Deficiency Records for Watertown Rehabilitation and Nursing Center
Updated as of April 01, 2024
A list of the most recent deficiencies for Watertown Rehabilitation and Nursing Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-10-25 | 2023-11-22 | Y |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2023-03-23 | 2023-04-20 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-03-23 | 2023-04-20 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-03-23 | 2023-04-20 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-03-20 | 2023-04-15 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-03-20 | 2023-04-15 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-03-20 | 2023-04-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-20 | 2023-04-15 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-03-20 | 2023-04-15 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-03-20 | 2023-04-15 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2023-03-20 | 2023-04-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-20 | 2023-04-15 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-03-20 | 2023-04-15 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-03-20 | 2023-04-15 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-03-20 | 2023-04-15 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2023-03-20 | 2023-04-15 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-03-20 | 2023-04-15 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-03-20 | 2023-04-15 | N |
| Provide or obtain dental services for each resident. | Health | 2023-03-20 | 2023-04-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-20 | 2023-04-15 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-03-20 | 2023-04-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-03-20 | 2023-04-15 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2023-03-20 | 2023-04-15 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-03-23 | 2023-04-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-23 | 2023-03-29 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-11-10 | 2022-12-15 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-11-10 | 2022-12-15 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2022-06-07 | 2022-08-03 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-06-07 | 2022-08-03 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2022-06-07 | 2022-08-03 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2022-06-07 | 2022-08-03 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2022-06-07 | 2022-08-03 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2022-06-07 | 2022-08-03 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2022-06-07 | 2022-08-03 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2022-06-07 | 2022-08-03 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2022-06-07 | 2022-08-03 | N |
| Establish methods for sharing information. | Fire Safety | 2022-06-07 | 2022-08-03 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2022-06-07 | 2022-08-03 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2022-06-07 | 2022-08-03 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-06-07 | 2022-08-03 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2022-06-07 | 2022-08-03 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-06-07 | 2022-08-03 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2022-06-07 | 2022-08-03 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2022-06-07 | 2022-08-03 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-06-07 | 2022-08-03 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-06-07 | 2022-08-03 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2022-06-07 | 2022-08-03 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-05-31 | 2022-07-15 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2022-05-31 | 2022-07-15 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-05-31 | 2022-07-15 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-05-31 | 2022-07-15 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-05-31 | 2022-07-15 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-05-31 | 2022-06-28 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-05-31 | 2022-06-28 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-05-31 | 2022-06-28 | N |
| Respond appropriately to all alleged violations. | Health | 2022-05-31 | 2022-06-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-05-31 | 2022-06-28 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-05-31 | 2022-06-28 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-05-31 | 2022-06-28 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-05-31 | 2022-06-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-31 | 2022-06-28 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2022-05-31 | 2022-06-28 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-05-31 | 2022-06-28 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-05-31 | 2022-06-28 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-05-31 | 2022-06-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-05-31 | 2022-06-28 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-06-07 | 2022-06-28 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-06-07 | 2022-06-27 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2022-06-07 | 2022-06-27 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2022-06-07 | 2022-06-27 | N |
| Develop a communication plan. | Fire Safety | 2022-06-07 | 2022-06-27 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2022-06-07 | 2022-06-27 | N |
| Provide emergency officials' contact information. | Fire Safety | 2022-06-07 | 2022-06-27 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2022-06-07 | 2022-06-27 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-06-07 | 2022-06-27 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-06-07 | 2022-06-27 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-06-07 | 2022-06-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-06-07 | 2022-06-25 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-06-07 | 2022-06-09 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-06 | 2022-04-12 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-04-06 | 2022-04-12 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-04-06 | 2022-04-12 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-03-07 | 2022-03-29 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-03-07 | 2022-03-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-03-07 | 2022-03-29 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-03-07 | 2022-03-29 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-01-13 | 2022-03-22 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-01-13 | 2022-03-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-13 | 2022-03-22 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-01-13 | 2022-03-22 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2022-01-13 | 2022-03-22 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-01-13 | 2022-03-22 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-01-13 | 2022-03-22 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-12-15 | 2022-02-04 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-10-20 | 2021-12-10 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-10-20 | 2021-12-10 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-07-06 | 2021-10-05 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2021-07-06 | 2021-10-05 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-07-06 | 2021-10-05 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-06 | 2021-10-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-07-06 | 2021-10-05 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-07-06 | 2021-09-22 | N |
| Post nurse staffing information every day. | Health | 2021-07-06 | 2021-09-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-06 | 2021-09-22 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-07-06 | 2021-09-22 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2021-07-15 | 2021-08-29 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-07-15 | 2021-08-29 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-07-15 | 2021-08-29 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-07-06 | 2021-08-17 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-07-06 | 2021-08-17 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-07-06 | 2021-08-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-07-06 | 2021-08-17 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-07-06 | 2021-08-17 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-07-06 | 2021-08-17 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-06 | 2021-08-17 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-07-06 | 2021-08-17 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-07-06 | 2021-08-17 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2021-07-06 | 2021-08-17 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2021-07-06 | 2021-08-17 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2021-07-06 | 2021-08-17 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-07-06 | 2021-08-17 | N |
