Health inspection·April 13, 2023

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observations, staff interviews, and review of the facility policy, the facility failed to ensure the facility was maintained in a clean and sanitary condition. This had the potential to affect the 11 residents (#100, #102, #106, #110, #111, #118, #123, #133, #138, #148, and #163) who resided on the dementia unit. The facility census was 65. Findings include: Interview on 04/12/23 at 10:13 A.M. with Housekeeping #363 revealed a deep clean of resident rooms was completed everyday and verbalized a detailed list of everything cleaned in each resident room daily including the doorknobs, window ledges, bathroom floors, windows, dresser tops, nightstands, floors were swept and mopped, bathroom counters were cleaned and sanitized, and bathrooms were fully cleaned. Housekeeping #363 verified she has everything she needs to clean effectively. Observations and interview with State Tested Nursing Assistant (STNA) #334 on 04/12/23 from 5:01 P.M. to 5:05 P.M. revealed Resident #110's room had a sticky floor with crumbs, stains, sticky spots, dirt, and debris built up. Resident #100 and Resident #102's room had numerous dead bugs with wings by the wall by the bathroom and resident bed, and at least five ants crawling in the bathroom. Resident #111's bathroom had a couple of ants in the bathroom and the floor appeared dirty. The handrail between Resident #133 and Resident #138's room had numerous debris including crumbled wrappers. In the carpeted hallway near the nurse's station, there was a paper straw wrapper. STNA #334 confirmed the above observations. Subsequent observations on 04/13/23 at 8:04 A.M. revealed Resident #110's room had a sticky floor with crumbs, stains, sticky spots, dirt and debris built up. Resident #100 and Resident #102's room had numerous dead bugs with wings by the wall by the bathroom and resident bed, and at least five ants crawling in the bathroom. Resident #111's bathroom had a couple of ants in the bathroom and the floor appeared dirty. The handrail between Resident #133 and Resident #138's room had numerous debris including crumbled wrappers. In the carpeted hallway near the nurse's station, there was a paper straw wrapper. Observations on 04/13/23 at 3:00 P.M. revealed Resident #110's room had a sticky floor with small scrambled egg and stains. Resident #100 and Resident #102's room had numerous dead bugs with wings by the wall by the bathroom and resident bed, and at least five ants crawling in the bathroom. Resident #111's bathroom had a couple of ants in the bathroom and the floor appeared dirty. The handrail between Resident #133 and Resident #138's room had numerous debris including crumbled wrappers. In the carpeted hallway near the nurse's station, there was a paper straw wrapper. Page 1 of 2 365617 365617 04/13/2023 Ayden Healthcare of Waterville 8885 Browning Drive Waterville, OH 43566

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation and interview on 04/12/23 at 3:10 P.M. revealed Housekeeping #344 and Housekeeping #363 were in the housekeeping supply room sitting down talking. Housekeeping #363 stated she was scheduled to work until 4:30 P.M. but had her duties completed and had just finished with the dementia unit. Observation and interview on 04/12/23 at 3:15 P.M. with Housekeeping #363 again verified she had just finished fully cleaning the dementia unit but it gets dirty very quickly. Upon entering the unit, Housekeeping #363 noted the straw wrapper was new as she had just swept. It was noted the straw wrapper had been there since the day prior and there was no response. Upon entering Resident #110's room, Housekeeping #363 stated she cleaned the floors. Observations of egg, dirt, hair, sticky unknown debris by the resident's foot. The stains were addressed and Housekeeping #363 stated she did not have a good mop and probably could have utilized the scrapper. Housekeeping #363 verified Resident #100 and #102's room had dead bugs and ants, Resident #111's bathroom had ants, and a uncleaned handrail. Review of the facility policy titled Homelike Environment, dated May 2017, revealed the facility staff and management shall maximize to the extent possible the characteristics of the facility to reflect a personalized homelike setting to include a clean, sanitary, and orderly environment. This deficiency represents non-compliance investigated under Master Complaint Number OH00141773 and Complaint Number OH00141575. 365617 Page 2 of 2