Care One At Newton
CARE ONE AT NEWTON in NEWTON, MA — inspection on December 31, 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
which was available in the facility's emergency medical supply, was administered in a timely manner,
titled Charting and Documentation, with a revision date of 06/2017, indicated the following:-All services provided to the resident, progress toward the care plan and goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record.-The following information is to be documented in the resident's medical record:*Medications administered.Resident #1 was admitted to the facility in June 2025, diagnoses included multiple pressure injuries, Type 2 Diabetes Mellitus, severe protein-calorie malnutrition, and hemiplegia/hemiparesis (paralysis/weakness) following a cerebral infarction affecting his/her left side.Review of Resident #1's Nursing Progress Note, dated 10/05/25 at 7:17 P.M., indicated Resident #1 had a reddened genital area with swelling which was tender to touch.
The [on-call] Nurse Practitioner was notified and gave an order to start Levofloxacin (antibiotic) 500 milligrams (mg) daily for 10 days and for Resident #1 to be seen the following day by a Nurse Practitioner or Physician.Review of Resident #1's Medication Administration Record (MAR) for the month of October 2025, indicated the first dose of Levofloxacin was not administered to him/her until 10/06/25 at 9:00 A.M. (14 hours after the order was received).
Review of the lists of medications available at the facility from both the everyday medication dispensing machine and the emergency medication dispensing machine, indicated Levofloxacin 500 milligram tablets and/or Levofloxacin 250 mg tablets were available.
During an interview on 12/31/25 at 3:55 P.M., Nursing Supervisor #1 said that he was on duty on 10/05/25 and obtained the order for Resident #1's antibiotic from the on-call Nurse Practitioner.
Nursing Supervisor #1 said that he entered the order in Resident #1's Medication Administration Record (MAR) with the first dose to be given the following morning (10/06/25) because he thought that was what he was supposed to do.During a telephone interview on 01/02/26 at 10:25 A.M., Physician #1 said he had reviewed Resident #1's medical record [the Nurse Practitioner no longer works for the company] and said the first dose of the antibiotic should have been administered on 10/05/25, the evening the order was given to nursing.During a telephone interview on 01/02/26 at 1:28 P.M., the Director of Nurses (DON) said all medications administered by nursing are documented on the residents' MAR.
The DON said when a nurse receives a new antibiotic order, the first dose should be administered to the resident.
The DON said he considered 7:00 P.M. and thereabouts, a reasonable time and that Resident #1 should have received his/her first dose of the Levofloxacin on the evening of 10/05/25.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
225268 12/31/2025
Care One at Newton 2101 Washington Street Newton, MA 02462
resident's primary care provider as he is only in the facility every Monday.
Wound Physician #1 said
facility to evaluate him/her on 10/06/25.Wound Physician #1 said Resident #1's lab results indicated
genital area edema.
Wound Physician #1 said he determined that Resident #1 needed to be transferred to the Hospital Emergency Department (ED) for evaluation and treatment.During a telephone interview on 01/02/26 at 1:28 P.M., the Director of Nurses said when the nurses receive residents' abnormal lab results, they are responsible for notifying the provider and are supposed to document in the resident's medical record that the provider was notified and if there were changes in orders or not.
225268 12/31/2025
Care One at Newton 2101 Washington Street Newton, MA 02462
which include:-Hand Hygiene when entering the room and before leaving the room.-Apply gloves
respiratory infection.-The patient may leave the room if wearing a mask.The surveyor observed
proceeded into Resident #4's room, then turned back and applied a pair of gloves but no gown, then proceeded back into his/her room.Certified Nurse Aide #3 said that he only wore gloves when he provided care to Resident #4 and thought he needed a gown and a mask but did not wear either of them because he forgot to.
During an interview on 12/31/25 at 2:20 P.M., the Director of Nurses (DON) said that all three residents (Resident #3, Resident #4, and Resident #5) were on different infection control precautions and that he expected the staff to implement and follow the appropriate precautions and wear the appropriate PPE per the signage on each resident's doorway.
Frequently Asked Questions
More Reports
Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.