Inspection·January 26, 2024

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, community staff interview, and facility policy review, the facility failed to provide residents with food in the form and texture as ordered by the physician. This affected one (#80) of three residents reviewed for altered texture diets. The census was 84. Findings Include: Review of the medical record revealed Resident #80 was admitted to the facility on [DATE]. Diagnoses included Parkinsonism, multiple sclerosis, type II diabetes, major depressive disorder, anxiety disorder, dementia, mild intellectual disabilities, post traumatic stress disorder, and bipolar disorder. Review of Resident #80's Minimum Data Set (MDS) assessment dated [DATE]) revealed the resident was assessed with a mild cognitive impairment. Review of Resident #80's physician orders revealed she was prescribed a mechanical soft diet with no bread due to her diagnosis of dysphagia and being a choking risk. Resident #80 was readmitted to the facility from a hospital stay on 10/24/23, and the mechanical soft diet with no bread dietary order was active since that time. Interview with County Investigator (CI) #102 on 01/26/24 at 8:47 A.M. and 2:55 P.M. confirmed she completed an investigation and determined the facility sent a peanut butter and jelly sandwich to Resident #80's day programming workshop. CI #102 did not know exactly when the incident occurred because she did not have her investigation documents readily available, but CI #102 confirmed she completed her investigation and found the facility did not follow Resident #80's dietary order and diet texture. Interview with Registered Nurse (RN) #101 on 01/26/24 at 11:30 A.M. revealed she received a call from Resident #80's case manager to confirmed what Resident #80's diet texture or was, and confirmed it was mechanical soft with no bread. RN #101 stated the case manager then reported Resident #80 had taken a peanut butter and jelly sandwich to her day programming workshop when she should not have. RN #101 confirmed the incident did occur; but stated she did not see a sandwich in Resident #80's lunch bag prior to leaving the facility. RN #101 stated she could not remember the exact date she received the call from Resident #80's case manager, but thought it was either 01/11/24 or 01/12/24. Interview with County Day Program Staff (CDPS) #103 on 01/26/24 at 12:03 P.M. confirmed the facility sent a peanut butter and jelly sandwich to work with Resident #80 on 01/11/24. CDPS #103 confirmed (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: 365747 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 365747 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Place of Waterville 555 Anthony Wayne Trail 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)