Average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Care One At Lowell during CMS and state inspections, most recent first.
The facility did not ensure that required physician visits were completed on schedule for several residents, resulting in missed or delayed face-to-face assessments by the physician or nurse practitioner. Some residents were only seen upon admission, while others experienced significant gaps between visits, contrary to regulatory requirements. Staff interviews confirmed lapses and confusion regarding the mandated visit schedule.
A resident with diabetes and other chronic conditions had physician orders to hold insulin if blood sugar was 200 or below, but nursing staff documented insulin administration in the MAR on multiple occasions when blood sugar was below this threshold. Interviews confirmed that the resident was actively involved in their care and would not have allowed insulin to be given under these circumstances, and staff acknowledged the documentation was inaccurate.
A resident with epilepsy and a history of heart attack experienced a leaking bathroom sink for about two months, with the issue repeatedly reported to staff but not documented or addressed. The resident had to empty a basin collecting the leak, and staff interviews confirmed the problem was known but not communicated to maintenance as required.
A resident with Huntington's disease and moderate cognitive impairment was discharged from hospice services, but the facility did not complete a Significant Change in Status Assessment (SCSA) MDS as required. The care plan and nursing notes continued to reference hospice care after discharge, and staff confirmed the assessment was not completed within the mandated timeframe.
A resident with a gastrostomy tube did not have their water flush bag changed every 24 hours as required by facility policy, with the same bag remaining in use for over 62 hours. Nursing staff were unclear about shift responsibilities for changing the bag, and there was no documentation explaining the lapse.
A resident with cardiac and pulmonary conditions was observed receiving oxygen therapy via a face mask at 3L/min, contrary to the physician's order for 2L/min via nasal cannula. Staff interviews confirmed that oxygen should be administered according to the physician's order, but the observed practice did not match the prescribed method or flow rate.
Two residents experienced medication errors when nurses administered an incorrect dose of atorvastatin and gave aspirin without a specified dosage, resulting in a medication error rate above 5%. Both the nurses and the DON acknowledged that medications were not administered according to complete and accurate physician orders.
A resident with a history of traumatic subdural hemorrhage and paraplegia reported genital pain, leading to a physician's order for an ultrasound. The ultrasound was performed, but the results were not filed in the clinical record, reviewed by staff, or reported to the attending physician as required by facility policy. Staff were unaware of the missing results until prompted by a surveyor.
The facility did not provide required written transfer/discharge and bed hold notices to three residents, including individuals with significant physical and cognitive needs, during multiple hospitalizations. The Social Worker confirmed that these notifications were not completed when she was not present.
The facility did not perform a Massachusetts Nurse Aide Registry background check for a CNA before hiring, as required by their policy. The policy mandates background checks to ensure no findings of abuse, neglect, mistreatment, or theft are associated with the applicant. Despite attempts by the HR department, the necessary documentation was not found.
A facility failed to monitor and assess the use of thigh bands as a potential restraint for a resident with Huntington's disease, psychosis, and depression. The resident, who is severely cognitively impaired, was observed in a Broda chair with straps preventing them from exiting. The facility's records did not indicate the use of restraints, and the Occupational Therapy Discharge Summary did not specify the use of thigh bands while lying flat. Interviews revealed that the straps were used to prevent the resident from exiting the chair, and the use of thigh bands should have been evaluated and care planned.
A facility failed to create a care plan for a resident with migraines, despite pre-admission paperwork and a physician's order indicating the condition. The resident, who is cognitively intact, reported daily migraines and wearing sunglasses for relief. Interviews with staff revealed they were unaware of the resident's migraines, highlighting a gap in communication and care planning.
The facility failed to obtain a doctor's order for the transfer of two residents. One resident with Huntington's disease, schizophrenia, and depression was transferred to the hospital without authorization. Another resident with alcohol dependence and cirrhosis was discharged home without a doctor's order. The DON confirmed that orders should have been obtained for both transfers.
The facility failed to provide trauma-informed care for two residents with PTSD by not conducting proper trauma assessments and not developing personalized care plans. One resident's care plan lacked details on re-traumatization triggers and interventions, while another's did not include specific traumatic events or identified triggers. The social worker and DON acknowledged the lack of personalized care planning.
A resident with cognitive intactness and dental issues, including cavities and broken teeth, did not receive necessary dental care despite documented pain and a physician's order. The facility's staff, including the DON, were unaware of the resident's condition, and the resident relied on over-the-counter medication provided by family for pain relief. The facility's policy for routine and emergency dental services was not followed, resulting in a deficiency.
A housekeeper failed to follow hand hygiene protocols by wearing the same gloves while emptying trash from multiple resident rooms without performing hand hygiene between tasks. Facility policies require gloves to be removed and hands sanitized between tasks, which was not adhered to, leading to a deficiency in infection control.
A resident was inaccurately coded in the MDS assessment as using a trunk restraint, despite being observed ambulating independently without any restraint. The resident's medical record did not support the use of a restraint, and interviews with staff confirmed the coding error.
Failure to Complete Timely Physician Visits for Multiple Residents
Penalty
Summary
The facility failed to ensure that required physician visits were completed in a timely manner, as mandated by state and federal regulations. Specifically, several residents did not receive face-to-face visits from their attending physician or nurse practitioner within the required intervals following admission. For example, three residents were only seen by the physician upon admission and did not have subsequent visits every 30 days as required for new admissions. Another resident was not seen by the physician until approximately three months after admission, with the next visit by the nurse practitioner occurring several months later. Additionally, for four other residents, the facility did not ensure that physician visits were conducted as required. In these cases, residents were either seen only once by the physician or had irregular visits from the nurse practitioner, with significant gaps between visits. Some residents reported not having seen the physician or nurse practitioner in a considerable amount of time. Review of progress notes confirmed these lapses, with documentation showing missed or delayed visits that did not meet the regulatory schedule. Interviews with staff, including the ADON, unit manager, nurse practitioner, and physician, revealed inconsistencies in understanding and implementing the required visit schedule. Staff acknowledged that some residents may have been missed for visits due to oversight, and there was confusion regarding the frequency of required visits, particularly for new admissions. The facility's policy required physician visits at least every 30 days for the first 90 days after admission and at least every 60 days thereafter, but this was not consistently followed for the sampled residents.
Inaccurate Insulin Administration Documentation
Penalty
Summary
The facility failed to accurately document the administration of insulin for one resident with diabetes, chronic kidney disease, and congestive heart failure. The resident had physician orders specifying that all insulin should be held if fasting blood sugar was 200 or below. Despite this, the Medication Administration Records (MAR) for April and May indicated that insulin was documented as administered on multiple occasions when the resident's blood sugar was below the specified threshold. Interviews with the resident, nursing staff, and the Director of Nursing confirmed that the resident was highly involved in their insulin management and would not allow insulin to be administered if their blood sugar was below 200. Nurses, including the one who documented the administrations, acknowledged that insulin should not have been documented as given when it was not, and that the documentation was inaccurate. A review of the facility's charting and documentation policy indicated that all documentation should be objective, complete, and accurate. However, there was no clarifying information in the nursing progress notes regarding whether insulin was actually administered or held on the dates in question, leading to a failure to maintain accurate medical records in accordance with professional standards.
Failure to Repair Leaking Sink and Ensure Homelike Environment
Penalty
Summary
The facility failed to provide a safe and homelike environment for one resident by not repairing a leaking bathroom sink for approximately two months. The resident, who was cognitively intact and had diagnoses including epilepsy and a history of heart attack, reported the issue to staff multiple times. The sink was observed to be actively leaking into a plastic basin, which the resident had to empty personally, and the water in the basin was discolored. The resident expressed that the situation was unpleasant and attracted bugs. Staff interviews revealed that a CNA was aware of the leaking sink for over a month but did not document the issue in the maintenance log as required. The maintenance log contained no record of the problem, and the Unit Manager was unaware of any maintenance requests or emails regarding the sink. The Maintenance Director confirmed he was not notified of the issue until the surveyor brought it to the attention of the Unit Manager. The DON acknowledged that maintenance should have been notified immediately and that waiting over a month was unacceptable.
Failure to Complete SCSA After Hospice Discharge
Penalty
Summary
The facility failed to identify and complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) for a resident who was discharged from hospice services. According to the MDS 3.0 Resident Assessment Instrument (RAI) Manual, a SCSA comprehensive assessment must be completed within 14 days following a significant change in a resident's status. The resident in question had diagnoses including Huntington's disease and hypertension, and was noted to have moderate cognitive impairment. The most recent MDS assessment indicated the resident was receiving hospice services, but documentation showed the resident was discharged from hospice on 4/30/25. Despite the discharge from hospice, the resident's care plan continued to reference hospice care, and nursing progress notes inaccurately documented that the resident was still receiving hospice services after the discharge. A review of the medical record confirmed that no SCSA was completed within the required timeframe. Interviews with facility staff, including the MDS Nurse and DON, confirmed awareness of the requirement and acknowledged that the assessment was not completed as mandated.
Failure to Change Water Flush Bag Every 24 Hours for Resident with Feeding Tube
Penalty
Summary
The facility failed to ensure appropriate care and services for a resident with a gastrostomy tube by not changing the water flush bag every 24 hours as required by facility policy. The resident, who had severe cognitive impairment and was rarely or never understood, was receiving tube feedings and scheduled water flushes through an enteral feeding pump. Observations revealed that the water flush bag in use had not been changed for over 56 hours, and subsequent review showed it remained unchanged for more than 62 hours. The facility's policy specified that open system bags and tubing may hang for up to 24 hours unless compromised, but this was not followed in the resident's care. Interviews with nursing staff and facility leadership confirmed that water flush bags should be changed every 24 hours, typically when a new tube feeding container is connected. However, both night and evening shift nurses believed it was the other shift's responsibility to change the bag, resulting in the task being overlooked. There was no documentation in the resident's nursing progress notes to explain the failure to change the water flush bag as required, and physician orders did not specify the frequency for changing the water flush bag.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to provide respiratory care and services consistent with professional standards of practice for one resident. Specifically, the resident had a physician's order for continuous oxygen at 2 liters per minute via nasal cannula. However, multiple observations over several days showed the resident receiving oxygen at 3 liters per minute via a face mask, which did not match the physician's order regarding both the delivery method and the flow rate. The facility's policy on oxygen administration requires verification and adherence to physician orders, including the specific device and flow rate. The resident involved had a history of chronic diastolic heart failure, primary pulmonary hypertension, and sleep apnea, and was cognitively intact according to the most recent assessment. Despite the care plan and physician's orders specifying oxygen administration via nasal cannula at a set rate, staff were observed providing oxygen through a different device and at a higher flow rate. Interviews with nursing staff and the Director of Nurses confirmed that oxygen should be administered exactly as ordered by the physician, both in terms of device and flow rate.
Medication Error Rate Exceeds 5% Due to Incorrect Dosage and Incomplete Orders
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by two medication errors observed out of 26 opportunities, resulting in a 7.69% error rate. For one resident with hypertension and hyperlipidemia, a nurse administered an incorrect dose of atorvastatin calcium, giving only 10 mg instead of the prescribed 20 mg. The nurse acknowledged the error, stating that the dose had recently been increased and she should have administered two tablets to meet the new order. The Director of Nursing confirmed that the medication was not administered according to the physician's order. In another instance, a nurse administered a chewable aspirin tablet to a resident with hyperlipidemia and atrial fibrillation without verifying the dosage, as the physician's order did not specify the required dosage. The nurse admitted that all medication orders should include a dosage and that the aspirin should not have been given without clarification. The Director of Nursing also confirmed that the order was incomplete, lacking the necessary dosage information.
Failure to Maintain and Communicate Diagnostic Test Results
Penalty
Summary
The facility failed to ensure that the results of a diagnostic ultrasound were maintained in the clinical record, reviewed by staff, and reported to the attending physician for one resident. The resident, who was admitted with diagnoses including traumatic subdural hemorrhage and paraplegia, reported genital pain to staff. A physician's order was placed for an ultrasound, which was performed on the same day. However, the results of the ultrasound were not included in the resident's clinical record, nor were they reviewed or communicated to the attending physician as required by facility policy. Interviews with staff revealed that the unit manager was unaware of the missing results until prompted by the surveyor and had not reviewed or reported the findings to the physician. The DON confirmed that results should be reviewed and reported the day they are received, but was not aware that this had not occurred for this resident. The facility's policy requires documentation of when, how, and to whom diagnostic information is provided, but this process was not followed in this instance.
Failure to Provide Required Transfer/Discharge and Bed Hold Notices
Penalty
Summary
The facility failed to provide required written documentation related to transfer/discharge notices and bed hold policies for three residents who experienced hospitalizations. For one resident with paraplegia and communicating hydrocephalus, who was cognitively intact and fully dependent on staff for daily activities, the clinical record showed multiple hospital transfers without any indication that transfer or bed hold notices were provided. Similarly, another cognitively intact resident with osteomyelitis and blindness was transferred to the hospital, but the clinical record did not show that the required notices were given. A third resident, who had severe cognitive impairment and could not participate in mental status interviews, was hospitalized three times, yet there was no documentation that transfer/discharge notices were provided to the resident or their representative. In interviews, the Social Worker confirmed that these notices were not completed and stated that the process does not occur in her absence.
Failure to Conduct Required Background Check for CNA
Penalty
Summary
The facility failed to conduct a Massachusetts Nurse Aide Registry background check for a Certified Nurse Aide (CNA) before hiring, as required by their policy. The policy, dated March 2019, mandates that background checks be completed prior to employment to ensure no findings of abuse, neglect, mistreatment, or theft are associated with the applicant. CNA #1 was hired on June 7, 2022, but there was no documentation in his personnel file to confirm that the required background check was conducted. During interviews, the facility's Administrator, Director of Nurses (DON), and Assistant Director of Nurses acknowledged that they could not locate the background check for CNA #1, despite ongoing attempts by their offsite Human Resource department.
Failure to Monitor and Assess Use of Potential Restraint
Penalty
Summary
The facility failed to monitor and assess the use of equipment being used as a potential restraint for a resident diagnosed with Huntington's disease, psychosis, and depression. The resident, who is severely cognitively impaired and totally dependent for all activities of daily living, was observed multiple times in a Broda chair with bilateral padded straps that prevented them from exiting the chair. The facility's policy on restraints requires that any restraint used must be the least restrictive device possible and used for the least amount of time necessary to treat medical symptoms. However, the medical record, doctor's orders, and care plan for the resident did not indicate the use of a restraint or thigh bands. The facility's Occupational Therapy Discharge Summary noted that thigh bands were used to prevent forward sacral sliding and promote skin integrity, but did not specify their use while the resident was lying flat. The Pre-Restraining Evaluation indicated that the thigh bands provided positional support without preventing volitional movements, but did not address their appropriateness when the resident was lying flat. The Physical Restraint Elimination Review failed to evaluate the use of thigh bands for purposes other than those recommended by Occupational Therapy. Interviews with the Unit Manager and Director of Nursing revealed that the straps were used to prevent the resident from exiting the chair and that the use of thigh bands while lying flat should have been evaluated, care planned, and ordered by a doctor.
Failure to Develop Care Plan for Resident's Migraines
Penalty
Summary
The facility failed to develop a comprehensive and individualized care plan for a resident suffering from migraine headaches. Despite the resident's pre-admission paperwork indicating a history of migraines and a physician's order for Excedrin Migraine, the resident's care plans and medical records did not reflect this condition. The resident, who is cognitively intact, reported experiencing daily migraines and wearing sunglasses to alleviate symptoms, yet this information was not incorporated into their care plan. Interviews with facility staff, including a CNA, Unit Manager, and the Director of Nurses, revealed a lack of awareness regarding the resident's migraine condition. The staff were unaware of the reason behind the resident's constant use of sunglasses and did not know about the resident's history of migraines. The Director of Nurses acknowledged that a care plan should have been developed based on the pre-admission paperwork, which clearly mentioned the resident's migraine headaches.
Failure to Obtain Doctor's Orders for Resident Transfers
Penalty
Summary
The facility failed to adhere to professional standards of practice by not obtaining a doctor's order for the transfer of two residents. Resident #150, who was admitted with Huntington's disease, schizophrenia, and depression, was transferred to the hospital via ambulance without a doctor's order on April 4, 2024. The progress notes confirmed the transfer, but the doctor's orders for April 2024 did not include authorization for this action. During an interview, the Director of Nursing acknowledged that a doctor's order should have been obtained for the hospital transfer. Similarly, Resident #151, admitted with alcohol dependence, alcoholic cirrhosis of the liver, and psychosis, was discharged home without a doctor's order on May 11, 2024. The progress notes documented the discharge, but the doctor's orders for May 2024 lacked the necessary authorization. The Director of Nursing also confirmed that a doctor's order was expected for the discharge home.
Failure to Provide Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care for residents diagnosed with Post Traumatic Stress Disorder (PTSD). Specifically, the facility did not conduct trauma assessments according to its policy and did not develop individualized comprehensive care plans for two residents with PTSD. Resident #146, admitted with diagnoses including PTSD, traumatic brain injury, and depression, had a care plan that aimed to avoid re-traumatization triggers. However, the care plan lacked specific details about the triggers, how the resident exhibits PTSD activation, and the necessary interventions to mitigate the impact during triggered events. Similarly, Resident #123, admitted with PTSD and moderate cognitive impairment, had a care plan that did not include personalized details about the traumatic events experienced or identified triggers to prevent re-traumatization. The social worker acknowledged that trauma is only assessed at admission unless a new traumatic event occurs during the resident's stay. The Director of Nurses confirmed that trauma care plans should be personalized with specific traumatic events and identified triggers, which was not done for Resident #123.
Failure to Provide Dental Services for Resident
Penalty
Summary
The facility failed to provide necessary dental services for a resident who was admitted with diagnoses including focal traumatic brain injury, major depressive disorder, and epilepsy. The resident's Minimum Data Set (MDS) assessment indicated obvious or likely cavities or broken natural teeth, and the resident was cognitively intact. Despite a care conference note from January indicating the need for dental care due to discomfort from rotting teeth, and a physician's order for dental care as needed, the resident did not receive dental services. The resident reported dental pain and was using over-the-counter medication for relief, which was provided by a family member. Interviews with facility staff, including the Unit Manager and Director of Nurses (DON), revealed a lack of awareness and follow-through regarding the resident's dental pain and need for care. The DON stated that a dentist and dental hygienist visit the facility every few months, but was unaware of the resident's condition and the family's provision of Orajel for pain management. The facility's policy indicated that routine and emergency dental services should be available, yet the resident had not been seen by a dentist since admission, highlighting a failure in the facility's process to address the resident's dental needs in a timely manner.
Failure in Hand Hygiene Practices by Housekeeping Staff
Penalty
Summary
The facility failed to ensure proper hand hygiene practices were maintained by housekeeping staff on one of the four nursing units. The facility's policy on hand hygiene, revised on March 18, 2024, emphasizes the importance of hand hygiene as the primary means to prevent the spread of healthcare-associated infections. It requires all personnel to adhere to hand hygiene practices, including washing hands after contact with contaminated surfaces, after glove removal, and before entering another resident's environment. Additionally, the policy on personal protective equipment specifies that gloves should be used only once, discarded appropriately, and hands washed after glove removal. On June 26, 2024, a surveyor observed a housekeeper on the [NAME] Park Unit failing to follow these protocols. The housekeeper was seen wearing the same pair of gloves while emptying trash from multiple resident rooms without performing hand hygiene between tasks. This was confirmed through interviews with the Housekeeping Manager, Infection Control Nurse, and Director of Nurses, all of whom stated that gloves should be removed before exiting a room, and hand hygiene should be performed before entering another room. The failure to adhere to these practices was identified as a deficiency in the facility's infection prevention and control program.
Inaccurate MDS Coding for Resident Restraint Use
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment for a resident, leading to a deficiency. The resident, admitted in January 2019 with diagnoses including traumatic subarachnoid hemorrhage and unspecified dementia, was incorrectly coded as using a trunk restraint. The MDS assessment indicated the resident used a trunk restraint less than daily, despite observations on multiple days showing the resident ambulating independently without any restraint. The resident's medical record lacked any physician's orders, care plans, or restraint assessments to support the use of a restraint. Interviews with the Unit Manager and the MDS Nurse confirmed that the coding was an error, as no residents in the facility used restraints.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Lowell
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Vantage At Lowell Llc | 1.6 mi | ★★★★★ | 3 | 0 |
| Regalcare At Lowell | 2 mi | ★★★★★ | 21 | 1 |
| Fairhaven Healthcare Center | 2.4 mi | ★★★★★ | 36 | 0 |
| D'youville Senior Care | 3.3 mi | ★★★★★ | 6 | 0 |
| Northwood Rehabilitation & Healthcare Center | 3.4 mi | ★★★★★ | 50 | 0 |
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