Waterford Place Health Campus

In the surveyor’s words

From the most serious findings on record at Waterford Place Health Campus, in the surveyor’s own words.

• Actual harm, isolatedF686Nov 21, 2022

  Based on observation, interview and record review, the facility failed to ensure a resident at risk for development of pressure ulcers received the necessary care, treatment, and services, consistent with professional standards of practice, to prevent a pressure ulcer and promote healing for 1 of 1 resident reviewed for pressure ulcers. (Resident 23) Resident 23 had developed two pressure ulcers at the facility and the wound was discovered as a stage 2 and unstageable. Finding includes: During the initial tour of the facility, on 11/14/22 at 11:30 a.m., Resident 23 was observed sitting, in her bed, with the head of the bed elevated. A low air loss mattress was on the resident's bed. The resident's heels were directly on the mattress. […]

• No harm, potential for more than minimal, patternF684Feb 2, 2026

  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. […]

• No harm, potential for more than minimal, patternF695Feb 17, 2025

  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. […]

• No harm, potential for more than minimal, patternF921Feb 17, 2025

  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. […]

• No harm, potential for more than minimal, patternF695Nov 21, 2022

  Based on observation, interview and record review, the facility failed to ensure an oxygen nasal cannula was dated, failed to ensure a physician's order was followed, failed to ensure a nebulizer mask and tubing were dated, and failed to ensure a resident had an order with BIPAP (machine used to treat sleep apnea) settings for 4 of 4 residents reviewed for respiratory care. (Resident 23, 38, 61 and 18) Findings include: 1. During an observation, on 11/14/22 at 12:51 p.m., Resident 23 was seated in her bed with the head of bed elevated to 50-degrees. Her oxygen tubing was positioned to her right cheek. Her door lacked indication she was on oxygen. No date or label was found on her tubing. […]