F 0727
Level of Harm - Minimal harm
or potential for actual harm
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on
a full time basis.
Based on staff schedule review, timesheet review, and staff interview, the facility failed to ensure a
Registered Nurse (RN) worked for eight hours daily in the facility. This affected all 68 residents in the facility.
Residents Affected - Many
Findings include:
Review of the staff schedules and timesheets for May 2015 revealed no RN coverage on 05/11/25.
Interview on 06/18/25 at 10:38 A.M. with Regional Clinical Support #500 confirmed there was no evidence
an RN worked in the facility on 05/11/25.
This deficiency represents non-compliance investigated under Complaint Number OH00165936.
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
06/18/2025
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)
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, staff interview, and review of a Safety Data Sheet (SDS), the facility failed to ensure
appropriate cleaning agents were used to clean residents rooms and common areas. This affected 32 (#11,
#12, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33,
#34, #35, #36, #37, #38, #39, #40, #41, and #42) residents on the upstairs unit. The facility census was 68.
Residents Affected - Some
Findings include:
Interview on 06/17/25 at 10:28 A.M. with the Administrator confirmed the Housekeeper Supervisor was on
vacation for the week.
Observation and interview on 06/17/25 at 11:46 A.M. revealed Housekeeper #302 used products she
personally purchased to clean the facility. Housekeeper #302 stated the chemical supplies were on the first
floor of the facility and because she worked on the second floor she felt it was easier to purchase her own
chemical cleaning supplies so she did not have to go downstairs when she needed to refresh her mop
and/or rag buckets with new cleaning solution. Housekeeper #302 showed two products with the brand
name Pinalen. One was green, which she used for the floors, and one was pink with a floral delight scent
which she used for surfaces and toilets. Further interview with Housekeeper #302 revealed her supervisor
was aware she was using the products and approved their use.
Follow-up interview on 06/18/25 at approximately 1:30 P.M. with Housekeeper #302 revealed she did not
measure the amount of cleaning solution she used in either her mop bucket or her rag bucket. Housekeeper
#302 stated the cleaners were strong and she used a little of it. Further interview with Housekeeper #302
revealed she was informed by her supervisor earlier in the morning on 06/18/25 that she was no longer
allowed to use the Pinalen cleaning products Housekeeper #302 purchased at the store.
Review of an email received 06/18/25 at 4:28 P.M. from the Administrator confirmed Housekeeper #302
was assigned to clean only the second floor and did not work throughout the building.
Review of the original Pinalen instructions revealed for general floor cleaning, use 1/4 cup of Pinalen in one
gallon of water; for dirtier floors use 1/4 cup of Pinalen in 1/2 gallon of water.
Review of the Floral Delight Pinalen instructions for kitchen and bathroom cleaning revealed 1/2 cup of
Pinalen should be diluted in 1/2 gallon of water.
The facility was unable to provide a policy regarding the types of cleaning products required to meet the
cleaning needs of the facility.
Review of the Safety Data Sheet for Pinalen, provided by the facility, revised 04/21/15, revealed it was a
household multipurpose cleaner and was not intended for industrial uses or as a sanitizing agent.
This deficiency represents non-compliance investigated under Complaint Number OH00165936.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365747
If continuation sheet
Page 2 of 2
