Inspection visit

Health inspectionJune 6, 2019

AYDEN HEALTHCARE OF WAUSEONCMS #3653309 citations on this visit

9 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 9 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview and facility policy review, the facility failed to notify the physician of new pressure wounds for a resident. This affected one (Resident #35) of one resident reviewed for physician notification. The facility census was 40. Findings include: Review of the medical record for Resident #35 revealed she was admitted to the facility on [DATE] and readmitted [DATE]. Diagnoses included chronic kidney disease, diabetes, hypertension, anemia and urinary tract infection. Review of the admission Minimum Data Set (MDS) assessment, dated 04/05/19, revealed she was cognitively impaired and was not interviewable. Review of the medical record revealed Resident #35 had pressure wounds at her right heel, left heel and left ischium. There was no documentation of any wounds on Resident #35's coccyx. Review of the physician order dated 05/01/19 revealed to apply barrier cream to coccyx twice daily and as needed. Interview on 06/04/19 at 1:13 P.M. with Licensed Practical Nurse (LPN) #245 verified the resident had pressure wounds on both heels and one on her left ischium. LPN #245 stated Resident #35 had a red coccyx but denied she had any open areas at the coccyx. Resident #35 had only a barrier cream treatment ordered for the coccyx as a preventative treatment. The state tested nurse aides (STNAs) applied the barrier cream. Observation and interview on 06/04/19 at 1:31 P.M. with LPN #250 and STNA #255 revealed incontinence care and barrier cream to the coccyx was provided. After cleansing Resident #35's coccyx area, observation revealed the coccyx was red and there was an open area in the center approximately one centimeters (cm.) by one cm. and with depth unknown. The wound bed had yellow slough. There were two additional areas on the left side of the coccyx that were open approximately one cm. by one cm. with red wound beds and a smaller open area on the right side of the coccyx. Interview with STNA #255, at the time of the observation, stated the area in the center of the coccyx was open since the weekend, on Sunday (06/02/19), and had the same yellow slough in the center and appeared to be about the same size it was at this observation. STNA #255 stated she reported the open area to the agency Registered Nurse (RN) #300 on 06/02/19 in the morning about 10:00 A.M. STNA #255 stated RN #300 told her the order was for barrier cream and to continue using the barrier cream. Review of the nursing progress notes from 05/31/19 until 06/04/19 at 3:15 P.M. revealed there was (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 14 Event ID: 365330 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 365330 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Wauseon 303 W Leggett St Wauseon, OH 43567 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 0580 Level of Harm - Minimal harm or potential for actual harm no documentation Resident #35 having a new unstageable pressure wound (slough and/or eschar: known but stageable due to coverage of wound bed by slough and/or eschar) at her coccyx (discovered on 06/02/19). There was no documentation of physician notification of the new open wound at Resident #35's coccyx. There were no physician orders for a new treatment of the unstageable pressure wound at her mid coccyx. Residents Affected - Few Observation of wound care and interview on 06/04/19 at 3:40 P.M. with LPN #260 and Director of Nursing (DON) revealed the DON verified Resident #35 had four new open areas. At Resident #35's mid coccyx, she identified an unstageable pressure ulcer measuring 0.5 cm. by 0.7 cm. by less than 0.3 cm. depth and with a yellow slough wound bed. At the left mid-coccyx, she identified a stage two pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound, without slough) measuring 0.9 cm. by one cm. by less than 0.2 cm. with a red wound bed. At the left lower coccyx, she identified a stage two pressure wound measuring 0.9 cm. by one cm. by less than 0.1 cm. with a red wound bed. At the right coccyx, she identified a stage one pressure wound (reddened area, not open) measuring 0.2 cm. by 0.2 cm. by 0.1 cm. with a red wound bed. The DON verified the barrier cream was not an appropriate treatment for the unstageable pressure wound or the other three new pressures. The DON verified new treatment orders should have been obtained when the wound opened on 06/02/19. The DON verified STNAs should not be providing treatment for pressure wounds. LPN #260 stated she had observed the coccyx area on Saturday (06/01/19) while providing care to Resident #35 and there had been no open areas to the coccyx on 06/01/19 but that she had noted two superficial areas that looked abraded but were not open on the evening of 06/01/19. Interview by telephone on 06/05/19 at 11:37 A.M. with Agency RN #300 denied anyone ever reported that Resident #35 had any new open areas. RN #300 verified she did not report the change of condition to the physician or obtained any new treatment orders for the pressure wounds. Review of the facility policy titled Physician Notification dated 12/01/18 revealed the physician must be notified of a resident's change in condition. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365330 If continuation sheet Page 2 of 14 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 365330 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Wauseon 303 W Leggett St Wauseon, OH 43567 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and facility policy review, the facility failed to issue a bed hold notice to a resident. This affected one (Resident #44) of one resident reviewed for hospitalization. The facility census was 40. Findings include: Review of the medical record of Resident #44 revealed an admission date of 01/14/19 and a discharge date of 04/05/19. Diagnoses included obstructive and reflux uropathy, dementia, hypertension, atrial fibrillation and presence of automatic cardiac defibrillator. Review of the progress notes, dated 04/05/19 at 4:18 A.M., revealed Resident #44 had a change in condition with heart rate of 136 beats per minute, respirations of 43 breaths per minute, a temperature of 102.6 degrees Fahrenheit and a low peripheral capillary oxygen saturation. Resident #44 was not responding as was normal for him. The doctor was notified and an order was received to send Resident #44 to the emergency room for an evaluation. Resident #44's wife was notified and apprised of the situation. Review of the medical record revealed no bed hold notice had been issued upon transfer to the emergency room. A progress note dated 04/05/19 at 2:15 P.M., written by Social Service (SS) #220, revealed a conversation held with Resident #44's wife reflecting her wish to hold a bed. Interviews on 06/04/19 at 2:00 P.M. with SS #220 and Admissions Coordinator #225 revealed no bed hold notice had been issued when Resident #44 was taken to the emergency room on [DATE]. Review of the facility policy titled Discharge, Transfer and Bed Hold Policy dated 01/01/16 revealed, in the event of a discharge, a resident or their representative will be notified, in writing, of the bed hold policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365330 If continuation sheet Page 3 of 14 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 365330 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Wauseon 303 W Leggett St Wauseon, OH 43567 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 medical record review, observation, staff interview and facility policy review, the facility failed to provide care and treatment of new pressure wounds for a resident. This affected one (Resident #35) of three residents reviewed for pressure wounds. The facility identified four residents with pressure ulcer wounds. The facility census was 40. Residents Affected - Few Findings include: Review of the medical record for Resident #35 revealed she was admitted to the facility on [DATE] and readmitted [DATE]. Diagnoses included chronic kidney disease, diabetes, hypertension, anemia and urinary tract infection. Review of the admission Minimum Data Set (MDS) assessment, dated 04/05/19, revealed she was cognitively impaired and was not interviewable. The resident required extensive assistance of two staff with her activities of daily living. Review of the Braden Scale for Predicting Pressure Sore Risk, dated 03/30/19, revealed she was at moderate risk of developing pressure wounds. Review of the medical record revealed Resident #35 had pressure wounds at her right heel, left heel and left ischium. There was no documentation of any wounds on Resident #35's coccyx. Review of the physician order dated 05/01/19 revealed to apply barrier cream to coccyx twice daily and as needed. Interview on 06/04/19 at 1:13 P.M. with Licensed Practical Nurse (LPN) #245 verified the resident had pressure wounds on both heels and one on her left ischium. LPN #245 stated Resident #35 had a red coccyx but denied she had any open areas at the coccyx. Resident #35 had only a barrier cream treatment ordered for the coccyx as a preventative treatment. The state tested nurse aides (STNAs) applied the barrier cream. Observation and interview on 06/04/19 at 1:31 P.M. with LPN #250 and STNA #255 revealed incontinence care and barrier cream to the coccyx was provided. After cleansing Resident #35's coccyx area, observation revealed the coccyx was red and there was an open area in the center approximately one centimeters (cm.) by one cm. and with depth unknown. The wound bed had yellow slough. There were two additional areas on the left side of the coccyx that were open approximately one cm. by one cm. with red wound beds and a smaller open area on the right side of the coccyx. Interview with STNA #255, at the time of the observation, stated the area in the center of the coccyx was open since the weekend, on Sunday (06/02/19), and had the same yellow slough in the center and appeared to be about the same size it was at this observation. STNA #255 stated she reported the open area to the agency Registered Nurse (RN) #300 on 06/02/19 in the morning about 10:00 A.M. STNA #255 stated RN #300 told her the order was for barrier cream and to continue using the barrier cream. Review of the nursing progress notes from 05/31/19 until 06/04/19 at 3:15 P.M. revealed there was no documentation Resident #35 having a new unstageable pressure wound (slough and/or eschar: known but stageable due to coverage of wound bed by slough and/or eschar) at her coccyx (discovered on 06/02/19). There was no documentation of physician notification of the new open wound at Resident #35's coccyx. There were no physician orders for a new treatment of the unstageable pressure wound at her mid coccyx. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365330 If continuation sheet Page 4 of 14 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 365330 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Wauseon 303 W Leggett St Wauseon, OH 43567 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 Residents Affected - Few Observation of wound care and interview on 06/04/19 at 3:40 P.M. with LPN #260 and Director of Nursing (DON) revealed the DON verified Resident #35 had four new open areas. At Resident #35's mid coccyx, she identified an unstageable pressure ulcer measuring 0.5 cm. by 0.7 cm. by less than 0.3 cm. depth and with a yellow slough wound bed. At the left mid-coccyx, she identified a stage two pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound, without slough) measuring 0.9 cm. by one cm. by less than 0.2 cm. with a red wound bed. At the left lower coccyx, she identified a stage two pressure wound measuring 0.9 cm. by one cm. by less than 0.1 cm. with a red wound bed. At the right coccyx, she identified a stage one pressure wound (reddened area, not open) measuring 0.2 cm. by 0.2 cm. by 0.1 cm. with a red wound bed. The DON verified the barrier cream was not an appropriate treatment for the unstageable pressure wound or the other three new pressures. The DON verified new treatment orders should have been obtained when the wound opened on 06/02/19. The DON verified STNAs should not be providing treatment for pressure wounds. LPN #260 stated she had observed the coccyx area on Saturday (06/01/19) while providing care to Resident #35 and there had been no open areas to the coccyx on 06/01/19 but that she had noted two superficial areas that looked abraded but were not open on the evening of 06/01/19. Interview by telephone on 06/05/19 at 11:37 A.M. with Agency RN #300 denied anyone ever reported that Resident #35 had any new open areas. RN #300 verified she did not report the change of condition to the physician or obtained any new treatment orders for the pressure wounds. This deficiency is an example of continued non-compliance from the survey dated 05/01/19. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365330 If continuation sheet Page 5 of 14 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 365330 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Wauseon 303 W Leggett St Wauseon, OH 43567 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, staff and resident interview, and review of a facility policy, the facility failed to ensure a resident's respiratory equipment was properly maintained. This affected one (Resident #40) of two residents reviewed for respiratory care. The facility identified 17 residents receiving oxygen and/or nebulizer therapy. The facility census was 40. Residents Affected - Few Findings include: Review of Resident #40's medical record revealed an admission date of 10/01/17. Medical diagnoses included myocardial infarction, pleurisy, acute bronchitis, acute respiratory failure, chronic obstructive pulmonary disease, and polyneuropathy. Review of the resident's physician's order revealed an order dated 03/18/19 for oxygen at three liters per minute via nasal cannula continuously. Observation of the resident on 06/03/19 at 10:43 A.M. revealed her nebulizer and oxygen tubing were both labeled with a piece of tape marked 04/19/19. Interview with Resident #40 on 06/03/19 at 10:43 A.M. revealed the staff only change her oxygen and nebulizer tubing when she requests it. Interview with Registered Nurse #230 on 06/04/19 at 2:02 P.M. verified the resident's oxygen tubing and nebulizer tubing was dated 04/19/19. She stated it should be changed weekly. Review of an undated facility policy titled Equipment Management revealed disposable nebulizer tubing and oxygen tubing was to be changed weekly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365330 If continuation sheet Page 6 of 14 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 365330 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Wauseon 303 W Leggett St Wauseon, OH 43567 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on record review and staff interview, the facility failed to administer medication as directed by the physician for a resident. This affected one (Resident #21) of five residents reviewed for unnecessary medications. The facility census was 40. Findings include: Review of the medical record of Resident #21 revealed an admission date of 11/08/11 and a readmission date of 12/29/11. Diagnoses included intracranial injury without loss of consciousness, Alzheimer's disease, anxiety, unspecified psychosis, unspecified dementia with behavioral disturbances. peripheral vascular disease, tremor, hyperlipidemia, major depressive disorder and chronic obstructive pulmonary disease. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/08/19, revealed the resident was severely cognitively impaired. Review of the physician orders dated 01/23/19 revealed an order for gentamicin eye drops three milligrams per milliliter to be administered one to two drops in each eye twice daily for 14 days. Review of the medication administration record (MAR) for 01/2019 revealed the medication was not administered and no documentation was available to explain why. Review of the MAR for 02/2019 revealed the order to be transcribed as gentamicin eye drops one or two in each eye twice daily, without the 14 day specification. The MAR documentation reflected the drops to be administered each day minus five doses (02/01/19 neither dose, 02/02/19 the A.M. dose, 02/15/19 the P.M. dose and 02/25/19 the P.M. dose). The medication should have been discontinued on 02/07/19. Review of the physician orders, dated 03/11/19, revealed the physician ordered for gentamicin eye drops three milligrams per milliliter to be administered one to two drops in each eye twice daily for 14 days Review of the 03/2019 MAR revealed the medication had been administered twice daily as ordered on 03/01/19 through 03/08/19. The medication should not have been administered until 03/11/19 after the new order had been obtained. The medication was not administered until two days after the physician orders on 03/13/19. Review of a pharmacy communication form, dated 03/05/19, revealed the facility was requesting a refill of the medication however there were no refills remaining on the prescription. The physician signed the request to authorize the refill and indicated no stop date. Review of the physician orders for 04/2019 revealed the Certified Nurse Practitioner had signed the orders on 04/03/19 indicating the gentamicin eye drops were to be administered for only 14 days. Review of the 04/2019 MAR revealed the order had been transcribed to indicate gentamicin eye drops to be administered twice daily for 14 days. The medication was documented as having been administered twice daily for 30 days. Review of the physician orders for 05/2019 revealed the Certified Nurse Practitioner had signed the orders on 05/09/19 indicating the gentamicin eye drops were to be administered for only 14 days. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365330 If continuation sheet Page 7 of 14 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 365330 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Wauseon 303 W Leggett St Wauseon, OH 43567 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Review of the 05/2019 MAR revealed the medication, gentamicin eye drops, were administered twice daily on 05/03 through 05/11 and 05/13 through 05/16, 05/18, 05/19, 05/21 and 05/22 and once daily on 05/01, 05/02, 05/12, 05/17 and 05/20. The order was indicated as having been discontinued since January. Interview on 06/06/19 at 9:45 A.M. with the Director of Nursing provided verification of the medication errors. Event ID: Facility ID: 365330 If continuation sheet Page 8 of 14 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 365330 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Wauseon 303 W Leggett St Wauseon, OH 43567 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on medical record review and staff interview, the facility failed to timely respond to a pharmacist recommendation for three residents (#5, #17 and #21). Furthermore, the facility failed to ensure the policy included the specific time frames for the steps of the Medication Regimen Review process. This had the potential to affect all 40 residents residing in the facility. Findings include: 1. Review of the medical record of Resident #5 revealed an admission date of 11/01/06. Diagnoses included dementia with behavioral disturbance and type two diabetes mellitus. Review of the progress notes revealed a Medication Regimen Review Note dated 09/05/18. The note indicated an order indicated fasting blood sugar and hemoglobin A1C (a lab test that tells you the average level of blood sugar over the past two to three months) every six months in February and July. At the time of the review, a Hemoglobin A1C and fasting blood sugar could not be located in the clinical record. Please consider the recommendation to follow up with the lab and monitoring fasting blood sugar and Hemoglobin A1C the next lab day and at least every six months. The medical record was silent for any response to the recommendation. Review of the lab results revealed the recommended lab tests were not obtained until 12/03/18, three months after the recommendation. Interview on 06/05/19 05:27 PM with Regional Director of Clinical Services (RDCS) #235 she verified there was no response in the clinical record to the pharmacy recommendation, dated 09/05/18, for Resident #5. 2. Review of the medical record for Resident #17 revealed an admission date of 01/31/17. Diagnoses included Alzheimer's disease, major depressive disorder and dementia without behavioral disturbances. Review of the progress notes revealed a Medication Regimen Review Note dated 09/05/18. The note indicated Mirtazapine (an antidepressant) 7.5 milligrams had been ordered since at least 03/2018. A recommendation to please consider a dose reduction was issued. The medical record was silent for any response to the recommendation. Interview on 06/05/19 05:27 PM with Regional Director of Clinical Services verified there was no physician response to the pharmacy recommendation for 09/05/18 for Resident #17. 3. Review of the medical record for Resident #21 revealed an admission date of 11/08/11 and a readmission date of 12/29/11. Diagnoses included Alzheimer's disease, anxiety and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/08/19, revealed Resident #21 had severe cognition deficits. Review of the Physician Recommendation Form, dated 03/25/19, revealed a recommendation to consider a dose reduction for Mirtazapine 15 milligrams (mg.) daily to be decreased to 7.5 mg. daily. The response was dated 05/19/19, 55 days after the recommendation, to decrease the Mirtazapine to 7.5 mg daily for 10 days and then discontinue it. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365330 If continuation sheet Page 9 of 14 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 365330 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Wauseon 303 W Leggett St Wauseon, OH 43567 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Interview on 06/06/19 at 9:45 A.M. with the Director of Nursing (DON) verified it took the physician about eight weeks to respond to the pharmacy recommendation. The DON verified the facilities policy did not have timeframes listed. Review of the facility policy titled Pharmacy Recommendations Policy dated 12/01/18 revealed the pharmacist will review the medication regimen, or each resident, routinely as required by state or federal regulations. Irregularities and/or clinically significant risks resulting from or associated with medications are reported to the Director of Nursing and the Medical Director and will be reviewed by the facility. The recommendations will be marked on the recommendation to show that it has been completed. The policy did not include specified timeframes for the completion of pharmacy recommendations. Event ID: Facility ID: 365330 If continuation sheet Page 10 of 14 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 365330 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Wauseon 303 W Leggett St Wauseon, OH 43567 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, staff interview, and review of a facility dietary spreadsheet, the facility failed to ensure the dietary spreadsheet was followed as approved by the dietitian. This affected 13 residents (#1, #5, #7, #12, #21, #22, #24, #33, #37, #39, #42, #43 and #197) who received a regular meat entree and five residents (#1, #21, #23, #24, and #43) who received a puree diet. The facility census was 40. Findings include: 1. Observation of lunch service on 06/04/19 at 11:15 A.M. with Dietary Manager #200 revealed residents were served a very small chicken breast. Review of the facility spreadsheet revealed residents were to receive a four ounce chicken breast. Interview with Dietary Manager #200 at time of service revealed the chicken breast served was three ounces. She verified the dietary spreadsheet indicated a four ounce chicken breast for those who received the regular entrée. She stated she did not have a policy regarding following the dietary spreadsheet. Review of the facility's list of residents on a regular diet revealed Resident #1, #5, #7, #12, #21, #22, #24, #33, #37, #39, #42, #43 and #197 were on a regular diet. 2. Observation of lunch service on 06/04/19 at 11:15 A.M. with Dietary Manager #200 revealed residents receiving the puree meal did not receive a bread per the facility dietary spreadsheet. Review of the facility spreadsheet revealed residents were to receive a puree wheat roll. Interview with Dietary Manager #200 at time of service revealed she forgot to puree the wheat rolls. She verified the dietary spreadsheet indicated residents on a puree diet were to receive a pureed wheat roll. She stated she did not have a policy regarding following the dietary spreadsheet. Review of the facility's list of residents on a pureed diet revealed Resident #1, #21, #23, #24, and #43 were on a pureed diet. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365330 If continuation sheet Page 11 of 14 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 365330 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Wauseon 303 W Leggett St Wauseon, OH 43567 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, staff interview, facility record review and review of facility policies, the facility failed to ensure appropriate kitchen sanitation and proper food storage. This had the potential to affect all 40 residents in the facility. The facility stated all residents ate food from the kitchen. Findings include: 1. Observation of the facility refrigerator with Dietary Manager (DM) #200 on 06/03/19 at 9:40 A.M. revealed unlabeled chopped turkey pieces in a clear zip top bag, one unlabeled plastic container of sweet potatoes, one unlabeled plastic container of coleslaw, one unlabeled plastic container of peach crisp, one unlabeled clear bag of cheese slices, and one opened zip bag of sliced turkey labeled 05/20/19. Dietary Manager #200 at time of the above observations verified these findings. She stated opened containers of food should be labeled and used within five days. Review of a facility policy titled Food Storage, dated 03/2017, revealed leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Leftover food is used within three days or discarded. 2. Observation of the facility dispenser type ice machine on 06/03/19 at 9:45 A.M. along with DM #200 revealed an attached scoop holder that had dust and debris on and around it. The top of the ice machine had a layer of dust. Inside the dispenser area, a black substance that appeared to be mold was noted on each side of the internal dispenser. Continued observation revealed a ceiling air intake vent located above the ice machine that was approximately three feet long by 18 inches wide. It was covered in dirt and debris and one side was not secured to the ceiling. Observation of three air ducts (located above food preparation areas) revealed they were covered in loose dirt/dust and some of the loose dirt/dust had blown on the surrounding ceiling area. DM #200 at time of the above observations verified these findings. She stated the maintenance department was responsible for care of the ceiling air intakes and ducts and ice machine. Interview with Maintenance Director #205 on 06/04/19 at 1:16 P.M. revealed he was only able to locate one service invoice for the ice machine dated 08/07/17. He stated he thought it had been in-serviced since but could not find any further invoices. Review of the ice machine invoice dated 08/07/17 revealed work completed was ice machine and dispenser were cleaned. Ice cleaner was placed in the water and made ice with it to get all the scale and mold out. This machine was very dirty. Took everything apart and was cleaned very good. Replaced hoses, rinsed good, cleaned the dispenser and storage bin. Further instructions stated the ice machine should be cleaned every six months. Review of an undated facility document titled Quick Reference for Maintenance Tasks revealed ice machine cleaning was to be completed annually. Review of an undated facility policy titled Dietary Sanitation revealed the food service area shall be maintained in a clean and sanitary manner. All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks and chipped areas. Ice which is used in connection with food or drink shall be from a sanitary (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365330 If continuation sheet Page 12 of 14 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 365330 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Wauseon 303 W Leggett St Wauseon, OH 43567 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 source and shall be handled and dispensed in a sanitary manner. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365330 If continuation sheet Page 13 of 14 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 365330 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Wauseon 303 W Leggett St Wauseon, OH 43567 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 Based on medical record review, review of the infection control log, staff interview and policy review, the facility failed to re-educate staff members when a trend of urinary tract infections was noted in 04/2019. This affected five residents (#14, #29, #35, #42 and #43). The facility census was 40. Residents Affected - Some Findings include: Review of the medical record of Resident #14 revealed an admission date of 09/08/18. Review of the facility log for infections for 04/2019 revealed Resident #14 had an onset date of 04/01/19 and 04/30/19 with a urinary tract infection (UTI.) The form revealed the organisms to be Proteus Mirabilis and Escherichia coli. Review of the medical record of Resident #29 revealed an admission date of 03/11/19. Review of the facility log for infections for 04/2019 revealed Resident #29 had an onset date of 04/03/19 with a urinary tract infection (UTI.) The form revealed the organism to be Escherichia coli. Review of the medical record of Resident #35 revealed an admission date of 03/29/19. Review of the facility log for infections for 04/2019 revealed Resident #35 had an onset date of 04/10/19 with a urinary tract infection (UTI.) The form revealed the organism to be Enterococcus faecalis. Review of the medical record of Resident #42 revealed an admission date of 11/27/18. Review of the facility log for infections for 04/2019 revealed Resident #42 had an onset date of 04/16/19 with a urinary tract infection (UTI.) The form revealed the organism to be Escherichia coli. Review of the medical record of Resident #43 revealed an admission date of 08/05/17. Review of the facility log for infections for 04/2019 revealed Resident #43 had an onset date of 04/21/19 with a urinary tract infection (UTI.) The form revealed the organism to be Escherichia coli. Review of the infection control log book was absent for any results after the trend was identified. Interview on 06/06/19 at 9:55 A.M. with the Director of Nursing provided verification of the lack of any response to the trend of UTI's identified on the 04/2019 log. Review of the facility policy titled Infection Control Policy & Procedure, dated 12/01/18, revealed when a trend is identified a response must be listed. The example given was an increase in UTI's with direct care staff being in-serviced on perineal care procedures and prevention of UTI's. A copy of the in-service outline and the staff sign in sheet should be attached. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365330 If continuation sheet Page 14 of 14

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Citations

9 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0625GeneralS&S Dpotential for harm
F625 - Transfer and discharge-
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
0880GeneralS&S Epotential for harm
F880 - Infection Control
Provide and implement an infection prevention and control program.
0580GeneralS&S Dpotential for harm
F580 - Notification of Changes
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
0686GeneralS&S Dpotential for harm
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
0695GeneralS&S Dpotential for harm
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
0755GeneralS&S Dpotential for harm
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
0756GeneralS&S Fpotential for harm
F756 - Drug Regimen Review
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
0803GeneralS&S Epotential for harm
F803 - Menus and nutritional adequacy
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
0812GeneralS&S Fpotential for harm
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

FAQ · About this visit

Common questions about this visit

What happened during the June 6, 2019 survey of AYDEN HEALTHCARE OF WAUSEON?

This was a inspection survey of AYDEN HEALTHCARE OF WAUSEON on June 6, 2019. The surveyor cited 9 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at AYDEN HEALTHCARE OF WAUSEON on June 6, 2019?

Yes, 9 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed i..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

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Data from CMS Care Compare public records. Dataset last refreshed June 15, 2026. If you believe any information is inaccurate, report it here.

Health inspection·June 6, 2019