The resident was allergic to penicillin and aspirin. The medications included both.
Federal inspectors intervened during the January 7 incident at Woburn Rehabilitation and Nursing Center, stopping what could have been a life-threatening medication error. The nurse had prepared amoxicillin-clavulanate potassium, a penicillin-based antibiotic, plus aspirin, for a resident whose medical record clearly documented allergies to both substances.
"Serious and occasionally fatal hypersensitivity reactions have been reported in patients on penicillin therapy," according to FDA prescribing information for the antibiotic. Such reactions require "immediate emergency treatment with epinephrine, oxygen, intravenous steroids, and airway management, including intubation."
The nurse also prepared flecainide acetate, a heart rhythm medication that can "cause new or worsened supraventricular or ventricular arrhythmias" with "potentially fatal consequences," and escitalopram oxalate, an antidepressant.
None of these medications were prescribed for Resident 72.
The error began at 8:14 AM when Nurse 2 told the resident's roommate he would bring morning medications "right away." Five minutes later, inspectors watched the nurse prepare the four medications. At 8:37 AM, he placed them on Resident 72's bedside table.
"It was his medications," the nurse told the resident, who asked what the pills were. The nurse repeated the instruction to take them without checking the resident's identity bracelet, requesting name verification, or comparing the medications to the resident's medical record.
Resident 72 "presented as confused and stared from the medications to the nurse multiple times."
When an inspector asked if the medications belonged to the roommate, the nurse said no. He moved the pills closer to Resident 72 and again instructed him to take them. Only after the inspector's intervention did the nurse remove the medications.
"He was glad the surveyor intervened because he thought he had prepared Resident 72's medication but should have checked that it was the correct Resident's medication before attempting to administer them because there were some medications that could have jeopardized the Resident's health and safety," the inspection report states.
The facility's own medication administration policy requires nurses to "identify resident by photo in the MAR" and "compare medication source with MAR to verify resident name, medication name, form, dose, route, and time."
The Director of Nursing confirmed the nurse should have verified the resident's identity "in two ways before every medication administration," including checking the photograph in the medical record, identification bracelet, or asking the resident to identify themselves.
She noted that Resident 72 was on "a busy rehabilitation floor that is a revolving door making it especially important to verify identification prior to administering medications."
The medication errors were part of broader safety failures throughout the facility. Inspectors found prescription medications sitting unsecured in resident rooms across multiple units, treatment carts left unlocked and unattended in hallways, and critical medications stored without proper dating.
On the B Unit, inspectors observed glycerin suppositories, diclofenac gel, metamucil, lidocaine patches, and artificial tears sitting openly on dressers, windowsills, and bedside tables. The same medications remained visible during follow-up inspections the next day.
Unit Manager 2 told inspectors no residents on B Unit had completed self-administration assessments that would allow bedside medication storage. "There should be no medications stored at bedside," she said.
On D Unit, nicotine lozenges were scattered on a bedside table next to their container. Nurse 4 confirmed the lozenges were medication that required secure storage.
The Director of Nursing said she wasn't "aware of any residents in the building who currently are able to have any medications stored at bedside."
Treatment carts containing prescription topical medications were found unlocked and unattended in hallways on both C and D Units. Nurses acknowledged the carts should have been secured when not within their view.
Inside medication carts, inspectors found critical medications stored without opening dates. A bottle of proheal liquid protein sat undated despite labeling requiring disposal 60 days after opening. Insulin medications lacked opening dates even though they must be discarded 28 days after opening. One insulin pen had two different dates written on it.
"The insulin pen with two dates should have been discarded and not used because the open date was unclear," the Director of Nursing told inspectors.
The facility also failed basic dental care requirements. Resident 8, who lived at the facility since January 2023, had a broken upper tooth and hadn't seen a dentist in over 18 months. His last dental visit was May 16, 2023, with a recommendation for an annual exam in May 2024 that never happened.
The resident told inspectors he believed staff were aware of his broken tooth but had received no dental care. His teeth appeared discolored during the interview.
An oral assessment in December 2024 documented the broken tooth, prompting creation of a care plan stating the resident should be "seen by a dentist routinely and as needed." But no one notified nurses or medical providers, and no dental appointment was scheduled.
The Unit Coordinator responsible for scheduling dental appointments was unaware of the resident's broken tooth. The Director of Nursing said she was "unsure of how often residents should be seen by the dentist" and didn't know the resident hadn't received dental care since 2023.
Food service problems compounded the safety issues. During a resident group interview, all participants reported that facility food was "consistently cold and does not taste good."
Temperature checks confirmed their complaints. Turkey in gravy measured 101 degrees Fahrenheit and tasted "lukewarm and bland." Eggs ranged from 89 to 118 degrees, consistently below safe serving temperatures. Milk was served at 52 degrees.
One resident with dementia who required pureed foods received regular scrambled eggs that posed a choking risk. The nurse responsible for checking trays acknowledged the error.
Kitchen sanitation violations included missing thermometers in two refrigerators, unlabeled food packages, and temperature logs filled out hours before meals were actually served. A cook kept a lighter next to a gas stovetop because "sometimes he needs to use the lighter to light the middle cooktop burner."
The Administrator acknowledged "issues in the food service department" and said she was planning point-of-service steam tables to address temperature problems.
But for Resident 72, the most serious threat came from a nurse who bypassed multiple safety protocols designed to prevent exactly the kind of medication error that could have killed him. The resident's cognitive assessment showed he was mentally intact with a perfect score on standard testing, meaning he was fully aware of what was happening when a nurse insisted he swallow medications that could have triggered a fatal allergic reaction.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Woburn Rehabilitation and Nursing Center from 2025-01-09 including all violations, facility responses, and corrective action plans.
Additional Resources
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