Watertown Health Care Center

In the surveyor’s words

From the most serious findings on record at Watertown Health Care Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF880Nov 14, 2024

  Based on observation, interview, and record review, the facility does not have an effective infection control program to control the spread of infectious disease, in this case COVID-19; this has the potential to affect all 71 residents residing at the facility. Staff were observed going in and out of COVID positive rooms without appropriate PPE (Personal Protective Equipment). Staff were observed exiting COVID positive room with PPE on and doffing PPE in the hallway. Staff were observed not using source control. Staff were working with COVID symptoms and not tested . Facility is not utilizing dedicated equipment in COVID positive resident rooms. Privacy curtains are not being pulled between COVID positive and COVID negative residents. […]

• Immediate jeopardy, patternF689Mar 4, 2024

  Based on observation, interview and record review, the facility did not ensure each resident receives adequate supervision to prevent accidents for 6 of 8 residents reviewed for smoking (R1, R3, R4, R8, R9, and R10) and to prevent accidents from accessing alcohol and drugs for 6 of 8 residents reviewed for substance abuse (R3, R4, R5, R6, R7, and R8). On 12/18/23, R1 was observed smoking cigarettes in his room. R1 was observed again on 12/28/23 smoking in his room while telling staff he was going to burn the building down. On 1/3/24, R1 was again observed smoking in his room with ashes and burn holes in his bedsheets observed. R8 was observed by staff to have an e-cigarette in his room on 1/3/24. R10 was observed smoking in his room on 2/10/24. […]

• Immediate jeopardy, patternF700Jan 19, 2024

  Based on observations, interviews, record reviews, and review of the facility's policy, the facility failed to assess the risk, advise of the risk and/or benefits, and obtain consent prior to use of bed rails with air mattresses for 8 residents (R23, R11, R16, R18, R19, R24, R25, and R28) on the skilled unit. R23's bed was equipped with an alternating air mattress as well as bed rails so she could assist with bed mobility. On [DATE], R23 was having a hard time breathing and wanted to get up. R23 was found entrapped between the bed rail and the air mattress. Facility staff were able to free her and began CPR (Cardio Pulmonary Resuscitation) which was unsuccessful. […]

• Immediate jeopardy, isolatedF600Aug 27, 2026

  Based on interview and record review, the facility failed to protect a resident's (R2) right to be free from physical abuse from another Resident (R3) for 1 of 11 sampled residents. R3 had 5 verbal and physical altercations with other residents, including entering R2's room while he was sleeping and punching him 7-8 times in the jaw. The facility's failure to provide adequate supervision and protect residents from physical abuse created a reasonable likelihood for psychosocial harm, thus resulting in the finding of immediate jeopardy (IJ) that began on 8/4/26. Surveyor notified NHA A (Nursing Home Administrator) of immediate jeopardy on 8/18/26 at 4:07 PM. The immediate jeopardy was removed on 8/13/26). […]

• Immediate jeopardy, isolatedF689Aug 27, 2026

  Based on observation, interview, and record review, the facility did not ensure each resident received adequate supervision to prevent accidents for 3 of 3 residents (R6, R2 & R11) reviewed for supervision.R6, who is cognitively impaired, was at risk for elopement, exited the facility unsupervised, and was found 2.5 hours later about 2 miles from the facility.The facility's failure to provide adequate supervision for a resident who is at risk for elopement, created a finding of immediate jeopardy that began on 8/9/26. Surveyor notified NHA A (Nursing Home Administrator) and DON B (Director of Nursing) of the immediate jeopardy on 8/18/26 at 3:30 PM. […]