Waterford Crossing

Based on record review and interview, the facility failed to keep documentation of the facilities infection control surveillance records. This deficient practice had the potential to affect 73 of the 73 residents who resided in the facility. Finding includes: A review of the Infection Control Binder (ICB) was completed on 3/23/2026 at 10:37 A.M. The ICB included the infection control surveillance for January through March 2026, but did not include any other months before January 2026. During an interview with the Infection Prevention Nurse (IPN) at 3/23/2026 at 10:40 A.M., the IPN indicated she had not believed she was required to have kept any of the infection control surveillance information and she had been throwing away the monthly infection control surveillance information at the beginning of the next month. The IPN indicated the last annual survey had been December 2024. During an interview with the Region Nurse Consultant (RNC) on 3/23/2026 at 11:45 A.M., the RNC indicated monthly infection control surveillance documents should have been kept in the ICB from one annual survey…

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 failed to provide pneumococcal immunizations for 2 of 5 residents whose immunizations were reviewed. (Residents 39 & 40)Findings include: 1. Resident 39's record review was completed on 3/23/2026 at 10:00 A.M. Diagnoses included, but were not limited to: dementia, major depressive disorder and chronic pulmonary disease. Resident 39's record lacked the documentation indicating she had been offered or had been administered the pneumococcal vaccination in the last year. 2. Resident 40's record review was completed on 3/23/2026 at 10:05 A.M. Diagnoses included, but were not limit to: vascular dementia, hypertension, dysphagia and major depression. Resident 40's record lacked the documentation indicating she had been offered or had been administered the pneumococcal vaccination in the last year. During an interview with the Infection Prevention Nurse (IPN) on 3/23/2025 at 10:30 A.M., the IPN indicated vaccinations should be offered yearly and she would have to look to see if Residents 39 and 40 had been offered or had received 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 interview and record review, the facility failed to honor a resident's shower preference for 1 of 1 resident reviewed for choices. (Resident 13) Finding includes: During an interview, on 12/13/2024 at 9:42 A.M., Resident 13 was unsure if the facility asked her about her preference for showers. She indicated she received a shower two times a week on the evening shift. She indicated she would like to have a shower daily on the day shift, as she had never showered in the evening before this admission. A record review for Resident 13 was completed on 12/16/2024 at 1:05 P.M. Diagnoses included, but were not limited to: anemia, end stage renal disease and celiac disease. An admission Minimum Data Set (MDS) assessment, dated 10/26/2024, indicated Resident 13 was cognitively intact and it was important to her to choose between a tub bath, shower, bed bath or sponge bath. On 12/11/2024, the census information indicated Resident 13 had moved from room [ROOM NUMBER] to room [ROOM NUMBER]. A Shower Schedule, 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.

Based on interview and record review, the facility failed to ensure a care plan for vision needs was in place for 1 of 2 residents reviewed for communication and sensory needs. (Resident 8) Finding includes: During an interview, on 12/12/2024 at 10:25 A.M., Resident 8 indicated he could not read the newspaper or the Bible. A record review for Resident 8 was completed, on 12/13/2024 at 12:57 P.M. Diagnoses included, but were not limited to: metabolic encephalopathy, major depressive disorder and macular degeneration. A Quarterly Minimum Data Set (MDS) assessment, dated 9/9/2024, indicated Resident 8 had moderate cognitive impairment and had impaired vision and utilized corrective lenses. An Annual MDS assessment, dated 8/19/2024, indicated a CAA (care area assessment) was triggered for visual impairment for Resident 8, but a plan of care related to vision needs was not developed. A Social Service Comprehensive Note, dated 8/19/2024 at 3:36 P.M., indicated Resident 8 had impaired vision with ability to see large print but not regular print when reading newspapers or books. A care plan…

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, interview and record review, the facility failed to ensure 1 of 7 nursing staff administering medications maintained professional standards of quality. (QMA 4) Findings include: During a medication observation, on 12/16/2024 at 8:25 A.M., QMA 4 was observed to remove a soufflé medication cup from the top drawer of the 300-hall medication cart. Resident 56's name was written on the side of the souffle cup that contained 14 different medications. The top drawer of the medication cart also contained 2 more souffle cups with the names of Residents 13 and 134 written on the side of the cups. During an interview, on 12/16/2024 at 8:26 A.M., QMA 4 indicated he should not have preset the medications. On 12/18/2024 at 11:51 A.M., the Director of Nursing provided the policy titled, Medication Administration-General Guidelines, with a revision date of 11/2018, and indicated the policy was the one currently used by the facility. The policy indicated . 4. Medications are not pre-poured either in advance of the med pass or for more than one resident at a time 3.1-35(g)(1)

Based on observation, interview and record review, the facility failed to ensure over the counter medications were labeled appropriately for 1 of 2 medication storage carts. (300 hall- back medication cart). Finding includes: During a medication administration observation, on 12/17/2024 at 6:09 A.M., RN 11 obtained medication bottles from the cart. The following medications had labels indicating the ordering physician, resident's name or ordered dose: - a bottle of 81 mg (milligrams) aspirin. - multiple bottles of men's multi vitamin capsules - q bottle of vitamin B 12 - 5000 mg tablets - a bottle of multi-vitamins - a bottle of Acetaminophen 650 mg. During an interview, RN 11 indicated the medications observed without labels should have been labeled. On 12/17/2024 at 9:52 A.M., the Director of Nursing provided the policy titled, Medication Ordering and Receiving from Pharmacy- Medication Labels, dated 11/2018, and indicated the policy was the one currently used by the facility. The policy indicated . F. Resident-specific non prescription medications (not floor stock) that are not…

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, record review and interview, the facility failed to follow infection control practices regarding enhanced barrier precautions for 1 of 1 resident reviewed for dialysis care. (Resident 13) Finding includes: A record review for Resident 13 was completed on 12/16/24 at 1:05 P.M. Diagnoses included, but were not limited to: anemia, end stage renal disease and dependence on renal dialysis. An admission Minimum Data Set (MDS) assessment, dated 10/26/2024, indicated Resident 13 had moderate cognitive impairment and received dialysis care. A Physician's Order, dated 11/2/2024, indicated staff were to use enhanced barrier precautions, wearing a gown and gloves at minimum, during high-contact care activities three times a day. A current Care Plan, initiated on 10/22/2024, indicated Resident 13 required enhanced barrier precautions (EBP) during high-contact care related to presence of dialysis treatment with a fistula. Interventions included, but were not limited to: don/doff and dispose of PPE (Patient Protective Equipment) systematically and appropriately per policy,…

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.

During observation, interview, and record review, the facility failed to develop and implement a personalized care plan for 1 of 22 residents whose care plans were reviewed. (Resident 49) Finding includes: The record review for Resident 49 was completed on 1/23/2024 at 2:47 P.M. Diagnoses included, but were not limited to: Parkinson's Disease and obstructive sleep apnea. A Physician's Order, dated 9/18/2023, indicated oxygen- bilevel positive airway pressure (BiPap) at 10 cm water at 0 liters to wear during the night and as needed during the day. There was no care plan available for the resident's BiPap machine. During an interview on 1/24/2024 at 9:38 A.M., the MDS Support indicated that Resident 49 should have had a care plan for his BiPap. On 1/25/2024 at 9 A.M., the Clinical Support Nurse provided a policy titled, Comprehensive Care Plan Guideline, dated 12/31/22, and indicated the policy was the one currently used by the facility. The policy indicated . 6. Comprehensive care plans need to remain accurate and current. a. New interventions will be added and updated or directly…

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, record review, and observation, the facility failed to provide treatment for a skin tear and dry skin for 1 of 3 residents reviewed for non-pressure related skin conditions. (Resident 43) Finding includes: During an interview on 1/23/2023 at 10:39 A.M., Resident 43 indicated he had sores on both shins. He was scratching and broke the skin open. A record review was conducted on 1/24/2023 at 10:25 A.M. Diagnoses included, but were not limited to: diabetes mellitus type 2, Parkinson's disease, and Alzheimer's disease. An Annual Minimum Data Set (MDS) assessment, dated 11/25/2023, indicated Resident 43 had moderate cognitive impairment. Current Physician's Orders indicated a weekly skin assessment was to be completed. There were no orders for any treatment to the shins. A Shower Sheet, dated 1/22/2024, indicated no bruising or redness was observed. A weekly Skin Assessment, dated 1/22/2024, indicated no skin issue was observed. A Care Plan, dated 12/08/2022, indicated Resident 43 was at risk for skin breakdown related to incontinence and impaired mobility. The goal…

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.

3. During observations on 1/22/204 at 9:38 A.M., 1/23/2024 at 10:44 A.M., and 1/24/2024 at 3:12 P.M., Resident 50's CPAP (continuous positive airway pressure) mask was observed lying on the bedside table, and a gallon of distilled water was on the floor undated. A record review was completed on 1/25/2024 at 10:26 A.M. Diagnoses included, but were not limited to: pulmonary fibrosis, sleep apnea, and unspecified dementia. A Quarterly Minimum Data Set (MDS) assessment, dated 12/13/2023, indicated Resident 50 had a non-invasive mechanical ventilation device. A Physician's Order, dated 5/11/2022, indicated to wear the CPAP at night and as need during the day. A Care Plan, dated 5/26/2022, indicated Resident 50 had the potential for complications of functional and cognitive status decline related to respiratory disease, due to pulmonary fibrosis and sleep apnea with the use of a CPAP. During an interview on 1/25/2024 at 1:04 P.M., the Director of Nursing (DON) indicated the CPAP mask should be stored in a respiratory bag when it was not in use, and the gallon of distilled water should be…

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, interview, and record review, the facility failed to ensure a Physician reviewed a Medication Regimen Review (MRR) provided by the Pharmacist following a monthly MRR, for 1 out of 5 residants selected for unnecessary medication review. (Resident 225) Finding includes: A record review was completed for Resident 225 on 1/24/2024 at 2:43 P.M. Diagnoses included, but were not limited to: Alzheimer's disease, dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, neurocognitive disorder with Lewy body, and unspecified psychosis not due to a substance or known physiological condition. A Physician's Order, dated 12/9/2022, indicated doneprizil 10 mg (milligram) tablet, orally at bedtime. A Pharmacy Recommendation, dated 9/26/2023, indicated Resident 225 has an order for DONEPEZIL TAB 10 MG daily. The most recent BIMS [Brief Interview for Mental Status] score on file is < 7 which indicated severe impairment [BIMS =3 on 6/27/23]. The American Geriatric Society has found that deprescribing…

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, record review, and interview, the facility failed to ensure 1 of 4 nursing staff (QMA 4) administering medications followed infection control policies regarding hand washing. Finding includes: During an observation of a medication administration pass, on 1/24/2024 at 11:01 A.M., QMA 4 administered a crushed oral medication to Resident 31. After he completed the medication administration for Resident 31, he then prepared medication for Resident 62. He assessed Resident 62's vital signs, and then crushed the medications and administered them to Resident 62. QMA 4 then pushed Resident 62 back to the dining table. Next, QMA 4 prepared a medication for Resident 63 and administered the oral medication. QMA 4 did not perform hand hygiene in between any of the three resident's medication preparations and administrations. During an interview with the Administrator, on 1/26/2024 at 2:31 P.M., she indicated the medication policy included instructions for handwashing during the medication administration process. The facility policy, titled, Preparation and General…

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.