Waterford Nursing and Rehabilitation Center

Inspectors wroteBased on observations, interviews and record reviews, the facility failed keep residents' medical information confidential on four (second-floor medication cart #1 and cart # 2, third-floor medication cart #1 and cart #2) out of eight medication carts; at one (first floor nursing station) out of four nursing stations and failed to provide privacy for one (Resident #116) out of three sampled residents during medication administration. Observations of unattended open computer screens on the second-floor medication cart # 2 and third-floor medication cart #1; unsecured paperwork left at the first-floor nursing station, on the second-floor medication cart #1 and on the third-floor medication cart #1 and cart #2 with resident's information visible. There were 206 residents residing in the facility at the time of the survey.

Inspectors wroteBased on observations, interviews and record reviews facility failed to keep residents' environment free of accident hazards on one (third-floor) out of four Soiled Utility Rooms that contained Biohazardous materials, on two (first and third floor) Clean Utility Rooms which locked from the inside and did not contain a call light, the Sprinkler Room which locked from the inside and contained hazardous materials and for one (Resident #142) out of three sampled residents during medication administration as evidenced by:1) Observation of an unlocked Soiled Utility Room on the third floor2) Observation of an unlocked Clean Utility Room on the first and third floor3) Observation of an unlocked Sprinkler Room on the first floor4) Observation of facility's staff leaving a lancet on top of the third-floor medication cart #1 and unattended at Resident #142's bedside. [...]

Inspectors wroteBased on observations, interviews and records reviewed the facility did not honor resident's right to a dignified experience for one (Resident #77) out of two sampled residents with Percutaneous Enteral Gastronomy (PEG) feeding pumps. Resident #77's PEG pump was overtly visible while the resident received enteral feeding in common areas. there were nine residents residing in the facility with PEG tube feeding pumps at the time of the survey.

Inspectors wroteBased on observations, interviews and record reviews, facility failed to properly store and label medications on two (first-floor medication cart #1 and the second-floor medication cart #1) out of eight medication carts as evidenced by: 1) Staff left a normal saline syringe on top of the first-floor medication cart #1 during medication administration. 2)An illegible label of a stock medication on the first-floor medication cart #1. 3) Second-floor medication cart #1 left unlocked. There were 206 residents residing in the facility at the time of survey.

Inspectors wroteBased on record review and interview, the facility's quality assurance and assessment committee failed to identify quality concerns to implement effective plans of action related to failed to properly store and label medications during medication administration; failed to prevent accident hazards and failed to protect resident's privacy resulting in repeated deficient practice. The facility was cited for Label/Store Drugs and Biologicals, Personal Privacy/Confidentiality of Records and Free of Accident Hazards/Supervision/Devices in 2024. This repeated deficiency practice has the potential to affect any of the 206 residents residing in the facility.

Inspectors wroteBased on observations, interviews and record review the facility failed to ensure the walk-in freezer was working properly. The curtains in the walk-in freezer contained ice. This has the potential to affect one hundred and ninety-eight out of two-hundred and six residents who eat orally residing in the facility at the time of the survey.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the safety for one out of nine sampled residents as evidenced by 1) Resident #54, a vulnerable resident with orders for bilateral floor mats was observed in bed with one floor mat 2) failed to ensure three out of four soiled utility rooms were locked. There were 201 residents residing in the facility at the time of survey.

Inspectors wroteBased on observation and interviews, the facility failed to provide privacy for residents on one out of eight medications carts as evidenced an observation of residents' personal health information visible on an electronic medication administration screen left unattended. There were 201 residents residing the facility at the time of survey.

Inspectors wroteBased on record review and interview, the facility failed to accurately code a Minimum Data Set (MDS) assessment for one (Resident number 199) out of three residents reviewed for hospital discharges. Resident number 199 was coded as being discharged to the hospital but the resident was discharged home. There were 201 residents residing in the facility at the time of the survey.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure medications were stored safely for one out of nine sampled residents (Resident #51). As evidenced by two ointments, one medicated powder and one cream were observed on the overbed table in Resident #51's room.

Inspectors wroteBased on observations, records reviews and interviews, the facility failed to ensure dignity during dining for one (Resident #90) out of 40 residents who are dependent on assistance with eating. As evidenced by one facility staff standing while feeding the resident.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to follow physician orders for oxygen therapy as prescribed for one (Resident #118) out of 3 residents sampled. The Findings Included: During observation on 04/10/2023 at 08:56 AM, Resident #118 was observed sitting in the wheelchair in the room, the oxygen (02) was running at 3 liters per minute (LPM), via nasal cannula, the 02 tubing observed was not dated, no dated supplies were observed around the 02 concentrator. On 04/11/23 at 08:46 AM, Resident #118 was observed in the room in the wheelchair watching television, there was no 02 running, stated today is a great day, 02 tubing observed in a plastic bag dated 4/10/23. On 4/12/23 at 10:30AM, Resident #118 was observed in the Activities room fixing puzzles with other residents, no distress was noted. [...]

Inspectors wroteBased on interview and record review, the facility's quality assurance and assessment committee failed to identify quality concerns as evidenced by not implementing an effective plan of action to correct identified quality deficiencies in problem-prone areas, related to respiratory/tracheostomy care and suctioning as evidenced by repeated deficient practice during consecutive annual surveys. Cross reference F695 Respiratory/Tracheostomy Care and Suctioning. The facility had deficient practice during the last recertification survey conducted in 2022. The facility had a census of 191 residents at the time of the survey.