LAWRENCE, MA - Royal Wood Mill Center, a nursing home facility on Essex Street, was cited for multiple safety violations during a federal inspection in April 2025, including improper medication storage, inadequate infection control practices, and inaccurate medical documentation that potentially compromised resident care.
The inspection, conducted by the Centers for Medicare & Medicaid Services, identified serious lapses in basic safety protocols that left residents vulnerable to medication errors, infections, and delayed medical treatment.
Medication Security Breaches Put Residents at Risk
Federal inspectors documented numerous instances where nursing staff left medication carts unlocked and unattended, creating dangerous opportunities for unauthorized access to controlled substances and other medications. The facility's own policies clearly state that medication carts must remain locked when not under direct nurse supervision, yet staff repeatedly violated these protocols.
On multiple occasions throughout the inspection, surveyors observed nurses walking away from open medication carts while residents and other staff members had unrestricted access to potentially dangerous medications. In one particularly concerning incident, a nurse left an entire card of Rosuvastatin, a cholesterol medication, sitting on top of an unlocked cart while attending to other duties.
"I should not have left the card of medicine on top of the medication cart," acknowledged one nurse when confronted about the violation by inspectors.
The medication security failures extended beyond simple cart management. Inspectors discovered that medications had been left at a resident's bedside despite clear documentation that the individual was not approved for self-administration. The resident, who had been assessed as unable to manage their own medications, was found with a cup of pills including blood pressure medications, pain relievers, and other prescribed treatments sitting unattended on their dresser.
This practice violates fundamental medication safety principles designed to prevent overdoses, missed doses, and drug interactions. When medications are left unattended, there is no way to verify whether the correct patient received the right medication at the proper time - a basic tenet of safe medication administration known as the "five rights" of medication safety.
Infection Control Failures During Critical Care Procedures
The inspection revealed serious breaches in infection control protocols that could expose residents to preventable infections and complications. During a wound dressing change for a stroke patient, inspectors observed a nurse repeatedly changing gloves without performing proper hand hygiene - a fundamental infection prevention measure.
The nurse was observed removing and donning new gloves multiple times during a single wound care procedure without washing or sanitizing hands between glove changes. This practice can transfer bacteria and other pathogens from contaminated surfaces to sterile wound sites, potentially causing serious infections in vulnerable residents.
Proper wound care protocols require healthcare workers to perform hand hygiene before donning gloves and after removing them. This creates a barrier that prevents the transfer of microorganisms that could compromise wound healing or cause systemic infections. For residents recovering from strokes or other serious medical conditions, infections can significantly delay recovery and lead to life-threatening complications.
Additional infection control violations included a nurse touching medications with bare hands during distribution and inadequate placement of personal protective equipment for residents requiring enhanced barrier precautions. These failures represent breakdowns in basic infection prevention practices that are essential in long-term care settings where residents often have compromised immune systems.
Delayed Implementation of Critical Medical Treatments
The facility failed to provide timely specialized rehabilitation services for a stroke patient who required continued occupational therapy and specialized equipment. The resident had been receiving occupational therapy at their previous facility and required a palm guard splint to prevent further hand contractures and maintain basic hygiene capabilities.
Despite clear documentation from the previous facility recommending continued splinting and range of motion therapy, the resident went without this essential equipment for approximately two months after admission. The failure occurred because rehabilitation staff were not automatically notified of new admissions requiring therapy services, and nursing staff did not communicate the resident's ongoing therapy needs.
"I was not under the impression from nursing that Resident #28 had been receiving therapy at the previous facility so I did not look for and/or read any therapy notes," explained the Director of Rehabilitation when questioned about the oversight.
Hand contractures in stroke patients can become permanent without proper intervention, limiting the individual's ability to perform basic activities like eating, personal hygiene, and self-care. Early and consistent occupational therapy intervention is crucial for maintaining function and preventing complications that could significantly impact quality of life.
Medical Documentation Inaccuracies Compromise Care Quality
Inspectors identified systematic problems with medical record accuracy that could interfere with proper treatment decisions and continuity of care. In four separate cases, nursing staff documented treatments and assessments that did not match actual observations, creating misleading information in residents' medical records.
These documentation errors included recording oxygen administration for a resident who was not receiving oxygen therapy, documenting blood pressure measurements on the wrong arm for a dialysis patient with specific medical restrictions, and falsely recording the placement of safety equipment for residents with seizure disorders and pressure ulcer prevention needs.
Accurate medical documentation serves as the foundation for clinical decision-making, treatment planning, and communication between healthcare providers. When records contain inaccurate information, it can lead to inappropriate treatment decisions, medication errors, and failures to recognize changes in patient condition that require immediate intervention.
The documentation failures were particularly concerning for residents with complex medical conditions requiring precise monitoring and specialized care protocols. For example, the dialysis patient had a specific physician's order prohibiting blood pressure measurements on their right arm due to an arteriovenous fistula - a surgically created connection between an artery and vein used for dialysis access. Taking blood pressure on the wrong arm could damage this critical access point and compromise the patient's ability to receive life-sustaining dialysis treatments.
Infection Control Crisis: C. diff Response Delays
Perhaps most concerning was the facility's delayed response to a confirmed case of Clostridioides difficile (C. diff), a highly contagious bacterial infection that causes severe diarrhea and can be life-threatening in elderly residents. The resident had been experiencing symptoms and tested positive for the infection, but contact precautions were not implemented until 48 hours after positive results were received.
C. diff infections spread rapidly in healthcare settings and require immediate isolation precautions to prevent transmission to other vulnerable residents. The bacteria can survive on surfaces for extended periods and is resistant to alcohol-based sanitizers, making proper isolation procedures critical for containing outbreaks.
During the delay period, staff continued providing care without appropriate protective equipment, potentially exposing other residents and creating conditions for facility-wide transmission. The facility's own policies clearly state that residents with suspected or confirmed C. diff should be placed on contact precautions immediately.
Additional Issues Identified
Beyond these major violations, inspectors documented several other concerns including inadequate storage of controlled substances, missing personal protective equipment supplies, and failures to follow physician orders for specialized medical equipment. These additional findings suggest broader systematic issues with care protocols and staff training throughout the facility.
The inspection also revealed gaps in staff communication between departments, particularly between nursing and rehabilitation services, that contributed to delays in implementing ordered treatments and therapies for residents with complex medical needs.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Royal Wood Mill Center from 2025-04-09 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.