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.
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
09/25/2023
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)
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.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365617
If continuation sheet
Page 2 of 2
