Aicota Health Care Center

In the surveyor’s words

From the most serious findings on record at Aicota Health Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Aug 30, 2021

  Based on interview and document review, the facility failed to ensure 2 of 2 residents (R40 and R46) reviewed for diabetic management were provided adequate care in accordance with current standards of practice and facility standing orders. This practice included lack of monitoring of low diabetic blood glucose (sugar) readings and lack of physician notification, which resulted in an immediate jeopardy (IJ) for R40 and R46. The Immediate Jeopardy (IJ) began on 6/2/21, when R40 had a blood glucose reading of 40 milligrams per decilitre (mg/dl) without physician notification for further evaluation of diabetic management, and further lack of continued monitoring of R40's blood glucose (BG) until R40's BG was 70 mg/dl , or higher. […]

• No harm, potential for more than minimal, widespreadF812Jan 9, 2026

  Based 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,… […]

• No harm, potential for more than minimal, widespreadF851Jan 9, 2026

  Based 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.Findings include:The facility's PB&J data submitted to CMS for 7/1/25, through 9/30/25, identified the facility was triggered for no registered nurse hours on the following days: 7/1/25, 7/2/25, 7/8/25, 7/9/25, 7/14/25, 7/15/25, 7/16/25, 7/23/25, 7/24/25, 7/26/25, 7/27/25, 8/10/25, 8/14/25, 8/21/25, 8/22/25, 8/23/25, 8/25/25, 8/28/25, 9/1/25, 9/4/25, 9/5/25, 9/6/25, 9/7/25, 9/8/25, 9/11/25, 9/12/25, 9/15/25, 9/19/25, 9/25/25, 9/26/25, 9/27/25, 9/28/25, 9/30/25.In addition, the facility's PB&J data submitted to CMS for 7/1/25,… […]

• No harm, potential for more than minimal, widespreadF851Jan 17, 2025

  Based 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. Findings include: Review of the Payroll Based Journal Report (PBJ) [NAME] Report 1705D for fiscal year 2024 quarter 1 (October 1- December 31) and fiscal year 2024 quarter 2 (January 1- March 31), identified no data had been submitted. During interview on 1/17/25 at 4:35 p.m., director of nursing (DON) stated it was their responsibility to send staffing data to CMS. […]

• No harm, potential for more than minimal, patternF726Jan 9, 2026

  Based 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. Findings include:A review of agency orientation paper work identified the following sections: HR (human resources) and HR paper work, orientation tour, safety, other (care plans in closet, bath schedule, point click care log in and documentation, dining room cards, walking expectations, linen rooms/hopper, barrel empty, lift training total lift, daily routines, lift training sit to stand), changes in physical and mental condition changes, breaks, daily routines am (day), daily routines pm (evening), daily routines noc (night). […]