Health inspection·September 25, 2023

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 interviews, review of menu, and policy review, the facility failed to provided residents with the proper size meal portions as directed by the facility dietician. This affected 35 residents who received the turkey pot pie meal and did not affect 29 (#9, #10, #13, #18, #20, #24, #25, #26, #27, #29, #33, #40, #42, #43, #46, #50, #51, #52, #54, #55, #56, #57, #58, #60 #61, #62, #63, #64, and #65) residents who received alternate meat or does not receive meal service. The facility census was 64. Findings include: Review of the dietician provided dietary menu dated Week 4, Monday revealed the meal at lunch would be turkey pot pie served in eight-ounce portions over a biscuit. Observation of meal service on 09/25/23 at 11:42 A.M., revealed [NAME] #400 began plating the turkey pot pie using a six-ounce scoop. Interview with [NAME] #400 on 09/25/23 at 11:42 A.M., verified she was serving six ounces of the turkey pot pie because she felt eight ounces would be too much for the residents. Interview with the Dietary Manager on 09/25/23 at 11:43 A.M., verified that the turkey pot pie serving size was to be eight ounces. Review of the undated policy titled Kitchen Weights and Measures, revealed food service staff will be trained in proper use of cooking and serving measurements to maintain portion control. This deficiency represents non-compliance investigated under Complaint Number OH00146165. Page 1 of 2 365617 365617 09/25/2023 Ayden Healthcare of Waterville 8885 Browning Drive Waterville, OH 43566

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, and policy review, the facility failed to maintain an adequate pest control program. This affected one (#40) of four resident rooms observed for pest control. The facility census was 64. Residents Affected - Few Findings include: Review of Resident #40's medical record revealed an admission date of 05/26/23, with diagnoses including: epilepsy, left below the knee amputation, peripheral vascular disease, chronic obstructive pulmonary disease, alcohol dependence, and adult failure to thrive. Review of Resident #40's Minimum Data Set (MDS) dated [DATE] revealed he had a moderate loss of cognitive function. He required supervision for all activities of daily living. Interview with Resident #40 on 09/25/23 at 11:15 A.M., revealed he had bugs in his room, and no one would do anything about the issue. Resident #40 stated he reported the infestation to State Tested Nursing Aide (STNA) on 09/22/22 but nothing was done about the problem. Observation of Resident #40's room on 09/25/23 at 11:15 A.M., revealed 4 small ants crawling on the floor behind the garbage can. On the outside wall to the right of the heat/air conditioning unit were a large number of ants on the floor crawling on and around his prosthetic leg. Observation of the bathroom revealed approximately 30 large gnats sitting on a wet washcloth on the sink. Gnats were also flying about the main area in the resident's room. Observation and interview on 09/25/23 at 11:17 A.M., with STNA #300 verified the insects in Resident #40's room and stated she would inform the Maintenance Director. Review of the undated policy titled Pest Control,revealed our facility shall maintain an effective pest control program. The facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. This deficiency represents non-compliance investigated under Complaint Number OH00146165. 365617 Page 2 of 2