Waterford Place Health Campus

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure daily weights were obtained as ordered by the physician, admission weights were obtained in a timely matter, and the physician was notified according to the physician's order for 4 of 4 residents reviewed for quality of care. (Resident 3, 93, 10 and 94)Findings include:1. The clinical record for Resident 3 was reviewed on 1/29/26 at 1:52 p.m. The diagnoses included, but were not limited to, acute respiratory failure with hypoxia, chronic obstructive pulmonary disease with exacerbation, heart failure, fluid overload, chronic kidney disease, and acute pulmonary edema. A physician's order, dated 12/2/25, indicated to obtain a daily weight once a day. A care plan, dated 12/3/25, indicated to obtain a weight as ordered. The Medication Administration Record (MAR), dated 12/1/25 to 12/31/25, indicated the daily weight was not obtained and documented on 12/2/25, 12/3/25, 12/6/25, 12/9/25, 12/12/25, 12/15/25, 12/24/25, 12/26/25 and 12/31/25. The MAR,…

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 PASARR (Preadmission Screening and Resident Review) was completed when the resident had a new mental health diagnosis and was prescribed an antipsychotic medication for 1 of 3 residents reviewed for PASARR. (Resident 4)Findings include:The clinical record for Resident 4 was reviewed on 1/28/26 at 12:27 p.m. The diagnoses included, but were not limited to, depression, atrial fibrillation, heart disease, vascular dementia, pseudobulbar affect, post-traumatic stress disorder (PTSD), and adjustment disorder with anxiety.A physician's order, dated 9/19/25, indicated to administer diazepam (an antianxiety medication) 2 mg (milligram) twice a day. A PASARR level I screen related to the diagnosis of anxiety disorder, and the new medication was not completed until 2/2/26 after the start of the survey.During an interview, on 2/2/26 at 3:39 p.m., the Administrator indicated when a resident had a new psychotic medication or a new mental health diagnosis added, a new level I needed to be completed. The resident did not have a…

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 catheter bag and tubing were maintained in a sanitary manner for 1 of 2 residents reviewed for catheters. (Resident 11) Findings include: During an observation, on 1/30/26 at 11:13 a.m., Resident 11's catheter was attached to the trash can next to the bed. The urine in the catheter tubing was cloudy with sediment (matter which settles to the bottom of liquid). The trash can had trash in the bottom. The clinical record for Resident 11 was reviewed on 1/28/26 at 10:22 a.m. The diagnoses included, but were not limited to, history of urinary tract infection (UTI), acute kidney failure, anxiety disorder, chronic pain syndrome, hypertension, heart failure, chronic obstruction pulmonary disorder, retention of urine, and atrial fibrillation.A care plan, dated 5/30/24, indicated Resident 11 had a Foley catheter related to the diagnosis of neurogenic bladder. Interventions included, but were not limited to, observe the catheter tubing.A recently completed physician's order, dated 12/27/25, indicated to…

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 infection control practices were followed for 1 of 1 randomly observed resident reviewed for infection control. (Resident 11) Findings include:During an observation, on 1/30/26 at 11:13 a.m., Resident 11's catheter was attached to the trash can next to the bed. The urine in the catheter tubing was cloudy with sediment (matter which settles to the bottom of liquid). The trash can had trash in the bottom. The clinical record for Resident 11 was reviewed on 1/28/26 at 10:22 a.m. The diagnoses included, but were not limited to, history of urinary tract infection (UTI), acute kidney failure, anxiety disorder, chronic pain syndrome, hypertension, heart failure, chronic obstruction pulmonary disorder, retention of urine, and atrial fibrillation.A recently completed physician's order, dated 12/27/25, indicated to administer ciprofloxacin (an antibiotic) 500 milligrams two times a day for 14 days for a UTI.During an interview, on 1/30/26 at 11:19 a.m., the Assistant Director of Nursing (ADON) indicated 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, interview and record review, the facility failed to ensure oxygen was administered at the physician's ordered level and to obtain an order to administer oxygen for 4 of 4 residents reviewed for oxygen. (Resident 118, 51, 9 and 58) Findings include: 1. During an observation, on 2/10/25 at 12:49 p.m., Resident 118 was sitting on her recliner wearing oxygen. The oxygen concentrator was set on 0.5 liters via nasal cannula. During an observation, on 2/11/25 at 3:30 p.m., the resident was sitting on her recliner wearing oxygen. Her oxygen concentrator was set on 1 liter via nasal cannula. During an observation, on 2/14/25 at 10:20 a.m., the resident was lying in bed eating her breakfast. The resident's oxygen concentrator was set on 3 liters via nasal cannula. During an interview, on 2/14/25 at 10:25 a.m., LPN 5 indicated Resident 118's concentrator was set on 3 liters, and she was not sure of the resident's oxygen order. The clinical record for Resident 118 was reviewed on 2/12/25 at 10:01 a.m. The diagnoses included, but were not limited to, chronic obstruction…

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 resident rooms and hallways were maintained and kept in clean and sanitary condition for 3 of 8 rooms (room [ROOM NUMBER], 106 and 107) and 3 of 3 hallways (hallway 100, 200 and 300) reviewed for environment. Findings include: During room observations, starting on 2/10/25 at 11:18 a.m., the following were observed: a. The 100-hallway had a very strong urine and bowel movement odor. b. room [ROOM NUMBER] had a large uneven area with peeling paint and cracks on the wall next to the bathroom. c. room [ROOM NUMBER] had an unsecured outlet on the wall at the foot of the resident's bed. The outlet was pulled away from the wall with black cords plugged into the outlet. The room had a very strong urine and bowel movement odor. d. room [ROOM NUMBER] had a large basketball-size dried blood smear on the wall by the first bed near the door. The resident's sheets had dried blood on both sides of the resident. The bed by the window had two little…

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.

2. The clinical record for Resident 54 was reviewed on 2/12/25 at 2:26 p.m. The diagnoses included, but were not limited to, dementia, psychotic disturbance, mood disturbance, and anxiety. A care plan, dated 11/29/23, indicated the resident had the potential for cardiovascular distress related to a diagnosis of hypertension. Interventions included, but were not limited to, administer medications as ordered and obtain vital signs as ordered. A physician's order, dated 10/24/24, indicated to give metoprolol tartrate (a medication used to treat high blood pressure) 12.5 milligrams (mg) twice a day with special instructions to hold the medication for a systolic blood pressure less than 110. A Medication Administration Record (MAR), dated 11/1/24 through 11/30/24, indicated metoprolol tartrate 12.5 mg was given with a recorded systolic blood pressure of less than 110 on the following dates: On 11/1/24, the morning dose was given with a systolic blood pressure of 105. On 11/1/24, the evening dose was given with a systolic blood pressure of 107. On 11/6/24, the morning dose was given with…

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 ensure there was documentation to show the resident or resident's representative made the choice about the Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) for 2 of 3 residents reviewed for beneficiary notification. (Resident 27 and 315) Findings include: 1. The Notice of Medicare Non-Coverage (NOMNC) for Resident 27 indicated rehabilitation services would end on 12/26/23. The SNF ABN form, for Resident 27, indicated the resident no longer required skilled services but wanted to continue to reside in the SNF. Medicare would not pay for the stay at the facility since the resident did not require daily skilled care. The resident had three options to choose and was to choose only one option. The options included the resident wanted the services to continue and to bill Medicare for an official decision on payment, the resident wanted to continue the services and do not bill Medicare, or the resident did not want the services. The facility could not choose the option for the resident. 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, interview and record review, the facility failed to ensure a cognitively impaired resident who resided on the memory care unit was provided with preferred activities while in isolation for Covid-19 for 1 of 4 residents reviewed for activities. (Resident 45) Finding includes: During an observation, on 1/3/24 at 10:37 a.m., Resident 45 was lying in bed, in her room, and her eyes were closed. There was no music playing and no reading material noted on the resident's bedside table. During an observation, on 1/4/24 at 10:21 a.m., Resident 45 was lying in bed and her eyes were closed. There was no music playing and the television was not on. During an interview, on 1/4/24 at 11:20 a.m., CRCA (Certified Resident Care Assistant) 3 indicated the television in the resident's room did not work. The resident would watch television in the common area when she was not in isolation. During an observation, on 1/4/24 at 2:47 p.m., the resident was lying in bed, her eyes were opened. There was no music, the television was not on, and there were no books on the resident's side 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.

Based on interview and record review, the facility failed to follow the physician's order to call the provider and complete a re-check for low blood sugars for 1 of 1 resident reviewed for quality of care related to insulin. (Resident 1) Finding includes: During an interview, on 1/2/24 at 3:05 p.m., Resident 1 indicated she had to go to the hospital for high blood sugars in the past. The record for Resident 1 was reviewed on 1/4/24 at 12:02 p.m. Diagnoses included, but were not limited to, type 2 diabetes with history of ketoacidosis (uncontrolled production of ketones) without coma, peripheral vascular disease, iron deficient anemia, and cognitive communication deficit. A physician's order, with a start date of 10/27/22 and an end date of 9/19/23, indicated the resident received insulin lispro (short acting insulin) per sliding scale 3 times per day. If the blood sugar was less than 70, call the MD. A current physician's order, dated 3/2/2020, indicated for blood sugars between 50-69, give a 15-gram carbohydrate oral feeding, wait 15 minutes, and recheck the blood sugar. If less…

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 identify a weight loss, notify the physician, and implement interventions for 1 of 3 residents reviewed for nutrition. (Resident 12) Finding includes: The record for Resident 12 was reviewed on 1/5/24 at 12:18 p.m. Diagnoses included, but were not limited to, dementia without behavioral disturbance, type 2 diabetes mellitus, adult failure to thrive, anxiety, and major depressive disorder. A physician's note, dated 4/3/23 at 6:04 p.m., indicated the resident tested positive for Covid-19 on 3/30/23. If the resident had signs of dehydration an intravenous line should be considered for fluid resuscitation. The resident was to be monitored for falls, increased thirst, urination, weight loss, constipation, and diarrhea. The resident had the following weights: a. On 3/1/23, the weight was 114.4 pounds. b. On 4/7/23, the weight was 106.8 pounds which was a 6.64% weight loss in 37 days. The Electronic Health Record (EHR) did not include notification to the physician of the weight loss, a nutrition note, or interventions in place…

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.