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. (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 2 Event ID: 365617 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 365617 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Waterville 8885 Browning Drive Waterville, OH 43566 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)