Inspection Reports for
Waterville Residential Care Center

F 0684: The facility did not ensure residents received treatment and care according to professional standards. Resident #1 exhibited a change in condition and expired during transport without documented assessment or consistent staff communication.

F 0689: The facility failed to ensure a nursing home area was free from accident hazards and did not provide adequate supervision or implement fall prevention interventions for Residents #1 and #2, resulting in multiple falls and incomplete assessments.

Standard Health Citation — quality of care: Free Of Accident Hazards/supervision/devices deficiency noted.

Standard Health Citation — quality of care: Quality Of Care deficiency noted.

Standard Health Citation — quality of care: Activities Meet Interest/needs Each Resident deficiency noted.

Standard Health Citation — quality of care: Food Procurement,store/prepare/serve-sanitary deficiency noted.

Standard Health Citation — quality of care: Label/store Drugs And Biologicals deficiency noted.

Standard Health Citation — quality of care: Nutritive Value/appear, Palatable/prefer Temp deficiency noted.

Standard Health Citation — quality of care: Safe/clean/comfortable/homelike Environment deficiency noted.

Standard Health Citation — quality of care: Treatment/svcs To Prevent/heal Pressure Ulcer deficiency noted.

Life Safety Code Citation — NFPA requirements: Cooking Facilities deficiency noted.

Life Safety Code Citation — NFPA requirements: Corridor - Doors deficiency noted.

Life Safety Code Citation — NFPA requirements: Egress Doors deficiency noted.

Life Safety Code Citation — NFPA requirements: Electrical Equipment - Testing And Maintenanc deficiency noted.

Life Safety Code Citation — NFPA requirements: Electrical Systems - Essential Electric Syste deficiency noted.

Life Safety Code Citation — NFPA requirements: Elevators deficiency noted.

Life Safety Code Citation — NFPA requirements: Fire Alarm System - Testing And Maintenance deficiency noted.

Life Safety Code Citation — NFPA requirements: Hazardous Areas - Enclosure deficiency noted.

Life Safety Code Citation — NFPA requirements: Interior Nonbearing Wall Construction deficiency noted.

Life Safety Code Citation — NFPA requirements: Means Of Egress - General deficiency noted.

Life Safety Code Citation — NFPA requirements: Portable Fire Extinguishers deficiency noted.

Life Safety Code Citation — NFPA requirements: Sprinkler System - Installation deficiency noted.

Life Safety Code Citation — NFPA requirements: Sprinkler System - Maintenance And Testing deficiency noted.

Life Safety Code Citation — NFPA requirements: Subdivision Of Building Spaces - Smoke Barrie deficiency noted.

Standard Health Citation — quality of care: Reporting - National Health Safety Network deficiency noted.

Standard Health Citation — quality of care: Notify Of Changes (injury/decline/room, Etc. ) deficiency noted.

F 0584: The facility did not ensure a safe, clean, comfortable, and homelike environment. Issues included urine odors, dirty and sticky floors, unclean and damaged areas, and missing ceiling tiles with water leaks.

F 0679: The facility did not provide an ongoing program of activities meeting the interests and preferences of Resident #28, who was often left isolated and not engaged in activities.

F 0686: Resident #30 with a Stage 3 pressure ulcer was not consistently provided pressure relieving heel boots while in bed as ordered, risking skin breakdown.

F 0761: The facility did not ensure drugs and biologicals were properly labeled with expiration dates and stored securely. Medication and treatment carts were found unlocked and unattended with expired syringes and unlabeled insulin pens.

F 0804: Food served was not palatable or at safe temperatures. Test trays showed hot foods below recommended temperatures and residents reported food was cold, bland, and missing items.

F 0812: Food was not procured, stored, prepared, distributed, and served in accordance with professional standards. Observations included expired, moldy, undated, and dented food items, sanitizer issues, and a dish machine not properly heated.

F 0812: Food storage was improper with shelving units and kitchen equipment stored under a sewage drain line and raw hamburger patties stored above ice cream cups. Floors and equipment including the #10 can opener were soiled with food debris. The commercial dishwasher did not achieve required rinse temperatures of 180°F, operating at 160°F instead. Garbage was improperly stored in the kitchen air handler closet.

F 0584: The facility did not ensure a safe, clean, and homelike environment on one unit, with multiple resident areas in disrepair including a rusty ice machine grate, damaged countertops, loose toilet paper holders, missing base molding, and damaged walls and toilet seats.

F 0584: The Plant Operations Director was unaware of the maintenance issues and could not find work orders for the identified deficiencies.

F 0656: The facility failed to develop and implement a complete care plan for Resident #48, who did not have skin breakdown prevention boots in place as planned, increasing risk of pressure ulcers.

F 0656: Staff were unable to locate the resident's pressure relieving boots, and communication between nursing and therapy regarding the boots was inadequate.

F 0688: Residents #31 and #48 with limited range of motion did not have hand contracture devices in place as care planned, risking further decline in mobility.

F 0688: Therapy was responsible for issuing hand orthotics but failed to provide replacements timely, and nursing staff were unaware of changes to care plans.

F 0761: Multiple expired medications and undated opened multi-dose vials were found in two medication rooms and two medication carts, violating medication storage and labeling standards.

F 0804: Food and drinks were not served at safe and palatable temperatures for three meals reviewed, including lukewarm chipped beef, cold ham and cheese sandwiches, and lukewarm pancakes and milk.

F 0804: Food temperature logs were incomplete, and staff failed to record temperatures of food on steam tables prior to serving dinner on 9/9/20.

F 0812: The three-door nourishment cooler was not maintained at 41 degrees Fahrenheit or less, with air temperatures measured at 50 degrees and milk temperatures up to 56 degrees Fahrenheit.