Inspection·April 29, 2024

F 0692 Provide enough food/fluids to maintain a resident's health. 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 and staff interview, the facility failed to document meal intakes per dietician recommendation and care plan intervention to monitor for weight status. This affected two (#35 and #61) of three residents reviewed for weight loss. The census was 68. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #35 revealed an admission date of 03/18/24 with diagnoses including but not limited to displaced fracture of the posterior column of the left acetabulum, dysphagia, burn of respiratory tract, hypertension, and dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35 had severe cognitive impairment and was dependent on staff for eating. Review of the care plan dated 03/18/24 revealed Resident #35 has potential for alteration in nutrition and hydration status related to possible significant weight loss since initial admission and underweight status. Interventions included to add enhanced foods to every meal, assist and/or feed the resident as needed in the dining room, encourage the resident to dine in the dining room as appropriate, offer meal substitutions as needed, and provide supplements as ordered. Review of a nutrition note dated 04/17/24 revealed Resident #35's current weight of 83 pounds indicated the resident was extremely underweight and it was suspected the resident's weight obtained at admission may not have been accurate. Resident #35 needed to be fed by staff and should eat meals in the dining room. Resident #35 received a house shake three times daily, a magic cup supplement with all meals, and it was discussed with the resident that enhanced foods would be added at all meals. Further review of the note revealed to monitor meal and supplement acceptance, obtain weekly weights, and follow. Review of Resident #35's meal intake documentation for the past 14 days revealed no documentation of meal intakes recorded for 04/17/24, 04/20/24, 04/21/24, 04/24/24, 04/27/24, and 04/28/24. 2. Review of the medical record for Resident #61 revealed an admission date of 03/15/24 with diagnoses including but not limited to pneumonia, cerebral infarction, congestive heart failure, and hypertension. Review of the MDS assessment dated [DATE] revealed Resident #61 was cognitively intact and required set up and supervision for meals. (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 04/29/2024 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)