Aicota Health Care Center

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure milk products were served to residents at safe temperatures for consumption. This deficient practice had the potential to affect 5 residents (R8, R11, R17, R20, R38) who were served milk at unsafe temperatures. In addition, the facility failed to ensure staff preparing food had proper hair restraints in place. This deficient practice had the potential to affect any person consuming food prepared by the facility. R8's admission Record dated 1/9/26, identified an admission date of 10/30/25 and diagnoses of malignant neoplasm of part of the left bronchus or lung, and chronic kidney disease. R11's admission Record dated 1/9/26, identified an admission date of 3/21/22 and diagnoses of chronic atrial fibrillation, vascular dementia, hypertension and diabetes. [...]

Inspectors wroteBased on interview and document review, the facility failed to accurately submit the payroll-based journal system (PB&J) staffing data to Centers for Medicare and Medicaid Services (CMS). This had the potential to affect all 53 residents residing in the facility.

Inspectors wroteBased on interview and document review, the facility failed to ensure agency nursing staff received appropriate orientation, training and supervision. This had the potential to affect all 53 residents who resided in the facility.

Inspectors wroteBased on observation, interview, and document review the facility failed to facilitate resident preferences for meals for 1 of 1 resident (R27) reviewed for choices.

Inspectors wroteBased on interview and document review, the facility failed to develop a person-centered care plan to include necessary post-treatment assessments and documentation needs for 1 of 2 residents (R42) reviewed for care planning. R42's admission minimum data set (MDS) dated [DATE], identified intact cognition and diagnoses of acute and chronic respiratory failure with hypoxia, kidney transplant rejection, end-stage-renal-disease (ESRD), and dependence on renal dialysis. R42's care plan dated 1/6/26, identified a focus statement for a high risk of complications related to on-going dialysis treatments. Interventions didn't include instructions to assess R42 upon return from a dialysis treatment for his overall condition and status, vital signs, presence of thrill or bruit in fistula, or status of dressings on the fistula. [...]

Inspectors wroteBased on interview and document review, the facility failed to follow bowel protocols for 1 of 3 residents (R3) reviewed for quality of care. R3's significant change in status assessment (SCSA) minimum data set (MDS), dated [DATE], identified severely impaired cognition and diagnoses of Alzheimer's dementia, anxiety disorder, major depressive disorder, uterovaginal prolapse and constipation. R3's MDS also indicated moderate assistance needed for bed mobility, transfers, and toilet hygiene. The MDS also identified R3 was occasionally incontinent of bowel and bladder and was on a toileting program, R3 needed moderate assist for transferring and toilet hygiene. R3's care plan, dated 8/18/21, identified R3 was incontinent of bowel and bladder and needed an assist of one to bring her to the toilet and provide incontinent care as needed. The care plan didn't address constipation. [...]

Inspectors wroteBased on observation, interview and document review the facility failed to ensure a resident was toileted timely to prevent an incontinence accident for 1 of 1 resident (R27) reviewed for bowel and bladder.

Inspectors wroteBased on interview and document review, the facility failed to perform vital sign monitoring, assessment, and documentation of resident's condition and fistula status (also called a shunt, a connection made between a vein and an artery for the necessary blood flow to facilitate a machine to remove the excess waste and water from the person's blood which the kidneys are not able to) after returning from a renal dialysis treatment at an offsite dialysis facility for 1 of 1 (R42) resident reviewed for dialysis care. R42's admission minimum data set (MDS), dated [DATE], identified intact cognition and diagnoses of acute and chronic respiratory failure with hypoxia, kidney transplant rejection, end-stage-renal-disease (ESRD), and dependence on renal dialysis. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure the information on the daily nurse staffing was in a format that was clear to residents and visitors. This had the potential to affect all 53 residents who resided in the facility and their families and visitors.

Inspectors wroteBased on interview and document review, the facility failed to timely submit staffing data for 2 of 4 quarters reviewed (quarter 1 and 2) to the Centers for Medicare and Medicaid Services (CMS) according to specifications established by CMS. The provider had implemented corrective action prior to the investigation, therefore, the deficiency was issued as past non-compliance.

Inspectors wroteBased on interview and document review, the facility failed to consistently provide a surety bond (a written agreement to guarantee payment of another company's obligation under a separate contract) to protect the account balance of the resident trust fund. This had the potential to affect 26 of 26 residents at the facility who have a trust account.

Inspectors wroteBased on interview and document review the facility failed to ensure submitted Minimum Data Set (MDS) assessments were accurate and/or comprehensive for 35 out of 54 residents (R2, R3, R4, R5, R6, R7, R9, R11, R13, R14, R17, R20, R21, R24, R25, R26, R28, R29, R31, R32, R33, R34, R35, R36, R38, R39, R42, R43, R44, R47, R48, R49, R50, R152. R204) reviewed for MDS accuracy.

Inspectors wroteBased on interview and record review the facility failed to ensure provider required regulatory visits occurred face to face for 33 out of 54 residents (R1, R3, R4, R6, R7, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R21, R23, R24, R25, R27, R28, R30, R31, R32, R33, R34, R35, R39, R43, R44, R45, R49) reviewed for regulatory visit compliance.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure non-pharmacological interventions were attempted prior to the administration of psychotropic medications [mood altering medications] for 1 of 6 residents (R252) reviewed for psychotropic medications.

Inspectors wroteBased on interview and document review the facility failed to ensure orders for PRN (as needed) psychotropic medication (mood altering medications) were time limited to 14 days for 2 of 6 residents (R29, R42). In addition, the facility failed to ensure provider assessment and documentation of rationale and duration of continuation of a psychotropic PRN medication beyond 14 days occurred for one of six residents (R29) reviewed for PRN psychotropic medication use. R29 R29's Minimum Data Set (MDS) dated [DATE], identified R29 was cognitively intact. R29's diagnoses included wedge compression fracture of second lumbar vertebra, congestive heart failure, major depression, anxiety disorder, intermittent explosive disorder. R29's Order Summary Report listed orders as of 1/2025, identified lorazepam solu tab give 0.5 mg by mouth every 4 hours as needed for anxiety ordered. [...]

Inspectors wroteBased on interview and document review, the facility failed to offer pneumococcal conjugate vaccine 20 variant (PVC20) as directed by the Centers for Disease Control (CDC) for 4 of 5 residents (R11, R16, R37, R44) reviewed for immunizations.

Inspectors wroteBased on interview and document review, the facility failed to ensure residents were allowed to transfer back to the facility following transfer to the hospital for 1 of 2 residents (R204) reviewed for hospitalization.

Inspectors wroteBased on interview and document review, the facility failed to ensure a written notice of bed hold was provided at the time of transfer along with ongoing attempts at getting the beg hold signed following an emergent transfer for 1 of 1 resident (R204) reviewed for hospitalization.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure the actual hours and amount of staff were posted per each shift. This had the potential to affect all residents residing in the facility.