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The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lowell Healthcare during CMS and state inspections, most recent first.
A dignity-related deficiency occurred when a resident with cognitive impairment and an indwelling urinary catheter was repeatedly observed in bed with an uncovered catheter collection bag containing visible urine hanging from the side of the bed and visible from the hallway. The resident’s care plan, which addressed obstructive uropathy, required that the catheter bag be stored inside a protective dignity pouch, but this intervention was not followed. During interview, the DON acknowledged the visibility of the catheter bag and stated that dignity covers were available and expected to be used by staff.
A cognitively impaired resident with multiple diagnoses, including hypertension and mental health conditions, was given oral medications and Miralax by an LPN, who left the partially consumed Miralax at the bedside and returned to the nurse's station without ensuring it was taken. The resident had no documented assessment for self-administration of medications and no physician order authorizing self-administration, despite facility policy requiring an IDT assessment and a physician order before allowing residents to self-administer medications.
A deficiency was cited when a dependent female resident with Alzheimer's disease, care planned to need assistance with ADLs and documented as severely cognitively impaired, was repeatedly observed with visible facial hair on her chin despite receiving regular baths and showers. Records showed she had not been assisted with shaving for several days, and there were no documented refusals on shower sheets, even though leadership reported she frequently refused shaving. This failure to provide and document needed shaving care was inconsistent with the facility’s AM care policy requiring shaving when needed and documentation of the procedure.
Surveyors found that three residents with COPD and other respiratory diagnoses did not consistently receive oxygen therapy and equipment management as ordered and per facility policy. One resident used oxygen via nasal cannula from a concentrator with a humidity bottle that remained in use well beyond the facility’s 7‑day change requirement, despite orders to change humidity and tubing weekly. Another resident, care planned for impaired gas exchange and ordered oxygen at 2 L/min every shift, was observed with a nasal cannula on the floor and with varying concentrator flow rates that did not match the order. A third cognitively impaired resident, ordered oxygen at 2 L/min every shift, was seen with oxygen on one day and then without oxygen on multiple subsequent days. The ADON reported no additional information regarding these discrepancies.
Surveyors observed an LPN preparing oral medications for a resident by popping multiple pills from medication cards directly into her hand and then placing them into a medication cup before administration. This practice was later reported to the DON. The facility’s Medication Administration policy required that medications be opened without contaminating, and the LPN’s method of handling the pills with bare hands did not comply with that standard.
The facility was found to have improper glove use in food handling, as observed in the main kitchen. Staff members, including a dietary food manager, handled food and other items without changing gloves or performing hand hygiene, contrary to the facility's policy. This failure to maintain sanitary conditions had the potential to affect residents receiving food from the kitchen.
The facility failed to maintain infection control standards during medication administration and equipment cleaning. A QMA was observed touching pills with her hands before administering them to three residents, violating the facility's policy. Additionally, a blood pressure machine was used on two residents without being disinfected before or after use, contrary to the facility's cleaning policy.
A resident with edema did not receive the necessary care as Medigrips were not applied as ordered. Despite a physician's order to apply Eucerin cream and Medigrips daily, the resident was observed multiple times without them, and her legs were discolored and swollen. The Medication Administration Record indicated the treatment was signed out as completed, with no documentation of discontinuation or refusal. The RN and DON were unaware of the current order status.
A facility failed to follow physician's orders for a resident with a stage 4 pressure ulcer. During wound care, the wound nurse did not apply Sureprep to the surrounding skin as ordered, admitting to forgetting this step. The resident, who has multiple sclerosis and diabetes, requires moderate assistance for bed mobility and is dependent on staff for transfers.
A medication was left unsecured on top of a medication cart by a QMA during administration rounds. The QMA was preparing medications for a resident and could not find the Miralax, which was later retrieved by an RN. The QMA placed the Miralax on top of the cart and proceeded to administer medications to another resident, leaving the Miralax unattended. The facility's policy requires medications to be stored in a locked cabinet or cart.
Failure to Maintain Dignity by Leaving Catheter Bag Uncovered and Visible
Penalty
Summary
Surveyors identified a dignity-related deficiency when a resident with an indwelling urinary catheter was repeatedly observed with an uncovered urinary catheter bag visible from the hallway. On three separate observations over consecutive days, the resident was lying in bed with the catheter collection bag hanging from the side of the bed, containing visible urine and lacking any cover, making it observable to anyone passing by. Record review showed the resident had diagnoses including hypertension, osteoarthritis, and obstructive uropathy, and a Quarterly MDS indicated cognitive impairment and the presence of an indwelling urinary catheter. The resident’s care plan, updated prior to the observations, specified that the catheter collection bag should be stored inside a protective dignity pouch, but this intervention was not implemented during the observed times. During an interview, the DON acknowledged that the catheter bag was visible from the hallway and stated that the facility had dignity covers that staff were supposed to use. This failure to follow the care-planned intervention to store the catheter collection bag in a protective dignity pouch resulted in the resident’s urinary catheter bag being exposed and visible from the hallway on multiple occasions.
Failure to Assess and Obtain Order for Self-Administration Before Leaving Medication at Bedside
Penalty
Summary
The deficiency involves a nurse leaving a medication at a cognitively impaired resident's bedside without an assessment or physician order for self-administration. During observation, an LPN prepared the resident's medications, including 17 grams of Miralax dissolved in water, and brought them to the resident's room. The resident took his pills and only a few sips of the Miralax, then placed the cup on the bedside table. The LPN stated she would return later to assist the resident with finishing the Miralax but left the room and returned to the nurse's station, leaving the Miralax in the resident's room and not remaining to ensure the medication was taken. Record review showed the resident had diagnoses including hypertension, generalized anxiety disorder, and major depressive disorder, and the most recent Quarterly MDS indicated the resident was cognitively impaired. There was no documentation of any physician's orders authorizing self-administration of medications and no assessment for self-administration in the record. The facility's policy on self-administration of medications required an interdisciplinary team assessment of the resident's competence and a physician order specifying the resident's ability to self-administer and which medications were included, but these steps had not been completed for this resident when the medication was left at the bedside.
Failure to Provide and Document ADL Assistance With Shaving for Dependent Resident
Penalty
Summary
Surveyors identified a deficiency in providing ADL assistance when a dependent female resident with Alzheimer's disease was repeatedly observed with visible facial hair on her chin over several days. On three separate observations, the resident was seen sitting in her wheelchair watching television with facial hair present, despite being care planned as needing assistance with ADLs, including bathing and personal hygiene. Her MDS assessment documented severe cognitive impairment and a need for partial/moderate assistance with personal hygiene and substantial/maximal assistance with bathing. Record review showed that the resident’s care plan included assistance with showers twice weekly in the morning and partial baths in between per her preference, but the shower sheets for the prior 60 days indicated she had last been assisted with shaving on 2/3/26. She had received a bed bath or shower on 2/5/26 and 2/10/26, with no refusals for shaving documented. The ADON reported that the resident frequently refused shaving, but this was not reflected in the care plan, and the Administrator stated that staff were supposed to document refusals on the shower sheets, which had not been done. This was inconsistent with the facility’s AM Care policy, which required shaving the resident if needed or requested and documenting the procedure.
Failure to Provide Ordered Oxygen Therapy and Maintain Oxygen Equipment
Penalty
Summary
The deficiency involves the facility’s failure to provide proper respiratory care and oxygen administration for three residents with orders for oxygen therapy. One resident with COPD was observed multiple times in bed using oxygen via nasal cannula from a concentrator set at 1.5 L/min, with a humidity bottle attached that was dated several weeks earlier than allowed by facility policy, which required humidity bottles to be changed every seven days. This resident’s physician orders included changing oxygen tubing and humidity once a day on Sunday and allowing the resident, who was cognitively intact, to apply oxygen at 2 L/min via nasal cannula when feeling short of breath. Despite these orders and the policy, the humidity bottle remained outdated on repeated observations, and the ADON reported having no further information. Another resident with COPD and respiratory failure, care planned as being at risk for impaired gas exchange and requiring oxygen therapy, was observed with inconsistent oxygen use and handling. On one occasion, the resident’s nasal cannula was seen lying on the floor while still connected to an oxygen concentrator; on other occasions, the resident wore a nasal cannula connected to either a portable concentrator set at 3 L/min or a concentrator set at 1.5 L/min, despite a physician order for oxygen at 2 L/min via nasal cannula every shift. A third resident with COPD and asthma, assessed as severely cognitively impaired and requiring oxygen therapy, had a physician order for oxygen at 2 L/min via nasal cannula every shift but was observed with oxygen in use on one day and then without oxygen on three subsequent days. In all three cases, the facility did not ensure that oxygen therapy and related equipment were managed in accordance with physician orders and the facility’s oxygen concentrator policy.
Improper Handling of Oral Medications During Medication Pass
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control practices during medication administration. On 2/11/26 at 9:12 a.m., an LPN was observed preparing medications for Resident 60, which included 10 pills. The LPN popped each pill out of the medication cards one at a time directly into her hand and then transferred them from her hand into a medication cup before administering them to the resident. Later that morning, at 11:17 a.m., the DON was informed that the LPN had touched the medications with her hands. The facility’s written Medication Administration (Medication Pass Procedure) policy stated that medications are to be opened without contaminating, indicating that the observed practice did not follow the facility’s established infection control standards.
Improper Glove Use in Food Handling
Penalty
Summary
The facility failed to maintain sanitary conditions in food handling, as observed during a follow-up tour of the main kitchen. An individual, referred to as [NAME] 1, was seen wearing gloves while handling various items, including a box of cellophane wrap and a cardboard box containing frozen sausage patties. Without changing gloves or performing hand hygiene, he proceeded to scoop out sausage patties with the same gloved hands and placed them on a baking sheet. This action was contrary to the facility's policy, which requires handwashing before and after glove use and changing gloves when they become contaminated. Additionally, the Dietary Food Manager (DFM) was observed preparing food for lunch without adhering to proper glove use protocols. The DFM manipulated cellophane wrap, handled bread, and covered a baking sheet without changing gloves or performing hand hygiene. Although the DFM indicated that the food touched with the gloves would be disposed of, the actions observed were not in compliance with the facility's glove use policy, which emphasizes that gloves are not a substitute for handwashing and should be changed between tasks or when contaminated.
Infection Control Deficiencies in Medication Administration and Equipment Cleaning
Penalty
Summary
The facility failed to maintain proper infection control practices during medication administration for three residents. A Qualified Medication Aide (QMA) was observed touching pills with her hands before placing them into medication cups for administration to the residents. This practice was observed with three residents during medication administration rounds. The facility's Medication Administration policy specifies that medications should be opened without contamination, which was not adhered to in these instances. Additionally, the facility did not ensure that reusable equipment was disinfected after use on residents. A blood pressure machine was used on two residents without being cleaned or disinfected before or after use. Both the QMA and a Registered Nurse (RN) failed to clean the blood pressure cuff between uses, contrary to the facility's Equipment Cleaning policy, which requires the use of germicidal/disinfectant spray on all surfaces of electrical equipment.
Failure to Apply Medigrips as Ordered for Resident with Edema
Penalty
Summary
The facility failed to provide necessary care and treatment for a resident with edema, as the Medigrips (elastic type stockings) were not applied as ordered. The resident, who had diagnoses including venous insufficiency, hypertensive heart disease with heart failure, and dementia, was observed multiple times without the Medigrips in place. Her legs were noted to be discolored and swollen during these observations. Despite the physician's order from November 2023 to apply Eucerin cream and Medigrips daily, the Medigrips were not observed on the resident during the survey period. The Medication Administration Record for November and December 2024 indicated that the Eucerin and Medigrips were signed out daily as completed, with no documentation of the order being discontinued or the resident refusing the treatment. The RN and the Director of Nursing were both unaware of the current status of the order, with the RN initially indicating uncertainty about who was responsible for the application of the Medigrips. The DON believed the order had been discontinued due to resident refusal, but there was no documentation to support this belief, and the order was still active.
Failure to Follow Wound Care Orders for Pressure Ulcer
Penalty
Summary
The facility failed to provide the necessary treatment for a pressure ulcer for one resident. On December 11, 2024, during an observation of wound care, the wound nurse did not apply Sureprep to the surrounding skin of a stage 4 pressure ulcer on the resident's sacral area, as was ordered by the physician. The resident, who has multiple sclerosis, diabetes mellitus, and a stage 4 pressure ulcer, was observed to be cognitively intact and required moderate assistance for bed mobility and was dependent on staff for transfers. The physician's order from November 26, 2024, specified the use of Sureprep, but the wound nurse admitted to forgetting this step during the wound care process.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure that a medication was kept in a locked medication cart at all times for one of the residents observed during medication administration. On the morning of December 11, QMA 1 was preparing medications for a resident and could not find the resident's Miralax, a laxative medication. She informed RN 1, who then retrieved the medication from the Pyxis, a medication dispensing machine. RN 1 handed the Miralax to QMA 1, who wrote the resident's name on it and placed it on top of the medication cart instead of securing it inside the cart. QMA 1 then proceeded to prepare and administer medications for another resident, leaving the Miralax unattended on top of the cart and out of her sight. After completing the medication administration for the second resident, QMA 1 returned to the cart, retrieved the Miralax, and administered it to the first resident. The Director of Nursing was informed of the incident, and the facility's Medication Storage and Expiration Policy was reviewed, which mandates that medications should be stored in a locked cabinet or cart inaccessible to residents and visitors.
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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) |
|---|---|---|---|---|
| Cedar Creek Health Campus | 0.9 mi | — | 0 | 0 |
| Ignite Medical Resort Crown Point Llc | 7.2 mi | — | 37 | 0 |
| Saint Anthony | 7.6 mi | — | 3 | 0 |
| Colonial Nursing Home | 9.1 mi | — | 0 | 0 |
| Crown Point Health Campus | 11.3 mi | — | 23 | 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 August 2026) and official state health department websites.