Astoria Place of Waterville

Inspectors wroteBased on medical record review, staff interview, hospice interview, review of the local weather conditions, emergency medical services (EMS) interview, review of the EMS run report, and review of hospital records, the facility failed to adequately assess, monitor, document, and address a decline in a resident's mental health. This resulted in Actual harm to Resident #09 when on the evening of 01/01/26, the resident did not sleep, appeared to be experiencing hallucinations, and was aggressive toward staff. Facility staff failed to notify the physician or implement any interventions throughout the night. Subsequently, on 01/02/26 at approximately 7:50 A.M., Resident #09 was found outside of the facility, after exiting from his room window and without appropriate clothing for the cold temperatures, in the snow. [...]

Inspectors wroteBased on medical record review, review of the Certification, Licensure, and Survey (CALS) system (system for maintaining healthcare provider information), staff interview, and review of facility policy, the facility failed to notify the Ohio Department of Health (ODH) of a resident elopement. This affected one (#09) of three residents reviewed for elopement. The facility census was 60.

Inspectors wroteBased on medical record review, staff interview, review of the facility investigation, review of emergency medical service (EMS) and police reports, review of the county coroner case documentation, and review of facility policy, the facility failed to prevent resident to resident abuse. Actual harm occurred on 09/23/25 when Resident #29 was discovered in a resident room behind a closed door and Resident #53 was discovered in the same room behind a drawn privacy curtain laying supine on a sheet on the floor with towels secured tightly around the neck. Resident #53's head was purple in color, skin was cool to touch, with blood in her mouth, petechia to her skin, and no respirations or pulse were present. Resident #29 later admitted strangling Resident #53. The county coroner case documentation listed the cause of Resident #53's death as a homicide by means of strangulation. [...]

Inspectors wroteBased on medical record review, observation, staff interview, county coroner interview, review of the Emergency Medical Services (EMS) run report, review of the death certificate, and review of the facility self-imposed action plan, including in-service records and audits, the facility failed to provide residents food in the correct texture to meet individual needs, failed to ensure residents were provided feeding assistance/supervision as required, and failed to put monitoring systems in place to prevent the same actions, situations, and/or practices from reoccurring. [...]

Inspectors wroteBased on observation, medical record review, staff interview, review of a job description, and policy review, the facility failed to provide adequate administration over the facility when a resident died from a choking incident as a result of being provided unapproved food items. The facility subsequently put a corrective action plan into place that was not fully followed to prevent further episodes of resident's choking and prevent residents from receiving restricted food and drinks. This had the potential to affect all 74 residents residing in the facility. The facility census was 74. Findings Include:Interview on 08/12/25 at 1:47 P.M. [...]

Inspectors wroteBased on review of water flushing logs, review of water monitoring logs, review of water temperature logs, staff interview, review of a water pH level reading document, and policy review, the facility failed to accurately and adequately conduct water monitoring for the prevention of Legionella within the facility. This had the potential to affect all 74 residents in the facility. The census was 74.

Inspectors wroteBased on employee file review and staff interview, the facility failed to ensure employees completed Quality Assurance and Performance Improvement (QAPI) training. This had the potential to affect all 74 residents residing in the facility. The facility census was 74.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure the facility maintained a homelike environment. This affected eight (#35, #82, #22, #36, #12, #81, #7, and #29) of eight residents reviewed for environment. The facility census was 74.

Inspectors wroteBased on medical record review, resident and staff interview, review of shower schedules, and review of facility policies, the facility failed to ensure residents had the right to choose when they receive their medications to prevent refusal and choose the time they shower. This affected two (#50 and #47) of two residents reviewed for choices. The facility census was 74.

Inspectors wroteBased on review of a personal funds balance statement, staff interview, and policy review, the facility failed to ensure a resident was provided notification of spend down when personal funds were within $200.00 of the resource limit. This affected one (#51) of eight residents reviewed for personal fund accounts. The facility identified 41 residents with personal funds accounts. The facility census was 74.

Inspectors wroteBased on medical record review, review of hospital documentation, review of self-reported incidents, staff interview, and policy reviews, the facility failed to ensure appropriate notifications were made for three (#1, #71, and #56) of seven residents reviewed for resident-to-resident interactions and change in condition. The facility census was 74.

Inspectors wroteBased on review of the medical record, staff interview, and policy review, the facility failed to ensure an appropriate diagnosis for the use of an antipsychotic medication. This affected one (#6) of five residents reviewed for unnecessary medications. The facility identified 38 residents as receiving antipsychotic medications. The facility census was 74.

Inspectors wroteBased on review of the medical record, staff interview, and policy review, the facility failed to ensure baseline care plans were developed within 48 hours of admission. This affected three (#52, #15, #53) of 31 residents reviewed for baseline care plans. The facility census was 74.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to timely develop comprehensive care plans. This affected two (#6 and #16) of 31 residents reviewed for comprehensive care plans. The facility census was 74.

Inspectors wroteBased on review of the medical record, observation, resident and staff interview, and review of facility policy, the facility failed to ensure dependent residents received adequate nail care. This affected two (#40 and #45) of three residents reviewed for activities of daily living. The facility census was 74.

Inspectors wroteBased on observation, resident and staff interview, and medical record review, the facility failed to ensure residents received splints and immobilizer devices as ordered by the physician. This affected one (#1) of one residents reviewed for range of motion. The facility census was 74.

Inspectors wroteBased on observation, medical record review, and staff interview, the facility failed to adequately assess a resident following an unwitnessed fall and failed to ensure adequate supervision to prevent a resident from consuming food not in their diet. This affected two (#56 and #38) of two residents reviewed for accidents. The facility census was 74.

Inspectors wroteBased on observation, medical record review, staff interview, resident interview, physician interview, and policy review, the facility failed to ensure a resident urinary tract infection was timely and appropriately treated; and failed to ensure a urinary catheter was patent and functioning properly. This affected two (#69 and #81) of two residents reviewed for bowel and bladder concerns. The facility identified three residents with urinary tract infections and six residents with urinary catheters. The facility census was 74.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed timely notify the physician of abnormal laboratory results. This affected one (#69) of two residents reviewed for bowel and bladder concerns. The facility census was 74.

Inspectors wroteBased on medical record review, observation, resident interview, staff interview, and facility policy review, the facility failed to ensure residents received adaptive equipment with meals as ordered. This affected one (#15) of one residents reviewed for adaptive equipment at meals. The facility census was 74.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to maintain complete and accurate resident medical records. This affected one (#20) of three residents reviewed for medical record content. The facility census was 74. Findings Include:Review of the medical record for Resident #20 revealed the resident was admitted on [DATE]. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting the right side, Parkinson ' s disease, vascular dementia, major depressive disorder, and dysphagia. Review of the Minimum Data Set (MDS) assessment, dated 06/27/25, revealed Resident #20 had unclear speech, was not orientated to time, used wheelchair, required setup assistance for eating, toileting, and personal hygiene, and needed substantial assistance for shower, dressing, and transfers. [...]

Inspectors wroteBased on medical record review, staff and interview, physician interview, and policy review, the facility failed to ensure antibiotics were appropriately prescribed for urinary tract infections. This affected three (#69, #5, and #24) of four residents reviewed for antibiotic stewardship. The facility identified seven residents as receiving antibiotics. The facility census was 74.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure residents received education prior to accepting or refusing a pneumococcal vaccination. This affected two (#3 and #38) of five residents reviewed for pneumococcal vaccination. The census was 74.

Inspectors wroteBased on staff schedule review, timesheet review, and staff interview, the facility failed to ensure a Registered Nurse (RN) worked for eight hours daily in the facility. This affected all 68 residents in the facility.

Inspectors wroteBased on observation, staff interview, and review of a Safety Data Sheet (SDS), the facility failed to ensure appropriate cleaning agents were used to clean residents rooms and common areas. This affected 32 (#11, #12, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, and #42) residents on the upstairs unit. The facility census was 68.

Inspectors wroteBased on review of the medical record, review of a self-reported incident, review of an incident report, review of hospital records, review of staff statements, staff interview, staff job description, and policy review, the facility failed to ensure staff assisted a resident with safe ambulation, report a resident fall, and ensure a resident was assessed for injuries prior to moving the resident after a fall, and ensure the resident's fall was thoroughly investigated. Additionally, the facility failed to implement fall prevention interventions. This resulted in Actual Harm on 02/12/25 when staff assisted Resident #47 to the bathroom without his walker, staff then picked the resident up off the floor after a fall, toileted the resident, and then walked the resident back to bed further increasing the risk for injury then never reported the fall to the nurse. [...]

Inspectors wroteBased on record review, review of the facility policy, review of the Self-Reported Incidents (SRI) database, facility investigation, review of hospital records, resident interviews, and staff interviews, the facility failed to prevent resident-to-resident physical abuse. This resulted in actual harm when Resident #01, a resident with known history of resident-to-resident abuse incidents, struck Resident #02 in the face causing a hematoma (a pool of clotted blood that forms in the tissue) to her face and a closed fracture of the right orbital floor (one or more bones around the eyeball break, often from a blow to the face). Additionally, the facility failed to ensure Resident #03 was free from resident-to-resident physical abuse when Resident #01, who was supposed to be on one-to-one monitoring, struck Resident #03 in the back several times, while Resident #03 was asleep. [...]

Inspectors wroteBased on review of the Self-Reported Incident (SRI) database, review of policy, and staff interview, the facility failed to timely report allegations of resident-to-resident abuse. This affected three (#01, #02, and #03) of three residents reviewed for abuse reporting of allegations of abuse. The current census is 76.

Inspectors wroteBased on medical record review, staff interview, community staff interview, and facility policy review, the facility failed to provide residents with food in the form and texture as ordered by the physician. This affected one (#80) of three residents reviewed for altered texture diets. The census was 84. Findings Include: Review of the medical record revealed Resident #80 was admitted to the facility on [DATE]. Diagnoses included Parkinsonism, multiple sclerosis, type II diabetes, major depressive disorder, anxiety disorder, dementia, mild intellectual disabilities, post traumatic stress disorder, and bipolar disorder. Review of Resident #80's Minimum Data Set (MDS) assessment dated [DATE]) revealed the resident was assessed with a mild cognitive impairment. [...]

Inspectors wroteBased on observation, staff interview, and review of policy, the facility failed to ensure proper storage of medications and failed to ensure the medication refrigerator in the medication room was used only for medication storage. This had the potential to affect nine (#7, #17, #19, #35, #48, #51, #53, #62, and #67) of nine residents the facility identified as cognitively impaired and independently mobile an undetermined number of residents who could receive the tuberculin solution. The facility census was 81.

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to ensure drinking cups were adequately cleaned. This affected 28 (#2, #3, #4, #6, #13, #15, #20, #24, #25, #29, #30, #34, #38, #39, #40, #42, #43, #46, #47, #49, #56, #66, #68, #73, #75, #79, #80 and #81) of 29 residents in the A hall. The facility identified one resident (#72) to receive no food by mouth. The facility census was 81.

Inspectors wroteBased on observations, staff interview, training record review and policy review, the facility failed to ensure staff wore proper personal protective equipment (PPE) when entering a COVID positive environment. This had the potential to affect the remaining COVID negative residents on the second floor 21 (#9, #10, #12, #16, #17, #18, #19, #21, #28, #31, #35, #44, #48, #50, #53, #54, #57, #62, #63, #65, #76) of 21 residents the on the second floor. The facility census was 81.

Inspectors wroteBased on medical record review, observation, staff interview, and review of policy, the facility failed to ensure a clean and sanitary environment. This affected one (Resident #72) of 81 residents reviewed for environment. The facility census was 81.

Inspectors wroteBased on medical record review, observation, staff interview, and policy review, the facility failed to timely identify and treat new skin impairment. This affected one (Resident #72) of one resident reviewed for potential skin impairment. The facility census was 81.

Inspectors wroteBased on observation, staff interview, record review, and policy review, the facility failed to ensure care and treatment was provided to a resident with closed urinary drainage system to maintain the closed system to prevent potential infections. This affected one (#53) of one residents reviewed for catheter care. The facility identified four current residents with catheters. The facility census was 81.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure a resident's nutritional status was being routinely being assessed by a registered dietician; accurately assess and obtain weights; and timely notify the physician and dietician of significant weight changes. This affected two (#7 and #51) of three residents reviewed for nutrition. The facility census was 81.

Inspectors wroteBased on observation, staff interview, resident interview, review of the resident council concerns, and the facility extermination contractor documentation, the facility failed to ensure an effective pest control program was in place to address flying insects. This affected all 72 residents residing in the facility.

Inspectors wroteBased on medical record review, observation, and staff interview the facility failed to ensure residents were provided with dignified assistance eating during meals. This affected one resident (#14) of four identified as dependent on staff for eating. In addition, the facility to ensure clothing protectors were used in a dignified manner. This affected four additional residents (#23, #58, #65, #171) who were provided clothing protection during meals. The facility census was 72.

Inspectors wroteBased on observation and staff interview the facility failed to ensure resident meals were provided in a homelike fashion. This deficient practice affected 12 residents (#53, #62, #30, #48, #44, #29, #42, #14, #56, #15, #01, and #08) of 24 residents who resided on the unit who were observed during the lunch meal service. The facility census was 72.

Inspectors wroteBased on observation, staff interview, and review of a facility policy, the facility failed to store foods in a safe and sanitary manner. This had potential to affect 69 out of 72 residents who received food from the kitchen. The facility identified three residents (#06, #09, and #11) who did not receive food from the kitchen. The facility census was 72.

Inspectors wroteBased on observation, staff interview, medical record review, review of facility policies, review of the Centers for Medicare and Medicaid (CMS) COVID-19 Positivity Rates, and review of the Centers for Disease Control and Prevention (CDC) website the facility staff failed to wear appropriate personal protective equipment (PPE) while providing direct care for a resident who was on a COVID-19 quarantine, failed to maintain COVID-19 quarantine for a newly admitted resident with unknown COVID-19 status and not fully vaccinated. This directly affected two residents (#171 and #221) of two residents observed on COVID-19 transmission-based precautions This had the potential to affect 27 residents (#04, #05, #07, #12 #17, #18, #19, #20, #25, #27, #33, #34, #39, #41, #43, #45, #47, #49, #51, #55 #59, #60, #61, #63, #67, #69, and #70) who resided on the Cedar Pines Unit. [...]

Inspectors wroteBased on medical record review, resident interview, staff interview, and review of the facility policy, the facility failed to ensure resident mail was delivered unopened to residents. This affected one resident (#43) and had the potential to affect all 72 residents residing in the facility.

Inspectors wroteBased on medical record review and staff interview the facility failed to provide the resident and resident's representative in writing the reason for a transfer to the hospital. This affected one resident (#19) of one resident reviewed for hospitalization. The facility identified 19 residents who were hospitalized in the last three months. The facility census was 72.

Inspectors wroteBased on medical record review, staff interview, and policy review the facility failed to provide the resident and resident's representative with the facility's bed hold policy for a transfer to the hospital. This affected one resident (#19) of one resident reviewed for hospitalization. The facility identified 19 residents who were hospitalized in the last three months. The facility census was 72.

Inspectors wroteBased on medical record review, staff interview, and review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) User Manual, the facility inaccurately coded residents for anticoagulant medications. This affected two residents (#13 and #38) of three residents reviewed for anticoagulant use coded on the MDS assessment. The facility census was 72.

Inspectors wroteBased on medical record review, observation, staff interview, and policy review the facility failed to change oxygen supplies as ordered. This affected one resident (#69) of one resident reviewed for respiratory care. The facility census was 72.

Inspectors wroteBased on medical record review, observation, staff interview, and policy review the facility failed to obtain a physician order for oxygen. This affected one resident (#69) of one resident reviewed for respiratory care. The facility census was 72.

Inspectors wroteBased on personnel file review, staff interview, and review of the Employee Handbook the facility failed to ensure State Tested Nursing Assistants (STNA) received a 90 day or annual evaluation for three (#155, #160, #165) of three STNA personnel files reviewed. This had the potential to affect all 72 residing in the facility. The facility census was 72.