Astoria Place Of Waterville

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy review, the facility failed to timely develop comprehensive care plans. This affected two (#6 and #16) of 31 residents reviewed for comprehensive care plans. The facility census was 74.Findings include:1. Review of the medical record for Resident #16 revealed an admission date of 07/09/25 with diagnoses of schizoaffective disorder, chronic obstructive pulmonary disease, and unspecified psychosis. Review of the comprehensive admission Minimum Data Set (MDS) assessment, dated 07/16/25, revealed Resident #16 had intact cognition and used tobacco. Review of the admission packet, dated 07/09/25, revealed Resident #16 smoked, required supervision during smoking, and needed the facility to store his lighter and cigarettes. Further review revealed a care plan for safety revealed Resident #16 was at risk for injury. Goals were to maintain a safe environment during smoking and Resident #16 would comply with facility smoking policy. Review of the facility's list…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical record, observation, resident and staff interview, and review of facility policy, the facility failed to ensure dependent residents received adequate nail care. This affected two (#40 and #45) of three residents reviewed for activities of daily living. The facility census was 74.Findings include: 1. Review of the medical record revealed Resident #40 was admitted on [DATE]. Diagnoses included unspecified dementia with psychotic disturbance, major depressive disorder recurrent severe with psychotic symptoms, anxiety disorder, Alzheimer's disease, and cognitive communication dysfunctions.Review of the Minimum Data Set (MDS) assessment, dated 06/16/25, revealed Resident #40 was unable to complete the assessment interview. Review of the care plan, revised 01/04/24, revealed Resident #40 had a behavior problem including playing in her own feces. Review of the care plan, revised on 11/11/24, revealed Resident #40 had an activities of daily living (ADL) self-care performance deficit.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, resident and staff interview, and medical record review, the facility failed to ensure residents received splints and immobilizer devices as ordered by the physician. This affected one (#1) of one residents reviewed for range of motion. The facility census was 74.Findings include:Review of the medical record for Resident #1 revealed an admission date of 05/27/25 with diagnoses of anoxic brain damage, dementia, bipolar disorder, and schizoaffective disorder. Review of the comprehensive admission Minimum Data Set (MDS) assessment, dated 06/03/25, revealed Resident #1 had impaired cognition and an impairment to one side of her upper extremity and one side of her lower extremity. Resident #1 used a wheelchair for mobility.Review of the care plan updated 07/08/25 revealed Resident #1 had limited physical mobility due to decreased range of motion. Interventions included ensuring Resident #1's left arm was in a sling except at bedtime and bathing.Review of a physician order initiated 05/30/25 revealed Resident #1 should receive a Cock-up wrist splint to the left wrist…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, and staff interview, the facility failed to adequately assess a resident following an unwitnessed fall and failed to ensure adequate supervision to prevent a resident from consuming food not in their diet. This affected two (#56 and #38) of two residents reviewed for accidents. The facility census was 74.Findings include: 1. Review of the medical record for Resident #56 revealed an admission on [DATE] with diagnoses of paranoid schizophrenia, major depressive disorder, and pseudobulbar affect. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #56 was cognitively intact. Further review of the MDS assessment revealed Resident #56 used a walker to ambulate and required supervision for activities of daily living (ADLs). Review of the care plan dated 07/15/25 revealed Resident #56 was at risk for falls and potential injury related to psychoactive drug use, and staff were to minimize the potential risk factors related to falls.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, resident interview, physician interview, and policy review, the facility failed to ensure a resident urinary tract infection was timely and appropriately treated; and failed to ensure a urinary catheter was patent and functioning properly. This affected two (#69 and #81) of two residents reviewed for bowel and bladder concerns. The facility identified three residents with urinary tract infections and six residents with urinary catheters. The facility census was 74. Findings include:1. Review of the medical record for Resident #69 revealed an admission date of 03/29/21. Diagnoses included type two diabetes mellitus, depression, schizoaffective disorder, peripheral vascular disease, and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #69 had intact cognition. The resident was occasionally incontinent of bowel and bladder. The resident required substantial/maximal assistance of staff for toileting.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy review, the facility failed timely notify the physician of abnormal laboratory results. This affected one (#69) of two residents reviewed for bowel and bladder concerns. The facility census was 74.Findings include:Review of the medical record for Resident #69 revealed an admission date of 03/29/21. Diagnoses included type two diabetes mellitus, depression, schizoaffective disorder, peripheral vascular disease, and hypertension.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #69 had intact cognition. Review of Resident #69's physician order dated 07/22/25 revealed an order for a urinalysis with culture if indicated for dysuria. The nurse was to collect the urine and place in the laboratory refrigerator and follow up with result in three days. Review of a nurses note dated 07/24/25 at 9:01 A.M. revealed the nurse was unable to collect a urinary specimen as Resident #69 was unable to produce enough specimen. The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, resident interview, staff interview, and facility policy review, the facility failed to ensure residents received adaptive equipment with meals as ordered. This affected one (#15) of one residents reviewed for adaptive equipment at meals. The facility census was 74.Findings include:Review of the medical record revealed Resident #15 was admitted on [DATE]. Diagnoses included Parkinson's disease with dyskinesia with fluctuations, type two diabetes mellitus, paranoid schizophrenia, essential hypertension, and hypothyroidism. Review of the Minimum Data Set (MDS) assessment, dated 06/28/25, revealed Resident #15 was cognitively intact. Review of the care plan, revised 06/22/25, revealed Resident #15 had a nutritional concern and required adaptive equipment for meals. Interventions included weighted built up utensils, two handled cup, and separate bowl for all meals.Review of the physician order, dated 07/02/25, revealed Resident #15 was ordered a regular diet, regular…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy review, the facility failed to maintain complete and accurate resident medical records. This affected one (#20) of three residents reviewed for medical record content. The facility census was 74.Findings Include:Review of the medical record for Resident #20 revealed the resident was admitted on [DATE]. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting the right side, Parkinson ' s disease, vascular dementia, major depressive disorder, and dysphagia.Review of the Minimum Data Set (MDS) assessment, dated 06/27/25, revealed Resident #20 had unclear speech, was not orientated to time, used wheelchair, required setup assistance for eating, toileting, and personal hygiene, and needed substantial assistance for shower, dressing, and transfers.Review of the care plan, dated 06/09/25, revealed Resident #20 was at possible nutritional risk due to comorbidities and has hemiplegia and hemiparesis to right dominate side related to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff and interview, physician interview, and policy review, the facility failed to ensure antibiotics were appropriately prescribed for urinary tract infections. This affected three (#69, #5, and #24) of four residents reviewed for antibiotic stewardship. The facility identified seven residents as receiving antibiotics. The facility census was 74. Findings include:1. Review of the medical record for Resident #69 revealed an admission date of 03/29/21. Diagnoses included type two diabetes mellitus, depression, schizoaffective disorder, peripheral vascular disease, and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #69 had intact cognition. The resident was occasionally incontinent of bowel and bladder. The resident required substantial/maximal assistance of staff for toileting. Review of Resident #69's urinalysis laboratory report dated 08/02/25 revealed a urine specimen was collected on 07/30/25 and received by the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record review, staff interview, and policy review, the facility failed to ensure residents received education prior to accepting or refusing a pneumococcal vaccination. This affected two (#3 and #38) of five residents reviewed for pneumococcal vaccination. The census was 74.Findings include:1. Review of the medical record for Resident #3 revealed an admission date of 08/28/13 with diagnoses of chronic respiratory failure, heart disease, hyperlipidemia, and dementia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/03/25, revealed Resident #3 had intact cognition.Review of the immunization history for Resident #3 revealed she received the pneumococcal conjugate vaccine (PCV) 20 on 12/15/23.2. Review of the medical record for Resident #38 revealed an admission date of 12/28/23 with diagnoses of Alzheimer's disease, dementia, schizoaffective disorder, chronic obstructive pulmonary disease, and hypertension. Review of the quarterly MDS assessment, dated 07/07/25, revealed Resident #38 had mildly impaired cognition. Review of the immunization history…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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. 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.

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. 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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of the Self-Reported Incident (SRI) database, review of policy, and staff interview, the facility failed to timely report allegations of resident-to-resident abuse. This affected three (#01, #02, and #03) of three residents reviewed for abuse reporting of allegations of abuse. The current census is 76. Findings include: Review of the Self-Reported Incident dated 08/14/24 at 5:33 P.M., revealed the incident was reported on 08/09/24 at 6:35 P.M., when Resident #01 was seen grabbing Resident #02's hair and punching her in the face. Per the SRI, the facility separated the residents, sent Resident #02 to the hospital, then upon return placed both residents in 15-minute checks until Resident #02 was transferred to another unit. Per the SRI report, the police were notified but no report was made, and no charges were filed. The SRI was unsubstantiated for abuse due to Resident #01's diagnosis of dementia. Review of the facility's investigation into the resident-to-resident abuse dated 08/09/24 to 08/16/24 revealed no evidence the incident was reported to the SRI database on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview, and review of policy, the facility failed to ensure proper storage of medications and failed to ensure the medication refrigerator in the medication room was used only for medication storage. This had the potential to affect nine (#7, #17, #19, #35, #48, #51, #53, #62, and #67) of nine residents the facility identified as cognitively impaired and independently mobile an undetermined number of residents who could receive the tuberculin solution. The facility census was 81. Findings include: Observation on 12/04/23 from 2:05 P.M. to 2:33 P.M., revealed a sealed large brown plastic bag on the top of nurse's station top desk left unattended. On the outside of the plastic bag was an itemized inventory sheet of the contents inside the sealed large brown plastic bag that revealed the large brown plastic bag contained resident prescription medications. Further observation revealed the following staff and residents walked by the unattended large brown bag: four unknown State Tested Nursing Assistant (STNA), 10 unknown residents, two Licensed Practical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview, and policy review, the facility failed to ensure drinking cups were adequately cleaned. This affected 28 (#2, #3, #4, #6, #13, #15, #20, #24, #25, #29, #30, #34, #38, #39, #40, #42, #43, #46, #47, #49, #56, #66, #68, #73, #75, #79, #80 and #81) of 29 residents in the A hall. The facility identified one resident (#72) to receive no food by mouth. The facility census was 81. Findings include: Observation on 12/06/23 at 12:20 P.M., of the lunch meal service revealed a tray of empty drinking cups to be served to the residents on the A hall for lunch. The empty cups appeared dirty with speckles of pink remnants. Interview on 12/06/23 at 12:18 P.M., with State Tested Nursing Assistant (STNA) #119 and STNA #187 verified the drinking cups brought by the dietary staff appeared to be dirty. STNA #119 and STNA #187 stated the glasses are always dirty. Subsequent observation revealed the STNAs made no effort to have the cups returned to the kitchen to be cleaned and waited for the lunch meal to arrive. Interview on 12/06/23 at 12:23 P.M., with Dietary…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, staff interview, training record review and policy review, the facility failed to ensure staff wore proper personal protective equipment (PPE) when entering a COVID positive environment. This had the potential to affect the remaining COVID negative residents on the second floor 21 (#9, #10, #12, #16, #17, #18, #19, #21, #28, #31, #35, #44, #48, #50, #53, #54, #57, #62, #63, #65, #76) of 21 residents the on the second floor. The facility census was 81. Findings included. Observation on 12/04/23 at 5:20 P.M. revealed staff were passing meal trays for dinner. Residents #51 and #67 were roommates and were both COVID positive and had been walking around in the hallway without PPE on. Residents were instructed to go to their rooms for the meal tray to be delivered and residents followed the instructions. After waiting residents became restless and began to argue about who would get their food and why one resident was standing in the doorway waiting for food. Residents were over 5 feet apart and were not gesturing toward each other State Tested Nurse Assistant (STNA)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview, and review of policy, the facility failed to ensure a clean and sanitary environment. This affected one (Resident #72) of 81 residents reviewed for environment. The facility census was 81. Findings include: Review of the medical record revealed Resident #72 was admitted on [DATE]. Diagnoses included hemiplegia and hemiparases following cerebral infarction affecting right dominant side, vascular dementia, chronic obstructive pulmonary disease, dysphagia, gastrostomy status, anxiety disorder, delusional disorders, essential primary hypertension, hyperlipidemia, and hypokalemia. Review of the Minimum Data Set (MDS) assessment, dated 10/06/23, revealed the resident was severely cognitively impaired, incontinent, and was dependent for oral and personal hygiene, toileting, showering/bathing, and putting on/taking off footwear. Resident #72 had one venous/arterial ulcer. Observation on 12/06/23 at 9:19 A.M., revealed numerous streaks of unknown reddish…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview, and policy review, the facility failed to timely identify and treat new skin impairment. This affected one (Resident #72) of one resident reviewed for potential skin impairment. The facility census was 81. Findings include: Review of the medical record revealed Resident #72 was admitted on [DATE]. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, vascular dementia, chronic obstructive pulmonary disease, dysphagia, gastrostomy status, anxiety disorder, delusional disorders, essential primary hypertension, hyperlipidemia, and hypokalemia. Review of the Minimum Data Set (MDS) assessment, dated 10/06/23, revealed the resident was severely cognitively impaired, incontinent, and was dependent for oral and personal hygiene, toileting, showering/bathing, and putting on/taking off footwear. Resident #72 had one venous/arterial ulcer. Review of care plan, dated 10/02/23 and revised on 10/25/23, revealed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, record review, and policy review, the facility failed to ensure care and treatment was provided to a resident with closed urinary drainage system to maintain the closed system to prevent potential infections. This affected one (#53) of one residents reviewed for catheter care. The facility identified four current residents with catheters. The facility census was 81. Findings included: Review of the medical record for Resident #53 revealed an admission date of 02/07/23. Diagnoses included encephalopathy, cerebral infarct, vascular dementia, diabetes, urine retention and neuromuscular dysfunction of the bladder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident 53 was cognitively impaired and was rarely if ever understood and required partial to moderate assistance for bed mobility, transfers, and toileting. Review of the care plan dated 11/16/23 revealed the resident had an indwelling catheter with interventions to ensure it was placed below the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy review, the facility failed to ensure a resident's nutritional status was being routinely being assessed by a registered dietician; accurately assess and obtain weights; and timely notify the physician and dietician of significant weight changes. This affected two (#7 and #51) of three residents reviewed for nutrition. The facility census was 81. Findings include: 1. Review of the medical record for Resident #7 revealed a re-admission date of 05/07/23. Diagnoses included epileptic seizures, intellectual disabilities, schizophrenia, chronic obstructive pulmonary disease, dysphagia, anxiety disorder, and adjustment disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 was cognitively impaired and required supervision assistance with transfers and mobility. Review of the plan of care dated 10/12/23 revealed Resident #7 revealed resident had potential for a nutritional problem related to severe hand tremors and required…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, resident interview, review of the resident council concerns, and the facility extermination contractor documentation, the facility failed to ensure an effective pest control program was in place to address flying insects. This affected all 72 residents residing in the facility. Findings include: Observations on 08/23/21 at 9:20 A.M. noted several gnats flying in the corridor and clinging to the corridor wall outside room [ROOM NUMBER]. Observation inside room [ROOM NUMBER] noted a tray of food items with gnats swarming the food and the resident seated in bed. Located at the nurses station near room [ROOM NUMBER] identified several gnats flying and clinging to the wall above the medication cart. Interview with Licensed Practical Nurse (LPN) #200 at the time verified gnats were present in the facility, disruptive to the environment, and residents. Further observation located inside room [ROOM NUMBER] noted the resident in bed two with tube feeding infusing. The resident had…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, and staff interview the facility failed to ensure residents were provided with dignified assistance eating during meals. This affected one resident (#14) of four identified as dependent on staff for eating. In addition, the facility to ensure clothing protectors were used in a dignified manner. This affected four additional residents (#23, #58, #65, #171) who were provided clothing protection during meals. The facility census was 72. Findings include: 1. Review of the medical record revealed Resident #14 admitted to the facility on [DATE]. Diagnoses included dementia, low back pain, symbolic dysfunction, major depression, dysphagia, osteoarthritis, insomnia, anxiety disorder, chronic obstructive pulmonary disease, type 2 diabetes mellitus, vitamin D deficiency, psychosis, peripheral vascular disease, hypertension, and cerebral infarction. According to the most current minimum data set (MDS) assessment dated [DATE] Resident #14 was identified with severe cognitive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview the facility failed to ensure resident meals were provided in a homelike fashion. This deficient practice affected 12 residents (#53, #62, #30, #48, #44, #29, #42, #14, #56, #15, #01, and #08) of 24 residents who resided on the unit who were observed during the lunch meal service. The facility census was 72. Findings include: Observation on 08/23/21 at 12:30 P.M. noted the state tested nurse aide (STNA) #300 and #306 delivered lunch meal trays to the residents in the [NAME] Edge units. The STNA #300 and #306 placed the food trays in front of the residents (#53, #62, #30, #48, #44, #29, #42, #14, #56, #15, #01, and #08) and had not removed the utensils or dinnerware (plates or cups) from the tray. Leaving the residents with an institutional style of meal service. Interview on 08/23/21 at 1:02 P.M., the Licensed Practical Nurse (LPN) #200 revealed the resident meal service included leaving the trays under resident dinnerware. This has been the practice of the unit for an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview, and review of a facility policy, the facility failed to store foods in a safe and sanitary manner. This had potential to affect 69 out of 72 residents who received food from the kitchen. The facility identified three residents (#06, #09, and #11) who did not receive food from the kitchen. The facility census was 72. Findings include: Observation on 08/23/21 at 8:10 A.M. of the dry storage area revealed significantly dented cans including 106 ounce canned tropical salad, 117 ounce canned jellied cranberry sauce, and 106 ounce canned diced peaches. Observation on 08/23/21 at 8:16 A.M. of the refrigerator revealed a box of shelled eggs with best by date of 06/20/21, 43 fat free half pint milk with a sell by date of 08/20/21, gallon of milk sell by date of 08/21/21, a box of Idaho potatoes with fuzzy light and dark mold like substance, and a box of cucumbers with fuzzy dark mold like substance. Interview on 08/20/21 at 8:23 A.M., the Dietary Staff #302 verified the dented cans and expired food in the refrigerator. Review of facility policy, Storage…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, medical record review, review of facility policies, review of the Centers for Medicare and Medicaid (CMS) COVID-19 Positivity Rates, and review of the Centers for Disease Control and Prevention (CDC) website the facility staff failed to wear appropriate personal protective equipment (PPE) while providing direct care for a resident who was on a COVID-19 quarantine, failed to maintain COVID-19 quarantine for a newly admitted resident with unknown COVID-19 status and not fully vaccinated. This directly affected two residents (#171 and #221) of two residents observed on COVID-19 transmission-based precautions This had the potential to affect 27 residents (#04, #05, #07, #12 #17, #18, #19, #20, #25, #27, #33, #34, #39, #41, #43, #45, #47, #49, #51, #55 #59, #60, #61, #63, #67, #69, and #70) who resided on the Cedar Pines Unit. In addition, the facility failed to ensure proper hand hygiene was completed while staff assisted a dependent resident with feeding. This affected one…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record review, resident interview, staff interview, and review of the facility policy, the facility failed to ensure resident mail was delivered unopened to residents. This affected one resident (#43) and had the potential to affect all 72 residents residing in the facility. Findings include: Review of the medical record for Resident #43 revealed an admission date of 10/20/17. Diagnosis included bipolar disorder current episode depressed severe with psychotic features, hyperlipidemia, unspecified atrial fibrillation, chronic obstructive pulmonary disease, emphysema, heart failure, atherosclerotic heart disease of native coronary artery without angina pectoris, chronic kidney disease, unspecified psychosis not due to a substance or known physiological condition, essential (primary) hypertension, unspecified asthma, difficulty in walking, muscle weakness, dysphagia, anxiety disorder, generalized anxiety disorder, bipolar disorder current episode depressed moderate, bipolar disorder current episode manic severe with psychotic features, and osteoarthritis left shoulder.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record review and staff interview the facility failed to provide the resident and resident's representative in writing the reason for a transfer to the hospital. This affected one resident (#19) of one resident reviewed for hospitalization. The facility identified 19 residents who were hospitalized in the last three months. The facility census was 72. Findings include: Review of Resident #19's medical record revealed an admission date of 12/06/19. Diagnoses included diabetes mellitus type II, cellulitis of the lower limb, unspecified dementia with behavioral disturbances, atrial flutter, and heart failure. Review of a nursing progress note dated 08/13/21 revealed Resident #19 was noted with redness and increased swelling to her left leg which required an evaluation in the hospital. Review of the Discharge - return anticipated Minimum Data Set (MDS) assessment revealed Resident #19 was discharged on 08/13/21 to an acute hospital. Review of a nursing progress note dated 08/19/21 revealed Resident #19 returned to the facility at 5:45 P.M. Review of Resident #19's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record review, staff interview, and policy review the facility failed to provide the resident and resident's representative with the facility's bed hold policy for a transfer to the hospital. This affected one resident (#19) of one resident reviewed for hospitalization. The facility identified 19 residents who were hospitalized in the last three months. The facility census was 72. Findings include: Review of Resident #19's medical record revealed an admission date of 12/06/19. Diagnoses included diabetes mellitus type II, cellulitis of the lower limb, unspecified dementia with behavioral disturbances, atrial flutter, and heart failure. Review of a nursing progress note dated 08/13/21 revealed Resident #19 was noted with redness and increased swelling to her left leg which required an evaluation in the hospital. Review of a Discharge - return anticipated Minimum Data Set (MDS) assessment revealed Resident #19 was discharged on 08/13/21 to an acute hospital. Review of a nursing progress note dated 08/19/21 revealed Resident #19 returned to the facility at 5:45 P.M.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) User Manual, the facility inaccurately coded residents for anticoagulant medications. This affected two residents (#13 and #38) of three residents reviewed for anticoagulant use coded on the MDS assessment. The facility census was 72. Findings include: 1). Review of Resident #13's medical record revealed an admission date of 04/16/21. Diagnoses included Alzheimer's disease, anemia, dementia with behavioral disturbances, hyperlipidemia, and delirium. Review of the MDS assessment dated [DATE] revealed Resident #13 was coded as receiving an anticoagulant medication seven days of the seven day look-back period. Review of Resident #13's medication administration record (MAR) for May 2021 revealed Resident #13 received no anticoagulant medications during the month. Further review of the May 2021 MAR revealed Resident #13 received the antiplatelet medication aspirin during the seven day…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview, and policy review the facility failed to change oxygen supplies as ordered. This affected one resident (#69) of one resident reviewed for respiratory care. The facility census was 72. Findings include: Review of the medical record revealed Resident #69 was admitted on [DATE]. Diagnosis included essential (primary) hypertension, schizophrenia unspecified, major depressive disorder recurrent severe with psychotic symptoms, constipation, chronic obstructive pulmonary disease with (acute) exacerbation, other cerebrovascular disease, and unspecified osteoarthritis. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was moderately cognitively impaired. The resident had not received oxygen treatment. Review of the discontinued physician orders, dated 01/31/21 to 07/05/21, revealed an order for Resident #69's oxygen tubing and bag should be changed every night shift on Sunday. The order specified to ensure to date and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview, and policy review the facility failed to obtain a physician order for oxygen. This affected one resident (#69) of one resident reviewed for respiratory care. The facility census was 72. Findings include: Review of the medical record review for Resident #69 revealed the resident was admitted on [DATE]. Diagnosis included essential (primary) hypertension, schizophrenia unspecified, major depressive disorder recurrent severe with psychotic symptoms, constipation, chronic obstructive pulmonary disease with (acute) exacerbation, other cerebrovascular disease, and unspecified osteoarthritis. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was moderately cognitively impaired. The resident does not receive oxygen treatment. Review of the discontinued physician orders dated 03/11/20 to 07/05/21, revealed the Resident #69 received oxygen one to three liters per minute via nasal cannula as needed for shortness of breath.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.