Woburn Rehabilitation and Nursing Center

In the surveyor’s words

From the most serious findings on record at Woburn Rehabilitation and Nursing Center, in the surveyor’s own words.

• Actual harm, isolatedF689Sep 27, 2024

  Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who required the use of a Hoyer lift (mechanical device, person is placed in a specialized sling for transfer from one surface to another) for all transfers, the Facility failed to ensure staff maintained his/her safety, when on 9/09/24 during a transfer using the Hoyer lift, the sling was not properly attached to the Hoyer lift by the Certified Nurse Aides (CNAs) performing the transfer, Resident #1 fell from the lift sling to the floor, was noted to be bleeding from his/her head, was transferred to the Hospital Emergency Department (ED), where he/she was diagnosed with multiple injuries including a closed head injury, scalp laceration, fractures to his/her left leg, and was admitted for treatment. […]

• No harm, potential for more than minimal, widespreadF880Jun 4, 2021

  Based on observation, interview and policy review, the facility failed to implement infection control standards to prevent the potential spread of communicable diseases including COVID-19 by failing to 1) properly screen employees upon entry to the building and 2) failed to ensure staff members were performing hand hygiene appropriately on 3 out of 3 units. 1. Review of the facility policy titled Visitor Screening Policy and Procedure, effective March 12, 2021, indicated the following: *Policy-[NAME] Healthcare screens all individuals entering the building for COVID-19 according to DPH (Department of Public Health) and CDC (Centers for Disease Control and Prevention) guidance. […]

• No harm, potential for more than minimal, patternF550Jan 9, 2025

  Based on observation, record review and interview, the facility failed to provide a dignified existence and self determination. Specifically, the facility failed to: 1. Ensure staff did not utilize resident rooms for personal storage for one Resident (#32) out of a total of 29 sampled residents. 2. Attempt to accommodate one Resident (#16)'s, who is his/her own person, desire to attend the senior center, out of a total of 29 sampled Residents. 3. Provide a dignified dining experience in one unit dining room. […]

• No harm, potential for more than minimal, patternF610Jan 9, 2025

  Based on record review and interviews, the facility failed to investigate allegations of potential abuse for six Residents (#35, #39, #253, #254, #255, and #256) out of a total sample of 29 residents. Findings include: Review of the facility policy titled, Abuse, Neglect and Exploitation, dated 2/203, indicated the following: -An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. -Written procedures for investigations include: -identifying staff responsible for the investigation; -exercising caution and handling evidence that could be used in a criminal investigation; -investigating different types of alleged violations; -identifying and interviewing all involved persons, including the alleged… […]

• No harm, potential for more than minimal, patternF759Jan 9, 2025

  Based on observations, interviews, and record review for two Residents (#72 and #37) out of three residents observed, the facility failed to ensure it was free from a medication error rate of greater than 5%. One out of two nurses observed made 13 errors out of 25 opportunities resulting in a medication error rate of 56%. Specifically, 1.) Nurse #2 attempted to administer 13 medications to the incorrect Resident (#72), which were meant for Resident #37. 2.) Nurse #2 administered the incorrect dose of aspirin to Resident #37. Findings include: Review of the facility policy titled 'Medication Administration', dated as reviewed September 2024, indicated: - Identify resident by photo in the MAR (medication administration record). […]