Above average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Westford Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident who changed hospice providers did not have a Significant Change in Status Assessment (SCSA) MDS completed within the required timeframe, and was not offered a care plan meeting after the change. Facility staff were unaware of the requirement for a SCSA in this situation and failed to notify the Regional MDS Coordinator, resulting in a significant delay and lack of resident involvement in care planning.
A deficiency was cited when a resident's care plan did not address all identified needs and lacked measurable timetables and specific actions, resulting in incomplete planning and documentation.
A resident with right-sided hemiplegia and a contracted hand, dependent on staff for ADLs, was repeatedly observed with fingernails about one inch long pressing into the palm. Despite documentation of daily grooming, staff confirmed the nails had not been trimmed as required by facility policy and the resident's care plan.
A facility failed to provide proper care for two residents with G-tubes. One resident was not supported in restoring oral eating skills due to a lack of communication about therapy discharge and vomiting episodes. Another resident's G-tube placement was not verified before feeding, contrary to facility policy. These issues reflect inadequate communication and protocol adherence.
The facility failed to notify the State LTC Ombudsman in writing about the transfer or discharge of four residents to the hospital. The social worker was unaware of the requirement, leading to non-compliance. Residents with various medical conditions, including CHF, dementia, and diabetes, were transferred without notification. Interviews confirmed the lack of evidence for required notifications.
A resident with Dementia was not reassessed using the Quarterly MDS Assessment as required. The last assessment was completed in January, and no subsequent assessments were done, despite the need for one in April. The MDS Coordinator confirmed the oversight, which increased the risk of an unidentified change in the resident's status.
The facility failed to accurately assess two residents, one with dementia and wandering behaviors, and another with severe cognitive impairment related to smoking. Despite documentation of daily wandering, the MDS assessment for the first resident did not reflect these behaviors. The second resident, with Wernicke's Encephalopathy, was inaccurately assessed as having no cognitive impairment on the Smoking Assessment, allowing independent smoking. Staff interviews confirmed these assessment inaccuracies.
The facility failed to conduct interdisciplinary team (IDT) reviews and revisions of care plans following MDS assessments for three residents with dementia. The social worker misunderstood the requirement, leading to a lack of collaborative IDT meetings and updates to care plans as mandated by facility policy.
The facility failed to ensure a safe environment for two residents during smoking activities. One resident, with cognitive impairment, was found with a lighter despite policy prohibiting it. Another resident, with a seizure disorder, experienced a seizure and fell while smoking unsupervised, resulting in injuries. The facility's smoking policy was not effectively enforced, leading to unsafe conditions.
A resident with End Stage Renal Disease and other health conditions did not receive meals in coordination with their dialysis schedule, leading to missed breakfasts on treatment days. Facility staff were unsure if meals were provided, and documentation was lacking. The issue was observed and confirmed through interviews and observations.
The facility failed to accurately reconcile controlled medications on two units, Edgewood and [NAME], as required by their policy. During a review, it was found that prescription numbers and dates of receipt were missing for several medications, and there were discrepancies in the transfer of medication records. Interviews with staff revealed that expected documentation practices were not followed, leading to deficiencies in the handling of controlled substances.
A facility failed to develop a baseline Care Plan within forty-eight hours for a resident with paraplegia and a Stage IV pressure injury, as required by their policy. The DON confirmed that no baseline ADL Care Plan was created within the required timeframe, constituting a deficiency in meeting the resident's immediate health and safety needs.
A facility failed to maintain complete and accurate medical records for a resident with paraplegia and a Stage IV pressure injury. CNA ADL Flow Sheets and Positioning Sheets were inconsistently completed, with several care areas left blank across multiple shifts. Staff interviews confirmed that documentation should be completed electronically by the end of each shift, but this was not consistently done.
Failure to Complete Timely SCSA and Care Plan Meeting After Hospice Provider Change
Penalty
Summary
The facility failed to identify and complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) for a resident who changed hospice providers while remaining in the facility. According to the MDS 3.0 Resident Assessment Instrument (RAI) Manual, a SCSA must be completed within 14 days when a terminally ill resident changes hospice providers. The resident, admitted with diagnoses including malnutrition and chronic obstructive pulmonary disease, transferred from one hospice provider to another, but the required SCSA was not completed until 57 days after the change. This delay was due to a lack of communication between facility staff and the Regional MDS Coordinator, as staff were unaware that a change in hospice provider necessitated a SCSA and failed to notify the coordinator. Additionally, the resident was not offered or invited to a care plan meeting following the change in hospice provider, as required within seven days after the completion of an MDS assessment. Interviews revealed that neither the unit manager nor the social worker scheduled or attended a care plan meeting for the resident after the hospice provider change. The social worker was unaware of the requirement for a SCSA in this situation and acknowledged that the resident would have benefitted from a care plan meeting to review the plan of care. The deficiency was only identified at the end of June, resulting in the resident not being involved in care planning during this period.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This omission was observed during the survey process, where it was noted that the care plan did not comprehensively cover the resident's needs as required.
Failure to Provide Nail Care for Dependent Resident with Contracture
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for a resident who was dependent on staff for care. The resident, who had multiple sclerosis and right-sided hemiplegia with a contracted hand, was observed on multiple occasions with fingernails on the right hand that were approximately one inch long and pressing into the palm. The resident was unable to recall the last time their nails were trimmed, and staff interviews confirmed that the resident was totally dependent on staff for ADLs, including nail care. The care plan and Kardex both indicated the need for extensive to total assistance with personal hygiene, including grooming. Despite documentation that grooming care was provided daily, direct observation and staff interviews revealed that the resident's fingernails had not been trimmed as required. Staff, including CNAs, a nurse, the Director of Rehab, and the DON, all acknowledged that the resident's nails were excessively long and should have been cut, especially given the hand contracture. The facility's policy required staff to maintain residents' grooming and personal hygiene, but this was not followed for this resident, resulting in a failure to meet the resident's ADL needs.
Deficiencies in G-Tube Care and Monitoring
Penalty
Summary
The facility failed to provide appropriate care and monitoring for two residents with gastrostomy tubes (G-tubes). For one resident, the facility did not facilitate the restoration of oral eating skills despite the resident's requests and a previous successful swallow evaluation. The resident was discharged from speech therapy due to vomiting episodes during therapy sessions, but this information was not communicated to the Nurse Practitioner (NP) or Director of Nursing (DON), preventing further assessment and intervention. The resident's health care proxy expected continued speech therapy, and the resident expressed a desire to eat orally, but staff were unaware of the discharge from therapy and the need for further evaluation. For the second resident, the facility staff failed to verify the proper placement of the G-tube before administering a bolus feeding. The facility's policy required verification of tube placement, but the nurse administering the feeding did not perform this check. The Unit Manager was unsure of the requirement, and the DON acknowledged that there should have been a physician's order to check tube placement upon the resident's admission. These deficiencies highlight a lack of communication and adherence to protocols regarding the care and monitoring of residents with G-tubes. The failure to verify tube placement and to communicate therapy discharge and related concerns to the appropriate medical staff resulted in inadequate care for the residents involved.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care Ombudsman in writing regarding the transfer or discharge of four residents. This deficiency was identified through record reviews and interviews, revealing that the facility did not comply with the notification requirements for residents who were transferred to the hospital. The social worker responsible for providing bed hold and transfer notices was unaware of the requirement to notify the Ombudsman, leading to multiple instances of non-compliance. Resident #66, admitted with diagnoses including congestive heart failure, atrial fibrillation, and dementia, was transferred to the hospital on four occasions without the Ombudsman being notified. Similarly, Resident #43, with peripheral vascular disease and diabetes mellitus, was transferred to the hospital without notification. Resident #73, who was cognitively intact and had a history of cerebral infarction, atherosclerotic heart disease, and pulmonary embolism, was also transferred multiple times without the required notification. Resident #51, admitted with severe protein-calorie malnutrition and gastrostomy status, was transferred to the hospital after removing their G tube. The facility failed to notify the Ombudsman of this transfer as well. Interviews with the social worker and the Director of Nursing confirmed the lack of evidence for written notifications to the Ombudsman, highlighting a systemic issue in the facility's transfer and discharge notification process.
Failure to Complete Quarterly MDS Assessment
Penalty
Summary
The facility failed to reassess a resident using the quarterly review instrument specified by the State and approved by CMS at least once every three months. The resident, who was admitted in October 2023 with a diagnosis of Dementia, had a Quarterly Minimum Data Set (MDS) Assessment completed on January 30, 2024. However, there was no evidence of any subsequent Quarterly MDS Assessments being completed after this date. During an interview on June 13, 2024, the MDS Coordinator confirmed that the last MDS Assessment for the resident was indeed completed on January 30, 2024, and acknowledged that another Quarterly MDS Assessment should have been conducted in April 2024. The failure to complete the assessment increased the risk of an unidentified change in the resident's status between assessments.
Inaccurate Resident Assessments for Wandering and Smoking
Penalty
Summary
The facility failed to complete accurate assessments for two residents, leading to deficiencies in care. Resident #103, who was admitted with dementia and a history of wandering, was not accurately assessed for wandering behaviors. Despite documentation indicating daily wandering and intrusive behavior, the Minimum Data Set (MDS) assessment did not reflect these behaviors, and the Quarterly Nursing Assessment failed to identify the resident as being at risk for wandering or include interventions for such behavior. Interviews with staff, including a CNA, the Unit Manager, and the MDS Coordinator, confirmed that the resident exhibited wandering behaviors during the assessment period, but these were not properly documented in the MDS assessment. Resident #95, admitted with Wernicke's Encephalopathy and severe cognitive impairment, was inaccurately assessed on the facility's Smoking Assessment. The MDS assessment indicated severe cognitive impairment, but the Smoking Assessment incorrectly noted no cognitive impairment, allowing the resident to smoke independently. Interviews with the Unit Manager and the Administrator revealed that the Smoking Assessment was inaccurate, as the resident's cognitive impairment should have precluded independent smoking. These deficiencies highlight the facility's failure to accurately assess and document residents' behaviors and cognitive abilities, which are critical for ensuring appropriate care and safety measures. The inaccuracies in the assessments for both residents were confirmed through staff interviews and record reviews, indicating a lapse in the facility's assessment processes.
Failure to Conduct IDT Care Plan Reviews Post-MDS Assessment
Penalty
Summary
The facility failed to provide interdisciplinary team (IDT) review and revision of care plans after each Minimum Data Set (MDS) assessment for three residents. Specifically, the care plans for residents with dementia and behavioral disturbances were not reviewed and revised by the IDT following the completion of MDS assessments. Resident #103's care plan was not updated after assessments completed on 3/13/24 and 6/4/24. Resident #55's care plan lacked updates following assessments on 8/10/23, 2/6/24, and 5/7/24. Similarly, Resident #61's care plan was not revised after assessments on 1/12/24 and 4/10/24. The facility's policy requires comprehensive, person-centered care plans to be developed by an IDT based on resident assessments. However, the social worker responsible for organizing care plan meetings misunderstood the requirement, believing that IDT reviews could occur anytime during the month of the MDS assessments. Consequently, the IDT did not meet collaboratively to review and revise care plans, and there was no evidence of such reviews for the specified residents. This oversight led to a deficiency in the facility's compliance with care plan review and revision requirements.
Failure to Ensure Safe Smoking Practices for Residents
Penalty
Summary
The facility failed to maintain a safe environment for Resident #95, who was admitted with a diagnosis of Wernicke's Encephalopathy and was severely cognitively impaired. Despite the facility's policy prohibiting residents from keeping disposable lighters, Resident #95 was observed with a lighter in his possession after returning from a smoking activity. This was confirmed during an interview with Nurse #1, who stated that lighters should be kept at the nurse's station. The Administrator also confirmed that residents are required to return lighters after smoking, indicating a lapse in adherence to the facility's smoking policy. Resident #44, who was admitted with a Seizure Disorder and left-sided hemiparesis, experienced a seizure while smoking independently, resulting in a fall from the wheelchair and subsequent skin tears. The resident reported the incident, and it was noted that the care plan did not include specific precautions for smoking activities despite the resident's seizure history. Interviews with the Unit Manager and Nurse Evening Supervisor revealed uncertainty about the seizure precautions in place for Resident #44 during smoking activities, highlighting a lack of adequate supervision and monitoring. The facility's failure to secure a lighter from Resident #95 and to implement appropriate monitoring for Resident #44 during smoking activities led to unsafe conditions. These deficiencies were identified through observations, interviews, and a review of the facility's smoking policy, which was not effectively enforced or updated to reflect the residents' needs and safety requirements.
Failure to Coordinate Meals with Dialysis Schedule
Penalty
Summary
The facility failed to provide appropriate care and services for a resident requiring dialysis by not coordinating meal delivery with the resident's dialysis treatment schedule. The resident, who was moderately cognitively impaired and diagnosed with End Stage Renal Disease, Type 1 Diabetes, Nutritional Anemia, and Protein-Calorie Malnutrition, was observed to have an untouched breakfast tray in their room on a dialysis treatment day. The resident expressed concern about not receiving breakfast before or after dialysis on treatment days, which occurred four times a week. Interviews with facility staff, including the Unit Manager and Director of Nursing, revealed uncertainty and lack of documentation regarding whether the resident received meals or snacks on dialysis days. Observations confirmed that the resident did not receive breakfast on treatment days until the issue was addressed, as evidenced by the resident receiving breakfast before dialysis on a subsequent day, which improved their treatment experience.
Deficiencies in Controlled Medication Documentation
Penalty
Summary
The facility failed to ensure that nursing staff implemented and established systems to accurately reconcile controlled medications using acceptable standards of practice on two units, Edgewood and [NAME]. The facility's policy on controlled substances, revised in April 2019, requires that the nurse receiving the medication and the individual delivering it verify the name, dose, and quantity of each medication, with both individuals signing the controlled substance record of receipt. However, during a medication storage review, it was observed that the documentation in the Narcotic Books for Controlled Substance logs was incomplete and inconsistent. On the Edgewood Unit, Medication Cart #1, several instances were noted where prescription numbers and dates of receipt were missing for medications such as Tramadol, Clonazepam, Pregabalin, and Oxycodone. Additionally, there were discrepancies in the transfer of medication records between pages, with some medications being transferred to pages that contained records for different residents. Similar issues were observed on Medication Cart #2, where medications like Lacosamide, Lorazepam, Morphine Sulfate, and Oxycodone also lacked prescription numbers and dates of receipt. The [NAME] Unit's Medication Cart #1 exhibited comparable deficiencies, with missing prescription numbers and dates for medications such as Buprenorphine, Morphine Sulfate, Tramadol, Lorazepam, Dilaudid, and Clonazepam. Interviews with nursing staff, including Nurse #2, Unit Manager #2, and the Director of Nursing (DON), revealed that the nurses were expected to document prescription numbers and dates of receipt for controlled substances, as well as to ensure proper documentation when medications were transferred between pages. However, these expectations were not met, and the required documentation was not consistently maintained. The DON also noted that when controlled substances are sent home with a resident upon discharge, two nurses are expected to count and sign off on the medication, but this procedure was not followed. The lack of adherence to established protocols and documentation standards led to the identified deficiencies in the facility's handling of controlled medications.
Failure to Develop Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The Facility failed to ensure they developed a baseline Care Plan for a resident with paraplegia and a Stage IV pressure injury within forty-eight hours of admission, as required by their policy. The resident, who required physical assistance for Activities of Daily Living (ADL) such as bathing, dressing, and grooming, was admitted in November 2023. However, a review of the resident's medical record indicated that there was no documentation to support that a baseline Care Plan was developed within the required timeframe. During an interview, the Director of Nurses (DON) confirmed that no baseline ADL Care Plan was developed for the resident and acknowledged that it should have been created within twenty-four hours of admission. This failure to develop a baseline Care Plan within the specified timeframe constitutes a deficiency in meeting the resident's immediate health and safety needs as per the facility's policy.
Incomplete Documentation of Resident Care
Penalty
Summary
The Facility failed to ensure they maintained a complete and accurate medical record for a resident with paraplegia and a Stage IV pressure injury. The resident required physical assistance from staff for mobility and positioning. However, the Certified Nurse Aide (CNA) Activity of Daily Living (ADL) Flow Sheets and Positioning Sheets were not consistently completed. Specifically, documentation on the ADL Flow Sheets was incomplete on multiple shifts across different time periods, with several care areas left blank. Similarly, the Positioning Sheets were also found to be incomplete on various shifts, indicating a lack of consistent documentation of the resident's positioning every two hours. Interviews with staff revealed that all care provided to residents should be documented electronically and completed by the end of their shift. The Director of Nurses acknowledged that documentation had been a problem and confirmed that the CNA ADL Flow Sheets and Positioning Sheets should not be incomplete. The failure to maintain accurate and complete medical records for the resident was identified during the survey, highlighting a significant deficiency in the facility's documentation practices.
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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 Westford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Life Care Center Of Nashoba Valley | 3.8 mi | ★★★★★ | 8 | 0 |
| Palm Springs Post Acute | 5.5 mi | ★★★★★ | 12 | 0 |
| Life Care Center Of Acton | 5.6 mi | ★★★★★ | 0 | 0 |
| Sunny Acres Skilled Nursing And Rehabilitation Ctr | 6.2 mi | ★★★★★ | 0 | 0 |
| Northwood Rehabilitation & Healthcare Center | 6.9 mi | ★★★★★ | 50 | 0 |
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