Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Apple Rehab Watertown during CMS and state inspections, most recent first.
A resident with dementia had wound care physician notes documenting stage 3 pressure ulcers on the coccyx and thoracic spine, but the MDS was coded with different pressure ulcer stages than reflected in the clinical record. RN and an LPN stated they had viewed the wound and concluded it was stage 2, and noted the wound physician notes should have been reviewed to determine the correct MDS coding.
An LPN failed to use the facility’s required two identifiers before giving meds to three residents. In one case, the resident was identified by name only; in another, by name only because the LPN was nervous; and in the third, by name band only without verifying DOB. The facility policy required at least two identifiers before medication administration.
A resident with cognitive impairment and dependence for eating had a significant monthly weight loss, but the weight discrepancy was not reweighed in a timely manner and no interventions were documented after the initial loss was identified. The resident’s confirmed weight loss was later reviewed by the dietitian, who recommended supplements and monitoring, but the response occurred days after the loss was confirmed and weeks after the discrepancy was first noted.
CPAP order missing individualized settings for a resident with OSA. The resident used CPAP nightly, and the chart included directions to apply and remove the device and clean the mask, but the physician order did not reflect the resident’s specific pressure setting. A hospital discharge summary identified CPAP at PEEP 9, and the DON stated RT had set the machine internally while the facility did not have the settings documented in the order.
Failure to maintain consistent dialysis communication for a resident receiving HD three times weekly. The resident had ESRD, DM2, and was cognitively intact but dependent for some ADLs. The Dialysis Communication Book had no entries for multiple treatments, and nursing notes did not show follow-up calls when information was missing. An LPN was unaware of the communication book, while the DON stated staff were expected to obtain post-dialysis vitals, weights, meds, and any concerns from the dialysis clinic.
Expired medications were found in a medication cart and a medication storage room. Surveyors observed Narcan and Milk of Magnesia on a cart, along with Bisacodyl, geri-dryl, and stool softener in a medication room, all past their expiration dates or due to expire based on month-and-year labeling. An LPN, RN, and the Regional Clinical Director stated expired meds should be removed from circulation and discarded by the expiration date, with month-and-year items discarded on the first day of that month.
A resident with cardiovascular disease, prior stroke, and moderate cognitive impairment experienced escalating agitation and combative behavior, including attempts to climb out a window and physical aggression toward staff, leading an APRN to order hospital transfer after an unsuccessful attempt to administer antianxiety medication. EMS transported the resident, and the hospital later adjusted psychiatric medications and recommended follow-up. Documentation showed that LPNs recorded the behavioral changes, the transfer, and the resident’s eventual return from the hospital, but no RN assessments were documented at the time of the significant change in condition or upon readmission, despite facility policies and expectations from the RN supervisor and DON that an RN assessment be completed and documented in both situations.
A resident with cardiovascular disease, a history of stroke, and moderate cognitive impairment became unresponsive during morning care and was found with a carotid pulse of 30 bpm before regaining responsiveness, at which time low blood pressure and bradycardia were documented and the APRN was notified. A physician then ordered vital signs every shift for three days, and the MAR was initialed each shift to indicate that vital signs were obtained; however, no actual vital sign values were documented in the MAR, nursing notes, or vital sign records for multiple consecutive shifts. The DON reported that staff were expected to follow physician orders and document temperature, BP, pulse, and respirations promptly per the facility’s Nursing Documentation Policy, but could not explain why the ordered vital signs were not recorded.
A resident with multiple chronic conditions experienced significant changes to their diabetes management, including discontinuation of sliding scale insulin and frequent blood glucose checks, as well as an increase in long-acting insulin dosage. Despite facility policy requiring family notification of such changes, there was no documentation that the resident's family was informed.
A resident with diabetes and multiple comorbidities did not have a Hemoglobin A1C test obtained as ordered, despite clear recommendations and agreement from medical staff. The order for the bloodwork was not implemented, and no documentation was provided to explain the omission, resulting in a failure to follow physician orders and facility policy.
Two residents at risk for falls in an LTC facility experienced multiple falls due to inadequate supervision and failure to implement care plan interventions. One resident, with a history of falls and severe cognitive impairment, was not monitored hourly as required, leading to a fall and hip fracture. Another resident with dementia had 13 falls over several months, with documentation missing for required 15-minute checks. Staff interviews revealed a lack of adherence to monitoring protocols, contributing to the residents' injuries.
The facility failed to manage and account for resident council funds after the closure of a bank account in 2021, with $1808.64 unaccounted for. Residents were unaware of the funds, and there was no designated treasurer. The Director of Recreation and Business Office Manager could not locate the funds, and the VP of Operations confirmed no record of the funds in the corporate account. Facility policies on fund management and resident rights were not followed.
An LPN failed to maintain resident confidentiality by leaving a computer screen open with personal information visible during medication administration. The LPN was unaware of the requirement to close the screen, and the DNS confirmed the breach of protocol, emphasizing the need for privacy as per facility policies.
The facility was found to have numerous deficiencies in maintaining a clean and homelike environment across all units. Inspections revealed issues such as damaged floors, stained walls, and rusty radiator covers. Staff interviews indicated a lack of awareness or partial awareness of these problems, and the infection control surveillance form failed to document room conditions. The deficiencies suggest a failure to execute responsibilities outlined in staff job descriptions.
The facility failed to maintain proper temperature logs for refrigeration units, address maintenance issues with the walk-in freezer, and adhere to food labeling and storage practices. Observations revealed incomplete temperature logs, significant frost buildup in the freezer, unlabeled and expired food items, and improper storage of personal items in the kitchen. Additionally, dietary staff did not consistently wear beard guards, and food temperatures were not recorded before serving.
An LPN failed to perform hand hygiene during medication administration, as observed in multiple instances. The LPN prepared and administered medications to residents without sanitizing hands before or after the process, despite being educated on the importance of hand hygiene. Interviews with the DNS and Infection Control Nurse confirmed that the facility's policy required hand sanitization before and after medication preparation and direct resident contact.
The facility failed to manage roam alert bracelets effectively, resulting in expired devices and undocumented orders. Additionally, neurological and post-fall assessments were incomplete for residents who experienced falls, and weight monitoring was not conducted as per physician's orders for residents with specific health conditions.
A resident with acute respiratory failure and other conditions did not have their oxygen saturation monitored as ordered by the physician. Despite a care plan that included oxygen therapy and regular monitoring, the facility only measured oxygen saturation 16 times out of 51 opportunities. The DNS confirmed that physician's orders were not followed, as oxygen levels should have been checked every shift.
The facility failed to date and discard Insulin medications properly in two medication carts. An LPN found a Humalog Insulin vial expired and a Lispro Insulin pen undated on the upper level. On the lower level, a Lispro Insulin pen and a Levemir Insulin pen were opened without dates. The DNS confirmed that Insulin should be dated when opened and discarded per pharmacy guidelines.
A resident with multiple sclerosis and dementia was burned after staff reheated soup without checking its temperature, contrary to facility policy. The resident, who required assistance with daily activities, spilled the soup and sustained a second-degree burn. Interviews revealed that staff were not trained or equipped to check food temperatures, despite a policy against reheating outside food.
The facility failed to maintain accurate documentation for several residents, leading to deficiencies in care. One resident's burn incident was not properly documented, another resident's pressure ulcer was not recorded before a physician's evaluation, and a third resident's fall was inaccurately documented with entries made before the fall and after hospital transfer. The DNS and ADNS were unable to provide complete and accurate records.
A resident with multiple sclerosis and dementia sustained a burn from hot soup after facility staff reheated it, contrary to policy. The resident, dependent on staff for daily living activities, requested a smaller portion of their favorite soup, which was brought in by a visitor. The soup was reheated for the usual time, likely making it hotter, and the resident was left alone, resulting in a burn. The facility's policy prohibited reheating outside food, but this was not enforced, contributing to the incident.
The facility failed to ensure staff documented care as performed by licensed personnel per the physician's order for a resident with multiple diagnoses, including dementia and an unstageable pressure ulcer. The Treatment Administration Record showed multiple instances where there were no nurses' signatures indicating that the wound care and offloading of heels were performed as ordered. The DON confirmed the absence of documentation and acknowledged it should have been done per policy.
Inaccurate MDS Coding of Pressure Ulcer Stages
Penalty
Summary
The facility failed to ensure staff accurately reviewed the clinical record and coded pressure ulcer stages on the MDS to reflect Resident #10’s condition. Resident #10 had a diagnosis of dementia, and wound care physician progress notes dated 3/3/2026 and 3/10/2026 indicated a stage 3 pressure ulcer on the coccyx and a stage 3 pressure ulcer on the thoracic spine that had reopened and had previously been stage 3. However, the significant change MDS assessment indicated the resident was at risk for pressure ulcers and had unhealed pressure ulcers, including 1 stage 2 pressure ulcer, 1 stage 3 pressure ulcer, and 1 stage 4 pressure ulcer, all not present on admission. The care plan dated 3/16/2026 addressed potential skin breakdown related to limited mobility and incontinence, with interventions including a low air loss mattress, repositioning side to side in bed, and incontinent care after each episode. During an interview and record review on 3/25/2026, RN #2 and LPN #12 stated that although the wound had been viewed with the nurse caring for the resident, both had concluded it was a stage 2 pressure ulcer, and the wound physician progress notes should also have been reviewed to determine how to code the MDS.
Failure to Use Required Resident Identifiers During Medication Administration
Penalty
Summary
The facility failed to identify residents prior to administering medications in accordance with its policy for 3 of 11 residents reviewed for medication administration. For Resident #37, whose diagnoses included TIA, depression, cerebrovascular disease, hyperlipidemia, and hypertension, the MAR and physician orders directed staff to administer acidophilus probiotic, Eliquis, folic acid, levetiracetam, Senna Plus, and vitamin B-1. During observation on 3/23/26, an LPN administered these medications and identified the resident by name only. The LPN stated the resident was not identified before medication administration because he/she already knew the resident. For Resident #48, whose diagnoses included depression, TIA, cardiac pacemaker, hypertension, and atrial fibrillation, physician orders directed Eliquis and metoprolol. During observation on 3/24/26, an LPN administered both medications and identified the resident by name only, stating he/she was nervous and only asked the resident's name. For Resident #47, whose diagnoses included vascular dementia with behavior disturbances, anxiety, adjustment disorder, depression, and bilateral knee pain, the order directed quetiapine 25 mg three times daily. During observation on 3/25/26, an LPN administered quetiapine and identified the resident by name band only, stating the resident's date of birth was not verified because a computer was not nearby. The facility's policy required confirmation of identity using at least two identifiers before medication administration, and the Regional Clinical Director stated the standard of practice was to use two identifiers prior to giving medications.
Delayed Reweight and Nutrition Intervention After Significant Weight Loss
Penalty
Summary
The facility failed to reweigh a resident with a significant weight discrepancy in a timely manner and failed to implement interventions in a timely manner after a confirmed weight loss. The resident had diagnoses including arthritis of the knee, anxiety, and depression, and was moderately cognitively impaired and dependent for eating and oral hygiene. A physician’s order directed monthly weights, and the care plan identified potential for nutritional decline with interventions to provide fortified foods and supplements as ordered and to weigh the resident as ordered. Documented weights showed the resident weighed 160 lb. on 1/1/2026 and 151.6 lb. on 2/1/2026, an 8.4 lb. loss or 5.2% in one month. Nursing progress notes did not identify any resident refusals of weights and did not identify interventions for the 5.2% weight loss. A STAT reweight was not ordered until 2/12/2026, when the resident weighed 149.9 lb., reflecting a 10.1 lb. loss or 6.3% from the initial weight. The dietician’s note dated 2/19/2026 identified the significant weight loss and recommended a house supplement twice daily and monitoring of intake and weight. Interviews with the LPN, dietician, DON, ADNS, and administrator indicated the weight discrepancy and confirmed loss were discussed in weekly at-risk meetings, but the dietician could not identify a rationale for starting interventions 7 days after the confirmed loss and 18 days after the initial discrepancy was identified.
CPAP Order Missing Individualized Settings
Penalty
Summary
Resident #52, who had a diagnosis of obstructive sleep apnea and used a CPAP machine, had physician orders dated 2/14/2026 directing staff to provide a CPAP machine already programmed with settings for nightly use, apply it at bedtime after filling the water chamber with sterile or distilled water, remove it in the morning, and clean the facemask daily. The admission MDS indicated the resident used a CPAP machine, and the care plan identified sleep apnea with an intervention to apply and remove the CPAP as ordered. A hospital discharge summary dated 3/13/2026 at 3:00 PM indicated the resident should continue CPAP every evening set at PEEP 9. During interview and record review on 3/26/2026 at 2:30 PM, the DNS stated the CPAP settings were put in by RT, nurses did not change them because they were set on the inside, and the DNS did not have the settings. The DNS also stated the respiratory physician would have the required settings and that staff needed to obtain a physician order for the required settings because the resident could be transferred to another medical facility. The facility policy for CPAP/BiPAP stated the order must include the settings, including pressure levels and mode of therapy, and any specific instructions for use.
Failure to Maintain Dialysis Treatment Communication
Penalty
Summary
The facility failed to ensure consistent communication between the facility and the dialysis clinic for a resident who required dialysis services three times weekly. The resident was admitted with end stage renal disease, dependence on renal dialysis, and Type 2 diabetes mellitus, and was identified as cognitively intact with a BIMS of 15 and dependent for toileting and lower body dressing, using a wheelchair for transport. The resident care plan directed staff to contact the dialysis center with questions regarding care. Review of the Dialysis Communication Book did not identify entries for dialysis treatments in February 2026 or March 2026, and the facility did not provide additional notes or communications for those treatments. An LPN stated that after the resident returned from dialysis, staff were expected to check the communication book and, if nothing was documented, follow up by phone, document the call, and inform the provider of any concerns; however, nursing notes did not show calls to the dialysis facility. The DON stated that if treatment information was not logged, staff were expected to call the dialysis facility to obtain the resident's vitals, weight, medications, and any changes from treatment. Another LPN stated she/he was not aware of the Dialysis Communication Book and did not recall being told to check it after the resident's dialysis treatments. The facility's hemodialysis policy directed that a completed W-10 and/or communication sheet, current medication list, and other pertinent information be sent with the resident for each treatment, and that the dialysis center communicate post-treatment information back to the facility.
Expired Medications Found in Medication Cart and Storage Room
Penalty
Summary
Expired drugs and biologicals were found in the facility’s medication storage areas during survey observations. On the Crestbrook medication cart, surveyors observed two Narcan single-dose nasal spray devices with an expiration date of 3/2026 and an opened bottle of Gericare Milk of Magnesia with an expiration date of 10/2025. During interview, an LPN stated that medications dated with only a month and year expire on the first day of that month and should have been removed from the medication cart before expiration. In the medication room located central to the [NAME] and Crestbrook wings, surveyors observed a container of Bisacodyl 5 mg tablets with an expiration date of 9/2024, a container of geri-dryl 25 mg tablets with an expiration date of 10/2025, and a container of stool softener 100 mg tablets with an expiration date of 8/2025. An RN stated expired medications should be disposed of before their expiration date and that the DON or ADON was responsible for evaluating medication storage rooms and disposing of expired medications. The Regional Clinical Director stated expired medications should be removed from circulation and discarded by the expiration date, and if only month and year were listed, staff were directed to dispose of the medication on the first day of that month.
Failure to Complete Timely RN Assessments After Change in Condition and Hospital Return
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely RN assessments in response to a significant change in condition and upon readmission from the hospital for one resident. The resident had a history of stroke, thyroid disorder, hypertension, and cardiovascular disease related to bradycardia and hyponatremia, and required assistance with ADLs and transfers. On 12/30/2024, LPN staff documented that the resident became increasingly agitated and combative, attempting to climb out of a window, hitting, scratching, and yelling at staff, and being considered a danger to self. An APRN was notified, a one-time antianxiety medication was ordered and attempted but spit out by the resident, and the APRN then ordered a transfer to the hospital. EMS records showed the resident was transported that evening. Despite this documented significant change in mental and behavioral status and transfer to the hospital, record review did not identify that an RN assessment was completed at the time of the change in condition. After evaluation and treatment at the hospital, including psychiatric assessment and medication changes, the resident returned to the facility on 1/1/2025. A nursing note by an LPN documented the resident’s return, and the hospital discharge summary included recommendations for medication adjustments and geriatric psychiatric follow-up. However, review of the 24-hour report sheets and the resident’s medical record revealed no RN assessment documented upon the resident’s return from the hospital. Interviews with the RN supervisor who worked on the date of the initial change in condition confirmed she could not recall assessing the resident and stated that if she had done so, it would have been documented. She also acknowledged that an RN assessment should be completed for a significant change in condition and upon admission/readmission. The DON similarly stated she would expect an RN assessment in these circumstances. Facility policies on Change in Resident Condition and Nursing Documentation required an RN assessment when there is a significant change in physical, mental, or emotional status and that documentation occur as soon as possible after the assessment, but no such RN assessments were found for either the change in condition or the readmission.
Failure to Document Ordered Vital Signs After Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate clinical record and to ensure vital signs were recorded timely after a change in condition was identified for one resident. The resident had a history of stroke, convulsions, thyroid disorder, and hypertension, and a quarterly MDS showed moderate cognitive impairment, no behaviors, assistance needed with ADLs and transfers, and no antianxiety or antidepressant medications. The resident’s care plan noted cardiovascular disease due to bradycardia and hyponatremia, with interventions to obtain vital signs and provide medications as ordered. During morning care, the resident became unresponsive while moving bowels; an RN assessed the resident and found them unresponsive to tactile and verbal stimuli with a carotid pulse of 30 beats per minute. After a few minutes, the resident became responsive, and vital signs were documented at that time as blood pressure 90/60, pulse 50, and respirations 14, and the APRN was updated. Following this event, a physician order directed that vital signs be obtained every shift for three days. Although vital sign monitoring was initiated as ordered on the afternoon of the same day, the clinical record did not contain documentation of the vital signs for multiple subsequent shifts. The MAR for the relevant days showed that staff had initialed all shifts to indicate vital signs were obtained, but the actual vital sign values were not recorded on the MAR, in nursing notes, or in any vital sign records for the night shift of the first day, all three shifts of the next two days, and the day shift of the final day. The DON stated that nursing staff were expected to follow physician orders and document temperature, blood pressure, pulse, and respirations in the medical record, and that she did not know why staff failed to document the ordered vital signs. The facility’s Nursing Documentation Policy directed that documentation should occur as soon as possible after care was completed, but this was not followed in these instances.
Failure to Notify Family of Significant Change in Medication and Care Plan
Penalty
Summary
The facility failed to notify the family of a resident when there were significant changes in the resident's medication regimen and plan of care. The resident, who had diagnoses including type 2 diabetes mellitus, liver cirrhosis, dementia, and Alzheimer's disease, was receiving insulin therapy and regular blood glucose monitoring. Following a pharmacist's recommendation and subsequent physician orders, the resident's sliding scale insulin and frequent blood sugar checks were discontinued, and the dosage of long-acting insulin was increased. Despite these changes, there was no documentation that the resident's family was informed of the modifications to the medication and care plan. Interviews with facility staff, including the APRN and DNS, confirmed that it was the nurses' responsibility to notify the resident's next of kin about such changes. However, the DNS was unable to provide evidence that the family had been notified as required by facility policy, which mandates reporting all significant changes in a resident's condition to both the physician and family. This lack of documentation and communication constituted a failure to follow established procedures for family notification during changes in the resident's care.
Failure to Obtain Ordered Diabetes Bloodwork
Penalty
Summary
A deficiency occurred when the facility failed to ensure that diabetes bloodwork, specifically a Hemoglobin A1C test, was obtained for a resident with type 2 diabetes mellitus, liver cirrhosis, dementia, and Alzheimer's disease. The resident's care plan included interventions for diabetes management, such as administering medications as ordered, monitoring for symptoms of hypo- or hyperglycemia, and obtaining labs as ordered. Despite a physician's note and a pharmacist's medication review recommending regular A1C monitoring, and an APRN agreeing to the order, the A1C was not obtained as required. The last documented A1C was several months prior, and no new result was available in the medical record within the expected timeframe. Interviews with the APRN and MD confirmed that the expectation was for the resident's A1C to be monitored every six months, and the order to obtain the test had been agreed upon and should have been implemented. The DNS acknowledged that the nurses and/or ADNS are responsible for reviewing pharmacy recommendations and implementing physician orders, but could not provide documentation or an explanation for why the order to obtain the A1C was not carried out. Facility policy requires all physician orders to be complete and accurate, but this was not followed in this instance.
Failure to Implement Fall Prevention Measures for At-Risk Residents
Penalty
Summary
The facility failed to implement adequate interventions and supervision to prevent falls for two residents at risk, resulting in injuries. Resident #27, who had a history of frequent falls, was admitted with conditions including diabetes, atrial fibrillation, and dementia. Despite a care plan requiring hourly monitoring after a fall on 11/20/23, documentation showed that this monitoring was not conducted between 11/21/23 and 11/23/23. This lapse in supervision led to another fall on 11/23/23, resulting in a femoral neck fracture that required surgical intervention. Resident #41, diagnosed with dementia, experienced 13 falls between 1/24/24 and 5/30/24. The care plan included interventions such as 15-minute checks and analysis of fall patterns, but documentation failed to show that these checks were consistently performed. The resident's care card indicated the need for frequent monitoring, yet the facility did not adhere to these guidelines, leading to multiple unwitnessed falls, one of which resulted in a head injury requiring sutures. Interviews with facility staff, including the DNS, revealed a lack of awareness and adherence to the monitoring protocols outlined in the care plans. The facility's policies on close monitoring and fall prevention were not followed, as evidenced by the absence of documentation for required checks and the failure to update care plans with necessary interventions. This oversight contributed to the repeated falls and injuries sustained by the residents.
Mismanagement of Resident Council Funds
Penalty
Summary
The facility failed to properly manage and account for the resident council funds, as evidenced by the closure of the Resident Council Funds bank account in April 2021, with a withdrawal of $1808.64, and the subsequent lack of documentation or discussion regarding these funds in resident council meetings. Interviews with several residents revealed that they were unaware of any funds or accounts associated with the resident council, and there was no designated treasurer to manage these funds. The Director of Recreation, who was previously the Assistant Director, indicated that the prior Director of Recreation had managed the funds, but upon their departure, the account was closed, and the funds were reportedly held in the business office, although this could not be confirmed. Further interviews with the Business Office Manager and the VP of Operations revealed that there was no ledger or accounting documentation for the $1806, and the funds could not be located in the business office or the corporate account. The Business Office Manager, who started in January 2024, was unaware of the corporate account containing resident council funds and confirmed that there was no record of the $1806 being transferred or deposited. The facility's policies on Resident Council Funds and Resident Rights emphasize the residents' right to manage their personal financial affairs and the facility's responsibility to maintain and account for these funds, which was not adhered to in this case.
Failure to Maintain Resident Confidentiality During Medication Administration
Penalty
Summary
The facility failed to maintain the confidentiality of residents' personal and medical information during medication administration. On the morning of June 17, 2024, an LPN was observed administering medications to residents without closing the computer screen on the medication cart, which displayed personal demographics of 16 residents, including names, photos, and room numbers. This occurred multiple times as the LPN moved between residents' rooms and the nurse's station, leaving the computer screen open and unattended. Interviews revealed that the LPN was unaware of the requirement to close the computer screen when not in use, believing it was only necessary when medication lists were visible. The Director of Nursing Services (DNS) confirmed that the LPN should not have left the computer screen open with resident information visible and explained the procedure to either close the screen or activate a screen saver to protect resident confidentiality. The facility's policies on medication administration and resident rights emphasize the importance of maintaining privacy and confidentiality of resident information.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, sanitary, and homelike environment across all four units, as observed during multiple inspections. The inspections revealed numerous issues, including damaged, missing, or broken floor tiles in bedrooms and bathrooms, stained and chipped walls, and rusty or broken radiator covers. Additionally, there were problems with stained and dirty floors, peeling ceilings, and damaged furniture such as nightstands and dressers with missing knobs. These deficiencies were noted in various rooms across the [NAME], Crestbrook, Cortland, and Taft units. Interviews with facility staff, including the Housekeeper/Laundry Supervisor, Maintenance Supervisor, RN #1, and the Administrator, indicated a lack of awareness or partial awareness of these issues. The Housekeeper/Laundry Supervisor, who had been employed for approximately eight months, was unaware of the stained and dirty floors and curtains. The Maintenance Supervisor, employed since October 2023, acknowledged some awareness of the issues and mentioned ongoing repair efforts. RN #1, with three years of employment, was also aware of some issues, and the Administrator, employed for four months, recognized the need for improvement in maintaining a homelike environment. The facility's infection control surveillance and safety rounds form, dated 4/24/24, did not document the conditions of resident rooms, indicating a gap in monitoring and reporting. The job descriptions for the Maintenance Supervisor, Maintenance Technician, Housekeeping Supervisor, and Housekeeping Assistant outlined responsibilities for maintaining a safe and clean environment, yet the observed deficiencies suggest these duties were not fully executed. The report highlights a systemic issue in ensuring the facility's environment meets the required standards for resident safety and comfort.
Deficiencies in Food Safety and Maintenance Practices
Penalty
Summary
The facility failed to maintain proper temperature logs for their refrigeration units, as observed during a kitchen tour. The temperature logs for the walk-in refrigerator and freezer were incomplete, with several days missing records. The Director of Dietary (DOD) indicated that the cook was responsible for recording these temperatures but had not done so due to being absent. Additionally, the milk refrigerator and ice cream freezer logs were also incomplete, with numerous instances of missing temperature recordings. This lack of documentation was attributed to dietary aides not fulfilling their responsibilities. The facility also failed to address maintenance issues with the walk-in freezer, which had a significant frost buildup. The DOD and the Director of Maintenance were aware of the problem, which persisted even after a new door was installed. The Director of Maintenance had not successfully contacted the company responsible for the door installation to address the issue, leading to continued frost accumulation. This issue was known for several months, but no effective action was taken until prompted by the surveyor's inquiry. Furthermore, the facility did not adhere to proper food labeling and storage practices. Observations revealed that prepared food items in the walk-in refrigerator were not labeled or dated, and some items were not discarded after the recommended three-day period. Personal items were improperly stored in the kitchen area, and dietary staff did not consistently wear beard guards while preparing food. Additionally, expired food items were found in the resident nourishment refrigerator, and the facility failed to record food temperatures before serving, as required by their policy.
Failure in Hand Hygiene During Medication Administration
Penalty
Summary
The facility failed to ensure proper hand hygiene was practiced by a nurse during medication administration, as observed on multiple occasions. An LPN was seen moving a medication cart to a resident's room, preparing and administering medications without performing hand hygiene before or after the process. The LPN also touched a resident's roommate and another resident without sanitizing hands afterward. Despite being educated on hand hygiene, the LPN admitted to not knowing why she failed to perform it during these instances. Interviews with the Director of Nursing Services (DNS) and the Infection Control Nurse confirmed that the facility's policy required nurses to sanitize their hands before and after preparing medications, after direct contact with residents, and between residents during medication passes. The facility's Medication Administration Policy also emphasized the importance of appropriate hand hygiene before and after direct resident contact. Despite this, the LPN did not adhere to these protocols, leading to the identified deficiency.
Deficiencies in Roam Alert Management, Fall Assessments, and Weight Monitoring
Penalty
Summary
The facility failed to effectively manage roam alert bracelets for residents at risk of elopement. Several residents were found wearing expired roam alert bracelets, and there were discrepancies in the documentation of bracelet serial numbers in the physician orders. Additionally, some residents were wearing elopement bracelets without a physician's order. The facility's policy required the night supervisor to check the roam alerts nightly, but the Assistant Director of Nursing Services (ADNS) was responsible for overseeing the process. The discrepancies were identified during testing, revealing expired devices and mismatched serial numbers. The facility also failed to ensure that neurological assessments and post-fall assessments were completed following falls for two residents. One resident experienced multiple unwitnessed falls, and the facility's documentation was incomplete or missing for neurological checks and post-fall assessments. The facility's policy required neurological checks for 72 hours following an unwitnessed fall, but the documentation did not reflect this practice. The Director of Nursing Services (DNS) acknowledged the lack of completed assessments and indicated a need for staff education. Furthermore, the facility did not follow physician's orders related to weight monitoring for two residents. One resident had orders to check weight three times weekly, but the clinical record did not document weights as frequently as required. Another resident, who had a history of congestive heart failure, was supposed to have weekly weight monitoring, but the documentation was inconsistent. The DNS recognized the failure to follow physician's orders and planned to reeducate staff on the importance of adhering to weight monitoring protocols.
Failure to Monitor Oxygen Saturation as Ordered
Penalty
Summary
The facility failed to monitor oxygen saturation as ordered by the physician for a resident who was admitted with acute respiratory failure with hypoxia, malignant neoplasm of breast, and supraventricular tachycardia. The resident's care plan included interventions for cardiovascular disease, such as oxygen therapy and monitoring oxygen saturations as ordered. A physician's order required monitoring oxygen saturation with a pulse oximeter every 8 hours and adjusting oxygen levels to maintain saturation above 90% on room air. However, from June 1 to June 17, out of 51 opportunities, oxygen saturations were only measured 16 times. The Director of Nursing Services (DNS) confirmed that it was expected for physician's orders to be followed, and oxygen saturations should have been measured and documented every shift for titration.
Failure to Date and Discard Insulin Medications
Penalty
Summary
The facility failed to ensure proper labeling and timely disposal of Insulin medications in two of four medication carts. During a review of the medication cart on the upper level, a Humalog Insulin vial was found to be opened and expired without being discarded, and a Lispro Insulin pen was opened but not dated. Similarly, on the lower level, a Lispro Insulin pen and a Levemir Insulin pen were both opened without being dated, despite stickers indicating they should be discarded after a specific number of days once opened. An interview with the Director of Nursing Services (DNS) confirmed that all Insulin vials and pens should be dated when first opened and discarded based on the date written on them, as per pharmacy recommendations. The DNS acknowledged that each type of Insulin has a different shelf life once opened, which the nursing staff is expected to adhere to.
Resident Burned Due to Improper Food Reheating
Penalty
Summary
The facility failed to ensure that food reheated for a resident was at a safe temperature, resulting in a second-degree burn. Resident #8, who has multiple sclerosis, spasmodic torticollis, and dementia, required assistance with activities of daily living and had severely impaired cognition. On a specific date, the resident requested that a portion of soup brought in by a visitor be reheated. The staff reheated the soup without checking its temperature, as there was no system in place to do so. This led to the resident spilling the soup and sustaining a burn on the chest area. Interviews revealed that the facility's policy prohibited staff from reheating outside food, and staff were not trained or provided with thermometers to check food temperatures. Despite this policy, staff had been reheating food for residents without proper temperature checks. The Director of Nursing Services confirmed that the policy had been in place for several years, but staff were not in-serviced on reheating temperatures, leading to the incident where Resident #8 was burned.
Deficiencies in Documentation and Incident Reporting
Penalty
Summary
The facility failed to maintain accurate and complete documentation for several residents, leading to deficiencies in care. For one resident, the clinical record did not accurately reflect the circumstances surrounding a burn incident. The resident, who had multiple sclerosis and spasmodic torticollis, spilled hot soup on themselves after it was reheated by facility staff, contrary to the facility's policy that prohibited staff from reheating outside food. The Director of Nursing Services (DNS) was aware of the incident but did not document the details in the clinical record or reportable event form. Another resident's clinical record lacked documentation of a newly identified pressure ulcer. The wound care physician noted the ulcer during an evaluation, but there was no prior nursing assessment or provider notification documented. The wound care nurse and the LPN involved in the resident's care acknowledged the oversight in documentation, as the ulcer was identified before the physician's visit. Additionally, the facility failed to provide accurate documentation following a resident's unwitnessed fall. The neurological checks and post-accident assessments were incorrectly documented, with entries made before the fall occurred and after the resident had been transferred to the hospital. The Assistant Director of Nursing Services (ADNS) could not explain the discrepancies and was unable to produce the original documents, indicating a failure to maintain accurate medical records.
Failure to Honor Resident Meal Choice Leads to Burn Incident
Penalty
Summary
The facility failed to honor a resident's meal choices, leading to an incident where a resident sustained a burn from hot soup. The resident, who had multiple sclerosis, spasmodic torticollis, and dementia, was dependent on staff for assistance with activities of daily living and required setup only with meals. On the day of the incident, the resident spilled soup on themselves, resulting in a second-degree burn with blistering on the chest area. The soup was brought in by a visitor and reheated by facility staff, contrary to the facility's policy. Interviews revealed that the resident had a favorite soup brought in by a visitor, which was reheated by staff upon request. On the day of the incident, the resident requested only half a cup of soup to be reheated for the usual time, which likely resulted in the soup being hotter than expected. The facility's policy stated that outside food should not be reheated by staff, yet this practice was not followed, leading to the resident being left alone with the hot soup and subsequently getting burned. The facility's policy on reheating outside food was not consistently enforced, as staff had been reheating food for residents prior to the incident. The DNS confirmed that the policy prohibited staff from reheating outside food, and no thermometers were available to check food temperatures. This lack of adherence to policy and absence of proper equipment contributed to the incident, highlighting a failure to ensure resident safety and choice in meal preferences.
Failure to Document Care as Ordered
Penalty
Summary
The facility failed to ensure staff documented care as being performed by licensed personnel per the physician's order for one of three sampled residents. Resident #1, who had diagnoses including dementia, muscle wasting and atrophy, an unstageable pressure ulcer to the sacrum, urinary tract infection, and acute kidney failure, required extensive assistance with daily living tasks and was frequently incontinent. A physician's order directed that Resident #1's heels be offloaded when in bed each shift, and another order required specific wound care for a stage 2 sacrum pressure ulcer. However, the Treatment Administration Record (TAR) for September and October 2023 showed multiple instances where there were no nurses' signatures indicating that the wound care and offloading of heels were performed as ordered. The Director of Nursing (DON) confirmed during an interview and chart review that the facility policy requires staff to document care when it is provided. The DON acknowledged the absence of documentation for the wound care and offloading of heels on the specified dates and was unsure why the care was not documented. The facility policy on nursing documentation directs that it should provide an account of the resident's health care status, changes in condition, current assessments, and any concerns that alter the resident's plan of care. The lack of documentation indicates a failure to adhere to this policy, leading to the identified deficiency.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 694 citations issued within 25 miles in the last 12 months — including the 10 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.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Watertown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Waterbury Center For Nursing & Rehabilitation Llc | 0.9 mi | ★★★★★ | 1 | 0 |
| Complete Care At Middlebury | 2.9 mi | ★★★★★ | 1 | 0 |
| Mattatuck Health Care Facility, Inc. | 2.9 mi | — | 0 | 0 |
| Abbott Terrace Health Center | 3.5 mi | — | 0 | 0 |
| Autumn Lake Healthcare At Bucks Hill | 3.8 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.