Lowell Healthcare

Based on observation, record review, and interview, the facility failed to ensure a resident's dignity was maintained related to an uncovered urinary catheter bag for 1 of 2 residents reviewed for dignity. (Resident 8)Finding includes:On 2/9/26 at 3:10 p.m. Resident 8 was observed lying in bed. A urinary catheter bag was hanging from the side of the bed with visible urine in the bag. There was no cover over the bag, and the bag was visible from the hallway.On 2/10/26 at 10:24 a.m. Resident 8 was observed lying in bed. A urinary catheter bag was hanging from the side of the bed with visible urine in the bag. There was no cover over the bag, and the bag was visible from the hallway.On 2/11/26 at 11:07 a.m. Resident 8 was observed lying in bed. A urinary catheter bag was hanging from the side of the bed with visible urine in the bag. There was no cover over the bag, and the bag was visible from the hallway.Record review for Resident 8 was completed on 2/11/26 at 11:26 a.m. Diagnoses included, but were not limited to, hypertension, osteoarthritis, and obstructive uropathy.The Quarterly…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure residents were assessed for self-administration of medications and had a physician's order to self-administer medications for 1 of 1 resident reviewed for self-administration of medication. (Resident 60)Finding includes:On 2/11/26 at 9:12 a.m., LPN 1 was observed preparing Resident 60's medications, which included Miralax (polyethylene glycol, a laxative medication) 17 grams. She dissolved the medication in a cup of water and entered the resident's room to administer the medications. The resident took his pills and drank a few sips of the Miralax then set the cup on his bedside table. LPN 1 indicated she would come back later and assist him with finishing the Miralax. She completed administering the resident's other medications, exited the room, and returned to the Nurse's Station. She left the Miralax in the resident's room and had not stayed with the resident to ensure the medication was taken. Record review for Resident 60 was completed on 2/11/26 at 12:08 p.m. Diagnoses included, but were not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to provide ADL (activities of daily living) assistance to dependent residents related to removing facial hair for female residents for 1 of 2 residents reviewed for ADL care. (Resident 45)Finding includes: On 2/9/26 at 11:29 a.m., Resident 45 was observed sitting in her wheelchair watching television. The resident had facial hair observed on her chin. On 2/11/26 at 9:43 a.m. and 11:42 a.m., Resident 45 was observed with facial hair on her chin. Resident 45's record was reviewed on 2/12/26 at 3:18 p.m. Diagnoses included, but were not limited to, Alzheimer's disease. A Care Plan, dated 9/7/16, indicated the resident required assistance with activities of daily living. Interventions included, but were not limited to, assist with bathing as needed, assist with showers twice weekly in the morning and partial bath in between per resident's preference. The Quarterly Minimum Data Set (MDS) assessment, dated 10/17/25, indicated the resident was severely cognitively impaired and required partial/moderate assistance with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure residents received proper treatment and care related to oxygen administration and humidity bottles that were outdated for 3 of 3 residents reviewed for respiratory care. (Residents 72, 15, and 10)Findings include: 1. On 2/9/26 at 11:41 a.m., Resident 72 was observed in bed with oxygen on via a nasal cannula. The resident indicated she administered the oxygen when she felt she needed it. The oxygen concentrator was set to 1.5 liters per minute and had a humidity bottle attached that was dated 1/19/26. On 2/11/26 at 9:25 a.m., Resident 72 was observed asleep in bed. She was wearing a nasal cannula attached to the oxygen concentrator set to 1.5 liters per minute. The humidity bottle was dated 1/19/26. Resident 72's record was reviewed on 2/12/26 at 3:36 p.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease A Physician's Order, dated 8/21/24, indicated change oxygen tubing and humidity once a day on Sunday. The Quarterly Minimum Data Set (MDS) assessment, dated 11/11/25,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure infection control practices and standards were maintained, related to staff touching pills during medication administration for 1 of 5 residents observed during medication administration. (Resident 60) Finding includes:On 2/11/26 at 9:12 a.m., LPN 1 was observed preparing Resident 60's medications, which included 10 pills. She popped each pill out of the medication cards one at a time, into her hand, and then put them in a medication cup. She then administered the medications to the resident.During an interview on 2/11/26 at 11:17 a.m., the Director of Nursing was made aware LPN 1 had touched the medications with her hands.A facility policy, titled Medication Administration (Medication Pass Procedure), indicated, .5. Medications are opened without contaminating.3.1-18(b)

Based on observation, record review, and interview, the facility failed to serve food under sanitary conditions related to touching food with dirty gloves. This had the potential to affect 76 residents who received food from the kitchen. (Main Kitchen) Findings include: 1. During a follow-up tour of the kitchen on 12/11/24 at 12:00 p.m., [NAME] 1 was observed donning gloves. He picked up a box of cellophane wrap and moved it, then picked up a cardboard box containing frozen sausage patties. He opened the box of the frozen sausage patties with the same gloved hands, opened the plastic bag inside, scooped out handfuls of the sausage patties with the same gloved hands, and placed the patties on a baking sheet. He did not perform hand hygiene or change his gloves during the preparation of the food. 2. On 12/11/24 at 12:03 p.m., the Dietary Food Manager (DFM) was observed preparing food for lunch. She had placed a baking sheet that was covered by a single layer of cellophane wrap on the food preparation counter. She manipulated the cellophane wrap to try and cover the baking sheet…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure infection control practices and standards were maintained, related to staff touching pills during medication administration for 3 of 6 residents observed during medication administration. (Residents 71, 10, and 9) The facility also failed to ensure reuseable equipment was disinfected after use on residents for 2 of 6 residents observed during medication administration. (Residents 10 and 47) Findings include: 1. On 12/11/24 at 9:06 a.m., QMA 1 was observed preparing Resident 71's medications. She popped each pill out of the medication cards one at a time, into her hand, and then put them in a medication cup. She then administered the medications to the resident and continued to the next resident. At 9:17 a.m., QMA 1 was observed preparing Resident 10's medications. She popped multiple pills out of the medication cards one at a time, into her hand, and then put them in a medication cup. She then administered the medications to the resident and continued to the next resident. At 9:33 a.m., QMA 1 was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review and interview, the facility failed to ensure a resident with edema received the necessary care and treatment related to Medigrips (elastic type stocking) not in place as ordered for 1 of 2 residents reviewed for edema. (Resident 12) Finding includes: On 12/8/24 at 1:18 p.m., Resident 12 was observed seated in her wheelchair. Her legs were discolored a light purple and swollen, there were no Medigrips on her legs. On 12/10/24 at 1:22 p.m., the resident was observed in bed. Her legs were discolored, swollen and there were no Medigrips in place. On 12/11/24 at 9:38 a.m., the resident was observed with RN 1 seated in her wheelchair. There were no Medigrips in place. The RN indicated she was unsure who was responsible for putting them on or removing them. The RN later indicated the Medigrip order had been discontinued. The resident's record was reviewed on 12/10/24 at 10:54 a.m. Diagnoses included, but were not limited to, venous insufficiency, hypertensive heart disease with heart failure and dementia. The Quarterly Minimum Data Set assessment, dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review and interview, the facility failed to ensure a resident received the necessary treatment for a pressure ulcer related to the incorrect treatment provided during wound care for 1 of 3 residents reviewed for pressure ulcers. (Resident 73) Finding includes: On 12/11/24 at 9:15 a.m., Resident 73's wound care was observed with the Wound Nurse. The resident had a stage 4 pressure ulcer to her sacral area. The nurse positioned the resident on her left side and removed the old dressing. She cleansed the wound bed with Anasept (a wound cleanser) and gauze. She then applied a sheet of collagen to the wound bed and a piece of Maxorb (absorbent material used for wounds). The wound nurse then used an absorbent island border dressing to cover the wound. The resident's record was reviewed on 12/9/24 at 12:55 p.m. Diagnoses included, but were not limited to, multiple sclerosis, diabetes mellitus and stage 4 pressure ulcer. The Quarterly Minimum Data Set assessment, dated 11/22/24, indicated the resident was cognitively intact and required moderate assistance for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review and interview, the facility failed to ensure a medication was kept in a locked medication cart at all times for 1 of 6 residents observed during medication administration. (Resident 10) Finding includes: On 12/11/24 at 9:17 a.m., QMA 1 was observed preparing medications for Resident 10. She indicated she could not find the resident's Miralax (a laxative medication) so she could not administer it. She notified RN 1 that she could not find the medication. RN 1 indicated she would look in the medication room to see if it was with the overflow medications. QMA 1 finished preparing the resident's other medications and gave them to the resident. On 12/11/24 at 9:33 a.m., QMA 1 began preparing Resident 9's medications. RN 1 approached the medication cart and indicated she was able to get Resident 10's Miralax from the Pyxis (a medication dispensing machine). She handed the Miralax medication to QMA 1. QMA 1 wrote Resident 10's name on the medication and set it on top of the medication cart. She then continued to prepare Resident 9's medications, entered…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure residents received the necessary treatment and services related to the lack of monitoring and assessments of a skin discoloration for 1 of 2 residents reviewed for non-pressure skin conditions. (Resident 47) Finding includes: On 1/23/24 at 11:28 a.m., Resident 47 was observed with a reddened area noted on her nose. The resident indicated it was from her BiPAP (bilevel positive airway pressure) mask that she wore at night. On 1/24/24 at 9:19 a.m., Resident 47 was observed sitting in a chair. She had a reddened area noted on the bridge of her nose. On 1/25/24 at 2:28 p.m., Resident 47 was observed sitting up in a chair. She had a reddened area with a small scab present, along with an indentation on the bridge of her nose. Resident 47's record was reviewed on 1/24/24 at 9:00 a.m. Diagnoses included, but were not limited to, chronic respiratory failure, obstructive sleep apnea, and chronic obstructive pulmonary disease. The State Optional Minimum Data Set (MDS) assessment, dated 11/9/23, indicated the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure a medication error rate of less than 5% for 1 of 5 residents observed during medication pass. Two errors were observed during 30 opportunities for errors during medication administration. This resulted in a medication error rate of 6.67%. (Resident 282) Finding includes: On 1/24/24 at 11:11 a.m., RN 1 was observed preparing Resident 282's medications to be administered via a gastrostomy tube (g-tube, a tube inserted through the belly that brings nutrition to the stomach). The nurse crushed 2 different medications, which included 1 Nephro Vite (vitamin) tablet and 1 Carafate (anti-ulcer medication) tablet. She poured the crushed medications together into a plastic cup and added an unmeasured amount of water. The RN indicated she added approximately 30 ml (milliliters of water to the medications). She then proceeded to check for placement of the g-tube by auscultation. She flushed the g-tube with 30 ml of water and then administered the cup with the 2 medications into the tube. The nurse then…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.