Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Regency At Waterford during CMS and state inspections, most recent first.
A resident was injured during return transport from an outside appointment when the wheelchair was not properly secured in a contracted transport van. The resident fell backward as the van moved, was hospitalized with C6 and C7 fractures, and reported ongoing neck pain. CNA and facility interviews described difficulty securing the wheelchair and confirmed the resident was not safely strapped in during transport.
A resident with multiple cardiac and renal comorbidities developed severe abdominal pain, nausea, and vomiting shortly after admission. Morning VS showed markedly elevated BP, tachycardia with irregular rhythm, and hypothermia, but there was no documented notification of the MD, NP, or PA despite the nurse later stating they had "reached out." By mid-afternoon, the resident continued to have significant pain, abnormal VS, and green emesis; a PA assessed the resident, noted poor condition, suspected sepsis, and ordered an abdominal X-ray and stat labs but did not send the resident to the ER at that time and was unaware of the earlier abnormal VS. That evening, the resident was found hyperventilating with tachycardia and tachypnea, and a critically high WBC was reported, after which the on-call provider ordered transfer to the ER for sepsis. The supervising physician and DON both stated the earlier VS should have been reported, and facility policies required practitioner notification for significant status changes and transfer when the resident’s needs could not be met in the facility.
A resident with severe cognitive impairment had their protected health information (PHI) inappropriately disclosed by a CNA to unauthorized family members, including during video chats at work and in conversations outside the facility. The resident's DPOA had not authorized these disclosures, and the CNA was terminated for violating confidentiality policies.
A newly hired LPN was allowed to begin orientation and training without completion of the required fingerprint-based background check. The personnel file lacked documentation of completed fingerprints, and the HR coordinator confirmed the appointment was missed and no fingerprints were on file, despite state law requiring this check before employment.
Two residents made allegations of abuse involving staff, including being struck with a washcloth or towel and having water thrown at them during an altercation. In both cases, staff members who were informed of the allegations did not promptly notify the abuse coordinator or the State Agency, resulting in significant delays in reporting and investigation, contrary to facility policy.
Multiple residents with intact cognition reported that meals were frequently served in Styrofoam containers, resulting in food that was not hot and lacked palatability. Residents stated this occurred several times per week and had been ongoing for months, with concerns raised repeatedly in Resident Council meetings. The Dietary Manager confirmed that staffing shortages led to the use of disposable containers, making it difficult to maintain proper food temperatures as required by facility policy.
The facility failed to ensure timely submission of progress notes for two residents. A progress note for a resident was entered after their death, and multiple notes for another resident were entered on the same day, indicating delays. The Director of Nursing confirmed the expectation for timely documentation, but the facility's policy did not address this requirement.
A resident with severe cognitive impairment and multiple health issues was found with a red raised lump on their head after returning from dialysis. The facility failed to report this injury of unknown origin to the Administrator and State Agency, as required by their policy. Despite hospital records indicating a suspected unwitnessed fall, the facility did not classify or report the incident properly.
The facility failed to maintain timely and accurate clinical documentation for a resident, resulting in a deficiency. A complaint revealed that staff entered late progress notes and documented in the clinical record after the resident's death. A nurse entered a late entry progress note seven days after the resident was found unresponsive, and documented medication outcomes after the resident's death. The DON confirmed that documentation should have been immediate, as per the facility's medical records management policy.
The facility failed to provide timely and appropriate pressure ulcer care for two residents, resulting in the development and worsening of pressure ulcers. One resident developed stage 3 pressure ulcers on the sacrum and left heel, and the right heel wound worsened due to delayed assessment and treatment. Another resident had a stage II pressure ulcer on the sacrum, but treatments were not initiated until 12 days after re-admission. The facility's policy on skin management was not followed, leading to these deficiencies.
The facility failed to provide a dignified dining experience for several residents, as observed during two dining sessions. Residents were left waiting for their meals while others received assistance, leading to expressions of hunger and dissatisfaction. Interviews with staff revealed that the protocol of serving residents needing 1:1 assistance first caused delays for others, conflicting with the facility's policy on resident dignity.
A resident with a history of stroke and dysphagia was observed multiple times with fluids placed out of reach, leading to potential dehydration. Despite being on a pureed diet with thickened liquids, the facility did not ensure fluids were accessible, and no policy was provided to address this issue.
The facility failed to provide necessary ADL assistance for two residents, leading to potential issues with nutrition and hygiene. One resident, non-verbal and cognitively impaired, had long nails with debris and consistently returned meal trays with unopened food, despite needing 1:1 feeding assistance. Another resident, with Alzheimer's and hemiplegia, struggled to eat without required 1:1 assistance and verbal cues. The facility's policies did not adequately address these care needs, contributing to the deficiencies.
A resident with epilepsy, traumatic brain injury, hallucinations, and dementia was found incapable of making medical decisions, yet the facility failed to secure legal representation. Despite a capacity determination, no legal decision maker was documented, and the facility delayed referring the case to a consulting company for guardianship. The facility eventually decided to proceed with filing for guardianship, despite the family's attorney's involvement.
A resident with a paralyzed right arm was supposed to be on a Maintenance Splint Program, but reported not wearing a splint for months and not receiving therapy, despite CNA documentation indicating otherwise. The order for the splint had been discontinued, yet staff continued to document its application, violating the facility's documentation policy.
The facility failed to follow proper infection control practices, particularly in the use of PPE and signage for transmission-based precautions. Staff were observed not wearing required PPE, such as N95 masks and gowns, when caring for residents on enhanced barrier precautions. Discrepancies were noted between signage and physician orders, and some residents did not have appropriate precautions initiated. Interviews revealed a lack of awareness among staff about the correct precautions needed, leading to potential infection spread.
Two residents were observed self-administering medications without being assessed for safety, contrary to facility policy. One resident with dementia was using a nebulizer treatment unsupervised, and another with end-stage renal disease had a nasal spray at their bedside. Both lacked documented assessments for self-administration, as confirmed by the DON.
A resident with severe cognitive impairment was found with pills scattered in their bed and on the floor, indicating a failure in medication administration standards. An LPN confirmed all medications were given and observed as taken, but the facility's policy requires nursing staff to ensure residents swallow their medications. The DON confirmed this policy, highlighting a lapse in adherence.
A resident with impaired cognition and mobility issues reported feeling bored and only watching TV, as the facility failed to provide diverse and engaging activities. The resident's care plan was outdated, and activities were limited to brief visits and TV, with no other options offered due to the resident's inability to get out of bed.
A facility failed to perform accurate clinical assessments and ensure interdisciplinary collaboration for a resident with a PEG tube, leading to recurrent infections and pain. Despite the resident no longer needing enteral feedings, the PEG tube remained, and the resident was not discussed in the At Risk Meeting. Additionally, the facility failed to administer prescribed ear drops to another resident, resulting in continued pain. The medication was unavailable, and the DON was unaware of how it was signed off as administered.
A resident with COPD was observed receiving oxygen at six liters per minute, contrary to the physician's order of three to four liters per minute to maintain oxygen saturation between 93-94%. The resident's oxygen levels consistently exceeded the recommended range, reaching up to 100%. The DON acknowledged the staff's failure to follow the physician's orders, and the facility's policy did not address this requirement.
A resident on hemodialysis did not have Physician orders for treatment or regular monitoring of their dialysis access site, as required by the facility's policy. The resident reported inconsistent assessments by nursing staff, and the Director of Nursing acknowledged the lack of necessary orders in the resident's records. This deficiency was identified through observations, interviews, and medical record reviews.
A resident was found to have duplicate orders for Montelukast Sodium, receiving 20mg daily due to an inappropriate order for hypertension. The DON confirmed the error after consulting with the NP, who indicated that one order should be discontinued.
The facility failed to label narcotic medications with resident identifiers and secure medication carts. An LPN found 30 syringes of Morphine Sulfate without resident names, and the DON confirmed they were returned to the pharmacy. Additionally, a medication cart with treatment creams was left unlocked and unattended in a common area.
A resident with dementia and legal blindness was not provided with necessary adaptive eating equipment during meals, despite facility policy requiring such provisions. The resident's care plan specified the need for a divided plate and a two-handed spouted cup, which were not provided on multiple occasions.
Unsafe wheelchair transport and improper securing of a resident
Penalty
Summary
The facility failed to ensure a resident was safely transferred in a contracted transportation vehicle, resulting in the resident falling backward in a wheelchair during transport and sustaining a C6 fracture, a C7 compression fracture, hospitalization, and pain. The citation was based on Complaint #2788554 and involved one resident reviewed for accidents/transportation. R701 was bedridden, had a BIMS score of 15/15, and had diagnoses that included type II diabetes and nondisplaced fractures of the sixth and seventh cervical vertebrae after the incident. Hospital records stated the resident was in a wheelchair in a transport vehicle when the vehicle made a sudden movement, the wheelchair tipped over on its side, and the resident hit their head on the vehicle wall because the wheelchair was not properly secured. Imaging showed a nondisplaced fracture of the left-sided C6 and a questionable minimal compression fracture at C7, and the resident was treated with pain control and a cervical collar. During interview, R701 stated that on the return trip from an appointment the van started to shake, the resident began to fall backward, and the resident continued to have neck pain and had worn a cervical collar for months. CNA A reported that the driver was responsible for locking the wheelchair in the transport vehicle, that the leg rest appeared to be problematic, and that the driver struggled to secure the wheelchair. CNA A also stated that as the van was near the facility, the resident had fallen back and the chair and resident were folded up like a pretzel, after which EMS was called. The facility’s incident investigation documented that R701 fell backward in the wheelchair in the transportation van upon return from a medical appointment and was transferred to the hospital, where the cervical fractures were diagnosed. The investigation included interviews in which R701 stated the male driver could not strap the legs and that the resident felt like someone was yanking on them before falling backward, while the transportation company owner stated the driver did not follow proper procedure and had been suspended. The Administrator also stated the facility could substantiate that the transport driver did not safely secure R701 in the vehicle.
Failure to Notify Practitioner and Timely Transfer for Acute Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify a practitioner of an acute change in condition and to ensure timely transfer to the ER for a resident who was newly admitted with diagnoses including heart failure, edema, chronic kidney disease, atrial fibrillation, high blood pressure, and muscle wasting/atrophy. Shortly after admission, the resident developed extreme abdominal pain with nausea and vomiting. On the morning in question, vital signs documented at 9:27 AM by a nurse showed a blood pressure of 178/105, heart rate of 125 with an irregular rhythm, and a temperature of 94.8°F. The nurse later stated they were “pretty sure” they reached out to the NP or PA, but the clinical record contained no indication that the MD, NP, or PA had been notified of these abnormal vital signs. In the afternoon, another nurse documented at 2:38 PM a blood pressure of 101/86, heart rate of 133 with an irregular rhythm, and temperature of 96.6°F, with a pain score of 7/10 at 2:44 PM. A progress note at 2:39 PM indicated the PA assessed the resident at bedside with the daughters present, noting abdominal pain and 10 cc of green emesis, and ordered an abdominal X-ray and stat labs for abdominal pain and nausea. The PA later reported the resident was in “poor condition,” lying flat in bed with a damp towel on the chest, complaining of left upper quadrant abdominal pain, and stated they suspected sepsis, ordering the X-ray and stat labs but choosing to wait for results before sending the resident to the ER. The PA also stated they had not been made aware of, nor reviewed, the earlier abnormal vital signs from that morning. That evening, a nurse documented that at approximately 6:30 PM the resident was observed hyperventilating, with vital signs of 154/78, heart rate 120 bpm, and respiratory rate 32/min. While the nurse was on the phone with the on-call prescriber to report “sepsis like symptoms,” another nurse received a call from the lab reporting a critically high WBC of 31,700, which was communicated to the provider, who then ordered transfer to the ER for sepsis. The supervising physician later stated that the morning vital signs should have been reported and that, had they been contacted, they might have started fluids and probably would have sent the resident to the ER. The DON agreed that the morning blood pressure, heart rate, and temperature were a concern and should have been reported, and acknowledged that the PA waited to see if ordered interventions would work before sending the resident out. The facility’s policies on Notification of Change and Transfer and Discharge require practitioner notification for significant changes in status and transfer when the resident’s needs cannot be met in the facility. The resident’s death certificate listed sepsis and pneumatosis intestine as the causes of death.
Failure to Maintain Resident PHI Confidentiality
Penalty
Summary
A facility failed to maintain the privacy and confidentiality of a resident's protected health information (PHI) for one of two residents reviewed. The resident in question had diagnoses including Alzheimer's disease, heart disease, and a history of lung cancer, and was assessed as having severely impaired cognition and being incapable of making informed medical decisions. A complaint was filed alleging that a facility employee disclosed the resident's diagnosis and personal information to other family members without authorization. The Durable Power of Attorney (DPOA) for the resident reported that a Certified Nursing Assistant (CNA) had video chatted with her cousin while at work, during which the cousin could see the resident and other residents. Additionally, the CNA disclosed to another family member at a store that the resident was not doing well and was expected to pass soon. The DPOA confirmed that she had not given permission for the CNA to share this information and specifically wanted to inform the resident's sister herself. Review of facility records showed that the CNA was no longer employed at the facility, having been terminated for disclosing confidential and privileged information to a family member not authorized to receive it. The facility's policy defined health information and disclosure, and the administrator confirmed that all employees were educated on HIPAA requirements. However, the incident demonstrated that the resident's PHI was shared inappropriately with unauthorized individuals, violating the facility's policy and federal privacy regulations.
Failure to Complete Required Background Check Prior to Staff Employment
Penalty
Summary
The facility failed to implement its abuse prevention policy by not ensuring a complete background check, including fingerprinting, was performed for a newly hired LPN. The personnel file for the LPN showed that while a fingerprint appointment was scheduled, there was no documentation that the fingerprinting was actually completed. The LPN began orientation and training at the facility and participated in several training days without the required fingerprint-based criminal history check being finalized. During interviews, the Human Resources coordinator confirmed that the LPN did not attend the scheduled fingerprint appointment and that no fingerprints were on file. The coordinator stated that they tracked and followed up on the process weekly but did not have evidence of completed fingerprints for the LPN. The administrator was made aware of the issue and acknowledged the concern. State law requires that fingerprint-based background checks be completed before employment for individuals with direct resident access, and the facility did not retain verification of compliance for this staff member.
Failure to Timely Report Allegations of Abuse to Authorities
Penalty
Summary
The facility failed to timely report allegations of abuse involving two residents to the abuse coordinator and the State Agency. In the first incident, a resident informed a family member that a staff member had thrown a washcloth or towel at them. The family member reported this to the charge nurse, but the charge nurse did not promptly notify the abuse coordinator. As a result, the facility did not notify the State Agency or initiate an investigation until approximately 64 hours after the allegation was first reported to staff. In the second incident, a resident with a history of paranoid schizophrenia, diabetes, and acute kidney failure, and who had recently been hospitalized for aggressive behavior, was involved in an altercation with a staff member. The resident alleged that a staff member threw water at them during an argument about medication administration. Multiple staff interviews confirmed that the resident was agitated and that water was involved, but the incident was not reported to the abuse coordinator or investigated at the time. The administrator and staff were unaware of the abuse allegation until it was brought to their attention by the surveyor several days later. Facility policy requires that all allegations of abuse be immediately reported, thoroughly investigated, and documented by the administrator, and that appropriate authorities be notified. In both cases, staff members who were aware of the allegations did not follow these procedures, resulting in delayed reporting and investigation of the alleged abuse.
Meals Not Served at Palatable Temperatures Due to Use of Disposable Containers
Penalty
Summary
The facility failed to ensure that meals were enjoyable and served at palatable temperatures, as required, due to the use of disposable Styrofoam containers for meal service. Surveyors observed that breakfast and lunch meals were being served in Styrofoam boxes, and multiple residents reported that the food was not hot and did not taste good when served in these containers. The use of disposable containers was observed to occur multiple times per week, affecting the palatability and temperature of the food. Three long-term residents, all with intact cognition as indicated by their BIMS scores, were interviewed and confirmed ongoing dissatisfaction with the temperature and taste of meals served in Styrofoam containers. One resident, who was vegetarian and ate fish, stated they had stopped eating facility food and relied on food brought by family due to the poor quality and temperature of meals. Another resident, who was receiving supplemental oxygen, reported that food was not hot and did not taste right when served in disposable boxes. The Resident Council president also confirmed that the issue had been raised multiple times in council meetings, with several residents expressing similar concerns. The Dietary Manager acknowledged that staffing shortages led to the use of Styrofoam containers, particularly during breakfast and dinner when staff called off. The manager admitted that maintaining appropriate food temperatures was difficult with disposable containers. Facility documentation required hot foods to be held above 135°F and cold foods below 41°F at the point of service, but the use of Styrofoam containers and staffing issues interfered with compliance. The administrator was made aware of the ongoing concerns and the frequency of the issue, as well as the repeated reports from the Resident Council.
Failure to Ensure Timely Submission of Progress Notes
Penalty
Summary
The facility failed to ensure timely submission of physician or physician extender progress notes for two residents, R901 and R902. For R901, a progress note by Nurse Practitioner (NP) 'C' was entered into the record after the resident's death, indicating a delay in documentation. For R902, multiple progress notes were created and entered into the record by NP 'C' on the same day, suggesting a lack of timely documentation for each visit. An interview with the facility's Director of Nursing confirmed that the expectation was for progress notes to be entered in a timely manner. However, the facility's policy on Physician Services did not address the timely entry of progress notes into the record.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for a resident, identified as R903, to the Administrator and the State Agency. R903, who was severely cognitively impaired and required extensive assistance with most Activities of Daily Living, was admitted with diagnoses including end-stage renal failure and heart disease. On a specific date, a nurse noted a red raised lump on the left side of R903's head after the resident returned from dialysis. The resident was unable to explain the cause of the injury and was sent to the hospital for observation. Hospital records indicated a suspected unwitnessed fall, but the facility stated there was no fall, and the resident was not found on the ground. Despite the injury being classified as an injury of unknown source, it was not reported to the Abuse Coordinator/Administrator or the State Agency. Interviews with facility staff, including Nurse D, the Director of Nursing (DON), and the Abuse Coordinator, revealed that the injury was not reported as required by the facility's Abuse Prohibition Policy. The policy mandates that staff immediately report incidents of abuse and suspected abuse, including injuries of unknown source, to the Administrator and DON. The policy also requires notification of the resident's representative and any State or Federal agencies per state guidelines. The failure to report the injury of unknown origin was a deficiency identified during the survey, as the facility did not adhere to its own policy and state reporting requirements.
Failure to Maintain Timely and Accurate Clinical Documentation
Penalty
Summary
The facility failed to ensure clinical documentation met professional standards for a resident, leading to a deficiency. A complaint was received by the State Agency alleging that staff entered late progress notes and documented in the clinical record after the resident's death. A review of the resident's clinical record revealed a late entry progress note for a specific date and time, which was entered into the record seven days later by a nurse. The note indicated that the resident was observed unresponsive in bed with no pulse or respirations, and that the hospice nurse, physician, and family were notified. Additionally, the nurse documented the effective outcome of as-needed pain and anti-anxiety medications at a time after the documented death of the resident. An interview with the facility's Director of Nursing confirmed that the note regarding the resident's death should have been entered into the record immediately, not several days later. The facility's policy on medical records management requires that records be complete, accurately documented, and maintained in accordance with professional standards and legal requirements.
Failure to Provide Timely Pressure Ulcer Care
Penalty
Summary
The facility failed to provide timely and appropriate pressure ulcer care for two residents, resulting in the development and worsening of pressure ulcers. Resident 903 was admitted with a history of right-sided stroke and was noted to have a wound on the right heel and redness to the coccyx/sacral area upon re-admission. Despite an order for evaluation by a wound care practitioner on the day of re-admission, the resident was not assessed until 20 days later. During this period, the resident's condition worsened, developing a stage 3 pressure ulcer on the sacrum and left heel, and the right heel wound also worsened. The delay in assessment and treatment was attributed to the absence of the wound care nurse and a change in wound care nurse practitioners. Resident 902 was admitted with a facility-acquired stage II pressure ulcer on the sacrum. Upon re-admission, the resident's nursing admission assessment noted an open area on the sacrum, but no treatments were implemented until 12 days later. The facility's wound care nurse confirmed that there was no evidence of treatments being initiated upon re-admission. This delay in treatment was contrary to the facility's policy, which mandates the identification and implementation of interventions to prevent and treat pressure injuries. Interviews with the facility's wound care nurse and the Director of Nursing revealed awareness of the delays in assessment and treatment. The Director of Nursing acknowledged the family's concerns about the lack of heel protector boots on Resident 903, despite their presence in the room. The facility's policy on skin management emphasizes the importance of timely interventions to prevent and heal pressure injuries, which was not adhered to in these cases.
Failure to Ensure Dignified Dining Experience
Penalty
Summary
The facility failed to ensure a dignified dining experience for several residents, as observed during two separate dining observations. On the first day, residents were seen waiting for their meals while others were being assisted with eating. Some residents expressed hunger and noted that delays in receiving food were common. The final food trays were served significantly later than when the dining began. On the second day, similar observations were made, with residents again waiting for their meals while others received assistance. Residents expressed their hunger and desire to eat, but their meals were delayed. Interviews with the Registered Dietician and Dietary Manager revealed that the facility's protocol was to serve meals to residents needing 1:1 assistance first, which resulted in delays for other residents. The facility's policy on resident dignity and personal privacy emphasizes providing care that respects and enhances each resident's dignity and self-worth. However, the observed dining practices did not align with this policy, as residents were left waiting and watching others eat, which compromised their dignity and self-determination.
Failure to Provide Accessible Fluids for Resident
Penalty
Summary
The facility failed to ensure that water and other fluids were available and accessible for a resident, resulting in the potential for thirst and complications from dehydration. On multiple occasions, the resident was observed in their bed with their lunch tray, which included a pureed meal and two magic cup supplements. However, two full cups of thickened orange juice were placed across the room on a dresser, out of the resident's reach, and the staff member who set up the tray did not move the juices within reach. Additionally, no water was observed to be provided within the resident's reach. The resident's clinical record indicated they had been readmitted to the facility with diagnoses including stroke, dysphagia, hemiplegia, and vascular dementia, and were on a regular diet with pureed texture and honey thickened liquids. Despite these needs, the facility's Director of Nursing acknowledged that fluids should have been within the resident's reach, but no policy on accommodation of needs or water within reach was provided by the end of the survey.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for two residents, resulting in potential issues related to nutrition and personal hygiene. Resident 39, who is non-verbal and severely cognitively impaired, was observed with long fingernails and dark debris under the nail beds over several days. Additionally, Resident 39's meal trays were consistently returned with unopened food items, despite the resident's care plan indicating a need for 1:1 assistance with eating. The facility's documentation inaccurately recorded the resident's meal consumption as 'Refused,' despite the resident's inability to verbally refuse food. Resident 98, who has Alzheimer's disease, protein-calorie malnutrition, and hemiplegia, was observed struggling to eat without the required 1:1 assistance and verbal cues as indicated in their care plan. On multiple occasions, Resident 98 was left to eat independently, despite their documented need for assistance due to cognitive and physical impairments. The facility's failure to provide the necessary support during meals was confirmed by the registered dietician, who acknowledged that staff should have been assisting Resident 98. The facility's policies on personal hygiene and meal service were reviewed, but the provided policy did not address the specific ADL care required for residents. The meal service policy indicated that residents should receive appropriate assistance during meals, which was not adhered to in the cases of Residents 39 and 98. This lack of adherence to care plans and facility policies contributed to the deficiencies observed during the survey.
Failure to Secure Legal Representation for Incapacitated Resident
Penalty
Summary
The facility failed to advocate for legal representation for a resident, identified as R107, who was deemed incapable of making informed medical decisions due to conditions including epilepsy, traumatic brain injury, hallucinations, and dementia. Despite a Statement of Capacity dated March 21, 2023, indicating R107's inability to make medical decisions, the facility did not have any documents showing a legal decision maker for R107. An interview with Social Services Staff 'K' revealed that the family had retained an attorney who was allegedly preventing the facility's consulting company from proceeding with obtaining guardianship, although no explanation was provided as to how the attorney was preventing the petition process. The facility's social services staff provided a timeline indicating that R107 was referred to the consulting company on November 6, 2023, which was eight months after the capacity determination. The timeline also noted that the facility decided to move forward with filing for guardianship on June 11, 2024, despite the family's attorney's involvement. The facility's Social Worker Job Description included the responsibility of facilitating the appointment of a responsible party as needed, highlighting a lapse in fulfilling this essential function for R107.
Inaccurate Medical Records for Resident's Splint Program
Penalty
Summary
The facility failed to maintain accurate medical records for a resident, identified as R74, who was observed lying in bed and reported being unable to stand due to paralysis in the right arm. The resident, who had been at the facility for about two years, was supposed to be on a Maintenance Splint Program that required the application of a right hand splint for up to four hours daily, along with monitoring skin integrity and performing passive range of motion (PROM) exercises. However, the resident reported not having worn a splint for several months and not receiving any therapy, despite CNA staff documentation indicating that the splint had been applied daily from 5/14/24 through 6/11/24, except for one day. Upon review, it was found that the order for the splint had been discontinued on or about 8/10/23, yet CNA staff continued to document its application. The Unit Manager Nurse confirmed the absence of a current order for the splint and acknowledged that CNAs should not record services that were not provided. The facility's policy on documentation emphasized the importance of accurate and truthful record-keeping, highlighting that false entries are considered willful acts of falsification. This discrepancy between the resident's care and the documentation reflects a failure to adhere to the facility's documentation standards.
Infection Control Deficiencies in PPE and Precaution Signage
Penalty
Summary
The facility failed to adhere to proper infection prevention and control practices, particularly concerning transmission-based precautions (TBP) and contact precautions for several residents. Observations revealed that staff did not consistently follow the required protocols for personal protective equipment (PPE) when entering rooms of residents on enhanced barrier precautions (EBP) and contact/droplet precautions. For instance, staff were observed entering rooms without donning N95 masks or eye protection, despite signage indicating these were necessary. Additionally, there were discrepancies between the signage and the actual physician orders, as seen with residents who had signs for contact/droplet precautions but only had orders for EBP. Several residents were affected by these lapses in infection control. One resident, who was on dialysis, did not have appropriate signage indicating the need for EBP, and staff reportedly did not wear gowns during care. Another resident with a PEG tube had their dressing changed by an LPN who failed to follow EBP by not wearing a gown, even after being reminded. Furthermore, a resident with a catheter was mistakenly placed on EBP due to a lack of awareness about their condition of impetigo, which required contact precautions instead. Interviews with staff, including a Certified Nurse Aide and the Director of Nursing (DON), highlighted a lack of awareness and understanding of the correct precautions needed for specific residents. The DON acknowledged that certain precautions were not correctly implemented, such as the unnecessary contact/droplet precaution signage and the failure to initiate EBP for a resident upon admission. These deficiencies indicate a systemic issue in the facility's infection control practices, potentially leading to the spread of infections among residents.
Failure to Assess Residents for Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that two residents, R12 and R43, were assessed for the safe self-administration of medications. R12, who has diagnoses including Dementia with mood disturbance and mild cognitive impairment, was observed self-administering a nebulizer solution treatment without any nursing supervision. A review of R12's medical records, including the physician orders and comprehensive care plan, did not show any assessment for the safe self-administration of the nebulizer treatment. R12's BIMS score indicated moderately impaired cognition, which further necessitates a formal assessment before allowing self-administration of medication. Similarly, R43, who has diagnoses including end-stage renal disease and congestive heart failure, was found with a fluticasone nasal spray on their bedside table, which they had been using without any formal assessment for self-administration. R43's medical records also lacked any indication of an assessment for safe self-administration of the nasal spray. The facility's policy requires a self-administration evaluation to be completed prior to allowing residents to self-administer medications, which was not adhered to in these cases. The Director of Nursing confirmed that these residents should not have been self-administering medications without an assessment.
Failure in Medication Administration Standards
Penalty
Summary
The facility failed to ensure that nursing services met professional standards for medication administration for a resident with severe cognitive impairment. The resident, who was admitted with hospice services and had a history of COPD, atrial fibrillation, hypertension, heart disease, bladder pain, anxiety, and dementia, was found with multiple pills scattered in their bed and on the floor. The resident was unable to recall if the medications were given that morning, indicating a lapse in proper medication administration and monitoring. An LPN confirmed that all medications were given and observed as taken, but the presence of pills in the resident's environment suggested otherwise. The facility's policy on medication administration requires that nursing staff observe residents swallowing their medications and prohibits leaving medications with residents to self-administer. The Director of Nursing confirmed that medications should be observed by nursing staff to ensure they are taken, highlighting a failure to adhere to the facility's medication administration policy.
Failure to Provide Engaging Activities for Resident
Penalty
Summary
The facility failed to provide meaningful, diverse, and engaging activities for a resident, identified as R74, who was observed to be lying in bed and reported feeling bored all the time. R74, who had been at the facility for about two years, was diagnosed with vascular dementia, depression, and type II diabetes, and had a BIMS score indicating impaired cognition. The resident required extensive assistance with most Activities of Daily Living and was unable to stand, with a paralyzed right arm and non-functional legs. Despite these conditions, the resident reported that they were only watching TV and had not been offered any other activities, and they could not see the activity schedule due to vision problems. The resident's care plan, which had not been updated since March 2022, indicated a preference for independent or in-room activities and included interventions such as offering outdoor activities and providing an activities calendar. However, there was no documentation of activities being provided or refused, and no notes from the Activity Director were found in the resident's clinical record. Interviews with the Activity Director and an Activity Assistant revealed that the resident did not get out of bed, and the activities provided were limited to brief 1:1 visits, music/radio, and TV/movies, with no other activities offered due to the resident's inability to get out of bed. The facility's policy on activities emphasized the importance of providing an ongoing program based on individual evaluations and care plans, but this was not reflected in the services provided to R74.
Deficiencies in Clinical Assessment and Medication Administration
Penalty
Summary
The facility failed to perform ongoing, accurate clinical assessments and ensure interdisciplinary team collaboration for a resident with a Percutaneous Endoscopic Gastrostomy (PEG) tube. The resident, who had severe cognitive impairment and a history of stroke, was observed with a PEG tube site that had significant bloody drainage and purulent discharge. Despite the resident no longer requiring enteral feedings and tolerating a regular diet, the PEG tube remained in place, leading to recurrent infections and pain at the site. The interdisciplinary team, including wound care and infection control, did not collaborate effectively to address the resident's condition, and the resident was not discussed in the facility's At Risk Meeting. Another deficiency involved the facility's failure to administer prescribed ear drops to a resident experiencing ear pain. The resident, who had moderately impaired cognition, reported not receiving the ear drops ordered by the medical doctor. The medication was documented as unavailable for several days, and the resident continued to experience pain. The Director of Nursing was unaware of how the medication was signed off as administered when it was not available on the medication cart. These deficiencies highlight a lack of proper communication and coordination among the facility's staff, leading to inadequate care and prolonged discomfort for the residents involved. The facility's policies and procedures for ensuring timely and accurate medical treatment were not effectively implemented, resulting in negative outcomes for the residents.
Failure to Adhere to Physician-Ordered Oxygen Therapy
Penalty
Summary
The facility failed to ensure that a resident received the correct physician-ordered oxygen therapy, resulting in elevated blood oxygen levels. The resident, who had a history of chronic obstructive pulmonary disease (COPD), pneumonia, and dependence on oxygen, was observed receiving oxygen at six liters per minute via nasal cannula, despite a physician's order specifying three to four liters per minute to maintain oxygen saturation levels between 93-94%. Observations over several days confirmed that the oxygen concentrator was set at six liters per minute, and the resident's documented oxygen saturation levels consistently exceeded the recommended range, reaching as high as 100%. The Director of Nursing acknowledged that staff should have adhered to the physician's orders, and the facility's policy for oxygen therapy did not address the necessity of following physician orders for appropriate oxygen delivery.
Failure to Ensure Physician Orders for Dialysis Care
Penalty
Summary
The facility failed to ensure that Physician orders were in place for the treatment, monitoring, and assessment of a resident who was on hemodialysis. The resident, identified as R43, was observed on multiple occasions and reported that the nursing staff did not regularly assess their dialysis access site. Additionally, the medical record review revealed that there were no Physician orders for dialysis treatment or monitoring of the access site for potential complications such as thrill, bruit, stenosis, or thrombosis. The facility's policy required such orders and regular assessments, but these were not documented in R43's records. The Director of Nursing (DON) confirmed that residents on dialysis should have Physician orders and regular monitoring of the access site, but was unable to explain why R43's records lacked these orders. The facility's policy on hemodialysis outlined specific procedures for assessing the dialysis access site for various complications, yet these procedures were not followed for R43. This deficiency was identified through observations, interviews, and a review of the resident's medical records, highlighting a failure in the facility's adherence to its own policies regarding dialysis care.
Duplicate Medication Order for a Resident
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, resulting in a deficiency. A review of the medical records revealed that a resident was receiving duplicate orders for Montelukast Sodium, with one order for allergies and another incorrectly for hypertension, leading to a total daily dosage of 20mg. The Director of Nursing (DON) confirmed that hypertension was not an appropriate indication for Montelukast and acknowledged the duplicate order after consulting with the nurse practitioner, who stated that one of the orders should be discontinued.
Improper Labeling and Security of Medications
Penalty
Summary
The facility failed to properly label and secure narcotic medications and medication carts. During an observation, a medication cart was found with 30 syringes of Morphine Sulfate, each labeled with the dosage but lacking resident identifiers. The LPN acknowledged the absence of identifiers and indicated the need to contact the pharmacy. The Director of Nursing confirmed that the pharmacy sent the medications without names and that they were returned. Additionally, a medication cart containing various wound and treatment creams was observed unlocked and unattended in a common area, posing a security risk.
Failure to Provide Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide adaptive equipment and assistive devices for a resident, identified as R17, who required them for eating. On two separate occasions, R17 was observed in the dining room attempting to eat lunch without the necessary adaptive equipment specified on their meal ticket. The meal ticket indicated that R17 should have been provided with a divided plate and a two-handed spouted cup, but these items were not provided. R17's medical record indicated that they had diagnoses including dementia and legal blindness, and their care plan included the use of adaptive equipment to assist with eating. The facility's policy on adaptive equipment requires the dietary manager or dietitian to assess residents for the need for adaptive equipment and to ensure that such equipment is provided if needed. However, despite these requirements, R17 was not provided with the necessary adaptive devices during meals. The facility's failure to adhere to its own policy and provide the required equipment resulted in a deficiency in the care provided to R17.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,066 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Waterford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lourdes Rehabilitation And Healthcare Center | 1.2 mi | ★★★★★ | 1 | 0 |
| Oakland Manor Nursing And Rehabilitation Center Ll | 3.2 mi | ★★★★★ | 14 | 0 |
| Villa At Pine Place | 3.3 mi | ★★★★★ | 14 | 0 |
| The Orchards At Canterbury On The Lake | 3.4 mi | ★★★★★ | 5 | 0 |
| The Villa At Silverbell Estates | 5.1 mi | ★★★★★ | 13 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.