Alden Courts of Waterford

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident with a neck fracture had his cervical neck collar (C-collar) in place. This applies to 1 resident (R1) reviewed for quality of care.

Inspectors wroteBased on interview and record review, the facility failed to prevent a cognitively impaired resident (R1) from eloping through an unalarmed door. The facility also failed to secure an exit door with nonfunctioning alarm in accordance with the facility policy. This failure resulted in R1 exiting the facility unnoticed by staff and discovered outside the facility in cold weather on January 31, 2026, putting R1 at risk for injury due to falls and cold weather, and becoming lost due to cognitive impairment. This applies to 1 of 3 residents (R1) reviewed for risk of elopement in the sample of 13. V1 (Administrator) was notified of the Immediate Jeopardy on March 4, 2026, at 10:55 AM. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow standard infection control practices during provisions of care with regards to hand hygiene and changing gloves. The facility also failed to use the required PPE (Personal Protective Equipment) for residents who were placed on EBP (Enhance Barrier Precaution) and Isolation Precaution. This applies to 4 of 16 residents (R3, R24, R29, R36) reviewed for infection control in the sample of 16.

Inspectors wroteBased observation, interview, and record review, the facility failed to ensure safe transfer for a resident who requires extensive assistance. This applies to 1 of 1 resident (R24) reviewed for transfer in the sample of 16.

Inspectors wroteBased on observation, interview and record review the facility failed to provide urinary catheter care, failed to ensure that the urinary catheter tubing was not dragging on the floor during transport and failed to secure the urinary catheter to prevent movement based on the facility's policy. This applies to 1 of 3 residents (R29) reviewed for urinary catheter in the sample of 16.

Inspectors wroteBased on observation, interview and record review, the facility failed to administered oxygen as ordered by the facility and failed to ensure that the facility's policy regarding oxygen administration was followed. This applies to 1 of 2 residents (R29) reviewed for oxygen therapy in the sample of 16.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pressure injury treatment to a resident as ordered by the physician. This applies to 1 of 3 residents (R29) reviewed for pressure injury in the sample of 16.

Inspectors wroteBased on interview and record review, the facility failed to ensure medication orders were transcribed accurately on admission. This applies to 2 of 3 residents (R1 and R2) reviewed for medications in a sample of 3.

Inspectors wroteBased on observation, interview, and record review the facility failed to assess a new pressure injury area, failed to implement pressure injury treatment orders, and failed to ensure pressure reducing interventions were in place for four of six residents (R16, R31, R6, R46) reviewed for pressure injuries in the sample of 15.

Inspectors wroteBased on observation, interview, and record review the facility failed to secure controlled substances and the facility failed to label insulin pens with the date opened for 5 of 15 residents (R47, R33, R6, R24, R8) reviewed for medications in the sample of 15.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a resident urinary drainage bag below the level of her bladder in order to prevent urinary tract infections for one of five residents (R16) reviewed for urinary catheter or urinary tract infections in the sample of 15.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure dietary supplements were provided for 2 of 15 residents (R46, R14) reviewed for weight loss in the sample of 15.

Inspectors wroteBased on interview and record review the facility failed to ensure PRN (as needed) psychotropic medications had a stop date for 2 of 5 residents (R16, R33) reviewed for psychotropic medications in the sample of 15. The findings inlcude: R16's Physician Orders (POS) dated 08/08/24 shows an order for lorazepam intensol oral concentrate 2 mg/ml Give 0.25 ml sublingually every 1 hour as needed for anxiety/agitation related to unspecified dementia, unspecified severity, with agitation, bipolar disorder. There are no stop dated included in this order. R33's POS dated 5/28/24 shows an order lorazepam intensol oral concentrate 2 mg/ml Give 0.25 ml by mouth every 2 hours as needed for anxiety, restlessness and another order for lorazepam intensol oral concentrate 2 mg/ml Give 0.5 ml by mouth every 2 hours as needed for anxiety, restlessness. There are no stop dates included in this order. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow enhanced barrier precautions (EBP) and failed to change their gloves and perform hand hygiene in a manner to prevent cross contamination for two of 15 residents (R16, R44) reviewed for infection control in the sample of 15.

Inspectors wroteBased on observation, interview and record review, the facility failed to assist residents identified as needing assistance with personal hygiene. This applies to 5 of 5 residents (R14, R26, R36, R245 and R249) reviewed for ADLs (activities of daily living) in the sample of 15.

Inspectors wroteBased on observation, interview and record review, the facility failed to serve roasted potatoes suitable for mechanical soft diets and failed follow menu spread sheet for serving vegetables and pulled pork. This applies to 7 of 7 residents (R8, R23, R27, R35, R36, R39, R245) reviewed for dining in the sample of 15.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow standard infection control practices with regards to hand hygiene and gloving during incontinence care, wound care, and medication administration. In addition, the facility failed to provide clean barrier during blood glucose monitoring. This applies to 6 of 15 residents (R1, R4, R7, R14, R29, R33) reviewed for infection control in the sample of 15.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's medications were administered timely in accordance with the prescriber's order and the facility's Medication Pass Guidelines. This applies to 1 of 1 resident (R21) reviewed for medication administration in a sample of 15.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain dumpster area free from debris. This has potential to affect 54 residents that reside in the facility.