Inspection·September 2, 2022

F 0558 Level of Harm - Minimal harm or potential for actual harm On 08/30/22 at 10:28 A.M., an interview with the Regional Nurse #497 and Administrator confirmed Resident #44's wheelchair was smaller than the resident required. On 08/30/22 at 12:10 P.M., the Administrator revealed no documentation was available indicating the wheelchair was evaluated for proper fit for Resident #44. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365849 If continuation sheet Page 2 of 19 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 365849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Toledo 4293 Monroe St Toledo, OH 43606 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 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, observation, staff interview and review of the facility's policy, the facility failed to ensure residents were transferred out of bed and provided showers as requested by the resident. This affected one (Resident #6) of four residents reviewed for choices. The facility census was 56. Findings include: Review of Resident #6's medical record revealed an admission date of 10/29/20. Diagnoses included hemiplegia, epilepsy, major depressive disorder, and stroke. Review of Resident #6's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12 indicating Resident #6 was moderately cognitively impaired. Resident #6 was totally dependent on staff for transfer. Resident #6 required extensive assistance with bed mobility, dressing, toilet use, and personal hygiene. Resident #6 displayed no behaviors during the review period. Review of Resident #6's care plan revised 08/29/22 revealed support and interventions for self-care deficit. Interventions included to assist to shower as needed, total mechanical lift with two staff assist, bathing total assistance of one staff, and assist to bathe/shower as needed. Review of Resident #6's State Tested Nursing Assistant (STNA) Tasks for the last 30 days revealed Resident #6 was to be bathed on Mondays and Thursdays of each week. Resident #6 received one shower on 08/18/22 and received a bed bath on on 08/01/22, 08/04/22, 08/11/22, 08/22/22, 08/25/22, and 08/29/22. Resident #6 was not available on 08/15/22 and was marked as not applicable on 08/08/22. Review of Resident #6's STNA Task for Transfer Assistance revealed Resident #6 was transferred once on 08/02/22, twice on 08/09/22, twice on 08/18/22, twice on 08/19/22, four times on 08/20/22, twice on 08/24/22, twice on 08/25/22, and three times on 08/26/22. Resident #6 went six days without being transferred out of bed and then went eight days without being transferred out of bed. One refusal to be transferred was found on 08/22/22. Interview on 08/29/22 at 10:31 A.M. with Resident #6 revealed Resident #6 was alert and aware. Resident #6 reported the staff were not getting him up and out of bed when he wanted them to and were not giving him the showers he wanted. Resident #6 reported he required a two person assist with a hoyer lift for transfer and that got in the way of staff getting him up even into his recliner or down to the shower room like he wanted. Resident #6 pointed out the dry erase board note written by his daughter. The note said provide Real Showers. Resident #6 stated they gave him bed baths but he wanted to actually go in the shower. Resident #6 stated he just wanted up out of bed to relax in his recliner a few times a week and to go down to the shower room so his hair could be washed in the shower room. Interview on 08/31/22 at 8:30 A.M. with the Administrator and Corporate Nurse (CN) #497 verified Resident #6 was provided one shower in the last 30 days. Interview on 08/31/22 at 8:42 A.M. with State Tested Nursing Assistant (STNA) #433 verified (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365849 If continuation sheet Page 3 of 19 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 365849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Toledo 4293 Monroe St Toledo, OH 43606 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 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #6 was not transferred out of bed or showered as he chose. STNA #433 reported Resident #6 required a two person hoyer lift for transfer and he was the only male staff available. He reported the female aides were not typically comfortable with transferring Resident #6 even with two of them because it was harder for them. STNA #433 reported he floated around the building when he was working to help with two assist transfers. STNA #433 reported when Resident #6 was not transferred for a shower the aides would give him a very thorough bed bath. STNA #433 reported he would make sure Resident #6 got up out of bed and showered when he was working and Resident #6's shower was on his shift but he was not always assigned to him and he didn't work every day. STNA #433 reported all resident refusals were documented in the electronic medical record. Interview on 08/31/22 at 3:02 P.M. with CN #497 verified Resident #6's Transfer documentation matched what was Resident #6 reported and on two occasions in the last 30 days he went close to a week at a time without being transferred out of bed. No refusals were noted. Review of the facility's policy titled Resident Rights, revised December 2016, revealed resident's had the right to self-determination. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365849 If continuation sheet Page 4 of 19 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 365849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Toledo 4293 Monroe St Toledo, OH 43606 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 0565 Honor the resident's right to organize and participate in resident/family groups in the facility. Level of Harm - Minimal harm or potential for actual harm Based on staff and resident interviews, observations, review of the facility's policy, and record review, the facility failed to ensure the resident's concerns regarding activities were addressed timely after the issue was identified during resident council meetings. This affected the four residents who attended the resident council meetings regularly, Residents #11, #39, #47, and #51). The facility census was 56. Residents Affected - Some Findings include: Review of the Resident Council Meeting Minutes revealed there were meeting held monthly from January 2022 to June 2022. There were no minutes found by the facility for July 2022 or August 2022. Resident #11, #38, #47 and #51 attended resident council meetings regularly. On 06/29/22, it was noted the residents expressed concerns regarding lack of activities such as going outside and bingo. There was no evidence there was any follow up to the resident's concerns regarding activities. Interview during the Resident Council Review on 08/30/22 at 10:59 A.M. with the Resident Council President, Resident #47, revealed the facility had no scheduled activities since the activity staff quit a few months ago. The concern for lack of activities was brought up in the June meeting. Resident #47 stated nothing was done to address this concern until very recently. Resident #47 stated they were told by the new Administrator the facility was now working on trying to hire someone for activities. Interview on 08/30/22 at 2:58 P.M. with the Administrator and Corporate Nurse (CN) #479 verified there was no activity staff since May of 2022 when the last activities staff left. The Administrator and CN #479 verified the concerns brought up in the June 2022 Resident Council Meeting were not yet addressed. CN #479 reported they were starting to work on organizing volunteers and encouraging other staff to assist with activities while they work to hire someone new. The Administrator reported they were working on paying off the library fines so the mobile library would be available to residents again. Observations throughout the annual survey from 08/29/22 through 08/31/22 revealed there were no scheduled group activities or outings scheduled or implemented. Review of the facility's policy titled Resident Council, revised April 2017, revealed a Resident Council Response Form would be utilized to track issues and their resolution. The facility department related to any issues was responsible for addressing the items of concern. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365849 If continuation sheet Page 5 of 19 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 365849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Toledo 4293 Monroe St Toledo, OH 43606 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 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 observations, medical record review, and staff interview, the facility failed to ensure a resident's wheelchair armrest were maintained and intact. This affected one (Resident #11) of 24 residents reviewed for medical equipment. The facility census was 56. Findings include: Review of Resident #11's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included schizophrenia and dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE] Resident #11 was assessed with intact cognition and required supervision with staff assistance with ambulation. Review of the nursing plan of care dated 01/17/22 revealed the care plan addressed Resident #11's activity in daily living (ADL) self care deficit related to schizophrenia (delusional psychotic paranoia), bipolar disorder, anxiety, depression, dementia, and generalized weakness. Interventions included uses assistive/adaptive equipment including as wheelchair, hemi-walker and cane. Observations on 08/29/22 at 9:48 A.M. and 4:02 P.M., and on 08/30/22 at 7:53 A.M. revealed Resident #11 was seated in a wheelchair with bilateral armrest were heavily tattered and had torn upholstery. The upholstery edges were jagged with concealed padding exposed. Observation and interview on 08/30/22 at 11:46 A.M. with Regional Nurse #497 and the Administrator verified Resident #11's wheelchair armrest were worn and tattered with jagged edges of upholstery. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365849 If continuation sheet Page 6 of 19 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 365849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Toledo 4293 Monroe St Toledo, OH 43606 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 0679 Provide activities to meet all resident's needs. 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, observations, staff interviews, and review of the facility's policy, the facility failed to ensure activity programs were designed, scheduled, and implemented to meet the interests and needs of the residents. This affected four (Residents #6, #7, #10, and #159) of four residents reviewed for activities. The facility census was 56. Residents Affected - Some Findings include: 1. Review of Resident #6's medical record revealed an admission date of 10/29/20. Diagnoses included hemiplegia, epilepsy, major depressive disorder, and stroke. Review of Resident #6's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12 indicating Resident #6 was moderately cognitively impaired. Resident #6 was totally dependent on staff for transfer. Resident #6 displayed no behaviors during the review period. Review of Resident #6's care plan revised 08/29/22 revealed support and interventions for his preference to stay in his room daily and relax in his chair or his bed, self-care deficit, and suicidal risk due to prior attempt. Interventions for suicidal risk included to encourage participation in social activities of interest. Interview on 08/29/22 at 10:33 A.M. with Resident #6 revealed he was alert and orientated. Resident #6 reported there was no activities person so there were no activities. Resident #6 reported he missed someone going shopping for him the most. Resident #6 reported he had money and liked to get extra things from the store and they no longer went out and no one went for them anymore. Resident #6 reported it had been at least two months with no activities. 2. Review of Resident #159's medical record revealed an admission date of 04/22/22. Diagnoses included alcohol abuse, anxiety disorder, epilepsy, and depression. Review of Resident #159's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of six indicating Resident #159 was severely cognitively impaired. Resident #159 required extensive assistance with personal hygiene and required supervision, set up only for all other activities of daily of living. Review of Resident #159's care plan revised 07/06/22 revealed supports and interventions for self-care deficit and Resident #159 was dependent on staff for activities. Interventions for activities included to familiarize the resident with nursing home environment and provide the resident with a calendar of scheduled activities, and provided activity programs on a regular basis. Interview on 08/29/22 at 9:55 A.M. with Resident #159 revealed there were no activities at the facility and he was frustrated and bored. 3. Review of Resident #10's medical record revealed an admission date of 03/14/12. Diagnoses included pain, major depressive disorder, and type II diabetes mellitus. Review of Resident #10's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365849 If continuation sheet Page 7 of 19 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 365849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Toledo 4293 Monroe St Toledo, OH 43606 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some for Mental Status (BIMS) score of 13 indicating Resident #10 was cognitively intact. Resident #10 required extensive assistance with personal hygiene and was supervision with all other activities of daily living. Resident #10 displayed no behaviors during the review period. Review of Resident #10's care plan revised 07/20/22 revealed supports and interventions for depression and preference to not attend group activities. Interventions for preference to not attend group activities included encourage participation in group activities of interested and respect choice in regard to activity participation. Interview on 08/29/22 at 11:53 A.M. with Resident #10 revealed she was alert and aware. Resident #10 reported she did activities on her own but the facility had not had activities staff in a few months. She reported there were no calendar and no scheduled activities taking place at all and she didn't like not having a choice of activities. 4. Review of Resident #7's medical record revealed an admission date of 06/21/18. Diagnoses included lymphedema, morbid obesity, and major depressive disorder. Review of Resident #7's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #7 was cognitively intact. Resident #7 required extensive assistance with bed mobility, transfer, dressing and personal hygiene. Resident #7 displayed no behaviors during the review period. Review of Resident #7's care plan, revised 02/23/22, revealed supports and interventions for enjoying favorite activities such as playing bingo, cards, scrabble and watching movies with other residents. Interventions included offering activities consistent with resident's known interest, physical and intellectual capabilities. Interview on 08/29/22 at 10:12 A.M. with Resident #7 revealed she was alert and aware. Resident #7 reported there were no activities taking place and there had not been any for several months. Resident #7 reported there was no activities staff so there was no one to set activities up. Resident #7 reported she suffered from depression and getting out for activities helped her socialize and feel better. Interview on 08/30/22 at 8:14 A.M. with Stated Tested Nursing Assistant (STNA) #465 verified there were no organized activities taking place in the facility. STNA #465 reported the activity staff quit a few months back and since then there were no activities. STNA #465 reported the posted activity calendar was for May 2022 and none of those activities were taking place. Interview during the Resident Council Review on 08/30/22 at 10:59 A.M. with the Resident Council President, Resident #47, revealed the facility had no scheduled activities since the activity staff quit a few months ago. The concern for lack of activities was brought up in the June meeting. Resident #47 stated nothing was done to address this concern until very recently. Resident #47 stated they were told by the new Administrator the facility was now working on trying to hire someone for activities. Interview on 08/30/22 at 2:58 P.M. with the Administrator and Corporate Nurse (CN) #479 verified there was no activity staff since May of 2022 when the last activities staff left. The Administrator and CN #479 verified the concerns brought up in the June 2022 Resident Council Meeting were not yet addressed. CN #479 reported they were starting to work on organizing volunteers and encouraging other (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365849 If continuation sheet Page 8 of 19 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 365849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Toledo 4293 Monroe St Toledo, OH 43606 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 0679 Level of Harm - Minimal harm or potential for actual harm staff to assist with activities while they work to hire someone new. The Administrator reported they were working on paying off the library fines so the mobile library would be available to the residents again. Observations throughout the annual survey from 08/29/22 through 08/31/22 revealed there were no scheduled group activities or outings scheduled or implemented. Residents Affected - Some Review of the facility's policy titled Activity Programs, revised August 2006, revealed activities programs designed to meet the needs of each resident were to be available on a daily basis. Activities were to be scheduled seven days a week. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365849 If continuation sheet Page 9 of 19 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 365849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Toledo 4293 Monroe St Toledo, OH 43606 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, staff interview, and review of the facility's skin management program policy, the facility failed to ensure pressure relief devices were placed in use for a resident identified with a pressure ulcer to the hip. This affected one (Resident #55) of two residents reviewed for pressure ulcer relief interventions. The facility identified five current residents with pressure ulcers. The facility census was 56. Residents Affected - Few Findings include: Review of Resident #55's medical record revealed Resident #55 was admitted to the facility on [DATE]. Diagnoses included acute kidney failure, adult failure to thrive, alcohol abuse, schizophrenia, and bipolar disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #55 had severe cognitive impairment and was dependent on staff for the completion of activities of daily living. Resident #55 was incontinent of bowel and bladder, received nutrition via tube feeding, was at risk for pressure ulcer development with one stage III pressure ulcer (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed), and one unstageable deep tissue injury (Purple or maroon area of discolored intact skin due to damage of underlying soft tissue). The assessment revealed pressure relief was applied to the bed and chair. Review of the skin risk assessment dated [DATE] revealed Resident #55 was at moderate risk for pressure ulcer development. On 08/30/22, a skin risk assessment was completed and revealed Resident #55 was now at a high risk for pressure ulcer development. Review of the skin grid pressure documentation dated 08/04/22 revealed Resident #55 was admitted with a right hip stage III pressure ulcer measuring 1.8 centimeters (cm) long by (x) 2.0 cm wide x 0.1 cm deep and a left heel deep tissue injury measuring 0.2 cm long x 0.2 cm wide. Review of Resident #55's plan of care dated 08/05/22 revealed a nursing plan of care was initiated to address the resident's risk for pressure ulcers due to failure to thrive, difficulty ambulating, nothing taken by mouth (NPO), incontinence, and dementia/cognitive deficits. Interventions included to administer medications as ordered, monitor/document for side effects and effectiveness, administer treatments as ordered and monitor for effectiveness, follow facility policies/protocols for the prevention/treatment of skin breakdown. Resident #55's plan of care was revised on 08/15/22 to address the resident being admitted with pressure ulcer to left heel due to immobility and malnutrition. Interventions included a pressure reducing device to the wheelchair and bed, and treatment as ordered. Additionally, a plan of care was implemented on the same date to address Resident #55 was admitted with a pressure ulcer to right lateral trochanter due to immobility and malnutrition. Interventions included to administer medications as ordered, assist resident to turn and reposition at routine intervals and as needed, and wound care treatments as ordered by provider. Observation on 08/29/22 at 10:12 A.M. revealed Resident #55 was laying in bed with a standard pressure relief mattress, and a wheelchair in the room without a pressure relief cushion. Observations on 08/30/22 at 12:47 P.M. revealed Resident #55 sitting in a wheelchair on the patio. No cushion or pressure relief was applied to the seat. On 08/31/22 at 6:23 A.M., Resident #55 was in a low bed with with a standard pressure relief mattress in place and a wheelchair without pressure relief to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365849 If continuation sheet Page 10 of 19 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 365849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Toledo 4293 Monroe St Toledo, OH 43606 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 0686 Level of Harm - Minimal harm or potential for actual harm seat inside the room. Additionally, a geriatric reclining chair (broda) chair was discovered in the room with no pressure relief device to the seat. At 10:39 A.M., Resident #55 was observed seated in the broda chair with his head and feet elevated. Seated on a pillow. No pressure relief cushion was placed to the seat. At 11:50 A.M., Resident #55 was observed to remain seated in the broda chair with a pillow to the seat. No cushion was applied to the seat. Residents Affected - Few Observation and interview on 08/30/22 at 10:58 A.M. with Wound Physician #1 during a weekly wound evaluation revealed Wound Physician #1 described the wound to the right hip as a stage III pressure ulcer, healing with no exudate, 100% dermis tissue, healing and improved. The wound measured 1.0 cm long x 0.5 cm wide with no measurable depth. Interview with Wound Physician #1 stated Resident #55 required a pressure relief device or cushion to the wheelchair/chair due to history of pressure ulcer development and a high risk of skin breakdown. Observation and interview on 09/01/22 at 9:54 A.M. with LPN #496 revealed Resident #55 was up in the broda chair with a pillow placed to the seat. No cushion was in place. Further observation confirmed no pressure relief seat cushion was located in Resident #55's room. Interview on 09/01/22 at 10:00 A.M. with Regional Nurse #497 confirmed a pressure relief cushion was to be applied to Resident #55's broda chair. Review of the facility's policy titled Skin Management Program, revised June 2022, revealed an initial admission assessment for skin conditions or risk of pressure injuries is completed upon admission. Upon completing a Braden Scale, the nurse will initiate/review the resident's skin alteration plan of care and verify the plan of care recognizes interventions to assist in reducing the residents risk of skin breakdown. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365849 If continuation sheet Page 11 of 19 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 365849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Toledo 4293 Monroe St Toledo, OH 43606 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, staff interview, medical record review, and review of the facility's medication administration policy, the facility failed to ensure the residents received medications as physician ordered resulting in a medication error rate above five percent (%). There were four medications errors out of 36 opportunities, resulting in a medication rate of 11.11%. This affected two (#32 and #111) of three residents reviewed for medication administration. The facility census was 56. Residents Affected - Few Findings include: 1. Observations on 08/30/22 at 8:00 A.M. revealed Licensed Practical Nurse (LPN) #496 obtained the glucose monitor and proceeded to Resident #32's room. Resident #32 had concluded eating his breakfast meal. LPN #496 proceeded to obtain a blood sugar reading which resulted in error and at 8:02 A.M. obtained a second blood sugar reading of 235. LPN #496 returned to the medication cart and obtained the residents medications including lispro insulin four international units (IU) via syringe, proair hydrofluoroalkane (HFA) aerosol inhaler, and fluticasone furoate-vilanterol aerosol powder inhalation. At 8:14 A.M., LPN #496 returned to Resident #32's room and administered the lispro insulin via subcutaneous injection. LPN #496 then obtained the proair hydrofluoroalkane (HFA) aerosol inhaler and Resident #32 inhaled two puffs followed by immediately inhaling one puff of the fluticasone furoate-vilanterol aerosol powder inhalation. No pause between inhalers was observed and LPN #496 did not confirm Resident #32 rinsed his mouth with water following the administration of the fluticasone furoate-vilanterol aerosol powder inhalation. Interview on 08/30/22 at 8:21 A.M. with LPN #496 revealed she was unaware a pause was required between administration of different inhalers or visualizing the resident rinse his mouth after the administration of the fluticasone furoate-vilanterol aerosol powder inhalation. LPN #496 also confirmed obtaining Resident #32's blood sugar after Resident #32 had consumed his entire breakfast and not before consumption. Review of Resident #32's medical record revealed a physician order dated 05/12/21 for Fluticasone Furoate-Vilanterol Aerosol Powder Breath Activated 200-25 microgram (mcg) per inhalation (INH) one puff orally one time daily. Rinse mouth after use of fluticasone furoate-vilanterol aerosol powder inhalation. An order, dated 09/14/21, revealed to administer ProAir hydrofluoroalkane (HFA) aerosol solution two puff inhaled orally every four hours while awake. Additionally, on 08/11/22, a physician order for insulin lispro three times daily before meals. Sliding scale administration included blood sugar between 150-200 inject two units, 201-250 inject four units, 251-300 inject six units, 301-350 inject eight units, and 351-400 inject 10 units. Review of the facility's policy titled 'Nursing Care of Resident with Diabetes Mellitus, revised December 2015, revealed glucose monitoring frequency will be ordered by the physician. Review of the facility's policy titled Administering Medications through a Metered Dose Inhaler, revised October 2010, revealed if repeat inhalation is ordered, allow at least one minute between inhalations of the same medication and at least two minutes between inhalations of different medications. 2. Observation on 08/30/22 at 8:29 A.M. revealed LPN #453 administering medications from the south medication cart. Located on the cart identified an intravenous piggyback (IVPB) antibiotic cefepime reconstituted and mixed. Posted on the IVPB label in all capital letters noted- ACTIVATE AND USE (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365849 If continuation sheet Page 12 of 19 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 365849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Toledo 4293 Monroe St Toledo, OH 43606 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 0759 WITHIN ONE HOUR OF ACTIVATION. Level of Harm - Minimal harm or potential for actual harm Interview with LPN #453 at the time of observation revealed she was waiting for Resident #111 to finish breakfast before administering the IVPB antibiotic. Additional observation noted LPN #453 to proceed administration of resident medications located in two facility corridors with the IVPB antibiotic remaining on the medication cart. Residents Affected - Few Observation at 10:00 A.M. revealed LPN #453 attempted to spike the IVPB bag and prime tubing with the antibiotic. Surveyor intervention at the time called LPN #453's attention to the warning posted on the IVPB bag. LPN #453 indicated she was unaware of the warning and proceeded to obtain a new un-constituted IVPB bag for administration. On 08/30/22 at 12:21 P.M., a telephone interview with the facility's Pharmacist #500 revealed the IVPB antibiotic was to be infused in accordance with instructions contained on the IVPB bag. Review of Resident #111's medical record revealed a physician order for the administration of the IV medication Cefepime Solution two grams (gm) per 100 milliliters (ml) every twelve hours for seven days. The physician ordered times were noted to be at 8:00 A.M. and 8:00 P.M. Review of the facility's policy titled Administering of Medications, revised December 2012, revealed medications must be administered in accordance with physician orders, including any required time frame. Medications must be administered within one hour of their prescribed time, unless otherwise specified. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365849 If continuation sheet Page 13 of 19 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 365849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Toledo 4293 Monroe St Toledo, OH 43606 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 0810 Provide special eating equipment and utensils for residents who need them and appropriate assistance. 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, observations, resident interview, and staff interview, the facility failed to ensure residents were provided adaptive devices to support independence during meals. This affected one (Resident #6) of six residents reviewed for meals and dining. The facility identified there were no residents who required adaptive equipment to assist at meal time. The facility census was 56. Residents Affected - Few Findings include: Review of Resident #6's medical record revealed an admission date of 10/29/20. Diagnoses included hemiplegia, epilepsy, major depressive disorder, and stroke. Review of Resident #6's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12 indicating Resident #6 was moderately cognitively impaired. Resident #6 displayed no behaviors during the review period. Review of Resident #6's care plan revised 08/29/22 revealed support and interventions for potential for altered nutrition and hydration. Interventions included a sipper (two handled lidded) cup and divided plate, Resident #6's food preferences were to be honored. Additionally, Resident #6 was identified as having a self-care deficit. Interventions included use of a divided plate with two handled cups with meals. Observation on 08/29/22 at 11:45 A.M. of Resident #6 revealed he was provided a regular plate with goulash and peas. Resident #6 was provided a regular cup for his beverage. Resident #6 was observed having difficulty getting the peas onto his spoon to feed himself. Observation on 08/30/22 at 8:10 A.M. of Resident #6 revealed he was provided a regular plate with eggs and toast. Resident #6 was provided a regular cup for his beverages. Resident #6 was observed having trouble getting the eggs onto his fork to feed himself. Interview on 08/30/22 at 8:14 AM. with Stated Tested Nursing Assistant (STNA) #465 revealed Resident #6 required total assistance with his daily care, but was able to feed himself with set up. Resident #6 was able to make his needs known and was cooperative with care. STNA #465 reported Resident #6 chose to eat in his room and had no adaptive equipment for eating. Interview on 08/30/22 at 4:09 P.M. with Resident #6 revealed he was alert and aware. Resident #6 reported he had not been getting a divided plate with any meals. Resident #6 stated it would be helpful, he was supposed to have one but he never had been provided one. Resident #6 stated the two handled cup wasn't something he wanted any more. Interview on 08/31/22 at 8:30 A.M. with the Administrator, Director of Rehabilitation (DR) #476, and Corporate Nurse (CN) #497 verified Resident #6's divided plate was documented in his care plan as a support and should have been implemented if it was helpful for Resident #6. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365849 If continuation sheet Page 14 of 19 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 365849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Toledo 4293 Monroe St Toledo, OH 43606 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 record review, observations, staff interview, and review of the facility's policy, the facility failed to ensure a clean and sanitary kitchen and utilized the appropriate hand hygiene when serving food. This had the potential to affect all residents, except Resident #55 and Resident #59, who the facility identified as not receiving food by mouth. The facility census was 56. Findings include: 1. Observation on 08/29/22 at 9:00 A.M. of the kitchen revealed a thick, heavy buildup of dirt, bugs, and an unidentifiable sawdust like substance on top of the dishwasher and on the windowsill next to the dishwasher. Interview on 08/29/22 at 9:08 A.M. with Dietary Supervisor #452 verified the buildup of debris on top of the dishwasher and windowsill next to the dishwasher. Observation on 08/31/22 at 11:00 A.M. of the kitchen revealed a thick layer of dust and grime on the kitchen exhaust hood, piping along the wall, and on the windowsill. Interview on 08/31/22 at 11:16 A.M. with Corporate Dietary Manager #498 verified the buildup of dust and grime stating they had cleaned some of it earlier that day and would need a degreaser. 2. Observation on 08/29/22 at 9:02 A.M. of the low temperature sanitation dishwasher revealed the sanitation test strip was spotted indicating low sanitation levels. Interview on 08/29/22 at 9:07 A.M. with Dietary Manager #498 stated she had inquired if the facility was using the correct test strips and was told they were. Interview on 09/01/22 at 3:32 P.M. with the Administrator revealed the facility does not have the correct test strips for the dishwasher to ensure proper sanitation. 3. Observation on 08/29/22 at 9:00 A.M. of the dry storage area revealed a one-gallon jug of soy sauce that was approximately four-fifths full. The labeled instructions stated to refrigerate after opening for quality. Additional observation revealed a one-gallon jug of teriyaki marinade and sauce approximately two-thirds full. The labeled instructions stated to refrigerate after opening. Interview on 08/29/22 at 9:26 A.M. with Corporate Dietary Manager #498 verified the soy sauce and teriyaki marinade were not refrigerated and should have been refrigerated after opening. 4. Observation on 08/31/22 at 11:49 P.M. revealed [NAME] #487 serving the lunch meal of barbeque baked chicken, au gratin potatoes, butter carrots and a roll. While serving the meal, [NAME] #487 took off the disposable gloves and reapplied new disposable gloves without washing his hands. No garbage can was observed and [NAME] #487 placed the dirty gloves and a used paper towel on a empty cart. [NAME] #487 then continued serving. At 11:53 A.M. [NAME] #487 used the dirty paper towel next to the used gloves to wipe his gloved hands. Interview on 08/31/22 at 11:59 A.M. with Corporate Dietary Manager #498 and [NAME] #487 verified no hand washing between changing gloves and wiping gloved hands on a used towel. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365849 If continuation sheet Page 15 of 19 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 365849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Toledo 4293 Monroe St Toledo, OH 43606 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 Review of the facility's list of resident diets revealed Resident #55 and #59 were nothing by mouth. Level of Harm - Minimal harm or potential for actual harm Review of the facility's policy titled Sanitization, revised October 2008, revealed kitchen and dining room surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent accumulation of grime. Residents Affected - Many Review of the facility's policy titled Food Receiving and Storage, revised October 2017, revealed food services will maintain clean food and storage areas at all times, refrigerated foods must be stored below 41 degrees Fahrenheit. Review of the facility's policy titled Food Preparation and Service, revised October 2017, revealed food and nutrition services employees shall prepare and serve food in a manner that complies with safe food handling practices. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365849 If continuation sheet Page 16 of 19 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 365849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Toledo 4293 Monroe St Toledo, OH 43606 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observation, medical record review, staff interview, review of the facility's policy, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to ensure staff wore Personal Protective Equipment (PPE) as required. This affected Residents #109, #110, and #111 and had the potential to affect all 56 residents residing in the facility. Residents Affected - Many Findings include: Review of Resident #109's medical record revealed Resident #109 was admitted to the facility on [DATE] with no known COVID-19 vaccination status. On 08/26/22, the physician ordered for Resident #109 to be placed in New admission COVID-19 Quarantine; May discontinue after seven days with a negative test on day five-to-seven of quarantine. Review of Resident #110's medical record revealed the resident was admitted to the facility on [DATE] with no known COVID-19 vaccination status. On 08/26/22, the physician ordered for Resident #110 to be placed in New admission COVID-19 Quarantine; May discontinue after seven days with a negative test on day five-to-seven of quarantine. Review of Resident #111's medical record revealed the resident admitted to the facility on [DATE] with no known COVID-19 vaccination status. On 08/26/22, the physician ordered for Resident #111 to be placed in New admission COVID-19 Quarantine; May discontinue after seven days with a negative test on day five-to-seven of quarantine. Observation on 08/29/22 at 3:42 P.M. revealed Resident #111, #110, and #109's rooms with the room doors closed and a sign on each door reading, stop see nurse before entering. No specific type of isolation indicated or specific personal protective equipment (PPE) was posted. Outside each room noted plastic three drawer cabinets (isolation cart) containing isolation gowns, shoe coverings, disposable surgical mask and plastic gloves. No N95 mask or micro-bacterial cleanser was placed on the isolation carts. Inteview on 08/29/22 at 3:50 P.M. with Licensed Practical Nurse (LPN) Unit Manager #475 stated the three residents (#109, #110, and #111) were placed into isolation due to being new admissions and not up to date on COVID-19 vaccines. LPN #475 stated the residents were in contact isolation with droplet precautions. Observation on 08/29/22 at 3:52 P.M. revealed Physical Therapy Assistant (PTA) #483 walking out of Resident #109's room. Resident #109 was wearing surgical mask, and PTA #483 was wearing surgical mask and a face shield. PTA #483 did not have a gown, gloves, or N95 mask applied. Interview on 08/29/22 at 3:56 P.M. with PTA #483 verified he did not wear a N95 while in Resident #109's room and removed the gown before ambulating in the hall with the resident. Observation on 08/29/22 at 3:55 P.M. revealed State Tested Nurse Aide (STNA) #442 was observed exiting Resident #111's room and doffing PPE in the corridor outside the room in the common corridor. STNA #442 proceeded to walk in the corridor to the dirty linen room located past the south nurse's station to discard the PPE. STNA #442 did not cleanse her face shield. Interview on 08/29/22 at 4:00 P.M. with STNA #442 confirmed doffing soiled PPE in the corridor. STNA #442 stated no trash receptacle was inside the room to doff soiled PPE and verified she did not clean her face shield. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365849 If continuation sheet Page 17 of 19 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 365849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Toledo 4293 Monroe St Toledo, OH 43606 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Interview on 08/30/22 at 10:14 A.M. with LPN #484 North Unit Manager verified no hand sanitizer was available at doffing and exits of rooms. LPN #484 Unit Manager confirmed staff were to wear full PPE including N95, gloves, gown, and face shield or goggles when going into droplet isolation. Observation on 08/30/22 at 8:34 A.M. revealed STNA #401 and #410 inside Resident #111's room and standing at the bedside. The STNAs did not have N95 mask or gloves applied. Interview on 08/30/22 at 8:37 A.M. with STNA #401 revealed the signs posted to the resident doors does not direct staff on the type of mask to apply. Additional observation at the time noted STNA #410 with a surgical mask applied not covering her nose. Observation at the time with STNA #401 and STNA #410 confirmed the isolation cart outside resident rooms (#109, #110, and #111) were equipped with N95, gowns, and gloves. However, no cleanser/antimicrobial wipes were available for goggles or face shields. Interview on 08/30/22 at 10:18 A.M. with the Regional Nurse #497 verified staff were to wear all PPE when entering droplet isolation rooms including N95. When staff exit rooms, they were to doff soiled PPE into approved receptacles inside isolation rooms, cleanse hands, and wipe face shields or goggles with approved sanitizer. Review of the facility's Admissions, Re-admissions, Frequently Out of Center policy, updated February 2022, revealed newly admitted residents and readmissions whose COVID-19 status is unknown shall be admitted to a COVID-19 observation room. Staff shall wear all recommended PPE during care, which includes use of an N95 or higher level respirator, eye protection, gloves, and gown. Residents are to remain in their rooms as they are not permitted to leave the observation unit during the 10 day period of observation. The quarantined period may be shortened, and the resident may be removed from quarantine after day seven with a negative test on day five. Review of the CDC SARS-CoV-2 Infection (COVID-19) guidelines, updated 02/02/22, regarding Manage Residents with Suspected or Confirmed SARS-CoV-2 Infection health care personnel caring for residents with suspected or confirmed SARS-CoV-2 infection should use full PPE (gowns, gloves, eye protection, and a NIOSH-approved N95 or equivalent or higher-level respirator). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365849 If continuation sheet Page 18 of 19 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 365849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Toledo 4293 Monroe St Toledo, OH 43606 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 0888 Ensure staff are vaccinated for COVID-19 Level of Harm - Minimal harm or potential for actual harm Based on staff interview, review of personnel records, review of Staff Vaccination COVID-19 log and infection control log, review of the facility's policy, and review of the Centers for Medicare and Medicaid Services (CMS) memorandum QSO-22-09-ALL, the facility failed to ensure staff were fully COVID-19 vaccinated, had an approved exemption, or had been identified as appropriate for a temporary delay per Center for Disease Control and Prevention (CDC) guidance. The vaccination rate for the facility was calculated at 98.0%. The facility census was 56. Residents Affected - Few Finding included: Review of the Staff Vaccination COVID-19 log, provided 08/29/22, revealed the facility had 99 employees with 69 employees vaccinated and 30 employees with a religious exemption. The Staff Vaccination COVID-19 log indicated 100% of staff were vaccinated or had an approved religious exemption. However, State Tested Nursing Assistant (STNA) #432 and #466 did not have completed religious exemption forms available during the survey. This revealed 28 employees with a religious exemption indicating a 98% of staff were vaccinated or had an approved religious exemption. Review of STNA #432's personnel file revealed STNA #432 was hired on 08/11/22 and had no discipline. STNA #432's COVID-19 Religious Accommodation/Exemption Request Form revealed the box next to denied was checked and there was no administrator signature. Review of STNA #466's personnel file revealed STNA #466 was hired on 02/10/22 and there was no COVID-19 Religious Accommodation/Exemption Request Form completed or maintained by the facility. Interview on 08/31/22 at 1:43 P.M. with Licensed Practical Nurse (LPN) #484, Human Resource (HR) Director #408, and Corporate Infection Control #499 revealed staff COVID-19 exemption approval forms were maintained in personnel files and could provide verification the religious exemption forms were completed. Follow-up interview on 08/31/22 at 1:50 P.M. with LPN #484, HR Director #408, and Corporate Infection Control #499 verified STNA #432's form was checked as denied and had not been provided to the Administrator for approval or denial. HR Director #408 also verified STNA #466 did not have an exemption request form completed. Review of the facility's infection control log revealed there were no COVID-19 cases at the time of the survey. Review of the facility's policy titled COVID-19 Vaccine Policy, dated January 2022, verified all employees shall have completed the doses of COVID-19 vaccine requirement or have an approved medical or religious exemption. Review of the Centers for Medicare & Medicaid Services (CMS) memorandum, QSO-22-09-ALL regarding COVID-19 health care staff vaccination, dated 01/14/22, revealed CMS expected all providers' and suppliers' staff to have received the appropriate number of doses by the time frames specified in the QSO-22-07 unless exempted as required by law, or delayed as recommended by the CDC. Facility staff vaccination rates under 100% constitute non-compliance under this rule. Within 30 days after issuance of this memorandum, less than 100% of all staff have received at least one dose of COVID-19 vaccine, or have a pending request for, or have been granted a qualifying exemption, or identified as having a temporary delay as recommended by the CDC, the facility is non-compliant under the rule. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365849 If continuation sheet Page 19 of 19