Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Waterford Care Center, The during CMS and state inspections, most recent first.
A resident with cognitive impairment and multiple medical conditions was found by hospital staff to have bruising and bleeding in the vaginal and perineal area, in addition to other bruises. The ER nurse notified the facility nurse, but the information was not promptly reported to the abuse coordinator or state agency as required by facility policy. Facility staff interviews confirmed delays and lack of communication regarding the incident, resulting in a deficiency in abuse reporting procedures.
A resident with cognitive impairment and on anticoagulants was found by hospital staff to have unexplained bruising and bleeding in the vaginal and perineal areas, which was reported to a facility nurse. The facility failed to document, report, or investigate these findings as required by policy, and key leadership, including the DON and Administrator, were not notified. No investigation into the injury of unknown origin was initiated.
A resident with moderate cognitive impairment and multiple psychiatric diagnoses experienced a choking episode requiring the Heimlich maneuver and supplemental oxygen. Although the provider was notified, the state guardian was not informed of the incident or the change in condition, contrary to facility policy and guardianship requirements.
A resident in an LTC facility did not receive their prescribed Baclofen 10 mg due to a medication shortage. The nurse used a substitute Baclofen 5 mg card with a torn-off label, which is against professional standards. The DON was unaware of the shortage and confirmed that borrowing medications is not allowed. Facility policies require proper labeling and administration of medications.
A resident did not receive her prescribed Ambien medication for two days after returning from knee surgery due to unavailability in the facility. Despite a sufficient supply being dispensed, the medication was not administered as confirmed by the MAR. The DON and RN were aware of the issue, but the facility failed to adhere to its policy of administering medications as per prescriber orders.
The facility failed to follow proper sanitation and food storage practices, with uncovered and unlabeled food items found in the freezer and personal items on the clean dish rack. The Dietary Manager confirmed these practices were against facility policy, which requires food to be dated and personal items stored in designated areas.
The facility failed to conduct timely PASARR screenings for four residents, leading to a deficiency. These residents, with various mental health diagnoses, were not evaluated for Level I or Level II PASARR prior to or upon admission, as required. The Social Services Director acknowledged the oversight but could not provide a reason for the lapse.
The facility failed to set low air loss mattresses to the correct weight settings for four high-risk residents, compromising the effectiveness of these devices in preventing pressure ulcers. The Wound Care Nurse confirmed that the settings should match the residents' current weights, but observations showed discrepancies, such as a resident weighing 219 pounds with a mattress set to 290 pounds.
A survey found deficiencies in medication management at an LTC facility. An LPN left a medication cart unattended and unlocked on the first floor, while an RN found expired vitamin D tablets on the second floor. The DON confirmed the importance of securing medication carts and discarding expired medications, as per facility policy, to prevent unauthorized access and administration of expired drugs.
The facility failed to maintain proper infection control by not covering a linen cart, risking contamination, and a CNA did not wear a gown while caring for a resident on Enhanced Barrier Precautions. The resident had a history of MRSA and required specific precautions, which were not adhered to, as confirmed by the DON.
The facility failed to maintain the dignity of two residents. One resident, with a history of dementia, was repeatedly observed disrobed in bed with the privacy curtain open, exposing them to others. Despite the resident's preference to disrobe, staff acknowledged the need for privacy measures, which were not consistently applied. Another resident with a urinary catheter was seen with an uncovered drainage bag, despite expressing the need for a privacy bag with straps. These incidents highlight a failure to adhere to policies ensuring resident dignity and privacy.
A resident with respiratory failure and asthma was found with an incorrect oxygen flow rate of 2 LPM instead of the prescribed 3 LPM. The resident's oxygen cannula was also not in place, reportedly removed by a CNA. A nurse confirmed the error and corrected the flow rate. The DON highlighted the importance of following physician orders and ensuring proper oxygen administration.
Failure to Timely Report Injury of Unknown Origin and Hospital Findings
Penalty
Summary
The facility failed to report an allegation of injury of unknown origin for a resident who was cognitively impaired and had multiple medical conditions, including long-term use of anticoagulants. The resident was re-admitted to the facility with documented bruising on her arms, legs, and thighs, but there was no documentation of bruising or bleeding in the vaginal or perineal area in the facility's records. During a subsequent hospitalization, an ER nurse identified bleeding and bruising in the resident's vaginal and perineal area, as well as additional bruising on the right thigh, and communicated these findings to the facility nurse. The facility nurse stated she was unaware of the bruising and bleeding in those areas and did not immediately report the information to the abuse coordinator or the state agency. Interviews with facility staff revealed that the wound care nurse had observed bruising on the resident's extremities and groin area upon re-admission and reported this at a morning meeting, but did not observe vaginal bleeding. The nurse in charge at the time of the resident's transfer to the hospital acknowledged being informed by the ER nurse about the bruising and bleeding but delayed notifying the Director of Nursing and did not report the incident to the abuse coordinator or state agency as required. The Director of Nursing and Administrator both confirmed they were not notified about the hospital's findings of vaginal bleeding and bruising, and facility policy requires immediate reporting of any suspected abuse, including injuries of unknown origin. Facility policies reviewed indicate that all incidents, allegations, or suspicions of abuse, neglect, or injuries of unknown source must be reported immediately to the administrator and appropriate authorities, with initial reporting to the state agency required within two hours if abuse or serious bodily injury is suspected. In this case, the failure to promptly report the injury of unknown origin and the findings communicated by the hospital staff constituted a deficiency in the facility's abuse reporting procedures.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate an allegation of injury of unknown origin for one resident with significant medical history, including long-term anticoagulant use, cognitive impairment, and a colostomy. The resident was re-admitted to the facility with documented bruising on her arms and legs, but there was no documentation in the care plan or progress notes regarding bruising or bleeding in the vaginal, groin, or perineal areas. Hospital records and interviews with the emergency room nurse indicated that the resident was found with bleeding and bruising in these sensitive areas, which was communicated to the facility nurse at the time of hospitalization. Despite this notification, the facility staff did not document or report the new findings of vaginal and perineal bruising and bleeding. The nurse in charge at the time of the incident acknowledged being informed by the hospital but did not immediately notify the Director of Nursing or the Administrator, as required by facility policy. The Director of Nursing and Administrator both stated they were not made aware of the hospital's findings regarding the vaginal injuries, and no investigation was initiated into the injury of unknown origin. Facility policy requires immediate reporting and investigation of any alleged abuse or injury of unknown source, especially when the resident cannot explain the injury and the location is suspicious. In this case, the lack of timely reporting and investigation by staff resulted in a failure to respond appropriately to an allegation of potential abuse or injury of unknown origin, as required by both facility policy and regulatory standards.
Failure to Notify State Guardian After Resident Choking Incident
Penalty
Summary
The facility failed to notify a resident's state guardian following a significant change in the resident's condition. The resident, who has a history of dementia, schizoaffective disorder, and major depressive disorder, experienced a choking episode during dinner. The nurse on duty responded by performing the Heimlich maneuver, clearing the airway obstruction, and administering supplemental oxygen when the resident's oxygen saturation dropped to 89-90%. The resident's condition stabilized after intervention, and the provider was notified, but there was no documentation that the state guardian was informed of the incident or the change in oxygen saturation within 24 hours. Interview with the nurse involved revealed that he was unaware the resident had a state guardian and therefore did not notify the guardian after the incident. The Director of Nursing confirmed that facility policy requires notification of the resident's physician and representative or guardian in the event of a change in condition or incident. The resident's guardianship documentation also specifies that the public guardian must be notified immediately of incidents or changes in condition. Despite these requirements, the guardian was not informed as required.
Medication Mismanagement and Labeling Deficiency
Penalty
Summary
The facility failed to adhere to professional standards of medication management, affecting a resident who was prescribed Baclofen 10 mg for musculoskeletal therapy. The issue arose when the resident's Baclofen medication was not available in the facility, and the nurse discovered that the medication had been lost. The pharmacy confirmed that a 30-day supply had been dispensed and signed for by a facility staff member, indicating that the medication should still have been available. In response to the shortage, a nurse used a substitute bingo card containing Baclofen 5 mg tablets, which had a torn-off label with another resident's name and the current resident's name handwritten on it. The Director of Nursing (DON) was unaware of the medication shortage until the day of the survey and confirmed that the practice of borrowing medications from one resident to administer to another is against professional standards. The facility's policy clearly states that medications ordered for a particular resident may not be administered to another resident, and any drug containers with missing or incorrect labels should be returned to the pharmacy for proper labeling. The DON also mentioned that she collects discontinued medication bingo cards in her office until the pharmacy picks them up, but she did not supply the Baclofen 5 mg card to the nurses. This incident highlights a breach in medication management protocols, as the facility failed to ensure proper labeling and administration of medications according to professional standards.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to ensure that medications were administered as ordered by the resident's physician, resulting in a significant medication error for one resident. The resident, who had returned to the facility after knee surgery, did not receive her prescribed Ambien medication for two days. The Director of Nursing (DON) and a Registered Nurse (RN) were aware of the issue, as the medication was not available in the facility. Despite a 30-day supply of Ambien being dispensed to the facility and signed for by a staff member, the medication was not administered on the specified dates, as confirmed by the medication administration record (MAR). The General Manager of Pharmacy confirmed that there was a sufficient supply of Ambien, and there should not have been any lapses in administration. However, the DON was unsure if the medications were properly managed when the resident was readmitted, and did not verify if the medication was available in the emergency box. The facility's policy requires medications to be administered in accordance with prescriber orders, which was not adhered to in this case, leading to the deficiency.
Improper Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to adhere to proper sanitation and food storage practices, as observed during a kitchen tour. Several food items, including turkey hot dogs, chicken patties, and chicken leg quarters, were found in the walk-in freezer uncovered and without open or discard dates. This lack of labeling and proper storage could potentially lead to foodborne illnesses, as dietary staff may not be aware of how long the food has been open. The Dietary Manager acknowledged that all food items should be dated once removed from their original packaging, in accordance with the facility's policy. Additionally, personal items such as cell phones and eyeglasses were found on the clean dish rack, which is against the facility's policy that prohibits storing personal belongings in the kitchen to prevent cross-contamination. The Dietary Manager confirmed that these items belonged to dietary employees and reiterated that personal items should be stored in designated areas like the locker room. The facility's policy on food storage and employee personal items, dated 2017, outlines these requirements to ensure safe food handling and storage practices.
Failure to Conduct Timely PASARR Screenings
Penalty
Summary
The facility failed to initiate a new Level I PASARR screening for four residents, which is a requirement for assessing mental disorders or intellectual disabilities. The deficiency was identified during a survey where it was found that residents R6, R7, R11, and R32 did not have the necessary PASARR screenings completed prior to or upon their admission to the facility. This oversight was discovered when the surveyor requested the PASARR screenings and found that they were only completed on 12/18/2024, despite the residents having been admitted earlier. Resident R11 was admitted with diagnoses including schizoaffective disorder and bipolar disorder, yet there was no documentation of a PASARR Level I or Level II evaluation prior to the survey date. Similarly, Resident R6, who has a history of schizoaffective disorder and other mental health conditions, was found to require a Level II evaluation, but this had not been conducted. Resident R7, with a history of bipolar disorder and self-harmful ideation, also required a Level II evaluation, which was not completed in a timely manner. Resident R32, who has a history of major depressive disorder and dementia, was similarly found to need a Level II evaluation. The Social Services Director acknowledged the responsibility for completing and submitting PASARR screenings but could not provide a reason for the failure to conduct these screenings. The facility's policy mandates that all new admissions undergo a Level I PASARR screening to determine the need for a Level II evaluation, which was not adhered to in these cases.
Incorrect Low Air Loss Mattress Settings for High-Risk Residents
Penalty
Summary
The facility failed to ensure that low air loss mattress devices were set to the correct weight settings for four residents who were at high risk of developing pressure ulcers. These residents were observed to have their mattress settings either too high or too low compared to their current weights, which could compromise the effectiveness of the mattresses in preventing pressure ulcers. For instance, one resident with a weight of 219 pounds had their mattress set to 290 pounds, while another resident weighing 86 pounds had their mattress set to 120 pounds. The facility's Wound Care Nurse confirmed that the low air loss mattresses should be set according to the current weight of the residents to effectively decrease pressure on bony areas and prevent pressure ulcers. The facility uses the BRADEN score to assess the risk of skin breakdown, and all four residents had scores indicating a high risk for developing pressure ulcers. The facility's policy requires that individuals at risk for pressure ulcers be placed on appropriate support surfaces, but the incorrect settings observed indicate a failure to adhere to this policy.
Medication Storage and Disposal Deficiencies
Penalty
Summary
The facility failed to properly manage medication storage and disposal, as observed during a survey. On the first floor, a medication cart was found unattended and unlocked, which was the responsibility of an LPN. This cart contained medications for residents on that floor, posing a risk of unauthorized access. Additionally, on the second floor, a medication cart inspection revealed a bottle of vitamin D tablets with an expiration date of the previous month. The RN acknowledged that expired medications should be discarded promptly to prevent administration to residents. The Director of Nursing confirmed the importance of securing medication carts when unattended to prevent access by residents or visitors. The facility's policy mandates that all drugs and biologicals be stored in locked compartments and that expired medications be returned to the pharmacy or destroyed. The survey findings indicated that these policies were not followed, potentially affecting the 86 residents residing in the facility.
Infection Control Deficiencies in Linen Storage and PPE Usage
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures were in place, specifically regarding the storage of facility linen and the use of Personal Protective Equipment (PPE) by staff. A linen cart was observed in the hallway without a side covering, containing towels, sheets, pillowcases, and gowns, which could lead to contamination. The Director of Nursing and the Maintenance Supervisor acknowledged that uncovered linen could become contaminated, and the linen cart with the missing flap needed replacement. Additionally, a Certified Nurse Assistant (CNA) was observed providing care to a resident on Enhanced Barrier Precautions without wearing a disposable gown, as required. The resident, who had a history of MRSA and was on long-term enteral feeding, required Enhanced Barrier Precautions. The Director of Nursing confirmed that staff should wear a mask, gloves, and a disposable gown when caring for such residents, but this protocol was not followed in this instance.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to maintain the dignity of a resident, identified as R6, by not ensuring their body was covered to prevent exposure to others. R6, who has a history of dementia and schizoaffective disorder, was observed multiple times lying in bed with only a diaper and socks on, with the privacy curtain open, allowing them to be viewed from the doorway. Despite R6's preference to disrobe, the facility staff, including the Director of Nursing and Social Services Director, acknowledged that the privacy curtain should be drawn to maintain dignity. However, the care plan addressing R6's behavior of disrobing was only updated after the surveyor's observation, indicating a lack of proactive measures to address the issue. Another deficiency was noted with a resident identified as R117, who was observed with a urinary catheter drainage bag hanging underneath their wheelchair without a privacy bag. R117, who has a neurogenic bladder and uses a suprapubic catheter, expressed the need for a privacy bag with straps, as the one provided by the facility was deemed useless. The Registered Nurse confirmed that the urinary drainage bag should be covered for dignity reasons, and the Director of Nursing reiterated that covers are supposed to be used. However, the lack of a proper privacy bag at the time of observation indicates a failure to uphold the resident's dignity. The facility's policies on Activities of Daily Living and Quality of Life-Dignity emphasize the importance of maintaining residents' dignity and privacy. These policies require that residents be treated with respect and that their privacy be protected, including covering urinary catheter bags. The observed deficiencies in maintaining resident dignity and privacy suggest a failure to adhere to these policies, as evidenced by the exposure of R6 and the uncovered urinary drainage bag of R117.
Failure to Follow Physician's Order for Oxygen Administration
Penalty
Summary
The facility failed to adhere to a resident's care plan by not following the physician's order for the correct oxygen flow rate. The resident, who has acute and chronic respiratory failure with hypoxia and unspecified asthma, was observed with an oxygen flow rate set to 2 liters per minute (LPM) instead of the prescribed 3 LPM. This discrepancy was noted during an observation when the resident was found with the oxygen cannula tubing not in place, and the resident reported that a CNA might have removed it during care. The resident expressed the need for continuous oxygen use due to shortness of breath related to asthma and COPD. A registered nurse confirmed the incorrect oxygen flow rate and adjusted it after checking the physician's orders. The Director of Nursing emphasized the importance of following doctor's orders for oxygen administration to meet the individual needs of residents and stated that CNAs should not remove oxygen tubing but should inform nurses to ensure proper administration. The facility's policy on oxygen administration requires verification of physician orders and adherence to the care plan, which was not followed in this instance.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 938 citations issued within 25 miles in the last 12 months — including the 22 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Chicago
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Birchwood Plaza | 0.1 mi | — | 0 | 0 |
| Chalet Living & Rehab | 0.1 mi | — | 16 | 1 |
| Fargo Health Care Center | 0.2 mi | — | 4 | 0 |
| Lakefront Nursing & Rehab Ctr | 0.2 mi | — | 0 | 0 |
| Aperion Care Lakeshore | 0.3 mi | — | 5 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Waterford Care Center, The.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.