Watertown Rehabilitation and Nursing Center

Inspectors wroteBased on record review and interview the facility failed to implement an Antibiotic Stewardship Program to promote and monitor the appropriate use of antibiotics.

Inspectors wroteBased on observation and interviews, the facility failed to ensure staff stored drugs and biologicals in accordance with State and Federal laws. Specifically, the facility failed to ensure medications were dated once opened according to manufacturer's guidelines, failed to ensure an unopened insulin injector pen was stored properly and failed to ensure access to the medication storage room was limited to authorized personnel on one of three units.

Inspectors wroteBased on observation and interview, the facility failed to properly follow food storage practices in the kitchen to prevent the risk of foodborne illness in accordance with professional standards for food service safety. Specifically, the facility failed to properly store, date and label food product to prevent the risk of foodborne illness.

Inspectors wroteBased on observation, record review and interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically,1. For Resident #15, the facility a. failed to ensure staff implemented contact precautions for Resident #15, with active C-diff Infection (Clostridium difficile, a spore forming toxin that can develop in the intestines after antibiotic use and causes watery diarrhea), and b. failed to follow proper infection control practices for shared medical equipment, and c. failed to ensure staff performed hand hygiene after providing care. 2. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure their process for self-administration of medications was followed for two Residents (#82 and #30) out of a total sample of 32 residents. Specifically:For Resident #82, the facility failed to ensure the Resident took his/her medications timely after leaving the medications at the bedside and failed to have a physician's order to self-administer any other medications other than the inhaler. For Resident #30, the facility failed to ensure the Resident was assessed for the capacity to self-administer medications and failed to ensure the Resident took his/her medications after leaving the medications at the bedside.

Inspectors wroteBased on observation, record review and interview the facility failed to provide reasonable accommodation of needs and preferences for one Resident (#52) out of a total sample of 32 residents. Specifically, for Resident #52, the facility failed to provide an appropriate wheelchair and therapy to manage the wheelchair, to increase desired independence.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to provide assistance with Activities of Daily Living (ADLs) for dependent Residents for one Resident (#73) out of a total sample of 32 Residents. Specifically, the facility failed to ensure incontinence care was provided timely and in accordance with the standards of care and the Resident care plan.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure a safe smoking environment for the residents of the facility. Specifically, 1. The facility failed to provide adequate supervision for Resident #69 during smoking, resulting in a burn. 2. The facility failed to provide adequate supervision for other residents, while smoking.

Inspectors wroteBased on interviews and record review, the facility failed to develop a care plan for one Resident #46 out of a sample of 32 residents. Specifically, the facility failed to develop a person centered Post Traumatic Stress Disorder (PTSD) care plan with the Resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the Resident.

Inspectors wroteBased on observation, record review and interview, the facility failed to provide or obtain from an outside resource, routine and emergency dental services to meet the needs of one Resident (#52) out of a total sample of 32 residents. Specifically for Resident #52, the facility failed to obtain a dental consult for broken carious teeth and mouth pain resulting in the development of an abscess in the left jaw.

Inspectors wroteBased on observations, record review and interview the facility failed to accurately document in the medical record for two Residents (#82 and #30) out of a total sample of 32 residents. Specifically: For Residents #82 and #30 the facility failed to accurately document the time the Residents took their medications on the Medication Administration Record.

Inspectors wroteBased on observation and interviews, the facility failed to maintain a functioning call system for one Resident (#61) out of a total sample of 32 residents.

Inspectors wroteBased on record review and interviews, for one of three sampled residents (Resident #1) who was alert, oriented and able to make his/her needs known, the Facility failed to ensure that Resident #1 was treated in a dignified and respectful manner, when during a treatment session with rehabilitation department, the Physical Therapist Assistant (PTA) approached Resident #1, leaned forward close to Resident #1's face, and loudly stated, Get off the drugs, before exiting the area. Resident #1 said that the PTA's statement was disrespectful and that he/she did not like it.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1) who was alert, oriented and able to make his/her needs known, the Facility failed to ensure that staff implemented and followed their abuse policy, when during a rehabilitation session Occupational Therapist (OT) witnessed Physical Therapist Assistant (PTA) interact with Resident #1 in potentially abusive manner, but did not immediately report the incident as required, but instead waited several weeks to do so, which was when Administration first became aware of the incident.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who had an activated Health Care Proxy (HCP), the facility failed to ensure that on 08/11/25, his/her Health Care Agent (HCA) was notified of his/her transfer to another Skilled Nursing Facility (SNF).

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide assistance with meals for five Residents (#33, #44, #67, #2 and #48) out of a total sample of 32 residents.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure respiratory care was provided consistent with professional standards of care for one Resident (#42) out of a sample of 32 residents. Specifically for Resident #42, the facility failed to ensure oxygen was administered in accordance with the physician's orders and the oxygen equipment was kept clean.

Inspectors wroteBased on observations, interviews, and record reviews for three Residents (#95, #20, and #53) out of four residents observed, the facility failed to ensure it was free from a medication error rate of greater than 5%. Three out of three nurses observed made 4 errors out of 32 opportunities resulting in a medication error rate of 12.5%. Specifically, 1.) For Resident #95, the nurse administered the incorrect dose of vitamin B6 and failed to administer scheduled xarelto (a blood thinner). 2.) For Resident #20, the nurse failed to ensure the correct dose of metoprolol (a blood pressure lowering medication) was administered when she did not ensure blood pressure and pulse were within acceptable parameters as indicated in the physician's order. 3.) For Resident #53, the nurse administered the incorrect dose of polyethylene glycol (a laxative medication).

Inspectors wroteBased on observation and interviews, the facility failed to ensure staff stored drugs and biologicals in accordance with State and Federal laws. Specifically: 1.) The facility failed to ensure medications and biologicals were labeled and stored according to manufacturer's guidelines in four of four medication carts observed. 2.) The facility failed to ensure nicotine lozenges were not left unsecured at the residents bedside, for one Resident (#92) out of a total sample of 32 residents.

Inspectors wroteBased on observations, interviews and records reviewed, the facility failed to ensure staff treated residents in a dignified manner during the dining experience for two Residents, (#44, and #71), out of a total sample of 32 Residents. Specifically: 1. For Resident #44, the facility failed to acknowledge a resident's request for assistance in the day room. 2. For Resident #71, facility failed to provide a dignified dining experience evidenced by staff not communicating with him/her for the duration of the meal.

Inspectors wroteBased on record review and interviews, the facility failed to obtain consent for the use of psychotropic medication for one Resident (#82), out of a total sample of 32 residents.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one Resident, (#82) was free from an unnecessary psychotropic medication, out of a total sample of 32 residents.

Inspectors wroteBased on observation, interviews, and records reviewed, the facility failed to implement a communication care plan for one Resident (#71) out of a total sample of 32 Residents.

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide services that meet professional standards of quality evidenced by failing to implement physicians orders for one Resident, (#20), out of a total sample of 32 residents. Specifically: For Resident #20, the facility failed to implement a physician's order to obtain vital signs prior to administering metoprolol (a medication that lowers blood pressure).

Inspectors wroteBased on observation, record review and interview the facility failed to provide quality care for one Resident (#105) out of a total sample of 32 residents. Specifically, for Resident #105 a new bruise was not identified during daily care.

Inspectors wroteBased on record review, interview and observation, the facility failed to ensure physicians orders for the care of pressure ulcers were implemented for one Resident (#69 and #110) out of a total sample of 32 residents. Specifically, For Resident #69, the facility failed to ensure the wound physicians orders were completed.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure three Residents (#80, #95, and #76) were free from significant medication errors, out of a total sample of 32 residents. Specifically, 1.) For Resident #80, the facility failed to ensure insulin (an injectable hormone that lowers the level sugar in the blood) was administered before meals as ordered by the physician. 2.) For Resident #95, the facility failed to ensure the nurse administered xarelto (a blood thinner that treats or prevents blood clots). 3.) For Resident #76, the facility failed to ensure insulin was administered timely in accordance with physician orders.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure dental services were provided for one Resident (#105) out of a total sample of 32 residents.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure resident records were complete and accurate for two Residents (#105 and #95) out of a total of 32 sampled residents. Specifically: 1. For Resident #105, the facility failed to accurately document a weekly skin assessment. 2. For Resident #95, the nurse inaccurately documented miralax (a laxative) as administered when it was not.

Inspectors wroteBased on record review and interviews, the facility failed to ensure a current hospice plan of care was present in the medical record and coordinated with facility staff for one Resident (#48) out of a total sample of 32 residents.

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure its staff implemented the facility smoking policy for one Resident (#64) out of a total sample of 32 resident. Specifically, the facility failed to ensure staff stored Resident #64's smoking materials in a locked area.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who was assessed by nursing to be at increased risk for skin breakdown and developed both pressure and non-pressure related wounds, the Facility failed to ensure nursing developed and implemented a comprehensive care plan that included interventions, goals and outcomes that addressed his/her risk for skin breakdown and actual alteration in skin integrity.

Inspectors wroteBased on records reviewed and interviews for one of seven sampled residents (Resident #3), who upon admission was assessed as being at high risk for skin breakdown and was documented by nursing to have intact skin, the Facility failed to ensure Resident #3 received adequate care and services related to the prevention of the development and/or worsening of a pressure injury. On 8/02/24, Resident #3's weekly skin assessment indicated he/she had an area of impaired skin integrity on his/her buttocks that was un-measurable, however physician's orders for treatment were not obtained until 8/14/24, almost two weeks later. Upon his/her discharge from the facility, Resident #3's pressure injury was documented as having worsened into an unstageable pressure injury due to necrosis.

Inspectors wroteBased on records reviewed, interviews and observations for three of seven sampled residents (Resident #4, #5, and #7), the Facility failed to ensure they provided the residents with a safe, clean, comfortable, and homelike environment. When during the survey, there were bugs noted in the resident rooms, insect spray on a resident's side table, old water pitchers, and an open perishable food package stored in a nightstand drawer.

Inspectors wroteBased on observations, records reviewed, and interviews, for three of seven sampled residents (Resident #4, Resident #6 and Resident #7) and three non-sampled residents (NS RT #A, #B and #C), the facility failed to ensure the call bell system button was accessible and within reach for residents to call for assistance, per facility policy.

Inspectors wroteBased on records reviewed and interviews for one of seven sampled residents (Resident #3), who had an activated Health Care Proxy (HCP) and had experienced a significant decline in medical status, the Facility failed to ensure Resident #3's Health Care Agent (HCA) had been notified of the change in condition which included the development of an unstageable pressure (unable to stage due to necrosis) injury to his/her sacrum.

Inspectors wroteBased on records reviewed and interviews for one of seven sampled residents, (Resident #3), the facility failed to ensure that upon admission, nursing developed and implemented baseline care plans with interventions, treatments, goals, and outcomes that addressed the residents overall immediate care needs.

Inspectors wroteBased on records reviewed and interviews for one of seven sampled residents (Resident #3), who had a planned discharge and required services be in place upon discharge home, the Facility failed to ensure their discharge process included that services required upon discharge were confirmed and had accepted the resident on their service, when Visiting Nurse Association (VNA) services were not in place and he/she did not receive VNA services for approximately one week after his/her discharge.

Inspectors wroteBased on records reviewed, interviews and observations for three of seven sampled residents (Resident #2, #6 and #7), who had physician's orders for the continuous administration of oxygen, the facility failed to ensure that 1) Resident #2's oxygen equipment was continuously plugged in and/or functioning properly, and 2) Resident #6 and #7's oxygen therapy liter flow rates were administered per physician's orders.

Inspectors wroteBased on records reviewed, interview, and observations for one of seven sampled residents (Resident #7) and one of four resident care units (Unit #4), the Facility failed to ensure nursing staff properly secured prescription medications, when 1) on 08/27/24 a prescription topical powder medication had been found at the bedside of Resident #7 and 2) on 08/27/24 and 08/28/24, Unit #4's medication room door was observed to be unlocked, and therefore medications were not secured.

Inspectors wroteBased on observations, records reviewed, and interviews, for one of four resident care units (Unit 5), the Facility failed to ensure they 1) maintained a functioning call bell system that allows residents to call for staff assistance through a communication system which relays to a centralized staff work area from resident's bedside and 2) for one of seven sampled residents (Resident #4), the facility failed to ensure the call bell system was functioning properly in his/her room.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), who was cognitively impaired, had a guardianship in place, and had been assessed by nursing to be at increased risk for elopement, the Facility failed to ensure he/she was provided an adequate level of staff supervision to prevent an incident of elopement, when on 06/20/24, Resident #1 was transported to a medical appointment, unsupervised by staff or a guardian/responsible party, upon completion of the medical appointment, he/she eloped from the medical facility, and was not found until the next day, when he/she showed up at his/her home in the community.

Inspectors wroteBased on record review and interview the facility failed to ensure residents who have their personal needs accounts maintained by the facility received quarterly statements as required. Specifically, the facility failed for 56 residents who have personal needs accounts held by the facility, to provide quarterly statements of the personal needs account balances for over one year.

Inspectors wroteBased on observation, record review, and interview, the facility failed to follow professional standards of nursing practice for three Residents (#422, #29, #24) out of a total sample of 29 residents. Specifically, 1) for Residents #422 and #29, the facility failed to measure the external measurement of the Peripherally Inserted Central Catheter (PICC) line as ordered by the physician, and 2) for Resident #24, the facility failed to identify and treat oral thrush (a fungal infection of the mouth).

Inspectors wroteBased on observations, record review, policy review and interviews, the facility failed to provide supervision and assistance with Activities of Daily Living (ADLs), for three Residents (#25, #92 and #69) out of a total sample of 29 residents. Specifically, the facility failed to 1.) provide supervision with meals for two Residents (#25, #92) and 2.) provide assistance with meals for one Resident (#69).

Inspectors wroteBased on record review and interview, the facility failed to report an allegation of abuse within the required time frame for one Resident (#26) out of a total of 29 sampled residents.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure one Resident (#10) returned to his/her original bed upon returning from a hospitalization out of a total of 29 sampled residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure baseline care plans indicated the level of assistance related to Activities of Daily Living (ADLs) and mobility for one Resident (#273) out of a total of 29 sampled residents.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to ensure that one Resident (#25) received treatment and care in accordance with professional standards of practice out of a total sample of 29 residents. Specifically, for Resident #25, the facility failed to complete a dressing change in accordance with physician's orders. Findings Include: Resident #25 was admitted to the facility August 2011 dysphagia, traumatic brain injury, hemiplegia and hemiparesis, and dementia. Review of Resident #25's most recent Minimum Data Set (MDS), dated [DATE], indicated he/she scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident is cognitively intact. On 5/8/24 at 8:17 A.M., the surveyor observed the Resident in bed without a dressing on his/her nose. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to address the nutrition status of one Resident (#422) out of a total sample of 29 residents. Specifically, for Resident #422, the facility failed to provide the ordered diet of double protein with meals to help promote wound healing.

Inspectors wroteBased on record review and interview, the facility failed to ensure the ongoing communication and collaboration with the dialysis facility regarding dialysis care and services for one Resident (#273) out of a total of 29 sampled residents.

Inspectors wroteBased on observation, policy review and interview the facility failed to ensure medications and biological's were stored in a safe and secure manner in two of four medication carts and two of four units.

Inspectors wroteBased on observation and interview, the facility failed to follow infection control protocols to prevent the possible spread of infection by failing to follow proper hand hygiene protocols and the use of Personal Protective Equipment (PPE) for an Enhanced PPE Precaution room. Review of the facility policy titled Isolation - Categories of Transmission-Based Precautions, dated and revised September 2022, indicated the following: -Standard precautions are used when caring for residents at all times regardless of their suspected or confirmed infection status. -Transmission-based precautions are additional measures that protect staff, visitors and other residents from becoming infected. -When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door. [...]

Inspectors wroteBased on records reviewed and interviews for three of three sampled residents (Resident #1, Resident #2, and Resident #3), the Facility failed to ensure the residents and/or their family members or legal representatives participated in the development and implementation of their person-center care plans, which included conducting and inviting residents and/or their legal representatives to an interdisciplinary care plan meeting following the completion of any Comprehensive Minimum Data Set (MDS) Assessments, including the Quarterly and Annual MDS Assessments.

Inspectors wroteBased on record review and interviews for one of three sampled residents (Resident #1) who was severely cognitively impaired and who had an activated Health Care Proxy, the facility failed to ensure they maintained a complete and accurate medical record, which included having an actual signed copy of his/her Massachusetts Medical Order for Life-saving Treatment (MOLST) Form as part of the medical record.