Waters of Hartford City Skilled Nursing Facility

In the surveyor’s words

From the most serious findings on record at Waters of Hartford City Skilled Nursing Facility, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF804Mar 3, 2026

  Based on observation, interview, and record review, the facility failed to ensure food was served at a comfortable and palatable temperature for 1 of 7 residents reviewed for dining services. (Resident 37)Findings include:During a dining observation on 2/24/26 at 12:08 p.m., Resident 3 indicated to her tablemate that the mashed potatoes were very hot and warned the tablemate to be careful when eating them. During the same meal service, Resident 37 was seated at a separate table and was being assisted by a hospice certified nurse aide (CNA). When the CNA provided a spoonful of mashed potatoes, Resident 37 immediately lifted her fingers to her lips and widened her eyes. The CNA continued offering other food items and subsequently re-offered the mashed potatoes. […]

• No harm, potential for more than minimal, patternF600Mar 28, 2022

  Based on observation, interview and record review, the facility failed to provide adequate supervision to prevent resident to resident abuse for 5 of 6 residents reviewed for abuse (Resident 35, 42, 1, 43 and 6). Findings include: 1. Resident 35 had the following observations: On 3/23/22 at 1:48 p.m. she was lying in bed. On 3/24/22 at 9:54 a.m., she sat in her wheelchair across from the 300 hall nurses station. On 3/25/22 at 12:07 p.m., she was in the main dining room eating lunch a staff member was sat next to her and assisted her with her meal. On 3/28/22 at 10:41 a.m., she was lying in bed. Resident 35's clinical record was reviewed on 3/23/22 at 3:23 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, patternF744Mar 28, 2022

  Based on observation, interview and record review, the facility failed to develop individualized interventions to prevent resident to resident abuse for 5 of 6 residents reviewed for abuse (Resident 35, 42, 1, 43 and 6) and for failed to develop individualized interventions and indication for use of an anti-psychotic for 2 of 5 resident reviewed for unnecessary medications (Resident 43 and 22). Findings include: 1. Resident 35 had the following observations: On 3/23/22 at 1:48 p.m. she was lying in bed. On 3/24/22 at 9:54 a.m., she sat in her wheelchair across from the 300 hall nurses station. On 3/25/22 at 12:07 p.m., she was in the main dining room eating lunch a staff member was sat next to her and assisted her with her meal. On 3/28/22 at 10:41 a.m., she was lying in bed. […]

• No harm, potential for more than minimal, isolatedF645Feb 9, 2024

  Based on interview and record review, the facility failed to ensure a preadmission screening and resident review (PASRR) was completed when the initial authorization for placement expired for 1 of 4 residents reviewed for PASRR. (Resident 12) Finding includes: Resident 12's clinical record was reviewed on [DATE] at 11:12 a.m. Her current diagnoses included bipolar disorder, other schizoaffective disorders, and major depressive disorder, recurrent. Current physician orders included bupropion hydrochloride extended release (antidepressant) 300 mg daily, hydroxyzine 50 mg (used for anxiety) three times a day and quetiapine fumarate (antipsychotic) 100 mg daily and 150 mg at bedtime. […]

• No harm, potential for more than minimal, isolatedF686Feb 9, 2024

  Based on observation, record review, and interview, the facility failed to implement and review individualized interventions to prevent the development of a pressure injury for 1 of 3 residents reviewed for pressure injuries. (Resident 32) Finding includes: During an observation on 2/5/24 at 10:57 a.m., Resident 32 was sitting in her room in her wheelchair with a heel boot on her left leg and foot. During a wound observation on 2/7/24 at 9:11 a.m., the bandage was removed from the pressure injury to the left heel. The wound was the size of a half dollar in length, the size of a quarter in width, and had a 0.1 cm depth. The center of the wound was tan slough (nonviable tissue) with the length of the entire wound and the width of a pencil eraser. […]