Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Woburn Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
The facility failed to uphold resident dignity and self-determination, as staff used a resident's room for personal storage, did not accommodate a resident's wish to attend a senior center, and provided an undignified dining experience. A cognitively impaired resident's room was used for staff storage, while another resident's request to visit a senior center was denied due to family concerns. Additionally, meal service was disorganized, with residents receiving trays at different times and improper hand hygiene observed.
The facility failed to investigate potential abuse allegations for six residents, despite having a policy requiring immediate investigation. Grievances included reports of physical harm, unsatisfactory care, and inappropriate staff comments. The facility's follow-up was inadequate, often limited to staff education without a full investigation. The Administrator admitted that full investigations were not conducted.
A facility experienced a 56% medication error rate when an LPN attempted to administer medications to the wrong resident and gave an incorrect aspirin dose to another. The LPN failed to verify resident identities and did not follow the physician's order for the correct dosage. Both residents were cognitively intact, and the errors were identified during a survey.
The facility failed to secure medications properly, with unsecured medications found in resident rooms and treatment carts left unlocked and unattended. Medications were also not dated upon opening, violating guidelines. No residents had been assessed for self-administration, which is required for bedside storage.
The facility failed to serve meals at appetizing and safe temperatures, as observed during resident interviews and test tray observations. Residents reported consistently cold and unappetizing food. Observations revealed turkey in gravy at 101°F, milk at 52°F, and eggs at varying lukewarm or cold temperatures. The Administrator acknowledged the issue.
The facility failed to maintain proper foodservice sanitation practices, including missing thermometers in refrigerators, premature temperature logging, and unlabeled food items. Additionally, a lighter was used to light a gas stovetop burner due to equipment issues.
The facility failed to ensure residents were aware of the grievance process and had access to grievance forms, and did not resolve a grievance from a resident who reported being hurt by a staff member. Many residents expressed fear of retaliation and lack of knowledge on how to file grievances. Grievance forms were unavailable due to construction, and a grievance from over a year ago remained unresolved.
A facility failed to develop and implement baseline care plans within 48 hours for a resident admitted with multiple diagnoses, including a cervical vertebra fracture and diabetes with polyneuropathy. The resident, who had severe cognitive impairment, did not receive timely interventions for a coccyx pressure wound, a left calf skin tear, and the use of an Aspen neck collar. The Director of Nursing acknowledged the importance of timely care plans for safe and appropriate resident care.
A resident with dementia, requiring assistance for self-care, was observed with long chin hair despite expressing a desire for its removal. The facility's policy mandates grooming care, but the resident's care plan lacked details on grooming assistance, and no refusals of care were documented, highlighting a failure in providing necessary ADL support.
A facility failed to manage edema for a resident with heart failure by not obtaining weekly weights or notifying the medical provider of significant weight changes. Additionally, the facility did not properly document or assess a resident's skin condition, resulting in untreated open ulcers. Staff interviews revealed a lack of awareness and communication regarding these issues.
The facility failed to address significant weight losses in two residents with Alzheimer's, leading to a deficiency in nutritional care. One resident lost 7.6% of body weight over several months without re-weighs or timely interventions, while another lost 5.7% in a month without evaluation or supplements. Staff interviews revealed non-compliance with weight monitoring policies, delaying necessary interventions.
A resident with depression and anxiety experienced worsening mood, as indicated by an increased PHQ-9 score, but the facility failed to provide adequate follow-up behavioral health services. The resident expressed unhappiness and fear of retaliation, and only met with a therapist once, despite wanting regular sessions. The social worker was not informed of the mood change, preventing a team meeting to address the resident's needs.
A resident was nearly administered incorrect medications, including those they were allergic to, due to a nurse's failure to verify the resident's identity. The nurse did not check the resident's identification or request identifying information, leading to a significant medication error that was only prevented by surveyor intervention.
A resident with a broken tooth did not receive timely dental care due to a lack of communication and follow-up within the facility. Despite having a consent for dental treatment and a physician order, the resident had not seen a dentist since May 2023. Staff interviews revealed unawareness of the resident's dental needs, leading to the deficiency.
A resident with severe cognitive impairment and dietary orders for a pureed diet was served scrambled eggs that were not pureed. Despite the physician's orders and the resident's condition, the facility failed to provide the appropriate diet texture, as confirmed by a nurse who checks the trays.
A resident who required a Hoyer lift for transfers fell due to improper sling attachment by CNAs, resulting in multiple injuries. The facility's protocol required matching colored loops for stability, but the CNAs did not verify this, leading to the fall.
The facility failed to provide timely care for residents at high risk for pressure injuries, as evidenced by delays in implementing dietary and wound care recommendations. A resident's dietary recommendations were delayed by five days, while another's wound care orders were delayed by eleven days. Similar delays were noted for other residents, indicating a systemic issue in the facility's process for reviewing and implementing care recommendations.
The facility failed to maintain complete and accurate medical records for residents requiring assistance with ADLs, with CNA flow sheets often left blank. A resident with a new pressure injury lacked documented physician's orders for wound care. Interviews revealed systemic issues with documentation completion, despite facility expectations for daily completion.
A resident with multiple health issues developed a new pressure injury upon readmission to the facility, but the physician was not notified, and no treatment orders were obtained. Despite documentation of ongoing wounds, interviews with nursing staff revealed a lack of communication and awareness regarding the resident's condition.
Deficiencies in Resident Dignity and Self-Determination
Penalty
Summary
The facility failed to ensure a dignified existence and self-determination for its residents, as evidenced by several observations and interviews. In one instance, staff used a resident's room for personal storage, with a black backpack repeatedly observed in Resident #32's room. The resident, who is severely cognitively impaired, was unable to identify the owner of the backpack. The Unit Manager and Administrator confirmed that the backpack belonged to an employee and acknowledged that staff should not store personal items in resident rooms. Another deficiency involved the facility's failure to accommodate a resident's desire to attend a senior center. Resident #16, who has intact cognition, expressed a wish to visit the senior center but was denied by staff. Despite the resident's ability to make independent decisions, the facility did not develop a plan to facilitate this request, citing family concerns about the resident's safety due to potential drinking and elopement. The Social Worker and Administrator acknowledged the situation but did not provide an alternative plan to address the resident's wishes. Additionally, the facility did not provide a dignified dining experience for residents in one unit dining room. Observations during meal times revealed that residents were served at different times, resulting in some residents eating while others waited for their trays. This was compounded by improper hand hygiene practices by staff, such as touching a straw with ungloved hands. The Administrator noted the logistical challenges of serving meals in a shared dining room and mentioned plans to implement a point of service dining system, but these issues were not addressed at the time of the survey.
Failure to Investigate Allegations of Potential Abuse
Penalty
Summary
The facility failed to investigate allegations of potential abuse for six residents, as required by their policy on abuse, neglect, and exploitation. The policy mandates an immediate investigation when there is suspicion or reports of abuse, neglect, or exploitation. However, the facility did not conduct thorough investigations for grievances submitted by residents and their family members. These grievances included reports of physical harm, unsatisfactory care, inappropriate comments by staff, and discomfort caused by staff actions. Despite the facility's policy requiring identification and interviewing of all involved persons, including the alleged victim and perpetrator, these steps were not followed. The grievances involved residents with various medical conditions, such as Alzheimer's Disease, congestive heart failure, and diabetes. For instance, one resident reported being hurt by a staff member during an appointment, while another resident complained about a CNA's rough handling. In each case, the facility's grievance follow-up was inadequate, often limited to staff education without a full investigation. The Administrator acknowledged that these grievances could potentially indicate abuse and admitted that full investigations were not conducted, which included interviewing other staff and residents to ensure abuse did not occur.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by a 56% error rate observed during a survey. Nurse #2 made 13 errors out of 25 opportunities, including attempting to administer 13 medications to the wrong resident. Specifically, Nurse #2 prepared medications intended for Resident #37 but attempted to give them to Resident #72 without verifying the resident's identity through any means such as checking the identification bracelet or asking for identifying information. This error was only averted when the surveyor intervened, prompting Nurse #2 to realize the mistake. Additionally, Nurse #2 administered an incorrect dose of aspirin to Resident #37. The physician's order required two tablets of 81 mg aspirin, but Nurse #2 only administered one tablet. Both residents involved were cognitively intact, with Resident #72 having a BIMS score of 15 and Resident #37 a score of 14. The Director of Nursing acknowledged that Nurse #2 should have verified the resident's identity and followed the physician's order for the correct medication dosage.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to ensure that medications were stored securely, as required by State and Federal regulations. During observations on the B Unit, medications such as glycerin suppositories, diclofenac gel, metamucil, lidocaine patches, and artificial tears eye drops were found unsecured in resident rooms. These medications were visible and accessible, and no self-administration of medication assessments had been completed for the residents, which is a prerequisite for bedside storage. The Unit Manager and the Director of Nursing confirmed that no residents had been assessed for self-administration, and therefore, medications should not have been stored at bedside. Additionally, the facility did not properly secure treatment carts on the C and D Units. The surveyor observed these carts unlocked and unattended in the hallways, with prescription topical medications accessible. Nurses responsible for these carts acknowledged that they should have been locked when not in view, as per facility policy. The Director of Nursing reiterated that treatment carts should be locked when unattended. The facility also failed to ensure medications were dated once opened, as per manufacturer's guidelines. On the D Unit, a bottle of proheal, a vial of insulin lantus, and an insulin lispro kwik pen were found open and undated, or with unclear dating. Similarly, on the B Unit, a bottle of timolol maleate eye drops was open and undated. Nurses confirmed that these medications should have been dated upon opening due to their shortened expiry dates, and the Director of Nursing agreed that the lack of proper dating was a violation of policy.
Failure to Serve Meals at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to provide meals at an appetizing, palatable, and safe temperature, as observed during a Resident Group Interview and multiple test tray observations. Residents consistently reported that the food served was cold and unappetizing. During a test tray observation, the turkey in gravy was found to be 101 degrees Fahrenheit, which was lukewarm and bland. On another occasion, milk was served at 52 degrees Fahrenheit, and eggs were served at varying temperatures of 118, 89, and 95 degrees Fahrenheit, all of which were lukewarm or cold. Additionally, oatmeal was served at 115 degrees Fahrenheit and was also lukewarm. The Administrator acknowledged awareness of the issues in the food service department.
Deficiencies in Foodservice Sanitation Practices
Penalty
Summary
The facility failed to maintain proper foodservice sanitation practices, as observed during a survey. Specifically, there were no thermometers in two refrigerators, and the temperature log for a dinner meal was filled out prematurely. Additionally, opened packages of meat, cheese, and pepperoni were found unlabeled and undated in the kitchenette on the C and D unit. Containers of bread crumbs, flour, and white rice in the kitchen were also not labeled or dated. Furthermore, a lighter was found next to a gas stovetop burner, which the cook admitted to using to light the middle burner, indicating equipment issues. The Food Service Director acknowledged the absence of thermometers and the premature logging of temperatures.
Failure to Ensure Grievance Process Awareness and Resolution
Penalty
Summary
The facility failed to ensure that residents were aware of the grievance process and had access to grievance forms, as well as failed to resolve a grievance for one resident. During a resident group meeting, 15 out of 20 residents expressed that they did not know how to file a grievance, felt their concerns were not resolved, and feared retaliation from staff if they complained. The surveyor was unable to locate grievance forms on any nursing unit during the survey. The Administrator and Director of Nursing acknowledged that the grievance forms were removed due to construction but should have been available to residents. Additionally, a grievance from a resident dated over a year prior was found unresolved. The resident reported being hurt by a staff member during an appointment, but the grievance follow-up section was blank, indicating no resolution. The Administrator, who was not working at the time the grievance was filed, confirmed that all grievances should be resolved within two days, but this grievance lacked a resolution.
Failure to Implement Timely Baseline Care Plans
Penalty
Summary
The facility failed to develop and implement baseline care plans within 48 hours of admission for a resident, leading to a deficiency. The resident was admitted with diagnoses including an unspecified displaced fracture of the fifth cervical vertebra, diabetes mellitus with diabetic polyneuropathy, and muscle weakness. The resident also had severe cognitive impairment, scoring three out of 15 on the Brief Interview for Mental Status exam. Baseline care plans for the resident were developed on dates that exceeded the 48-hour requirement, specifically on 1/6/25 and 1/7/25, after the resident's admission. Additionally, interventions related to the resident's coccyx pressure wound, left calf skin tear, and the use of an Aspen neck collar were not implemented upon admission. The Director of Nursing acknowledged the necessity of creating a baseline care plan upon admission to ensure safe and appropriate care for the resident.
Failure to Assist Resident with Grooming Needs
Penalty
Summary
The facility failed to provide necessary assistance with Activities of Daily Living (ADLs) for a resident, identified as Resident #4, who was admitted with a diagnosis of dementia. Despite being cognitively intact with a Brief Interview for Mental Status (BIMS) score of 13 out of 15, Resident #4 required physical assistance from staff for all self-care activities, as indicated in the Minimum Data Set (MDS). Observations on two separate occasions revealed that Resident #4 had significant long chin hair, which the resident expressed a desire to have removed with staff assistance. The facility's policy on ADLs, dated September 2024, mandates that care and services be provided for activities such as grooming, yet Resident #4's care plan did not specify the level of assistance required for grooming tasks or document any refusals of care. Interviews with Certified Nursing Assistants (CNAs) revealed inconsistencies in the provision of grooming care, with one CNA acknowledging that facial hair should be removed if preferred by the resident, while another mentioned that the resident sometimes refused care. However, there was no documentation of any care refusals or displayed behaviors in Resident #4's medical record, indicating a lapse in adherence to the facility's policy and care expectations as stated by the Director of Nursing.
Deficiencies in Edema Management and Wound Care Documentation
Penalty
Summary
The facility failed to provide appropriate edema management for a resident with congestive heart failure. The resident, who was cognitively intact and required substantial assistance for daily activities, reported frequent leg swelling. Despite physician orders for weekly weight monitoring and notification of significant weight changes, the facility did not consistently obtain the resident's weight as ordered. There were two instances of significant weight changes that were not communicated to the medical provider, and there was no documentation indicating the resident refused weight monitoring or that the medical provider was notified. Another deficiency involved a resident with severe cognitive impairment who was admitted with a skin tear on the left calf. The facility failed to document and assess the resident's skin condition properly. Although the resident had multiple open skin ulcers on the left calf, the medical record did not reflect this, and there was no documentation of physician notification or updated treatment orders. The nurse applied dressings incorrectly, leaving part of the wound exposed, and the facility did not conduct weekly skin checks as required. Interviews with staff revealed a lack of awareness and communication regarding the residents' conditions. The Director of Nurses acknowledged issues with staff documentation and reporting of skin issues, and the need for physician notification and appropriate treatment orders. The facility's failure to follow physician orders and document changes in residents' conditions contributed to the deficiencies identified during the survey.
Failure to Address Significant Weight Loss in Residents
Penalty
Summary
The facility failed to address significant weight losses for two residents, leading to a deficiency in providing adequate nutrition. Resident #30, who has Alzheimer's and peripheral vascular disease, experienced a significant weight loss of 7.6% from August to November 2024. Despite the facility's policy requiring re-weighs and notification of the physician and dietitian in such cases, these actions were not taken. The resident's clinical record did not document refusals to be weighed in September and October 2024, and no re-weigh was conducted after the November weight was recorded. The dietitian was aware of the weight loss but did not implement interventions until January 2025. Resident #12, also with Alzheimer's and dysphagia, experienced a weight loss of 5.7% from November to December 2024, and a further loss by January 2025. The facility's policy was not followed as no re-weigh was conducted after the initial weight loss was documented. The dietitian had not evaluated or assessed the resident for possible interventions related to the weight loss until January 2025. The resident's physician orders did not include any supplements or appetite stimulants, and the staff failed to document or address the resident's change in appetite and weight loss in a timely manner. Interviews with staff revealed a lack of adherence to the facility's weight monitoring policy. Unit Manager #1 acknowledged that re-weighs should be conducted and documented, and that the dietitian and nurse practitioner should be involved when significant weight changes occur. However, these steps were not consistently followed, resulting in delayed interventions for both residents. The deficiency highlights the facility's failure to ensure proper nutritional care and monitoring for residents experiencing significant weight loss.
Failure to Provide Adequate Behavioral Health Services
Penalty
Summary
The facility failed to provide necessary behavioral health services to a resident, identified as Resident #16, who was part of a sample of 29 residents. Resident #16, admitted in May 2024 with diagnoses of depression and anxiety, showed signs of worsening mood as indicated by an increased score on the Patient Health Questionnaire (PHQ-9) from 0 to 9, suggesting mild depression. Despite this change, the facility did not follow up adequately. The resident expressed feelings of unhappiness and fear of retaliation, and reported only having met with a talk therapist once, despite a desire for regular sessions. The facility's Behavioral Health Services policy emphasizes the importance of providing care in an environment conducive to mental and psychosocial well-being, with person-centered care approaches. However, the record review revealed a lack of follow-up after a psychologist's initial attempt to provide support, and no further behavioral interventions were documented. The social worker was not notified of the resident's change in mood, which prevented a team meeting to address the resident's needs. This oversight contributed to the deficiency in providing appropriate behavioral health services to Resident #16.
Medication Administration Error Due to Lack of Resident Verification
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors. Nurse #2 attempted to administer medications to the wrong resident, Resident #72, which included medications that the resident was allergic to and could have jeopardized their health and safety. The medications prepared for administration included amoxicillin/clavulanate potassium, aspirin, flecainide acetate, and escitalopram oxalate. Resident #72 had known allergies to penicillin and aspirin, making the administration of these medications particularly dangerous. The incident occurred when Nurse #2 prepared the medications and placed them on Resident #72's bedside table, instructing the resident to take them without verifying the resident's identity. The nurse did not request any identifying information from the resident, such as their name or date of birth, nor did they check the resident's identification bracelet. The resident appeared confused and did not take the medications, and the surveyor intervened to prevent the administration of the incorrect medications. During an interview, the Director of Nursing acknowledged that Nurse #2 should have verified the resident's identity using two methods before administering the medications. The facility's policy on medication administration requires verification of the resident's identity by checking a photograph in the medical record, checking the identification bracelet, or asking the resident to identify themselves. The Director of Nursing emphasized the importance of this verification process, especially on a busy rehabilitation floor where residents frequently change.
Failure to Provide Dental Services for a Resident
Penalty
Summary
The facility failed to provide necessary dental services for a resident, identified as Resident #8, who was admitted in January 2023 with a diagnosis including pleural effusion. The resident, who was cognitively intact with a BIMS score of 13, required supervision for oral care tasks. Despite having a consent for dental treatment and a physician order for dental services as needed, the resident had not seen a dentist since May 2023. An oral assessment conducted in December 2024 revealed a broken tooth, but there was no indication in the medical record that this issue was communicated to the nursing staff or medical providers. Interviews with facility staff, including a nurse, the Unit Coordinator, the MDS Nurse, and the Director of Nursing, revealed a lack of awareness regarding the resident's broken tooth and the need for dental services. The Unit Coordinator, responsible for scheduling dental appointments, was unaware of the resident's condition and the resident was not on the list of those recently seen by the dentist. The Director of Nursing was also unaware of the resident's dental needs and the frequency of dental visits required. This lack of communication and follow-up resulted in the resident not receiving timely dental care for the broken tooth.
Failure to Provide Appropriate Diet Texture
Penalty
Summary
The facility failed to provide the appropriate diet texture for Resident #91, who was admitted with diagnoses including adult failure to thrive and dementia. The Minimum Data Set (MDS) indicated that Resident #91 had severe cognitive impairment and varied from independence to dependence with eating. The physician's orders specified that Resident #91 was to receive a pureed diet texture with nectar thickened liquids. However, during an observation, it was noted that Resident #91 was served scrambled eggs that were not pureed. Nurse #7 confirmed that although he checks the trays, Resident #91 was served eggs that were not in the prescribed pureed form.
Improper Use of Hoyer Lift Leads to Resident Injury
Penalty
Summary
The facility failed to ensure the safety of a resident who required the use of a Hoyer lift for all transfers. During a transfer, the sling was not properly attached to the lift by the CNAs, resulting in the resident falling from the sling to the floor. The resident sustained multiple injuries, including a closed head injury, scalp laceration, and fractures to the left leg, and was admitted to the hospital for treatment. The facility's policy on safe resident handling and transfers indicated that staff should ensure residents are handled and transferred safely to prevent injury. The protocol for using the Hoyer lift required that all sling positioning loops be checked to ensure they were attached correctly, with matching colored loops for stability. However, during the incident, the CNAs did not attach the sling loops correctly, leading to the resident's fall. Interviews with the CNAs involved revealed that they discussed which color loops to use but did not verify that the loops were attached equally on both sides. The facility's internal investigation confirmed that the loops were not attached properly, causing the resident to fall from the left side of the sling. The incident highlighted a failure to adhere to established protocols for using the Hoyer lift, resulting in a serious accident.
Removal Plan
- Ad-Hoc Quality Assurance Performance Improvement meeting was held, and Action Plan meeting minutes indicated the Facility leadership team met and developed a plan of correction related to the deficient practice.
- The Hoyer lift was immediately taken out of service until it was inspected by the Maintenance Director.
- The Regional Nurse, Administrator, SDC, and Director of Maintenance reviewed the manufacturer guidelines for the mechanical lift and sling involved in the incident.
- A re-creation of the event was conducted by the Regional Nurse and SDC using pictures of the Hoyer with the sling attached as it was at the time of the incident, and they determined the sling was not properly connected to the Hoyer lift at the time of the incident.
- The Director of Maintenance performed routine maintenance on the Hoyer lift.
- The QAPI team decided to simplify the use of Hoyer lift slings, and determined use of only the six-point connection slings was going to be the standard practice moving forward.
- CNA #1 and CNA #2 were re-educated by the SDC on the Facility Protocol titled, Hoyer Lift Education.
- The Medical Equipment Invoice indicated that the Facility ordered new, Hoyer lift slings, and staff have been in-serviced, educated and trained on use of the new lift slings.
- The Education Inservice Record Sign in Sheet indicated nurses and CNAs were re-educated to the Facility Protocol titled, Hoyer Lift Education by the SDC.
- The Director of Nurses and SDC completed audits and observations of staff performance of Hoyer lift transfers.
- Observations of Hoyer lift transfers will be completed by the Director of Nursing and/or designee, and need to continue observations will be evaluated by leadership team.
- Results of the Hoyer lift transfers observations will be reviewed with nursing leadership until substantial compliance is achieved.
- Hoyer lift inspections will be performed monthly for the next 90 days then quarterly thereafter by the Director of Maintenance.
- Results of the audits will be brought to QAPI, by DON and/or SDC, for further review and recommendations.
- The Director of Nurses and/or designee are responsible for ongoing compliance.
Delayed Implementation of Care Recommendations for Pressure Injury Management
Penalty
Summary
The facility failed to ensure that nursing staff provided care and services that met professional standards of practice for five residents who were at high risk for developing pressure injuries or had existing pressure injuries upon admission. The facility's policy on pressure injury prevention and management was not adhered to, as evidenced by the lack of timely follow-up on recommendations for preventative skin care and obtaining necessary medication and treatment orders. This deficiency was identified through a review of records and interviews with staff. Resident #1, who had multiple diagnoses including Parkinson's Disease and an unstageable pressure injury, did not receive timely implementation of dietary recommendations made by the Registered Dietician. The recommendations for Vitamin C, Zinc Sulfate, and Liquid Protein were not addressed until five days after being entered into the electronic medical record. Additionally, a dressing change order recommended by the Wound Physician Assistant was not obtained, indicating a lapse in communication and follow-up by the nursing staff. Similar issues were observed with other residents. Resident #2's wound care recommendations were delayed by eleven days, Resident #3's heel offloading order was delayed by over three months, and Resident #4's offloading booties were not implemented until 46 days after admission. Resident #5 experienced a nine-day delay in updating dressing change orders. These delays highlight a systemic issue in the facility's process for reviewing and implementing care recommendations, resulting in a failure to meet professional standards of quality care.
Incomplete Medical Records and Documentation Deficiency
Penalty
Summary
The facility failed to maintain complete and accurate medical records for five residents who required physical assistance with Activities of Daily Living (ADL) and positioning. The Certified Nurse Aide (CNA) ADL Flow Sheets and Positioning Sheets were not consistently completed, with numerous instances of flow sheets left blank across all three shifts. This lack of documentation was evident for multiple residents over several days, indicating a systemic issue in record-keeping. For Resident #3, who had a newly diagnosed pressure injury, the facility did not have physician's orders documented on the Treatment Administration Record (TAR) for the wound care. Despite nursing notes indicating treatments were in place, there was no supporting documentation of physician's orders or specific nursing documentation related to the wound care. Interviews with nursing staff revealed a lack of communication with the provider regarding the new skin breakdown, and the Director of Nurses (DON) was unaware of the new pressure areas upon the resident's readmission. Interviews with CNAs and nursing management highlighted ongoing challenges with completing daily ADL documentation. CNAs reported difficulty in completing documentation within their shifts, and management acknowledged that incomplete documentation was a known issue. The facility's expectation was for all CNA ADL documentation to be completed daily before the end of each shift, but this was not consistently achieved, contributing to the deficiency in maintaining accurate medical records.
Failure to Notify Physician of Resident's Pressure Injury
Penalty
Summary
The facility failed to notify the physician of a significant change in the medical status of a resident, who had been admitted with multiple diagnoses including Alzheimer's type dementia, peripheral vascular disease, congestive heart failure, chronic kidney disease, and amyloidosis. Upon readmission to the facility, the resident developed a suspected deep tissue injury to the intergluteal cleft and right buttocks, which was not communicated to the physician. Despite the presence of ongoing wounds and treatments documented in the resident's weekly skin assessments, there was no evidence in the medical records that the physician was informed or that treatment orders were obtained. Interviews with nursing staff revealed a lack of awareness and communication regarding the resident's new pressure injuries. Nurse #1 and the Nurse Supervisor both acknowledged the necessity of notifying the physician for treatment orders upon discovering new skin issues, yet there was no documentation of such communication. The Director of Nurses was also unaware of the new pressure area, indicating a breakdown in the facility's protocol for notifying physicians of significant changes in a resident's condition.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,339 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Woburn
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Winchester Rehabilitation And Nursing Center | 2.2 mi | ★★★★★ | 3 | 0 |
| Aberjona Rehabilitation And Nursing Center | 2.2 mi | ★★★★★ | 0 | 0 |
| Bear Hill Healthcare And Rehabilitation Center | 3.2 mi | ★★★★★ | 7 | 0 |
| Care One At Wilmington | 3.5 mi | ★★★★★ | 0 | 0 |
| Care One At Lexington | 3.6 mi | ★★★★★ | 11 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Woburn Rehabilitation And Nursing Center.
100% money-back within 48 hours.
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.