Alden of Waterford

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary care and treatment for residents with vascular ulcers. This applies to 2 of 3 residents (R1, R2) reviewed for quality of care in the sample of 3.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident received restorative walking services. This applies to 1 of 3 (R1) residents reviewed for restorative services in the sample of 3.

Inspectors wroteBased on interview and record review the facility failed to ensure expired medications were not stored in their medication dispensing machine for 1 of 3 residents (R1) reviewed for medications in the sample of seven.

Inspectors wroteBased on interview and record review, the facility failed to provide showers as scheduled. This applies to 2 of 2 residents (R1 and R3) reviewed for improper nursing in the sample of 5.

Inspectors wroteBased on interview and record review, the facility failed to notify local law enforcement after an allegation of physical abuse. This applies to 1 of 3 residents (R1) reviewed for physical abuse in the sample of 3.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician of a change in condition for a resident. This applies to 1 of 1 resident (R1) who was reviewed for a change in condition.

Inspectors wroteBased on the interview and record review, the facility failed to immediately assess a resident after a reported change in condition. This applies to 1 of 5 residents (R1) who was reviewed for quality of care.

Inspectors wroteBased on interview and record review, the facility failed to submit accurate licensed nurses working hours, for the PBJ (Payroll Based Journal) submission for the months of July, August and September 2024. This applies to all 75 residents who reside in the facility, according to form 671 dated March 24, 2025.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure accurate and timely accounting of controlled medications. This applies to 7 of 7 residents (R2, R18, R21, R24, R48, R69 and R234) reviewed for controlled medications in the sample of 18.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the menu extension sheet to serve portion sizes as shown for pureed and mechanical soft diets to meet the dietary requirements of the meal. This applies to 6 of 6 residents (R3, R27, R33, R59, R69, and R235) reviewed for dining in the sample of 18.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pureed consistency mashed potatoes and failed to avoid skin on potatoes for mechanical soft diets. This applies to 4 of 4 residents (R27, R33, R63 and R69) reviewed for mechanically altered diets in the sample of 18.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide privacy during activities of daily living (ADL) care, blood glucose level check, and administration of insulin. In addition, facility also failed to ensure that medical record was protected. This applies to 3 of 18 residents (R48, R50, R60) reviewed for privacy in the sample of 18.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that indwelling urinary catheter was not touching the floor and was not positioned above resident's bladder. This applies to 2 of 3 residents (R28, R78), reviewed for indwelling urinary catheter in the sample of 18.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer medications as ordered by the physician. There were 29 opportunities with 2 errors, resulting in a 6.9% medication error rate. This applies to 1 of 5 residents (R34) reviewed for medication pass in the sample of 18.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow standard infection control practices regarding hand hygiene and gloving during provisions of incontinence care. Staff also failed to wear a complete PPE (Personal Protective Equipment) in an isolation room while providing physical therapy. This applies to 2 of 18 residents (R28, R134), reviewed for infection control in the sample of 18.

Inspectors wroteBased on interview and record review, the facility failed to administer, store, and dispose of narcotics in accordance with facility policy. This resulted in nursing staff using R2's medication (a discharged resident) for R10 an active resident in the facility. This applies to 2 resident's (R2 and R10) reviewed for narcotic administration and disposal in a sample of 10 residents. On 3/18/25 at 11:27 AM, surveyor noted R2's Controlled Drug Receipt/Record/Disposition Form for Hydrocodone/APAP 5-325 mg (milligram) tablets showed 30 tablets were dispensed on 12/13/24. R2 was given 7 of the 30 tablets between the dates of 12/19/25 and 1/19/25. R2's MAR (Medication Administration Record) shows the 7th tablet was administered to R2 on 1/19/25 at 10AM, which matches the Controlled Drug Form. R2's Face sheet shows he was discharged from the facility on 1/20/25. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to follow a physician's treatment order for a resident (R1) with a stage 3 pressure injury to the sacrum. The facility also failed to inform R1's physician of a newly identified pressure injury wound. This applies to 1 of 4 residents reviewed for pressure injuries.

Inspectors wroteBased on interview and record review the facility failed to ensure staff safely transferred a resident by not using a gait belt for 1 of 3 residents (R1) reviewed for safety in the sample of 3.

Inspectors wroteI. Based on interview and record review the facility failed to send a resident to the hospital in a timely manner when they became aware of the resident's critically low potassium level (2.4mmol (millimoles)/L (liter) with a reference range of 3.3-5.1). This failure resulted in R76 going into cardiac arrest, requiring CPR (Cardiopulmonary Resuscitation) and expiring at the hospital on [DATE]. This applies to 1 of 3 residents (R76) reviewed for quality of care in the sample of 18. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents requiring extensive assist were toileted in a timely manner and assisted with eating. This applies to 2 of 18 residents (R377 & R3) reviewed for activities of daily living (ADL's) in the sample of 18.

Inspectors wroteBased observation, interview and record review the facility failed to ensure residents were transferred in a safe manner with a mechanical lift and failed to supervise a resident while eating with a diagnosis of dysphagia. This applies to 3 of 18 residents (R43, R429 & R52) reviewed for safety and supervision in the sample of 18.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident was provided pain control before performing a dressing change for 1 of 18 residents (R7) reviewed for pain in the sample of 18.

Inspectors wroteBased on interview and record review the facility failed to ensure pharmacy recommendations were reported to the physician. This applies to 1 of 5 residents (R1) reviewed for medication regimen reviews in the sample of 18.

Inspectors wroteBased on interview and record review the facility failed to ensure PRN (as needed) anti-psychotic and anti-anxiety (psychotropic) medications had a duration/end date. This applies to 2 of 5 residents (R61, R40) reviewed for unnecessary medications in the sample of 18.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident was provided with assistive devices when eating. This applies to 1 of 18 residents (R3) reviewed for assistive devices in the sample of 18.

Inspectors wroteBased on observation, interview and record review the facility failed to use the required Personal Protective Equipment (PPE) to prevent the spread of COVID-19, failed to ensure PPE was worn when performing a dressing change for a resident on Enhanced Barrier Precautions (EBP) and failed to remove their gloves and perform hand hygiene during a dressing change for 2 of 18 residents (R7 and R429) reviewed for infection control in the sample of 18.

Inspectors wroteBased on observation, interview, and record review, the facility failed to perform hand hygeine to mitigate risk of infection and cross contamination during wound care and incontinence cares. This applies to 4 of 5 residents (R44, R22, R56, and R32) reviewed for Infection Prevention and Control in a sample of 19.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly position a catheter bag and follow standards during catheter and incontinence care. This applies to 1 of 3 residents (R32) reviewed for catheters in a sample of 19.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's eye drops and eye cleansing wipes were available for administration per Physician order. This applies to 1 of 5 residents (R55) reviewed for medications in the sample of 19.

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose of a resident's insulin when it expired. This applies to 1 resident (R40) reviewed for medication storage.