Inspection Reports for Alden of Waterford

The facility failed to provide showers as scheduled to 2 of 2 residents reviewed for improper nursing care. Residents missed multiple scheduled showers over consecutive days, indicating inadequate staffing and failure to meet the facility's own policy and regulatory requirements.

This complaint investigation involved one resident (R1) who alleged physical abuse by a CNA. The allegation was reported to the Administrator on August 24, 2025, but local law enforcement was not notified by the facility until August 27, 2025, after the family contacted police. The Administrator acknowledged the failure to report immediately and recognized the requirement to notify police within 24 hours or immediately if serious bodily injury is suspected.

The facility failed to notify local law enforcement immediately after an allegation of physical abuse by a CNA against a resident. The Administrator admitted to not reporting the allegation to police until the family called, contrary to facility policy requiring timely reporting.

The complaint investigation found that the facility did not notify the physician or nurse practitioner of the resident's change in condition and failed to assess the resident promptly. The resident's family and staff interviews confirmed these failures. The facility's policy requires notification and assessment, which were not followed.

The facility failed to notify the physician of a change in condition for one resident and did not immediately assess the resident after the reported change. Documentation of the change of condition assessment was not completed prior to transferring the resident to the hospital.

The facility was found deficient in multiple areas including failure to maintain resident privacy during care and medication administration, improper catheter care leading to potential infection risk, inaccurate accounting and administration of controlled medications, failure to follow dietary menu and food preparation guidelines, inaccurate licensed nurse staffing data submission, and inadequate infection prevention practices including improper use of PPE and hand hygiene.

The complaint investigation found that two Hydrocodone/APAP tablets prescribed for resident R2 (discharged) were given to resident R10 by nursing staff V14 (RN) and V15 (RN). The facility confirmed the discrepancy and staff admitted to unauthorized sharing of narcotics. The Director of Nursing stated that staff were educated not to share narcotics and that proper procedures involving physician orders and pharmacy authorization were not followed.

The facility failed to follow proper controlled substance policies, leading to a discrepancy of two Hydrocodone/APAP tablets that were given from a discharged resident's supply to another resident without proper authorization. Nursing staff admitted to sharing narcotics between residents, which is against facility policy and regulations.

The facility failed to follow a physician's treatment order for R1's sacral wound and did not notify the wound physician promptly about a new right buttock pressure injury. The wound care nurse did not use the prescribed foam dressing, opting instead for an ABD dressing, which the physician stated was inadequate for proper wound protection and coverage. The wounds were chronic and prone to reopening, with bleeding noted at times.

The facility failed to ensure staff used a gait belt when transferring a resident (R1) who required assistance, resulting in multiple falls. The deficiency was noted as minimal harm with few residents affected.

The complaint investigation was triggered by allegations of inadequate care including failure to assist residents with toileting and eating, delayed hospital transfer for a resident with critical lab values, incomplete wound care and weight monitoring, unsafe transfers, pain management issues, medication regimen concerns, and infection control breaches.

The facility was found deficient in multiple areas including failure to provide timely toileting and eating assistance, delayed hospital transfer for a resident with critically low potassium resulting in death, incomplete wound care and daily weights, unsafe mechanical lift transfers, inadequate pain management, failure to report pharmacy recommendations timely, improper use of psychotropic medications, lack of assistive eating devices, and failure to follow infection control protocols including PPE use.

The complaint investigation found that the facility failed to administer Gentamicin bladder irrigation as ordered, with missed doses and incorrect transcription of the medication schedule. The resident's urine was positive for ESBL, a multi-drug resistant organism. The Director of Nursing and the resident's physician confirmed awareness of the missed irrigations and transcription errors.

The facility failed to administer Gentamicin bladder irrigation as ordered for resident R1, resulting in missed doses and incorrect transcription of the medication schedule. The resident's urine tested positive for a multi-drug resistant organism, and the Director of Nursing and the resident's physician acknowledged the errors.

The complaint investigation found that the resident's indwelling urethral catheter was clamped for several hours after antibiotic administration, causing bladder pain. The issue was substantiated with interviews of nursing staff and physician orders.

The facility failed to properly follow physician orders for clamping and unclamping the indwelling urethral catheter during Gentamicin irrigation, resulting in the catheter being left clamped for several hours. This caused bladder pain and discomfort to the resident (R1), who required pain medication and additional interventions. The physician was notified and ordered Pyridium for bladder discomfort.

The complaint investigation focused on an alleged improper transfer of resident R3 on 2/1/2023. The CNA transferred R3 alone despite the care plan requiring 2-person assist. The allegation of bruising was not substantiated as staff observed no new bruises or injuries.

The facility failed to implement the assessed need for a 2-person assist for resident R3 during transfers. The CNA responsible transferred R3 alone without assistance, contrary to the resident's care plan. No bruises or falls were observed during the transfers, but the required 2-person assist was not followed.

The facility was found deficient in multiple areas including catheter care, medication administration, infection prevention and control, and medication storage. Specific issues included improper catheter bag positioning, failure to provide ordered eye medications, use of expired insulin, and inadequate hand hygiene during wound care and catheter care.

The facility failed to properly position catheter bags, perform appropriate hand hygiene, and follow infection control protocols during catheter care and wound dressing changes. These deficiencies were observed in multiple residents and involved staff not changing gloves or washing hands between tasks, increasing the risk of infection.