Care One At Newton

previous 30 days for admissions medication transcription accuracy.D) A weekly monitoring audit on

continue monthly for two months to ensure compliance.E) On 08/04/25 through 08/30/25, the

department heads on the Facility policy for medication verification and reconciliation for all new admissions and re-admissions.F) On 08/04/25, the unit managers or designee will review the medication reconciliation forms within 24 hours of admission or readmission to ensure they are complete, accurate, and all areas of conflict were addressed with the MD or provider.G) On 08/04/25 through 08/30/25, the licensed staff will review resident admitted in the last 30 days to ensure the medication reconciliation is completed and any potential conflicts are reported and resolved.H) The Director of Nurses reviews the medication reconciliation forms during morning clinical meeting to ensure completion.I) On 08/15/25, audits to ensure the medical reconciliation was completed were initiated and are on-going by the Director of Nurses or designee.J) Audits to be reviewed at the quarterly QAPI meetings by the QAPI committee.K) The Director of Nurses and/or Designee are responsible for overall compliance.

225268 09/03/2025

Care One at Newton 2101 Washington Street Newton, MA 02462

in accordance with accepted professional standards.

records reviewed and interviews, for one of three sampled residents (Resident #1), the facility failed

medication order in error and 2) the Nurse Practitioner documented that all of Resident #1's medications were reviewed at each visit.Findings include:

Review of the facility's policy, titled Charting and Documentation, with a revision date of 07/2017, indicated the following:-Documentation in the medical record will be objective, complete, and accurate.-Electronic entries that are auto-filled, or auto-prompts must be reviewed and updated when more current information is available or required; or accepted as it is after review.

Review of the facility's policy, titled Medication and Treatment Orders, with a revision date of 07/2016, indicated the following:-Orders for medications and treatments will be consistent with principles of safe and effective order writing.-The signing of orders shall be by signature or a personal computer key.Resident #1 was admitted to the facility in July 2025, diagnoses included Antiphospholipid Syndrome (an autoimmune, hypercoagulable state which can lead to blood clots in both arteries and veins, and other symptoms like low platelets) and CREST syndrome (also known as the limited cutaneous (skin) form of systemic sclerosis which causes the body to destroy healthy tissue).Review of Resident #1's Hospital Discharge summary, dated [DATE], indicated he/she was to receive Methotrexate 2.5 milligram (mg) tablets, take 10 tablets by mouth every 7 days (5 tablets in the morning and 5 tablets in the evening).1) Review of Resident #1's Order Audit Report for his/her Methotrexate medication order indicated the following:-On 07/22/25 Nurse #1 entered a medication order for Methotrexate Tablet 2.5 milligrams -Give 5 tablets by mouth two times a day for R/A (Rheumatoid Arthritis).-The Methotrexate medication order was electronically signed by Physician #1 on 07/28/25.During a telephone interview on 09/04/25 at 9:02 A.M., Physician #1 said he was in the facility when Resident #1 was admitted .

Physician #1 said he had reviewed his/her Hospital Discharge Summary and that all the medications listed on the Summary were to be continued at the facility.

Physician #1 said he was very familiar with Methotrexate and that it was administered weekly.Physician #1 said that orders are sent to him electronically and often are received in bulk with 150 to 200 orders received at a time.

Physician #1 said he had no reason to believe there had been a transcription error when nursing initially entered the orders for Resident #1 and therefore, he signed his/her order for Methotrexate to be administered twice daily instead of once weekly.2) Review of Resident #1's Nursing Progress Notes, indicated Nurse Practitioner (NP) #1 visited Resident #1 at the facility on 07/23/25 and 07/28/25.Review of Resident #1's NP Progress Notes indicated that on 07/23/25 and 07/28/25, NP #1 documented that Resident #1's Methotrexate order was as follows:-Methotrexate 2.5 milligrams- take 5 [tablets] by mouth everyday two times per day.During a telephone interview on 09/04/25 at 8:35 A.M., Nurse Practitioner #1 said that although he listed all of Resident #1's medications in his Progress Notes, he reviewed only the medications that were pertinent to his visits. NP #1 said that Methotrexate was managed by specialists, and he was not familiar enough with the recommended administration frequency to have questioned the directions as they were listed on Resident #1's physician's orders.During a telephone interview on 09/04/25 at 9:55 A.M., the Medical Director said he expected the providers to catch mistakes such as this Methotrexate medication order and that all entries made into the medical record must be right.During a telephone interview on 09/09/25 at 12:52 P.M., the Director of Nurses (DON) said he expected all medical record entries to be complete and accurate.