Waterford Nursing And Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The findings included.1) Observation on 03/02/2026 at 9:20 AM on the facility's second floor revealed unattended medication cart # 2's computer screen was open with residents' information visible.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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.There were 206 residents residing in the facility at the time of survey. The findings included.On 03/02/2026 at 9:16 AM observational tour on the third floor…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The findings include. On 03/02/2026 at 11:48 AM Resident #77 was observed in the hallway seated in a wheelchair with enteral feeding in progress via Percutaneous Endoscopic Gastrostomy (PEG) with the system uncovered (photo evidence). Observation on 03/03/2026 at 1:45 PM revealed Resident #77 in the dining area seated in wheelchair during activities amongst other residents and the enteral feeding was in progress via PEG and not covered (photo evidence).Record review of Resident #77's clinical records documented the resident was re-admitted on [DATE] with diagnosis that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. The findings included.During a medication administration observation on 03/05/2026 at 8:07 AM Staff H, Registered Nurse (RN) removed a pill from a bottle to administer to a resident, however the expiration date and open date were not legible (photo). Staff H, RN was unable to read the expiration date. The 1st floor supervisor RN was made aware and took a new bottle to cart. Staff H, RN entered the resident's room with medication, leaving a syringe with normal saline on top of the first-floor medication cart #1 (photo).Interview on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. The findings included: Record review of the facility's Quality Assurance and Performance Improvement (QAPI) Policy and Procedure (issued June 2021) documented the following: Policy-It is the policy of this facility to develop, implement and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care and quality of life. Policy Explanation and Compliance Guidelines: 2) The QAA…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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.The findings included: Record review of the Physical Environment Policy and Procedure (issued 3/2020); Policy: It is the policy of the facility to provide a safe environment in accordance to State and Federal regulations; Procedure: 2) The facility will maintain all essential mechanical and electrical equipment in safe operating condition.Review of the Freezer Defrost and Maintenance Policy and Procedure (no written date); Policy-All freezer units are equipped with an automatic defrost cycles as designed by the manufacturer. The defrost cycle operates automatically during scheduled off-peak hours to maintain normal freezer function. Dietary and Maintenance departments are to ensure proper freezer operation and sanitation; Procedure: Dietary…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The findings included: During initial observation on 08/12/24 at 08:20 AM Resident #54 was observed there in bed, there was mat on the floor to the right side of Resident #54's bed. On 08/13/24 at 09:24 AM Resident # 54 was asleep in bed and bilateral floor mats observed in place. On 08/14/24 at 07:47 AM Resident # 54 was in bed being fed breakfast and one floor mat was against the wall and one on the floor at the right side of the bed. During an interview on 08/14/24 at 09:30 AM Licensed Practical Nurse (LPN) (Staff C) stated: The resident is supposed to have two floor mats, if during rounds I see any of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. The findings included: On 8/12/24 at 9:52 AM observation on the third floor unattended medication cart #2 revealed residents' personal health information visible on the electronic medication administration screen. Staff E, Registered Nurse (RN) exited a resident's room and was approached by the surveyor. When asked why the computer screen was left open, Staff E, RN replied, I left the computer screen open because I went into the room quickly. I am supposed to close the screen when away from the medication cart. Record review of the facility's Policy: HIPAA. Date implemented: 11/27/2019. Policy: It is the policy of the facility to apply sanctions against employees who fail to comply with all policies and procedures regarding the protection of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The findings included: Record review of the MDS (Minimum Data Set) Assessment Completion and Accuracy Policy and Procedure (issued 9/2020) documented: Policy: It is the policy of the facility to adhere to the following procedures related to the proper documentation and utilization of a resident's Minimum Data Set (MDS) to ensure a comprehensive and accurate assessment of residents will be completed in the format and in accordance with time frames. This assessment system will provide a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacities and assist staff to identify health problems for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The findings include: During initial observation on 08/12/24 at 07:58 AM Resident# 51 was in bed asleep, medications (creams, ointments, medicated powder) were observed on overbed table (Photo available). On 08/13/24 at 09:11 AM Resident #51 was observed in geriatric chair asleep in the room. On 08/14/24 at 08:56 AM the resident in room receiving care from Certified Nursing Assistant (CNAs) (Staff B). Review of the medical records for Resident #51 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Cerebral Infarction due to embolism of left posterior cerebral artery. Review of the Physician's Orders Sheet for August 2024 revealed Resident #51 had orders that included…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. The findings include: In an observation on 04/10/23 at 09:12 AM, Resident #90 is dressed and in the wheelchair with eyes closed. In an observation on 04/11/23 at 08:47 AM, Staff C, a Diet Technician was observed standing while feeding resident #90 breakfast. Staff C stated, There is no chair in the room for me to sit down in and feed the resident. This resident eats pureed food and needs assistance with eating. In an observation on 04/13/23 at 08:02 AM, Resident #90 was in the wheelchair. Staff D, Certified Nursing Assistant (CNA) pulled a chair to resident #90. Staff D washed hands in the restroom. Prepared tray to serve the resident. Staff D sat in the chair to feed the resident. The meal was pureed and thickened liquids. Resident #90's left hand arm is observed to be contracted, the resident holds it to chest & the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Review of the medical records for Resident #118 revealed, the resident was admitted to the facility on [DATE]. Clinical diagnoses included but were not limited to: Chronic respiratory…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. The findings included: Record review of the facility's survey history revealed, during the annual survey exit dated 01/03/2022, deficient practice was cited related to F 695- Respiratory/Tracheostomy Care and Suctioning. F 695 was also cited during the current annual recertification survey exit dated 04/13/2023. Review of the facility's plan of correction for the last annual survey with an exit date 01/03/2022 related to F 695 Respiratory/ Tracheostomy Care and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.