Waters of Middletown Skilled Nursing Facility, The

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF812Dec 9, 2024

  Based on observation, interview, and record review, the facility failed to ensure food items were closed to air and contaminants, expired food was disposed of timely, and label food containers with the date opened and discard dates with the potential to affect 19 of 19 residents residing at the facility. Findings include: The facility kitchen was observed with the Kitchen [NAME] (KC) on [DATE] at 10:30 a.m. The dry storage area contained a bag of sugar in a box. The bag of sugar was open to air. There was an undated loaf of cinnamon bread, with mold visible through the packaging, present on the bread rack. […]

• No harm, potential for more than minimal, patternF880Dec 9, 2024

  Based on observation, interview, and record review, the facility failed to ensure infection control was maintained during medication administrations by not utilizing hand hygiene, glove usage, and touching pill medication with bare hands for 5 of 5 residents reviewed for medication administrations. (Residents' 8, 11, 12, D, and 19) Findings include: 1. The clinical record for Resident D was reviewed on 12/4/24 at 2:00 p.m. The diagnoses included, but were not limited to, stroke. An observation was made of Resident D's medication administration with Registered Nurse (RN) 3 on 12/5/24 at 9:00 a.m. RN 3 was observed finishing up with administering medications to another resident. After the administration, RN 3 hugged the resident. […]

• No harm, potential for more than minimal, patternF732Apr 26, 2024

  Based on observation, interview and record review, the facility failed to post the facility's nursing staffing for five (5) consecutive dates. This deficient practice has the potential to adversely affect all residents. Findings include: On 4-24-24 at 9:55 a.m., the facility's posted staffing was observed to be located by the nursing station. The posted staffing dates were for 4-18-24 and 4-19-24. This posting was unchanged at an observation conducted on 4-24-24 at 1:35 p.m. This posting was updated as of an observation on 4-25-24 at 1:56 p.m., to the current date of 4-25-24. In an interview with the Executive Director on 4-25-24 at 4:30 p.m., she indicated she has been conducting the nursing work schedules for some time at the facility. […]

• No harm, potential for more than minimal, isolatedF656Jan 29, 2026

  Based on observation, interview and record review, the facility failed to ensure a comprehensive plan of care was completed to address limited range of motion for 1 of 1 resident reviewed. (Resident 26) Findings include: During an observation, on 01/27/2026 at 8:56 AM with Assistant Director of Nursing (ADON), Resident 26 was sitting in common area in a Broda chair. Resident 26 had her eyes closed and had her head and chin tucked down and bent into her right shoulder without any support. Resident 26 denied any pain. Resident 26 was willing to shake her head yes or no. When asked to bring her head to her left shoulder, she was unable to bring her head to midline. […]

• No harm, potential for more than minimal, isolatedF740Jan 29, 2026

  Based on interview and record review, the facility failed to ensure behaviors were accurately recorded and managed for 1 of 3 residents reviewed (Resident B).Findings include:Resident B's record was reviewed on 1/27/25 at 10:52 AM. Diagnoses included dementia, moderate, with behavioral disturbance.Resident B's current quarterly Minimum Data Set (MDS) assessment, dated 12/26/2025, indicated their Basic Interview for Mental Status (BIMS) score was 14 (cognitively intact). The MDS indicated Resident B did not have any behavior occurrences in the last 7 days of the review period.Resident B's current care plan, titled sexually inappropriate behavior indicated the resident had a problem of sexually inappropriate touching and verbal remarks, with a goal date of 4/3/2026. […]