Average — CMS composite of the measures below.
A standard survey is most likely before around November 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 New Bedford during CMS and state inspections, most recent first.
A resident did not receive appropriate care for existing pressure ulcers, and the facility did not take adequate steps to prevent new ulcers from developing. This resulted in insufficient monitoring and management of pressure ulcer risks.
The facility did not procure food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards, as identified during the survey.
The facility did not maintain a water management program specific to its building, as required for infection prevention and control. Documentation and diagrams referenced non-existent features and failed to identify hazardous areas for Legionella growth. Both the Director of Maintenance and the Administrator confirmed the program was not tailored to the facility and did not meet required criteria.
A resident with a right hand contracture and severe cognitive impairment did not have a comprehensive, individualized care plan addressing contracture or limited range of motion, despite documented needs and occupational therapy recommendations. Staff interviews confirmed the absence of a care plan for contracture management, and the DON acknowledged that one should have been developed.
Nursing staff did not ensure a resident, who was not approved for self-administration, took their prescribed medications as required. The resident was repeatedly found with multiple pills left in a medication cup, and staff admitted to not confirming ingestion before leaving the room, contrary to facility policy.
The facility did not maintain accurate and complete medical records for two residents. One resident's record lacked documentation of a historical diagnosis of schizoaffective disorder, despite staff having received this information from an outside provider. For another resident, the electronic medical record contained documents belonging to other individuals, which staff acknowledged were uploaded in error.
The facility failed to ensure accurate MDS assessments for two residents, with one resident incorrectly documented as using a restraint and another inaccurately recorded as receiving insulin when only a non-insulin injectable was administered. These inaccuracies were identified through interviews, record reviews, and direct observation.
The facility failed to secure controlled substances on Unit #1, where two medication carts had narcotic boxes that could be opened without a key. Despite the facility's policy requiring double-locked storage for such medications, staff interviews revealed awareness of the issue but no reporting. The DON was unaware of the problem, highlighting a breach in policy and federal regulations.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a Stage III pressure injury, as required by their policy to prevent the spread of MDROs. There was no signage or PPE available, and staff were unaware of the need for EBP. Interviews revealed a lack of communication and awareness among staff, including the Infection Preventionist and Director of Nurses, who acknowledged the oversight.
The facility failed to ensure that three residents were free from significant medication errors by administering Oxycodone outside the physician's prescribed pain parameters. Nursing staff did not notify the physician when administering the medication for lower pain scores, contrary to the orders.
The facility failed to act on the Consultant Pharmacist's recommendations during the monthly Medication Regimen Reviews (MRR) for a resident with chronic kidney disease and diabetes. The pharmacist did not identify irregularities in the administration of Oxycodone, leading to both dosages being prescribed for severe pain without a pain scale parameter.
The facility failed to accurately complete the MDS assessments for five residents, leading to multiple deficiencies. These included not indicating the use of formal assessment tools, antianxiety medications, diuretic medications, and antipsychotic medications, as well as inaccurately recording a discharge location. The discrepancies were confirmed through record reviews and staff interviews.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency indicates that residents were not consistently monitored or treated according to established protocols for pressure ulcer prevention and care, resulting in inadequate management of existing ulcers and insufficient prevention strategies for those at risk.
Failure to Follow Professional Standards for Food Procurement and Service
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Failure to Maintain Facility-Specific Water Management Program for Infection Control
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically regarding its water management program intended to prevent the growth and transmission of Legionella and other waterborne pathogens. Review of the facility's Legionella Water Management Program policy and related documentation revealed that the written description of the building's water system and devices was not specific to the actual facility. The water system flow diagram included features, such as a trellis fountain and references to water supplied by the town, that did not exist in the facility. Additionally, the diagram did not clearly identify or classify hazardous areas or conditions that could encourage bacterial growth, such as stagnation, permissive temperatures, lack of disinfectant, or external hazards. Interviews with the Director of Maintenance and the Administrator confirmed that the water management program and assessment were not tailored to the facility and did not meet all required criteria. The Director of Maintenance acknowledged that the documentation was not specific to the facility and that the flow diagram failed to depict hazardous concerns. The Administrator also confirmed that the program should have been facility-specific and comprehensive, as required by policy.
Failure to Develop and Implement Comprehensive Care Plan for Contracture Management
Penalty
Summary
The facility failed to develop and implement a comprehensive, individualized care plan for a resident with a right hand contracture. Despite the resident's admission with diagnoses including right hand contracture, cerebral infarction, and muscle weakness, and documentation in the Minimum Data Set (MDS) assessment indicating severe cognitive impairment and upper extremity range of motion (ROM) impairment, there was no care plan addressing the contracture or limited ROM. Observations confirmed the presence of a contracture, and the occupational therapy (OT) discharge summary recommended specific interventions, such as a right resting hand splint and a left palm pillow, with a detailed wear schedule. However, these interventions were not reflected in the resident's care plan. Interviews with facility staff, including a CNA, nurse, unit manager, and DON, revealed a lack of awareness and documentation regarding a care plan for the resident's contractures. The CNA and nurse acknowledged the use of splints for the resident, but the nurse was unsure if a care plan existed. The unit manager confirmed that care plans are updated at least quarterly or with changes in condition, but upon review, found no care plan related to the resident's contractures or limited ROM. The DON also confirmed that such a care plan should have been in place.
Failure to Ensure Medication Administration According to Professional Standards
Penalty
Summary
Nursing staff failed to ensure that a resident was administered medications in accordance with professional standards of quality. The resident, who was cognitively intact and had not been assessed or approved to self-administer medications, was observed with multiple medications left in a cup on the overbed table on two separate occasions. The resident expressed confusion about when the medications were provided and indicated that they had not yet taken them. Review of the medical record confirmed that the resident had requested nursing staff to administer medications and had not been assessed for self-administration. Interviews with nursing staff and the unit manager confirmed that the resident was not on the list of those permitted to self-administer medications. Despite this, a nurse admitted to not waiting to ensure the resident had taken all medications before leaving the room. The facility's policy requires that only licensed personnel administer medications and that administration is completed in accordance with prescriber orders, including ensuring medications are actually taken. The failure to confirm medication ingestion resulted in the resident having unsupervised access to prescribed medications.
Incomplete and Inaccurate Medical Records for Two Residents
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents. For one resident, the medical record did not include full documentation of all diagnoses and psychiatric history, specifically omitting a historical diagnosis of schizoaffective disorder. Although the psychiatric nurse practitioner received records from the resident's community provider indicating a long history of schizoaffective disorder, this information was not entered into the facility's medical record or reflected in progress notes. The diagnosis was later added to the record following a hospitalization, but supporting documentation was not present in the medical record at the time of survey. Staff interviews confirmed that relevant documents were not filed appropriately and the medical record did not accurately reflect the resident's history or diagnoses. For another resident, the electronic medical record contained documents belonging to other residents, including an inpatient order and a provider progress note for two different individuals. Staff interviews revealed that these documents were incorrectly uploaded into the wrong resident's record by facility personnel. The Director of Nursing confirmed that these documents should have been filed in the correct residents' records and not in the affected resident's file.
Inaccurate MDS Assessments for Restraint and Insulin Administration
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for two residents. For one resident, the MDS inaccurately indicated the use of a physical restraint, specifically a bed rail, when in fact the resident had never had a restraint and the bed rails in use did not restrict movement. This was confirmed through interviews and direct observation, as well as a review of the resident's medical record and the facility's Matrix form. For another resident, the MDS assessments incorrectly documented the administration of insulin during two separate assessment periods. Review of the medical record showed that the resident had not received insulin during those times. The MDS Coordinator stated that the error occurred because she had mistakenly recorded the use of Victoza, a non-insulin injectable diabetes medication, as insulin. Upon review, the MDS Coordinator acknowledged that Victoza is not an insulin and that the MDS entries were inaccurate.
Failure to Secure Controlled Substances in Medication Carts
Penalty
Summary
The facility failed to ensure the secure storage of controlled substances on Unit #1, where two medication administration carts (A & B) were found to have narcotic boxes that could be opened without a key. This deficiency was identified during an observation by Surveyor #2, who noted that the narcotic boxes on both carts could be easily opened, making the controlled substances inside accessible. The facility's policy, last revised in February 2019, mandates that Schedule II-V medications and other drugs subject to abuse or diversion must be stored in a permanently affixed, double-locked compartment separate from other medications. Interviews with nursing staff revealed that Nurse #1 was aware of the issue with the narcotic box on cart A but had not reported it, while Nurse #2 acknowledged that the narcotic box on cart B sometimes opened without a key. The Director of Nurses (DON) was unaware of the malfunctioning locks and stated that the facility's expectation was for all narcotic boxes to be double-locked, with any issues reported immediately to the DON and maintenance. The failure to secure these medications properly represents a breach of the facility's policy and federal regulations regarding the handling and storage of controlled substances.
Failure to Implement Enhanced Barrier Precautions for Resident with Pressure Injury
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a worsening Stage III pressure injury, which is a necessary infection control measure to prevent the spread of Multi-Drug-Resistant Organisms (MDROs). The facility's policy requires EBP for residents with wounds, yet there was no documentation or physician's order indicating that EBP was needed for the resident. During the survey, it was observed that there was no signage or Personal Protective Equipment (PPE) available outside the resident's room, and staff were unaware of the need for EBP. Interviews with facility staff, including a Certified Nurse Aide, the Unit Manager, the Infection Preventionist, and the Director of Nurses, revealed a lack of awareness and communication regarding the resident's need for EBP. The Infection Preventionist and Director of Nurses acknowledged the oversight, indicating that the resident should have been placed on EBP due to the pressure injury. The deficiency highlights a breakdown in the facility's infection control procedures, as staff failed to initiate and maintain necessary precautions for the resident's condition.
Failure to Administer Pain Medication According to Physician's Orders
Penalty
Summary
The facility failed to ensure that three residents were free from significant medication errors, specifically in the administration of pain medication according to the physician's orders. Resident #73, who was cognitively intact, received Oxycodone for pain scores of 4 or below on multiple occasions, contrary to the physician's order that specified Oxycodone should only be administered for moderate to severe pain (pain scores of 5-10). Interviews with nursing staff revealed a lack of understanding of the pain scale parameters and a failure to notify the physician when administering Oxycodone outside the prescribed parameters. Resident #11, also cognitively intact, was administered Oxycodone 10 out of 21 times outside the physician's parameters, which specified that Oxycodone should only be given for severe pain (pain scores of 7-10). The nursing staff did not contact the physician for clarification or authorization before administering the medication outside the prescribed pain parameters. Interviews with the nursing staff and the Director of Nursing confirmed that the physician should have been notified in such cases, but there was no documentation to support that this was done. Resident #133, who had chronic kidney disease and diabetes with diabetic neuropathy, received Oxycodone 24 out of 34 times outside the physician's parameters. The physician's orders specified that Oxycodone should be administered for severe pain (pain scores of 8-10), but the medication was given for lower pain scores without notifying the physician. Interviews with the nursing staff and the resident confirmed that the medication was administered outside the prescribed parameters, and the Director of Nursing acknowledged that the physician should have been contacted in these instances but was not.
Failure to Act on Pharmacist's Recommendations for Pain Medication
Penalty
Summary
The facility failed to act promptly upon recommendations made by the Consultant Pharmacist during the monthly Medication Regimen Reviews (MRR) for one resident. Specifically, the pharmacist did not review and report irregularities related to the administration of Oxycodone for Resident #133, who was admitted with chronic kidney disease and diabetes with diabetic neuropathy. The resident's physician orders included two different dosages of Oxycodone for severe pain, but both orders lacked a pain scale parameter to distinguish between moderate and severe pain. This oversight was not identified in the MRR dated 5/17/24. Interviews with facility staff, including the MDS Nurse, Nurse #3, and the Director of Nursing (DON), confirmed that the orders should have included a pain range and that the two dosages should not have both been for severe pain. The resident reported being offered a choice between the two dosages and consistently chose the higher dose. The pharmacist acknowledged that he should have made a recommendation to distinguish between the two doses based on a pain scale but failed to do so during his review.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessment for five residents, leading to multiple deficiencies. For Resident #127, the facility did not indicate that a formal assessment instrument/tool was completed, despite the presence of a [NAME] Assessment in the resident's admission evaluation. Resident #11's MDS assessment failed to reflect the administration of an antianxiety medication, Clonazepam, which was prescribed and administered as per the physician's orders. Similarly, Resident #133's MDS assessment did not indicate the administration of a diuretic medication, Furosemide, which was also prescribed and administered according to the physician's orders. Resident #13's MDS assessment did not reflect the use of an antipsychotic medication, Nuplazid, due to a lack of awareness by the MDS nurse that Nuplazid is classified as an antipsychotic medication. Lastly, Resident #141's MDS assessment inaccurately indicated that the resident was discharged to an acute hospital, whereas the resident was actually discharged home with services, as documented in the care conference notes and nursing notes. These inaccuracies were identified through a combination of record reviews and staff interviews. The facility's policy on certifying the accuracy of the resident assessment, which requires that any person completing a portion of the MDS must sign and certify the accuracy of that portion, was not adhered to in these cases. The MDS nurses involved acknowledged the discrepancies during interviews, confirming that the MDS assessments should have accurately reflected the residents' conditions and treatments during the observation period. The failure to accurately complete the MDS assessments for these residents indicates a lapse in the facility's adherence to its own policies and procedures for ensuring the accuracy of resident assessments.
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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 New Bedford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oaks, The | 2.8 mi | ★★★★★ | 3 | 0 |
| Alden Court Nursing Care & Rehabilitation Center | 2.9 mi | ★★★★★ | 0 | 0 |
| Sacred Heart Nursing Home | 3.6 mi | ★★★★★ | 3 | 0 |
| Hathaway Manor Extended Care | 3.9 mi | ★★★★★ | 1 | 0 |
| Royal Of Fairhaven Nursing Center | 4 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.