Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Samaritan Senior Village, Inc during CMS and state inspections, most recent first.
The facility failed to properly cool potentially hazardous foods and had insufficient lighting in the kitchen's walk-in cooler and freezer. Observations showed cooked beef and pasta were not cooled to required temperatures, and staff used flashlights due to poor lighting. Interviews revealed misunderstandings about cooling requirements and inadequate documentation.
During a survey, deficiencies were found in medication storage and labeling. A medication room lacked refrigerator temperature logs, a medication cart was left unlocked and unattended, and eye drops were not labeled with an opened date. Staff interviews revealed lapses in following procedures, such as not recording temperatures and uncertainty about labeling eye drops. The DON confirmed the importance of these practices for medication efficacy and safety.
The facility failed to serve food at appropriate temperatures, as evidenced by resident complaints and observations during a survey. Meals were often cold and lacked flavor, with food items like chicken tenders and potatoes served below recommended temperatures. Staff interviews revealed that food was reheated without temperature checks, and test trays were not consistently conducted due to staffing issues.
Three residents in a facility did not receive care according to their care plans. A resident with quadriplegia did not have palm protectors applied as planned, another with edema was not wearing prescribed Tubigrips, and a third with a skin tear did not receive timely treatment. Staff interviews revealed issues with communication and documentation, leading to these deficiencies.
A resident with Type 2 diabetes did not have their condition included in their care plan, despite facility policies requiring individualized plans for chronic conditions. The resident was on Metformin and had dietary and lab test orders, but these were not documented in the care plan. Staff interviews confirmed the importance of care plans for monitoring diabetes, yet the oversight persisted.
A resident with dementia and muscle weakness was unable to attend a preferred Petting Zoo activity due to a lack of coordination between staff members. Despite being ready and eager to participate, the resident was not assisted to the activity location, resulting in a missed opportunity for socialization and enjoyment.
A resident with end-stage renal disease did not receive proper dialysis care at an LTC facility. The facility failed to conduct pre and post-dialysis assessments or monitor the dialysis access site. Communication with the dialysis center was inconsistent, and the communication book contained outdated information. Staff were unaware of the resident's current dialysis access type, leading to potential complications.
A resident with a history of MRSA and COVID-19 was not properly managed under contact precautions by an LPN during medication administration. The LPN failed to perform hand hygiene and wear a gown, despite signage indicating the need for such precautions. Interviews with staff confirmed these actions were against facility policy, and supplies were available to prevent such breaches.
A resident's electric wheelchair was found unclean, with dried debris, due to the facility's failure to adhere to its cleaning protocol. Staff interviews revealed confusion about the cleaning schedule, and the resident expressed dissatisfaction with the cleanliness of their wheelchair. The Environmental Services Supervisor confirmed the chair was not brought out for cleaning, and the DON was unaware of the cleaning process.
A resident's family member raised concerns about long call bell wait times via email to the facility's Administrator, but the issues were not addressed in a timely manner. Despite acknowledging the message, the Administrator did not follow up after technical issues with the attachment. Interviews with staff revealed a lack of awareness and follow-up on the unresolved issues, leading to a deficiency in grievance resolution.
A resident with mobility issues was not assisted out of bed as required due to staffing shortages at the facility. Despite having intact cognition and not rejecting care, the resident was left in bed all day without documentation explaining the reason. Interviews revealed that staff shortages led to prioritization of residents needing meal assistance, and the resident's family was unable to reach the facility's Administrator to discuss their concerns.
Improper Food Cooling and Insufficient Lighting in Kitchen
Penalty
Summary
The facility failed to ensure that food was stored and prepared in accordance with professional standards for food service safety, as observed during a recertification survey. Specifically, potentially hazardous foods were not cooled properly in the main kitchen. The facility's policy required proper cooling of food to prevent foodborne illness, but the Temperature-Time Cooling Log did not document any food products cooled on a specific date, and one item was logged without identifying the food. Observations revealed that cooked beef and pasta were not cooled to the required temperatures. The beef, covered in plastic wrap, was found at 68 degrees Fahrenheit, and the pasta, double stacked in pans, was between 46 and 53 degrees Fahrenheit. Staff interviews indicated a lack of understanding of the cooling requirements, with discrepancies in the cooling process and documentation. Additionally, the facility had insufficient lighting in the walk-in cooler and freezer, requiring staff to use flashlights to see the contents. This issue was acknowledged by the Food Service Director, who stated that proper cooling should occur in the walk-in cooler or freezer, not in the upright cooler where the deficiencies were observed. The lack of adequate lighting was a known challenge, further complicating the safe handling and storage of food.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored according to professional principles, as observed during a recertification survey. Specifically, the First floor B side medication room lacked documented refrigerator temperatures for two days, which is crucial for maintaining the efficacy of temperature-sensitive medications like insulin. Interviews with nursing staff confirmed that the responsibility for recording these temperatures lay with the night shift, and the absence of records indicated that the task was not completed on those days. Additionally, the Fourth floor B side medication cart was found unlocked and unattended for at least 20 minutes, posing a risk as it contained potentially dangerous medications. The LPN responsible admitted to not locking the cart after being distracted by another task, despite the presence of residents who might wander and access the cart. The Director of Nursing confirmed that the standard practice required medication carts to be locked when not in view. Furthermore, eye drops on the Second floor B side and Fourth floor A side medication carts were not labeled with an opened date, which is necessary to ensure they are used within their effective period. Staff interviews revealed uncertainty about the duration eye drops remain effective once opened, and some staff relied on the dispensed date instead of the opened date. The Director of Nursing stated that eye drops should be labeled with an opened date, and if not, they should be discarded and reordered.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to ensure that food and drink were served at palatable, attractive, and safe temperatures, as evidenced by multiple observations and resident complaints during a recertification survey. Specifically, during a lunch meal observation, food items such as chicken tenders and potatoes were served at temperatures below the recommended range, with the chicken tenders at 127.8 degrees Fahrenheit and the potatoes at 117.3 degrees Fahrenheit. Residents, including Residents #22 and #31, reported that their meals were often cold and lacked flavor, leading to reduced consumption. Additionally, during a Resident Council meeting, seven anonymous residents expressed dissatisfaction with the temperature and taste of their meals, noting that hot foods were not always hot, cold foods were not always cold, and meal trays were sometimes missing items. Interviews with staff revealed systemic issues contributing to the deficiency. Certified Nurse Aide #31 mentioned that residents frequently complained about cold and flavorless food, and when food was reported as cold, it was reheated in a microwave without using a thermometer to check the temperature. Food Service Worker #32 and the Food Service Director #33 acknowledged that food was cooked in the main kitchen and transported to units in hot boxes, but they admitted that test trays were not consistently conducted due to staffing shortages. The Food Service Director also confirmed hearing complaints about food temperatures during Resident Council meetings and acknowledged that the serving temperatures for hot foods should be between 140-165 degrees Fahrenheit. Despite these acknowledgments, there was no documentation of test trays being performed, and staff were unsure if they were completed regularly.
Failure to Provide Proper Treatment and Care
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Resident #59, who had functional quadriplegia and contractures of both hands, was not provided with palm protectors as care planned. Despite the occupational therapist's discharge recommendations and the care plan instructions, there was no documented evidence of a physician order for the palm protectors, and they were not applied during multiple observations. Interviews with staff revealed a lack of communication and documentation regarding the application of the palm protectors, leading to the resident being without them, which could exacerbate their condition. Resident #67, diagnosed with chronic congestive heart failure and edema, was not wearing the prescribed Tubigrips for their lower extremities as ordered. The physician's order required the Tubigrips to be on at all times, but observations showed the resident without them. The Treatment Administration Record inaccurately documented that the Tubigrips were verified as being on, despite the LPN admitting they had not checked. This discrepancy highlights a failure in following the care plan and ensuring the resident's medical needs were met, potentially leading to increased swelling and skin injuries. Resident #86, who had a skin tear on their left forearm, did not receive timely and appropriate treatment. The initial treatment orders were not obtained, and the wound dressing was observed to be unclean. Despite the presence of steri-strips, there was no documented physician order for the treatment, and the wound was not properly monitored or cleaned, as evidenced by the presence of dried blood. Interviews with nursing staff indicated a lack of proper documentation and communication regarding the wound care, resulting in inadequate treatment and monitoring of the resident's skin tear.
Failure to Include Diabetes in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with a diagnosis of Type 2 diabetes. Despite the facility's policy requiring individualized care plans for all residents, including those with chronic conditions, the care plan for this resident did not include their diabetes diagnosis or associated interventions. The resident was admitted with diabetes mellitus and had physician orders for Metformin, a no concentrated sweets diet, and regular HGBA1C tests. However, there was no documented evidence that these were included in the resident's care plan. Interviews with facility staff revealed that the care plans were accessible to nurse aides and were crucial for monitoring residents with diabetes for symptoms of abnormal glucose levels. The LPN Unit Manager and the Director of Nursing acknowledged that the care plans should reflect the resident's diabetes diagnosis to ensure proper monitoring and intervention. Despite the resident's daily use of an oral hypoglycemic, their care plan did not address their diabetes, which was a significant oversight in their care management.
Failure to Facilitate Resident Participation in Preferred Activity
Penalty
Summary
The facility failed to ensure that Resident #137 was able to attend a meaningful activity that aligned with their interests and preferences, as documented during a recertification survey. Resident #137, who had diagnoses including dementia and muscle weakness, expressed a desire to attend a Petting Zoo activity scheduled on the facility's Recreational Therapy Calendar. Despite being ready in their wheelchair and having communicated their interest, the resident was not assisted to the activity location. The resident's family member confirmed that the resident was eager to participate, a rare occurrence given their usual disinterest in facility activities. The deficiency occurred due to a lack of communication and coordination between the staff members responsible for assisting the resident. Activity Coordinator #29 and Certified Nurse Aide #30 both acknowledged the resident's interest in attending the activity. However, the resident was not transported to the activity because the aide did not take them to the elevator, assuming the coordinator would return to pick them up. This oversight resulted in the resident missing an opportunity for socialization and enjoyment, which was important for their quality of life and mental health.
Deficiency in Dialysis Care and Communication
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis services received care consistent with professional standards. The resident, who had end-stage renal disease and required hemodialysis, attended a community-based dialysis center three times a week. However, the facility did not conduct ongoing assessments of the resident's condition or monitor for complications before and after dialysis treatments. Additionally, there was a lack of consistent communication and collaboration between the facility and the dialysis center. The facility's policy on dialysis care, effective April 2024, required maintaining proper standards and communication with the dialysis center. However, the policy did not specify the information to be included in the communication book, nor did it outline the need for pre or post-dialysis assessments or monitoring of the dialysis access site. The resident's care plan and physician orders also lacked details on these assessments and monitoring. Observations and interviews revealed that the resident's dialysis access site was not monitored by facility staff, and no pre or post-dialysis assessments or vital signs were recorded. Interviews with facility staff, including nurses and the assistant director of nursing, highlighted a lack of awareness and responsibility regarding the monitoring of the dialysis access site and the communication book. The communication book contained outdated information, and staff were unsure of the resident's current dialysis access type. The failure to monitor the dialysis access site and conduct necessary assessments could lead to complications, as noted by the staff during interviews.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of an LPN during medication administration to a resident on contact precautions. The resident had a history of methicillin-resistant Staphylococcus aureus (MRSA) and was also COVID-19 positive, requiring both contact and droplet precautions. However, the LPN did not adhere to the necessary infection control measures, such as wearing a gown and performing hand hygiene, when entering the resident's room. The LPN entered the resident's room without performing hand hygiene, wearing gloves, or donning a gown, despite the presence of a contact precautions sign outside the room. After administering medications, the LPN removed their gloves, handled the resident's inhaler and eye drops with ungloved hands, and placed them on the medication cart without proper disinfection. The LPN acknowledged the oversight, citing the unavailability of gowns outside the room as a reason for not following protocol. Interviews with facility staff, including the RN Unit Manager and the Infection Preventionist, confirmed that the LPN's actions were inconsistent with the facility's infection control policies. Staff emphasized the importance of wearing personal protective equipment and performing hand hygiene to prevent the spread of infections. The Infection Preventionist noted that supplies were available in the clean utility room, and staff were expected to restock them as needed. The resident's contact precautions for COVID-19 had been discontinued, but the signage remained, leading to confusion about the current precautionary measures.
Failure to Maintain Cleanliness of Resident's Wheelchair
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for a resident who used an electric wheelchair. The resident, who had left hemiplegia and hemiparesis following a stroke, was observed with a wheelchair that had a significant amount of dried debris underneath and around the footrest and on the front middle portion of the seat. The facility's policy required wheelchairs to be cleaned and disinfected once a month and as needed, but the cleaning log did not document that the resident's chair was cleaned. Interviews with staff revealed uncertainty about the cleaning schedule and acknowledged that wheelchairs, including the resident's, were often missed during cleaning. The resident expressed dissatisfaction with the cleanliness of their wheelchair, stating that it required extra effort to have it cleaned. Staff interviews indicated that wheelchairs were supposed to be cleaned by housekeeping on the night shift, but there was confusion about the schedule, and some chairs were missed. The Environmental Services Supervisor confirmed that wheelchairs were cleaned monthly, but the resident's chair was never brought out for cleaning. The Director of Nursing was unaware of the cleaning process but expected dirty wheelchairs to be spot cleaned and a work order submitted for further cleaning. The lack of a clear process and monitoring for wheelchair cleanliness contributed to the deficiency.
Failure to Address Grievances Promptly
Penalty
Summary
The facility failed to ensure prompt resolution of grievances for a resident, as evidenced by the lack of timely response to concerns raised by the resident's family member. The family member had sent an electronic message to the facility's Administrator expressing concerns about long call bell wait times and other issues. Although the Administrator acknowledged the message and requested the attachment to be resent due to technical issues, there was no documented follow-up or resolution of the concerns. The resident, who had intact cognition and required moderate assistance with daily activities, confirmed that call bells were not answered promptly, necessitating intervention from their family member. Interviews with facility staff, including the Assistant Director of Nursing and the Director of Social Services and Grievance Officer, revealed a lack of awareness and follow-up on the unresolved issues. The Administrator admitted to not following up with the family member after the initial communication. The facility's policy required that complaints and grievances be addressed promptly, but this was not adhered to in the case of the resident's family member's concerns, leading to the deficiency noted in the survey.
Resident Not Assisted Out of Bed Due to Staffing Shortages
Penalty
Summary
The facility failed to ensure that a resident, who required assistance with activities of daily living, received the necessary services to maintain grooming and personal hygiene. Resident #26, who had diagnoses including transient ischemic attack, abnormalities of gait and mobility, and muscle weakness, required substantial assistance for bed mobility and transfers. Despite having intact cognition and not rejecting care, the resident was not assisted out of bed as requested. On a specific day, the resident was left in bed all day due to staffing shortages, and there was no documentation explaining why the resident stayed in bed. Interviews revealed that the resident had been asked to stay in bed because there was not enough staff to assist them. The resident's family member had attempted to contact the facility's Administrator to discuss concerns about the resident being left in bed, but received no response. Staff interviews indicated that on the weekend in question, there were only two certified nurse aides available until 10:00 AM, leading to prioritization of residents who needed assistance with meals. The Assistant Director of Nursing stated that it was unacceptable for staff to ask a resident to stay in bed due to staffing issues and expected to be notified about such problems.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 12 citations issued within 25 miles in the last 12 months — including the 1 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
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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) |
|---|---|---|---|---|
| Samaritan Keep Nursing Home Inc | 1.5 mi | ★★★★★ | 12 | 1 |
| Carthage Center For Rehabilitation And Nursing | 15.3 mi | ★★★★★ | 0 | 0 |
| Lewis County General Hospital-nursing Home Unit | 23.9 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.