Inspection·June 6, 2024

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few indicating the blood sugar results were documented in the medical record to monitor blood sugar levels as ordered by the physician. Review of the policy titled, Nursing Care of the Resident with Diabetes Mellitus, dated Revised December 2015, revealed the physician will order the frequency of glucose monitoring. Residents whose blood sugar is poorly controlled or those taking insulin may require more frequent monitoring, depending on the situation. Documentation should reflect the carefully assessed diabetic resident and include the following: blood sugar results and other pertinent laboratory studies. This deficiency represents non-compliance investigated under Complaint Number OH00154139. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365849 If continuation sheet Page 2 of 5 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 06/06/2024 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 0760 Ensure that residents are free from significant medication errors. 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, staff interview, policy review, and manufacturer instructions for use review, the facility failed to ensure medications were administered as ordered by the physician and within prescribed time frames, resulting in delay in administration of insulin, and antidepressant medication. This affected one (#1) of three residents observed during medication administration. The facility census was 75. Residents Affected - Few Findings include: Observation on 06/05/24 at 9:45 A.M., noted Licensed Practical Nurse ( LPN) #300 obtain a blood glucose monitor from the medication cart and proceed into Resident #1 room. Upon entry Resident #1 had concluded the breakfast meal consuming between 50-75% of the meal. LPN #300 obtained a blood sample from Resident #1 left index finger which resulted at a blood sugar level of 286. LPN #300 returned back to the medication cart and obtained a Insulin Lispro pen, placed a needle to the pen and returned to the room. At 10:00 A.M., LPN #300 dialed six (6) units to the indicator window and injected the insulin into the resident. No prime of the pen was conducted. Once the needle was injected, LPN #300 pressed the injection button for two (2) seconds and removed the needle. No count for 10 seconds was conducted. LPN #300 then provided Resident #1 with additional morning medications including a dose of Paxil 20 milligrams (mg). Interview on 06/05/24 at 10:11 A.M., Resident #1 stated she frequently receives blood sugar monitoring and associated insulin coverage after meals. The resident also stated she had not received her antidepressant Paxil. The resident indicated she felt a change in mood and lack of tolerance with staff due to not receiving the Paxil 20 mg. Interview on 06/05/24 at 10:19 A.M., with LPN #300 verified Resident #1 blood sugar monitoring and insulin sliding scale administration were past prescribed time frames. LPN #300 confirmed Resident #1 had consumed 50-75% of the breakfast meal before obtaining blood sugar. LPN #300 also confirm she was unaware the Insulin Lispro pen required a prime before administration and stated she was unaware to inject the needle for slow count of ten seconds before removing the injection needle. Review of Resident #1's medical record revealed an admission date of 05/18/24, with the diagnoses including: chronic obstructive pulmonary disease, cerebral infarction, occlusion and stenosis of basilar artery, myocardial infarction, chronic ischemic heart disease, morbid obesity, type 2 diabetes mellitus, polyneuropathy, bipolar personality disorder, borderline personality disorder, and major depression. Review of the most current minimum data set assessment dated [DATE], assessed Resident #1 with moderate cognitive impairment, required substantial/maximal assistance with activities of daily living, utilized a wheelchair and walker for mobility, incontinent of bowel and bladder, received antianxiety, diuretic, opioid, antiplatelet, hypoglycemic medications. Review of a nursing plan of care was implemented on 05/18/24 and revised on 05/21/24, to address Resident #1 risk for hyper/hypoglycemic episodes related to diabetes mellitus type II. Interventions included blood sugar testing as ordered/as needed, insulin as ordered, medications as ordered. On 05/21/24, a nursing plan of care was implemented to address Resident #1 mood problem related to bipolar, borderline personality disorder, depression with interventions to administer medications as ordered. Monitor/document for side effects and effectiveness. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365849 If continuation sheet Page 3 of 5 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 06/06/2024 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Hospital Discharge physician orders dated 05/17/24 noted an order Paroxetine (Paxil) 20 milligrams (mg) one tablet at bedtime. Review of the medication administration record (MAR) from 05/17/24 to 05/30/24 was silent to the administration of Paxil 20 mg. On 05/31/24, a physician order was obtained for Paxil 20 mg give one tablet once daily for Major Depressive Disorder scheduled to be given upon rising between 7:00 A.M. and 10:00 A.M. Review of Resident #1 medical record revealed a physician order dated 05/19/24 for the administration of Insulin Lispro (1 Unit Dial) Subcutaneous Solution Pen-injector 100 units per (/) milliliter (Insulin Lispro) to Inject as per sliding scale: if blood sugar (BS) level 151 - 200 = 2 units notify physician for BS <70; 201 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; 401 - 450 = 12 units; 451 - 500 = 14 units notify physician if BS >451, administer subcutaneously before meals related to type 2 diabetes mellitus. Prescribed administration times were listed for before meals at 7:30 A.M., 11:00 A.M., and 4:00 P.M. Interview on 06/05/24 at 11:45 A.M., with the Administrator and Director of Nursing verified Resident #1 insulin pen is to be primed before administration and Resident #1 blood sugar monitoring and associated insulin coverage was given outside of prescribed timeframe's. Interview on 06/06/24 at 1:55 P.M., with the Director of Nursing revealed no documentation could be provided indicating Resident #1 Paxil 20 mg was administered or discontinued between admission on [DATE] and 05/31/24. Review of the Paxil (Paroxetine) manufacturer indications for use revised September 22, 2022 all dose changes should be gradual, including discontinuation. Review of the policy titled, Administering Medications, dated Revised December 2012, revealed medications must be administered in accordance with physician orders, including any required time frame. Medications must be administered within one (1) hour of their prescribed time, unless otherwise specified for example before and after meals. Review of policy titled, Medication Administration Subcutaneous Insulin, dated January 2022 indicates to prepare syringe/pen and safety needle. (See pen example). Performing the safety test ensures an accurate dose by: ensuring that pen and needle work properly, removing air bubbles. Hold the pen with the needle pointing upwards. Tap the insulin reservoir so that any air bubbles rise up towards the needle. Press the injection button all the way in. Check if insulin comes out of the needle tip. You may have to perform the safety test several times before insulin is seen. If no insulin comes out, the needle may be blocked. Change the needle and try again. If no insulin comes out after changing the needle, the pen may be damaged. Do not use this pen. Insert the needle into the skin at a 90 degree angle. Deliver the dose by pressing the injection button in all the way. The number in the dose window will return to 0 as you inject. Keep the injection button pressed all the way in. Slowly count to 10 before you withdraw the needle from the skin. This ensures that the full dose was delivered. Review of policy titled, Nursing Care of the Resident with Diabetes Mellitus, policy dated Revised December 2015 revealed the physician will order the frequency of glucose monitoring. Residents whose blood sugar is poorly controlled or those taking insulin may require more frequent monitoring, depending on the situation. Documentation should reflect the carefully assessed diabetic resident and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365849 If continuation sheet Page 4 of 5 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 06/06/2024 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 0760 include the following: Blood sugar results and other pertinent laboratory studies. Level of Harm - Minimal harm or potential for actual harm Review of Humalog KwikPen (insulin lispro) instructions for use revised July 2023 priming pen which removes the air from the needle and cartridge that may collect during normal use and ensures the pen is working correctly. If pen is not primed before each injection, this may result in the patient receiving too much or too little insulin. To prime pen, turn the dose knob to select 2 units. Hold pen with needle pointing up. Tap cartridge holder gently to collect air bubbles at the top. Continue holding pen with needle pointing up. Push the dose knob in until it stops, and 0 is seen in the dose window. Hold the dose knob in and count to five slowly. Insulin should be seen at tip of needle. If insulin is not seen, repeat priming no more than four times. If still no insulin is observed, change the needle and repeat priming. Residents Affected - Few This deficiency represents non-compliance investigated under Complaint Number OH00154139. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365849 If continuation sheet Page 5 of 5