The Waterton Healthcare & Rehabilitation

In the surveyor’s words

From the most serious findings on record at The Waterton Healthcare & Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jan 8, 2024

  Based on observation, interviews, and record review the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 6 (Residents #1) residents reviewed for accidents. The facility failed to ensure adequate supervision for Resident #1 who was at risk for elopement. The facility staff were not aware Resident #1 was missing when he eloped on 09/18/23. The facility failed to ensure the function of Resident #1's Wander Guard Monitoring Bracelet was documented each shift for the month of July 2023, August 2023, and September 2023. […]

• Actual harm, isolatedF684Apr 23, 2026

  Based on observation, interview, and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 2 residents (Resident #1) reviewed for quality of care. The facility did not obtain physician order's for wound care to her post-surgical incision sites during her stay at the facility from 3/28/26 to 4/8/26. LVN A did not obtain physician order's for the betadine (a widely used, non-stinging antiseptic that kills germs) she applied to Resident #1's post-surgical incision sights. The facility did not thoroughly assess and document Resident #1's post-surgical incision sites on 3/29/26 and 3/31/26. […]

• Actual harm, isolatedF656Apr 10, 2021

  Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 1 of 6 residents reviewed for care plans. (Resident #1) The facility did not assess or follow physician orders for wound care to left buttocks, right buttocks, coccyx, left and right foot for Resident #1. The facility did not implement interventions to promote the healing of multiple unstageable pressure injuries and wounds to Resident #1 according to the comprehensive care plan. These failures could place residents at risk for unmet care needs due to lack of implementation and following orders. […]

• No harm, potential for more than minimal, patternF641Mar 26, 2025

  Based on interview and record review the facility failed to ensure accurate assessments were completed for 7 of 15 residents (Residents #9, #15, #20, #24, #25, #38, and #112) reviewed for accuracy of assessments. The facility failed to ensure (Residents #9, #15, #20, #24, #25, #38, and #112's MDS assessment was accurately coded for Preadmission Screening and Resident Review (PASRR). These failures could place residents at risk for not receiving the appropriate care and services to maintain the highest level of well-being. […]

• No harm, potential for more than minimal, patternF692Mar 26, 2025

  Based on observation, interview and record review, the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance and offered a therapeutic diet when there is a nutritional problem, and the health care provider orders a therapeutic diet for 1 of 4 residents (Resident #21) reviewed for nutrition. The facility failed to ensure Resident #21 received a health shake (nutritional supplement) on 03/24/25, 03/25/25, 03/26/25 and 2 desserts on 03/24/25, 03/25/25 with her meals as prescribed by the physician. These failures placed the resident at risk for weight loss, malnutrition, loss of energy, and decreased quality of life. […]