Ayden Healthcare Of Waterville

Based on medical record review, staff interview, and policy review, the facility failed to ensure non-pharmacological interventions were attempted prior to receiving an as-needed pain medication. This affected one (#63) of one residents reviewed for pain. The facility census was 76.Findings include:Review of the medical record for Resident #63 revealed an admission date of 04/02/25 with diagnoses of dementia, rheumatoid arthritis, disc degeneration, and neuropathy. Review of the quarterly Minimum Data Set (MDS) assessment, dated 12/24/25, revealed Resident #63 had intact cognition, received as-needed pain medications, and did not receive non-medication interventions for pain.Review of the care plan, initiated 04/03/25, revealed Resident #63 was at risk for alteration in comfort due to complaints of pain, generalized pain, and gastroesophageal reflux disease. Interventions included but were not limited to staff attempting non-pharmacological interventions if the resident allowed.Review of the physician order dated 11/21/25 revealed Resident #63 received oxycodone hydrochloride (HCl)…

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 facility guidelines, the facility failed to ensure resident-specific interventions were implemented to address a resident's history of trauma. This affected three (#63, #13 and #2) of three residents reviewed for trauma informed care and treatment. The facility census was 76. Findings include:1. Review of the medical record for Resident #63 revealed an admission date of 04/02/25 with diagnoses of dementia, bipolar disorder, and depression. Review of the Minimum Data Set (MDS) assessment, dated 12/24/25, revealed Resident #63 had intact cognition. Review of Resident #63's comprehensive care plan, initiated 04/02/25 and revised 04/15/25, revealed Resident #63 had trauma related to sexual abuse. Interventions included providing reassurance and comfort measures if applicable; provide visits to the resident to communicate the activity schedule and encourage the resident to participate in social interactions; and referral to psychiatric services and/or…

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 ensure medications were administered per physician order. This affected one (#63) of five residents reviewed for medications. The facility census was 76.Findings include:Review of the medical record for Resident #63 revealed an admission date of 04/02/25 with diagnoses of dementia, hypertension, and anxiety. Review of the Minimum Data Set (MDS) assessment, dated 12/24/25, revealed Resident #63 had intact cognition.Review of the physician order dated 08/29/25 revealed Resident #63 received midodrine hydrochloride (HCl) tablet 2.5 milligrams (mg) to give one table by mouth every eight hours for hypotension with instructions to give the medication for systolic blood pressure (SBP; the reading of pressure against the artery walls when the heart beats and is represented as the top number of a blood pressure reading) less than 100 millimeters of Mercury (mmHg). Review of Resident #63's February 2026 medication administration record (MAR) revealed Resident #63 received midodrine HCl on 02/09/26 at 10:00 P.M. for a…

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, medical record review, and policy review, the facility failed to ensure medications were stored in a secure manner. This affected one (#9) of one residents reviewed for hemodialysis and related care. The facility census was 76.Findings include:Review of the medical record for Resident #9 revealed an admission date of 05/13/21 with diagnoses of dementia, heart disease, and end stage renal disease. Review of the Minimum Data Set (MDS) assessment, dated 12/23/25, revealed Resident #9 had intact cognition and received dialysis.Review of the current physician order, initiated 01/09/26, revealed Resident #9 received midodrine hydrochloride (HCl) oral tablet 10 milligrams (mg) with instructions to give 10 mg orally in the afternoon every Monday, Wednesday, and Friday, and send with the resident to dialysis.Review of the current physician order, initiated 01/20/26, revealed Resident #9 went to an offsite hemodialysis (HD) clinic three times weekly and as needed for HD.Interview on 03/17/26 at 10:23 A.M. with Registered Nurse (RN) #706 revealed Resident…

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, resident representative interview, and staff interview, the facility failed to ensure diagnostic testing results were obtained and communicated in a timely manner. This affected one (#44) of one residents reviewed for diagnostic testing. The facility census was 76.Findings include:Review of the medical record for Resident #44 revealed he was admitted on [DATE] with diagnoses including respiratory failure, depression, anxiety, pneumonia, neurogenic bladder, acute infarction of the spinal cord, hypertension, and gastrointestinal hemorrhage. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] for Resident #44 revealed he was cognitively impaired. Resident #44 experienced functional range of motion limitations on both sides to his upper and lower extremities and was dependent for all care and transfers.Interview on 03/16/26 at 2:23 P.M. with Resident #44's representative revealed diagnostic testing results completed in January 2026 had not been communicated 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.

Based on medical record review and staff interview, the facility failed to ensure a resident's medical record was complete to include communication with a dialysis provider. This affected one (#9) of one residents reviewed for hemodialysis. The facility census was 76.Findings include:Review of the medical record for Resident #9 revealed an admission date of 05/13/21 with diagnoses of dementia, heart disease, and end stage renal disease. Review of the Minimum Data Set (MDS) assessment, dated 12/23/25, revealed Resident #9 had intact cognition and received dialysis.Review of a document on the hemodialysis (HD) clinic's letterhead titled, Patient Curfew Letter, dated 10/01/25, revealed Resident #9 was receiving emergency HD treatments at the clinic in the area and the scheduling of the treatments required him/her to be traveling through the area during hours before and after curfew. Review of Resident #9's nursing progress notes dated 10/01/25 through 02/25/26 revealed communication between the facility and Resident #9's HD clinic was documented on 10/31/25, 11/13/25, 12/08/25, 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 record review, observation, staff interview, and review of the facility policy, the facility failed to ensure a resident who was dependent on staff for activities of daily living (ADL) received adequate assistance with personal hygiene. This affected one (#16) of three residents reviewed for ADL care. The facility census was 75. Findings include:Review of the medical record for Resident #16 revealed an admission date of 03/30/18. Diagnoses included chronic respiratory failure, tracheostomy status, ventilator dependent, quadriplegia, and chronic obstructive pulmonary disease (COPD). Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 was severely cognitively impaired and was dependent on staff for all ADL care. Review of the care plan revised 08/2025 revealed Resident #16 was care planned for risk for decline in ADL function with an intervention of total dependent assistance for all ADL care. Review of the facility's shower schedule revealed Resident #16 was…

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, 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…

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, review of the facility investigation, review of the facility's Self-Reported Incidents, and review of the facility policy, the facility failed to ensure incidents of potential neglect related to elopement of cognitively impaired residents were reported to the state agency. This affected one resident (#3) of three residents reviewed for risk of elopement. The facility census was 72. Findings include: Review of Resident #3's medical record revealed an admission date of 08/26/24. Diagnoses included dementia, frontotemporal neurocognitive disorder, seizures, general anxiety disorder, major depressive disorder, osteoarthritis, cognitive communication deficit, and hallucinations. Review of Resident #3's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of zero indicating Resident #3 was rarely or never understood. A Staff Interview for Mental Status was completed and indicated Resident #3 was severely cognitively impaired.…

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 observations, medical record review, staff interview and review of facility policy, the facility failed to provide supervision to prevent resident elopement for residents identified as at risk for elopement. This affected one resident (#3) of three residents reviewed for being at risk for wandering and elopement. The facility census was 72. Findings include: Review of Resident #3's medical record revealed an admission date of 08/26/24. Diagnoses included dementia, frontotemporal neurocognitive disorder, seizures, general anxiety disorder, major depressive disorder, osteoarthritis, cognitive communication deficit, and hallucinations. Review of Resident #3's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of zero indicating Resident #3 was rarely or never understood. A Staff Interview for Mental Status was completed and indicated Resident #3 was severely cognitively impaired. Resident #3 was independent with mobility and required moderate assistance with…

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, facility exterminator interview, and review of facility exterminator treatments, the facility failed to have an effective pest control program for bed bugs. This affected one resident (#9) of three residents reviewed for pest control. The facility census was 72. Findings include: Review of Resident #9's medical record revealed an admission date of 01/16/24. Diagnoses included respiratory failure, type II diabetes, major depressive disorder, anxiety disorder, muscle wasting, convulsions, cognitive communication deficit, and altered mental status. Review of Resident #9's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of five indicating Resident #9 was severely cognitively impaired. Resident #9 was dependent on staff for all activities of daily living as well as bed mobility and transfer. Resident #9 displayed no behaviors during the review period. Review of Resident #9's progress notes…

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 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. 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…

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, resident interview, staff interview, and review of policy, the facility failed to ensure a resident was assessed for self administration and physician orders were obtained to self administer. This affected one (#43) of one resident observed to have medications at the bedside. The facility census was 75. Findings include: Review of the medical record for Resident #43 revealed an admission date of 09/28/23, with a diagnoses of diabetes mellitus, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and hearing loss. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #43 is cognitively intact. Review of the current monthly physician orders for Resident #43 revealed no order for refresh eye drops and there was not an order for self-administration of the eye drops. Review of the assessments for Resident #43 revealed there was no assessment for self-administration of medication in the medical record. Review of the care plan for…

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 record review and staff interview, the facility failed to ensure proper and timely notice was given to residents when they were discharged from skilled service. This affected two (#63 and #79) of three sampled residents who were discharge from skilled services in the past six months. The facility census was 75. Findings Include: Review of the Beneficiary Notification for Resident #63 revealed Resident #63 began Medicare Part A services on 09/20/23 and his last covered day was 10/19/23. A Notification of Medicare Non-Coverage (NOMNC) form CMS 10123 was documented as not provided. In addition, Resident #63 remained in the facility and a skilled nursing facility advanced beneficiary notice of non-coverage (ABN) form CMS-1005 was not provided. Review of the Beneficiary Notification for Resident #79 revealed Resident #79 began Medicare Part A services on 10/18/23 and his last covered day was 12/07/23. A Notification of Medicare Non-Coverage (NOMNC) form CMS 10123 was provided and signed on 12/06/23. In addition, Resident #79 remained in the facility and a skilled nursing…

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, and review of policy, the facility failed to ensure a resident's care plans were revised to include supports and interventions to address communication needs. This affected two (#6 and #46) of three residents reviewed for communication. The facility census was 75. Findings include: 1. Review of Resident #46's medical record revealed an admission date of 02/12/24. Diagnoses included cerebral palsy, contracture of multiple locations, epilepsy, developmental disorder, cognitive communication deficit, and schizophrenia. Review of Resident #46's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of zero indicating Resident #46 was rarely or never understood. A staff assessment for mental status was completed and indicated Resident #46 had short and long term memory problems. Resident #46 was severely cognitively impaired. Resident #46 was dependent on staff for all activities of daily living. Resident #46 displayed physical…

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, resident interview, staff interview, and review of policy, the facility failed to ensure a resident who was dependent on staff for care received personal hygiene care as desired. This affected one (#6) of two resident's reviewed for activities of daily living. The facility census was 75. Findings include: Review of Resident #6's medical record revealed an admission date of 01/15/24. Diagnoses included quadriplegia, protein calorie malnutrition, convulsions, severe sepsis with septic shock, dysphagia, and gastrostomy status. Review of Resident #6's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of zero indicating Resident #6 was rarely or never understood. Resident #6 was totally dependent on staff for all activities of daily living. Resident #6 displayed no behaviors during the review period. Review of Resident #6's care plan revised 01/16/24 revealed supports and interventions risk for alteration in comfort, self-care…

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 the facility policy, the facility failed to ensure fall interventions were in place and residents received post fall assessments as required. This affected two (#36 and #55) of three residents reviewed for falls. The facility census was 75. Findings include: 1. Review of the medical record revealed Resident #36 was admitted on [DATE]. Diagnoses included unspecified dementia with other behavioral disturbances, atherosclerotic heart disease of native coronary artery without angina pectoris, other hyperlipidemia, hypertensive chronic kidney disease, anxiety disorder due to known physiological condition, major depressive disorder recurrent, anxiety disorder due to known physiological condition, major depressive disorder, chronic kidney disease, fibromyalgia. Review of the Minimum Data Set (MDS) assessment, dated 01/24/24, revealed Resident #36 was moderately cognitively impaired. Review of the most recent care plan dated 05/24/19 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 record review, observations, staff interview, and review of facility policy, the facility failed to ensure a resident received enteral feeding (delivery of nutrients through a feeding tube directly into the stomach, duodenum, or jejunum) per physicians orders. This affected one (Resident #31) of one resident reviewed for enteral feeding. The facility identified six residents that required total nutrition by enteral feeding. The facility census was 75. Findings include: Medical record review revealed Resident #31 was admitted on [DATE] with diagnoses of dysphagia and gastrostomy. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 had cognitive impairment. Resident #31 received total nutrition by enteral feeding and has not had any weight loss. Review of the current physician orders for 03/2024 for Resident #31 revealed an order enteral feeding of Vital AF 1.2 at 65 milliliters (ml) per hour for 22 hours, off from 3:00 A.M. to 5:00 A.M. for Synthroid medication…

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 the facility policy, the facility failed to maintain appropriate emergency tracheostomy supplies at the bedside of a resident with a tracheostomy. This affected one (#53) of two residents reviewed for tracheostomy and ventilator. The facility identified six residents that required tracheostomy emergency supplies at the bedside. The facility census was 75. Findings include: Medical record review revealed Resident #53 was admitted to the facility on [DATE]. Diagnoses included malignant neoplasm of the head, face, neck, glottis, and larynx, and tracheostomy. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #53 was cognitively intact and required suctioning and tracheostomy care. Review of the current monthly physician orders for Resident #53 revealed to verify emergency equipment in room to include ambu bad, oxygen, and suction canister, if tracheostomy becomes dislodged maintain patent airway, notify…

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 facility policy, the facility failed to develop interventions for dementia care. This affected one (Resident #64) of one resident reviewed for dementia care. The facility census was 75. Findings include: Review of the medical record revealed Resident #64 was admitted on [DATE]. Diagnoses included other specified disorders of brain, acute respiratory failure with hypoxia, diffuse traumatic brain injury with loss of consciousness status unknown, acute respiratory failure with hypercapnia, Parkinson's disease, depression, dementia with agitation, and adult failure to thrive. Review of the Minimum Data Set (MDS) assessment, dated 02/07/24, revealed Resident #64 was severely cognitively impaired. Resident #64 had verbal or other behavioral practices exhibited one to three of seven days. Review of the most recent care plan revealed the care plan did not include interventions for Resident #64's diagnoses of dementia. Interview on 03/13/24 at 11:10 A.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, observation, staff interview, and policy review, the facility failed to ensure residents rooms were clean and provided with clean linen. This affected three (#28, #44, and #64) of three residents reviewed for physical environment. The facility census was 75. Findings include: 1. Review of the medical record revealed Resident #28 was admitted on [DATE]. Diagnoses included Alzheimer's disease with late onset, muscle weakness, paranoid personality disorder, restlessness and agitation, major depressive disorder recurrent, Parkinson's disease, and schizophrenia. Review of the Minimum Data Set (MDS) assessment, dated 01/11/24, revealed the resident was severely cognitively impaired. Resident #28 required partial/moderate assistance with chair to bed transfer, toilet transfer, and tub/shower transfer. Observation on 03/10/24 at 10:18 A.M., revealed Resident #28's floor had what appeared to be approximately 8 inch diameter of jelly smeared on the floor right next to the resident's bed.…

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 interviews, and facility policy, the facility failed to ensure a clean and sanitary environment. This affected six (Residents #53, #74, #78, #79, #81, and #82) of six residents reviewed for environment. The facility census was 74. Findings include: Observation on 12/28/23 at 12:25 P.M. revealed light red colored sponge like spots covering all walkable areas of Resident #57's floor. Subsequent interview with Resident #57 revealed the spots were blood from when her foot wound bled through the dressing yesterday. Resident #57 verified the dressing was changed but the blood was not cleaned. Observation on 12/28/23 at 4:45 P.M. revealed the identified blood spots throughout Resident #57's floor had not been cleaned and remained visible. Interview on 12/28/23 at 4:37 P.M. with Laundry and Housekeeping Supervisor #203 verified housekeeping had not cleaned Resident #57's hall due to leaving early. Housekeeping and Laundry Supervisor #203 verified the blood spots throughout the floor. Subsequent interview with the unknown aide working the hall…

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 facility policy the facility failed to ensure clean and sufficient laundry was available to residents. This affected three (Residents #60, #64, and #68) of three residents reviewed. The facility census was 74. Findings include: Observation on 12/26/23 and 12/28/23 revealed a common area inaccessible to residents with an abundant of both hung, folded, and unfolded clothing and blankets. Interview on 12/26/23 at 10:56 A.M. with State Tested Nursing Assistant (STNA) #202 revealed the only concern they have at the facility is supplies, specifically towels and resident laundry. STNA #202 reported they always needed to hunt down resident laundry so the resident has something to wear. Interview on 12/26/23 at 11:28 A.M. with Laundry and Housekeeping Supervisor #203 verified the common area inaccessible to residents was used as a folding area. Laundry and Housekeeping Supervisor #203 verified other than what aides were able to do in their spare time laundry had not been folded since last Saturday (3 days). Laundry and Housekeeping…

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 facility policy, the facility failed to ensure resident's received timely assistance with eating. This affected one (Resident #59) of three residents reviewed for assistance with Activities of Daily Living (ADLs). The facility census was 74. Findings include: Review of the medical record revealed Resident #59 was admitted on [DATE]. Diagnoses included arthropathic psoriasis, bulimia nervosa, bipolar disorder, suicidal ideations, post traumatic stress disorder, major depressive disorder, hypothyroidism, essential (primary) hypertension. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the residents cognition was not assessed. Resident #59 required supervision or touching experience for eating. Observation on 12/26/23 at 1:00 P.M. revealed Resident #59 laying in bed with his eyes closed. The lunch meal tray was sitting on the bedside table with a plate cover over the food and the tray appeared untouched. Further observation…

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 the facility failed to ensure fall interventions were in place. This affected one (Resident #57) of three residents reviewed for falls. The facility census was 74. Findings include: Review of the medical record revealed Resident #57 was initially admitted on [DATE]. Diagnoses included paranoid schizophrenia, muscle weakness, parkinsonism, auditory hallucinations, anxiety disorder, unspecified lack of coordination, hypothyroidism, and major depressive disorder recurrent severe with psychotic symptoms. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was rarely understood. Review of the most recent care plan revealed Resident #57 was care planned for falls due to impaired balance/poor coordination, use of psychotropic medications, impaired decision making and unsteady balance. Interventions included having a perimeter mattress. Observation on 12/26/23 at 1:06 P.M. 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.

Based on observation, staff interviews, review of menu, and policy review, the facility failed to provided residents with the proper size meal portions as directed by the facility dietician. This affected 35 residents who received the turkey pot pie meal and did not affect 29 (#9, #10, #13, #18, #20, #24, #25, #26, #27, #29, #33, #40, #42, #43, #46, #50, #51, #52, #54, #55, #56, #57, #58, #60 #61, #62, #63, #64, and #65) residents who received alternate meat or does not receive meal service. The facility census was 64. Findings include: Review of the dietician provided dietary menu dated Week 4, Monday revealed the meal at lunch would be turkey pot pie served in eight-ounce portions over a biscuit. Observation of meal service on 09/25/23 at 11:42 A.M., revealed [NAME] #400 began plating the turkey pot pie using a six-ounce scoop. Interview with [NAME] #400 on 09/25/23 at 11:42 A.M., verified she was serving six ounces of the turkey pot pie because she felt eight ounces would be too much for the residents. Interview with the Dietary Manager on 09/25/23 at 11:43 A.M., verified that…

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, resident interview, staff interview, and policy review, the facility failed to maintain an adequate pest control program. This affected one (#40) of four resident rooms observed for pest control. The facility census was 64. Findings include: Review of Resident #40's medical record revealed an admission date of 05/26/23, with diagnoses including: epilepsy, left below the knee amputation, peripheral vascular disease, chronic obstructive pulmonary disease, alcohol dependence, and adult failure to thrive. Review of Resident #40's Minimum Data Set (MDS) dated [DATE] revealed he had a moderate loss of cognitive function. He required supervision for all activities of daily living. Interview with Resident #40 on 09/25/23 at 11:15 A.M., revealed he had bugs in his room, and no one would do anything about the issue. Resident #40 stated he reported the infestation to State Tested Nursing Aide (STNA) on 09/22/22 but nothing was done about the problem. Observation of Resident #40's room on 09/25/23 at…

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 record review, staff interview and policy review, the facility failed to notify the physician and family of a decreased oral intake for one (#6) out of three residents reviewed for notification. The facility census was 69. Findings include: Review of the medical record for Resident #6 revealed an admission date of 07/12/23. Admitting diagnoses for Resident #6 included cerebral infarct, vascular dementia, hypertension, acute kidney failure, insomnia, anxiety disorder, and hyperlipidemia. Resident #6 was discharged on 08/10/23 to the hospital. Review of the admission assessment dated [DATE] revealed Resident #6 was on a regular diet with thin liquids and had no difficulty swallowing. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 07/19/23, revealed Resident #6 had moderate cognitive impairment and had disorganized thinking. The resident required supervision after setup for eating. Review of the care plan initiated on 07/20/23, revealed Resident #6 was noted with potential for altered…

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 store food items in a safe and sanitary manner. This affected 52 residents who received food from the kitchen. The facility identified eight (#3, #5, #9, #18, #27, #49, #51, #58) residents who have orders for nothing by mouth and receive no food or drinks from the kitchen. The census was 60. Findings include: Observation on 01/03/22 at 9:07 A.M., during tour of the kitchen revealed two large pitchers which contained a yellow substance that had no labels or dates. There were sliced tomatoes in the walk-in refrigerator that were labeled as sliced on 12/30/21 and meatballs that were prepared on 12/29/21. Interview on 01/04/22 at 1:20 P.M., with the Dietary Manager (DM) #104 stated left over foods and drinks that are opened can be kept in the refrigerator for three days before they are discarded. DM #104 verified the items in the walk-in refrigerator that were not discarded appropriately and the yellow substance that was not labeled or dated. Review of a facility policy titled, Food Preparation and Service,…

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, record review, staff interview and policy reviews, the facility failed to ensure medications were administered in a sanitary manner. This affected one (#57) of five residents observed during medication administration. The census was 60. Findings include: Observation on 01/04/22 at 10:53 A.M., revealed Licensed Practical Nurse (LPN) #206 prepared to administer medications to Resident #57 on the 100 Hall. LPN #206 used her bare hands to remove medication cards, packs, and bottles from the medication cart. LPN #206 was not able to locate one of Resident #57's ordered medication so she retrieved the keys to the medication storage room and used her bare hands to open the door, sort through medications stored in the storage room, and exit the medication storage room. LPN #206 then returned to the medication cart without washing or sanitizing her hands. LPN #206 removed Resident #57's blood pressure medication Lisinopril 10 milligrams (mg) tablet from a medication card directly into her unsanitized hand and placed it into a plastic medication cup for Resident #57 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.