Wakefield Care and Rehab

In the surveyor’s words

From the most serious findings on record at Wakefield Care and Rehab, in the surveyor’s own words.

• Immediate jeopardy, patternF609Aug 21, 2023

  The facility identified a census of 43 residents with three residents reviewed for abuse and neglect. Based on record review, observation, and interview, the facility failed to ensure staff identified a situation of abuse and mistreatment and failed to immediately report to the facility administrator (LNHA). On 08/14/23 at approximately 07:30 AM Certified Medication Aide (CMA) R entered Resident(R) 1's room and offered the resident a shower. R1 stated she would like a shower but requested assistance to the bathroom first. CMA R asked Licensed Nurse (LN) G to assist with toileting R1, who required extensive assistance from two staff for toileting and transfer. […]

• Immediate jeopardy, isolatedF600Aug 21, 2023

  The facility identified a census of 43 residents with three residents reviewed for abuse and neglect. Based on record review, observation, and interview, the facility failed to ensure residents remained free from abuse and mistreatment. On 08/14/23 at approximately 07:30 AM Certified Medication Aide (CMA) R entered Resident(R) 1's room and offered the resident a shower. R1 stated she would like a shower but requested assistance to the bathroom first. CMA R asked Licensed Nurse (LN) G to assist with toileting R1, who required extensive assistance from two staff for toileting and transfer. CMA R and LN G assisted R1 onto the toilet, CMA R stayed in the bathroom with the resident, and LN G stepped back into the resident's room. […]

• Actual harm, isolatedF689Jan 11, 2023

  The facility identified a census of 40 residents with three residents reviewed for falls. Based on record review and interview, the facility failed to provide activities of daily living (ADL) assistance with the appropriate number of staff in order to prevent accidents for Resident (R)1. On 11/25/22 Licensed Nurse (LN) G provided incontinence care to R1 without secondary staff assistance when LN G lost her balance, let go of R1causing R1 to fall to the floor, face first. As a result, R1 sustained a laceration to her left eyebrow and a large, complicated tongue laceration, despite not having any teeth, which required suturing by a specialized physician. […]

• No harm, potential for more than minimal, widespreadF812Sep 10, 2025

  The facility had a census of 45 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to store, prepare, distribute, and serve food by professional standards for food service safety in one kitchen. This deficient practice placed the residents who received their meals from the facility's kitchens at risk for foodborne illness.Findings included:- On 09/09/25 at 09:00 AM, observation in the kitchen revealed a three-door refrigerator had the following:An unlabeled, undated container of steak fry casserole.An unlabeled, undated plastic bag with salad and cheese.A three-door refrigerator located in the dry storage room had an unlabeled, undated plastic bag with sliced ham and lacked a backup thermometer.On 09/09/25 at 11:15 AM,… […]

• No harm, potential for more than minimal, widespreadF801Nov 20, 2023

  The facility had a census of 42 residents. The sample included 13 residents. Based on observation, record review and interview, the facility failed to employ a certified dietary manager, placing the residents at risk for unmet nutritional needs. Findings included: - On 11/13/23 at 08:05AM, initial observation of the kitchen revealed dietary staff prepared breakfast. On 11/13/23 at 08:15AM, Dietary Staff (DS) BB verified she was not a certified dietary manager. On 11/14/23 at 1:00PM, Administrative Staff A verified the dietary manager was not certified. The facility Food Service Staffing policy dated 10/2023, stated the facility will employ a certified dietary manager to oversee the day-to-day operation of food service to the residents. […]