Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Watertown Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
Failure to Implement Antibiotic Stewardship Program: The facility did not implement an antibiotic stewardship program or a system to monitor antibiotic use. Record review showed antibiotics were given to a resident for pneumonia, a resident for UTI, and a resident for eye redness without an appropriate indication for use, and there was no documented tracking or follow-up with the MD/NP after antibiotics were started. Staff interviews confirmed there were no unit line listings for infections or antibiotics, and the DON stated the program was not being implemented.
Medication storage and labeling were not maintained as required. An LPN left a Lantus insulin pen on a nursing station desk after a pharmacy delivery issue, unopened Humalog insulin was found unrefrigerated, several opened meds including Spiriva inhaler, Latanoprost eye drops, Spiriva Respimat, and a Lantus vial were undated, and a medication storage room was left unlocked and accessible to residents and others. The DON and nurses stated that opened meds should be dated and insulin refrigerated until ready to use.
Improper Food Storage and Labeling in Kitchen: The facility failed to properly date, label, cover, and store multiple food items in the kitchen. Surveyors observed unlabeled and undated foods, items past their use-by dates, raw chicken sitting in juice and blood, uncovered food in the freezer, and food products stored directly on the floor or left open to air. The FSD stated prepared foods should be dated and labeled and acknowledged several items should have been discarded.
Staff failed to follow infection control practices for a resident with active C. diff and for two residents requiring EBP. A nurse and a CNA entered the C. diff resident’s room without proper PPE, did not perform hand hygiene, and shared a vital signs machine without disinfecting it between uses. Staff also provided personal care to two residents on EBP using gloves only and not gowns, despite posted precaution signs and staff acknowledgment that gown-and-glove use was required.
Failure to Follow Self-Administration Medication Process: Two residents had meds left at the bedside without the facility following its self-administration process. One cognitively intact resident with a history of suicidal ideations, psychoactive substance abuse disorder, and depression had six nighttime meds left in a cup and took them hours later, despite only having an order to self-administer an inhaler. Another cognitively intact resident with alcohol abuse, depression, and type 2 diabetes had pills and topical meds at the bedside, but the record showed no assessment, no physician order, and no care plan for self-administration.
A resident with bipolar disorder, depression, anxiety, and moderate cognitive impairment wanted a wheelchair to improve independence, but was observed in a Geri-chair and reported prior wheelchair problems. PT and OT records showed a standard/new wheelchair was issued, yet documentation did not show the wheelchair was assessed as appropriate or that wheelchair training outcomes were completed. The DOR stated the facility should have provided an appropriate wheelchair and therapy to maximize the resident’s functional mobility.
Failure to Provide Timely Incontinence Care: A dependent resident with severe cognitive impairment and bowel/bladder incontinence was observed sitting in a hallway chair with a large puddle of urine beneath the chair. Staff walked past the resident, and although the resident was returned to the room, incontinence care was not provided right away. The resident was later seen with a sagging, urine-soaked brief that appeared to be leaking, and staff interviews confirmed the resident should have been changed when first found wet.
Unsafe Supervision During Resident Smoking: A resident who required supervised smoking sustained a right ankle burn after using another resident's cigarette to light his/her own cigarette and ash fell into the resident's boot. Surveyors observed multiple residents in the smoking area lighting each other's cigarettes while only one staff member supervised, with cigarette butts littering the ground. The DON, Activities Director, and staff confirmed residents should not be lighting each other's cigarettes and that staff should be supervising smoking safety.
A resident with PTSD and intact cognition did not have a person-centered PTSD care plan in place. The resident’s trauma questionnaire showed multiple affirmative responses related to serious accidents, disasters, and witnessing injury or death, but the care plan did not identify PTSD triggers or other individualized measures to minimize retraumatization. The SW and DON both stated that residents with PTSD should have a person-centered care plan with personalized triggers.
Failure to obtain routine and emergency dental care for a resident with broken carious teeth and mouth pain. The resident had cognitive impairment, was dependent for ADLs, and had oral/dental problems identified on admission, but the dental consult form was blank and no dentist evaluation was documented. The resident later required oxycodone for mouth pain and clindamycin for a tooth abscess, while staff and the DON reported the resident had not been enrolled in the facility dental service and the HCP had not been offered that option.
Inaccurate MAR Documentation for Medications Left at Bedside: Two cognitively intact residents had medications left at the bedside and later taken outside the documented administration time. One resident with a history of suicidal ideations, substance abuse, and depression took nighttime meds in front of the surveyor after the MAR had already recorded them as given at the scheduled time. Another resident with alcohol abuse, depression, and type 2 diabetes had pills and topical meds at bedside, while the MAR documented administration at 9:00 A.M. despite the observed timing and the resident's statement that staff sometimes leave meds for later.
A resident with intact cognition and diagnoses including paranoid schizophrenia and schizoaffective disorder was repeatedly observed without access to a call light while in bed, and there was no call light cord to pull. Staff interviews showed a CNA did not realize the resident lacked a call light, a nurse stated all residents should have access to one, and the Maintenance Director said he was unaware the resident did not have a call light.
A resident with multiple medical and psychiatric diagnoses was spoken to in a disrespectful manner by a PTA during a therapy session, when the PTA interrupted a conversation and loudly told the resident to "Get off the drugs." The incident was witnessed by an OT, who did not immediately report it, and the resident later expressed feeling disrespected by the comment.
A resident with multiple medical and psychiatric diagnoses was subjected to a potentially abusive comment by a PTA during a therapy session, which was witnessed by an OT. The OT did not immediately report the incident to administration as required by the facility's abuse policy, instead waiting several weeks before disclosure. This delay resulted in a failure to follow established abuse prevention and reporting procedures.
A resident with significant cognitive impairment and an activated Health Care Proxy was transferred to another SNF without the Health Care Agent being informed of the actual transfer date or time. Although the transfer was requested by the HCA, facility staff relied on unconfirmed emails and voicemails, resulting in the HCA only learning of the transfer after the resident arrived at the new facility. The accepting SNF also did not receive complete transfer information.
Several residents with cognitive impairment, dysphagia, or physical limitations were left unsupervised or without needed assistance during meals, despite care plans and physician orders requiring staff supervision or help. Observations showed residents eating alone, spilling food, or not consuming their meals properly, while staff interviews revealed a lack of adherence to care instructions and misunderstanding of required support levels.
A resident with COPD received oxygen at a higher flow rate than ordered by the physician, and the oxygen concentrator filter was observed to be filled with dust on multiple occasions. Staff did not consistently monitor oxygen levels or maintain equipment cleanliness, contrary to facility policy and care plan directives.
Surveyors observed a medication error rate of 12.5% when three nurses made four errors out of 32 opportunities, including administering incorrect dosages of vitamin B6 and polyethylene glycol, omitting a scheduled dose of a blood thinner, and failing to check vital signs before giving a blood pressure medication. These errors involved three residents with varying cognitive and medical conditions, and staff acknowledged not following physician orders or medication administration protocols.
Surveyors found that medications and biologicals were not properly labeled or securely stored, including open and undated bottles of supplements, loose pills in medication carts, an expired insulin pen, and an unlabeled syringe with insulin. Additionally, a resident who was not permitted to self-administer medications was found with unsecured nicotine lozenges at the bedside, contrary to facility policy and staff statements.
Staff did not treat two residents with dignity during meals, as one resident's repeated requests for assistance were ignored, and another resident with severe cognitive impairment was fed without any communication in their preferred language, despite staff being able to speak it. Care plans specifying communication needs and language preferences were not followed, and staff did not use available communication tools.
A resident with an invoked healthcare proxy was administered Ativan, a psychotropic medication, prior to a medical appointment without documented consent from the proxy. Facility policy and staff interviews confirmed that consent is required before administering such medications, but the necessary consent process was not completed or documented in this case.
A resident with generalized anxiety disorder was given PRN Ativan for pre-appointment anxiety without a required 14-day stop date or documented physician rationale for continued use, contrary to facility policy. Staff interviews confirmed the absence of appropriate stop dates and re-evaluation for the psychotropic medication.
A resident with severe cognitive impairment and Haitian-Creole as a primary language did not receive care in accordance with their communication care plan. Staff provided care and assistance with meals without attempting to communicate in the resident's preferred language, and did not use communication boards or interpreter services, despite facility policy and care plan requirements.
A nurse administered metoprolol to a resident with hypertension and severe cognitive impairment without first obtaining vital signs, despite a physician's order requiring blood pressure and pulse checks before administration. The nurse later acknowledged the oversight, and the DON confirmed that such parameters must be followed to meet professional standards.
A resident with morbid obesity and diabetes, requiring significant assistance with dressing, developed a bruise on the forearm that was not identified or documented by staff during routine skin assessments, despite care plans and physician orders requiring such monitoring. Staff interviews confirmed the expectation to report and document new bruises, but the bruise was only discovered during a surveyor's observation.
A resident with multiple stage 4 pressure ulcers and a high risk for skin breakdown did not receive updated wound care and antibiotic treatments as recommended by the wound physician and NP after previous orders were discontinued. Staff interviews and record review confirmed that the new orders were not implemented, and the DON was unaware of the lapse in care.
Three residents experienced significant medication errors, including late or omitted administration of insulin and an anticoagulant. One resident with diabetes repeatedly received insulin hours after scheduled times and after meals, with no documented rationale. Another resident did not receive a prescribed dose of Xarelto during a morning med pass, and a third resident with diabetes had multiple instances of delayed insulin administration. Facility policy required medications to be given within one hour of the scheduled time, but this was not followed.
A resident with diabetes and morbid obesity experienced ongoing dental pain and tooth deterioration but was not seen by a dentist due to an incomplete consent form, despite care plans and orders indicating the need for dental consults. Staff were unaware of the resident's dental issues, and the required process for obtaining dental services was not followed.
Two residents experienced deficiencies in record documentation: one resident's weekly skin assessments failed to note a visible bruise, and another resident's MAR inaccurately recorded the administration of miralax that was actually declined. Staff interviews confirmed that these omissions and errors did not meet documentation standards.
A resident with severe cognitive impairment and end-stage disease was admitted to hospice care, but the hospice agency's plan of care was not present in the medical record for staff reference. Facility staff were unclear about the expected timeline for receiving the hospice plan, and documentation required by facility policy was missing.
A resident with chronic medical conditions was repeatedly observed with cigarettes and a lighter in their room and on their person, contrary to facility policy requiring all smoking materials to be stored by staff. Staff interviews revealed inconsistent understanding and enforcement of the smoking policy, and the resident's care plan indicated that smoking materials should be kept by staff, but this was not followed.
A resident at risk for skin breakdown developed pressure and non-pressure wounds, but the facility failed to update the care plan to include necessary interventions and treatments. Despite assessments indicating risk, no care plan was documented, and staff interviews revealed a lack of responsibility in updating care plans, contrary to facility policy.
A resident at high risk for skin breakdown developed a pressure injury that worsened due to the facility's failure to obtain timely physician orders for treatment. Despite the resident's condition being documented, there was a significant delay in communication and intervention, leading to the injury becoming unstageable. The facility did not follow its policy for immediate assessment and treatment of pressure injuries.
The facility failed to maintain a safe, clean, and homelike environment for three residents. One resident's room was infested with fruit flies and cluttered with dirty clothing and old water pitchers. Another resident had a month-old water pitcher and spoiled deli meat in their room. A third resident kept bug spray for pests. Staff acknowledged ongoing pest control issues and cluttered rooms, but no improvements were noted.
The facility failed to ensure call bells were accessible for residents, as observed by surveyors. A resident's call bell was on the wall, another's was wedged behind the bed, and others had no call bells plugged in. Interviews revealed residents struggled to reach call bells, with one waiting up to two hours for help. Staff confirmed call bells should be within reach, highlighting a policy adherence issue.
A resident with multiple health issues developed an unstageable pressure injury, but the facility failed to notify the Health Care Agent as required by policy. Despite assessments indicating skin breakdown, there was no documentation of communication with the HCA, highlighting a lapse in protocol adherence.
A facility failed to develop and implement baseline care plans for a resident within 48 hours of admission, as required by policy. The resident, admitted with multiple health conditions, had immediate care needs identified but not addressed in a timely manner. Interviews revealed a lack of clarity and communication among staff regarding care plan development, with the Director of Nurses confirming that care plans were initiated five days post-admission, missing the 48-hour requirement.
A resident was discharged from a facility without confirmed Visiting Nurse Association (VNA) services, leading to a deficiency in the discharge process. The resident, with multiple medical conditions, was expected to receive home health services, but the facility failed to ensure these were arranged. The ALF reported not receiving discharge paperwork promptly, and the VNA denied having the resident as a client. Facility staff interviews revealed a lack of communication and documentation regarding the setup of VNA services.
The facility failed to properly administer and monitor oxygen therapy for three residents, leading to health concerns. A resident experienced respiratory distress due to an unplugged oxygen concentrator, while two other residents received incorrect oxygen flow rates, contrary to physician orders. These incidents highlight lapses in following prescribed oxygen therapy protocols.
A resident was found with a prescription topical powder at their bedside without a physician's order or assessment for self-administration. Additionally, a medication room door was observed unlocked on two occasions, allowing unsecured access to medications. Nursing staff were unaware of these lapses, and the DON confirmed that medication room doors should always be locked.
The facility failed to maintain a functioning call bell system on Unit 5, with call bell cords removed due to safety concerns, leaving residents with handheld bells. A resident's call bell was out of reach and not working, with no staff response or maintenance record of the issue, indicating a lack of communication and prompt reporting.
A cognitively impaired resident at risk for elopement was sent to a medical appointment without an escort, leading to an unsupervised elopement from the facility. Despite being identified as a wanderer, the resident was transported alone due to staff assumptions that the transport company would supervise them. Miscommunication and lack of coordination among staff regarding the resident's supervision needs contributed to the incident.
The facility failed to provide quarterly statements for personal needs accounts to 56 residents for over a year. A resident expressed uncertainty about their finances, and the BOM confirmed that no statements had been sent out since March 2023.
The facility failed to follow professional standards of nursing practice for three residents. Two residents did not have their PICC line measurements documented as required, and another resident's oral thrush was not identified or treated properly. Interviews with staff confirmed these deficiencies.
The facility failed to provide supervision and assistance with ADLs for three residents during meal times. One resident with dysphagia and dementia was left unsupervised with meals, another with hemiplegia and dysphagia was not supervised as required, and a third with severe cognitive impairment did not receive the necessary assistance with eating. Staff interviews revealed misunderstandings and non-adherence to care plans.
A resident, who is moderately cognitively impaired, reported that a CNA grabbed him/her by the genitals. The incident was reported to the Social Worker and DON, but the facility failed to report the allegation to the state agency within the required two-hour timeframe. The DON cited multiple reportable events on the same day as the reason for the oversight.
A resident was not returned to their original room after hospitalization, contrary to the facility's policy and state regulations. The resident, who is cognitively intact and their own decision maker, was moved to a different room without prior notification or consent, leading to dissatisfaction.
A facility failed to specify the level of assistance required for ADLs and mobility in a resident's baseline care plans. The resident, admitted with cerebral palsy and a kidney disorder, had care plans indicating staff participation but lacked detailed assistance levels. The DON acknowledged the omission during a survey review.
The facility failed to ensure that a resident received wound care in accordance with physician's orders. The resident, who had a full-thickness wound on the nose, was observed multiple times without the required dressing. Interviews with staff confirmed that the dressing should have been in place and documented if not maintained.
The facility failed to provide a resident with the ordered double protein diet necessary for wound healing. Despite physician's orders and RD recommendations, the resident's meal tickets did not reflect the double protein requirement, leading to the resident not receiving the prescribed diet. Staff interviews confirmed the oversight.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an Antibiotic Stewardship Program to monitor the appropriate use of antibiotics. Review of the facility policy titled Antibiotic Stewardship, revised December 2016, stated that antibiotics would be prescribed and administered under the guidance of the facility's antibiotic stewardship program and that the purpose of the program was to monitor antibiotic use in residents. During the survey period, the surveyor requested infection control and antibiotic stewardship information, but the facility did not have a program in place and did not have a system to monitor antibiotic use. Based on record review, one resident received antibiotics for pneumonia without an appropriate indication for use, one resident received antibiotics for UTI without an appropriate indication for use, and one resident received antibiotics for eye redness without an appropriate indication for use. The facility had no documented tracking, follow-up, or review with the physician or NP after initiation of any active antibiotic orders. During interviews, Nurse #8 stated there were no line listings on the unit for infections or antibiotics and that he was not familiar with the antibiotic stewardship program or tracking start and stop dates. The Nursing Supervisor stated she did not review antibiotic usage or communicate with providers regarding start and stop dates and said the DON would manage the program. The DON stated the facility was not implementing the antibiotic stewardship program and did not have information regarding the program, and the Regional Nurse stated she expected an effective ongoing antibiotic stewardship program to be in place.
Medication Storage and Labeling Failures
Penalty
Summary
Drugs and biologicals were not stored and labeled in accordance with accepted professional principles and facility policy. The facility policy stated that medications are to be kept in locked compartments with access limited to authorized personnel and that medication labels include expiration dates when applicable. During observation, a Lantus insulin injector pen was left on the second-floor nursing station desk in an area where residents and staff were present. The nurse stated the pen had been placed there because the pharmacy delivered the wrong medication and acknowledged it should have been locked up rather than left on the desk. Additional observations on the fourth-floor medication carts found unopened Humalog insulin not refrigerated, although manufacturer directions required unopened insulin to be refrigerated until ready for use. The surveyor also observed opened and undated Spiriva inhaler, Latanoprost eye drops, and Spiriva Respimat on the high-side cart. On the third-floor unit, the medication storage room was unlocked and accessible when no staff were present, and the surveyor was able to enter the room. The third-floor high-side cart also contained an opened and undated Lantus vial. Nurses stated medications should be dated when opened and insulin should be refrigerated until ready to use, and the DON confirmed that opened medications and insulin should be handled in that manner.
Improper Food Storage and Labeling in Kitchen
Penalty
Summary
The facility failed to properly store, date, and label food products in the kitchen in accordance with professional standards for food service safety. During an initial kitchen walk-through, the surveyor observed multiple items in the walk-in refrigerator that were unlabeled, undated, or past their prepared/use-by dates, including coleslaw, beets, cooked rice, grilled hamburgers, a peanut butter sandwich, creamed peas, grated cheese, and croissants. A container of raw chicken breast was also observed sitting in about half an inch of juice and blood. In addition, a container of ginger ale was stored directly on the floor below the rack of food products. In the walk-in freezer, a pitcher of broccoli florets was left uncovered and open to the air, and boxes of product were stored directly on the floor. In the dry storage room, multiple bags of opened hamburger rolls were not covered or labeled and were open to air, and the rolls were hard to the touch. During interviews, the Foodservice Director stated that ready-to-eat food such as peanut butter sandwiches should be discarded after one day and all other food after three days, and that all prepared food should be dated and labeled. After the observations were reviewed, the Foodservice Director stated the food should have been properly labeled, dated, and discarded if past the written date, and that the raw chicken should have been discarded because it was sitting in juice and blood.
Infection Control Failures With C. diff Contact Precautions and EBP
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program as evidenced by multiple observations of staff not following contact precautions and enhanced barrier precautions. Resident #15 was admitted with diagnoses including pneumonia, primary hypertension, and osteoarthritis, and the record showed the resident had intact cognition with a BIMS score of 14 out of 15 and required substantial to maximal assistance with activities of daily living. The resident’s hospital discharge paperwork showed a positive C. diff test and oral antibiotics, and the physician orders and care plan directed contact precautions for severe C. diff, including wearing gown and gloves when entering the room and washing hands with soap and water after removing PPE. During observation, a nurse entered Resident #15’s room without PPE while the resident was on contact precautions for active C. diff. The nurse provided care, exited the room, closed the door with a bare contaminated hand, and did not perform hand hygiene before pushing a vital signs machine down the hall. The same contaminated vital signs machine was then taken into another resident’s room and used again without being disinfected between uses, and hand hygiene was not performed. The nurse later acknowledged that PPE should have been worn, the machine should have been wiped down between uses, and hand hygiene should have been performed. A CNA was also observed entering Resident #15’s room without PPE, providing care, exiting the room, closing the door with a bare contaminated hand, and not performing hand hygiene. The CNA stated she did not know why the resident was on precautions and had not been told that precautions were required. Staff interviews confirmed that Resident #15 had active C. diff and that staff were expected to wear PPE, disinfect equipment between uses, and wash hands with soap and water. The facility also failed to implement enhanced barrier precautions for two residents who required them. A CNA was observed providing personal care to one resident on the fourth floor while using gloves only and not wearing a gown, despite a sign indicating enhanced barrier precautions for both beds. The same CNA was later observed providing personal care to another resident with enhanced barrier precautions in place, again using gloves only and not wearing a gown. The CNA stated he should have used the appropriate PPE for both residents and that he was giving bed baths. The nursing supervisor and DON stated that staff must follow the enhanced barrier precaution guidelines and wear the appropriate PPE when providing personal care.
Failure to Follow Self-Administration Medication Process
Penalty
Summary
The facility failed to follow its process for self-administration of medications for two residents. The facility policy stated that residents may self-administer medications only when the interdisciplinary team determines it is clinically appropriate and safe, and that nursing staff review the self-administered medication record each shift and transfer pertinent information to the MAR. In this sample of 32 residents, the survey found that Resident #82 and Resident #30 had medications left at the bedside and were not managed in accordance with the facility’s self-administration process. Resident #82 was admitted with diagnoses including history of suicidal ideations, psychoactive substance abuse disorder, and depression. The resident’s MDS showed cognitive intactness with a BIMS score of 15 out of 15 and need for supervision with ADLs. During observation, a medication cup containing six medications was found at the bedside, and the resident stated these were nighttime medications left by the evening nurse to take when ready for sleep. The resident said he/she did not fall asleep until around 3 A.M. and forgot to take the medications, then took them in front of the surveyor at 8:13 A.M. Review of the physician’s orders showed only an order allowing self-administration of an inhaler kept locked at bedside, with no order for self-administration of the other medications. The care plan addressed only self-administration of the inhaler, while the medication self-administration screen indicated the resident was fully able to self-administer medications as ordered. Resident #30 was admitted with diagnoses including alcohol abuse, depression, and type 2 diabetes. The resident’s MDS showed cognitive intactness with a BIMS score of 15 out of 15 and need for supervision with ADLs. During observation, pills were seen in a cup at the bedside along with tubes of hydrocortisone cream, ketoconazole cream, and an anti-fungal cream. The resident stated that the nurse sometimes leaves medication for later. The medical record did not show an assessment for safe self-administration, there was no physician order for self-administration of medications, and the care plan did not indicate that the resident could self-administer medications.
Failure to Provide Appropriate Wheelchair Support and Therapy
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of Resident #52 by not providing an appropriate wheelchair and related therapy to support wheelchair management and increase independence. Resident #52 was admitted with diagnoses including bipolar disorder, depression, and anxiety, was assessed as moderately cognitively impaired on the MDS, and was dependent on staff for activities of daily living. The care plan also identified dependence on staff for ADLs. During observation, Resident #52 was seen in a Geri-chair next to the bed and stated a desire for a wheelchair to be more independent, reporting that a prior wheelchair had leg rests that did not fit and that the wheelchair had disappeared. The PT evaluation included wheelchair management training with goals for the resident to propel self in a wheelchair with assistance and eventually with modified independence, and PT notes documented issuance of a standard wheelchair and wheelchair management training. However, the treatment notes did not show assessments or outcomes of the wheelchair training and did not indicate whether the wheelchair was appropriate for Resident #52. The PT discharge summary stated the resident was dependent on others for wheelchair propulsion. OT records showed a new wheelchair was provided, but the evaluation did not include wheelchair goals and the treatment and discharge documentation did not show wheelchair training or assessment of whether the new wheelchair was appropriate. The DOR stated the facility should have provided an appropriate wheelchair, assessed what type was suitable, and provided therapy to help the resident achieve maximum functional ability, adding that the facility had not provided the therapy needed to maximize functional mobility with a wheelchair.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely assistance with ADLs, specifically incontinence care, for a dependent resident who had severe cognitive impairment and was incontinent of bowel and bladder. Resident #73 was admitted with diagnoses including vascular dementia with behavioral disturbance, type 2 diabetes mellitus, acute kidney failure, and primary hypertension. The resident’s care plans directed staff to assist to toilet as needed, provide incontinence care as needed, provide peri-care after each incontinent episode, and provide total staff participation with toilet use, personal hygiene, and oral care. On the morning of the observation, the resident was seen sitting in a chair in the hall wearing a gown and socks. A large puddle was observed under the chair extending into the hallway, with no beverage or other spill noted in the area. Staff walked past the resident, and one staff member was standing at the nurses’ station across from the resident. When the Nursing Supervisor noticed the resident was wet and urine was on the floor, housekeeping was contacted to clean the area and another staff member was told to come change the resident. The resident was then walked back to the room, but incontinence care was not provided at that time. The resident remained without incontinence care through breakfast and was later observed walking in the hall with the brief appearing full of dark urine and sagging, with urine leaking from the brief. Staff again returned the resident to the room, but care was still not immediately provided. During interviews, CNA #3 stated she had not provided incontinent care when she first arrived and changed the resident only after breakfast, while Nurse #8, the Nursing Supervisor, the DON, and the Regional Nurse all stated the resident should have been changed when first found wet and leaking urine. The report states the resident sat in a wet incontinence brief for about an hour during breakfast.
Unsafe Supervision During Resident Smoking
Penalty
Summary
The facility failed to ensure a safe smoking environment and adequate supervision during resident smoking activities. The smoking policy stated the facility maintains safe resident smoking practices, and the resident smoking agreement stated residents may not provide other residents with cigarettes or light cigarettes for another resident. Resident #69, admitted with diagnoses including muscle wasting and atrophy, multiple sclerosis, and anxiety disorder, had a BIMS score of 14 and was identified as a tobacco user who required supervised smoking. Resident #69 reported that a cigarette burn occurred when he/she went to light a cigarette using another resident's cigarette and ash fell into the resident's boot. The resident stated there was a staff member outside during smoking, but the resident did not alert staff at the time and later developed a blister that opened. A progress note documented an open blister on the right ankle with serous drainage and noted the resident's footwear was wide open with no lace in place. The resident's smoking evaluation and plan of care identified the resident as requiring supervision with smoking. During observation of the smoking group, multiple residents were seen outside in the designated smoking area with cigarette butts littering the ground. Only one staff member was supervising, and residents were observed lighting their cigarettes from each other's cigarettes. The DON also observed residents and staff borrowing another resident's cigarette to light another resident's cigarette. Staff interviews confirmed that residents should not be lighting each other's cigarettes and that the supervising staff member should be lighting the cigarettes, while one activity staff member stated two staff should always supervise smoking but were not always present.
Missing Person-Centered PTSD Care Plan
Penalty
Summary
The facility failed to develop a person-centered PTSD care plan for one resident with a diagnosis of PTSD. The resident was admitted in March 2026 with diagnoses including PTSD, had a BIMS score of 15 out of 15 indicating intact cognition, and the most recent MDS also identified PTSD. A trauma questionnaire completed on 3/13/26 showed the resident answered yes to questions about having been in a serious accident, having experienced a major natural or technological disaster, and having witnessed someone being seriously injured or killed or feared that someone would be seriously injured or killed. Review of the resident’s care plan showed that no PTSD care plan was in place and no personalized triggers were identified to help minimize retraumatization. During interview and record review, the Social Worker stated the resident had PTSD and should have a person-centered PTSD care plan with triggers, and that the process begins with identifying trauma at intake through a trauma assessment and then creating a person-centered care plan from that information. The DON also stated that residents with a PTSD diagnosis should have a person-centered PTSD care plan with personalized triggers to minimize retraumatization.
Failure to Obtain Dental Care for Resident With Broken Teeth and Mouth Pain
Penalty
Summary
The facility failed to provide or obtain routine and 24-hour emergency dental care for one resident with broken carious teeth and mouth pain. The resident was admitted with diagnoses including bipolar disorder, depression, and anxiety, was moderately cognitively impaired, and was dependent on staff for activities of daily living. The care plan identified oral/dental health problems and included interventions to coordinate dental care and provide mouth care, and the resident’s HCP was activated on 1/13/26. On admission, the resident’s oral evaluation documented broken/carious teeth and mouth pain, but the dental consult activation form in the record was blank and the record did not show that the resident was evaluated by a dentist after admission. The physician order for dental consultation as needed was dated 1/10/26. The resident received oxycodone for mouth pain on multiple dates in April, and on 4/25/26 an order was written for clindamycin for tooth abscess. A progress note documented oxycodone for mouth pain on 4/10/26, and the record did not include an NP note for 4/25/26. During observation, the resident’s left face was swollen and the bottom teeth were broken, jagged, and black, with red and swollen gums along the lower jaw line. The resident stated the mouth pain had been present for a long time and had just started an antibiotic for a mouth abscess. The NP later stated that on 4/25/26 she observed black and broken lower teeth, red and inflamed gums, significant facial swelling, and a lower left jaw abscess, and said mouth pain can indicate an underlying infection. The DON stated that a dental consultation should be obtained for any resident admitted with broken carious teeth and/or mouth pain, and the unit secretary stated she had not been informed to obtain a dental consultation until 4/26/26 and that the resident was not signed up for the facility’s regular dental service.
Inaccurate MAR Documentation for Medications Left at Bedside
Penalty
Summary
The facility failed to accurately document the time medications were taken in the medical record for two residents out of a sample of 32. For Resident #82, who was admitted with diagnoses including history of suicidal ideations, psychoactive substance abuse disorder, and depression, the MDS showed the resident was cognitively intact and required supervision with activities of daily living. On 4/26/26, the surveyor observed a medication cup with 6 medications at the bedside, and the resident stated these were nighttime medications left by the evening nurse to take when ready for sleep. The resident said he/she did not fall asleep until around 3 A.M. and forgot to take the medications, then took them in front of the surveyor at 8:13 A.M. The MAR for 4/25/26 documented the medications as taken at 9:00 P.M. and 10:00 P.M., which did not match the observed event. The physician's orders only indicated that the resident could self-administer an inhaler kept locked at bedside, and did not indicate self-administration of the other medications. For Resident #30, who was admitted with diagnoses including alcohol abuse, depression, and type 2 diabetes, the MDS showed the resident was cognitively intact and required supervision with activities of daily living. On 4/26/26 at 7:40 A.M., the surveyor observed pills in a cup at bedside along with tubes of hydrocortisone cream, ketoconazole cream, and an anti-fungal cream. The resident stated that the nurse sometimes leaves the pills and creams for him/her to take later. Review of the April 2026 physician orders did not show pills scheduled within the two-hour window before and after 7:40 A.M., yet the MAR for 4/26/26 documented the medications as taken at 9:00 A.M. The DON and Nurse #1 stated that medications should not be left at the bedside and that administration must be documented accurately in the MAR.
Missing Call Light Access for a Resident
Penalty
Summary
A functioning call system was not maintained in one resident’s bathroom and bathing area, and the resident did not have access to a call light while in bed. The facility policy titled “Answering the Call Light,” revised September 2022, stated that the call light must be accessible from the bed, toilet, shower or bathing facility, and floor, and that defective call lights should be reported promptly and kept plugged in and functioning at all times. Resident #61 was admitted in April 2026 with diagnoses including paranoid schizophrenia and schizoaffective disorder. The MDS dated 4/14/26 indicated a BIMS score of 14 out of 15, showing intact cognition, and that the resident required set-up assistance for ADLs. On 4/26/26, 4/27/26, and again during multiple observations, the resident was seen lying in bed without access to a call light and without a call light cord to pull; when asked how help would be summoned, the resident said he/she would yell out. During interviews, a CNA stated she did not realize the resident lacked a call light, a nurse stated all residents should have access to a call light, and the Maintenance Director said he was not aware the resident did not have one and that staff used the clipboard or TELS system to report maintenance needs. The Administrator stated he expected all residents to have access to a call light.
Failure to Ensure Resident Dignity During Therapy Session
Penalty
Summary
A deficiency occurred when a Physical Therapist Assistant (PTA) failed to treat a resident in a dignified and respectful manner during a therapy session. The resident, who was alert, oriented, and able to communicate needs, had diagnoses including multiple sclerosis, schizoaffective disorder bipolar type, stimulant use, and mild cognitive impairment. During a discussion about therapy progress and fatigue with an Occupational Therapist (OT), the PTA interrupted, approached the resident, leaned in close, and loudly stated, "Get off the drugs," before leaving the area. The resident later reported feeling disrespected by the comment, although they did not initially report the incident because they did not want the PTA to get in trouble. The OT, who witnessed the incident, did not immediately report it, believing the behavior was unprofessional but not abusive. The incident was only brought to the attention of the Director of Rehabilitation (DOR) about three weeks later during a meeting. The facility's policy on resident rights emphasizes the importance of dignity and respectful treatment, which was not upheld in this situation. Interviews with the PTA confirmed the statement was made, with the PTA stating he believed he had a good rapport with the resident and did not think the advice would be upsetting.
Failure to Immediately Report Potential Verbal Abuse Incident
Penalty
Summary
A deficiency occurred when staff failed to follow the facility's abuse prevention and reporting policy after an incident involving a resident who was alert, oriented, and able to communicate needs. During a therapy session, an Occupational Therapist (OT) and a Physical Therapist Assistant (PTA) were present with the resident, who had diagnoses including multiple sclerosis, schizoaffective disorder bipolar type, stimulant use, and mild cognitive impairment. The PTA interrupted a conversation between the OT and the resident, leaned forward, and loudly told the resident to "Get off the drugs" before leaving the area. The OT witnessed this interaction and felt it was unprofessional, but did not immediately report the incident to facility administration as required by policy. Instead, the OT waited approximately three weeks before disclosing the incident to the Director of Rehabilitation (DOR) during a meeting. The DOR then informed the OT that the incident should have been reported immediately to the Administrator or Director of Nursing (DON). The OT acknowledged awareness of the facility's abuse policy and admitted to not following the required reporting procedures. The delay in reporting meant that administration was not made aware of the potentially abusive interaction until several weeks after it occurred, constituting a failure to implement and follow established abuse prevention and reporting protocols.
Failure to Notify Health Care Agent of Resident Transfer
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's Health Care Agent (HCA) was properly notified of the resident's transfer to another Skilled Nursing Facility (SNF). The resident, who had an activated Health Care Proxy due to significantly impaired cognition and a primary language of Haitian Creole, was transferred without the HCA being informed of the actual date or time of transfer. Although the HCA had requested the transfer, she was not notified when the transfer was scheduled or completed, and only learned of the transfer after being contacted by the accepting SNF. The facility's policy required prompt notification of the resident's representative regarding changes in condition or status, including discharge or transfer. Records and interviews revealed that while the social worker sent referral emails and left a voicemail for the HCA, there was no confirmation that the HCA received or acknowledged the transfer details. The Director of Social Services assumed the HCA was aware due to previous communications but did not confirm receipt or understanding. The Nurse Supervisor and Director of Nursing also did not directly communicate the transfer details to the HCA, relying on the assumption that the social services department had done so. The accepting SNF reported that they were not provided with a confirmed transfer date, time, or a completed nurse-to-nurse clinical report.
Failure to Provide Required Assistance and Supervision During Meals
Penalty
Summary
The facility failed to provide appropriate assistance and supervision with meals for five residents who required varying levels of support due to conditions such as dysphagia, muscle weakness, cognitive impairment, and other medical diagnoses. Observations revealed that residents who were care planned for supervision or assistance during meals were left alone, often in their rooms or in areas not visible to staff. In several instances, residents were observed eating with their hands, spilling food onto themselves, or not consuming all components of their meals, indicating a lack of necessary support. For example, one resident with moderate cognitive impairment and dysphagia was repeatedly left unsupervised during meals, resulting in significant food spillage and incomplete intake. Another resident with feeding difficulties and muscle weakness was observed eating alone in the day room without staff supervision, despite care plans indicating the need for supervision and adaptive equipment. Staff interviews confirmed that these residents were not being supervised as required, and staff often misunderstood or disregarded the care plans and Kardex instructions. In one case, a resident with severe cognitive impairment and total dependence for eating was left alone with a meal tray, did not initiate eating, and was later found eating with hands or not eating at all until prompted by staff much later. Documentation reviews, including care plans, Kardex, and physician orders, consistently indicated the need for supervision or assistance during meals for these residents. However, staff interviews revealed a lack of awareness or adherence to these requirements. The Director of Nursing confirmed that the expected standard was not met, as residents requiring supervision or assistance were left unsupervised or without the necessary help during meals, contrary to their documented care needs.
Failure to Follow Oxygen Therapy Orders and Maintain Equipment Cleanliness
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for one resident with COPD and shortness of breath. The resident was observed multiple times over several days lying in bed with an oxygen nasal cannula, and the oxygen concentrator was consistently set to 4 liters per minute. However, the physician's order specified oxygen at 0-2 liters per minute via nasal cannula as needed for shortness of breath or low oxygen saturation. The care plan also directed staff to provide oxygen therapy as needed to maintain appropriate oxygen saturation levels. Despite these orders, the resident received oxygen at a higher rate than prescribed. Additionally, the oxygen concentrator's filter was repeatedly observed to be filled with dust during these observations. Nursing staff interviews revealed that oxygen levels were not checked as frequently as required, and staff were unaware of the dirty filter. The DON confirmed that oxygen orders should be followed as prescribed and that concentrators are expected to be clean, with responsibility for cleaning assigned to nursing or housekeeping staff.
Medication Error Rate Exceeds Acceptable Threshold Due to Incorrect Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by 4 errors out of 32 observed opportunities, resulting in a 12.5% error rate. Three nurses were observed making medication administration errors involving three residents. The errors included administering incorrect dosages and failing to follow physician orders regarding medication parameters and administration. One resident with a history of stroke and cognitive intactness was given an incorrect dose of vitamin B6 (50 mg instead of the ordered 100 mg) and did not receive a scheduled dose of xarelto, a blood thinner. The nurse responsible was unaware of the missed xarelto dose and did not realize the vitamin B6 tablets in the cart required two tablets to meet the prescribed dose. Another resident with severe cognitive impairment and hypertension received metoprolol without the nurse first checking vital signs, despite physician orders to hold the medication if blood pressure or pulse were below specified thresholds. The nurse admitted to not obtaining the required vital signs prior to administration. A third resident with moderate cognitive impairment and a history of intestinal obstruction was administered an insufficient dose of polyethylene glycol, as the Assistant Director of Nursing misread the measurement indicator on the medication cap. The ADON later acknowledged the error after reviewing the bottle. In all cases, the Director of Nursing confirmed that medications should be administered exactly as ordered, including correct dosages and adherence to any specified parameters.
Improper Storage and Labeling of Medications and Biologicals
Penalty
Summary
Surveyors identified multiple deficiencies related to the storage and labeling of drugs and biologicals. One resident, admitted with dysphagia and hemiplegia and assessed as cognitively intact, was observed with an open container of nicotine lozenges on the over-bed table, including partially dissolved lozenges, despite a documented evaluation indicating the resident was unable to self-administer medications. Staff interviews confirmed that the resident was not permitted to self-administer and that medications should not be left at the bedside, yet the lozenges were found unsecured. Further observations of medication carts on several floors revealed additional issues: open and undated bottles of liquid protein supplements (proheal and prostat) that require dating upon opening, numerous loose pills in medication cart drawers, an expired insulin pen, and an unlabeled, undated syringe filled with clear liquid (insulin) stored loosely in a drawer. Staff interviews confirmed that these practices were inconsistent with facility policy and manufacturer guidelines, which require proper labeling, dating, and secure storage of all medications and biologicals.
Failure to Provide Dignified Dining Experience and Communication
Penalty
Summary
Staff failed to treat two residents with dignity during the dining experience. One resident, who had dysphagia, feeding difficulties, muscle weakness, and required set-up assistance for self-feeding, was observed repeatedly calling for help and signaling staff by waving an empty coffee cup in the day room after breakfast. Multiple staff members entered and exited the room, removed items from the resident's tray, and turned on the television, but none acknowledged or responded to the resident's requests for assistance. The resident's care plan indicated that staff should anticipate and meet needs, and encourage the resident to communicate needs for safety, but these interventions were not followed. Another resident, with diagnoses including dysphagia, dementia, diabetes, and severe cognitive impairment, was observed during breakfast sitting alone with a tray not set up for consumption and no staff present to assist. When a CNA eventually arrived to feed the resident, there was no attempt to communicate with the resident in their preferred language, Haitian/Creole, despite the CNA being able to speak it. The CNA only spoke in English and did not engage the resident throughout the meal. Later, a nurse also fed the resident without attempting communication in the resident's language, only briefly asking a question in English. The resident's care plans specified the need for patience, use of simple questions, and communication in French Creole, but these were not implemented. Interviews with staff confirmed that they were aware of the residents' communication needs and language preferences, and that some staff could speak Haitian/Creole. However, staff did not use available communication tools or methods, such as cue cards or language lines, and did not attempt to communicate with the resident in their preferred language during meals. The DON stated that staff are expected to communicate with residents in their preferred language and provide appropriate supervision and care during meals.
Failure to Obtain Psychotropic Medication Consent
Penalty
Summary
The facility failed to obtain consent for the use of a psychotropic medication for one resident. According to the facility's policy, residents, families, or representatives must be involved in the medication management process, including being informed about the indication, dose, duration, and potential adverse consequences of psychotropic medications. In this case, a resident with generalized anxiety disorder and an invoked healthcare proxy was prescribed Ativan as needed prior to appointments. The resident's care plan referenced that psychotropic medication consent could be found in the medical record under consents. However, review of the medical record showed that there was no documentation indicating the healthcare proxy was informed of the new Ativan order or the associated risks and benefits before the medication was administered. The Medication Administration Record confirmed that Ativan was given prior to a medical appointment without documented consent from the healthcare proxy. Interviews with nursing staff and the Director of Nursing confirmed that consent is required before administering psychotropic medications, but this process was not followed in this instance.
Failure to Limit PRN Psychotropic Medication Use
Penalty
Summary
A deficiency occurred when a resident with a diagnosis of generalized anxiety disorder was prescribed and administered Ativan, an antianxiety medication, on an as-needed (PRN) basis prior to medical appointments. The facility's policy requires that PRN psychotropic medications be limited to 14 days unless the physician documents a rationale for extending the order, including the duration. However, the medical record for this resident did not indicate that a 14-day stop date was initiated for the PRN Ativan, nor was there documentation from the physician to justify extending the PRN order beyond 14 days. Record review confirmed that the resident received Ativan as needed, and interviews with nursing staff and the Director of Nursing verified that the required 14-day stop date and physician re-evaluation were not in place. The failure to follow facility policy regarding the use of PRN psychotropic medications resulted in the resident not being free from unnecessary psychotropic medication use.
Failure to Implement Communication Care Plan for Non-English Speaking Resident
Penalty
Summary
The facility failed to implement an effective communication care plan for a resident with severe cognitive impairment and limited English proficiency. The resident, who speaks Haitian-Creole and has diagnoses including dysphagia, dementia, diabetes mellitus, and mild cognitive impairment, was observed during multiple meal times where staff did not attempt to communicate in the resident's preferred language. Staff members spoke only in English, did not use communication boards, and did not utilize interpreter services or language lines, despite the facility's policy requiring meaningful access for individuals with limited English proficiency. Care plans and the Kardex indicated that staff should use simple questions and face-to-face communication, and the facility's policy emphasized the need for language access. However, during observations, staff did not follow these interventions, and interviews revealed a lack of awareness or use of communication aids. The Director of Nursing confirmed the expectation that staff communicate in the resident's preferred language, but this was not observed in practice.
Failure to Obtain Vital Signs Before Administering Metoprolol
Penalty
Summary
A deficiency occurred when a nurse failed to follow a physician's order regarding the administration of metoprolol to a resident with a history of hypertension and severe cognitive impairment. The physician's order specified that the medication should be held if the resident's systolic blood pressure was less than 100 or pulse was less than 60, and vital signs were to be obtained prior to administration. However, the nurse administered the medication without checking the resident's vital signs, as observed by the surveyor. During interviews, the nurse acknowledged not knowing the resident's blood pressure or pulse before giving the medication and admitted that vital signs should have been obtained due to the parameters in the physician's order. The Director of Nursing confirmed that nurses are expected to follow physician orders, including obtaining vital signs when required by medication parameters. This failure to implement the physician's order resulted in the facility not meeting professional standards of quality for medication administration.
Failure to Identify and Document New Bruise During Skin Assessment
Penalty
Summary
A deficiency occurred when staff failed to identify and document a new bruise on a resident with morbid obesity and type II diabetes mellitus, who required substantial to maximal assistance with upper body dressing and had intact cognition. The resident had an active physician's order for weekly skin assessments and care plans directing staff to monitor and report changes in skin integrity, including bruises. During a surveyor's observation, a fading bruise was noted on the resident's left forearm, which the resident was unaware of how it occurred and reported no pain. Review of the resident's recent skin assessments showed no documentation of the bruise, and staff interviews revealed that the CNA who last cared for the resident did not observe any bruises at that time. The CNA and nurse both confirmed that any new bruises should be reported and documented, but neither was aware of the bruise prior to the surveyor's observation. The Director of Nursing also confirmed that the bruise should have been identified and documented during the weekly skin assessment, but it was not.
Failure to Implement Physician Orders for Pressure Ulcer Care
Penalty
Summary
The facility failed to implement physician orders for pressure ulcer care for a resident with multiple stage 4 pressure ulcers and a history of paraplegia and amputation. The resident was identified as high risk for skin breakdown and had an active care plan and physician orders for regular wound assessments, skin checks, and specific wound treatments, including antibiotics and topical medications. Despite these orders and ongoing recommendations from the wound physician and nurse practitioner, the facility did not ensure that updated treatment orders were implemented after previous orders were discontinued. Documentation showed that the wound physician and nurse practitioner recommended continued antibiotic therapy and specific wound care treatments due to signs of infection, including increased drainage and odor from the sacral wound. However, after the discontinuation of prior orders, there was no evidence in the medical record that new treatment orders were put in place or carried out as recommended. Nursing staff confirmed that the wound physician's recommendations were not implemented, and the director of nursing was unaware that the necessary orders had not been established. Interviews with staff revealed that the expectation was for wound care recommendations to be implemented immediately, but this did not occur. The nurse practitioner and wound physician both stated that they expected the recommended treatments to be ordered and provided, but the documentation and staff interviews confirmed that the orders were not in place or followed for the resident's sacral wound after the previous orders ended.
Failure to Prevent Significant Medication Errors for Multiple Residents
Penalty
Summary
The facility failed to ensure that three residents were free from significant medication errors, as evidenced by late or omitted administration of critical medications. One resident with diabetes and renal impairment did not receive insulin as ordered before meals on multiple occasions. Documentation showed repeated late administration of insulin, sometimes several hours after the scheduled time and after meals had been consumed, with no rationale documented in the medical record. The resident expressed concern about the timeliness of insulin administration, and both nursing staff and the Director of Nursing confirmed that insulin should be administered as ordered, particularly before meals. Another resident with a history of stroke and hemiparesis did not receive a prescribed dose of Xarelto, an anticoagulant, during the morning medication pass. The nurse responsible for medication administration was unaware that the medication had not been given and confirmed that the resident had not declined the dose. The Director of Nursing acknowledged that this omission constituted a significant medication error. A third resident with diabetes, spinal stenosis, COPD, and bipolar disorder experienced repeated delays in the administration of fast-acting insulin (Fiasp) in accordance with physician orders. Observations and record reviews indicated that insulin doses were administered more than an hour after the scheduled times, including after meals had been consumed. The resident reported that medications were often forgotten or given late, particularly in the evenings. Facility policy required medications to be administered within one hour of the scheduled time, and staff interviews confirmed this expectation.
Failure to Provide Dental Services Due to Incomplete Consent Process
Penalty
Summary
A deficiency was identified when a resident, admitted with diagnoses including morbid obesity and type II diabetes mellitus, was not provided with necessary dental services. Despite having intact cognition and no documented dental issues on the most recent MDS assessment, the resident reported ongoing dental pain, specifically in a left lower molar that appeared black and was deteriorating. The resident expressed a desire to see the dentist and indicated that pieces of the tooth were breaking off, with increased sensitivity and intermittent pain. Although the care plan included dental consults as needed and oral care interventions, there was no evidence that the resident had been seen by a dentist since admission. Review of the medical record revealed that a dental consult order was present, but the required consent form was left blank and not completed, preventing the resident from being scheduled for a dental visit. Interviews with staff, including a CNA, nurse, DON, and Medical Records Director, confirmed that the resident had not been seen by the dentist due to the missing consent. Staff were unaware of the resident's dental pain, and the process for obtaining and tracking dental consents was not effectively followed, resulting in the resident not receiving timely dental care.
Incomplete and Inaccurate Resident Record Documentation
Penalty
Summary
The facility failed to ensure that resident records were complete and accurate for two residents. For one resident with morbid obesity and type II diabetes mellitus, there was a physician's order for weekly skin assessments. Despite this, recent skin assessments did not document a visible bruise on the resident's left forearm, which was observed by the surveyor. Staff interviews confirmed that the bruise should have been noted in the weekly skin assessment, but it was omitted from the documentation. For another resident with a history of stroke and residual hemiparesis, the nurse inaccurately documented the administration of a scheduled dose of miralax on the Medication Administration Record (MAR), even though the resident had declined the medication and it was not given. The nurse acknowledged the error, stating that the medication should have been documented as not administered or refused. The Director of Nursing confirmed that the documentation was inaccurate.
Missing Hospice Plan of Care in Resident Record
Penalty
Summary
The facility failed to ensure that a current hospice plan of care was present in the medical record and coordinated with facility staff for one resident. The resident, who had a diagnosis of cerebrovascular disease and severe cognitive impairment, was admitted to hospice care per a physician's order. Although the facility's care plan indicated the need for hospice services due to an end-stage disease process, the hospice agency's plan of care was not available in the resident's medical record for staff reference. Interviews with facility staff revealed uncertainty regarding the timeline for receiving the hospice plan of care. The DON stated that the plan is usually provided right away but could not specify an exact timeframe, while the social worker was unaware of how soon the hospice should provide the plan. The facility's policy requires a written agreement and coordination with the hospice provider, but documentation of the hospice plan of care was missing from the resident's record at the time of review.
Failure to Enforce Smoking Policy and Secure Smoking Materials
Penalty
Summary
Facility staff failed to implement the facility's smoking policy for one resident. The policy, as provided to surveyors, prohibits residents from keeping smoking paraphernalia in their rooms or on their person, requiring all such materials to be stored by nursing staff in a locked area. Despite this, a resident with chronic kidney disease stage 4 and chronic obstructive pulmonary disease, who was cognitively intact and a current tobacco user, was observed multiple times with cigarettes and a lighter in their room and on their person. The resident stated they were allowed to smoke independently, and staff did not intervene to store the smoking materials as required by policy. Review of the resident's care plan indicated that smoking materials should be kept by facility staff, and the resident was expected to comply with the facility smoking policy. However, the most recent smoking evaluation did not specify whether the resident could smoke independently or required supervision. Interviews with staff revealed inconsistent understanding and enforcement of the policy, with some staff believing certain residents could keep smoking materials in their rooms, while others stated that no residents were permitted to do so. The Director of Nurses confirmed that staff were expected to store all smoking materials for residents.
Failure to Update Care Plan for Resident at Risk of Skin Breakdown
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident who was at increased risk for skin breakdown and subsequently developed both pressure and non-pressure related wounds. Despite being assessed as at risk for pressure injuries, there was no documentation of a care plan addressing skin integrity concerns. The resident, diagnosed with Alzheimer's disease, dementia, difficulty in walking, abnormal posture, and hypertension, was admitted in August 2023. A quarterly assessment indicated the resident was at risk for pressure injuries, yet no care plan was documented to address this risk. The deficiency was further highlighted when the resident developed a stage 3 pressure wound on the coccyx and a non-pressure wound on the right buttock, both requiring daily treatments. Despite these developments, the resident's care plan was not updated to include preventative skin care measures or treatment needs. Interviews with nursing staff revealed a lack of responsibility in updating care plans, with an agency nurse stating it was not her responsibility, and the Assistant Director of Nursing unable to recall if the care plan had been updated. The Director of Nursing confirmed that the care plan was not updated, contrary to facility policy, which requires care plans to be revised with any change in a resident's condition.
Failure to Prevent and Treat Pressure Ulcer
Penalty
Summary
The facility failed to provide adequate care and services to prevent the development and worsening of a pressure injury for a resident who was assessed as being at high risk for skin breakdown upon admission. The resident, who had multiple diagnoses including metabolic encephalopathy, urinary tract infection, dementia with agitation, peripheral vascular disease, and hypertension, was admitted with intact skin. However, a weekly skin assessment later indicated an area of impaired skin integrity on the resident's buttocks, which was not addressed with timely physician orders for treatment. Despite the identification of skin breakdown on the resident's buttocks, there was a significant delay in obtaining physician orders for treatment. The resident's skin condition was documented as worsening into an unstageable pressure injury due to necrosis by the time of discharge. The facility's policy required immediate assessment, documentation, and notification of the physician for treatment orders, but these steps were not followed. The Director of Nurses and other staff interviews revealed a lack of awareness and communication regarding the resident's condition, contributing to the deficiency. The resident's medical records showed no documentation of a Baseline Care Plan or Comprehensive Care Plan related to skin breakdown, despite the resident being at high risk. The nursing staff failed to notify the physician and obtain treatment orders promptly, resulting in a delay of almost two weeks. The facility's expectation for handling pressure injuries was not met, as evidenced by the lack of timely intervention and communication with the physician and wound care specialist.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for three residents, as observed during a survey. Resident #4's room was infested with fruit flies, had piles of dirty clothing, a toaster on a walker, and multiple old water pitchers with trash. The resident expressed concerns about the lack of laundry service and the need for a toaster due to cold breakfast toast. The facility's nurse acknowledged ongoing pest control issues and the prohibition of toasters in rooms, while the Director of Maintenance was unaware of the toaster's presence. Resident #5 had a water pitcher dated over a month old and open, spoiled deli meat in their room. The resident and a nurse confirmed the pitcher was used daily, and the nurse removed it upon noticing the date. The Director of Social Services was unaware of the room's condition and unsure how to address it while respecting resident rights. Resident #7 had a bottle of Raid Bug Spray on their bedside table, used for fruit flies and bugs. The nurse stated pesticides should not be in resident rooms. The Maintenance Director reported multiple cluttered rooms, which he brought to the Administrator's attention, but saw no improvement. The Administrator acknowledged the difficulty in managing cluttered rooms, which may contribute to pest issues.
Inaccessible Call Bells for Residents
Penalty
Summary
The facility failed to ensure that the call bell system was accessible and within reach for residents, as required by their policy. During a tour of the facility, surveyors observed multiple instances where call bells were not within reach of residents. Specifically, Resident #7's call bell was hanging on the wall, Resident #4's call bell was wedged behind the bed, and Resident #6's call bell was also hanging behind the bed. Additionally, non-sampled residents NS RT #A, #B, and #C either had call bells on the floor or no call bell cords plugged in, making it impossible for them to call for assistance. Interviews with residents and staff further highlighted the issue. Resident #7 reported that they could not always reach the call bell and sometimes had to wait up to two hours for assistance. Resident #4 mentioned having to get out of bed to seek help due to the inaccessible call bell. Staff members, including CNAs and the Director of Nurses, acknowledged that call bells should be within easy reach of residents, indicating a failure to adhere to the facility's policy on call bell accessibility.
Failure to Notify Health Care Agent of Pressure Injury
Penalty
Summary
The facility failed to notify the Health Care Agent (HCA) of a resident who experienced a significant decline in medical status, specifically the development of an unstageable pressure injury on the sacrum. The resident, who was admitted in July 2024, had multiple diagnoses including metabolic encephalopathy, dementia with agitation, and peripheral vascular disease. Initial assessments indicated the resident's sacrum was pink and blanchable, but subsequent assessments revealed impaired skin integrity and a full-thickness wound. Despite the facility's policy requiring prompt notification of changes in a resident's condition, there was no documentation that the HCA was informed of the pressure injury. Interviews with nursing staff and family members highlighted the communication breakdown. Nurse #4, who conducted the weekly skin assessments, could not recall notifying the HCA about the skin impairment. Family members expressed concern about the resident's risk for skin breakdown, and it was noted that the physician eventually informed a family member of the pressure injury. The Director of Nurses confirmed that the facility's expectation was for the nurse to notify the HCA when a pressure injury is identified, but this did not occur in this instance.
Failure to Implement Baseline Care Plans Within 48 Hours
Penalty
Summary
The facility failed to develop and implement baseline care plans for a resident within 48 hours of admission, as required by their policy. The policy mandates that a baseline care plan should be created to address the resident's immediate health and safety needs within this timeframe. However, for one resident, who was admitted with conditions including metabolic encephalopathy, urinary tract infection, dementia with agitation, peripheral vascular disease, and hypertension, there was no documentation of such care plans being developed or implemented. The resident's immediate care needs, such as impaired cognition with agitation, risk for skin integrity alteration, new antidepressant medication, and occupational/physical therapy, were identified but not addressed in a timely manner. Interviews with facility staff revealed a lack of clarity and communication regarding the development of care plans. The Director of Social Services was uncertain about the process for creating baseline care plans and noted that the Interdisciplinary Team did not discuss care plans at the initial meeting. The Director of Nurses confirmed that the care plans for the resident were initiated five days after admission, which did not meet the 48-hour requirement. The facility's expectation is that the nurse completing the admission should initiate the baseline care plans, but this was not adhered to in this instance.
Failure to Confirm Post-Discharge Services
Penalty
Summary
The facility failed to ensure that necessary services were confirmed and in place for a resident upon discharge, leading to a deficiency in the discharge process. The resident, who had a planned discharge, required Visiting Nurse Association (VNA) services, which were not arranged prior to their discharge. The facility's policy required that a discharge summary and post-discharge plan be developed, including arrangements for follow-up care and services. However, there was no documentation confirming that VNA services were set up, and the resident did not receive these services for approximately one week after discharge. The resident, who had been admitted with diagnoses including metabolic encephalopathy, urinary tract infection, dementia with agitation, peripheral vascular disease, and hypertension, was expected to be discharged to an Assisted Living Facility (ALF). Despite the discharge summary indicating a need for home health services, including VNA, the facility did not confirm the acceptance of these services. The ALF reported not receiving discharge paperwork until two days after the resident's return, and the VNA denied having the resident as a client due to the level of care required. Interviews with facility staff revealed a lack of communication and documentation regarding the setup of VNA services. The Case Manager assumed the VNA had accepted the resident without confirmation, and the Director of Social Services acknowledged the need to document the setup of VNA services. The Director of Nurses was unaware of the lapse in service setup until a week after discharge, highlighting a breakdown in the facility's discharge planning process.
Oxygen Therapy Administration Failures
Penalty
Summary
The facility failed to ensure proper administration and monitoring of oxygen therapy for three residents, leading to significant health concerns. Resident #2, diagnosed with COPD, hypoxemia, obstructive sleep apnea, morbid obesity, and anxiety, experienced multiple incidents where their oxygen concentrator was either turned off or unplugged, resulting in respiratory distress and emergency hospital visits. On one occasion, despite family members alerting staff to the resident's distress, no immediate assistance was provided until emergency services arrived. The facility's records lacked documentation of any assessment by the nursing staff prior to the arrival of emergency services. For Resident #6, who was diagnosed with COPD, chronic respiratory failure, congestive heart failure, and anxiety, the facility failed to administer oxygen at the prescribed flow rate. During an observation, the resident's oxygen was set at 5 liters per minute, contrary to the physician's order of 2 liters. A nurse later adjusted the flow rate to the correct level, but this discrepancy highlights a lapse in following physician orders. Similarly, Resident #7, with diagnoses including chronic respiratory failure, COPD, congestive heart failure, and anxiety, was found to have their oxygen flow rate set at 0.5 liters per minute instead of the prescribed 2 liters. A nurse corrected the flow rate after the surveyor's observation. The Director of Nurses acknowledged that the facility's expectation is to adhere to physician orders, indicating a failure in maintaining the prescribed oxygen flow rates for residents requiring continuous oxygen therapy.
Medication Security Lapses
Penalty
Summary
The facility failed to ensure the proper security of prescription medications for a resident and within a medication room. A prescription topical powder medication was found at the bedside of a resident who had recently returned from the hospital. The resident reported using the medication without a physician's order or an assessment for self-administration. The nursing staff confirmed that the resident had not been assessed to self-administer medications, and no documentation supported the resident's ability to do so. Additionally, the medication room door on one of the resident care units was observed to be unlocked on two separate occasions, allowing unsecured access to medications. Nursing staff were unaware of the unlocked door, and it was acknowledged that medication room doors should always be locked. The Director of Nurses stated that residents should have a physician's order and a self-administration evaluation form completed before self-administering medications, and all medication room doors should be secured.
Deficiency in Call Bell System Functionality
Penalty
Summary
The facility failed to maintain a functioning call bell system on Unit 5, which is essential for residents to call for staff assistance. During a tour, surveyors observed that call bell cords were not plugged into the wall outlets in two rooms. Nurse #1 stated that call bell lights were not used on Unit 5 due to concerns about resident behaviors and noise. The Director of Maintenance confirmed that call bell cords were removed when the unit was reopened as a behavioral unit, and residents were instead given handheld bells. However, the presence of other accessible cords in the rooms contradicted the stated safety concerns. Additionally, the facility failed to ensure the call bell system was functioning properly for a resident whose call bell was out of reach and not working. The resident reported having to get up to inform staff when assistance was needed. When the surveyor tested the call bell, there was no response from staff, and the call bell light outside the room did not activate. The maintenance logbook showed no record of the malfunction, and the Director of Maintenance was unaware of the issue, indicating a lack of communication and prompt reporting of defective call bells.
Inadequate Supervision Leads to Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision for a cognitively impaired resident who was at increased risk for elopement. The resident, who had a court-appointed guardian and a history of attempting to leave medical facilities against medical advice, was sent to a medical appointment without an escort. Despite being identified as a wanderer and an elopement risk, the resident was transported to the appointment alone, leading to an incident where the resident eloped from the medical facility. The facility's policy emphasized individualized, resident-centered safety approaches, including adequate supervision based on assessed needs. However, there was a breakdown in communication and understanding among staff regarding the supervision required for the resident. The Director of Nurses (DON) and other staff members assumed that the transport company would supervise the resident during the appointment, which was not the case. The resident's refusal to wear a wander guard further complicated the situation, but the facility did not ensure that a staff member or the guardian accompanied the resident. Interviews with various staff members revealed a lack of clarity and coordination in decision-making about the resident's supervision needs. The Admission Clinical Liaison and the DON discussed the use of a wander guard, but the resident's refusal was not adequately addressed. The Scheduler and Nurse Supervisor assumed the transport company would provide supervision, while the Assistant Director of Nurses (ADON) and DON acknowledged the need for an escort due to the resident's guardianship status. This miscommunication and reliance on incorrect assumptions led to the resident's unsupervised elopement from the medical facility.
Failure to Provide Quarterly Statements for Personal Needs Accounts
Penalty
Summary
The facility failed to ensure that residents with personal needs accounts received quarterly statements as required. Specifically, for 56 residents, the facility did not provide quarterly statements of their personal needs account balances for over a year. During an interview, a resident expressed uncertainty about their finances and whether they had a personal needs account. The Business Office Manager (BOM), who had been working at the facility for about three months, confirmed that no quarterly statements had been sent out since March 2023. The BOM was unable to locate any documentation of quarterly statements being provided to residents or their representatives since the first quarter of 2023.
Failure to Follow Professional Standards of Nursing Practice
Penalty
Summary
The facility failed to follow professional standards of nursing practice for three residents. For Residents #422 and #29, the facility did not measure the external length of the Peripherally Inserted Central Catheter (PICC) line as ordered by the physician. Despite the facility's policy requiring the measurement of the external central vascular access device with each dressing change, the measurements were not documented in the residents' medical records. Interviews with the nursing staff and the Director of Nursing (DON) confirmed that the measurements were not recorded, although they should have been according to the facility's policy and physician's orders. Resident #422 was admitted with diagnoses including osteomyelitis, Diabetes Mellitus, and sepsis. The resident's medical records, including the Medication Administration Records (MAR) and nursing progress notes, did not contain the required PICC line measurements. Similarly, Resident #29, who was admitted with diagnoses including Parkinson's Disease, ulcerative colitis, and sepsis, also had missing PICC line measurements in their medical records. Both residents had physician's orders specifying the need for these measurements, but the facility failed to comply. For Resident #24, the facility failed to identify and treat oral thrush, a fungal infection of the mouth. Despite the resident being observed with a thick, white coating on the tongue and lips, the condition was not reported to the Nurse Practitioner (NP) or adequately addressed. The resident's care plan included daily oral care, but the staff assumed that nothing could be done to treat the oral thrush. Interviews revealed that the NP was not aware of the current condition and had not been informed by the nursing staff, leading to a lack of appropriate intervention for the resident's oral thrush.
Failure to Provide Supervision and Assistance with Meals
Penalty
Summary
The facility failed to provide supervision and assistance with Activities of Daily Living (ADLs) for three residents, specifically during meal times. Resident #25, who has dysphagia, traumatic brain injury, hemiplegia, hemiparesis, and dementia, was observed multiple times in bed with meals but without staff supervision, despite their care plan indicating the need for continual supervision. The resident was unable to initiate eating and was not visible from the hallway due to the privacy curtain being pulled, indicating a lack of adherence to the care plan by the staff. Resident #92, who has hemiplegia, hemiparesis following a cerebral infarct, dysphagia, and pneumonitis, was also observed eating in their room without staff supervision on multiple occasions. The resident's care plan and Kardex both indicated the need for supervision during meals, but staff interviews revealed that supervision was not consistently provided, with some staff believing the resident could eat independently. Resident #69, who has dementia and severe cognitive impairment, was observed eating meals without assistance from staff, despite their care plan and Kardex indicating the need for one staff member to assist with eating. Staff interviews revealed a misunderstanding of the resident's needs, with some staff believing the resident only required setup assistance. This discrepancy between the care plan and staff actions highlights a failure to provide the necessary assistance as outlined in the resident's care plan.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse within the required time frame for one resident. Resident #26, who is moderately cognitively impaired and his/her own decision maker, reported that a CNA grabbed him/her by the genitals while in the unit kitchenette. The incident was reported to the Social Worker and Director of Nursing (DON) on 5/9/24. However, a review of the facility reports filed to the state agency on 5/10/24 indicated that the allegation of abuse was not reported as required. The DON acknowledged that multiple reportable events on 5/9/24 led to the oversight in reporting the abuse allegation within the mandated two-hour window.
Failure to Return Resident to Original Room After Hospitalization
Penalty
Summary
The facility failed to ensure that a resident returned to their original bed after hospitalization, as required by the facility's Bed-hold and Returns policy and the Commonwealth of Massachusetts MassHealth Provider Nursing Facility Manual. Resident #10, who is cognitively intact and his/her own decision maker, was hospitalized and upon return, was moved to a different room on a different floor without prior notification or consent. The resident expressed dissatisfaction with the room change and stated a preference to return to the original room on the 4th floor. Interviews with the nursing staff and the Social Worker revealed that the decision to move the resident was based on safety concerns, as the resident is a fall risk and the new room is closer to the nurses' station. However, the Social Worker was unaware if the resident was notified about the room change prior to returning to the facility. The Director of Nursing confirmed that the decision was made for safety reasons and that she had discussed the room change with the resident upon their return from the hospital.
Failure to Specify Assistance Levels in Baseline Care Plans
Penalty
Summary
The facility failed to ensure that baseline care plans for a resident admitted in April 2024 included specific levels of assistance required for Activities of Daily Living (ADLs) and mobility. The resident, who has diagnoses including cerebral palsy and a disorder of the kidney and ureter, had care plans that indicated a need for staff participation in various ADLs and mobility but did not specify the exact level of assistance required. This omission was identified during a survey when the Minimum Data Set Assessment (MDS) for the resident was not available, and the baseline care plans were reviewed. During an interview, the Director of Nursing (DON) acknowledged that the baseline care plans should have included detailed information regarding the level of assistance needed for ADLs and mobility. The review of the resident's care plans revealed that the necessary details were missing, which the DON was not previously aware of. This deficiency highlights a gap in the facility's documentation and care planning processes for newly admitted residents.
Failure to Follow Physician's Orders for Wound Care
Penalty
Summary
The facility failed to ensure that Resident #25 received treatment and care in accordance with professional standards of practice. Specifically, the facility did not complete a dressing change on the resident's nose as per the physician's orders. Resident #25, who was admitted with dysphagia, traumatic brain injury, hemiplegia and hemiparesis, and dementia, was observed multiple times without the required dressing on the left side of the nose. The physician's order dated 4/18/24 indicated that the wound should be cleansed with normal saline, treated with bacitracin, and covered with a dry sterile dressing daily and as needed for soiled dressings. However, observations on 5/8/24, 5/9/24, and 5/10/24 revealed that the dressing was not in place as required. The wound physician's evaluation on 5/8/24 also confirmed the need for daily dressing changes following surgical debridement of the wound on the same day. Nursing progress notes did not indicate any refusal of treatment or behaviors of removing the dressing by the resident. Interviews with Nurse #4 and the Director of Nurses (DON) confirmed that the dressing should have been in place at all times and that any issues with the dressing should have been documented in the nursing progress notes. Nurse #4 acknowledged that the resident did not have the dressing on when she started her shift, and the DON emphasized the importance of documentation if the dressing could not be maintained. The lack of adherence to the physician's orders and the absence of proper documentation led to the identified deficiency in the care provided to Resident #25.
Failure to Provide Ordered Double Protein Diet
Penalty
Summary
The facility failed to provide the ordered diet of double protein with meals for Resident #422, who was admitted with diagnoses including osteomyelitis, Diabetes Mellitus, and sepsis. Despite the physician's orders and the Registered Dietitian's recommendations for a double protein diet to promote wound healing, the resident consistently did not receive the prescribed diet. Observations on multiple occasions revealed that the resident's meal tickets did not indicate the need for double protein, and the meals served lacked the required double protein portions. Interviews with the resident, nursing staff, and the Food Service Director confirmed that the diet orders were not being followed as the meal tickets were not updated to reflect the double protein requirement. The Registered Dietitian, who had been working at the facility for three weeks, acknowledged that she was unaware that the double protein was not listed on the resident's meal tickets. The nursing staff also confirmed that the diet orders were not on the meal tickets, which led to the resident not receiving the necessary double protein portions. The deficiency was further corroborated by the Regional Nurse and the Director of Nursing, who stated that the resident's diet should be accurately reflected on the meal tickets to ensure proper dietary provision.
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 1,133 citations issued within 25 miles in the last 12 months — including the 4 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 Watertown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Spaulding Nursing And Therapy Center - Brighton | 1 mi | ★★★★★ | 0 | 0 |
| Presentation Rehab And Skilled Care Center | 1.2 mi | ★★★★★ | 3 | 0 |
| Neville Center At Fresh Pond For Nursing & Rehab | 1.5 mi | ★★★★★ | 5 | 0 |
| Sancta Maria Nursing Facility | 1.6 mi | ★★★★★ | 11 | 0 |
| Brighton Post Acute Care | 1.8 mi | ★★★★★ | 12 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Watertown Rehabilitation And Nursing Center.
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.