WEST NEWTON, MA - Federal inspectors documented a dangerous medication error rate of 20.93% at West Newton Healthcare during a January 2025 inspection, nearly four times higher than the federal limit of 5%.
Critical Medication Safety Failures
During the three-day inspection, surveyors observed one nurse making 10 medication errors out of 43 opportunities when administering medications to two residents. The nurse failed to give essential medications including heart medication (Atenolol), diabetes medication (Glipizide), and blood pressure medications (Amlodipine and Metoprolol) to residents who required them.
Resident #34 was scheduled to receive eight different medications at 8:00 AM and 9:00 AM but only received three. The missed medications included diabetes medication Glipizide, heart medication Namenda, and essential supplements. Resident #77 was similarly affected, missing critical heart medications Amlodipine and Metoprolol.
The facility's medication administration policy requires medications to be given within one hour of the prescribed time unless otherwise specified. The Director of Clinical Operations confirmed that "all scheduled medications should be given at the time ordered."
Unlocked Medication Carts Pose Additional Risk
Inspectors documented multiple instances where medication carts containing controlled substances were left unlocked and unattended in areas with residents present. On January 6th, surveyors were able to access an unlocked medication cart in the third-floor dining room while five residents were nearby and the nurse was across the room.
The same violation occurred the following day when three residents were present near an unlocked cart. The responsible nurse acknowledged that "medication cart should always be locked when not attended," yet the pattern continued.
Even more concerning, inspectors observed one nurse giving medication cart keys, including narcotic keys, to another unassigned staff member. The Director of Clinical Operations stated it was her expectation that "nurses maintain the keys to their own medication cart and not allow other nurses to access the cart."
Widespread Care Planning Deficiencies
The inspection revealed systematic failures in developing and implementing resident care plans across multiple areas:
Fall Prevention Failures: Resident #90, who had a history of 1-2 falls in six months, was repeatedly found in bed without proper fall prevention measures. Despite physician orders requiring the bed to be in the lowest position with floor mats on both sides, inspectors observed the bed at regular height with missing or displaced mats on multiple occasions.
Feeding and Basic Care Neglect: Inspectors documented residents being left without assistance during meals despite care plans indicating they required help. Resident #23, assessed as dependent for eating, was observed with food placed out of reach while lying flat in bed. Later, the resident was seen eating with hands and placing a milk cup in the middle of food, with staff walking past without offering assistance.
Medical Follow-up Failures
The facility failed to ensure timely medical follow-up for serious conditions. Resident #14's PSA (prostate-specific antigen) levels rose from 12.28 to 15.36, potentially indicating cancer progression. Despite a urology recommendation for follow-up within one month, the facility failed to schedule the appointment for over two months.
Progress notes from October through January repeatedly documented "elevated PSA" and scheduling difficulties, with appointments being canceled due to "lack of communication with facility." The Unit Manager acknowledged that "treatment options regarding the PSA level should have been discussed with the resident's responsible party."
Infection Control Violations
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with medical devices requiring additional infection prevention measures. Resident #16, who had a PICC line and required EBP, received intravenous medication from a nurse who did not wear the required gown during the high-contact procedure.
Similarly, Resident #88, who had an external dialysis catheter, was not placed on EBP despite facility policy requiring it for residents with indwelling medical devices. Nurses confirmed the resident should have been on Enhanced Barrier Precautions but was not.
Food Safety and Hygiene Concerns
Kitchen inspections revealed spoiled food items including tomatoes with "black spots and gray fuzz," mushy vegetables, and brown limes being stored alongside fresh food. Multiple food containers were found unlabeled and undated, violating food safety protocols designed to prevent foodborne illness.
The facility's Food Service Director acknowledged awareness of unlabeled items but failed to implement proper dating procedures. The Corporate Food Service Director confirmed that "expired and outdated foods should be discarded" and "foods without dates should be dated once opened."
Regulatory Response and Standards
These violations occurred during a routine federal inspection conducted by the Centers for Medicare & Medicaid Services. The medication error rate threshold of 5% exists because medication errors can result in serious adverse events, hospitalization, or death.
Enhanced Barrier Precautions are crucial for residents with medical devices like PICC lines and dialysis catheters because these devices create direct pathways for infections to enter the bloodstream, potentially causing life-threatening sepsis.
The facility's Administrator acknowledged that "nurse staffing should be posted as required" and that proper infection control measures should be in place. However, the scope of violations suggests systematic oversight failures rather than isolated incidents.
Impact on Resident Safety
Medical professionals recognize that medication errors, particularly at rates approaching 21%, represent a serious threat to resident safety. Essential medications for diabetes, heart conditions, and blood pressure require precise timing and dosing to prevent medical emergencies.
The combination of medication errors, unlocked controlled substances, and inadequate infection control creates a dangerous environment for vulnerable nursing home residents who depend on staff for their medical care and safety.
West Newton Healthcare must submit a plan of correction addressing each violation and demonstrate sustained compliance with federal regulations to continue participating in Medicare and Medicaid programs.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for West Newton Healthcare from 2025-01-10 including all violations, facility responses, and corrective action plans.
💬 Join the Discussion
Comments are moderated. Please keep discussions respectful and relevant to nursing home care quality.