Inspection·October 8, 2024

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, medical record review, and review of a facility policy, the facility failed to maintain a clean, sanitary, and homelike environment. This had the potential to affect all 72 residents residing in the facility. The census was 72. Findings Include: 1. Review of the medical record for Resident #64 revealed an admission date of 07/19/24 and diagnoses of malignant neoplasm of lower third of esophagus, hypothyroidism, diabetes mellitus type two, protein-calorie malnutrition, chronic obstructive pulmonary disease, hepatitis C, morbid obesity, bacteremia, and hypertension. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] for Resident #64 revealed a brief interview for mental status (BIMS) score of 14, indicating Resident #64 was cognitively intact. Interview on 10/07/24 at 8:01 A.M. with Resident #64 revealed the toilet and the toilet riser in his restroom had not been cleaned and were covered with feces. Resident #64 also stated the linens on his bed were soiled and had not been changed. Observation on 10/07/24 at 8:04 A.M. revealed the toiled and toiled riser in his restroom were covered with feces. Observation on 10/07/24 at 8:05 A.M. revealed the linen on Resident #64's bed was soiled with an unknown brown substance. Interview on 10/07/24 at 9:05 A.M. with Housekeeping Assistant #118 verified the toilet and toilet riser in Resident #64's restroom were covered in feces and verified the linen on Resident #64's bed was soiled with an unknown brown substance. 2. Review of the medical record for Resident #59 revealed an admission date of 10/05/22 with diagnoses of injury of unspecified body region, morbid obesity, hypothyroidism, hyperlipidemia, iron deficiency anemia, chronic pulmonary embolism, hypertension, syncope and collapse, and bipolar disorder. Review of the most recent MDS assessment dated [DATE] for Resident #59 revealed a BIMS score of 11, indicating Resident #59 was moderately cognitively intact. (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 10/08/2024 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)