Watertown Health Care Center

F 0558

Reasonably accommodate the needs and preferences of each resident.

Level of Harm - Minimal harm or potential for actual harm

Based on staff and resident interview, the facility did not ensure there were sufficient supplies for 1 of 4 Residents (Resident R2).Resident R2 indicated the facility ran out of the brief size Resident R2 needed and Resident R2 had to wear two briefs instead of one. Staff interviews verified the facility frequently ran out of wipes, briefs, and wash cloths used for resident care. Findings include:On 9/24/25, Surveyor observed the facility's supply closets which contained brief and wipes. Staff interviews indicated the supplies will be gone by the end of the week. On 9/24/25 at 9:02 AM, Surveyor interviewed Resident R2 who indicated the facility runs out of the briefs that Resident R2 uses and staff have to use two different briefs to make one brief. Resident R2 stated the facility also runs out of wipes and staff don't cleanse Resident R2 when they change Resident R2. Resident R2 indicated it occurred at least five or six times since Resident R2 was admitted in April. (Resident R2's medical record indicated Resident R2 was dependent on staff for toileting and required partial/moderate assistance with hygiene. Resident R2 was alert and oriented and did not have an activated Power of Attorney (POA).) On 9/24/25 at 11:50 AM, Surveyor interviewed Resident R11 who indicated the supply issue was bad a while ago but is a little better. Resident R11 indicated the facility used to run out of briefs and wipes all of the time.On 9/24/25 at 9:16 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-F who indicated supplies have been an issue, especially since the supply clerk left. LPN-F indicated the facility runs out of briefs and wipes every week. LPN-F stated residents have complained, especially when there are no briefs.

On 9/24/25 at 9:21 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-D who indicated the facility runs out of briefs and wipes by the end of the week. CNA-D stated when the facility does get supplies, there is a limited amount and they frequently have the wrong size briefs. CNA-D indicated the facility runs out of wash cloths because staff throw them out instead of putting them in the laundry. CNA-D indicated the lack of supplies affects resident care. CNA-D verified that residents have complained. On 9/24/25 at 11:42 AM, Surveyor interviewed Central Supply Clerk (CSC)-G who had been in the position a month and a half.

CSC-G indicated CSC-G checks supply closets twice a day. When supplies are ordered, CSC-G stated it's

a guess from the week before and depends on the census. CSC-G was aware the facility had run out of supplies before. On 9/24/25 at 12:32 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated the facility orders supplies on a periodic automatic replacement (PAR) level. Supplies are ordered weekly on Thursday and received on Monday. NHA-A was aware the facility ran out of wipes and stated the Assistant Director of Nursing (ADON) went to a store and purchased more. NHA-A was not sure why the facility ran out of wipes and was not aware the facility had run out of briefs or had the wrong size briefs.(Of note: A policy related to supplies was not provided during the survey.)

Residents Affected - Few

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/01/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Watertown Health Care Center

121 Hospital Dr Watertown, WI 53098

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0583

Keep residents' personal and medical records private and confidential.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation and staff and resident interview, the facility did not provide adequate privacy during cares in a double occupancy room for 1 of 4 Residents (Resident R2).Resident R2 reported a concern with a male visitor in the room while staff provided care for Resident R2. Findings include:On 9/24/25, Surveyor reviewed Resident R2's medical record. Resident R2 was admitted to the facility on [DATE REDACTED] and had diagnosis including muscle wasting, atrophy (is the partial or complete wasting away of a part of the body.), osteoarthritis, pain syndrome, dysthymic disorder (persistent depressive disorder (PDD), is a chronic form of depression characterized by a low mood lasting for at least two years), and anxiety disorder.Resident R2's Minimum Data Set (MDS) assessment, dated 7/15/25, indicated Resident R2 was dependent on staff for toileting and transfers, required substantial/maximal assistance with dressing, and required partial/moderate assistance with hygiene. Resident R2 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated Resident R2 had intact cognition. Resident R2 did not have an activated Power of Attorney (POA). On 9/24/25 at 9:02 AM, Surveyor interviewed Resident R2 who indicated when Resident R2 had a roommate,

a male visited frequently and was in the room while staff provided care for Resident R2. Resident R2 indicated Resident R2 felt uncomfortable and told nursing staff. Resident R2 indicated Resident R2 could see the male get items out of a refrigerator on top of a dresser while staff provided care for Resident R2 which made Resident R2 uncomfortable. On 9/24/25 at 1:17 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-F who was aware that Resident R2 was not comfortable with a male visitor in the room during cares but did not see anything when LPN-F was working.On 9/24/25 at 1:24 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-D who indicated Resident R2 mentioned to CNA-D on

the PM shift that Resident R2 could see a male visitor in Resident R2's room get something from the refrigerator while staff provided care which made Resident R2 uncomfortable. On 9/24/25 at 1:52 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated the facility did not have a policy regarding visitors in the room during cares. NHA-A indicated if a resident reports a concern, staff can ask the visitor to step out while cares are being completed. NHA-A recalled an instance when a nurse told NHA-A that Resident R2 was uncomfortable with a male visitor in the room. NHA-A told the nurse to ask the visitor to step out while cares were completed and

the visitor left the facility. NHA-A moved Resident R2's roommate to another room to alleviate any further concerns.

NHA-A indicated NHA-A did not follow-up with residents to see if there were other similar privacy concerns and did not provide education to staff in an attempt to prevent future concerns.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/01/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Watertown Health Care Center

121 Hospital Dr Watertown, WI 53098

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

inner cannula from the kit and inserted the inner cannula into Resident R6's tracheostomy tube. LPN C used the gauze and cotton swabs from the bedside table to clean around Resident R6's tracheostomy tube and place a new piece of gauze under the tracheostomy tube. LPN C cleaned up her work area, removed her gloves and performed hand hygiene.On 9/24/25 at 10:00 AM, Surveyor shared the observations made with LPN C.

Surveyor interviewed LPN C regarding her technique during the care of Resident R6's tracheostomy. LPN C indicated the bedside table was not clean and should have been cleaned prior to placing any items on the table. LPN C indicated she did not perform hand hygiene as she should have. LPN C indicated she had multiple infection control breaks in what should have been a sterile procedure. LPN C indicated this was not completed in a sterile manner and should have been. Surveyor asked LPN C when she checks Resident R6's neck for skin breakdown due to the tracheostomy necktie. LPN C indicated the skin check is completed when the tracheostomy care is done. Surveyor asked LPN C if she checked Resident R6's neck for skin breakdown. LPN C indicated she did not and should have.On 9/24/25 at 5:17 PM, Surveyor interviewed DON B (Director of Nursing) regarding Resident R6's tracheostomy care. Surveyor shared with DON B the observations made during Resident R6's tracheostomy care performed by LPN C. DON B indicated she would expect staff to follow the standard of practice. DON B indicated the work area should have been cleaned prior to starting the procedure, the procedure should have been sterile where required and hand hygiene should be performed every time gloves are removed.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/01/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Watertown Health Care Center

121 Hospital Dr Watertown, WI 53098

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880

Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection for 1 of 1 Residents (Resident R2).During the provision of peri-care for Resident R2, staff did not properly change gloves and complete hand hygiene. Findings include:The facility's Infection Prevention and Control Policy Program, dated 7/2025, indicates: The facility has established and maintains 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 disease and infection as per accepted national standards and guidelines .5. Standard precautions: .b. Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures. c. All staff shall use personal protective equipment (PPE) according to established facility policy governing the use of PPE. (Of note: A policy related to hand hygiene was not provided during the survey.)On 9/24/25, Surveyor reviewed Resident R2's medical record. Resident R2 was admitted to the facility on [DATE REDACTED]. Resident R2's Minimum Data Set (MDS) assessment, 7/15/25, indicated Resident R2 was dependent

on staff for toileting and required partial/moderate assistance with hygiene. Resident R2 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated Resident R2 had intact cognition. On 9/24/25 at 10:11 AM, Surveyor observed Certified Nursing Assistant (CNA)-D and CNA-E provide peri-care for Resident R2. CNA-D and CNA-E donned gowns and gloves and entered Resident R2's room. CNA-D put linens on the bedside table, removed clothing from the dresser, and turned off Resident R2's call light. CNA-E filled a basin with water. CNA-E removed pillows from Resident R2's bed and put a wash cloth on the table that Resident R2 had used to wipe Resident R2's face.

CNA-E washed Resident R2's underarms and breasts and gave Resident R2 a bra. CNA-D and CNA-E then rolled Resident R2 on the right side and partially removed a brief that contained stool from underneath Resident R2. CNA-D and CNA-E then rolled Resident R2 onto Resident R2's back and CNA-E pulled the brief down between Resident R2's legs. CNA-E wiped Resident R2's peri-area from front to back two times. With the same gloved hands, CNA-D and CNA-E rolled Resident R2 on the right side and CNA-E cleansed Resident R2's buttocks (which contained stool) from front to back two times. CNA-E then removed and disposed of the soiled brief. With the same gloved hands, CNA-D and CNA-E lifted Resident R2's left leg and CNA-E wiped Resident R2's buttocks from front to back a third time. CNA-D and CNA-E then rolled Resident R2 onto Resident R2's back and CNA-E removed gloves, washed hands, and donned clean gloves. CNA-E washed Resident R2's abdominal folds and washed Resident R2's peri-area again. With the same gloved hands, CNA-D and CNA-E rolled Resident R2 on the right side. CNA-E put a clean brief underneath Resident R2 and cleansed Resident R2's buttocks again. CNA-D and CNA-E then rolled Resident R2 to the left. CNA-D cleansed the other side of Resident R2's buttocks and applied A&D ointment. With the same gloved hands, CNA-D and CNA-E fastened Resident R2's brief and CNA-E finished dressing Resident R2. CNA-E then emptied the basin, removed gloves, and washed hands. On 9/24/25 at 10:29 AM, Surveyor interviewed CNA-D and CNA-E who verified CNA-D and CNA-E touched Resident R2 and multiple items in Resident R2's room with soiled gloves. CNA-D and CNA-E verified CNA-D and CNA-E should have changed gloves and washed hands after providing peri-care.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet