Ayden Healthcare of Toledo

Inspectors wroteBased on observation, staff interview, and review of a facility policy, the facility failed to ensure medications were securely stored and not maintained in stock past the expiration date. This had the potential to affect all 75 residents residing in the facility. The facility census was 75.

Inspectors wroteBased on observation, resident interview, staff interview, review of facility menus and spreadsheets, and policy review, the facility failed to follow scheduled menus and failed to ensure portion sizes were served per spreadsheets. This had the potential to affect all 74 residents who the facility identified as receiving food from the kitchen. The facility identified one (#85) resident with orders for nothing by mouth. The facility census was 75.

Inspectors wroteBased on observation, medical record review, resident interview, staff interview, and policy review, the facility failed to ensure measures developed for Legionella control measures were fully implemented, failed to ensure enhanced barrier precautions were in place for residents with indwelling medical devices, and failed to ensure proper infection control measures were maintained during administration of a subcutaneous medication. This had the potential to affect all 75 residents except one (#85) resident identified with orders for nothing by mouth, and directly affected one (#66) of one residents reviewed for dialysis and one (#68) of four residents observed for medication administration. The facility census was 75.1. Interview on 05/06/26 at 7:50 A.M. [...]

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to ensure resident were provided a respectful and dignified dining experience. This affected one (#56) of four residents observed seated at the same table during meal service. The facility census was 75.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on medical record review, review of facility investigation documents including written statements, review of pharmacy manifest documents, review of staffing schedules, review of narcotic count sheets, staff interview, policy review, and review facility corrective action, the facility failed to prevent the misappropriation of resident narcotic medications. This affected one (#86) of five residents reviewed for abuse, neglect, and misappropriation. The facility census was 75. Findings Include:Review of the medical record for Resident #86 revealed an admission date of 09/15/25 and a discharge date of 04/14/26. Diagnoses included chronic obstructive pulmonary disease (COPD), chronic respiratory failure, anxiety, and cancer of the pharynx. [...]

Inspectors wroteBased on observation, medical record review, resident interview, staff interviews, and review of a facility policy, the facility failed to ensure residents received appropriate assistance from staff to maintain adequate personal and oral hygiene. This affected two (Residents #38 and #42) of four residents reviewed for activities of daily living. The facility census was 75.

Inspectors wroteBased on observation, medical record review, staff interview, and policy review, the facility failed to ensure physician orders regarding wound treatments were followed. This affected one (#28) of three residents reviewed for wound care. The facility census was 75.

Inspectors wroteBased on observation, medical record review, resident interview, staff interview, and review of a facility policy, the facility failed to ensure residents assessed as unsafe to store smoking materials and ordered supplemental oxygen did not possess lighters. This affected one (Resident #43) of one residents reviewed for smoking. The census was 75.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure monitoring of fluid intake for residents with fluid restrictions and orders for daily weights were completed. This affected two (#50 and #66) of five residents reviewed for nutrition. The facility identified nine residents with fluid restrictions. The facility census was 75.

Inspectors wroteBased on observation, review of the medical record, staff interview, resident interview, and policy review, the facility failed to ensure a hemodialysis catheter was monitored every shift for signs of infection and bleeding. This affected one (#66) of one residents reviewed for dialysis services. The facility identified three residents receiving dialysis services. The facility census was 75.

Inspectors wroteBased on medical record review, staff interview, resident interview, and review of facility standards for trauma-informed care, the facility failed to ensure trauma-informed care and related interventions were provided to residents with a history of post-traumatic stress disorder. This affected one (Resident #12) of one residents reviewed for trauma-informed care. The facility census was 75.

Inspectors wroteBased on review of the medical record, resident interview, staff interview, and policy review, the facility failed to ensure routine dental services were provided. This affected one (#65) of two residents reviewed for dental services. The facility census was 75.

Inspectors wroteBased on medical record review, observation, resident interview, staff interview, interview with the local health department, and review of facility policy the facility failed to assist dependent residents with activities of daily living (ADL) care. This affected three (#26, #78, and #94) of four residents reviewed for ADL care. The facility census was 86.

Inspectors wroteBased on medical record review, resident interview, staff interview, and review of policy the facility failed to provide treatment for pressure ulcers. This affected two (Resident #43 and Former Resident #9) of three residents reviewed for pressure ulcers. The facility census was 86.

Inspectors wroteBased on medical record review, observation, resident interview, and staff interview, the facility failed to ensure adequate toenail care. This affected two (#15 and #94) of four residents reviewed for activities of daily living. The facility census was 86.

Inspectors wroteBased on record review, staff interview, and policy review the facility failed to ensure medical records were properly documented. This affected one resident (#73) of three reviewed for skin issues. The facility census was 86.

Inspectors wroteBased on observation, staff interview, and review of facility policy, the facility failed to ensure infection control standards were maintained during medication administration. This affected one resident (#60) of four residents (#16, #37, #40, and #60) observed for medication administration. The facility census was 86.

Inspectors wroteBased on review of personnel files, staff interview, review of the employee handbook, and review of facility policy, the facility failed to ensure state tested nurse aides (STNAs) received twelve hours of training annually and performance reviews were completed at least once every 12 months. This had the potential to affect all 67 residents in the facility. The census was 67.

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to store medications in a safe and sanitary manner and failed to ensure medications were not able to be used after expiration dates. This had the ability to affect all 67 residents residing in the facility. The facility census was 67. Findings Included: 1. Observation of the South hall medication refrigerator on [DATE] at 8:59 A.M. with Licensed Practical Nurse (LPN) #250 revealed the refrigerator contained a brown liquid substance on the bottom shelf. Located on that shelf, soaked in brown liquid, was an expired vial of influenza vaccine. The expiration dated was [DATE]. Interview with LPN #250 on [DATE] at 9:04 A.M. verified the refrigerator contained a brown liquid substance and contained expired influenza vaccine. 2. Inspection of the North medication storage refrigerator on [DATE] at 9:19 A.M. [...]

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to ensure the refrigerators at the nurses stations for resident food was kept clean and food labeled and dated. This has the potential to affect all 67 residents residing in the facility. The facility census was 67.

Inspectors wroteBased on resident interview, staff interview, review of Resident Council minutes, review of call light audits, and policy review, the facility failed to thoroughly address Resident Council concerns in a timely manner. This had the potential to affect 18 (#1, #8, #9, #11, #12, #17, #22, #24, #29, #33, #35, #41, #44, #45, #49, #52, #53, and #65) residents who regularly attended Resident Council meetings. The facility census was 67.

Inspectors wroteBased medical record review, resident interview, staff interview, and policy review, the facility failed to conduct care conferences as required. This affected eight (#9, #14, #17, #30, #34, #57, #59, and #62) of 26 residents reviewed for care conferences. The facility census was 67. Findings Included: 1. Review of Resident #9's medical record revealed an admission date of 09/28/23. Diagnoses included infection/inflammatory reaction due to internal left hip prosthesis, chronic obstructive pulmonary disease, peripheral vascular disease, alcoholic cardiomyopathy, chronic kidney disease, alcoholic hepatitis, alcohol abuse, and femur fracture. Review of Resident #9's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she had a high cognitive function. [...]

Inspectors wroteBased on observation, medical record review, resident interview, staff interview, and policy review the facility failed to ensure the facility maintained safe smoking practices as care planned and per the facility smoking policy. This directly affected four (#33, #59, #64, and #328) of four residents reviewed for smoking with the potential to affect all 15 (#1, #6, #7, #27, #28, #29, #33, #34, #41, #45, #46, #47, #59, #64, and #328) residents who smoke. Additionally, the facility failed to ensure fall interventions were in place as care planned. This affected one (#14) of three residents reviewed for falls. The facility census was 67.

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to maintain a safe and homelike environment. This had the potential to affect all 67 residents residing in the facility. The facility census was 67. Findings Included: 1. Observation on 07/10/24 at 2:28 P.M. revealed water was running out of the fire dampers from the ceiling onto the floor in the South halls of the facility. Buckets and wet floor signs were in place on four of the areas, but three additional areas had water sitting on the floor. Interview with Maintenance Assistant (MA) #162 on 07/10/24 at 2:30 P.M. revealed the rain water was coming down the vents from the duct work. MA #162 also confirmed the fire dampers contained a black substance on them. Interview with Maintenance Supervisor (MS) #163 on 07/10/24 at 3:03 P.M. revealed the water was coming in through the fire dampers from the roof. [...]

Inspectors wroteBased on review of the medical record, review of hospital documentation, resident and staff interview, and review of email correspondence, the facility failed to ensure meal accommodations were made to honor religious fasting preferences. This affected one (#21) of one resident reviewed for religious preferences. The facility census was 67.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure completed Minimum Data Set (MDS) assessments were completed and transmitted within required timeframes. This affected two (#43 and #61) of two residents reviewed for MDS assessment submission. The facility census was 67.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected the resident's status. This affected one (#33) of 26 residents reviewed for MDS assessments. The facility census was 67.

Inspectors wroteBased on medical record review, staff interview, and policy review the facility failed to implement a care plan to address the resident's desire to smoke. This affected one (#64) of four residents reviewed for smoking. The facility census was 67.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure consulted wound care specialist orders were completed. This affected one (#175) of three residents reviewed for wounds. The facility census was 67.

Inspectors wroteBased on medical record review, observation, resident interview, staff interview, and facility policy review, the facility failed to ensure residents had timely access to vision services. This affected one (#17) of two residents reviewed for vision services. The facility census was 67.

Inspectors wroteBased on observation, staff interview, medical record review, review of a mattress manual, and review of the facility policy, the facility failed to ensure pressure wound treatments were completed as ordered and wound care interventions were in place and functioning appropriately. This affected two (#16 and #56) of three residents reviewed for wounds and pressure reducing interventions. The facility census was 67.

Inspectors wroteBased on observation, staff interview, resident interview, and policy review the facility failed to ensure residents received timely and adequate assistance with incontinence care. This affected one (#62) of two residents reviewed for incontience. The facility census was 67. Findings Included: Review of Resident #62's medical record revealed an admission date of 01/25/24. Diagnoses included osteomyelitis the right femur, liver cancer, lung cancer, malnutrition, tachycardia, absence of the right leg below the knee, bone cancer, and a pressure ulcer on admission. Review of Resident #62's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a high cognitive function and required substantial/maximal assistance for toileting and rolling. [...]

Inspectors wroteBased on review of the medical record, hospital document review, and staff interview, the facility failed to ensure physician orders and dietitian recommendations were implemented to address weight changes. This affected one (#21) of two residents reviewed for nutrition. The facility census was 67.

Inspectors wroteBased on observation, staff interview, medical record review, and review of the facility policy, the facility failed to ensure physician orders for oxygen administration were in place prior to administering oxygen to residents. This affected two (#26 and #33) of two residents reviewed for oxygen administration. The facility census was 67.

Inspectors wroteBased on observation, medical record review, staff interview, and review of the facility policy, the facility failed to ensure medications were administered with a physician's order and were available for administration. This affected two (#55 and #175) of six residents reviewed for medications. The census was 67.

Inspectors wroteBased on medical record review, staff interview, and facility policy the facility failed to ensure pharmacy recommendations were timely reviewed and implemented. This affected two (#14 and #17) of five residents reviewed for unnecessary medications. The facility census was 67.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure physician orders for gradual dose reductions of psychotropic medications implemented in a timely manner. This affected one (#17) of five residents reviewed for unnecessary medications. The facility census was 67.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure consulted wound care specialist laboratory orders were completed. This affected one (#175) of three residents reviewed for wounds. The facility census was 67.

Inspectors wroteBased on medical record review, resident interview, staff interview, and review of a facility policy, the facility failed to keep accurate medical records. This affected one (#56) of 26 resident's medical records reviewed. The facility census was 67.

Inspectors wroteBased on medical record review, staff interview, and review of the facility policy, the facility failed to ensure antibiotic stewardship was practiced when treating residents with urinary tract infections (UTIs). This affected three (#12, #18, and #50) of three residents reviewed for UTIs. The facility census was 67.

Inspectors wroteBased on medical record review, review of immunization records, staff interview, review of policy, and review of the Centers for Disease Control and Prevention (CDC) guidance, the facility failed to ensure residents were offered pneumococcal and influenza vaccinations per CDC recommendations. This affected two (#14 and #30) of five residents reviewed for influenza and pneumococcal vaccinations. The facility census was 67.

Inspectors wroteBased on medical record review, review of immunization records, staff interview, review of a policy, and review of the Centers for Disease Control and Prevention (CDC) guidance, the facility failed to ensure COVID-19 vaccinations were offered per CDC recommendations. This affected two (#14 and #30) of five residents reviewed for COVID-19 vaccinations. The facility census was 67.

Inspectors wroteBased on observation, resident interview, and staff interview the facility failed to post a notice of the availability of survey results from the preceding three years is areas of the facility that are prominent and accessible to the public. This had the potential to affect all 67 residents. The facility census was 67.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure monitoring of a medication included obtaining blood sugar levels as ordered by the physician. This affected one (#2) of three residents reviewed for administration of medications and associated monitoring. The facility census was 75.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, medical record review, staff interview, and facility policy, the facility failed to ensure a dependent received bathing and associated grooming. This affected one (#3) of three sampled residents reviewed for the provision of activities of daily living in a facility census of 73.

Inspectors wroteBased 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.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure residents received ordered medications upon admission. This affected two residents (#15 and #71) of three residents reviewed for admission medications. The facility census was 70.

Inspectors wroteTHIS DEFICIENCY REPRESENTS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, record review, staff interview, and facility investigation review, the facility failed to ensure appropriate staff supervision/assistance was provided when Resident #6 was rolled out of bed by an State Tested Nursing Assistant (STNA) during bathing. Actual harm occurred when STNA #400 completed a bed bath for Resident #6, who was totally dependent on staff for bathing with two person physical assist, and Resident #6 fell from the bed and sustained a closed fracture of the right tibial plateau and fractured the right sixth tooth. This affected one (Resident #6) of three sampled residents reviewed for bed mobility and transfer assistance. The facility census was 70.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to provide incontinence care. This affected two (Residents #4 and #5) of three sampled residents reviewed for incontinence care. The facility census was 70.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, medical record review, and staff interview, the facility failed to ensure residents were provided with wheelchairs that were appropriately fitting. This affected one (Resident #44) of 24 residents observed for assistive devices. The facility census was 56.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.