Waters of Georgetown, the

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility was sufficiently staffed to provide adequate care related to medication administration and assistance with daily living for the residents. This deficient practice had the potential to affect 59 of 59 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents received their medication timely within an hour before or after the prescribe time for 3 of 3 resident reviewed for pharmacy services. (Resident E, Resident H, and Resident L)

Inspectors wroteBased on interview and record review, the facility failed to ensure the death of a resident (Resident C) was verified by two staff nurses for 1 of 1 resident; and failed to ensure physicians' orders were transcribed, in a timely manner for 1 of 3 residents reviewed for quality of care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident's (Resident F and Resident G) had properly functioning motion sensors in place and failed to ensure a resident (Resident F) had a physician's order in place for a motion sensor alarm for 2 of 3 residents reviewed for accidents.

Inspectors wroteBased on interview and record review, the facility failed to ensure medication administration records coincided with the administration of narcotic pain medication for 3 of 4 residents reviewed for medical records. (Resident E, Resident H and Resident L)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the facility was sufficiently staffed to provide adequate care related to medication administration and assistance with daily living for the residents. This deficient practice had the potential to affect 64 of 64 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure monitoring and flush orders were in place for a resident (Resident D and Resident G) with a midline; failed to ensure documentation was in place for the removal of a midline (Resident D); failed to ensure a pulse was obtained, as ordered, prior to the administration of a hypertensive medication (Resident L); and failed to ensure a blood pressure medication was held, as ordered, for a resident (Resident C) with out of parameter blood pressures for 4 of 6 residents reviewed for quality of care. Findings Include:1. The clinical record for Resident C was reviewed on 9/23/25 at 1:29 p.m. The resident's diagnosis included, but was not limited to, chronic hypotension. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's (Resident D) urine output was documented, as ordered, for 1 of 3 residents reviewed for Indwelling catheters.

Inspectors wroteBased on record review and interview, the facility failed to identify an unresolved quality deficiency which had been cited on previous surveys, and ensure actions were developed and implemented to attempt to correct the deficiency through the quality assessment and assurance (QAA) process, as evidenced by a repeated deficiency for sufficient staffing. This deficient practice had the potential to affect 64 of 64 residents residing in the facility.

Inspectors wrote2. During random observations of Villa 6, between 6/9/25 and 6/11/25, Residents 6, 7, and 20 were in a recliner asleep in the common area. No activities were going on either by the Activity Director or the CNAs. During random observations of Villa 2, between 6/9/25 and 6/11/25, Residents 19, 49, and 3 were in the dining room area just sitting at the table sipping coffee. No activities were going on either by the Activity Director or the CNAs. Resident 1 was observed in her recliner in the common area during random observations, between 6/9/25 and 6/12/25. The resident was usually asleep or just looking around. No activities were occurring on any of the observations. An Activities Care Plan, with a start date of 5/20/22 and a revision date of 2/2/25, indicated Resident 1 had been sitting in a recliner in the day room for long periods of time. [...]

Inspectors wrote2. During a confidential interview, between 6/9/25 and 6/16/25, Staff 100 indicated there was only one CNA in each building. If a resident was a mechanical full body lift, sit to stand, or required two staff members for mobility/transfers or toileting, then they would have to call the nurse to come over and help, but sometimes there was a wait until they were free to come over. Some days were harder than others. Staff 100 indicated they had to make time to get all their work done, even on weekends. Showers were being given as they made sure they were. For the most part the villa cleaning got done, maybe not the full deep cleaning that was supposed to be done in 2 rooms every day. During a confidential interview between 6/9/25 and 6/16/25, Staff 101 indicated some [NAME] were harder out of all the [NAME] as there were residents who required a lot of care. [...]

Inspectors wroteBased on record review and interview, the facility failed to schedule 8-hour consecutive RN coverage for 1 of 2 months reviewed. (June 2025). This deficiency had the potential to affect the 66 of 66 residents currently residing in the facility.

Inspectors wroteDuring a confidential interview, between 6/12/25 and 6/16/25, Staff 100 indicated there was only one CNA in each building. If a resident required the use of a full body mechanical lift, sit to stand, or required two staff members assistance for mobility/transfers or toileting, then the nurse would be called to come over and help. Sometimes there was a wait until the nurse was free to come over. Some days were harder than others. During an confidential interview, between 6/9/25 and 6/16/25, Staff 101 indicated some [NAME] were harder because there were some residents who required a lot of care. There were five out of ten residents who required the use of a full body mechanical lift to get up or be put back to bed. The lift would require the assistance of two staff members. [...]

Inspectors wroteBased on record review and observation, the facility failed to ensure residents received respiratory care and maintenance for 4 of 4 residents reviewed for respiratory therapy. (Resident 3, Resident 38, Resident 54, and Resident 35)

Inspectors wroteBased on record review and interview, the facility failed to follow appropriate infection control guidelines related to complete surveillance documentation to analyze a pattern of know infectious symptoms and patterns. This had the potential to affect 66 of 66 residents residing in the facility. ([NAME] 2, 3, 4, 5, 6, 7, and 8)

Inspectors wroteBased on interview and record review, the facility failed to notify the physician and the resident's responsible party related to elevated blood surgar levels for 1 of 3 residents reviewed for notifications. (Resident 33)

Inspectors wroteBased on record review, and interview, the facility failed to ensure communication between the wound clinic, and documentation of wound assessments for 1 of 7 residents reviewed for wounds. (Resident 33)

Inspectors wroteBased on record review and interview, the facility failed to ensure insulins were administered as prescribed for 2 of 19 residents reviewed for pharmacy services. (Residents 33 and 37)

Inspectors wroteBased on record review and interview, the facility failed to ensure adequate supervision for a resident at risk for elopement for 1 of 5 residents reviewed for accidents hazards. (Resident B).

Inspectors wroteBased on interview and record review, the facility failed to ensure Qualified Medication Aides did not sign off on treatments completed, outside the scope of practice, for 4 of 4 residents reviewed for medical records. (Residents D, E, F and H)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the facility was adequately staffed to provide adequate care and safety for the residents. This deficient practice had the potential to affect 67 of 67 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents (Resident D, Resident F and Resident G) were monitored for medication side effects and failed to ensure treatments were completed for a resident (Resident L) for 4 of 4 residents reviewed for quality of care.

Inspectors wroteBased on interview and record review, the facility failed to ensure unavailable medications were not documented as administered for 1 of 6 residents (Resident E); failed to ensure resident medication administration records accurately reflected the administration of medications for 5 of 6 residents (Resident D, Resident G, Resident H and Resident M); and failed to ensure a resident's (Resident E and Resident L) medication administration record accurately reflected the administration of narcotic pain medication for 2 of 3 reviewed for documentation.

Inspectors wroteBased on interview and record review, the facility failed to ensure an allegation of abuse was thoroughly investigated for 1 of 3 residents reviewed for abuse. (Resident P)

Inspectors wroteBased on interview and record review, the facility failed to ensure Indwelling catheter care was provided for a resident and failed to ensure urine output was documented as ordered for 2 of 2 residents reviewed for Indwelling catheters. (Resident K and Resident L)

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's (Resident L) ostomy output was documented and care of the ostomy completed, as ordered by the physician for 1 of 1 resident reviewed for ostomy care.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's (Resident H) scheduled narcotic was administered, as ordered by the physician, for 1 of 3 residents reviewed for medications errors.

Inspectors wroteBased on interview, record review, and observation, the facility failed to provide a resident-centered activities program to support residents in their choice of activities for 4 of 4 residents reviewed for activities (Residents B, C, D, and E). This had the potential to affect 63 of 63 residents that reside in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure each Villa/unit was staffed with the appropriate staff to ensure the resident received care and services in a timely manner related to bathing, toileting, behavior/supervision, and resident-centered activities. This deficient practice had the potential to affect 63 of 63 residents residing in the facility.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure a resident's plan of care was revised for 1 of 4 residents reviewed for behaviors and exit-seeking. (Resident E )

Inspectors wroteBased on interview, record review and observation, the facility failed to ensure residents who were dependent on staff for activities of daily living received the care and services needed related to incontinence care and bathing for 2 of 4 residents reviewed for Activities of Daily Living. (Residents D and E)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents were safe from falls with the use of motion sensor alarms, testing of alarms, and prompt attention for 2 of 7 residents reviewed for falls. (Residents 20 and 5)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident's (Resident B) plan of care was updated for 1 of 3 residents reviewed for care plans.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents (Residents D, E and F) were provided appropriate care for 3 of 5 residents reviewed for Activities of Daily Living.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure an ongoing activity program to meet the interest of and support the physical, mental, and psychosocial well-being of the residents for 6 of 6 resident observations. This deficient practice had the potential to affect all 65 residents residing in the facility. (Residents 24, 28, 35, 47, 50, and 45)

Inspectors wrote6. The record for Resident 16 was reviewed on 4/24/23 at 10:08 a.m. The diagnoses included but was not limited to rheumatoid arthritis. The nurse's note, dated 5/28/22 at 8:14 p.m., indicated the resident asked how much of her Humira was left when the nurse gave the resident her injection. The nurse indicated that was the resident's last dose in the refrigerator. Resident 16 indicated that her family member just brought some in and she should have a whole new box. The nurse rechecked in the refrigerator but did not find any. The nurse proceeded to check in the nurse's office and on the counters. She found the Humira box stuffed in a corner of the office above the refrigerator. She notified the resident who then notified her family member. The residents family member placed a call to the pharmacy to ask if the Humira injection was still good. [...]

Inspectors wroteBased on record review and interview, the facility failed to notify the physician when a resident developed a firm to the touch raised area in a recent surgical incision of a hip fracture for 1 of 6 residents reviewed for physician notification. (Resident 17)

Inspectors wroteBased on record review and interview, the facility failed to ensure a preventative device was placed timely to prevent the development of a pressure ulcer during the review of 1 of 4 pressure ulcers reviewed. (Resident 20)

Inspectors wroteBased on record review and interview, the facility failed to ensure the physicians' orders were transcribed accurately to pharmacy for timely administration for 2 of 7 residents reviewed for significant medication errors. (Residents 50 and 34)

Inspectors wroteBased on record review and interview, the facility failed to ensure the residents were COVID-19 tested in accordance with their policy for 2 of 23 residents reviewed for COVID testing. (Residents 43 and 17)