Blaire House of Tewksbury

In the surveyor’s words

From the most serious findings on record at Blaire House of Tewksbury, in the surveyor’s own words.

• Actual harm, patternF692Oct 17, 2023

  Based on observation, record review and interview for three Residents (#37, #90 and #87) of 26 sampled residents, the facility failed to ensure professional standards of practice were implemented to ensure acceptable parameters of nutritional status. Specifically: 1. for Resident #37, the facility failed to ensure a significant weight loss was verified and assessed resulting in a risk of malnutrition. 2. for Resident #90, the facility failed to implement his/her nutritional care plan resulting in a significant weight loss. 3. […]

• Actual harm, isolatedF686Dec 17, 2025

  Based on observations, interviews and record review, the facility failed to provide necessary treatment, services, or interventions to promote healing and prevent new ulcers from developing for two Residents (#111 and #32) out of 30 total sampled residents. Specifically:1a.) For Resident #111, the facility failed to prevent a new coccyx wound from developing and worsening by not ensuring the Resident's air mattress was inflated, notifying the physician of a new wound to obtain treatment orders and implementing a wound treatment without a physician's order.1b.) For Resident #111, the facility failed to prevent an existing heel wound from worsening by not assessing and monitoring the wound, not implementing physician orders for wound treatment and not following through with a referral to the… […]

• Actual harm, isolatedF689Dec 17, 2025

  Based on observations, record reviews and interviews, the facility failed to keep two Residents (#12 and #82) free from accidents out of a total sample of 30 residents. Specifically, the facility failed to:1) Ensure Resident #12 was supervised during waking hours resulting in a fall with major injury.2) Ensure a fall intervention for alarm when in bed was implemented for Resident #82 after he/she had recently sustained a fall. Findings include:Review of the facility policy titled, Quality Assurance & Performance Improvement Falls Policy and Procedure, dated as revised 9/2025, indicated the following: The interdisciplinary team shall review potential contributing/causative factors associated with the fall and implement individualized interventions accordingly. 1. […]

• No harm, potential for more than minimal, widespreadF801Oct 17, 2023

  Based on record review and interviews the facility failed to employ a Registered Dietician to assess the nutrition needs of all residents on all units as required resulting in risk for malnutrition. , Findings include: 1. Review of the Registered Dietician Job Description (sic.) indicated the following responsibilities of the Registered Dietician (RD): -Provide consultation and education to facilities staff regarding resident dietary needs and requirements. -Provide routine and periodic assessment of the facilities total dietary program -Participate in resident care planning, MDS (minimum data sets), assessments, monitoring, evaluating or any other required documentation in accordance with facilities policies -Meet with the residents to determine individual likes or dislikes -Participate… […]

• No harm, potential for more than minimal, patternF550Dec 17, 2025

  Based on observations and interviews, the facility 1) failed to provide a dignified existence for one Resident (#89) out of a total sample of 30 residents and 2a.) failed to provide a dignified dining experience for one Resident (#38) out of a total sample of 30 residents and 2b.) on two of three units. Specifically:1. For Resident #89 the facility failed to ensure privacy during incontinent care.2a. For Resident #38 the staff removed his/her utensils and guided him/her to eat syrup covered pancakes with his/her hands.2b. In the unit dining rooms residents waited for long periods to be served after their table mates were served, staff stood while feeding and staff referred to residents as feeders, rather than by their name. […]