Inspection·March 28, 2024

F 0677 refusal of ADLs. Level of Harm - Minimal harm or potential for actual harm Review of task documentation noted Resident #3's showers were scheduled to be provided on Wednesday and Saturday evenings. Review of shower documentation completed between 03/02/24 and 03/28/24 noted Resident #3 to receive a bed bath on 03/02/24 at 9:30 P.M., and 03/16/24 at 9:59 P.M. On 03/09/24 the resident was recorded to receive a shower. The resident was documented with refusals on 03/06/24, 03/13/24, 03/20/24, 03/23/24, 03/27/24. No documentation was contained in the medical record stating the resident was re-approached or attempts were made to determine the cause of the refusals. Residents Affected - Few Review of the facility policy titled Activities of Daily Living (ADLs), revised March 2018, noted residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out ADLs. Residents who are unable to carry out ADLs independently will receive the services necessary to maintain good nutrition, grooming, and personal care and oral hygiene. If residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. Approaching the resident in a different way or at a different time, or having another staff member speak with the resident may be appropriate. The resident's response to interventions will be monitored, evaluated and revised as appropriate. This deficiency represents non-compliance investigated under Complaint Number OH00151745. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365849 If continuation sheet Page 2 of 4 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 03/28/2024 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, and review of facility policy, the facility failed to ensure incontinence care was provided timely to a dependent resident. This affected one (#3) of three sampled residents reviewed for the provision of urinary incontinence care in a facility census of 73. Findings include: Review of the medical record revealed Resident #3 admitted to the facility on [DATE]. Diagnoses included myocardial infarction, coronary artery disease, hypertension, chronic obstructive pulmonary disease, obesity, anxiety disorder, and chronic kidney disease stage 3. Review of the Minimum Data Set assessment dated [DATE] documented Resident #3 was assessed with moderate cognitive impairment, no occurrence regarding refusal of care, required substantial to maximal assistance for the completion of activities of daily living including bed mobility and was incontinent of bowel and bladder. Review of the 02/19/24 nursing plan of care addressed Resident #3 had bladder incontinence related to (r/t) diuretic use and mobility. Plan of care goal noted the resident will decrease frequency of urinary incontinence. Interventions included to clean peri-area with each incontinence episode. Monitor/document/report as needed (PRN) any possible causes of incontinence: bladder infection, constipation, loss of bladder tone, weakening of control muscles, decreased bladder capacity, medication side effects. In addition, on 02/21/24 a nursing plan of care was revised to address risk for impaired skin integrity r/t weakness, difficulty ambulating, chronic pain, cardiac impairments, chronic kidney disease (CKD), cognitive deficits, incontinence, and edema. Goal was skin will be free of breakdown. Interventions included to assist resident to turn and reposition at routine intervals and as needed. Barrier cream/ointment after each incontinent episode as needed. No interventions contained in the plans of care or medical record indicated an established urinary frequency specific to the resident, type of incontinence, or interval to check and change the resident for incontinence. Interview on 03/27/24 at 7:46 A.M. with State Tested Nurse Aide (STNA) #200 revealed Resident #3 required incontinence checks every two hours. STNA #200 stated the resident was last checked and changed for incontinence after assuming care of the resident between approximately 6:35 A.M. and 6:40 A.M. Observations on 03/27/24 between 7:27 A.M. to 10:07 A.M. revealed Resident #3 to remain in bed. No attempts were observed by staff to check the resident for incontinence. Obsrvation on 03/27/24 at 10:07 A.M. revealed STNA #200 was at Resident #3's bedside to initiate a bed bath and removed the front of the incontinence brief. The incontinence brief contained a second incontinence pad. Both pads were heavily soiled. STNA #200 provided perineal care and proceeded to turn the resident to the side. Resident #3 was noted with both incontinence pads saturated with a heavy amount of urine soaking through to the linen pad under the resident. The resident was also observed to be incontinent of moderate amount of bowel. Interview on 03/27/24 immediately following the observation, STNA #200 verified checking Resident #3 between approximately 6:35 A.M. or 6:40 A.M. with no additional incontinence checks being provided (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365849 If continuation sheet Page 3 of 4 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 03/28/2024 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 0690 until the 10:07 A.M. observation. Level of Harm - Minimal harm or potential for actual harm Interview on 03/27/24 at 10:50 A.M. with the Director of Nursing (DON) confirmed no established or specific urinary frequency had been determined for Resident #3. Residents Affected - Few Review of the facility policy titled Urinary Continence and Incontinence Assessment and Management, revised September 2010, revealed the staff and practitioner will appropriately screen for and manage individuals with incontinence. Management of incontinence will follow relevant clinical guidelines. As part of assessment, nursing staff will seek and document details related to continence. Relevant details include: voiding patterns, associated pain or discomfort, types of incontinence. The nursing staff and physician will identify risk factors for becoming incontinent or for worsening of current incontinence. If the resident does not respond and does not try to toilet, or those with such severe cognitive impairment that they cannot either point to an object or say their own name, staff will use a check and change strategy. A check and change strategy involves checking the resident's continence status at regular intervals and using incontinence devices or garments. The primary goal is to maintain dignity and comfort and to protect the skin. The staff and physician will evaluate the effectiveness of interventions and implement additional pertinent interventions as indicated. This deficiency represents non-compliance investigated under Complaint Number OH00151745. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365849 If continuation sheet Page 4 of 4