Care One at Newton

In the surveyor’s words

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

• Actual harm, isolatedF756Sep 3, 2025

  Based on records reviewed and interviews for one of three sampled residents (Resident #1), whose physician's orders included the administration of a medication with a black box warning, the facility failed to ensure the dispensing Pharmacist and the Pharmacy Consultant identified and reported a medication that was prescribed and administered at an excessive frequency, which resulted in Resident #1 experiencing an overall decline in condition, requiring transfer and admission to the hospital.Findings include:Review of the facility's policy, titled Pharmacy Services Overview, with a revision date of 04/2019, included the following:-Pharmaceutical services consist of:*the processes of receiving and interpreting prescriber's orders; receiving, reconciling, and dispensing.all medications.*the… […]

• Actual harm, isolatedF760Sep 3, 2025

  Based on records reviewed and interviews, for one of three sampled residents (Resident #1), whose physician's orders included administration of a potentially toxic medication (oral chemotherapy agent used to treat rheumatoid arthritis) the facility failed to ensure he/she was free from a significant medication error, when upon admission, the medication was inaccurately reconciled from his/her Hospital Discharge Summary by nursing and he/she was administered the medication for consecutive days in error. Resident #1 experienced an overall decline in condition, was transferred and admitted to the Hospital, and was treated for toxic levels of the medication. […]

• Actual harm, isolatedF689Oct 9, 2024

  Based on records reviewed and interviews, for one of three sampled residents, (Resident #1) who had an allergy to shellfish, the facility failed to ensure his/her environment was free of hazards, when on 09/12/24, Resident #1 was served a meal that consisted of seafood (which included shrimp), Resident #1 consumed the meal, developed signs and symptoms of an allergic reaction, including shortness of breath (SOB), puffy watery eyes and flushed appearance, he/she developed stridor (abnormal, high-pitched respiratory sound produced by irregular airflow in a narrowed airway), 911 was called, and Resident #1 was transported to the Hospital Emergency Department (ED) for evaluation of anaphylaxis (a severe, potentially life-threatening allergic reaction) where he/she was admitted for further… […]

• Actual harm, isolatedF806Oct 9, 2024

  Based on records reviewed and interviews, for one of three sampled residents, (Resident #1), who had an allergy to shellfish, the Facility failed to ensure meals prepared and served to him/her accommodated his/her food allergy, when on 09/12/24, dietary staff preparing his/her dinner time meal tray put a meal that included shellfish (shrimp) on it, Resident #1 complained of not feeling well, said he/she had difficulty breathing, 911 was called and he/she was transported to the Hospital Emergency Department (ED), for evaluation and treatment of anaphylaxis (a severe, potentially life-threatening allergic reaction) and he/she was admitted . […]

• Actual harm, isolatedF689Jun 2, 2023

  Based on observation, record review and interview, the facility failed to 1. provide adequate supervision and interventions related to falls resulting in falls with injury for two Residents (#60 and #76) and 2. failed to develop and implement an elopement care plan resulting in elopement for one Resident (#103) out of a total of sample of 33 residents. Findings include: 1. For Resident #60, the facility failed to provide adequate supervision during ambulation. Resident #60 fell while ambulating independently and sustained a hip fracture requiring surgery and head laceration requiring sutures. Resident #60 was admitted to the facility in January 2023 with diagnoses including chronic obstructive pulmonary disease, repeated falls and schizoaffective disorder. […]