Care One at Weymouth

Inspectors wroteBased on records reviews and interviews, for one of three sampled residents (Resident #1), who was alert and able to make his/her needs known, the Facility failed to ensure he/she was treated in a respectful and dignified manner by staff, when Certified Nurse Aide (CNA) #1 was witnessed engaging in an interaction with Resident #1 that was unprofessional and per Resident #1, resulted in him/her being embarrassed while in the company of other residents.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #2), who was newly admitted related to his/her need for skilled nursing services, the Facility failed to ensure it provided treatment and care in accordance with professional standards of quality care, when during two separate Physician's visits, his/her provider indicated there were new treatment and/or medication orders for Resident #1, however they were not transcribed and entered as a Physicians order in a timely manner.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents, (Resident #2), the Facility failed to ensure they maintained complete and accurate medical/treatment records when nursing documentation nursing on his/her Medication Administration Record (MAR) and/or Treatment Administration Record (TAR) were omitted, with some care areas left blank.

Inspectors wroteBased on interview and record review, the facility failed to ensure the drug regimen for one Resident (#56), from a total sample of 28 residents, was free of unnecessary drugs. Specifically, the facility failed to ensure two oral antibiotic medications (Doxycycline and Amoxicillin/Clavulanate) were not given in excessive duration resulting in the Resident receiving five unnecessary doses of oral antibiotics while on intravenous (IV) antibiotics.

Inspectors wroteBased on observations and interviews, the facility failed to follow infection prevention and control practices. Specifically, the facility failed to:1. Ensure proper cleaning of resident shared equipment between resident use; and2. Ensure effective hand hygiene practices and appropriate personal protective equipment (PPE) were utilized when entering and exiting resident rooms, including residents on transmission-based precautions (implemented in addition to standard precautions in order to prevent or control infections.), to prevent the potential spread of infection.

Inspectors wroteBased on interview and record review, the facility failed to notify the Resident's Physician or Nurse Practitioner about a medication error to re-evaluate the potential need to alter the treatment plan for one Resident (#56), from a total sample of 28 residents. Specifically, the facility failed to notify the Physician or Nurse Practitioner of Resident #56 receiving five doses of two antibiotics.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and maintenance of a Peripherally Inserted Central Catheter (PICC-a flexible tube inserted through a vein in one's arm and passed through to larger veins near the heart, used to deliver medications intravenously (IV)), consistent with professional standards of practice for one Resident (#56), out of a total of 28 residents. Specifically, the facility failed to change the PICC dressing per professional standards.

Inspectors wroteBased on interviews and record review, the facility failed to provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being for one Resident (#18), in a total sample of 28 residents. Specifically, the facility failed to assist Resident #18 in their request for discharge planning.

Inspectors wroteBased on observation, interviews, and records reviewed, the facility failed to ensure residents were free from significant medication errors when one of two nurses observed during the medication pass failed to follow physician orders for an antiseizure medication. Specifically, for Resident #66, with a history of epilepsy (a brain disease that causes repeated seizures due to abnormal electrical signals in the brain), Nurse #1 failed to administer the correct dose of his/her anticonvulsant medication (drugs that control or prevent seizures by calming excessive electrical activity in the brain).

Inspectors wroteBased on record review and interviews, the facility failed to ensure staff maintained complete and accurate medical records for one Resident (#153), out of a total sample of 28 residents. Specifically, for Resident #153, the facility failed to ensure his/her medical record included his/her weight results. Review of the facility's policy titled Weight Assessment and Intervention, dated as revised March 2022, indicated but was not limited to:-Weights are recorded in each individual's medical record Resident #153 was admitted to the facility in December 2025 with diagnoses which included bacteremia (bacteria in the bloodstream) and sepsis (the body's reaction to extreme infection). Review of the Minimum Data Set (MDS) assessment, dated 12/23/25, indicated Resident #153 was 71 inches tall, weighed 155 pounds, and had no weight loss or gain. [...]

Inspectors wroteBased on records reviewed and interviews for one of four sampled residents (Resident #4), the Facility failed to ensure they maintained Resident #4's right to privacy and confidentiality related to his/her Protected Health Information (PHI), when one of Resident #4's provider progress notes, which contained (PHI) was included in another resident's discharge paperwork and the Facility only became aware after the discharged residents' family member called and notified the Facility.

Inspectors wroteBased on records reviewed and interviews for two of three sampled residents (Resident #1 and #2), the Facility failed to ensure that upon admission, nursing developed and implemented baseline care plans with interventions, treatments, goals, and outcomes that addressed the residents' overall immediate care needs.

Inspectors wroteBased on records reviewed and interviews for two of three sampled residents (Resident #1 and Resident #2) who had been assessed as requesting the use of bilateral side rails upon admission, the Facility failed to ensure nursing staff provided care and services that met professional standards of practice, when physician's orders were not obtained by nursing for the use of bilateral side rails.

Inspectors wroteBased on observation and interview, the facility failed to ensure residents in three of four dining areas had a dignified and homelike dining experience.

Inspectors wroteBased on interview and document review, the facility failed to ensure residents had the right to voice and formulate grievances, have those grievances responded to promptly, and be provided a resolution to their grievance. Specifically, the facility failed to: 1. Have voiced grievances investigated and addressed, for one Resident (#287), out of two residents investigated, who had repeatedly voiced concerns over call light answering times; 2. Provide one Resident (#238), out of a total sample of 25 residents, with a resolution to their grievance either in writing or by discussion once the grievance had been resolved; and 3. Ensure residents had access to grievance/concern forms so they could formulate grievances anonymously, should they choose not to alert a staff member to their concern.

Inspectors wroteBased on observation and interview, the facility failed to ensure all medications used in the facility were stored in accordance with currently accepted professional principles. Specifically, the facility failed to: 1. Dispose of oral medications that were no longer stored in their original dispensing systems in two of five medication carts reviewed; and 2. Provide a permanently affixed compartment for the storage of a schedule IV (potential for misuse and dependence) controlled substance in one of three medication room refrigerators reviewed.

Inspectors wroteBased on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential of foodborne illness to residents who are at high risk. Specifically, the facility failed to: 1. Handle ready-to-eat food (food which does not require cooking or further preparation prior to consumption) utilizing proper hand hygiene to prevent cross contamination (transfer of pathogens from one surface to another); and 2. Properly label and date food products and maintain safe and clean equipment in three of four nourishment kitchenettes.

Inspectors wroteBased on interview and document review, the facility failed to explain binding arbitration agreements and provide the Residents the right to fully review the agreement for three Residents (#238, #239, and #237), out of three sampled residents.

Inspectors wroteBased on record review, document review, policy review, and interview, the facility failed to implement policies and procedures to ensure residents were properly screened for eligibility to receive the recommended pneumococcal vaccine, residents/residents' representatives were educated on the benefits and potential side effects of the vaccine, and were offered and administered (if applicable) the vaccine in a timely manner for five Residents (#117, #25, #113, #388 and #1), out of a total sample size of five residents reviewed for immunizations.

Inspectors wroteBased on document review and interview, the facility failed to ensure two Residents (#238 and #237) were provided a summary of their baseline care plan meeting, out of a total sample of 25 residents.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure professional standards of practice were met for one Resident (#388), out of a total sample of 25 residents. Specifically, the facility failed to address the wound physician's recommendations timely for care and treatment of a post-operative site infection.

Inspectors wroteBased on observation and interviews, the facility failed to ensure mechanical equipment located in the main kitchen, specifically the walk-in freezer, was maintained in safe operating condition.

Inspectors wroteBased on interviews and review of the Health Care Facility Reporting System (HCFRS- State agency reporting system), the facility failed to provide written notice to the State Agency when a change in the facility's Administrator occurred.

Inspectors wroteBased on observation, policy review, interview, and record review, the facility failed to ensure that one Resident (#29), from a total sample of 25 residents, was assessed to be clinically appropriate to self-administer medication.

Inspectors wroteBased on record review and interview, the facility failed to ensure there was ongoing, accurate, and timely communication of information with the dialysis center in a manner that was consistent with professional standards of practice for one Resident (#55), of a total sample of 25 residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to notify the Physician when the Resident exceeded his/her prescribed daily fluid restriction of 1500 cubic centimeters (cc) and subsequently monitor the Resident accordingly for one Resident (#55), out of a total sample of 25 residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure one Resident (#111), out of a total sample of 25 residents, was referred for a Level II Preadmission Screening and Resident Review (PASRR) evaluation (an evaluation to determine if a resident needs specialized services to address his/her Serious Mental Illness (SMI)) once it was identified the Resident had a diagnosis of SMI.

Inspectors wroteBased on observation, interview, policy review, and record review, the facility failed to follow standards of practice for three Residents (#115, #55, and #17), in a total sample of 25 residents. Specifically, the facility failed to: 1. For Resident #115, a. follow their skin care policy for a newly identified area to the Resident's right posterior knee secondary to an ace wrap bandage that was placed too tightly, and b. ensure staff did not leave morning medications with the Resident to self-administer without a physician's order to do so; 2. For Resident #55, ensure nursing staff observed the consumption of administered medication prior to leaving the room; and 3. For Resident #17, ensure nursing staff reviewed and communicated wound consultant recommendations with the facility provider timely.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure that medications were secure and not accessible to residents, for one Resident (#10), of a total sample of 25 residents. Specifically, the facility failed to ensure Resident #10 was assessed for mental and physical ability to safely self-administer medications and not share medications that were left with him/her at the bedside.

Inspectors wroteBased on record review, hospice contract review, and staff interview, the facility failed to ensure for two Residents (#77 and #29), out of a total sample of 25 residents, that hospice services were provided in accordance with the agreement between the hospice and the facility. Specifically, the facility failed to provide ongoing documentation of hospice staff visits to ensure prompt and effective communication and continuity of care for the Resident, in accordance with the hospice agreement.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure staff maintained an infection control program designed to prevent the development and potential transmission of infections. Specifically, the facility failed: 1. To ensure proper infection control practices were followed while providing care for a resident who was on contact precautions for a methicillin-resistant staphylococcus aureus (MRSA) infection; and 2. To ensure staff properly transported linens so as to prevent the spread of infection.