Care One at Newton

Inspectors wroteBased on interviews and records reviewed, for one of seven sampled residents (Resident #7), who had been issued of Notice of Intent to Discharge and was to be transferred to another long-term care facility, the Facility failed to ensure they provided written notices of intent to discharge to the Office of the Long-Term Care Ombudsman, as required.

Inspectors wroteBased on records reviewed, photographs reviewed, and interviews, for three of three sampled residents (Residents #1, #2, and #3), who were cognitively impaired and dependent on staff for care, the Facility failed to ensure they protected their rights to respect and dignity, when on 10/16/25 and 10/17/25, a staff member took pictures of them and sent them via text message to a non-staff person, without their knowledge or consent.

Inspectors wroteBased on records reviewed and interviews, for one of five sampled residents (Resident #1), who was medically compromised, the facility staff failed to ensure a physician ordered antibiotic medication, which was available in the facility's emergency medical supply, was administered in a timely manner, placing him/her at risk for a worsening condition.

Inspectors wroteBased on records reviewed and interviews, for one of five sampled residents (Resident #1), who was medically compromised and had orders for blood laboratory work to be obtained, the facility staff failed to ensure his/her abnormal laboratory values were reported to his/her physician by nursing in a timely manner, placing him/her at risk for complications.

Inspectors wroteBased on records reviewed, observations, and interviews for three of five sampled residents (Resident #3, Resident #4, and Resident #5), who required specific infection control precautions, the facility failed to ensure staff providing direct care (Certified Nurse Aides) implemented and followed infection control precautions which included the need to wear the appropriate Personal Protective Equipment (PPE) during the provision of care.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), whose physician's orders included the administration of a medication with a black box warning, the facility failed to ensure the dispensing Pharmacist and the Pharmacy Consultant identified and reported a medication that was prescribed and administered at an excessive frequency, which resulted in Resident #1 experiencing an overall decline in condition, requiring transfer and admission to the hospital.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), whose physician's orders included administration of a potentially toxic medication (oral chemotherapy agent used to treat rheumatoid arthritis) the facility failed to ensure he/she was free from a significant medication error, when upon admission, the medication was inaccurately reconciled from his/her Hospital Discharge Summary by nursing and he/she was administered the medication for consecutive days in error. Resident #1 experienced an overall decline in condition, was transferred and admitted to the Hospital, and was treated for toxic levels of the medication.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), the facility failed to ensure his/her medical record was complete and accurate when 1) the Physician signed a medication order in error and 2) the Nurse Practitioner documented that all of Resident #1's medications were reviewed at each visit.

Inspectors wroteBased on observation and interview, the facility failed to provide a dignified experience for residents as evidenced by staff utilizing a resident bedroom for personal storage and documentation for one Resident, (#140), out of a total of 36 sampled Residents.

Inspectors wroteBased on observation and interview, the facility failed to ensure staff followed proper sanitation and food handling during meal service to prevent the potential outbreak of foodborne illness.

Inspectors wroteBased on record review and interview, the facility failed to obtain informed consent prior to administering psychotropic medication for one Resident #129 out of a sample of 36 residents. Specifically, the facility failed to obtain legal informed consent from court prior to administering an antipsychotic medication.

Inspectors wroteBased on record review and interview, the facility failed to formulate Advance Directives for one Resident #129 out of a sample of 36 Residents. Specifically, the facility failed to expand a Roger's treatment plan, (a court approved plan that outlines the specific medical treatment, particularly antipsychotic medication), prior to administering antipsychotic medication.

Inspectors wroteBased on observation, record review and interview, the facility failed to provide initial and ongoing assessments of a wheelchair seatbelt to ensure one Resident (#24) was free from restraints out of a total sample of 36 residents.

Inspectors wroteBased on record review and interview, the facility failed to accurately and timely report an allegation of misappropriation to the State Agency for one Resident (#29) of 36 sampled residents. Specifically, Resident #29 alleged that a staff member stole a piece of jewelry, and the facility did not report the allegation to the State Agency.

Inspectors wroteBased on record review and interview, the facility failed to develop a plan of care for monitoring the effects of psychotropic medications for one Resident (#179) out of a total sample of 36 residents.

Inspectors wroteBased on observation, record review and interview the facility failed to provide quality standards of professional practice for 3 residents (# 11 , #15 and #21), out of a total sample of 36 residents. Specifically:1. For Resident #11, the facility failed to implement physician's orders by administering liquid consistency as ordered.2. For Resident #15, the facility failed to implement the use of a Prevlon Boot (a specialty device utilized to prevent pressure on the heel) as ordered by the physician.3. For Resident #21 the facility failed to adhere to professional standards of nursing practice, when Nurse #2 left medications with Resident #21, who was not assessed as being able to self-administer medications.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to ensure the residents of the facility were free from accidents. Specifically, the facility failed to:1.) Ensure a wander guard was in place and ensure the resident was not moved to a less secure unit, resulting in the elopement of one Resident, (#62), out of a total of 36 sampled Residents.2.) Respond appropriately to an open flame fire during breakfast service in the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain 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 diseases and infections. Specifically, the facility failed to implement occupational health policies prohibiting contact with residents or their food, evidenced by observations of Dietary Aide #1 working in the facility kitchen while having a skin injury on his hand which prevented him from being able to perform hand hygiene.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), who had a diagnosis of diabetes mellitus, Peripheral Vascular Disease (PVD), and peripheral neuropathy, the facility failed to ensure foot care, including toenail care, was provided in a timely manner once requested.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), the facility failed to ensure they reviewed and revised the Comprehensive Care Plan following the completion of his/her scheduled Quarterly Minimum Data Set (MDS) assessment.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents, (Resident #1) who had an allergy to shellfish, the facility failed to ensure his/her environment was free of hazards, when on 09/12/24, Resident #1 was served a meal that consisted of seafood (which included shrimp), Resident #1 consumed the meal, developed signs and symptoms of an allergic reaction, including shortness of breath (SOB), puffy watery eyes and flushed appearance, he/she developed stridor (abnormal, high-pitched respiratory sound produced by irregular airflow in a narrowed airway), 911 was called, and Resident #1 was transported to the Hospital Emergency Department (ED) for evaluation of anaphylaxis (a severe, potentially life-threatening allergic reaction) where he/she was admitted for further treatment. Findings Include: [...]

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents, (Resident #1), who had an allergy to shellfish, the Facility failed to ensure meals prepared and served to him/her accommodated his/her food allergy, when on 09/12/24, dietary staff preparing his/her dinner time meal tray put a meal that included shellfish (shrimp) on it, Resident #1 complained of not feeling well, said he/she had difficulty breathing, 911 was called and he/she was transported to the Hospital Emergency Department (ED), for evaluation and treatment of anaphylaxis (a severe, potentially life-threatening allergic reaction) and he/she was admitted . Findings Include: Review of the Facility's Policy tilted Food and Nutrition Services, dated as revised October 2017, indicated the following: [...]

Inspectors wroteBased on observation, interview, record and policy review the facility failed to maintain 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 diseases and infections. Specifically, the facility failed to: 1) ensure staff utilized the appropriate personal protective equipment prior to entering resident rooms requiring transmission-based precautions for Resident (#22) with Clostridium difficile (a contagious bacteria that causes severe diarrhea and inflammation of the colon); 2) ensure staff performed hand hygiene after exiting a room identified as being on contact precaution for Clostridium difficile (C. difficile) per facility policy and; 3. ensure nursing staff performed hand hygiene appropriately during the medication administration task. [...]

Inspectors wroteBased on record review and interviews, the facility failed to formulate an advance directive for one Resident (#10) out of a total sample of 27 residents. Specifically, the facility failed to initiate the court process to renew an expired [NAME] guardianship (a treatment plan that states that antipsychotic medications are so intrusive, and their side effects are potentially so severe, that a court must approve them).

Inspectors wroteBased on observations, record review and interview the facility failed to implement a person centered care plan for two Residents (#82, #31) out of a total sample of 27 residents. Specifically, 1. For Resident #82 who was assessed as an elopement risk, the facility failed to ensure a wander guard was in place, 2. For Resident #31, that facility failed to ensure his/her heels were offloaded and that his/her glasses were donned daily.

Inspectors wroteBased on observations, record review, policy review and interviews, the facility failed to provide supervision with meals for one Resident, (#390) out of a total sample of 27 residents.

Inspectors wroteBased on observation and interview, and record review, the facility staff failed to provide the necessary services to ensure 1 Resident (#390) out of a total sample of 27 Residents, was able to effectively communicate his/her needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to administer Total Parenteral Nutrition (a form of administering nutrition through an intravenous (IV) line where nutrients enter through the veins and travel through the blood vessels to the entire body) as ordered by the physician for one Resident (#121) out of a total of 27 sampled residents.

Inspectors wroteBased on record review, policy review and interview the facility failed to assess a history of trauma and failed to develop a care plan with resident specific triggers and interventions for one Resident (#62) with a diagnosis of Post Traumatic Stress Disorder (PTSD), out of a total sample of 27 residents.

Inspectors wroteBased on observations, interviews and policy review the facility failed to ensure medication carts were locked on one of four nursing units.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure physicians orders were written correctly related to oxygen (02) for one Resident (#14) of a total of 27 sampled Residents.

Inspectors wroteBased on records reviewed and interviews for two of three sampled residents (Resident #1, whose Physician's Orders included the administration of a medication used to treat restless leg syndrome, and Resident #2 whose Physician's Orders included the administration of an antipsychotic medication) the Facility failed to ensure the Physician was promptly notified when the resident's medications were not administered as ordered. Findings Include: The Facility Policy titled Miscellaneous Special Situations, Unavailable Medications, dated 02/2019, indicated that medications used by residents in the Nursing Facility may be unavailable for dispensing from the pharmacy on occasion. The Policy indicated that the Facility must make every effort to ensure that medications were available to meet the needs of each resident. [...]

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), who had a Physician's Order for a medication to be administered at bedtime for restless leg syndrome, the Facility failed to ensure the medication was administered in a timely manner when, although the medication was delivered to the Facility early in the morning on 11/21/23 (and therefore was available for administration, as ordered for bedtime that evening), the medication was not administered to Resident #1 as ordered, and he/she was not administered the medication until the following evening (11/22/23) at bedtime. Findings Include: The Facility Policy titled Pharmacy Services Overview, dated as revised April 2019, indicated that medications are received, labeled, stored, administered, and disposed of according to all applicable state and federal law and consistent with standards of practice. [...]

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #2), who had a Physician's Order for administration of an antipsychotic medication, the Facility failed to ensure he/she was free from a significant medication error when he/she was not administered his/her antipsychotic medication multiple days in a row, which placed him/her at increased risks for adverse side effects as a result of abruptly stopping the medication. Findings Include: The Facility Policy titled Medication Errors, dated as revised February 2023, indicated a medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted standards professional standards and principles of the professional(s) providing services. [...]

Inspectors wroteBased on records reviewed and interviews for two of three sampled residents (Resident #1 and Resident #2) the Facility failed to ensure they maintained complete and accurate medical records related to nursing documentation in the resident's Medication Administration Records. Findings Include: The Facility Policy titled Documentation of Medication Administration, dated as edited 04/06/23, indicated a Medication Administration Record is used to document all medications administered. The Policy indicated that documentation of medication administration included the dosage, date and time of administration, reason(s) why a medication was withheld, not administered, or refused, and initials, signature and title of the person administering the medication. 1. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to 1. provide adequate supervision and interventions related to falls resulting in falls with injury for two Residents (#60 and #76) and 2. failed to develop and implement an elopement care plan resulting in elopement for one Resident (#103) out of a total of sample of 33 residents.

Inspectors wrote1b. Resident #84 was admitted to the facility in May 2023 following a psychiatric hospitalization for depression with a specific suicide plan. Review of the most recent Minimum Data Set (MDS) assessment, dated 5/11/23, indicated Resident #84 scored a 15 out of a possible 15 on the Brief Interview for Mental Status exam, indicating intact cognition. The MDS further indicated that on the Patient Health Questionnaire (PHQ9 is a multipurpose instrument for screening, diagnosing, monitoring and measuring the severity of depression) Resident #84 scored a 15 indicating moderately severe Major Depression. During an interview on 6/01/23 at 12:19 P.M., with the facility Social Worker (#1) she said that when a resident admits to the facility following a psychiatric hospitalization for Suicidal Ideation (SI) with a specific plan there should be an SI care plan in place. [...]

Inspectors wroteBased on observation, interview and policy review the facility failed to provide a dignified dining experience for two Residents (#41 and #74) out of a total sample of 33 residents. Specifically, 1. For Resident #41 he/she was not permitted to eat in his/her preferred location and 2. for Resident #74, staff stood over the Resident will feeding him/her meals, rather than seated at eye level.

Inspectors wroteBased on record review, interviews and policy review, the facility failed to obtain consent for the use of psychotropic medications for one Resident (#105) out of a total sample of 33 residents.

Inspectors wroteBased on observation and interview, the facility failed to maintain a home-like environment on one of three resident units.

Inspectors wroteBased on interview and record review the facility failed to ensure an allegation of abuse by one Resident (#27) was reported to the Department of Public Health's (DPH) Health Care Facility Reporting System (HCFRS) within the required two hour time frame, out of a total sample of 33 residents.

Inspectors wroteBased on interview and record review the facility failed to 1. follow professional standards in accurately identifying and implementing a plan of care for an implanted cardioverter-defibrillator (an implanted battery operated device used to detect and stop irregular heartbeats) for one Resident (#51) and 2. failed to administer medications as ordered for one Resident (#35) out of a total sample of 33 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide assistance with grooming for two Residents (#11 and #74) out of a total sample of 33 residents. Review of the facility policy titled Fingernails/Toenails, care of,, dated as revised February 2018, indicated the following: * Nail care includes daily cleaning and regular trimming. 1.) Resident #11 was admitted to the facility in June 2022 with diagnosis including muscle weakness. Review of the most recent Minimum Data Set (MDS) assessment, dated 4/5/23, indicated that Resident #11 scored a 15 out of 15 on the Brief Interview for Mental Status exam, indicating Resident #11 is cognitively intact. The MDS further indicates Resident #11 requires supervision with personal hygiene. [...]

Inspectors wroteBased on observation, record review and interview the facility failed to ensure one Resident (#107) with a right hand contracture had a hand roll in place, as ordered by the physician, out of a total sample of 33 residents.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure that care and treatment of a Peripherally Inserted Central Catheter (PICC) was provided, for one Residents (#235) in at total sample of 33 residents.

Inspectors wroteBased on observation, policy review and interview, the facility failed to secure medications on 1 of 3 resident units.

Inspectors wroteBased on observation and interview the facility failed to 1. maintain proper sanitation practices related to food labeling and storage in the kitchen and 2. maintain proper food storage for 1 Resident (#36) out of a total sample of 33 residents. Review of the facility policy titled Food Receiving and Storage, revised November 2022, indicated the following: * Potentially Hazardous Food (PHF) or Time/Temperature Control for Safety (TCS) Food means food that requires time/temperature control for safety to limit the growth of pathogens (i.e., bacterial or viral organisms capable of causing disease or toxin formation). * All foods stored in the refrigerator or freezer are covered, labeled and dated (use by date). * Refrigerated foods are labeled, dated, and monitored so they are used by their use-by date, frozen, or discarded. [...]