Care One At Newton
CARE ONE AT NEWTON in NEWTON, MA — inspection on September 3, 2025.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
medication transcription accuracy.G) A weekly monitoring audit on new admissions and re-admissions was completed on 08/20/25 by the Director of Nurses and will continue monthly for two months to ensure compliance.H) On 08/04/25 through 08/30/25, the Director of Nurses and Staff Educators educated all staff nurses, unit managers, supervisors, and department heads on the Facility policy for medication verification and reconciliation for all new admissions and re-admissions.I) 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.J) 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.K) The Director of Nurses reviews the medication reconciliation forms during morning clinical meeting to ensure completion.L) 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.M) Audits to be reviewed at the quarterly QAPI meetings by the QAPI committee.N) The Director of Nurses and/or Designee are responsible for overall compliance.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/03/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Care One at Newton
2101 Washington Street Newton, MA 02462
SUMMARY STATEMENT OF DEFICIENCIES
administering.On 09/03/25, the Facility was found to be in Past Non-Compliance, with an effective date of 08/30/25, and presented the Surveyor with a plan of correction which addresses the areas of concern as evidenced by:A) On 08/04/25 through 08/20/25, the Staff Educator educated the nursing staff on accurately transcribing medication orders for new admissions and readmissions to the facility, and the new system/process regarding Que orders.B) On 08/04/25, the Facility implemented a new system, the admitting nurse will Que the orders in the Electronic Medical Record, a second nurse will verify with the discharge summary and activate the orders.C) On 08/04/25 an audit was initiated for all current new admissions and readmissions for the previous 30 days for admissions medication transcription accuracy.D) A weekly monitoring audit on new admissions and re-admissions was completed on 08/20/25 by the Director of Nurses and will continue monthly for two months to ensure compliance.E) On 08/04/25 through 08/30/25, the Director of Nurses and Staff Educators educated all staff nurses, unit managers, supervisors, and 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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/03/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Care One at Newton
2101 Washington Street Newton, MA 02462
SUMMARY STATEMENT OF DEFICIENCIES
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.
Facility ID: