A list of the most recent deficiencies for Waterford Place Health Campus. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2024-01-29 | 2024-02-28 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2024-01-29 | 2024-02-28 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-01-29 | 2024-02-28 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-01-29 | 2024-02-28 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-01-29 | 2024-02-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-29 | 2024-02-28 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-01-29 | 2024-02-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-01-29 | 2024-02-28 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2024-01-09 | 2024-01-31 | N |
| Provide activities to meet all resident's needs. | Health | 2024-01-09 | 2024-01-31 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-09 | 2024-01-31 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-01-09 | 2024-01-31 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-12-29 | 2023-01-30 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-12-29 | 2023-01-30 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-12-29 | 2023-01-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-12-29 | 2023-01-30 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-12-29 | 2023-01-30 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-11-21 | 2022-12-20 | N |
| Assess the resident when there is a significant change in condition | Health | 2022-11-21 | 2022-12-20 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-11-21 | 2022-12-20 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-11-21 | 2022-12-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-21 | 2022-12-20 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-11-21 | 2022-12-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-21 | 2022-12-20 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2022-11-21 | 2022-12-20 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2022-11-21 | 2022-12-20 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-11-21 | 2022-12-20 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2022-11-21 | 2022-12-20 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-11-21 | 2022-12-20 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-11-21 | 2022-12-20 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-11-21 | 2022-12-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-11-21 | 2022-12-20 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-11-21 | 2022-12-20 | Y |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2020-02-05 | 2020-03-03 | N |
| Have exits that are accessible at all times. | Fire Safety | 2020-02-05 | 2020-03-03 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2020-02-05 | 2020-03-03 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2020-02-05 | 2020-03-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-02-05 | 2020-03-03 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-02-05 | 2020-03-03 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2020-02-05 | 2020-03-03 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-02-05 | 2020-03-03 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2020-02-05 | 2020-03-03 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2020-02-05 | 2020-03-03 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2020-02-05 | 2020-03-03 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2020-02-05 | 2020-03-03 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-02-05 | 2020-03-03 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2019-12-20 | 2020-01-19 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-12-20 | 2020-01-19 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2019-12-20 | 2020-01-19 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-12-20 | 2020-01-19 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-12-20 | 2020-01-19 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-12-20 | 2020-01-19 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-12-20 | 2020-01-19 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-12-20 | 2020-01-19 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-12-20 | 2020-01-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-12-20 | 2020-01-19 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2019-12-20 | 2020-01-19 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-12-20 | 2020-01-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-12-20 | 2020-01-19 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-12-20 | 2020-01-19 | N |
