Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ayden Healthcare Of Waterville during CMS and state inspections, most recent first.
A resident with dementia, Parkinsonism, schizophrenia, anxiety, and contractures was dependent on staff for eating, yet a CNA was observed standing while providing feeding assistance at bedside. The resident remained hungry with a full breakfast tray left in the room, and the DON confirmed staff should not stand while feeding residents; the facility policy also stated residents should be fed with attention to safety, comfort, and dignity.
Failure to provide timely repositioning and incontinence checks for dependent residents. Two residents with severe cognitive impairment and total ADL dependence were observed for hours without staff providing needed care. One resident remained in bed until a CNA later found the brief soiled with urine and stool, while another resident stayed in the same recliner position and was only briefly checked for urine, with no bowel check completed during the observed interval.
Delayed incontinence care affected two residents who were dependent on staff for toileting and hygiene. One resident with dementia, Parkinsonism, and other psychiatric diagnoses was always incontinent of bowel and bladder, and later observation found the brief contained urine and stool after only one morning check. Another resident with severe cognitive impairment, dementia, and CVA was frequently incontinent of urine and always incontinent of bowel; staff verified only one incontinence check during the morning despite a care plan calling for incontinence care as needed and a policy requiring regular check-and-change for residents with severe cognitive impairment.
Unsafe Food Storage and Unsanitary Kitchen Conditions: The facility failed to keep kitchen and food storage areas sanitary and to store food properly. Surveyors observed heavy dust buildup on vents, ceilings, and walls in food prep, dish, and serving areas; liquid eggs stored on the floor of the walk-in cooler; opened, undated pasta in dry storage; undated and unlabeled refrigerated items; and an opened cup of ice cream in the freezer. An DS was also observed cooking ground beef without a hair net.
Infection prevention failures were observed involving Legionella control, urinary catheter care, PPE use, and hand hygiene. The facility was not documenting water temperatures or tracking flushes in vacant areas, and a resident’s Foley drainage bag was found on the floor. For another resident with a urinary catheter, a CNA provided incontinence care without a gown despite EBP signage requiring gloves and gown for high-contact care, the catheter bag was again left on the floor, and an LPN performed finger stick blood glucose checks on two residents without gloves or hand hygiene between residents.
A resident with parkinsonism, dementia, schizophrenia, depression, and functional dependence was found in bed with a red pull-cord call light positioned near the shoulder, but she could not pull it. Observation showed she could not lift one arm and had very limited use of the other hand, and a CNA confirmed she was unable to activate the current device. The CNA stated soft-touch call lights were available but could not be used on that hall because of the outlet type.
Failure to provide scheduled bathing: A resident who was cognitively intact, dependent for all ADLs, and had multiple complex medical conditions did not receive bed baths twice weekly as scheduled. The resident reported missed bathing care, shower sheets showed multiple missed baths and two extended gaps without documentation, and the DON confirmed the resident did not refuse care and that there was no documentation supporting the missed baths.
Failure to monitor psychotropic medication side effects for two residents. One resident with PTSD and insomnia had orders for Ativan PRN and mirtazapine, and another resident with schizoaffective disorder and a history of TBI had orders for divalproex and mirtazapine. Both residents were cognitively intact, but their care plans did not direct monitoring for psychotropic side effects, and no active physician orders were in place for that monitoring; the DON verified the monitoring was not completed.
Unsafe discharge without required notice: A resident with epilepsy, TBI, severe cognitive impairment, and ongoing behavioral symptoms was sent with her husband to an ER after staff-directed aggression escalated. The hospital did not admit her, the facility then refused readmission, and the resident was ultimately taken home. The record showed no discharge notice or appeal rights were provided before the discharge, and the facility’s own policy allowed discharge only under limited circumstances.
A resident with hemiplegia, aphasia, impaired cognition, and dependence for transfers and mobility was identified as at risk for skin breakdown, with orders for bilateral protective boots and a care plan calling for pressure reduction devices. Observations showed the boots left off the resident while she sat in a reclining wheelchair, and one heel resting on the wheelchair footpad before staff later applied the boots.
A resident with dementia, RA, disc degeneration, and neuropathy received frequent PRN oxycodone for pain, but the record showed no evidence that non-pharmacological interventions were attempted before the doses were given. The care plan included trying non-medication interventions if the resident allowed, and an LPN confirmed that such interventions should be attempted before administering PRN pain medication.
Failure to Individualize Trauma-Informed Care Plans: Three residents with documented trauma histories, including sexual abuse, violent crime exposure, and PTSD from military history, had care plans that listed only general trauma-informed interventions. The DON confirmed the plans did not identify resident-specific triggers or include interventions tailored to avoid those triggers, and one resident’s plan also lacked trauma-specific triggers despite a history of sexual abuse.
Medication Given Outside Ordered BP Parameters: A resident with dementia, HTN, and anxiety had a physician order for midodrine HCl only when SBP was less than 100 mmHg, but MAR review showed multiple doses were given when BP readings were above the ordered parameter. The UM confirmed the medication was administered outside the ordered instructions on multiple occasions.
Medication storage was not secured for a resident receiving HD. Staff found the resident's HD binder and medication pouch in a tote bag in the resident's room, and CNA confirmed the medications were inside the notebook before bringing it to an LPN at the med cart. The LPN found a midodrine HCl card with seven tablets and placed the notebook in a locked drawer; the facility policy required drugs and biologicals to be stored in locked compartments.
Failure to Obtain and Communicate Diagnostic Test Results: A resident with respiratory failure, depression, anxiety, pneumonia, neurogenic bladder, spinal cord infarction, HTN, and GI hemorrhage had a bone biopsy rescheduled and then went out of the facility, but the chart contained no biopsy results. The resident’s representative said January test results were never communicated, and the DON confirmed the facility had not obtained or shared the bone biopsy results with the MD or representative; the Administrator stated there was no policy for obtaining or notifying about diagnostic test results.
Incomplete Documentation of Dialysis Provider Communication: A resident with dementia, heart disease, and ESRD received offsite HD three times weekly, and the care plan called for communication with dialysis staff and the physician. Although staff reported ongoing email and phone contact with the HD clinic, the resident’s medical record only documented limited communication, and the ongoing exchange of information was not routinely recorded.
A resident who was fully dependent on staff for ADLs, including personal hygiene, was observed with significant unshaved facial hair despite being scheduled and documented as having received showers. Staff interviews revealed that facial hair was not shaved due to reluctance to use facility razors, resulting in inadequate grooming care in violation of facility policy.
The facility failed to maintain a clean and homelike environment, affecting all 72 residents. A resident reported unclean conditions in his restroom and soiled bed linens, which were confirmed by a housekeeping assistant. Another resident's room was found dirty, as verified by an LPN. Additionally, the carpet in a hallway was stained and dirty, with food pieces ground into it, as confirmed by an STNA.
A cognitively impaired resident with dementia and wandering behaviors exited the facility without staff observation. An LPN found the resident outside and returned her to the facility. Despite the incident, the facility did not report it to the state agency as required by their policy. Interviews confirmed the incident, and the corporate director questioned the need for reporting, highlighting a failure to adhere to reporting policies.
A resident with dementia and a history of elopement exited the facility unsupervised due to inadequate supervision and staff oversight. Despite interventions in place, staff failed to notice the resident's exit, and the door alarm was not effectively responded to. The resident was found outside by an LPN on a smoke break and was safely redirected back inside.
A facility failed to effectively control a bed bug infestation affecting a resident with severe cognitive impairment. Despite exterminator treatments, bed bugs persisted due to the resident's family bringing contaminated items from their infested home. Staff confirmed the ongoing issue, and observations revealed evidence of bed bug activity in the resident's room.
The facility failed to document meal intakes as recommended by the dietician and outlined in the care plans for two residents, leading to a deficiency in maintaining their nutritional status. Both residents had missing meal intake documentation on several specified dates, despite having care plans that required monitoring and interventions to address their nutritional needs.
Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident was treated with dignity while receiving feeding assistance. Resident #112 had diagnoses including Parkinsonism, paranoid schizophrenia, anxiety, dementia, and a need for assistance with personal care. The resident’s quarterly MDS showed impaired cognition and dependence on staff for eating, and the care plan identified total assistance with ADLs, contractures of the hands and wrists, and a need for staff to feed the resident as needed. During observation, Resident #112 was lying in bed with a breakfast tray on the overbed table while a CNA stood next to the resident and held a cup for drinking. A later observation showed the CNA was no longer in the room and the breakfast tray remained full, while the resident stated she was still hungry and did not know if someone was coming back to assist her to eat. Another observation showed the CNA standing next to the resident instead of sitting while providing feeding assistance. The CNA confirmed he was standing while assisting the resident, and the DON confirmed staff should not be standing while feeding residents. The facility policy on Assistance with Meals stated residents who could not feed themselves would be fed with attention to safety, comfort, and dignity, including not standing over residents while assisting them with meals.
Failure to Provide Timely Repositioning and Incontinence Checks
Penalty
Summary
The facility failed to provide timely repositioning and incontinence care for dependent residents. Resident #112 had diagnoses including Parkinsonism, paranoid schizophrenia, anxiety, and dementia, and was dependent on staff for eating, repositioning, toileting hygiene, and all ADLs. The resident was also always incontinent of bladder and bowel. On 05/14/26, the resident was observed lying on her back in bed from 8:10 A.M. through 11:04 A.M. with no staff entering the room to provide incontinence care. A CNA confirmed the last incontinence check had been around 7:30 A.M., and when another CNA later assisted the resident, incontinence care was finally provided and the brief contained both urine and stool. Resident #113 had diagnoses including dementia, major depressive disorder, anxiety, fall, and CVA, with severe cognitive deficit on the MDS and dependence on others for toileting, personal hygiene, and rolling left to right. The resident was frequently incontinent of urine and always incontinent of bowel, required total staff assistance with ADLs, ambulation, and toileting, and was receiving diuretic therapy. Multiple observations on 05/14/26 showed the resident remained in the same position in a recliner from 8:10 A.M. through 2:04 P.M. A CNA verified the resident had last been checked for incontinence around 7:30 A.M., and at 11:34 A.M. the CNA checked only the front of the brief and stated the resident was not soiled, confirming this was the first incontinence check since 7:30 A.M. and that bowel incontinence had not been checked.
Delayed Incontinence Care for Two Residents
Penalty
Summary
The facility failed to provide timely incontinence care for two residents who were dependent on staff for toileting and personal hygiene. One resident had diagnoses including Parkinsonism, paranoid schizophrenia, anxiety, dementia, and need for assistance with personal care, and the quarterly MDS showed impaired cognition and that the resident was always incontinent of both bladder and bowel. The care plan identified the resident as needing total assistance with ADLs, transfers, ambulation, and toileting, with turning and repositioning per facility policy. A CNA verified the resident had last been checked for incontinence shortly after arrival, and later observation showed the resident’s brief contained both urine and stool when another CNA assisted the resident into a wheelchair. The second resident had diagnoses including dementia, major depressive disorder, anxiety, fall, and cerebral vascular accident, with a BIMS score of 5 indicating severe cognitive deficit. The MDS showed the resident was dependent on others for toileting, personal hygiene, and rolling left to right, and was frequently incontinent of urine and always incontinent of bowel. The care plan directed staff to provide incontinence care as needed, and noted diuretic therapy that could increase urinary output. A CNA verified the resident had last been checked shortly after arrival, and later observation showed the CNA checking the brief only once during the morning and stating the resident was not wet. The facility policy for residents with severe cognitive impairment called for a check-and-change strategy at regular intervals, but the report found this was not done.
Unsafe Food Storage and Unsanitary Kitchen Conditions
Penalty
Summary
The facility failed to ensure food was prepared and stored in a safe manner and failed to maintain the kitchen environment in a sanitary manner. During observation, significant dust buildup was found on the ceiling vent and surrounding ceiling over the coffee area, juice dispenser, toaster, and preparation area, as well as on the ceiling vents over the clean dish end of the dishwasher and over the clean plate stack for meal service. Dust buildup was also observed on the wall above the steam oven and on the wall along the meal tray line near the clean plates for meal service, and the Dietary Supervisor verified these conditions. Additional observations found a box of multiple cartons of liquid eggs stored on the floor of the walk-in cooler, two large bags of pasta opened and undated in dry storage with one bag open to air, one cup of cottage cheese and six small cups of ranch salad dressing undated and unlabeled in the reach-in cooler, and an opened cup of ice cream in the reach-in freezer with the lid not fully covering the ice cream. The Dietary Supervisor verified the storage issues and removed or discarded some of the items. The supervisor was also observed cooking ground beef without wearing a hair net, and verified the hair net was not being worn at that time.
Infection Prevention Failures With Legionella Monitoring, Catheter Care, PPE, and Hand Hygiene
Penalty
Summary
The facility failed to implement its infection prevention and control program in several areas. Review of the facility’s Legionella risk management plan showed that control measures included reviewing and removing long plumbing runs and dead ends, or otherwise regularly flushing the system, and storing water above 140 degrees Fahrenheit to kill Legionella bacteria. However, the last documented flush of vacant room water was on 03/12/24, no water temperature logs were provided, and the Director of Maintenance confirmed the facility was not recording water temperatures and was not tracking or logging flushes. The CDC Legionella guidance reviewed by surveyors described the need for a water management program team, system description, identification of growth areas, control measures, intervention steps, and documentation of activities. Resident #13 had diagnoses including morbid obesity, neuromuscular dysfunction of the bladder, and a right femur fracture, and was cognitively intact and dependent on staff for all ADLs. The resident had an indwelling Foley catheter and care plan interventions included catheter care every shift, emptying the bag every shift and as needed, and keeping the Foley catheter to straight drain. During observation, the resident’s urinary catheter drainage bag was laying on the floor and up against the bottom bedrail while the bed was in a low position. The CNA confirmed the bag was on the floor and stated staff could not figure out where to hang it when the bed was in the lowest position. The facility’s urinary catheter policy stated catheter tubing and drainage bags are to be kept off the floor. Resident #2 was cognitively intact and had an indwelling urinary catheter, including a suprapubic catheter order. The revised care plan did not direct the use of enhanced barrier precautions for the suprapubic catheter, and there was no order for EBP. During observation, a CNA provided incontinence care, including peri-care and changing the resident’s brief, while wearing gloves but no gown. The CNA confirmed a gown was not worn, and staff stated they believed a gown was not needed because wound care was not being provided. The EBP sign on the room door directed staff to wear gloves and gown for high-contact care activities such as changing briefs and device care or use of a urinary catheter. In a separate observation, the resident’s catheter drainage bag was again lying on the floor with no barrier between the bag and the floor until a CNA hung it on the side of the bed. In another event, an LPN obtained finger stick blood glucose levels for two residents without wearing gloves and without performing hand hygiene before or after the checks, and the DON and LPN confirmed this occurred. The facility’s hand hygiene policy required hand hygiene before and after direct contact with residents.
Resident Unable to Activate Call Light
Penalty
Summary
The facility failed to ensure Resident #7 was provided a call light that accommodated the resident's needs. Resident #7 was admitted with diagnoses including unspecified parkinsonism, acute respiratory failure with hypoxia, paranoid schizophrenia, major depressive disorder, suicidal ideations, dementia, and anxiety disorder. The significant change MDS dated 01/06/26 showed a BIMS score of 11, indicating moderate cognitive impairment, and the resident was dependent on others for eating, oral hygiene, toileting, showering/bathing, upper and lower body dressing, and personal hygiene. The revised care plan dated 12/09/25 identified self-care deficits, risk for alteration in mood and behavior related to schizophrenia and auditory hallucinations, and risk for falls related to debilitation and weakness. During observation and interview on 03/17/26 at 8:40 A.M., Resident #7 was lying awake in bed with a red pull-cord call light attached near her shoulder. When asked if she could pull the cord, the resident shook her head no. She was unable to lift her right arm, could only partially open the fingers of her left hand, and was unable to pull the string. During interview, CNA #651 stated the resident had limited movement in the left arm, no movement in the right arm, and a contracted left hand, and verified the resident was unable to use the current call light device. The CNA also stated the facility had soft touch call light devices that the resident could use, but they could not be used on that hall because of the outlet type.
Failure to Provide Scheduled Bathing
Penalty
Summary
The facility failed to ensure that Resident #46 was bathed according to his scheduled preference of twice weekly. Resident #46 was admitted with diagnoses including chronic respiratory failure, alveolar hypoventilation, morbid obesity, neurogenic bladder, hypertension, dependence on ventilator, COPD, asthma, type 2 diabetes mellitus, depression, and anxiety. The annual MDS assessment showed he was cognitively intact, had no behaviors or refusals of care, and was dependent for all ADLs and transfers, with bowel incontinence and a urinary catheter in place. The resident stated he did not receive bathing care twice a week as scheduled. Review of shower sheets showed missed bed baths on multiple dates, including 01/04/26, 01/14/26, 01/18/26, 02/08/26, and 02/22/26, as well as two separate two-week periods when no baths were documented. The DON confirmed the resident was scheduled for bathing on Wednesdays and Sundays, that he did not refuse bathing, and that there was no documentation supporting the missed bed baths. The DON also stated the facility standard was to offer bathing two times per week.
Failure to Monitor Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to ensure adequate monitoring for psychotropic medication effectiveness, side effects, and adverse effects for two residents reviewed for unnecessary medications. One resident had diagnoses including unspecified head injury, PTSD, and psychophysiologic insomnia, was cognitively intact with a BIMS score of 15, and had care plan interventions focused on anxiety, environmental stimulation, reassurance, and psychiatric referral. The resident’s medication orders included Ativan 0.5 mg twice daily as needed for anxiety and mirtazapine 7.5 mg at bedtime for sleep, but there were no physician orders initiated to monitor psychotropic medication side effects, and the care plan did not direct monitoring for those effects. The second resident had diagnoses including aphasia, hemiplegia and hemiparesis following cerebral infarction, schizoaffective disorder, and a history of traumatic brain injury. The resident’s quarterly MDS showed a BIMS score of 15, with depression noted during the look-back period and no behaviors at the time of assessment, while the care plan identified risks for behavior symptoms and mood changes related to depression, bipolar disorder, and antidepressant and antipsychotic medications. Medication orders included divalproex sodium 125 mg twice daily and mirtazapine 7.5 mg at bedtime, but there were no orders entered to monitor psychotropic medication side effects. The DON stated the facility used a house order for monitoring side effects, that the order was not active for these residents, and later verified that monitoring for psychotropic medication side effects had not been completed.
Unsafe discharge without required notice
Penalty
Summary
The facility failed to ensure a resident was provided a safe and appropriate discharge. Resident #84 was admitted with diagnoses including epilepsy, traumatic brain injury, anxiety disorder, mood disorder, depression, tracheostomy status, and thyroiditis. The resident’s MDS showed a BIMS score of zero, indicating she was rarely or never understood, and a staff assessment noted short- and long-term memory problems. She required moderate assistance with toilet use, bathing, and dressing, and her care plan identified cognitive impairment, risk for falls, and mood and behavior concerns, including crying, yelling for help, repeated questioning, and removing her clothes and walking in the hallway. Progress notes showed the resident’s behaviors were directed toward staff and included hitting, kicking, throwing items, and hitting the medication cart against the wall. The record did not show behaviors directed toward other residents or herself. The DON documented that she was notified the resident was out of control, had hit a nurse, and police were called. The DON emailed the physician stating the facility was not equipped for the resident’s behaviors and asked about psychiatric placement options. The physician responded that a psychiatric facility with neurology onsite was needed, but she did not know of one that met that need, and suggested the resident’s husband take her to an ER with a psychiatric center. The resident was sent to a local hospital with her husband, but the hospital did not admit her. The facility then determined the resident could not return because she was considered a harm to herself and others, despite the record showing her behaviors were directed toward staff. The resident’s husband reported the hospital would not admit her and that he had no place to take her. The facility provided the husband with the resident’s medications and belongings, and the resident ultimately went home with her husband. The medical record contained no documentation that the facility provided the resident or her husband with a discharge notice or appeal rights before the discharge. The facility policy stated residents could remain in the facility except when the resident or responsible party requested discharge, payment was not being made, or the health and safety of the individual or other residents were endangered.
Failure to Follow Ordered Heel Offloading Measures
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not ensured for one resident reviewed for pressure ulcers. Resident #11 was admitted with diagnoses including hemiplegia and hemiparesis, aphasia, and anxiety. The annual MDS showed impaired cognition, dependence on staff for transfers and mobility, and risk for skin breakdown, with no pressure ulcers at the time of assessment. The care plan identified risk for impaired skin integrity related to ADL needs, incontinence, and frail/thin skin, and included pressure reduction devices as needed. The physician order directed bilateral protective boots to be used per wound care and removed for hygiene and skin care. Observations showed Resident #11 in an adjustable reclining wheelchair with the offloading boots left on a dresser behind the television, and the resident stated she would allow staff to put the boots on. Later, the resident was observed in the wheelchair with a blanket covering her body, legs, and feet, and she stated she could not move her legs independently. A CNA stated the resident had been transferred from bed to wheelchair on the previous shift and that the boots were intended for use while in bed. During continued observation, the resident’s legs were crossed at the ankle and one heel was resting on the wheelchair footpad, which the CNA confirmed. The boots were not on the resident until later that day. The weekly body audit noted no skin breakdown.
Failure to Attempt Non-Pharmacological Pain Interventions Before PRN Oxycodone
Penalty
Summary
The facility failed to ensure non-pharmacological interventions were attempted before administering as-needed pain medication for one resident reviewed for pain. Resident #63 was admitted on 04/02/25 with diagnoses including dementia, rheumatoid arthritis, disc degeneration, and neuropathy. The quarterly MDS dated 12/24/25 indicated the resident had intact cognition, received as-needed pain medications, and did not receive non-medication interventions for pain. The care plan, initiated 04/03/25, identified the resident as at risk for alteration in comfort due to complaints of pain, generalized pain, and gastroesophageal reflux disease, and included an intervention for staff to attempt non-pharmacological interventions if the resident allowed. The physician ordered oxycodone HCl 5 mg by mouth every six hours as needed for pain on 11/21/25. The February 2026 MAR showed the resident received 59 doses of oxycodone HCl, and the March 2026 MAR showed 28 doses through 03/17/26 at 4:00 P.M. Review of the medical record found no evidence that non-pharmacological interventions were provided before these as-needed doses in February and March 2026. An LPN confirmed during interview that non-pharmacological interventions should be attempted before administering as-needed pain medication, and concurrent review of the record confirmed no evidence that the resident received such interventions prior to the oxycodone doses.
Failure to Individualize Trauma-Informed Care Plans
Penalty
Summary
The facility failed to ensure resident-specific interventions were implemented to address residents’ histories of trauma for three residents reviewed for trauma-informed care. For one resident with diagnoses including dementia, bipolar disorder, and depression, the care plan identified trauma related to sexual abuse and included general interventions such as reassurance, comfort measures, social interaction, and referral to psychiatric or counseling services, but the DON, an LPN, and the Social Service Director confirmed the care plan did not include trauma-specific triggers or interventions to address or avoid those triggers. For another resident with diagnoses including morbid obesity, neuromuscular dysfunction of the bladder, and a right femur neck fracture, the care plan identified a history of trauma related to being in a situation/environment and being a victim of a violent crime, but the documented interventions were general and did not identify any trauma triggers. For a third resident with diagnoses including an unspecified head injury, PTSD, and psychophysiologic insomnia, the care plan addressed trauma-related PTSD from military history with general interventions such as building trust, observing for anxiety, decreasing environmental stimulation, and providing reassurance, but it contained no resident-specific PTSD triggers. The DON verified that the care plans for these residents did not contain specific triggers and that the interventions were not resident-specific.
Medication Given Outside Ordered BP Parameters
Penalty
Summary
Medications were not administered per physician order for Resident #63, who was admitted on 04/02/25 with diagnoses of dementia, hypertension, and anxiety. The MDS assessment dated 12/24/25 indicated the resident had intact cognition. A physician order dated 08/29/25 directed midodrine HCl 2.5 mg by mouth every eight hours for hypotension, with instructions to give the medication only for SBP less than 100 mmHg. Review of the February 2026 MAR and March 2026 MAR showed multiple administrations of midodrine HCl when the resident's BP readings were above the ordered SBP parameter, including readings of 124/50, 117/58, 125/72, 163/59, 104/76, 108/62, 106/69, 106/54, 126/57, 108/74, and 143/51 mmHg. During interview on 03/19/26 at 9:13 A.M., the Unit Manager confirmed the medication was given outside the ordered parameters on each of those dates.
Medication Storage Not Secured
Penalty
Summary
Medications were not stored in a secure manner. Based on observation, staff interview, medical record review, and policy review, the facility failed to ensure that medications were stored in locked compartments. This affected one resident reviewed for hemodialysis and related care in a census of 76. The cited concern involved Resident #9, who had diagnoses including dementia, heart disease, and end stage renal disease, and whose MDS assessment indicated intact cognition and dialysis use. Resident #9 had a physician order for midodrine HCl 10 mg to be given in the afternoon every Monday, Wednesday, and Friday and sent with the resident to dialysis. Staff observed the resident's HD communication binder in a tote bag in the resident's room, and the tote bag was zipped closed on the recliner. With the resident's permission, the binder was opened and a medication pouch was found inside it. CNA #644 confirmed medications were inside the notebook, and the notebook was then carried to an LPN at the medication cart. The LPN observed a medication card for midodrine HCl 10 mg containing seven tablets and placed the notebook in a locked drawer of the medication cart. The facility policy stated that drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light, and humidity controls.
Failure to Obtain and Communicate Bone Biopsy Results
Penalty
Summary
The facility failed to ensure diagnostic testing results were obtained and communicated in a timely manner for one resident (#44) reviewed for diagnostic testing. Resident #44 was admitted with diagnoses including respiratory failure, depression, anxiety, pneumonia, neurogenic bladder, acute infarction of the spinal cord, hypertension, and gastrointestinal hemorrhage. The annual MDS assessment showed the resident was cognitively impaired, had functional range of motion limitations in both upper and lower extremities, and was dependent for all care and transfers. The medical record showed a progress note dated 01/20/26 indicating a bone biopsy had been rescheduled for 02/03/26, and a note dated 02/03/26 indicated the resident was out of the facility. The record contained no results from the bone biopsy scheduled on 02/03/26. The resident representative stated on 03/16/26 that diagnostic testing results completed in January 2026 had not been communicated. The DON confirmed on 03/18/26 that the bone biopsy results had not been obtained by the facility or communicated to the physician and resident representative. The Administrator stated on 03/19/26 that the facility did not have a policy for obtaining diagnostic testing results or notifying the physician and family representative of those results.
Incomplete Documentation of Dialysis Provider Communication
Penalty
Summary
The facility failed to ensure that Resident #9’s medical record was complete by not documenting ongoing communication with the resident’s dialysis provider. Resident #9 was admitted with diagnoses including dementia, heart disease, and end stage renal disease, and the MDS indicated the resident had intact cognition and received dialysis. The record also included a physician order for offsite hemodialysis three times weekly and as needed, and the care plan identified dialysis on Mondays, Wednesdays, and Fridays with interventions to check for new orders after dialysis and maintain communication with dialysis staff and the physician. Review of the record showed only limited documentation of communication between the facility and the hemodialysis clinic in nursing progress notes, despite staff stating there was ongoing contact by email and telephone. The HD clinic’s letterhead document noted the resident was receiving emergency HD treatments in the area and required travel through the area during hours before and after curfew. Interviews with the RN, LPN, DON, and Unit Manager confirmed the resident’s dialysis care involved routine communication with the clinic, but the ongoing exchange of information was not routinely documented in the resident’s medical record.
Failure to Provide Adequate Assistance with Personal Hygiene for Dependent Resident
Penalty
Summary
A resident with chronic respiratory failure, tracheostomy status, ventilator dependence, quadriplegia, and COPD was identified as being severely cognitively impaired and fully dependent on staff for all activities of daily living (ADLs). The resident's care plan required total assistance for ADLs, including personal hygiene. According to the facility's shower schedule and documentation, the resident received showers as scheduled. However, during observations, the resident was noted to have significant facial hair growth on the upper lip and chin, with hair measuring one to two inches in length and extending beyond the lip line and nearly touching the tracheostomy dressing. Staff interviews confirmed that although the resident was showered, facial hair was not shaved because staff were reluctant to use the facility's razors on the resident's face. The facility's policy required that residents unable to perform ADLs independently receive necessary services to maintain grooming and personal hygiene. Despite this, the resident did not receive adequate assistance with shaving, resulting in a failure to meet the facility's own standards for ADL care and personal hygiene.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, sanitary, and homelike environment, affecting all 72 residents. Resident #64, who was cognitively intact, reported that the toilet and toilet riser in his restroom were covered with feces, and his bed linens were soiled. These observations were confirmed by a Housekeeping Assistant. Resident #64 had multiple medical conditions, including malignant neoplasm of the esophagus, diabetes mellitus type two, and morbid obesity. Additionally, Resident #59, who was moderately cognitively intact, reported that her room was not kept clean, which was verified by an LPN who observed dirt on the floor. Furthermore, the carpet in the 300 Hall was observed to be stained and dirty with food pieces ground into it, a condition confirmed by an STNA who stated that this was the usual state of the area. The facility's policy on providing a clean and homelike environment was not adhered to, as evidenced by these findings.
Failure to Report Elopement Incident of Cognitively Impaired Resident
Penalty
Summary
The facility failed to report an incident of potential neglect related to the elopement of a cognitively impaired resident to the state agency. The incident involved a resident with multiple diagnoses, including dementia and severe cognitive impairment, who was noted to have wandering behaviors. On the day of the incident, the resident was observed closing fire doors and was later found outside the facility by an LPN during her smoke break. The resident was brought back inside without any staff having observed her exit the building. Despite the incident, the facility did not submit a Self-Reported Incident (SRI) to the state agency as required by their policy. Interviews with staff confirmed the resident's exit and return to the facility. The facility's policy mandates that alleged violations of neglect be reported immediately to the administrator, state agency, and other required agencies, with a thorough investigation and reporting of results within five working days. However, the facility did not adhere to this policy, as evidenced by the lack of an SRI for the incident. The corporate director questioned the need for reporting, indicating a gap in understanding or adherence to the facility's policies on reporting potential neglect.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident identified as at risk for wandering and elopement. Resident #3, who had a history of elopement and was diagnosed with dementia and other cognitive impairments, was able to exit the facility unsupervised. The resident's care plan included interventions for elopement risk, such as completing an elopement risk assessment and monitoring behavior, but these measures were not effectively implemented. On the day of the incident, Resident #3 was observed closing fire doors and pacing the hallway, indicating anxiety. Despite these behaviors, the resident was not adequately supervised, and staff failed to notice when the resident exited the building. The door alarm was found to be in working order, but staff did not hear it or respond in time to prevent the elopement. The resident was eventually found outside by an LPN who was on a smoke break and was able to redirect the resident back into the facility. Interviews with staff revealed lapses in supervision and communication. An LPN was supposed to be monitoring the hallway but did not see or hear the resident leave. Another staff member, an STNA, arrived late and heard the alarm but did not see the resident outside. A housekeeper also heard a beeping noise but did not recognize it as an alarm. These oversights contributed to the resident's unsupervised exit from the facility, highlighting a failure to ensure a safe environment for residents at risk of elopement.
Ineffective Pest Control Program for Bed Bugs
Penalty
Summary
The facility failed to maintain an effective pest control program for bed bugs, affecting a resident who was severely cognitively impaired and dependent on staff for all activities of daily living. The resident's medical record indicated that bed bug precautions were in place due to previous findings of bed bugs, and it was noted that the resident's family, who visited often, had a bed bug infestation at home. Despite treatments by an exterminator, the facility did not address the source of the infestation, allowing the family to continue visiting and bringing potentially contaminated items into the facility. Interviews with staff, including a housekeeper, LPN, and STNA, confirmed the presence of bed bugs in the resident's room and highlighted the facility's inadequate response to the issue. Staff reported that the exterminator's treatments were ineffective due to the ongoing introduction of bed bugs by the resident's family. Observations in the resident's room revealed evidence of bed bug activity, such as red-brown specks on the bed sheet, identified as bed bug droppings. The exterminator's records showed multiple treatments for bed bugs, yet live bed bugs were consistently found during inspections.
Failure to Document Meal Intakes
Penalty
Summary
The facility failed to document meal intakes as recommended by the dietician and outlined in the care plans for two residents, leading to a deficiency in maintaining their nutritional status. Resident #35, who had severe cognitive impairment and was dependent on staff for eating, had no meal intake documentation on several specified dates. The resident was extremely underweight, and the care plan included interventions such as adding enhanced foods to every meal, assisting with feeding, and providing supplements. Despite these interventions, the facility did not consistently document the resident's meal intakes, as verified by the Director of Nursing (DON). Similarly, Resident #61, who was cognitively intact but required supervision for meals, also had missing meal intake documentation on several specified dates. The resident had significant weight loss and was recommended to receive house shakes and have meal intakes monitored. The care plan included monitoring meal intakes and offering substitutes if less than 75% of a meal was consumed. However, the facility failed to document meal intakes consistently, as confirmed by the DON. This deficiency was investigated under Complaint Number OH00152780.
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What surveyors actually found near you
We read the 574 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Waterville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Astoria Place Of Waterville | 1.6 mi | ★★★★★ | 31 | 1 |
| Whitehouse Country Manor | 3.9 mi | ★★★★★ | 0 | 0 |
| Otterbein Monclova | 5 mi | ★★★★★ | 4 | 0 |
| Lakes Of Monclova Health Campus The | 6.1 mi | ★★★★★ | 14 | 0 |
| St Clare Commons | 6.5 mi | ★★★★★ | 14 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.