Westborough Healthcare
WESTBOROUGH HEALTHCARE in WESTBOROUGH, MA — inspection on February 25, 2026.
Found 6 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
Review of the Resident's Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #16:-was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15 possible points. -has adequate hearing and vision-has clear speech-could understand others and could make himself/herself understood. On 2/18/26 at 8:14 A.M., the surveyor observed Resident #16 lying in bed and the Resident's call bell hanging on the wall on the far side of the bedside chair.
During an interview at the time, the Resident said that he/she didn't have a call bell to call for staff.
When the surveyor asked how he/she would get assistance from staff, the Resident said he/she would just get out of bed and go into the hallway and ask for help. On 2/18/26 at 3:45 P.M., the surveyor observed Resident #16 lying in bed.
There was a bedside chair observed on the left side of the Resident's bed and on the far side of the chair the Resident's call bell was attached to the wall beyond his/her reach.
When the surveyor asked, the Resident said that he/she was not aware of any call bell, and if he/she needed someone he/she would just go into the hallway and call for help. On 2/19/26 at 9:39 A.M., the surveyor observed Resident #16 lying in bed and the call bell was clipped to the wall, on the other side of a chair that was placed beside the Resident's bed.
The call bell was observed beyond the Resident's reach.
During an interview at the time, Resident #16 said that he/she never had a call bell.
On 2/19/26 at 9:41 A.M., the surveyor and Nurse #2 observed Resident #16 lying in bed and the call bell hanging on the wall on the far side of the Resident's bedside chair.
During an interview at the time, Nurse #2 said the call bell should always be accessible to the Resident and not hooked on the wall beyond the Resident's reach.
Nurse #2 unhooked the call bell from the wall and made the call bell accessible to Resident #16.
During an interview on 2/19/26 at 11:15 A.M., the Director of Nursing (DON) said that call bells should always be accessible to the Residents.
225242 02/25/2026
Westborough Healthcare 8 Colonial Drive Westborough, MA 01581
Review of Resident #5's Minimum Data Sets (MDS) assessment dated [DATE] indicated:-taking anti-anxiety and antidepressant medications.-was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) exam score of 15 out of a possible 15.
Review of Resident #5's Psychotropic Medication Care Plan initiated 7/29/25 and revised 8/20/25 indicated:-Resident is taking psychotropic medications-Interventions included: discuss with MD, family re (regarding) ongoing need for use of medication.-Review behaviors/interventions and alternate therapies attempted and their effectiveness as per facility policy, initiated 7/29/25.
Review of Resident #5's February 2025 Physician's orders indicated the Resident had orders for the following medications:-Sertraline HCL (hydrochloride) oral tablet (Antidepressant medication) 100 mg (milligrams) (Sertraline HCL), give 2 tablets by mouth one time a day for depression, 2 TABS = 200 mg, start date 11/23/25.-Trazodone HCL oral tablet (Antidepressant medication) 50 mg (Trazadone HCL), give 2 tablets by mouth at bedtime for anxiety and insomnia, start date 11/22/25.
Review of Resident #5's Medication Administration Records (MAR) for November 2025, December 2025, January 2026 and February 2026 indicated the Sertraline HCL and Trazodone were administered as ordered by the Provider.
Review of Resident #5's medical record failed to indicate evidence that the Resident or Resident's Representative had signed a written informed consent for the Trazodone or the Sertraline medications.
The facility was unable to provide any evidence a signed informed consent was completed for Resident #5 prior to administration of Sertraline and Trazodone.
During an interview on 2/25/26 at 7:44 A.M., Nurse #4 said when a resident gets an order for a new psychotropic medication, a signed written consent was obtained from the resident or the resident's health care proxy, prior to administering the medication.
Nurse #4 said consent should always be obtained prior to administering any new psychotropic medications.
Nurse #4 was unable to find evidence a written signed consent for Resident #5's Sertraline and Trazodone had been completed but she said one should have been obtained prior to administering the medications.
During an interview on 2/25/26 at 8:00 A.M., the Director of Nursing (DON) said written signed consent for psychotropic medications should be obtained prior to administering any new psychotropic medications.
The DON said Resident #5 should have signed informed written consents prior to administering the Trazodone and Sertraline, but she had no evidence consent was obtained prior to administration of the medications.
225242 02/25/2026
Westborough Healthcare 8 Colonial Drive Westborough, MA 01581
followed up with Resident #13 and offered a resolution, but he did not.
225242 02/25/2026
Westborough Healthcare 8 Colonial Drive Westborough, MA 01581
Based on observation, and interviews, the facility failed to ensure that drugs and biologicals were
reviewed.
Specifically, the facility failed to ensure multi-dose vial medications were dated once opened according to manufacturer's guidelines in the 2nd Floor medication storage room.
Findings include:
Review of the facility policy titled Storage of Medications, established 4/2018, revised 1/2024, included but was not limited to:-the facility shall store drugs and biologicals in a safe, secure, and orderly manner.-the facility shall not use discontinued, outdated, or deteriorated drugs or biologicals.
All such drugs will be destroyed. On 2/19/26 at 9:56 A.M., the surveyor and Nurse #1 observed the 2nd Floor medication storage room.
The surveyor observed two multi-dose vials of medication opened with no open or expiration date indicated.
The medications observed were:-Tuberculin, Purified Protein Derivative Diluted/Aplisol 5TU (Tuberculin Units) for intradermal test, 1 ML (milliliter) (10 tests), Once entered, vial should be discarded after 30 days.
Review of the Tuberculin, Purified Protein Derivative Diluted/Aplisol package insert indicated that the multi-dose vial should be dated when opened and discarded after 30 days.-Insulin Lispro 10 ML multi-dose vial, 100 units per ML.
Review of the Insulin Lispro package insert indicated that the multi-dose vial once opened should be discarded after 28 days.
During an interview on 2/19/26 at 10:00 A.M., Nurse #1 said she did not know when the two vials of medication had been opened.
Nurse #1 said that the multi-dose vials of Tuberculin serum and Insulin Lispro should have been labeled when they were opened but the two vials had not been labeled.
Nurse #1 said that once opened the vials would be good for 30 days but since she couldn't tell when these two vials had been opened, she would have to discard them.
During an interview on 2/19/26 at 11:15 A.M., the Director of Nursing (DON) said all multi-dose medication vials should be labeled with an open date indicating when they were first opened.
During a follow-up observation and interview on 2/19/26 at 4:15 P.M., the
washed.-Dish machine wash temperature was observed at 100 degrees F.
During an interview at the
dish washing machine.
Dietary Aide #1 continued to wash dishes while the machine temperature was at 100 degrees F. At time of survey exit, no further evidence was provided to the survey team that the low temperature dishwashing machine met the minimum required temperature of 120 degrees F.
225242 02/25/2026
Westborough Healthcare 8 Colonial Drive Westborough, MA 01581
During an interview on 2/19/26 at 8:15 A.M., with Nurse #3 translating for CNA #7, CNA #7 said she should be performing hand hygiene between every meal tray passed, but she was not.
During an interview on 2/19/26 at 8:54 A.M., the Assistant Director of Nurses (ADON) who was also serving as the Infection Preventionist (IP) for the facility said the staff should be performing hand hygiene between every resident meal tray passed to decrease the risk for the spread of infection.
225242 02/25/2026
Westborough Healthcare 8 Colonial Drive Westborough, MA 01581