Care One At Newton

F 0756 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/03/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Care One at Newton

2101 Washington Street Newton, MA 02462

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/03/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Care One at Newton

2101 Washington Street Newton, MA 02462

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the facility failed to ensure his/her medical record was complete and accurate when 1) the Physician signed a 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 REDACTED], 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.

Event ID:

Facility ID:

If continuation sheet