served. Observation and interview on 05/30/23 at 10:10 A.M. with the Dietary Manager (DM) #145 confirmed the facility had washed several trays of soiled dishes and the gauges of the dishwasher had not moved. The DM #145 confirmed the dishwasher gauges were not moving. The DM #145 stated she was unable to confirm the temperature of the water for the wash or rinse cycle. The DM #145 took a litmus paper to test the potential hydrogen (PH) of the water to ensure it was working properly and placed the litmus paper on a plate and ran it through the dishwasher. The PH test strip indicated no color, the DM #145 attempted this three times. The DM #145 looked at the large bucket of sanitizing agent and it was empty. At this time the DM #145 refilled the sanitizing agent and was able to indicate a correct PH of the water, however, she was not able to confirm the correct temperatures because the gauges were not moving. The DM #145 stated the gauges were on order and this was why the facility ensured the litmus paper test was completed daily. The DM #145 removed the log from the kitchen temperature log book and the last date logged was 05/16/23. Review of the facility kitchen log titled Dishmachine Temperature Log, revealed no temperatures were recorded 05/17/23 through the date of inspection on 05/30/23. Review of the facility policy titled General Food Preparation and Handling, dated 11/20/20 revealed foods will be stored properly as soon as they are delivered. Further review of the policy stated, food will be covered for storage. Review of the facility policy titled Storage and Utilization of Trayline Leftovers, dated 11/20/20 revealed the facility leftovers will be covered, labeled, and dated. 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 05/31/2023 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, observation, staff and resident interview, review of the monthly pest control visits, and policy review, the facility failed to maintain an effective pest control program. This affected one resident (#31) out of three residents reviewed for pest control. The facility census was 65. Residents Affected - Few Findings include, 1. Review of the medical record for Resident #31 revealed an admission date of 06/01/21. Diagnoses included chronic obstructive pulmonary disease (COPD), diabetes mellitus, history of Coronavirus 2019 (Covid-2019), major depressive disorder, and essential primary hypertension. Review of the annual Minimum Data Set (MDS) assessment for Resident #31 dated 04/04/23 revealed she was cognitively intact. The resident required extensive assistance from staff with bed mobility, transfers, dressing, personal hygiene, and toilet use. She required supervision with eating. Interview on 05/30/23 at 12:43 P.M., with Resident #31 revealed she was seated in her room and eating her lunch. Resident #31 was upset and stated she was agitated because the floor nurse just killed two roaches crawling across my floor in front of me. Resident #31 stated she was frustrated with the lack of pest control at the facility. Interview on 05/30/23 at 12:45 P.M. with Licensed Practical Nurse (LPN) #209 confirmed she killed two roaches located in Resident #31's room while the resident ate her lunch. 2. Observation on 05/30/23 at 12:50 P.M. revealed a food substance on the floor outside the first floor dining room and adjacent to the nurse's station in the middle of the resident unit on the first floor with ants crawling all over the substance. Interview on 05/30/23 at 12:50 P.M., with Registered Nurse (RN) #219 confirmed the large amount of black ants crawling on the food debris on the floor outside of the first floor dining room adjacent to the nurse's station in the middle of the resident unit on the first floor. Review of the monthly pest control company visits dated from 12/16/22 through 05/22/23 revealed no treatments were completed to individual resident rooms. The facility was unable to provide a pest control binder in which the staff documented siting's per the facility policy. Review of the facility policy titled Pest Control Policy & Procedure, dated 12/01/19 revealed the purpose of the facility policy was to ensure the facility has an effective pest control and eradication policy. Further review of the policy revealed the facility will, track monthly visit by the pest control provider. The facility will have a pest control binder in which the staff can document pest siting's. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365738 If continuation sheet Page 7 of 7