Watertown Health Care Center
Watertown Health Care Center in Watertown, WI — inspection on December 1, 2025.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Based on staff and resident interview, the facility did not ensure there were sufficient supplies for 1 of 4 Residents (R2).R2 indicated the facility ran out of the brief size R2 needed and 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 R2 who indicated the facility runs out of the briefs that R2 uses and staff have to use two different briefs to make one brief. R2 stated the facility also runs out of wipes and staff don't cleanse R2 when they change R2. R2 indicated it occurred at least five or six times since R2 was admitted in April. (R2's medical record indicated R2 was dependent on staff for toileting and required partial/moderate assistance with hygiene. 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 R11 who indicated the supply issue was bad a while ago but is a little better. 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.)
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
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
12/01/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Watertown Health Care Center
121 Hospital Dr Watertown, WI 53098
SUMMARY STATEMENT OF DEFICIENCIES
Keep residents' personal and medical records private and confidential.
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 (R2).R2 reported a concern with a male visitor in the room while staff provided care for R2.
Findings include:On 9/24/25, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] 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.R2's Minimum Data Set (MDS) assessment, dated 7/15/25, indicated R2 was dependent on staff for toileting and transfers, required substantial/maximal assistance with dressing, and required partial/moderate assistance with hygiene. R2 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R2 had intact cognition. R2 did not have an activated Power of Attorney (POA). On 9/24/25 at 9:02 AM, Surveyor interviewed R2 who indicated when R2 had a roommate, a male visited frequently and was in the room while staff provided care for R2. R2 indicated R2 felt uncomfortable and told nursing staff. R2 indicated R2 could see the male get items out of a refrigerator on top of a dresser while staff provided care for R2 which made R2 uncomfortable. On 9/24/25 at 1:17 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-F who was aware that 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 R2 mentioned to CNA-D on the PM shift that R2 could see a male visitor in R2's room get something from the refrigerator while staff provided care which made 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 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 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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
12/01/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Watertown Health Care Center
121 Hospital Dr Watertown, WI 53098
SUMMARY STATEMENT OF DEFICIENCIES
inner cannula from the kit and inserted the inner cannula into R6's tracheostomy tube. LPN C used the gauze and cotton swabs from the bedside table to clean around 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 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 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 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 R6's tracheostomy care.
Surveyor shared with DON B the observations made during 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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
12/01/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Watertown Health Care Center
121 Hospital Dr Watertown, WI 53098
SUMMARY STATEMENT OF DEFICIENCIES
Provide and implement an infection prevention and control program.
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 (R2).During the provision of peri-care for 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 R2's medical record. R2 was admitted to the facility on [DATE]. R2's Minimum Data Set (MDS) assessment, 7/15/25, indicated R2 was dependent on staff for toileting and required partial/moderate assistance with hygiene. R2 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated 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 R2. CNA-D and CNA-E donned gowns and gloves and entered R2's room. CNA-D put linens on the bedside table, removed clothing from the dresser, and turned off R2's call light. CNA-E filled a basin with water. CNA-E removed pillows from R2's bed and put a wash cloth on the table that R2 had used to wipe R2's face.
CNA-E washed R2's underarms and breasts and gave R2 a bra. CNA-D and CNA-E then rolled R2 on the right side and partially removed a brief that contained stool from underneath R2. CNA-D and CNA-E then rolled R2 onto R2's back and CNA-E pulled the brief down between R2's legs. CNA-E wiped R2's peri-area from front to back two times.
With the same gloved hands, CNA-D and CNA-E rolled R2 on the right side and CNA-E cleansed 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 R2's left leg and CNA-E wiped R2's buttocks from front to back a third time. CNA-D and CNA-E then rolled R2 onto R2's back and CNA-E removed gloves, washed hands, and donned clean gloves. CNA-E washed R2's abdominal folds and washed R2's peri-area again.
With the same gloved hands, CNA-D and CNA-E rolled R2 on the right side. CNA-E put a clean brief underneath R2 and cleansed R2's buttocks again. CNA-D and CNA-E then rolled R2 to the left. CNA-D cleansed the other side of R2's buttocks and applied A&D ointment.
With the same gloved hands, CNA-D and CNA-E fastened R2's brief and CNA-E finished dressing 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 R2 and multiple items in 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.
Facility ID: