Watertown Rehabilitation and Nursing Center

In the surveyor’s words

From the most serious findings on record at Watertown Rehabilitation and Nursing Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF678Feb 3, 2021

  Based on records reviewed and interviews for one of seven sampled residents (Resident #3), who was a Full Code (attempt resuscitation), the Facility failed to ensure staff immediately activated their emergency code protocol (code blue), when he/she was found unresponsive. On [DATE], Nurse #1 found Resident #3 unresponsive, failed to call a code blue, initiate cardiopulmonary resuscitation (CPR), and activate 911, because when he checked the medical record to determine his/her code status, there was a photocopy of a Medical Order for Life Sustaining Treatment (MOLST) form that indicated a Do Not Resuscitate (DNR) status, however, that form belonged to another resident (Resident #6) with the same first and last name as Resident #3, that had been placed in Resident #3's medical record in… […]

• Immediate jeopardy, isolatedF842Feb 3, 2021

  Based on records reviewed and interviews for one of seven sampled residents (Resident #3), who was a Full Code (attempt resuscitation), the Facility failed to ensure policies and procedures were developed, implemented, and staff were trained to ensure a complete and accurate medical record was maintained with residents that have the same or similar names to ensure their advanced directives were followed in accordance with their physician's orders [REDACTED].>On [DATE], Nurse #1 found Resident #3 unresponsive, went to Resident #3's medical record, noted a white photocopy of a Medical Order for Life Sustaining Treatment (MOLST) form that indicated he/she was a Do Not Resuscitate (DNR), however, that form was Resident #6's MOLST form, who had the same first and last name as Resident #3. […]

• Actual harm, patternF692May 31, 2022

  Based on observation, record review and interview, the facility 1. failed to maintain acceptable parameters of nutrition for 3 of 6 sampled Residents (#57, #98 and #161) receiving tube feedings (TF), and 2. failed to identify a significant weight loss for 1 Resident not receiving tube feeding (#52) out of a total of 30 sampled Residents. Findings include: Review of the facility's Weighing and Measuring the Resident policy, dated March 2011 indicated: *The purpose of this procedure is to determine the resident's weight to provide a baseline and an ongoing record of the resident's body weight as an indicator of the nutritional status and medical condition of the resident. *Report significant weight loss/gain to the nurse supervisor. […]

• Actual harm, isolatedF686Aug 28, 2024

  Based 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. […]

• Actual harm, isolatedF686May 31, 2022

  Based on observation, record review and interview, the facility failed to implement a treatment in a timely manner for an existing pressure ulcer for 1 Resident (#161) out of a total of 36 sampled Residents. Findings include: Resident #161 was initially admitted to the facility in October 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of his/her most recent Minimum Data Set assessment dated [DATE] indicated Resident #161 is severely cognitively impaired, is totally dependent on staff for activities of daily living, and receives nutrition through a feeding tube. Review of Resident #161's Norton Plus Scale for Predicting Pressure Ulcers, dated 3/2/22 indicated he/she was at high risk for developing pressure ulcers. […]