Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avantara Watertown during CMS and state inspections, most recent first.
The facility failed to maintain safe bed systems and prevent accidents, resulting in loose side rails, unsecured or poorly fitted mattresses, and unassessed entrapment zones for multiple residents, including one who was legally blind and had a prior brain bleed after falling from bed. Maintenance logs showed incomplete or inaccurate entrapment audits, with several entrapment zones marked not applicable and some residents with rails omitted from audits, while the DON acknowledged missing side rail assessments, consents, and orders. Additional incidents included a resident with post‑stroke weakness who fell from a bed left at waist height, a resident care planned for two‑person mechanical lift transfers who was transferred by a single CNA using an incorrect sling setup, a cognitively impaired resident at risk for elopement who exited through a door with its alarm deactivated and remained outside briefly in cold weather, and a resident on anticoagulants who fell and hit her head after 11 falls in 30 days without effective revision of fall‑prevention interventions.
Administrator A and the DON did not ensure effective management and oversight of resident care and services, resulting in widespread system failures affecting all 45 residents. Surveyors found deficiencies in resident dignity, informed consent for psychotropic medications, self-administration of meds, honoring meal preferences, responses to resident council concerns, protection of health information, grievance procedures, and handling of abuse allegations. Additional problems included missing or inaccurate MDS and PASSR assessments, lack of timely PASSR refiling for new diagnoses, incomplete or delayed baseline and updated care plans, failure to notify physicians of elevated blood sugars, and unaddressed accident hazards related to bed siderails. The facility also had issues with nebulizer and nasal cannula cleaning and storage, siderail assessments and consents, call light response times, controlled substance accountability, medication errors, and improper storage of drugs and biologicals, despite job descriptions assigning the administrator and DON responsibility for regulatory compliance and quality care.
Staff failed to honor several residents’ stated preferences regarding where they undressed for bathing, affecting their dignity and privacy. One resident reported that a CNA repeatedly undressed him in his room, covered him with a blanket, and transported him through the hallway to the shower room, despite his expressed wish to undress in the shower room. Other residents described similar experiences, stating that the CNA did not ask their preferences and routinely undressed them in their rooms before covering them with a sheet or blanket and taking them to the tub or shower room. Staff interviews confirmed that residents, particularly those requiring a mechanical lift, were typically undressed in their rooms and then transported covered, and the DON stated that facility protocol was to follow resident preference, consistent with the written dignity and privacy policy.
A resident reported that a contracted travel CNA placed hands down his pants while he was in bed, which he described as groping and not part of his usual care routine. Two RNs received this allegation; one counseled the CNA but did not notify leadership and did not know the required reporting time frame, while the other, who knew the 2‑hour reporting requirement, also failed to promptly inform the DON or administrator, delaying notification to state authorities and omitting contact with law enforcement and the ombudsman. In a separate incident, a resident’s family member reported suspected financial abuse to the social services designee, who informed the administrator, but the concern was not reported to the state agency or investigated as an abuse allegation; instead, the family was only given contact information for outside agencies. These actions did not follow the facility’s abuse policy requiring immediate internal reporting, prompt investigation, and timely reporting of all abuse and misappropriation allegations to the state agency.
The facility failed to complete and individualize baseline care plans within 48 hours of admission for several newly admitted residents. Some residents had no baseline care plan in the EMR, while others had plans that were signed but undated or missing key information such as required assistance levels for ADLs, transfer methods, diet orders, use of assistive devices, and ordered rehab therapies. An LPN reported that nurses initiate baseline care plans at admission, and the MDS/RN acknowledged that staff may not know how to provide care if plans are not resident-specific. The regional nurse consultant confirmed that some residents lacked individualized baseline care plans and that the facility likely did not have signed baseline care plans or documentation that copies were provided, despite a policy requiring completion of a comprehensive baseline care plan within 48 hours including physician, dietary, therapy, and social service information.
The facility failed to keep several residents’ care plans accurate and resident‑specific. One resident with multiple chronic conditions had a care plan that omitted how transfers should be performed, her diet, and ordered rehab therapies. Another resident on sertraline and an antipsychotic for depression, behaviors, and poor mood had repeated episodes of agitation, combativeness, yelling, and aggression documented in progress notes, but her care plan did not identify antipsychotic use, target behaviors, or non‑pharmacological interventions. Two additional residents had care plan focus areas indicating risk of bruising and hemorrhage due to anticoagulant use even though they were not on anticoagulants, only on antiplatelet or aspirin therapy. CNAs reported relying on pocket care plans that were sometimes outdated, and clinical staff acknowledged that these care plans did not reflect current needs, contrary to facility policies on psychotropic medications and individualized care planning.
A hospice resident with liver disease and frequent scratching received escalating doses of fentanyl transdermal patches, some of which were later found to be missing and could not be located. Facility records showed multiple inconsistencies and omissions on the Transdermal Patch Controlled Drug Record, including patches removed without documented destruction times, patches applied without subsequent destruction entries, and patches documented as destroyed at the same time or shortly after being signed out for administration. Staff interviews revealed confusion about the tracking form and described storing used patches in a locked drawer when a second nurse was unavailable, while the DON acknowledged missing dates and times and that documentation did not consistently align with policy requirements for controlled substances and transdermal patch monitoring.
A resident with chronic kidney disease and other health issues suffered an acute kidney injury after receiving an incorrect dose of furosemide for five days. The error occurred due to a failure to discontinue a previous medication order, resulting in the resident receiving a total of 200 mg daily instead of the prescribed 160 mg. The oversight was discovered during a cardiology appointment, where increased creatinine levels and significant weight loss were noted.
The facility failed to maintain resident dignity by not covering urinary catheter bags in common areas. Observations showed three residents with uncovered catheter bags containing visible urine in the dining and activity areas. Interviews revealed staff were unaware of a policy requiring covers, although the facility had them available. The DON expected catheter bags to be covered when residents were outside their rooms.
The facility failed to ensure accountability for fentanyl patches for three residents, as patches were frequently unaccounted for and not documented properly. Despite standard practice requiring verification of patch placement each shift, this was not consistently done. The facility's policy required documentation and verification by two nurses for controlled substances, which was not adhered to, leading to the deficiency.
The facility failed to remove expired medications from the storage room. Observations revealed expired Hepatitis B and influenza vaccines in the locked refrigerator. The DON stated that the medication room should be checked monthly for outdated supplies, but there was no documented verification of this task. The facility's policy required expired medications to be removed and destroyed, which was not followed.
The provider failed to ensure consistent and accurate oral care for three residents, leading to significant plaque buildup and inadequate hygiene. CNAs documented oral care as completed without verifying it, and the facility lacked a policy for oral care, contributing to the inconsistency.
Failure to Maintain Safe Bed Systems and Prevent Accidents
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe bed environment free from entrapment hazards and to provide adequate supervision and accident prevention for multiple residents. Surveyors observed that several residents had loose side rails or grab bars and mattresses that were not secured or properly fitted, creating gaps between the rails, mattress, and bedframe. One resident’s bilateral side rails could move away from the bed one to two inches, and there was a five‑inch gap between the top of his mattress and the headboard. Another resident, who was legally blind and had previously fallen out of bed during a dream and sustained a brain bleed, had a left side rail that could move three inches away from the mattress; he reported telling a CNA and his daughter about the loose rail about a week earlier. A third resident used bilateral side rails for bed mobility; her right rail could move two to three inches away from the bed, the openings within the rails measured three and one‑half inches wide by 13 inches high, and there was a seven‑inch gap between the foot of her mattress and the footboard. Surveyors also found that the facility’s entrapment assessments and maintenance audits were incomplete or inaccurately documented. Review of the maintenance logbook for side rail inspections from January through April showed that only zone 1 (the opening within the side rail) was consistently assessed, while the other six FDA‑defined entrapment zones were often marked as not applicable, including zone 7 (the space between the mattress and headboard or footboard) even for residents without bed rails. In some months, all seven zones were documented as not applicable for numerous residents known to have side rails, and some residents with side rails were not included in the audits at all. The DON was unsure if there was a specific entrapment assessment policy and believed maintenance handled these assessments, while also acknowledging missing documentation for side rail assessments, consents, and physician orders, and that some side rails were installed without proper documentation. Additional deficiencies related to accident prevention and supervision were identified in several facility‑reported incidents. One resident with a history of stroke and left‑sided weakness fell from his bed while trying to remove his socks after a CNA left his bed at waist height; his care plan at that time did not specify a required bed height, and he was later diagnosed with a minor closed head injury and abrasions. Another resident, care planned to require two staff for transfers and use of a sit‑to‑stand lift, was transferred by a single contracted CNA using a sling that was too small and the wrong hook, causing back pain; the resident and his family reported that he was often transferred by only one staff member despite the care plan. A cognitively impaired resident at risk for elopement exited through a door whose alarm had been deactivated during daytime hours so visitors could enter and exit, walked outside in very cold weather, and re‑entered through another door after about 15 minutes. A further resident, on anticoagulant therapy, fell while transferring herself to the bathroom and hit her head; she had fallen 11 times in 30 days, and the provider failed to implement, review, and revise interventions to reduce her fall risk. These events collectively demonstrate failures to follow care plans, maintain environmental safety devices such as alarms and bed systems, and provide adequate supervision to prevent accidents. The surveyors determined that these failures, particularly the unsecured side rails and unassessed mattress gaps, created a risk for entrapment injury or harm and issued an Immediate Jeopardy finding under F689 related to accident hazards and supervision. Observations throughout the building confirmed multiple safety concerns with side rail installation, maintenance, and bed zone assessments, including loose rails and significant gaps between mattresses and headboards or footboards. Facility leadership and maintenance staff acknowledged that gaps between mattresses and bed ends and loose side rails posed a risk for entrapment and injury, and that entrapment zone measurements and assessments had not been consistently completed according to FDA guidance and facility policy.
Systemic Administrative and Nursing Leadership Failures Affecting Resident Care and Services
Penalty
Summary
Administrator A and DON B failed to operate and administer the facility in a manner that ensured quality of life and overall well-being for all 45 residents. Surveyors, through observation, interview, record review, policy review, and job description review over multiple days, identified a widespread system breakdown in ensuring that services met professional standards. Deficient areas included resident dignity, informed decision-making for psychotropic medications, resident self-administration of medications, honoring resident meal choices and preferences, responding to resident concerns raised in resident council meetings, protecting resident health information, informing residents how to file grievances, and handling allegations of resident abuse. Additional failures involved obtaining and documenting consent and diagnoses for psychotropic medications, timely reporting of allegations, and providing Ombudsman reports upon discharge. Further findings showed failures in clinical and regulatory processes, including inaccurate MDS assessments and PASSR evaluations, not refiling PASSR when residents had new diagnoses, and not developing resident-specific baseline care plans within 48 hours of admission or updating care plans as needed. The facility did not consistently notify physicians of residents' increased blood sugar levels and did not adequately address accident hazards related to bed side rails. There were issues with nebulizer and nasal cannula cleaning and storage, bed siderail assessments, orders and consent, call light response times, controlled substance accountability, medication errors, and storage of drugs and biologicals. Administrator A confirmed responsibility for daily operations and acknowledged frustration with siderail issues, while job descriptions for both the administrator and DON documented their responsibility for ensuring regulatory compliance and quality care, which was not achieved in these areas.
Failure to Honor Resident Bathing and Undressing Preferences
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to dignity, respect, and self-determination regarding bathing and undressing practices. One resident reported in a facility reported incident that on his bath days, a CNA undressed him in his room, covered him with a blanket, and transported him through the hallway to the shower room, despite his stated preference to undress in the shower room. During a later interview, this resident stated that the CNA continued this practice, that it made him uncomfortable, and that it happened all the time. The DON stated that the bathing protocol was to follow each resident’s preference for where to undress, and that the CNA had been informed of this resident’s preference. The resident’s care plan documented his need for assistance with dressing but did not include his specific bathing or undressing location preferences. Additional interviews showed that this practice extended to other residents and was not individualized based on resident choice. The CNA acknowledged awareness of the resident’s preference but stated that all residents were undressed in the shower room, while another CNA described a typical routine in which residents with limited mobility who required a mechanical lift were undressed in their rooms, covered with a blanket, and then transported to the shower room. Another resident reported seeing the first resident transported to the shower room covered only by a blanket and stated that the CNA did not ask where he preferred to undress, instead beginning to undress him after announcing it was time for a bath. A third resident stated that the same CNA transferred him from bed to a chair, covered him with a white sheet, and took him to the tub room without asking his preferences, and that he had seen other residents transported in the same manner. These practices conflicted with the facility’s Resident Dignity & Privacy Policy, which required staff to groom and dress residents according to their preferences and to maintain privacy during care.
Failure to Timely Report and Investigate Allegations of Sexual and Financial Abuse
Penalty
Summary
The deficiency involves the facility’s failure to timely report and initiate required investigations into two separate allegations of abuse, including sexual and possible financial abuse. One resident reported that at approximately 6:00 a.m. a contracted travel CNA placed hands down his pants while he was in bed, allegedly to check if he was wet, which the resident described as groping that made him feel cheap. The resident stated he typically did not receive nighttime incontinence checks, as he used a urinal and was usually only awakened for early morning blood sugar checks or lab draws. He reported this incident to two RNs, one of whom acknowledged that it was not appropriate for staff to put their hands down a resident’s pants to check incontinence products. Despite this, the nurses who received the allegation did not immediately report it to the DON, administrator, or state agency as required by facility policy and federal guidelines. One RN spoke with the contracted travel CNA to “educate” her but did not notify anyone else and did not know the required reporting time frame. Another RN, who was aware of the process and the two-hour reporting requirement to the state health department, also failed to promptly report the allegation to the DON or administrator, resulting in a delay until late morning before leadership became aware. At the time leadership was notified, the allegation had not yet been investigated, and law enforcement and the ombudsman had not been contacted, even though the allegation involved possible sexual abuse. A second deficiency arose when a resident’s family member reported concerns of suspected financial abuse to the social services designee, who then informed the administrator. Instead of treating this as an abuse allegation requiring reporting and investigation under the facility’s abuse and neglect policy, the administrator did not report it to the state health department, citing a lack of detailed information. The social services designee and administrator only provided the family with contact information for external agencies such as the state’s attorney and adult protective services. The facility’s own policy required that all allegations and suspicions of abuse, including misappropriation of property and exploitation, be immediately reported to the administrator or designee, investigated by the administrator or designee, and reported to the state agency within two hours, but these procedures were not followed for either the sexual abuse allegation or the suspected financial abuse concern.
Failure to Complete and Individualize Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The deficiency involves the facility’s failure to develop and complete individualized baseline care plans within 48 hours of admission that contained the minimum healthcare information necessary to properly care for multiple residents, and to ensure these plans were reviewed with and offered to residents or their representatives. Record review showed that one resident admitted on 9/25/25 had a signed baseline care plan that lacked documentation of required assistance levels for transfers, bed mobility, bathing, dressing, toileting, eating, and did not include the physician-ordered diet. Another resident’s baseline care plan, last revised on 1/9/26, was signed but undated and similarly omitted the level of assistance needed for transfers, bed mobility, bathing, dressing, toileting, and eating. A third resident admitted on a specified date had no baseline care plan at all, and a fourth resident’s baseline care plan, uploaded on 12/19/25 and signed but undated, did not indicate how the resident transferred, walked, whether assistive devices were required, or the amount of assistance needed for dressing or toileting. Additional record reviews revealed that another resident admitted on a specified date had no baseline care plan in the EMR, and a further resident’s baseline care plan dated 4/5/26 did not specify how she transferred between surfaces, her diet, or the specific physician-ordered rehabilitation therapies. Interviews with the regional nurse consultant confirmed that two residents did not have individualized baseline care plans completed and that the facility likely did not have signed baseline care plans or documentation that copies were provided to residents or their representatives. An LPN stated that nurses initiate baseline care plans during admission and that all nurses and leadership can update them, and the MDS/RN acknowledged that staff may not know how to provide care if care plans are not resident-specific and completed, and confirmed that two residents’ baseline care plans, although reviewed with their representatives, were not personalized with specific care information. Policy review showed that the facility’s care plan policy required baseline care plans to be started on the first day of admission, completed within 48 hours, and to include minimum healthcare information such as initial goals, physician orders, dietary orders, therapy services, social services, and PASARR recommendations, which was not consistently done.
Failure to Maintain Accurate, Resident-Specific Care Plans for Medications and Behaviors
Penalty
Summary
The deficiency involves the facility’s failure to ensure resident care plans were reviewed and revised to reflect current, resident-specific care needs as required. For one resident with moderately impaired cognition and multiple diagnoses including diabetes, Parkinson’s disease, Alzheimer’s disease, dementia, major depressive disorder, anxiety, and orthostatic hypotension, the care plan dated 4/5/26 did not identify how the resident transferred between surfaces, did not specify her diet, and did not list the specific rehabilitation therapies ordered by the physician. This omission meant key aspects of her daily care and ordered services were not captured in the individualized care plan. Another resident with intact cognition and a diagnosis of depression had physician orders for sertraline for depression and olanzapine for behaviors and poor mood, but the care plan did not identify that she was receiving an antipsychotic medication, did not address her documented behaviors, and did not include any non‑pharmacological interventions for those behaviors. Progress notes over several weeks documented repeated episodes of agitation, combativeness, yelling, name‑calling, ripping papers, attempting to pinch another resident, and spitting at staff, yet these behaviors and related interventions were not incorporated into the care plan. The only psychotropic use noted in her care plan was within a fall‑risk focus area, without target symptoms or non‑pharmacological strategies. Two additional residents with moderately impaired cognition had care plans that inaccurately identified a focus area of potential for bruising and hemorrhage due to anticoagulant use, even though one was receiving antiplatelet medications (clopidogrel and aspirin) and had never been on an anticoagulant, and the other was only receiving aspirin and had no anticoagulant ordered. Interviews with CNAs indicated they relied on pocket care plans and the Kardex to determine residents’ care needs and that pocket care plans were sometimes not up to date. The MDS nurse and an LPN confirmed that care plans were expected to be accurate, resident‑specific, and to include antipsychotic use and behavioral interventions when applicable, and acknowledged that the care plans for these residents were not updated to reflect their actual medication regimens and behavioral needs, contrary to the facility’s psychotropic medication and care plan policies.
Inaccurate Documentation and Handling of Fentanyl Transdermal Patches
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate and complete documentation and handling of fentanyl transdermal patches for a hospice resident, as required by policy and controlled substance procedures. The resident was admitted on hospice services and had physician orders for escalating doses of fentanyl patches, including 12 mcg/hr, 25 mcg/hr, 37 mcg/hr, and later 50 mcg/hr, with changes every 72 hours. The resident had liver disease and scratched frequently. On multiple occasions, fentanyl patches applied to the resident were later found to be missing and could not be located despite searches by nursing and laundry staff. The resident’s family member reported being present when a patch was applied and stated he had been notified twice that patches were missing, both times when the patches were placed on the resident’s chest. The facility’s own records and interviews showed inconsistent and incomplete documentation on the Transdermal Patch Controlled Drug Record. The record for April showed a fentanyl patch removed on one date without any date or time of destruction, and two 12 mcg patches applied on the same date that were never documented as destroyed. There were entries where a specific numbered 25 mcg patch was signed out for administration and then documented as destroyed at the same time, and another instance where a patch was documented as destroyed on the same day it was signed out, without clear correlation to removal from the resident. The missing fentanyl patch on one date was not documented on the Transdermal Patch Controlled Drug Record as missing. Additionally, a 50 mcg patch was documented as destroyed without a date or time, and another 50 mcg patch was documented as destroyed shortly after being signed out for administration. Interviews with staff confirmed confusion and deviation from the facility’s stated procedures. An LPN reported that the Transdermal Patch Controlled Drug Record was difficult to understand and described a practice where, if a second nurse was not available at night, used patches were placed in a medication cup and stored in a locked controlled medication drawer until day shift could witness destruction. The DON stated that fentanyl patches supplied by hospice did not come with a controlled medication tracking form, so the facility used the hospice-provided Transdermal Patch Controlled Drug Record to track removal from the cart and destruction. The DON expected accurate completion of this record, including date and time of removal from the cart and destruction, and acknowledged that the documentation suggested the patch being destroyed was the same one removed from the cart, as well as acknowledging missing dates and times of destruction. The facility’s Drug Diversion Prevention policy required placement checks every shift and two-nurse destruction with appropriate documentation, but the order for placement checks every shift was initially not entered, and the documentation on the controlled drug record did not consistently meet these requirements.
Significant Medication Error Leads to Acute Kidney Injury
Penalty
Summary
The provider failed to ensure that a resident was free from significant medication errors, resulting in an acute kidney injury. The resident, who had diagnoses including congestive heart failure, chronic kidney disease, localized edema, and hypertension, experienced several changes in the frequency and dosage of furosemide, a diuretic medication. On a specific date, the physician ordered an increase in the resident's daily furosemide dose from 80 mg to 120 mg. However, after a cardiology appointment, the resident was supposed to restart oral furosemide at 80 mg twice daily, but the previous additional 40 mg daily dose was not discontinued, leading to the resident receiving an incorrect total dose of 200 mg daily for five days. The medication error was discovered during a cardiology appointment, where it was noted that the resident's creatinine level had increased, indicating impaired kidney function. The resident also experienced a weight loss of 13 pounds over the five days. The error was attributed to a transcription oversight, where the additional 40 mg dose was not discontinued in the medication administration record (MAR). The facility's process required the nursing staff to verify and confirm medication orders, but this step was not adequately followed, resulting in the administration of the incorrect dose. Interviews with facility staff, including the director of nursing and a registered pharmacist, revealed that the error occurred due to a lack of proper verification and discontinuation of the previous medication order. The pharmacy staff did not discontinue the 40 mg dose when the new order was entered, and the nursing staff failed to catch the error during the confirmation process. The resident, who had moderate cognitive impairment, required assistance with medication administration, further complicating the situation.
Failure to Cover Urinary Catheter Bags in Common Areas
Penalty
Summary
The deficiency involves the failure of the facility to preserve the dignity of three residents by not ensuring their urinary catheter bags were covered while they were in common areas. Observations revealed that one resident was seen wheeling himself in the hallway and seated in the dining area with his catheter bag uncovered and visible urine. Another resident was observed during lunch and later while playing bingo and watching TV, with her catheter bag uncovered and visible to other residents. A third resident was also seen in the dining area with his catheter bag uncovered and visible to others. Interviews with staff, including an LPN and an RN, indicated a lack of awareness of any policy requiring catheter bags to be covered. The RN later discovered that the facility did have catheter covers but was unsure why they were not used. The DON expressed that it was her expectation for catheter bags to be covered when residents were out of their rooms, highlighting a disconnect between expectations and practice.
Failure to Monitor and Document Fentanyl Patch Placement
Penalty
Summary
The provider failed to ensure the accountability of fentanyl patches for three of five sampled residents, specifically residents 8, 30, and 144. The issue was identified when a registered nurse reported being unable to locate a fentanyl patch on resident 144, which had been placed three days prior. Further investigation revealed that the nursing staff had been unable to locate resident 144's fentanyl patch on four other occasions. Interviews with the resident and his spouse did not provide clarity on the missing patches, and a housekeeper did not recall seeing any patches on the floor. A pain assessment indicated that the resident rated his pain as zero on a scale of zero to ten. The facility's controlled substance/narcotic record showed that on multiple occasions, the record was signed by only one nurse, and it was documented that the patches were missing or not found. Additionally, the placement verification of fentanyl patches for residents 8 and 30 was not entered into their medication administration records (MAR) until a month or more after the patches were ordered. Interviews with nursing staff revealed that checking the placement of fentanyl patches each shift was considered standard practice, yet this was not consistently documented or followed. The facility's Drug Diversion Prevention policy required that the placement of transdermal controlled substances be checked and documented every shift, and that removal and destruction of such patches require verification by two nurses. However, the facility did not adhere to these procedures, leading to the deficiency in monitoring and documenting the placement of fentanyl patches for the affected residents.
Expired Medications Not Removed from Storage
Penalty
Summary
The provider failed to ensure expired medications were removed from the medication storage room. During an observation, it was found that 23 Hepatitis B vaccines and three multi-dose vials of influenza vaccine were expired and still stored in the locked refrigerator. The assistant director of nursing (ADON) confirmed these findings. An interview with the director of nursing (DON) revealed that the medication room was supposed to be checked for outdated medications and supplies each month, a task assigned to the night shift. However, there was no documented verification that this task was completed. The DON expected expired medications to be removed and properly disposed of, as per the facility's policy. The facility's policy from January 2018 stated that all expired medications should be removed from the active supply and destroyed in the facility, regardless of the amount remaining. The expired medications were not removed, indicating a failure to adhere to this policy.
Inconsistent and Inaccurate Oral Care Documentation
Penalty
Summary
The provider failed to ensure consistent and accurate oral care for three of four sampled residents. Resident 2 had significant plaque buildup and reported not having his teeth brushed for approximately three days, despite documentation indicating oral care was completed. The CNA admitted to not assisting with oral care as documented. Resident 2's care plan indicated he required assistance with oral care due to decreased mobility, but this was not consistently provided. Similarly, Resident 3 had visible plaque buildup and reported not having his teeth brushed for a couple of days. The CNA documented oral care as completed without verifying it with the resident. Resident 3's care plan also required assistance with oral care, which was not adequately provided. Resident 4's toothbrush was dry, and the CNA claimed to have thrown away the used toothbrush, which was inconsistent with the observation of the dry toothbrush. Resident 4's care plan lacked specific interventions for oral care despite her decreased mobility and need for assistance. Interviews with the DON and RN revealed an expectation that oral care should be completed twice daily for all residents. However, the facility did not have a policy for oral care, contributing to the inconsistency in care and documentation. The lack of a structured policy and failure to adhere to care plans resulted in inadequate oral hygiene for the residents, as evidenced by the observations and interviews conducted during the survey.
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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.
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Nursing homes near Watertown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Jenkin's Living Center | 0.7 mi | — | 0 | 0 |
| Estelline Nursing And Care Center | 20.9 mi | — | 0 | 0 |
| Avantara Lake Norden | 22.9 mi | — | 2 | 1 |
| Avantara Clark City | 30.9 mi | — | 7 | 0 |
| Avantara Milbank | 31.1 mi | — | 0 | 0 |
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