Waterford Care Center, the

Inspectors wroteBased on interview and record review, the facility failed to protect one resident (R2) from sustaining physical abuse from R3 who hit R2 in the head. This failure affected 1 of 3 residents reviewed for abuse. Findings Include: R2's face sheet documents a diagnosis of but not limited to unspecified inflammatory spondylopathy- thoracic region, abnormal posture, difficulty walking not elsewhere classified, other ossification of multiple sites, and personal history of benign neoplasm of the brain. R2's progress notes, dated 4/14/2025 at 4:30 PM, documented by V3 (Former Registered Nurse) R2 reported R3 physically made contact with him (R2) and R2 was sent to the hospital. R2's Minimum Data Set section C, dated 6/20/2026, documents a BIMS (Brief Interview Mental Status) Score of 15, which indicates an intact cognition. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food items were properly labeled and dated and manufacturer guidelines followed. These failures have the potential to affect all 129 residents receiving food prepared in the facility's kitchen.

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate information were included in the residents' Level I Pre-admission Screening and Record Review (PASRR) and failed to refer residents to the appropriate state-designated authority for a PASRR Level II Screen evaluation and determination with known mental illness for four (R2, R8, R62, R81) residents out of a final sample of 28 reviewed for PASRR screenings.

Inspectors wroteBased on observation, interview, record review, the facility failed to properly (a) discard a multi-dose insulin 28 days after opening, (b) store in the refrigerator unopened multidose insulin and (c) date / label multi dose inhalers after opening. These failures affected six (R25, R48, R93, R102, R117 and R132) residents reviewed for medication storage and labeling in three of six medication carts.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the pureed menu spreadsheets for five residents (R1, R12, R54, R83, R89) out of 12 residents receiving a pureed diet consistency in a total sample of 28. Findings Include:On 01/21/26 between 10:10-11:15 AM, observed V27 (AM Cook) prepare pureed food items for lunch including pureed bread. On 01/21/26 at 11:45 AM, observed V27 put prepared pureed bread on the tray line for service. On 01/21/26, observed lunch tray line between 11:45 AM - 12:00 PM. V27 did not put pureed bread on any of the trays going to the 2nd floor. On 01/21/26, during lunch observations on the 2nd floor, R1, R12, R54, R83, R89 did not receive pureed bread on their lunch trays. On 01/21/26 at 12:24 PM, observed R83 eating his pureed lunch tray. R83 stated he likes to eat and usually eats everything. R83 stated if he received pureed bread; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide thickened liquids as ordered by the physician for four residents (R1, R87, R89, R123) and failed to ensure mechanically altered diet was followed as ordered to one resident (R81) on a pureed diet in a total sample of 28. Findings Include: 1. R1 diagnosis includes but not limited to Chronic Respiratory Failure with Hypoxia, Dysphagia, Oropharyngeal Phase, Cognitive Communication Deficit, Dependence on Supplemental Oxygen, Dementia. R1's MDS (Minimum Data Set) dated 12/02/25 reveals R7 is moderately cognitively impaired, has a swallowing disorder (complains of difficulty or pain with swallow) and requires a mechanically altered diet - require change in texture of food or liquids. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light was within reach for two residents (R7 and R45) reviewed for reasonable accommodation of needs out of a sample of 28.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's (R51) wishes were consistent across medical records and failed to redo R51's Advanced Directive for one out of 28 residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was referred to the appropriate state-designated authority for Level II PASARR (Preadmission Screening and Resident Review) evaluation/determination and an Annual Resident Review/yearly review was completed for 1 (R74) resident reviewed for PASARR in a sample of 28. Findings Include:R74 was originally admitted to the facility on [DATE], with a readmission date of 01/02/21. R74 has diagnoses not limited to Chronic Kidney Disease, Stage 3, Paranoid Personality Disorder, Peripheral Vascular Disease, Chronic Diastolic (Congestive) Heart Failure, Chronic Obstructive Pulmonary Disease, Bipolar Disorder, Major Depressive Disorder, Insomnia, and Dementia. R74's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) indicate R74 is rarely/never understood. Review of R74's Diagnoses Information document: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a dependent resident received timely assistance with ADL's (activities of daily living) related to incontinence care for one (R32) resident reviewed for ADLs in a sample of 28. Findings Include:R32 has diagnoses not limited to Anxiety Disorder, Insomnia, Functional Dyspepsia, Migraine, Intractable, Cervicalgia, Spondylosis, Cervical Region, Major Depressive Disorder, Recurrent, Morbid (Severe) Obesity Due to Excess Calories, Personal History of Urinary (Tract) Infections, Chronic Pain, Rotator Cuff Tear or Rupture of Unspecified Shoulder, Spinal Stenosis, Lumbar Region, Bipolar Disorder, Low Back Pain, Diaphragmatic Hernia and Tension-Type Headache. R32's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 15, indicating intact cognitive response. R32's Care Plan document, Focus: Skin: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide timely and appropriate assistance with care needs in a timely manner, check and change one (R32) incontinent resident every 2-3 hours, resulting in prolonged exposure to urine/feces. Findings Include:On 01/20/26 at 11:26 AM, R32 stated, I have not been changed for 14 hours. It was before the pm and night shift changed last night. I am sopping wet; the bed is wet right now and I have an active urinary tract infection. I have been yelling and screaming but they come in and turn off the call light. They are not going to change me because they are passing trays. During interview on 01/20/26 at 11:53 AM, V23 (Licensed practical Nurse) stated, (R32) told me she had not been changed since last night. (R32) is incontinent. The residents are changed when they ask. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to a.) label/date food items in resident personal refrigerator, b.) discard undated and expired foods in resident personal refrigerator, c.) ensure resident refrigerator is in proper working order. This has the potential to effect one resident (R45) in a total sample of 28.

Inspectors wroteBased on observation, interview, and record review, the facility failed to place a resident (R143) with wounds on enhanced barrier precautions (EBP). The facility also failed to ensure staff performed hand hygiene during meal tray distribution/feeding for one (R12) resident in a total sample of 28 residents. Findings Include: 1. R12 has diagnosis not limited to Hyperlipidemia, Long Term (Current) use of Insulin, Long Term (Current) use of Oral Hypoglycemic Drugs, Glaucoma, Mild Intellectual Disabilities, Tachycardia, Metabolic Encephalopathy, Chronic Respiratory Failure with Hypoxia, Protein-Calorie Malnutrition, Dementia, Dysphagia, Lack of Coordination, Abnormal Posture, Type 2 Diabetes Mellitus with Hyperglycemia, Anxiety Disorder, Vitamin D Deficiency, Acute Kidney Failure, Anemia, Difficulty in Walking, and Peripheral Vascular Disease. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an allegation of injury of unknown origin was reported to the abuse coordinator and to the State Agency (SA) for 1 (R1) out of 3 residents reviewed for abuse. Findings Include: R1's clinical records show a re-admission date of 4/8/25, with included diagnoses not limited to long term use of anticoagulants, malignant neoplasm of large intestine, cognitive communication deficit, and encounter for attention to colostomy. R1's Minimum Data Set, dated [DATE] ,shows R1 was cognitively impaired. R1's comprehensive care plan and progress notes from 4/8/25 to 5/10/25 revealed no documentation of R1's vaginal bruising and bleeding. No documentation of bruising on R1's groin and perineal area. R1's progress notes, dated 4/8/25 and 4/19/25, show R1 was noted with bruising on both lower and upper extremities. [...]

Inspectors wroteBased on interview and record reviews the facility failed to ensure an allegation of injury of unknown origin was investigated for 1 (R1) out of 3 residents reviewed for abuse. Findings Include: R1's clinical records show a re-admission date of 4/8/25, with included diagnoses but not limited to long term use of anticoagulants, malignant neoplasm of large intestine, cognitive communication deficit, and encounter for attention to colostomy. R1's Minimum Data Set, dated [DATE], shows R1 was cognitively impaired. R1's comprehensive care plan and progress notes from 4/8/25 to 5/10/25 revealed no documentation of R1's vaginal bruising and bleeding. No documentation of bruising on R1's groin and perineal area. R1's progress notes, dated 4/8/25 and 4/19/25, show R1 was noted with bruising on both lower and upper extremities. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify a resident's state guardian when the resident experienced a change in condition for one (R6) resident out of four residents reviewed for notification of changes in a total sample of six.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care according to professional standards and properly label medication that had been open for resident use. These failures affect one (R1) resident out of three residents reviewed for medications. Findings Include: R1's physician order sheet/POS documents the following orders: Baclofen Tablet 10 MG- Give 1 tablet by mouth one time a day for musculoskeletal therapy agents. On [DATE] at 9:54 AM, V3 (Registered Nurse/RN) stated he has begun his medication administration pass already and is about to prepare R1's medications to administer. A medication bingo card was labeled Baclofen 5 mg, with a residents' name torn off of the label. R1's name was handwritten in black marker on the Baclofen medication bingo card. On [DATE] at 10:04 AM, V3 stated there was an issue with R1's Baclofen medication. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure medications were administered as ordered by the residents' physician for one (R1) resident out of three residents reviewed. Findings Include: R1's physician order sheet/POS documents the following order: Ambien Oral Tablet 5 MG (Zolpidem Tartrate) *Controlled Drug*- Give 1 tablet by mouth at bedtime for Sleeplessness. On 03/23/2025 at 10:41 AM, R1 stated she did not receive her Ambien medication for 2 days after returning to the facility from completing her knee surgery at the hospital. R1 stated V2 (Director of Nursing/DON) told her that her Ambien medication was not available, and V2 was in the process of trying to get it. On 03/23/2025 at 3:33 PM, V7 (Registered Nurse/RN) stated when R1 came back from the hospital, R1 was prescribed Ambien, but it was not available. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper sanitation and food storage practices as evidenced by food not properly labeled, and food not properly stored. These deficient practices have the potential to affect all 128 residents receiving food prepared for the nursing skilled facility.

Inspectors wroteBased on interview and record review, the facility failed to initiate a new Level I screen for four (R6, R7, R11, R32) residents reviewed for Pre-admission Screening and Record Review (PASARR) in a total sample of 26 residents reviewed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure low air loss mattress devices were on the correct weights setting for four residents (R2, R29, R40, R122) out of four who are high risk in developing pressure ulcers in a final sample of 26 residents. Findings Include: 1. On 12/17/24 at 11:29 AM, R29 was sleeping in bed on a low air loss mattress, with the machine set to 290 pounds (lbs.). On 12/18/24 at 10:17 AM, Surveyor entered R29's room with V8 (Registered Nurse) and noted R29 was lying in bed on a low air loss mattress with the machine set to 290 lbs. R29's BRADEN score dated 9/29/24 is 12. V7 stated 12 means high risk for developing pressure ulcer. R29 needs assistance with bed mobility and R29's current weight is 219 pounds (lbs.) dated 12/4/24. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose a house stock medication after the expiration date, and failed to ensure medications were locked and secured while unattended for two out of three carts reviewed for medication storage and labeling. These failures have the potential to affect 86 residents residing in the facility. Findings Include: On 12/17/24 at 9:47 AM, Surveyor observed a medication cart in the first-floor hallway unattended and unlocked. V6 (Licensed Practical Nurse) stated V6 was responsible for this medication cart. V6 stated, This medication cart stores medications for residents on the first floor of the facility. On 12/17/24 at 11:45 AM, second floor medication cart was inspected with V8 (Registered Nurse) and found a bottle of vitamin D tablets, with expiration date of 11/24 on the label. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the facility linen was stored on a linen cart to prevent contamination and failed to ensure staff wore the proper PPE (Personal Protective Equipment) while caring for 1 (R32) resident on Enhanced Barrier Precautions. These failures have the potential to affect 49 residents residing on the third floor based on the facilities census. Findings Include: 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident dignity was maintained by not covering the body of 1 (R6) to prevent exposure of their body to others, failed to address the behaviors of disrobing for 1 (R6) resident exposing their body and failed to ensure the urinary drainage bag (a device that urine drains into) was covered and/or placed in a dignity bag for 1 (R117) resident for residents reviewed for resident rights.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the resident's care plan to ensure physician order was followed and administer the correct oxygen (O2) flow rate for one (R29) out of one resident reviewed for respiratory care in the final sample of 26. Findings Include: R29's clinical records show R29 has included diagnoses but not limited to acute and chronic respiratory failure with hypoxia and unspecified asthma. R29's Minimum Data Set (MDS), dated [DATE], shows R29 is cognitively intact and is dependent with staff assistance for transfers and bed mobility. R29's comprehensive care plan reads in part: R29 presents with altered respiratory function secondary to COPD requiring O2 as ordered for shortness of breath with one intervention that reads, Administer oxygen per MD orders. Assist with application as needed (date initiated 4/29/23). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure cooking equipment was properly sanitized per manufacturer guidelines, failed to conduct hand washing in between handling dirty and clean plate ware/equipment, and failed to follow facility procedure for hand washing for appropriate length of time. These failures have the potential to affect all 132 residents receiving food prepared in the facility's kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that 1 (R2) resident on TBP (Transmission Based Precaution) have proper signage indicating contact precautions and instructions on the use of specific PPE (Personal Protective Equipment) posted outside of R'2 room; failed to implement written EBP (Enhance Barrier Precaution) policy and procedures for 4 (R3, R57, R61, R113) residents; failed to ensure that staff was safely handling linens by not properly bagging soiled linens to prevent the spread of infection; and failed to review IPCP (Infection Prevention and Control Program) policy at least annually. These failures can potentially affect 136 residents residing in the facility, as of census dated 1/9/24.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure by not obtaining a physician's order for 1 resident's (R128) code status, and to ensure code status were accurately addressed in the residents' comprehensive care plans for 4 (R2, R8, R24, R40) out of 27 residents reviewed for advance directives in a final sample of 27 residents.

Inspectors wroteBased on interview and record review, the facility failed to provide eligible residents and/or resident representatives education regarding the benefits and potential side effects of available influenza vaccine for 3 (R3, R57, R113) residents; failed to provide eligible residents and/or resident representatives education regarding the benefits and potential side effects of all available pneumococcal vaccinations for 4 (R19, R57, R61, R113) residents; failed to assess eligibility and offer pneumococcal vaccinations to 4 (R19, R57, R61 and R113) residents; and failed to update the facility's Pneumococcal and Influenza vaccine policy. These failures have the potential to affect 5 (R3, R19, R57, R61 and R113) out of 6 residents reviewed for influenza and pneumonia vaccination.

Inspectors wroteBased on interview and record review, the facility failed to assess eligibility and offer COVID-19 vaccination to 5 (R2, R3, R19, R57, and R113) residents; and failed to provide eligible residents and/or resident representatives education regarding the benefits and potential side effects of available Covid 19 vaccination for 5 (R2, R3, R19, R57, and R113) residents out 6 residents reviewed for COVID 19 immunization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the correct oxygen flow rate setting used per physician order. This failure applied to 1 resident (R12) out of 11 reviewed for oxygen therapy out of a total sample of 27.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policies and procedures to ensure a resident received their medications according to the physician's order for 1 (R118) out of 6 residents reviewed for pharmaceutical services in a sample of 27. Findings Include: R118 ' s Minimum Data Set (MDS), dated [DATE], shows R118 is cognitively intact. R118's Physician Order Sheet (POS) with active orders as of 01/09/24 shows an order for sennoside 8.6 MG, to give 1 tab 2 times a day. R118's clinical records had no documentation showing R118 is safe to administer R118 ' s own medications. A review of R118's clinical records do not show a self-administration of medication assessment was completed. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a totally dependent resident requiring a two plus person assist for bed mobility was provided the necessary assistance by failing to obtain help from another staff during resident care for 1 (R3) of 4 residents reviewed for falls. This failure resulted in R3 falling from the bed and sustaining a closed displaced spiral fracture of the shaft of the right humerus. Findings Include: [...]

Inspectors wroteBased on interview and record, review the facility failed to ensure the care plan was revised for 1 (R3) of 4 residents reviewed for care plan revision. The care plan did not accurately indicate R3 as being a totally dependent resident requiring two-person assistance for bed mobility and transfers. Findings Include: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide timely incontinence care to a dependent resident (R4) for one out of ten residents reviewed for Activities of Daily Living (ADL) care.

Inspectors wroteBased on interview, and record review, the facility failed to provide an antiretroviral medication for a resident with Human Immunodeficiency Virus (HIV), and failed to notify the prescribing physician the medication was not available to the resident for one (R2) of ten residents reviewed for medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and provide transfer assistance to two dependent residents (R1, R3) out of three residents reviewed for Activities of Daily Living (ADL).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate Medication Administration Records (MARs) for two (R1, R2) of two residents observed during medication pass.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than five percent for two (R1, R2) of two residents observed during medication pass. There were six medication errors out of a total of 39 opportunities. This resulted in a 15.38% medication error rate.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that two residents (R1, R2) were free of any significant medication errors for two of two residents observed for medication pass.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control procedures during medication administration for one (R1) out of two residents observed during medication pass.