Care One at Lowell

In the surveyor’s words

From the most serious findings on record at Care One at Lowell, in the surveyor’s own words.

• Actual harm, patternF692Jan 6, 2022

  Based on record review and staff interview, the facility staff failed to maintain acceptable parameters of nutritional status by providing adequate interventions to maintain body weight and prevent weight loss for 6 Residents (#71, #86, #121, #21, #12 and #84) in a total sample of 38 residents. Findings include: Review of the facility policy titled, Weight Assessment and Intervention, dated September 2008, indicated the following: *The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents. *A weight change of 5 lbs (pounds) or more in a patient weighing more than 100 lbs or 2 lbs in a patient weighing less than 100 lbs since the weight assessment will be retaken for validation. […]

• Actual harm, isolatedF688Apr 6, 2023

  Based on observations, record reviews and interviews, the facility failed to prevent a decline in range of motion for 1 Resident (#63) out of a total sample of 37 residents. Findings include: Resident #63 was admitted to the facility in January 2017 with diagnoses including dementia and Human Immunodeficiency Virus disease. Review of Resident #63's most recent Minimum Data Set (MDS), dated [DATE], indicates the Resident was unable to complete the Brief Interview for Mental Status exam and staff has assessed him/her to have severe cognitive impairment. The MDS also indicates Resident #63 is dependent on staff for all activities of daily living. On 4/4/23 at 10:10 A.M., Resident #63 was observed lying in bed. […]

• Actual harm, isolatedF689Dec 7, 2021

  Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was in a wheelchair and being transported by Facility staff in a Facility owned transport van, the Facility failed to ensure his/her safety was maintained to prevent incident or accidents resulting in an injury. On 11/12/21, during the return trip to the Facility from an outside appointment, although Resident #1's wheelchair had been secured in the van by staff, Resident #1 him/herself had not been secured with a seatbelt by staff, the van driver suddenly decelerated the vehicle, and he/she slid out of the wheelchair. Resident #1 landed on the floor of the van, his/her right leg was twisted underneath him/her, and he/she was transferred to the Hospital Emergency Department for evaluation. […]

• No harm, potential for more than minimal, patternF712May 21, 2025

  Based on observation, record review and interview, the facility failed to ensure physician visits were completed timely, completed as required for new admissions, and were alternated between the physician and the nurse practitioner for seven Residents (#26, #27, #144, #8, #129, #120 and #89) out of a total of 34 sampled residents. Specifically: 1. For Residents #26, #27 and #144, the facility failed to ensure they were seen by the physician as required after admission to the facility. 2. […]

• No harm, potential for more than minimal, patternF842May 21, 2025

  Based on observations, interviews, and record reviews, the facility failed to accurately document in the medical record for one Resident (#11) out of 34 total sampled residents. Specifically, for Resident #11, the nurses inaccurately documented insulin was administered when it was not. Findings include: Review of the facility policy titled 'Charting and Documentation', revised July 2017, indicated: - Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. […]