Care One At Newton

F 0684

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or potential for actual harm

Based on records reviewed and interviews, for one of five sampled residents (Resident #1), who was medically compromised, the facility staff failed to ensure a physician ordered antibiotic medication, which was available in the facility's emergency medical supply, was administered in a timely manner, placing him/her at risk for a worsening condition.Findings include:Review of the facility's policy, 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.

Residents Affected - Few

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 REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

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

Facility ID:

If continuation sheet

Event ID:

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

12/31/2025

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 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

findings on 10/05/25.During a telephone interview on 01/02/26 at 10:05 A.M., Wound Physician #1 said he had ordered labs that were drawn on 10/03/25 for Resident #1 due to his/her chronic wound infections.

Wound Physician #1 said abnormal lab results should be called in to the resident's primary care provider as

he is only in the facility every Monday. Wound Physician #1 said that it was not uncommon for him and the primary care providers to collaborate on a plan of care based on lab results and said he was not notified of Resident #1's lab results until he was in the facility to evaluate him/her on 10/06/25.Wound Physician #1 said Resident #1's lab results indicated an acute on-chronic condition and the new wound on his/her thigh may have been related to the 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.

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

12/31/2025

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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

causing fatigue and increased risk of infections and bleeding), colostomy (a surgical opening into the colon to allow for passage of stool), and acute and subacute endocarditis (infection of the heart's inner lining).During an observation and interview on 12/31/25 at 1:13 P.M. the surveyor observed a sign outside of Resident #4's room indicating he/she required Neutropenic Precautions which include:-Hand Hygiene when entering the room and before leaving the room.-Apply gloves before entering the room and remove them before leaving the room.-Apply a gown before entering the room and remove it before leaving the room.-Apply a mask before entering the room if you have a respiratory infection.-The patient may leave the room if wearing a mask.The surveyor observed Certified Nurse Aide (CNA) #3 enter Resident #4's room without applying gloves or gown, he 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.

Event ID:

Facility ID:

If continuation sheet